Seasonal variation in chronic heart failure hospitalizations and mortality in France.

BACKGROUND: Circannual variation in blood pressure and in the incidence of acute myocardial infarction is well known but has not been investigated in chronic heart failure. This report describes and compares the seasonal variation of chronic heart failure hospitalizations and mortality in the French population. METHODS AND RESULTS: All deaths that occurred among French adults over the period 1992 to 1996 (n=138 602) and all discharges by adults in French public hospitals for chronic heart failure over the period 1995 to 1997 (n=324 013) were examined retrospectively. First, chronic heart failure deaths in France occurred with a striking annual periodicity and peaked in winter (December through January), both in the overall population and in subgroups defined by age (>44 years old) and sex. The distribution of cumulative monthly deaths differed by nearly 35%, ranging from a peak of 20% above average in January to 15% below average in August (Roger's test: P<0.001). Second, hospitalizations for chronic heart failure in French public hospitals followed a similar seasonal pattern (P<0.001), with a winter-spring predominance (+7% to +10% from December through April). Third, for persons >/=85 years old, excess hospitalizations occurred earlier in the year, with marked synchronized peaks in January for both mortality and hospitalizations (P<0.001). CONCLUSIONS: Clear seasonal variations in adult chronic heart failure hospitalizations and deaths were identified. The considerable economic impact on health care services warrants further epidemiological investigations and a more comprehensive approach to disease management.

An evaluation of symptom classification systems used for the assessment of patients with heart failure in France.

Many systems have been proposed to assess the degree of functional impairment in patients with chronic heart failure in order to be able to draw comparisons between patients and assess the development of the disease in the same patient. The NYHA classification is subjective and insufficiently reproducible and has no real predictive value with respect to the exertion test. The Canadian classification does not contribute much in terms of validation. The Feinstein and Duke University classifications are too complex, not very easy to use and have never been validated. The scale of activity proposed by Goldman gives details on functional impairment by using examples from daily activities, selected for their variety and grouped according to the energy that they require. This classification is highly reproducible and is concordant with the exertion test (duration of the exertion test, VO2 max). However, it is not suitable for France. The examples are not precise enough: in addition, they do not eliminate contradictions that can make the patient impossible to classify. We propose a scale of activity specifically designed for use in France. It is reproducible and the VO2 peaks are highly concordant. Lastly, the questions the patient is asked are progressive, thus avoiding contradictory answers. This classification could prove to be useful in everyday life and also for multi-center studies in French-speaking countries.

Familial dilated cardiomyopathy: clinical features in French families.

UNLABELLED: The aims of the study were to analyze the clinical features, the penetrance and the mode of inheritance of 13 French families with dilated cardiomyopathy using diagnostic criteria recently established by a European collaboration. METHODS: Screening consisted of physical examination, ECG and Echo of all the probands first degree relatives (n = 118). Using major Echo criteria [ejection fraction (EF) < 45% or FS < 25% and left ventricular diameter (LVD) > 117% of the predictive value], or combined minor Echo/ECG criteria, relatives were classified as affected, unknown or healthy. RESULTS: (1) Adult affected relatives (n = 31) were identified with major Echo criteria in 74% of cases, and with combined minor Echo/ECG criteria in 26% of cases. (2) In the unknown relatives (n = 21), the most common abnormality was an isolated left ventricular dilation (67%). (3) Mode of inheritance was autosomal dominant (AD) in 11 families and possibly autosomal recessive in two. (4) In AD families, the penetrance was incomplete in adults (72%), age-related (O.R.: 1.3 per 10 years; 95% CI 1.03-1.56) and sex-related [greater in men (87%) than in women (61%), actuarial survival curve: P<0.002]. (5) Mortality related to end stage heart failure was 2.2 times as high as mortality related to sudden death (11% vs. 5%). CONCLUSIONS: (1) In the absence of a specific phenotype of FDC, the characterization of relatives appears more accurate when minor criteria were added. (2) Since high mortality (16%) and incomplete penetrance frequently give rise to small nuclei of clinically affected and alive relatives per family, the accurate model of penetrance that we proposed might be helpful in the future to enhance the statistical power of linkage analysis in this disease.

Detection of embolic signals using Doppler ultrasound: a new approach to cardiac embolism.

Cerebral embolism from cardiac, aortic or carotid cause can be detected by Doppler examination of carotid arteries or transcranial Doppler with long-duration recordings. The signals detected called HITS (high intensity transient signals), which have been described in vitro and in vivo, have specific physical characteristics. This novel technique is considered promising in establishing the relationship between the discovery of embolic heart disease and its clinical neurological manifestations. In the evaluation of a stroke, the detection of HITS could provide evidence in support of an embolic cause. The areas of application of this new technique are many: screening for asymptomatic embolism in patients with an embolic cardiac disorder, and effects of antiplatelet and anticoagulant medications or surgical treatments.

Changes in lymphocyte beta-adrenoceptor density after dilevalol oral treatment.

Dilevalol (R,R'-isomer of labetalol) is an antihypertensive agent combining non-specific beta blockade with peripheral vasodilatation due to beta 2-receptor agonism. The aim of this study was to determine the effects of chronic dilevalol administration on lymphocyte beta 2-adrenoceptor density. The investigation was conducted as a double-blind, placebo-controlled comparison. Ten days of chronic dilevalol (400 mg) or placebo treatment was administered to 12 healthy normotensive volunteers. Clinical and biochemical parameters: heart rate (HR) systolic and diastolic blood pressure (SBP, DBP), electrocardiogram, norepinephrine (NE), epinephrine (E), MHPG (3-methoxy-4-hydroxyphenylethylene glycol; one of the major brain metabolites of NE) were analysed on the first day (D1) before (H0) and 3 h after oral treatment (H3) and on the tenth day (D10). Clinical results showed no significant changes in HR, DBP, SBP in the two groups (placebo, n = 6; dilevalol, n = 6). NE increased 3 h after the first oral dilevalol intake (p less than 0.05). This increase is greater than that due to the circadian variation observed in the placebo group. Acute dilevalol treatment seems to increase the plasma circulating NE level, which returns to normal values after 10 days of chronic treatment. Binding assays were performed before and after 10 days of treatment. In the placebo group, no change in beta-adrenoceptor density was observed (36.6 +/- 8.3 versus 38.3 +/- 9.4 femtomol/mg of protein). Lymphocyte beta-adrenoceptor density (Bmax) significantly decreased after 10 days of dilevalol treatment without any changes in affinity (KD). Results were 40.3 +/- 11.6 (D1) and 30 +/- 7.6 (D10) (p less than 0.05). It was concluded that dilevalol down-regulated lymphocyte beta 2-adrenoceptor density, suggesting that beta 2 agonism of dilevalol is predominant.

[Role of angiotensin-converting enzyme inhibitors in the treatment of heart failure in the 21st century]. / Place des inhibiteurs de l'enzyme de conversion de l'angiotensine dans le traitement de l'insuffisance cardiaque au XXIe siècle.

The angiotensin converting enzyme (ACE) inhibitors have progressively stood out in a large population of heart failure patients as a gold-standard treatment, in relation with their beneficial effects on mortality and morbidity. In a recent meta-analysis published in the Lancet collecting 12,763 patients, Flather demonstrates global mortality decrease of 25% compared to placebo. This risk reduction not only concerns the mortality due to heart failure but also that due to myocardial infarction. The same goes for the morbidity. Thus, in international as well as European recommendations, ACE-inhibitors are indicated as a first lane treatment in heart failure due to systolic LV dysfunction. Nonetheless several questions remain unanswered. The ACE-inhibitors are under-utilised, not only they are under-prescribed (only 60% of heart failure patients benefit from them) but also when prescribed, the dosage (comparing to those used in clinical trials) is generally as low as the half expected. This under-utilisation seems to be related to the side effects as renal failure, hypotension or more often due to the concern of their occurrence especially in the elderly and in those with other concomitant morbidities. They are actually related in part to an under-estimation of the benefit/risk ratio. The ATLAS study suggests that high doses of ACE-inhibitors are associated with a deeper reduction of morbidity without significant differences compared to low doses concerning global mortality or side effects. However this study compared very high (extreme) doses to low ones and comparison between heavy- and mid-doses remains to be performed. After the HOPE study, new indications appear promising: heart failure with preserved systolic function; patients with risk factors without heart failure: risk reduction of subsequent heart failure and reduction of mortality. Tolerance of their association with beta-blocking agents. In conclusion, the optimisation of the ACE-inhibitors treatment goes through a wider prescription with higher doses, probably extended to new indications.

[Anticoagulant treatment and dilated cardiomyopathy]. / Traitement anticoagulant et cardiomyopathie dilatée.

The prevalence of intracardiac thrombi in patients with dilated cardiomyopathy is very variable from one study to another, but is generally high: 20 to 25% for interatrial thrombi and 50% for intraventricular thrombi. There is also a high incidence of left atrial spontaneous contrast (30-40%). Left atrial thrombosis or spontaneous contrast is more common in atrial fibrillation, when the LA diameter is increased with low velocity intra-left atrial blood flow on Doppler examination and when there are disturbances of haemorrheological factors (increased fibrinogen levels and plasma viscosity). Ventricular thrombi are more common when the fractional shortening is decreased (< 11% = 80% of thrombi). The frequency of embolism is controversial. It varies between 1.4 and 12 events per 100 patients per year. The risk of complications is higher in patients with intracavitary thrombosis. The number of cerebral haemorrhagic complications in patients on long-term oral anticoagulants is far from negligible. Large prospective multicenter trials should be instituted, as for atrial fibrillation to evaluate systematic anticoagulation with respect to the risks. In the meantime, it would seem to be prudent to prescribe oral anticoagulants to all patients with dilated cardiomyopathy with an intracardiac thrombus and/or atrial fibrillation, and to perform echocardiography regularly when left ventricular function is very poor.

[Aspirin, oral anticoagulants, and heart failure]. / Aspirine, antivitamines K et insuffisance cardiaque chronique.

The incidence of thromboembolic complications in patients with cardiac failure is low. The predisposing factors are principally the presence of a left ventricular mural thrombus, atrial fibrillation, a low ejection fraction and a low peak VO2. The risk of cerebral haemorrhage in a patient with cardiac failure treated with oral anticoagulants is about the same as the risk of thromboembolism. Therefore, anticoagulant therapy for patients with cardiac failure is controversial in the absence of a prospective large scale clinical trial demonstrating its benefits. In the meantime, a prudent approach with risk stratification to determine which patients would benefit the most from oral anticoagulation is advised.

[Prognostic value of study of heart rate variability in chronic cardiac insufficiency]. / Valeur pronostique de l'étude de la variabilité de la fréquence cardiaque dans l'insuffisance cardiaque chronique.

Analysis of heart rate variability is an attractive, non-invasive method for studying the cardiac response to stimulation by the autonomic nervous system which is decreased in chronic cardiac failure. The prognostic value of heart rate variability in cardiac failure has been the subject of recent research. The 24-hour standard deviation is the commonest parameter with an independent predictive value for mortality. However, its threshold value is variable according to the different studies. The percentage of successive RR intervals varying by more than 50 ms is a sign of parasympathetic activity and is not found to be an independent prognostic factor by all workers. The results of values of low frequency on spectral analysis are contradictory. Finally, the Poincaré graphic method showing an abnormal graph is one of the only predictive factors of sudden death. Blood pressure variability will probably complete the analysis of heart rate variability as a prognostic factor of chronic heart failure.

[Heart rate variability in chronic cardiac failure insufficiency. Effect of severity and etiology]. / Variabilité de la fréquence cardiaque dans l'insuffisance cardiaque chronique. Influence de la gravité et de l'étiologie.

The variability of the heart rate is a sign of the activation of the autonomic nervous system. This parameter was studied in 21 control subjects and 72 patients with chronic cardiac failure (20 stage II, 37 stage III and 15 stage IV of the NYHA) due to ischaemic heart disease in 48 cases and idiopathic in 24 cases. Spectral and non-spectral analysis of the variability of the heart rate recorded during 24 hour Holter monitoring was performed with the Marquette Electronics 8000 software. Plasma noradrenaline was measured in whole blood by HPLC. The left ventricular ejection fraction was measured by echocardiography. There was a superior to 40% decrease in non-spectral and over 50% decrease in spectral parameters in patients with cardiac failure. This was more pronounced when the cardiac failure was in an advanced stage. The decrease in sinus rhythm variability was proportional to the functional class (SDANN stage II: 96 +/- 34 ms; stage III: 63 +/- 34 ms; stage IV: 54 +/- 33 ms). Moreover, the non-spectral parameters were correlated to the ejection fraction and plasma noradrenaline levels (p < 0.01). In addition, with the same NYHA stage, plasma noradrenaline concentration, ejection fraction and heart rate, the SDNN and the pNN50 were over 50% lower in idiopathic cardiomyopathy than in ischaemic cardiomyopathy. In conclusion, the variability of the heart rate is reduced in chronic cardiac failure in relation with the severity and aetiology of the underlying disease.

[Functional classification of cardiac insufficiency]. / Classification fonctionnelle de l'insuffisance cardiaque.

Several systems have been proposed for assessing the degree of functional impairment of chronic cardiac failure in order to be able to compare patients and to appreciate progression of the condition in individual patients. The NYHA classification is subjective, not very reproducible, and does not provide a good prediction of exercise capacity. The Canadian classification is not much better. Feinstein's classification is too complex, impractical and has never been validated. The specific activity scale proposed by Goldman indicates the degree of functional incapacity by comparison with activities of everyday life selected for their variability and classified according to the effort required to perform them. This classification has a good reproducibility and correlates well with exercise stress testing (exercise duration, VO2 max). However, it is not particularly well suited to the French population. The examples are not very precise; in addition, contradictions are possible, making it difficult to classify some patients. The authors propose a specific activity scale adapted for French patients. This classification was studied in 45 patients with chronic primary dilated cardiomyopathy. It was reproducible and correlated well with peak VO2. The progressive design of the symptom questionnaire avoids contradiction. This classification could be useful both in everyday practice and for multicentre research studies.

Non-invasive blood pressure variability in chronic heart failure: characteristics and prognostic value.

BACKGROUND: Short-term variability of blood pressure can be used as an index of sympathetic vascular modulation and has been studied in patients with hypertension. AIM: The aim of this study was to characterise blood pressure variability (BPV) and its prognostic value in patients with congestive heart failure. METHODS AND RESULTS: 104 patients with congestive heart failure due to ischemia (n = 104) or idiopathic cardiomyopathy (n = 50) in New York Heart Association (NYHA) class II (n = 50), III (n = 71), IV (n = 33), and 40 healthy subjects were studied. The mean ejection fraction was 0.33 +/- 0.10. Continuous non-invasive BP recordings were obtained for 3,600 seconds with a photoplethysmographic finger device in patients and control subjects at rest. Patients with chronic heart failure (CHF) had significantly less pronounced BPV than control subjects. Diastolic blood pressure (DBP) variability was related to left ventricular ejection and to peak oxygen uptake. BPV was not different in patients with ischemic or idiopathic CHF. During the mean follow up (+/- SD) of 565 +/- 215 days, 44 patients died (28.6%). All deaths were cardiac related. Cox's univariate analysis identified the following factors to be predictors of death: peak oxygen uptake (p = 0.01), ejection fraction (p = 0.008), and among BPV parameters: total spectral amplitude (TA) for DBP (p = 0.002), very low frequencies over total amplitude (VLF/TA) for DBP (p = 0.005) and for mean blood pressure (MBP) (p = 0.03), and very low over high frequencies ratio (VLF/HF) for DBP (p = 0.002). Multivariate analysis showed that BPV predicted survival independently of EF or peak VO2. Kaplan-Meier survival curves revealed that VLF/TA < 55% for DBP, MBP and SBP are useful risk factors. One-year survival in patients with VLF/TA < 55% of DBP was 53% compared with 95% in those with VLF/TA > 55% (p = 0.005). CONCLUSIONS: Decreased BPV in patients with CHF is related to left ventricular dysfunction. Analysis of BPV can identify patients with CHF who have an increased risk of cardiac death.

[Hemodynamic study during 48 hours of delayed-release isosorbide dinitrate (repeated oral administration) in the acute phase of myocardial infarction complicated by left ventricular insufficiency]. / Etude hémodynamique pendant 48 heures du dinitrate d'isosorbide à libération prolongée (prise orale répétée) à la phase aiguë de l'infarctus du myocarde compliqué d'insuffisance ventriculaire gauche.

The aim of this study was to evaluate the haemodynamic effects of slow release isosorbide dinitrate (IDN) 40 mg oral preparation over a 48 hour period in patients with acute myocardial infarction complicated by left ventricular failure. Fourteen patients (8 male, 6 female) were treated by repeat dose ISD (8 hourly) and the haemodynamic changes were recorded at 1 hr, 2 hrs, 6 hrs, 12 hrs, 24 hrs, and 48 hrs. After 48 hours treatment the heart rate was unchanged; mean arterial blood pressure fell from 109.5 +/- 5.6 mmHg to 93.5 +/- 6.2 mmHg (-15%) (p less than 0.01). Cardiac index rose from 2.4 +/- 0.57 1/min/m2 to 2.8 +/- 0.65 1/min/m2 (+16%) (NS); diastolic pulmonary artery pressure fell from 22.5 +/- 7.07 mmHg to 13.7 +/- 4.5 mmHg (-39%) (p less than 0.003); systolic pulmonary artery pressure fell from 40.5 +/- 12.2 mmHg to 28.6 +/- 11.6 mmHg (-30%) (NS). Systemic vascular resistance fell from 2 095.2 +/- 63 dynes/s/cm5 to 1 537 +/- 60 dynes/s/cm5 (-22.3%) (NS). Finally, total pulmonary resistance fell from 561.9 +/- 15 dynes/s/cm5 to 301.9 +/- 14.5 dynes/s/cm5 (-47%) (p less than 0.003). The most valuable effect was therefore the reduction in left ventricular filling pressures which was maximal after about 48 hours. Two groups of patients were identified according to the clinical outcome. The patients in Group I (11 cases) were improved by the fall in diastolic pulmonary artery pressure, the rise in cardiac index and the reduction of systemic valvular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Significance of ST segment depression in the precordial leads during the acute phase of inferior myocardial infarction]. / Signification du sous-décalage du segment ST dans les dérivations précordiales à la phase aiguë de l'infarctus du myocarde inférieur.

Reciprocal changes of the ST segment in the acute phase of inferior myocardial infarction are common but their significance remain controversial. We studied this problem by comparing the ECG on admission of 83 patients with acute inferior myocardial infarction, with the clinical outcome and haemodynamic and angiographic data obtained on average 3 weeks after the onset of symptoms. Fifty nine patients (Group I) had ST depression greater than or equal to 1 mm in at least one of the leads V1 to V4; 24 patients (Group II) had no ST depression in this territory. The patients in Group I were older (59.6 +/- 6.4 vs 54 +/- 5.3 years, p less than 0.01), had higher total CPK (1 835 +/- 940 vs 875 +/- 305, p less than 0.01) and MB fractions (269 +/- 102 vs 95 +/- 35), more complications during the hospital period (80%, mainly haemodynamic vs 38%, p less than 0.01) and more severe left ventricular dysfunction: ejection fraction 52.2 +/- 6% vs 59.2 +/- 7%, p less than 0.05; cardiac index 2.75 +/- 0.4 l/min/m2 vs 3.25 +/- 0.3 l/min/m2, p less than 0.005). There was no difference in left ventricular wall motion between the groups on biplane angiography. However, coronary angiography showed left coronary disease to be more common in Group I (84%) than in Group II (37%), p less than 0.005. Left anterior descending and left circumflex disease was equally common. Patients with persistent ST depression after 48 hours had lower ejection fractions than those in whom it regressed within 48 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of chronic cardiac insufficiency with intravenous bolus enoximone. Study of a pharmacokinetic-hemodynamic relation]. / Traitement de l'insuffisance cardiaque chronique par l'énoximone en bolus intraveineux. Recherche d'une relation pharmacocinétique-hémodynamique.

The aim of this study was to evaluate the efficacy and pharmacokinetics of enoximone administered as an intravenous bolus in 12 patients (mean age 62 years) with severe chronic congestive cardiac failure (Stage IV of the NYHA) due to ischemic (N = 6) or idiopathic (N = 6) cardiomyopathy. The haemodynamic parameters and plasma concentrations of enoximone and its metabolite were measured 15, 30, 60, 90, 120 minutes, 4 and 6 hours, after IV bolus of enoximone 1 mg/kg in 10 minutes. Enoximone increased the cardiac index by an average of 37 p. 100 (1.92 +/- 0.3 to 2.63 +/- 0.35 l/mn/m2; p less than 0.001); pulmonary artery diastolic pressures fell by 33 p. 100 (p less than 0.01). Systemic arterial resistances decreased by 23 p. 100 (p less than 0.05). No significant changes in heart rate or blood pressure were observed. The peak effect was recorded between the 15th and 30th minute. The pharmacokinetic study showed the half life of enoximone to be 2.2 +/- 0.78 hours, the area under the curve to be 2,818 +/- 953, the volume of distribution to be 69.6 +/- 24 l and the total clearance to be 22.8 +/- 8.5 l/hour. The half life of the metabolite was 4.45 +/- 1.05 hours. There was a significant correlation between the percentage increase in cardiac index and peak enoximone concentration (r = 0.91; p less than 0.001). In conclusion, an IV bolus of enoximone is an effective treatment for chronic cardiac failure. The haemodynamic response was related to the peak enoximone plasma concentration.

[Transformation of left bundle branch block into simulated bundle branch block after ablation of the right bundle in a patient with branch-to-branch reentry ventricular tachycardia]. / Transformation d'un bloc de branche gauche en bloc de branche déguisé après ablation de la branche droite chez un patient présentant des tachycardies ventriculaires par réentrée de branche à branche.

Masquerading bundle branch block associates left bundle branch block in the standard lead and right bundle branch block in the precordial leads. Mr R., 67 year old, was referred for investigation of syncope. He had a history of idiopathic dilated cardiomyopathy (normal coronary arteries; EF: 14%, CI: 2.2 l/min/m2 at later investigations). The ECG showed LBBB with left axis deviation, a PR interval at the upper limits of normal and ventricular premature beats. During observation, he had another syncopal episode and the ECG showed wide complex tachycardia (160 bpm) reduced by external cardioversion. Electrophysiological investigations showed inducible VT due to bundle branch reentry. The HV interval in sinus rhythm was 80 ms. Radiofrequency ablation of the right bundle led to first degree AVB with masquerading bundle branch block with an increased HV interval of 120 ms. The usual facility of ablation of the right bundle branch block is an argument in favour of the hypothesis whereby masquerading bundle branch block is a variety of RBBB with severe conduction defects of the two branches.

[Value of an ergometric test for the assessment of cardiac failure]. / Intérêt d'un test ergométrique pour évaluer l'insuffisance cardiaque.

Cardiac failure is usually defined according to clinical and haemodynamic criteria at rest although these patients are mainly symptomatic on effort. Is it possible to substitute or associate a more "objective" method to the NYHA functional classification such as exercise stress testing? If so, is there a correlation between these two types of classification and resting haemodynamic data; have they any predictive value of the patient's exercise capacity? Twenty two patients with severe cardiac failure (Class III or IV of the NYHA), 18 men and 4 women with a mean age of 58 years, underwent a triangular exercise stress test on a bicycle ergometer to 80 p. 100 or more of their theoretical maximal heart rate. The ergometric parameters chosen for the study were the maximal oxygen consumption or its value when limited by symptoms, the maximal work with respect to weight, the total duration of exercise and the percentage increase in systolic blood pressure. The haemodynamic parameters chosen were pulmonary capillary pressure, systolic index, ejection fraction and the velocity of circumferential fibre shortening. No correlation was found between the NYHA functional class and exercise capacity. A dissociated correlation was observed between exercise capacity and resting haemodynamic data. The best correlation was between systolic index and exercise capacity (work performed corrected for body weight, r = 0.70, p less than 0.01; oxygen consumption, r = 0.60, p less than 0.01). After one month of treatment with a vasodilator (Prazosin) in 10 patients, the duration of exercise increased by 2.2 +/- 0.5 min.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ischemic clinical forms of hypertrophic cardiomyopathies: differential diagnosis with myocardial infarction. Apropos of 15 cases]. / Formes cliniques ischémiques des cardiomyopathies hypertrophiques: diagnostic différentiel de l'infarctus du myocarde. A propos de 15 cas.

This study reports 15 cases of ischaemic clinical forms of hypertrophic cardiomyopathy (HCM). In this retrospective study over a 3 year period, 15 patients with HCM presented with clinical and electrocardiographic signs simulating unstable angina (N = 5) or myocardial infarction (N = 10). All patients had chest pain lasting at least 20 minutes with pseudo-ischaemic ECG changes. Two patients were given thrombolytic therapy. The clinical and enzymatic outcome and results of complementary investigations (including coronary angiography) confirmed the absence of coronary artery disease. The diagnostic of HCM was made by echocardiography. These cases were all apparently primary forms of HCM without intraventricular pressure gradient under basal conditions. Three of the patients were known cases of HCM but the condition was diagnosed after the ischaemic presentation in the other cases. Eight of them had however been considered to have had coronary insufficiency for an average of 5 years. The clinical presentation of HCM represents a difficult differential diagnostic problem with myocardial infarction. Echocardiography is of little help in distinguishing the 2 diseases as septal hypokinesis is often observed in HCM. The clinical course usually reestablishes the diagnosis within a few hours but the delay is often too long in this situation of therapeutic emergency and the indications of thrombolysis may be wrongly posed. Although there is no available formal means of distinguishing the two conditions, this study underlines that this clinical form of HCM is not rare and that the diagnosis should be keep in mind with the other differential diagnoses of myocardial infarction.

[Disseminated coronary thrombosis and thrombopenia induced by pentosan polysulfate]. / Thromboses coronaires disséminées et thrombopénies induites par le polysulfate de pentosane.

Pentosan polysulfate may induce severe thrombocytopenia by an immunoallergic mechanism similar to that observed with heparin. We report five cases of serious arterial and venous thrombosis associated with pentosan polysulfate-induced thrombocytopenia: --two cases of fatal circumferential myocardial infarction due to disseminated thrombosis in patients whose coronary vessels were free from atheroma at angiography. Such cases have not previously been published. They seem to represent an unusual and dangerous manifestation of immunoallergic thrombocytopenia complicated by diffuse intravascular coagulation and induced by pentosan polysulfate; --two cases of myocardial infarction with favourable outcome; one of them was associated with hemiplegia with aphasia; --one case of extensive phlebitis of the inferior vena cava. The diagnosis was suspected on the ground that the patients had previously been treated with intramuscular pentosan polysulfate for 8 to 10 days and had less than 100,000 platelets per mm3; it was confirmed by in vitro platelet aggregation tests. Cross-allergy with heparin was present in all cases. Out of 18 published cases of pentosan polysulfate-induced thrombocytopenia, 15 were revealed by thrombosis of a coronary, cerebral or peripheral artery (80 p. 100) or of a vein (20 p. 100). Arterial thrombosis carries a 50 p. 100 risk of death, and for this reason pentosan polysulfate should be subjected to the same rules of prescription and monitoring as heparin.

[Treatment of chronic cardiac failure with cadralazine. Short- and medium-term results]. / Traitement de l'insuffisance cardiaque chronique sévère par la cadralazine. Résultats à court et à moyen terme.

The clinical and haemodynamic effects of a single oral dose of cadralazine were studied in 22 patients with an average age of 64 years presenting with severe chronic cardiac failure. Haemodynamic monitoring during the first 24 hours after oral administration of 30 mg of cadralazine showed a peak increase at the 8th hour of the cardiac index (+ 64 p. 100, p less than 0.001), the systolic index (+ 45 p. 100, p less than 0.001) and the left ventricular work (+ 52 p. 100, p less than 0.001) whilst the systemic and pulmonary arterial resistances decreased by 40 p. 100 (p less than 0.0001) and 30 p. 100 (p less than 0.01) respectively. There was no significant change in heart rate or diastolic pulmonary arterial pressures. The haemodynamic improvement was maintained at the 24th hour (cardiac index + 35 p. 100, p less than 0.01 and systemic arterial resistances - 20 p. 100). These results were confirmed at one month. There were few side effects, none of which necessitated withdrawal of the drug. This study shows the efficacy of a single 30 mg daily dose of cadralazine, an arterial vasodilator, in patients with severe cardiac failure. The treatment was well tolerated over the one month study period.