Contribution of natriuretic peptide testing and Doppler echocardiography at bedside to the diagnosis of acute heart failure. A practical overview.

Acute heart failure is one of the most common condition leading to hospital admission and is burdened by important mortality and readmission rates. A timely diagnosis of congestive heart failure at admission by hospitalists is essential for an early and tailored medical management. The initial clinical evaluation based on symptoms, physical signs and chest radiography remains inconclusive for the diagnosis in many patients with acute dyspnea, and the use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as first-line diagnostic complement in the acute care setting. Bedside Doppler echocardiography is another reliable, noninvasive method that offers additional diagnostic information over the initial clinical evaluation. Along with echocardiographic evidence of depressed left ventricular systolic function, several simple Doppler indexes have been validated in the emergency diagnosis of congestive heart failure. Doppler echocardiography at bedside may especially benefit to patients with intermediate, inconclusive natriuretic peptide concentrations. The aim of the present review was to offer to the hospitalist a practical overview on the relative contribution of natriuretic peptide testing and bedside Doppler echocardiography to the diagnosis of acute heart failure in the emergency care setting.

Current clinical applications of spectral tissue Doppler echocardiography (E/e' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved ejection fraction. Revisited 15 years later.

It is currently well established that more than half of heart failure patients have preserved ejection fraction. The diagnosis of heart failure with preserved ejection fraction is complex in clinical practice despite ESC recommendations issued in 2019. In this context, the demonstration of increased left ventricular filling pressures at rest or during exercise allows a definite diagnosis of heart failure with preserved ejection fraction in patients with signs and/or symptoms compatible with the diagnosis and a preserved ejection fraction. The spectral tissue Doppler-derived E/e' ratio by transthoracic Doppler echocardiography has been validated in the noninvasive assessment of left ventricular diastolic pressures at rest and during exercise. Several studies report the validity of E/e' in the diagnosis of heart failure with preserved ejection fraction in patients with both isolated exertional and acute dyspnea, as well as in risk stratification. In light of the current literature, E/e' deserves to be included on every transthoracic Doppler echocardiography report in patients with suspected heart failure with preserved ejection fraction. This updated review provides an overview of the diagnostic relevance of E/e' in patients in its two modes of clinical presentation, isolated exertional dyspnea and the decompensated congestive form.

Clinical relevance of spectral tissue Doppler-derived E/e' in older patients with preserved ejection fraction.

BACKGROUND: The E/e' index measured in spectral tissue Doppler is included in the recommendations for the diagnosis by transthoracic Doppler echocardiography of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. While E/e' is influenced by age in healthy individuals, no studies have evaluated this index in elderly patients. This study addressed the clinical relevance of E/e' in assessment of left ventricular diastolic function in elderly patients with preserved ejection fraction and its relevance from both a diagnostic and prognostic perspective based on the existing literature. METHODS: A total of 76 patients≥70years of age were prospectively included. The analysis of left ventricular diastolic function was adapted from the 2016 ASE/EACVI recommendations without consideration of E/e'. RESULTS: The mean age was 85years. In all, 42 patients had moderate-to-severe diastolic dysfunction (elevated left atrial pressure). Mean E/e' was significantly correlated with diastolic function (r=0.58, P<0.001). Mean E/e'>13.3 had a sensitivity of 86% and a specificity of 91% in the diagnosis of moderate-to-severe diastolic dysfunction (AUC: 0.92). E/(e'xs') (AUC: 0.89) and NT pro-BNP (AUC: 0.80) did not perform better than E/e'. The existing literature offers large body of evidence that E/e' provides essential diagnostic and prognostic information in older patients with cardiovascular disease. CONCLUSION: E/e' is accurate in the diagnosis of significant diastolic dysfunction, in the diagnosis of heart failure with preserved ejection fraction and in risk stratification in older patients with cardiovascular disease.

Accuracy of peak mitral e-wave velocity in the diagnosis of heart failure with preserved ejection fraction in older patients with acute dyspnea.

BACKGROUND: The diagnosis of heart failure with preserved ejection fraction is characterized by its complexity, especially for physicians without great experience in comprehensive transthoracic Doppler echocardiography. Peak mitral E-wave (E) velocity has been successfully correlated to invasive left ventricular diastolic pressures in patients with structural heart disease. The aim of the study was to address the accuracy of E in the diagnosis of heart failure with preserved ejection fraction in elderly patients with acute dyspnea. METHODS: This prospective study included 29 consecutive patients ≥70 years of age with heart failure with preserved ejection fraction and acute dyspnea and 29 controls ≥70 years of age. The final diagnosis was supported by the 2016 ASE/EACVI recommendations. RESULTS: Mean age of the overall population was 85±7 years. E was strongly correlated with left atrial volume index (r=0.72, P<0.001) and with peak velocity of tricuspid regurgitation (r=0.77, P<0.001). E >85cm/s was 90% sensitive and 93% specific in the diagnosis of heart failure with preserved ejection fraction (AUC, 0.95). E/e' (0.95) and E/(e'xs') (0.92) did not perform better. CONCLUSION: E/e' and E/(e'xs') provide essential diagnostic and prognostic information in heart failure with preserved ejection fraction and deserve to be included in every report of comprehensive transthoracic Doppler echocardiography. E velocity is a very simple and user-friendly parameter that can be used for the sole diagnostic purpose in elderly patients with acute dyspnea by operators without great deal of experience, such as cardiologists without formal training, emergency physicians, intensive care anesthetists, internists and geriatricians.

Serum albumin and cardiovascular disease: State-of-the-art review.

Cardiovascular disease is the leading cause of death worldwide. Conceptually, endothelial dysfunction, inflammatory conditions and oxidative stress are at the forefront of the onset and development of most cardiovascular diseases, particularly coronary artery disease and heart failure. Serum albumin has many physiological properties, including in particular antioxidant, anti-inflammatory, anticoagulant and anti-platelet aggregation activity. It also plays an essential role in the exchange of fluids across the capillary membrane. Hypoalbuminemia is a powerful prognostic marker in the general population as well as in many disease states. In the more specific context of cardiovascular disease, low serum albumin is independently associated with the development of various deleterious conditions such as coronary artery disease, heart failure, atrial fibrillation, stroke and venous thromboembolism. Low serum albumin has also emerged as a potent prognostic parameter in patients with cardiovascular disease regardless of usual prognostic markers. Remarkably, its potent prognostic value persists after adjusting for causative confounders such as malnutrition and inflammation. This prognostic value probably refers primarily to the syndrome of malnutrition-inflammation and the severity of comorbidities. Nevertheless, several recent meta-analyses strongly support the hypothesis that hypoalbuminemia may act as an unrecognized, potentially modifiable risk factor contributing to the emergence and progression of cardiovascular disease, primarily by exacerbating oxidative stress, inflammation and platelet aggregation, and by favouring peripheral congestion and pulmonary edema. Currently, it is unknown whether prevention and correction of low serum albumin offers a benefit to patients with or at risk for cardiovascular disease, and further studies are critically needed in this setting.

[Does hypoalbuminemia contribute to the worsening of heart failure?] / L'hypo-albuminémie contribue-t-elle à l'aggravation de l'insuffisance cardiaque ?

BACKGROUND: Hypoalbuminemia has now emerged as a powerful prognosticator in heart failure regardless of age, clinical presentation, left ventricular ejection fraction and usual prognostic markers. Growing evidence is that this prognostic value persists after adjusting for causative factors for hypoalbuminemia such as malnutrition, inflammation and liver dysfunction. OBJECTIVE: To address the prognostic relevance of hypoalbuminemia in frail elderly patients with well-characterized cardiogenic pulmonary edema at high risk for adverse outcome, beyond causative factors for low serum albumin levels. Serum albumin was measured after clinical stabilization to avoid hypervolemia. RESULTS: In all, 67 patients with a mean age of 86 years were included. Hospital mortality was 30%. Patients who died and who survived were similar in age, ejection fraction, BNP concentration, serum creatinine, serum hemoglobin, total bilirubin and prealbumin. Patients who died had lower serum albumin levels (P<0.001), higher blood urea nitrogen (P=0.03) and higher C-reactive protein (P=0.02). In multivariate analysis, serum albumin was the sole independent predictor of hospital death (P<0.01), after adjusting for malnutrition (prealbumin P=ns), inflammation (C-reactive protein P=ns) and liver dysfunction (total bilirubin P=ns). CONCLUSION: Serum albumin is a powerful prognosticator in frail elderly patients with acute cardiogenic pulmonary edema even after adjusting for main causative factors. These results suggest that hypoalbuminemia may contribute to the worsening of heart failure given the physiological properties of serum albumin that includes antioxidant activity and plasma colloid osmotic pressure action. Further studies are critically needed to address the relevance of prevention and correction of hypoalbuminemia in heart failure.

[Why not integrate the spectral tissue Doppler E/(e'xs') in the multiparametric assessment of cardiovascular diseases by transthoracic Doppler echocardiography?] / Pourquoi ne pas intégrer la mesure de l'indice E/(e'xs') en Doppler tissulaire spectral dans l'évaluation multiparamétrique des maladies cardiovasculaires par échocardiographie Doppler transthoracique ?

Assessment of left ventricular diastolic function by transthoracic Doppler echocardiography is based on a multiparametric approach which includes the spectral tissue Doppler-derived E/e'. Recently, a new Doppler index, E/(e'xs'), which combines E/e' with a spectral tissue Doppler-derived marker of systolic function, s', has been proposed in noninvasive assessment of left ventricular myocardial dysfunction. Current literature provides evidence that E/(e'xs') has good correlation with NT proBNP levels and invasive left ventricular end-diastolic pressure, both used as markers of left ventricular myocardial dysfunction, irrespective of left ventricular ejection fraction and wall motion abnormalities. More specifically, E/(e'xs') has good diagnostic accuracy in patients with intermediate values for E/e' (8 to 15). Average E/(e'xs')>1.6 is reported to predict invasive left ventricular end-diastolic pressure>15mmHg with a sensitivity of 86% and a specificity of 85%. Current literature provides evidence that E/(e'xs') could offer better prognostic information than E/e' in patients with systolic heart failure and heart failure with normal ejection fraction, as well as in patients with asymptomatic heart disease. A few clinical studies also suggest that E/(e'xs') could predict recurrence of atrial fibrillation after cardioversion and left ventricular remodeling after acute myocardial infarction. Further experimental and clinical investigation is critically needed to determine the role of this under-recognized tissue Doppler index in noninvasive assessment of cardiovascular diseases, in particular heart failure with normal ejection fraction.

Severity of periodontal disease correlates to inflammatory systemic status and independently predicts the presence and angiographic extent of stable coronary artery disease.

BACKGROUND: Periodontal disease (PD) has been recognized as a risk factor for systemic diseases, but its involvement in the pathogenesis of coronary artery disease (CAD) remains debated. OBJECTIVES: We sought to evaluate the potential relations between severity of the PD, inflammatory response and angiographic lesions extent in patients with stable CAD. DESIGN: A total of 131 subjects referred to our centre for coronary angiography were evaluated for presence and extension of CAD, then divided into two groups, one with presence of lesions (cases, n = 85) and other one with absence of lesions (controls, n = 46). Mean periodontal pocket depth (PPkD), high sensitivity C reactive protein (hs-CRP), serum amyloid A protein (SAA) and fibrinogen levels were measured in all patients. RESULTS: Cases and controls did not differ according to their baseline characteristics and prevalence of traditional cardiovascular risk factors. PPkD was greater in patients with CAD than in controls (2.24 +/- 1.28 mm vs 1.50 +/- 0.93 mm, P < 0.001 by Student's t-test). Systemic inflammatory response was more pronounced in cases than in controls, with higher values of hs-CRP, SAA and fibrinogen. Furthermore, PPkD values correlated with hs-CRP (r = 0.80, P < 0.001), SAA (r = 0.71, P < 0.001), fibrinogen levels (r = 0.72, P < 0.001) and the American College of Cardiology/American Heart Association angiographic score (r = 0.68, P < 0.001) in cases. Multivariate analysis indicated a persistent independent correlation between PPkD and angiographic score after adjustment for inflammatory markers levels. CONCLUSION: In the present study, PD lesions predicted presence of CAD stenosis in patients with cardiovascular risk factors. PD severity was correlated to angiographic extent of coronary lesions, independent of systemic inflammatory status. Those results suggest that these patients might benefit from an intensive periodontal therapy to prevent CAD progression.

[Serum albumin and cardiovascular diseases: A comprehensive review of the literature]. / Albumine sérique et maladies cardiovasculaires : une revue approfondie de la littérature.

Cardiovascular diseases are the leading cause of death worldwide. Conceptually, endothelial dysfunction, inflammatory status and oxidative stress are at the forefront in the onset and development of most cardiovascular diseases, particularly coronary artery disease and heart failure. Serum albumin, the most abundant plasma protein, has many physiological properties, including anti-inflammatory, antioxidant and antiplatelet aggregation activity. It also plays an essential role in the fluid exchange across the capillary membrane. Definite evidence is that hypo-albuminemia is a powerful prognostic marker in the general population as well as in many pathological settings. In the more specific context of cardiovascular diseases, serum albumin is independently associated with the development of a variety of deleterious conditions such as coronary artery disease, heart failure, atrial fibrillation and stroke. Serum albumin has also emerged as a powerful prognostic parameter in patients with coronary artery disease, heart failure, congenital heart disease, infective endocarditis, cardiovascular surgery and stroke, regardless of usual prognostic markers. This prognostic value probably refers mainly to the malnutrition-inflammation syndrome and the severity of comorbidities. Nevertheless, hypo-albuminemia may act as an unknown and modifiable risk factor that contributes to the emergence and the pejorative evolution of cardiovascular diseases, mainly by exacerbation of inflammation, oxidative stress and platelet aggregation, and by pulmonary and myocardial edema. This article provides an overview of the physiological properties of serum albumin, the prevalence, causes, prognostic value and potential contribution to the emergence and aggravation of cardiovascular disease of hypoalbuminemia, as well as its clinical implications.

[Usefulness of B-type natriuretic peptide (BNP) for the diagnosis of new-onset heart failure with a preserved left ventricular systolic function in longstanding hypertensive patients with acute dyspnea]. / Apport du peptide natriurétique de type B dans le primo-diagnostic d'insuffisance cardiaque à fonction systolique preservée chez le patient hypertendu souffrant de dyspnée aiguë.

BACKGROUND: B-type natriuretic peptide (BNP) has been largely validated in the etiologic diagnosis of acute dyspnea. Nevertheless, its reliability in the setting of a preserved left ventricular systolic function (ejection fraction >50%) has not been adequately established. OBJECTIVE: the study addressed the usefulness of BNP in the diagnosis of new-onset heart failure with a preserved systolic function in hypertensive patients hospitalized for acute dyspnea. METHODS: 59 consecutive hypertensive patients without history of heart failure and coronary disease were included. BNP was measured at presentation with the Triage system. Noninvasive estimation of left ventricular filling pressures by bedside tissue Doppler echocardiography at presentation was incorporated in the diagnostic criteria. RESULTS: the 30 patients with heart failure were not significantly different from the 29 patients with noncardiac cause of acute dyspnea regarding age, gender, body mass index and ejection fraction. Median levels of BNP were significantly higher in heart failure (447 [245-644] versus 87 [43-139] pg/mL). By multivariate logistic regression analysis, BNP (odds ratio of 44, [3.6-531], p=0.003) provided independent and incremental diagnostic information over the clinical score of Boston criteria (2.25, [1.3-3.9], p=0.0037). A BNP value of >142 pg/mL (area under the ROC curve of 0.89, p<0.0001) was 93 sensitive and 79% specific for the diagnosis of heart failure in this setting. CONCLUSION: BNP is a reliable biomarker of new-onset heart failure with a preserved systolic function in hypertensive patients, in particular older, hospitalized for acute dyspnea and can be safely integrated in the diagnostic strategy.

[Usefulness of spectral tissue Doppler (E/e' ratio) in the management of patients with atrial fibrillation]. / Apport du Doppler tissulaire spectral (rapport E/e') dans la prise en charge des patients en fibrillation auriculaire.

Atrial fibrillation is the most common cardiac rhythm disorder encountered in daily clinical practice. It carries high morbidity and mortality rates, mainly related to sudden death, heart failure and stroke. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is therefore attractive in this clinical setting. The spectral tissue Doppler-derived E/e' ratio is a simple and user-friendly index which has been validated in the assessment of left ventricular diastolic pressures, regardless of rhythm. A septal E/e' >11 is associated with invasive left ventricular diastolic pressures >15mmHg in patients with atrial fibrillation. Several studies have reported the clinical relevance of abnormal values of E/e' at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. There is now convincing evidence that increased E/e' is associated with adverse outcome in patients with atrial fibrillation and predicts the recurrence of arrhythmia after cardioversion or catheter ablation. In conclusion, we recommend the measurement of E/e' in each patient with atrial fibrillation referred for clinically indicated transthoracic Doppler echocardiography.

[Prognostic value of BNP for hospital mortality in elderly subjects hospitalised for acute diastolic cardiac failure]. / Valeur pronostique du BNP pour la mortalité hospitalière chez le sujet agé hospitalisé pour insuffisance cardiaque diastolique aiguë.

The aim of this study was to evaluate the prognostic value of BNP in elderly patients hospitalised for acute diastolic cardiac failure. 108 consecutive subjects were included, aged at least 70 years old, hospitalised for isolated acute diastolic cardiac failure. All of them had a left ventricular ejection fraction > or = 50% and evidence of diastolic dysfunction on echocardiography performed shortly after admission. The plasma BNP concentration measured in the emergency department on admission was >100 pg/ml in all of the patients except five. It was positively correlated with age (R = 0.29, p = 0.002), with the plasma creatinine level (R = 0.37, p < 0.0001) and the plasma urea level (R = 0.41, p < 0.0001). On univariate analysis, compared to the patients who survived, the 20 patients who died before discharge were significantly older (88.6 versus 84.4 years, p = 0.01), and were more often residents of a care home (60 versus 31%. p = 0.02), had a lower systolic blood pressure on admission (127 +/- 33 versus 154 +/- 30 mm Hg), a higher plasma urea level (16.8 +/- 12 versus 8.9 +/- 5 mmol/l, p = 0.002) and a higher BNP (median = 1290 pg/ml, interquartile range: 721, 3026 pg/ml versus 430 pg/ml, interquartile range: 243, 886 pg/ml). On multivariate analysis, the only factors that remained significantly associated with mortality were the BNP levels (p = 0.005) and the systolic blood pressure (p = 0.01). The negative predictive value of a BNP level < 631 pg/ml (median) for death was 94% (95% confidence interval: 91 to 97%). We conclude that BNP does have an independent prognostic value for in-hospital death in elderly subjects with acute diastolic cardiac failure.

[Usefulness of natriuretic peptide testing and Doppler echocardiography at bedside in the diagnosis of acute heart failure]. / Apport du peptide natriurétique de type B et de l'échocardiographie Doppler transthoracique au lit du patient dans le diagnostic d'insuffisance cardiaque aiguë.

Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.

[Value of Doppler indices of diastolic left ventricular dysfunction in acute cardiac insufficiency]. / Valeur des indices Doppler de dysfonction ventriculaire gauche diastolique dans l'insuffisance cardiaque aiguë.

OBJECTIVE: To examine the prevalence of diastolic dysfunction by Doppler study in acute cardiac failure. CONTEXT: A recent study showed that diastolic dysfunction is constant in stable cardiac failure with preserved systolic function and suggested that its measurement was not necessary for the diagnosis of diastolic cardiac failure, but the prevalence of diastolic dysfunction in acute cardiac failure is not known. METHOD: The mitral and pulmonary venous profiles, the propagation velocity Vp of colour filling flow, and the lateral velocity Ea of the mitral ring in DTI were studied at the time of treatment initiation in 28 patients in sinus rhythm and in acute cardiac failure (11 NYHA IV and 17 with pulmonary oedema), of whom 18 had an ejection fraction greater than 50%. RESULTS: Diastolic dysfunction was present in the combined study of mitral and pulmonary profiles in 95% and 100% respectively of patients in cardiac failure with preserved systolic function and altered systolic function, and Vp < 45 and/or Ea < 8 cm/s was observed in 55% and 100% respectively of these patients. At respective pathological threshold values of 1.5 and 10, the combined indices E/Vp and E/Ea were concordant with the evaluation of filling pressures in 83% of patients with preserved systolic function and 100% of the systolic cardiac failure cases. CONCLUSION: Diastolic dysfunction is almost constant in acute cardiac failure independently of the ejection fraction value. However, normal values of Ea and Vp do not exclude the diagnosis of diastolic cardiac insufficiency in the acute situation.

[Silent ischemia and acute cardiac insufficiency with normal systolic function: diagnostic value of troponin I measurement]. / Ischémie silencieuse et insuffisance cardiaque aiguë à fonction systolique conservée: intérêt diagnostique du dosage de la troponine I.

The physiopathological mechanisms resulting in increased left ventricular pressures in acute cardiac failure with normal systolic function are not well understood. Although coronary artery disease is commonly associated with acute episodes, the diagnostic value of troponin I measurement and the prevalence of ischaemia as the predisposing factor are not known. Twenty coronary patients (mean age 77 +/- 9 years) in acute cardiac failure with left ventricular ejection fractions of 50% or over and without angina, were studied retrospectively. The diagnostic value of troponin I (cTnI, AxSYM, method) was assessed by comparing with a control group of 16 acute cardiac failure patients without coronary disease. The frequency of hypertension and diabetes in the coronary group was 50 and 45% respectively. At the time of investigation, the pulmonary capillary and systemic arterial pressures were comparable in the coronary patients irrespective of the cTnl value. At threshold levels of 0.5 microgram/l, cTnl had a specificity of 100% and confirmed ischaemia in 60% of the coronary patients. Ischaemia was the commonest predisposing factor for increased cardiac pressures. Over a 268 +/- 101 days follow-up period, half the coronary patients were readmitted for acute cardiac failure and a third of them died. The authors conclude that silent ischaemia is a common predisposing factor for acute cardiac failure in coronary patients with normal systolic function and troponin I measurement is a useful diagnostic help.

[Study of non-invasive hemodynamic parameters in pulmonary edema: hypoalbuminemia is a factor frequently associated with acute diastolic cardiac insufficiency]. / Etude des paramètres hémodynamiques non invasifs dans l'oedème pulmonaire: l'hypo-albuminémie est un facteur favorisant fréquent de l'insuffisance cardiaque diastolique aiguë.

SUBJECT: A critical diminution of the gradient between plasma oncotic pressure (PO) and pulmonary capillary pressure (PCP) is the origin of the formation of haemodynamic pulmonary oedema (OAP), but the respective contribution of these two haemodynamic forces as a function of the type of cardiac insufficiency is not known. METHOD: 74 cases of OAP were included (78 +/- 15 years old, 43 diastolic defined by an ejection fraction greater than 45%, and 31 systolic), and 33 control subjects. PO and PCP were calculated respectively from total protein and albumin serum levels, and from transthoracic echocardiography with the new Doppler indices using refilling flow propagation speed in colour TM or the study of pulmonary venous flow, at the start of treatment. RESULTS: The gradient was very significantly diminished in those with diastolic and systolic cardiac insufficiency compared to the control group (p < 0.001), with no difference between the two types of OAP. An elevation of PCP > or = 18 mm Hg was the principal haemodynamic factor in the critical diminution of the gradient in the systolic group and in the diastolic group with ischaemic or valvular cardiopathy. In parallel with the elevation in PCP was a state of plasma hypo-oncocity < or = 18 mm Hg, consecutive with a significant diminution of albuminaemia, contributing to the critical diminution of the gradient in 41% of diastolic cases versus 3% of systolic cases. CONCLUSION: Hypo-albuminaemia is a factor frequently favouring acute diastolic cardiac insufficiency in elderly subjects and must be sought systematically.

[Validation of quantitative parameters of paraprosthetic mitral valve regurgitation of the zone of convergence by transthoracic echocardiography]. / Validation de paramètres quantitatifs dans l'évaluation des insuffisances mitrales paraprothétiques en échocardiographie transthoracique par étude de la zone de convergence.

The study of the convergence zone by echocardiography is a validated method of quantification of native valve mitral regurgitation. However, there is little data concerning its applications to paraprosthetic mitral regurgitation. The aim of this study was to evaluate the method in this indication. Thirty consecutive patients (21 mechanical and 9 bioprostheses) with paraprosthetic mitral regurgitation quantified by transoesophageal echocardiography were included: 4 mild, 13 moderate and 13 severe. The regurgitant volume RV) and the regurgitant surface area (RSA) were calculated by the following formulae: RV = 2 pi.r2.Va.t.alpha/180 and RSA = RV/VTI (r: mid systolic radius of the convergence zone, Va: aliasing velocity, t: regurgitation time, alpha/180: the angular correction due to parietal stress, VTI: velocity time integral of the regurgitant flow). The feasibility of the calculation of the RV and RSA was 93 and 63% respectively. There was a statistically significant correlation between the RV and transoesophageal echocardiography (r: 0.85, p < 0.001), between RSA and transoesophageal echocardiography (r: 0.67, p < 0.05) and between RV and RSA (r: 0.95, p < 0.001). When severe paraprosthetic regurgitation was defined by a RV greater than 60 ml and RSA greater than 40 mm2, the concordance between RV, RSA and transoesophageal echocardiography was 75% and 74% respectively. Therefore, the study of the convergence zone provides an accurate evaluation of paraprosthetic mitral regurgitation by transthoracic echocardiography.

[Cardioversion by external electric shock for atrial fibrillation: does patient age affect immediate results?]. / Cardioversion par choc électrique externe de la fibrillation auriculaire: l'âge des patients affecte-t-il les résultats immédiats?

The restoration of sinus rhythm by external electric shock in patients with persistent atrial fibrillation is a well established treatment. However, in current practice this treatment is generally indicated less in the elderly subject although this attitude is not factual. The objective of this work was to evaluate the immediate results of cardioversion by external electric shock, comparing the success rates in four age groups: under 60 years, between 60 and 69 years, between 70 and 79 years, and over 80 years. This study was performed on 182 consecutive patients aged from 25 to 89 years: 35 patients aged less than 60 years, 52 patients aged from 60 to 69 years, 65 patients aged from 70 to 79 years, and 30 patients aged 80 years or over. The success rates were 91.4% before 60 years, 90.4% between 60 and 69 years, 90.8% between 70 and 79 years, and 83.3% after 80 years. There was no significant difference between the success rates in the four age groups (p = 0.68). Among the other factors analysed, only the duration of atrial fibrillation and the body mass index significantly influenced the results of external electric shock in this series. This work suggests that age does not significantly influence the immediate results of external electric shock. According to these data it does not appear justified to contra-indicate cardioversion by external electric shock on the sole criterion of age.

[Usefulness in clinical practice of noninvasive measurement of colloids osmotic pressure-capillary pulmonary pressure gradient in the management of acute dyspnea]. / Intérêt en pratique clinique de la mesure non invasive du gradient pression oncotique-pression capillaire pulmonaire dans la prise en charge d'une dyspnée aiguë.

BACKGROUND: Increased pulmonary capillary pressure (PAWP) and decreased serum colloid osmotic pressure (COP) are important factors in pulmonary edema (PE) formation. The aim of this study was to evaluate the clinical usefulness of noninvasive determination of COP, PAWP and COP-PAWP gradient in patients with acute dyspnea. METHODS: Thirty four patients presenting with PE, 19 with preserved left ventricular systolic function (Ia) and 15 with depressed systolic function (Ib), and 26 patients presenting with acute pulmonary diseases (II) were enrolled. COP was estimated using Landis and Pappenheimer formula (COP = 2.1 x P + 0.16 x P2 + 0.009 x P3, P: serum total protein concentration). PAWP was measured by transthoracic Doppler echocardiography using E/Vp and 1000/(2 x IPT + Vp) Doppler indexes. RESULTS: The mean value of the gradient was 0.5 +/- 5, 1.7 +/- 3.4 and 10.4 +/- 4.7 mmHg in Ia, Ib and II respectively (P < 0.001 Ia and Ib vs II). PAWP was higher in Ia and Ib than in II (P < 0.001). However, hypoalbuminemia with COP < or = 18 mmHg was observed in 63% of patients in Ia as compared to those in Ib (7%) and II (8%). CONCLUSIONS: Severe hypoalbuminemia frequently contributes to PE formation in the presence of normal left ventricular systolic function. A COP-PAWP gradient value lower than 6 mmHg is highly predictive of the diagnosis of acute heart failure in these patients presenting with acute dyspnea.

[Novel Doppler indexes of estimation of pulmonary capillary pressure: influence of age, feasibility in the acute setting and reproducibility]. / Nouveaux indices doppler d'estimation de la pression capillaire pulmonaire: influence de l'âge, faisabilité en situation aiguë et reproductibilité.

BACKGROUND: The Doppler indexes E/Vp, E/Ea, 1000/(2 x IRT + Vp), 1000/(2 x IRT + Ea) and DTd (E: peak E mitral velocity; Vp: flow propagation velocity by color M-mode; Ea: peak early diastolic velocity at lateral mitral annulus by tissue Doppler; IRT: isovolumic relaxation time; DTd: deceleration time of the pulmonary venous diastolic wave) have been proposed for the non-invasive prediction of left ventricular filling pressures. However, the influence of age, the feasibility in acute setting and the reproducibility of these Doppler indexes have never been simultaneously investigated. OBJECTIVE: The present study was conducted to evaluate the influence of age in 56 healthy subjects (57 +/- 20 years of age), the feasibility in 40 critically ill patients (72 +/- 13 years of age; 21 with decompensated heart failure) and the reproducibility in 15 patients. RESULTS: Only the indexes E/Vp (R = 0.37, P = 0.005) and E/Ea (R = 0.72, P < 0.001) were correlated with age. The feasibility was 92, 90, 72, 72 and 45% for E/Ea, 1000/(2 x IRT + Ea), E/Vp, 1000/(2 x IRT +Vp) and DTd, respectively. The best reproducibility was observed for the Doppler parameters E and Ea. CONCLUSION: Despite it is influenced by age, E/Ea appears to be the most useful index for predicting left ventricular filling pressures routinely.