Short- and long-term treatment of mild to moderate hypertension with verapamil.

Forty-three patients with mild to moderate hypertension (supine diastolic blood pressure 95 to 115 mm Hg) were entered into a short-term (3 months) study. All received verapamil, 120 mg 3 times a day. After 1 month of treatment on verapamil alone, supine diastolic blood pressure was normalized (less than 95 mm Hg) in 29 patients (67%). These patients continued with verapamil at the same dosage. In 14 nonresponders (supine diastolic blood pressure greater than 95 mm Hg) a combination of althiazide (15 mg/day) and spironolactone (25 mg/day) was added. This resulted in diastolic blood pressure normalization in 9 additional patients. Verapamil induced a slight but moderate decrease in heart rate after 1 month, but no further decrease was observed thereafter. During the trial, 21% of patients reported adverse effects, mostly transient and mild. No patient had to discontinue treatment because of them. Twenty-six patients on verapamil alone were followed for 1 year. Systolic and diastolic blood pressure was adequately controlled in all patients except 1. In 13 the dosage was decreased to 120 mg 2 times a day. There were no significant differences in blood pressure between this group and patients given 120 mg 3 times a day. It is concluded that verapamil is an effective and safe antihypertensive agent in mildly to moderately hypertensive patients. Because a dosage of 120 mg 2 times a day was as effective as 120 mg 3 times a day, the former should be recommended, as it may improve patient compliance.

Value of transesophageal echocardiography combined with computed tomography for assessing repaired type A aortic dissection.

Thirty-two patients with repaired type A aortic dissection were examined by transthoracic echocardiography (TTE) (n = 32), transesophageal echocardiography (TEE) (n = 30), computed tomography (CT) (n = 29), or a combination of all 3, to assess course and complications as a function of the surgical procedure. The mean follow-up period was 55.7 months (range 3 to 132). Surgery consisted of a replacement of the ascending aorta in 25 patients (group 1) with extension to the transverse aorta in 7 (group 2). The transverse diameter of the aorta, the persistence of the false lumen, thrombus formation and flow dynamics in the false lumen were evaluated by TEE. Ten patients (31%) had a dilation in the initial ascending aorta (sinus of Valsalva aneurysm in 6 patients, and a false aneurysm in the other 4). Three of 4 patients with a proximal pseudoaneurysm underwent operation after TEE and CT evaluation. In the descending thoracic aorta, there was good agreement between TEE and CT scan determinations of transverse vessel diameter. Persistence of flow within the false lumen was significantly more frequent in patients with a dilated aorta (p < 0.05), whereas thrombosis was seen more often and false lumen less often in patients with nondilated aorta. No significant differences in vessel status or outcome were observed between the 2 groups, although this may have been due to the small size of group 2. TEE is thus a well-tolerated method for postoperative follow-up of type A aortic dissection whatever the type of surgery. For the upper ascending aorta, CT provided sufficient data.

High night blood pressure in treated hypertensive patients: not harmless.

UNLABELLED: The left ventricular mass index (LVMI) is better related to activity than resting systolic blood pressure (BP) in treated hypertensive patients. Many recommend ambulatory BP monitoring only during the day. However, 24-hour BP monitoring may be useful in treated patients to check adequate control of BP during the entire 24-hour period. We tested the influence of night BP on LVMI in treated versus nontreated patients. We compared two groups of hypertensive patients: A: 40 patients who had discontinued therapy at least 8 days prior to the study; B: 24 patients treated for more than 3 months with the same drugs (beta-blockers in 14 cases). Ambulatory BP was recorded every 30 minutes during night and every 15 minutes during day (Spacelabs 5200). The LVMI was calculated from M mode echo blind reading (Devereux's formula). Correlation coefficients between LVMI and casual, systolic BP were calculated for both day (7:00 AM to 10:59 PM) and night time (11:00 PM to 6:59 AM). Day systolic BP is better related to LVMI than casual and night systolic BP in group A. In contrast, a significantly higher correlation existed between night BP and LVMI in B, though average night BP level was lower. CONCLUSION: 24-hour BP monitoring may be useful in treated hypertensive patients. Inadequate lowering of night BP may partially account for persistent LVH in treated hypertensive patients.

Relationship between left ventricular mass and noninvasive monitoring of blood pressure.

We studied the relationship between left ventricular mass index (LVMI) and blood pressure (BP) monitored during 24 hours in 35 normotensive and 58 hypertensive patients with no treatment for more than three months. We found a close correlation between LVMI and the average daytime systolic BP (r = 0.68). Other parameters derived from BP monitoring were also correlated with LVMI: daytime diastolic BP (0.54), nighttime systolic and diastolic BP (0.61 and 0.54), pulse pressure (0.58), the average of the five highest systolic and diastolic BP (0.57 both), and the percentage of systolic BP above 140 mm Hg (r = 0.64). However, in a stepwise multiple regression analysis only daytime systolic BP was independently correlated to LVMI. The standard deviation of systolic BP was not significantly correlated to LVMI. The same positive correlation between daytime systolic BP and LVMI was found in normotensive and hypertensive patients, males and females, and patients with and without left ventricular hypertrophy. So, at least regarding the prediction of the degree of left ventricular hypertrophy, the average systolic BP during daytime seems to be the only valuable parameter to look at in ambulatory BP monitorings of untreated hypertensive patients.

Captopril test in the detection of renovascular hypertension in a population with low prevalence of the disease. A prospective study.

The value of the captopril test as a screening test for identifying renovascular hypertension has been outlined by several studies performed in populations with a high prevalence of renovascular disease (20% to 50%). We prospectively assessed the value of the test in 103 hypertensive patients referred to our center for evaluation of their hypertension. They had taken no diuretics and no converting-enzyme inhibitors for more than four days. The interpretation of the results of the test was done according to the criteria defined by Muller et al. All patients underwent a digital venous angiography and when positive or doubtful, a conventional angiography. Eleven patients (10%) had unilateral or bilateral artery stenosis greater than 70%. The sensitivity of the test was 73% with a specificity of 84% and a positive predictive value of 35%. The three patients with a false negative test underwent a surgical treatment or a transluminal angioplasty of the stenosis but remained hypertensive. Thus, the captopril test is a useful screening test for identifying patients with renovascular disease, even in a population with a low prevalence of the disease.

Effects of perindopril on left ventricular hypertrophy, coronary blood flow, and mechanical properties of cardiac muscle in renovascular hypertensive rats.

We studied the effects of perindopril on left ventricular hypertrophy, systemic and coronary hemodynamics, and mechanical cardiac performance in renovascular hypertensive rats (Goldblatt, two-kidneys, one-clip). Systemic and coronary hemodynamics, before and after carbochrome infusion, were assessed by radioactive microspheres injection via an atrial catheter in conscious rats. Mechanical performance was measured on isolated papillary muscle from the same animal. Twelve treated hypertensive rats were compared with 10 nontreated hypertensive rats and nine sham-operated normotensive rats of the same age. Perindopril treatment induced a complete control of blood pressure (mean blood pressure from 156 +/- 22 mm Hg in the untreated group to 100 +/- 24 mm Hg in the treated group (P less than .01), compared to 106 +/- 18 mm Hg in the sham group). This was associated with a nearly complete regression of left ventricular hypertrophy (left ventricular mass/body weight 2.26 +/- 0.38 mg/g in the treated group v 3.1 +/- 0.6 in the untreated group [P less than .01], compared to 2 +/- 0.25 mg/g in the sham group [p = NS]). Minimal left ventricular coronary resistances after carbochrome were slightly higher in the hypertensive group compared both to sham and treated group. A reversal of impaired myocardial mechanical parameters towards control values was observed, except for some parameters of relaxation. We conclude that perindopril allows in this model a complete control of blood pressure, and a regression of left ventricular hypertrophy with normalization of coronary hemodynamics and contractile function.

Left ventricular mass in normotensive subjects. Importance of blood pressure response to activity.

Recent works have shown the importance of blood pressure (BP) response to exercise or to daily activity as determinants of hypertensive cardiac hypertrophy. We have tested the relationship between BP and left ventricular (LV) mass in 23 normotensive young adults (mean age 25 +/- 5) with normotensive parents. Blood pressure was measured at rest, at the end of maximal exercise test, and during 24-hour ambulatory monitoring during daily routine. Left ventricular mass was assessed with M-mode echocardiography. We found a closer relationship between LV mass with BP when measuring during activity (average day time BP and end exercise BP) than with rest BP (rest BP and average nighttime BP). Multiple regression analysis indicates an independent association of LV mass with both average day time and end exercise systolic blood pressure. Thus, we conclude that these two ways of assessing "activity" BP may be more complementary than opposing. Ambulatory BP monitoring appreciates the reactions to daily stresses and the exercise test measures the response to physical activity.

ACE inhibitors in mild to moderate hypertension: comparison of lisinopril and captopril administered once daily. French Cooperative Study Group.

A double-blind, parallel-group, multicentre study was carried out to compare the effects of once-daily treatment with lisinopril 20 mg and captopril 50 mg in 304 patients with mild to moderate hypertension. Following a 2-week placebo run-in period, patients with a lying DBP between 95 and 115 mmHg were randomised to either active treatment for 10 weeks. BP measurements were made approximately 24 h after the previous dose of either drug. After 6 weeks, hydrochlorothiazide 25 mg once daily was added for patients with a lying DBP greater than or equal to 95 mmHg and a final assessment was made in all patients after a further 4 weeks of treatment. After 6 weeks of monotherapy, lisinopril had reduced lying and standing BP by an average of 18/14 mmHg and 19/12 mmHg, respectively, compared with 15/12 mmHg and 14/11 mmHg respectively for captopril. The larger fall in SBP with lisinopril was statistically significant (lying SBP, P = 0.01; standing SBP, P = 0.0001). In addition, a significantly larger proportion of patients achieved BP control (DBP less than 95 mmHg) with lisinopril than with captopril (79% versus 67%; P = 0.02). Neither drug significantly altered heart rate. The addition of hydrochlorothiazide in some patients produced a further, small reduction in mean BP in both groups although, 10 weeks after randomisation, the proportion of patients in whom BP control had been achieved with lisinopril was still significantly greater than that achieved with captopril (90% versus 79%; P = 0.02). Both drugs were well tolerated and no serious adverse events occurred during the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of dissecting aortic aneurysm by two dimensional echocardiography: experience with 58 patients.

UNLABELLED: Recent improvements in surgical technics have dramatically changed the outcome of patients with aortic dissection (AD). The aim of this work is to evaluate the reliability of two dimensional echocardiography (2DE) in the diagnosis of AD. The 2DE was recorded in all patients with a systematic approach in order to visualize the entire aorta (Ao). 58 cases were studied in a three years period. At the beginning of this study we validate 2DE by comparison with angiography (angio) in 14 of our first patients: the 2 angio criteria (dilatation, abnormal intraluminal image) have been found on 2DE in 12 pts (92%), with intraluminal image) have been found on 2DE in 12 pts (92%), with no significant difference between internal diameter of Ao on angio and 2DE. In our experience with 58 pts a positive diagnosis was possible in 90% of AD type I and only 18% of AD type III. IN CONCLUSION: 2DE is a practical and valuable method for the assessment of type I and II AD. Two 2DE criteria must be present at the same anatomical level (dilatation, abnormal intraluminal echo). In these conditions we have been able to avoid aortography in 26 of our last patients with type I and II.

An unusual complication of the Le Veen shunt: a right atrial ventricular chamber pseudotumor.

We report the case of a right atrial-ventricular chamber thrombus discovered four years after insertion of a Le Veen shunt for treatment of refractory ascites. A two-dimensional echocardiogram, performed after the discovery of an isolated systolic murmur, demonstrated a "tumorlike" mass seated in both the right atrium and the right ventricle. The mass was surgically removed and histologic examination confirmed that it was a thrombus developed at the tip of the catheter. We propose that two-dimensional echocardiography should be performed periodically for the survey of such intracardiac devices.

Accuracy of M-mode and two-dimensional echocardiography in the diagnosis of aortic dissection: an experience with 128 cases.

The accuracy of combined M-mode and two-dimensional echocardiography in the diagnosis of aortic dissection was evaluated in 673 patients with a clinical suspicion of aortic dissection, over a six-year period. In 128 cases, the diagnosis of aortic dissection was confirmed by angiographic, tomographic (CT scan), or autopsy findings, or during surgery. Two echocardiographic features were found to support a diagnosis of aortic dissection: a dilation of at least one segment of the aorta (sensitivity 95%, specificity 51%) and a typical abnormal linear intraluminal echo corresponding to the intimal flap (sensitivity 67%, specificity 100%). This pathognomonic intimal flap was observed in 86 cases, of which three types could be distinguished: (1) a long oscillating flap (n = 15), (2) a long but minimally mobile linear echo which was duplicated and parallel to one or two aortic walls (n = 64), (3) a short, double linear image with a rapid systolic motion and high frequency oscillations. These features were found to have a high sensitivity in type I aortic dissection (88%), although in types II and III the sensitivity was much lower. In some cases, a fourth type of abnormal image could be detected: a small intraluminal echo moving in parallel to the aortic wall. This feature should be interpreted with caution since its predictive value for a positive examination was low (48%). Out of 23 cases in which the diagnosis of aortic dissection was suspected on the basis of this doubtful abnormal echo, it was confirmed in only 11 patients. The results in these 128 cases of aortic dissection indicate that two-dimensional echocardiography, which is easily performed at the patient's bedside, could take priority in investigations of this condition. It is extremely sensitive in the diagnosis of ascending aortic dissection, but much less so in the diagnosis of descending aortic dissection.

[Left ventricular remodeling in hypertension. Physiopathology]. / Remodelage ventriculaire gauche dans l'hypertension artérielle. Physiopathologie.

The usual concept of ventricular hypertrophy is simple and logical: increased systolic wall stress induces a hypertrophic reaction which is 1) symmetrical affecting all ventricular walls harmoniously, 2) concentric, developing at the expense of cavity size, increasing the thickness to radius ratio, and, 3) appropriate allowing normalisation of wall stress. This hypertrophy appears initially to be useful as it contributes to the maintenance of systolic function in the face of increasing load. However, it is accompanied by abnormalities of ventricular filling, of coronary circulation and myocardial excitability which may have undesirable consequences on the prognosis. In fact this simplistic and didactic view is inadequate for describing the complexity of left ventricular remodeling in hypertension. This is apparent at three levels at least: the stimuli responsible; if increased wall stress is a necessary and sometimes in itself enough to induce hypertrophy, other mechanisms may effect the degree and nature of this reaction; the protein, cellular and tissular expression; this is particularly true with respect to the connective (collagen) tissue which seems to develop in response to distinct stimuli and which could have an important influence on the functional properties of the myocardium; the morphological expression; this is the only parameter which can be analysed directly by the clinician by echocardiography. This investigation enables assessment of the frequency of eccentric and asymmetric forms of hypertrophy, the significance of which remains unclear.

[Left ventricular hypertrophy and ambulatory blood pressure]. / Hypertrophie ventriculaire gauche et pression artérielle ambulatoire.

The relationship between ambulatory blood pressure and degree of left ventricular hypertrophy is analysed with a triple objective: to assess the value of ambulatory blood pressure recording; the observation of better correlations between left ventricular mass (LVM) and systolic BP with ambulatory rather than clinical recordings is one of the most convincing arguments in favour of the prognostic value of this technique; to guide analysis of ambulatory blood pressure recordings. These recordings provide a large number of measurements over a period of variable duration. The selection of the frequency of measurement, the duration of the recording and the periods of recording (at work, during the day or night), of the criteria of interpretation (average, variability, distribution of values) is partially arbitrary. The possibility of predicting the degree of LVH from these results is one of the only rational approaches while awaiting validation with respect to long-term outcome. In the author's experience, the average of the systolic blood pressure values during the period of activity is the parameter which is most closely related to LVM in untreated hypertensive patients; to improve our understanding of the relationship between the blood pressure, LVM and left ventricular function. There is evidence that the LVH of hypertensive patients has a multifactorial basis. The use of only occasional blood pressure measurements in clinical studies may have increased the apparent importance of one or another factor related to the degree of LVH. The precise influence of these factors, independent of their possible relationship to the blood pressure, should now be reevaluated with respect to ambulatory blood pressure recordings.(ABSTRACT TRUNCATED AT 250 WORDS)

[Study of infectious endocarditis using Doppler echocardiography]. / Etude des endocardites infectieuses en échocardiographie Doppler.

Infective endocarditis is still a common and serious disease. Echocardiography is an essential complementary investigation in this condition. Its value in the diagnosis of valvular vegetations has become more accurate since the introduction of two-dimensional and transesophageal echocardiography. Transesophageal echocardiography is currently the most reliable non-invasive technique for demonstrating small vegetations of less than 5 mm diameter. The diagnosis and surveillance of complications (valvular destruction, ring abscess) are also privileged indications of transthoracic and transesophageal echocardiography coupled with intracardiac Doppler blood flow studies. The finding of these lesions may sometimes lead to early surgical management.

[Doppler echocardiography of ventricular diastole]. / Etude de la diastole ventriculaire par écho-doppler cardiaque.

Non-invasive studies of left ventricular relaxation and filling by means of doppler-echocardiography are of considerable interest owing to easy recording and good reproducibility. However, such physiological parameters as site of measurement, heart rate and, chiefly, age may interfere with the curves obtained. The interpretation of tracings must also take into account the presence of mitral valve pathology (stenosis or regurgitation), aortic stenosis, disorders of atrioventricular (prolonged PR complex) or intraventricular (left bundle branch block) conduction and medication (e.g. vasodilators). In clinical practice, one of the main advantages of the technique is that it makes it possible to distinguish between the physiological left ventricular hypertrophy (LVH) of top-class sportsmen (without impaired ventricular filling) and the pathological LVH of hypertrophic cardiomyopathy. The purpose of this study, with a review of the literature, was to take stock of the value and limitations of the doppler indices.

[Effects of verapamil and nifedipine on blood pressure during rest and exertion and on left ventricular hypertrophy]. / Effets du vérapamil et de la nifédipine sur la pression artérielle au repos et à l'effort et la masse ventriculaire gauche.

UNLABELLED: The effects of 6 months treatment with nifedipine 20 mg SR (N) or verapamil 240 mg SR (V) on rest and exercise BP and left ventricular mass (LVM) and function were evaluated in 31 essential hypertensive patients (mean age: 54, 19 males, 12 females), never treated with calcium antagonist. After a 15 days placebo run in, BP was measured at rest and during a maximal bicycle exercise test (stages: 30 watts, 3 min). 2D guided M mode echocardiography and pulsed Doppler allowed assessment of left ventricular mass (Devereux's formula) and function (fractional shortening FS, peak early (E) and late (A) velocities of LV filling). Patients were randomised to N (n = 18) or V (n = 13) and reassessed 6 months later. All echo-Doppler recordings were read blindly by 2 observers. RESULTS: rest BP was similarly reduced in both groups (V: 148 +/- 12/88 +/- 5 vs 162 +/- 10/101 +/- 7; N: 148 +/- 15/90 +/- 7 vs 170 +/- 14/101 +/- 8), as well as exercise maximal BP (V: 224 +/- 32/93 +/- 11 vs 243 +/- 21/104 +/- 11; N: 206 +/- 27/90 +/- 10 vs 231 +/- 17/97 +/- 8). The duration of exercise was significantly increased with V (15 +/- 5 min vs 12 +/- 4, p < 0.05) and insignificantly decreased with N (11 +/- 2 vs 12 +/- 3). Left ventricular mass was higher in V group at entry and was significantly more reduced with V (250 g +/- 74 vs 302 g +/- 92, p < 0.01) than with N (225 g +/- 54 vs 234 g +/- 69).(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypertensive cardiopathy: study of external tracings and noninvasive tests]. / La cardiopathie hypertensive. Etude des traces externes et des épreuves non sanglantes.

Hypertensive heart disease has been studied by means of the maximal exercise test, mechanographic techniques and echocardiography. The patients have been divided into three groups according to their electrocardiogram and the size of their heart as measured radiologically: I: normal ECG, normal size; II: ECG shows left atrial hypertrophy, heart of normal size; III: ECG shows left ventricular hypertrophy, heart is dilated. The total work on exercise decreases from group I to group III. The parameters of the pumping action (PEP/TEVG, VCF, FE) were identical in all three groups and were normal. The relationship A/H on the apexogram and the left ventricular mass/volume relationship on the echocardiogram increased from group I to group III. One possible interpretation of these findings suggests an alteration in diastolic compliance of the left ventricle in the early stages of hypertensive heart disease. The response to beta-blockers as measured on the echocardiogram also argue in favour of this theory.

[Recurrent acute pericarditis. 20 cases]. / Les péricardites aiguës récidivantes. 20 observations.

62 of 100 cases of acute pericarditis observed over 15 years were so-called acute benign pericarditis. 20 of these patients (30%) had multiple relapses. Relapse could not be predicted. The interval between the initial affection and first relapse was usually more than one month (18/20). Each relapse was accompanied by pain, fever, ST-T changes, slight cardiomegaly and acceleration of the ESR. Corticotherapy appeared to be responsible for relapse in 13 cases. In 6 cases the eradication of a deep septic focus prevented further relapses. In two cases the duration of anti-inflammatory therapy was thought to have been insufficient. Antibiotic therapy did not seem to be a provocative factor. Relapses may be numerous (10 to 12) and prolonged (24-36 months) especially in the corticodependant forms in which steroids should be tailed off gradually according to a strict protocol.

[Secondary tumors of the right heart. Echocardiographic aspects. Apropos of 6 cases in the adult]. / Tumeurs secondaires du coeur droit. Aspects échocardiographiques. A propos de 6 observations chez l'adulte.

Secondary cardiac tumours are rare but but are now more frequently diagnosed by echocardiography. We report 6 cases of intracardiac metastases affecting the right heart which were diagnosed by 2D echocardiography. In 3 cases, a very mobile, oval-shaped tumour was visualised within the right atrium prolapsing into the tricuspid orifice in diastole like a myxoma but associated in 2 cases with signs of invasion of the inferior vena cava. Two other non-mobile tumours were observed causing massive invasion of the right atrium and the last case was of an infiltrating tumour of the right ventricle resulting in pulmonary infundibular obstruction. In the light of our experience and a review of the literature, it is difficult to distinguish secondary tumours of the right atrium from myxomas especially when the tumours are mobile and when it is impossible to visualise a pedicle inserted on the interatrial septum or tumoral invasion of the inferior vena cava. At the ventricular level, the diagnostic signs differ according to whether there is tumoral invasion of the cavity or infiltration of the muscular wall. These cases illustrate the value of 2D echocardiography in the diagnosis of intracardiac metastases, sometimes even in the absence of clinical signs.

[M-mode and two-dimensional echocardiography of 7 cases of cardiac amyloidosis]. / Etude échocardiographique TM et bidimensionnelle de 7 cas d'amylose cardiaque.

Although rare, cardiac amyloidosis is the commonest cause of infiltrative myocardiopathy. The diagnosis may be suspected clinically in patients with mainly right ventricular failure of sudden onset. The aim of this study was to assess the diagnostic value of M-Mode and 2D echocardiography in this condition. Seven cases of cardiac amyloidosis were studied. Biventricular hypertrophy, usually more severe on the left side with reduction in size of the left ventricular chamber, was observed in all cases. Parameters of systolic and diastolic function were abnormal. A significant pericardial effusion was demonstrated in 3 patients. 2D echocardiography also allows evaluation of the myocardial structure: in 3 cases the whole of the left ventricular myocardium seemed granular, sparkling and abnormally echogenic. In patients with cardiac failure these appearances are very suggestive of amyloidosis, especially when the ECG shows low voltage complexes and pathological Q waves. In 3 other patients, this abnormal echogenic myocardial appearance was observed only in the interventricular septum, which is much less suggestive of cardiac amyloidosis. In conclusion, in patients with cardiac failure with cardiomegaly and a low voltage ECG, echocardiographic findings of hypertrophic cardiomyopathy (only rarely with dilatation) and hypokinetic wall motion are suggestive of cardiac amyloidosis, especially when the myocardium has a granular, sparkling appearance.