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Early and easy to do detection of left ventricular (LV) failure is crucial to improve following and outcomes of patients with right ventricular (RV) overload in congenital heart diseases. Electrical cardiometry (Osypka medical) is easy handling, even in medical office or in pre-hospital condition, and can provide cardiac output, and a new contractility index (ICON) supposed to be independent from load conditions. ICON have never been previoulsy challenged to our knowledge. We aim to compare ICON with the only contractility parameter independent from load conditions: the elastance slope (Emax). Using porcine models of Fallot repaired and pulmonary hypertension (PH), we assess LV function using conductance catheter and electrical cardiometry devices over 4 months after surgery. We measured ICON, Emax, Contractile reserve (ΔE max) and VIC (respiratory variations of ICON) at basal state and after adrenergic stimulation (Dobutamine). Three animals of each group were compared with 6 controls. Non parametric correlation (spearman) hightlights at basal state a non significant and low correlation between ICON and Emax and ΔEmax (r = 0.5). However after Dobutamine, correlation is important and strong with r = 0.98 between ICON/Emax (0.05) and 0.89 between VIC/Emax. We did not find strong correlation between ΔEmax and VIC or ΔICON. These results obtain on a small in vivo/animal cohort highlight than electrical cardiometry device could be a usefull and easy handling (4 skin patchs) tool for LV failure and loss of contractility early screening, specially after adrenergic stimulation and stress conditions. It could provide precious help in patients following. [ABSTRACT FROM AUTHOR]

Early detection of left ventricular (LV) failure is crucial to improve prognosis of patients with right ventricular (RV) overload. We aim to assess whether LV function is precociously affected in 2 surgical porcine models of moderate (Fallot repaired) and severe RV dysfunction (progressive pulmonary hypertension HP) at in vivo and in vitro levels. Three animals of each surgical group were compared with 6 controls/Sham. 4 months after surgeries, LV function was evaluated using echocardiography/strain compared with conductance catheter. At cellular level using isolated cardiomyocytes, calcium transients amplitude with relaxation time associated and sarcomere shortening were recorded using Ionoptix system. T-tubules network integrity (DI-4-ANEPPS) and colocalization (Immunofluorescence) between main Excitation/Contraction (EC) actors (Ca2+v1.2-Ryr) were analyzed. Contractile reserve was evaluated by adrenergic stimulation in-vivo and in-vitro (Dobutamine-isoproterenol). Despite RV dysfunctions in both groups, LV present hemodynamic impairment only in HP group (Longitudinal strain 9 versus 18%. Conductance catheter with dobutamin: Elastance arterial 7.7 versus 1,32, SV 14 versus 75 ml and tau (relaxation) 49 versus 27, P < 0.05).In cardiomyocytes, we observe decrease of Ca2+ transient amplitude and cardiomyocytes contraction, acceleration of Ca2+ relaxation time, T-tubule network disorganisation and Cav1.2/Ryr decoupling (Fig. 1). In vivo and in vitro, adrenergic stimulations increase dysfunction. In vitro experiments pointed early abnormalities in LV EC particularly after adrenergic stimulation. A better understanding of cellular alterations could lead to survival improvement. [ABSTRACT FROM AUTHOR]

Early and easy to do detection of left ventricular (LV) failure is crucial to improve following and outcomes of patients with right ventricular (RV) overload in congenital heart diseases. Electrical cardiometry (Osypka medical) is easy handling, even in medical office or in pre-hospital condition, and can provide cardiac output, and a new contractility index (ICON) supposed to be independent from load conditions. ICON have never been previously challenged to our knowledge. We aim to compare ICON with the only contractility parameter independent from load conditions: the elastance slope (Emax). Using porcine models of Fallot repaired and pulmonary hypertension (PH), we assess LV function using conductance catheter and electrical cardiometry devices over 4 months after surgery. We measured ICON, Emax, Contractile reserve (ΔEmax) and VIC (respiratory variations of ICON) at basal state and after adrenergic stimulation (Dobutamine). Three animals of each group were compared with 6 controls. Non parametric correlation (spearman) hightlights at basal state a non significant and low correlation between ICON and Emax and ΔEmax (r = 0.5). However after Dobutamine, correlation is important and strong with r = 0.98 between ICON/Emax (0.05) and 0.89 between VIC/Emax. We did not find strong correlation between ΔEmax and VIC or ΔICON. These results obtain on a small in vivo/animal cohort highlight than electrical cardiometry device could be a useful and easy handling (4 skin patchs) tool for LV failure and loss of contractility early screening, specially after adrenergic stimulation and stress conditions. It could provide precious help in patients following. [ABSTRACT FROM AUTHOR]

Early detection of left ventricular (LV) failure is crucial to improve prognosis of patients with right ventricular (RV) overload. We aim to assess whether LV function is precociously affected in 2 surgical porcine models of moderate (Fallot repaired) and severe RV dysfunction (progressive pulmonary hypertension HP) at in vivo and in vitro levels. Three animals of each surgical group were compared with 6 controls/Sham. 4 months after surgeries, LV function was evaluated using echocardiography/strain compared with conductance catheter. At cellular level using isolated cardiomyocytes, calcium transients amplitude with relaxation time associated and sarcomere shortening were recorded using Ionoptix system. T-tubules network integrity (DI-4-ANEPPS) and colocalization (Immunofluorescence) between main Excitation/Contraction (EC) actors (Ca2 + v1.2-Ryr) were analyzed. Contractile reserve was evaluated by adrenergic stimulation in-vivo and in-vitro (Dobutamine-isoproterenol). Despite RV dysfunctions in both groups, LV present hemodynamic impairment only in HP group (Longitudinal strain 9 versus 18%. Conductance catether with dobutamin: Elastance arterial 7.7 versus 1.32, SV 14 versus 75 ml and tau (relaxation) 49 versus 27, P < 0.05). In cardiomyocytes, we observe decrease of Ca2+ transient amplitude and cardiomyocytes contraction, acceleration of Ca2+ relaxation time, T-tubule network desorganisation and Cav1.2/Ryr decoupling (Fig. 1). In vivo and in vitro, adrenergic stimulations increase dysfunction. In vitro experiments pointed early abnormalities in LV EC particularly after adrenergic stimulation. A better understanding of cellular alterations could lead to survival improvement. [ABSTRACT FROM AUTHOR]

Background Few data are available on the value of BNP in older-old subjects. The aim of this study was to evaluate the benefit of BNP for heart failure diagnosis in very old patients. Methods The BED is a French multicenter observational prospective study that enrolled 383 very old subjects (≥80 yo) hospitalized in geriatric care with acute dyspnea. BNP was measured in acute phase, before any diuretic treatment. Cardiologists categorized the subjects into 3 subgroups according to ESC criteria and blinded to BNP level: heart failure (HF), respiratory failure and mixed disease (HF and respiratory failure combined). Subjects with mixed disease were then reclassified into HF or respiratory failure groups according to the predominant feature (cardiac or respiratory). We analyzed the prognostic value (sensibility, sensitivity and area under curve (AUC)) of the BNP for the diagnosis of HF, mixed disease included and excluded. Results Mean age was 89±5 years, 66% of the patients were women, 57% had previous history of HF, 67% hypertension, 13% diabetes, 33% coronary heart disease and 49% atrial fibrillation. Mean LVEF was 56±13%. Several patients had non-cardiac comorbidities, malnutrition 48%, severe renal failure 41%, dementia 38%, depression 32%, COPD 17%, and cancer 12%. Fifty percent of the subjects had cardiac dyspnea, 26% respiratory dyspnea and 24% dyspnea of mixed origin. Mean BNP values were 675 (835), 301 (366), 558 (796) pg/mL (p<0.001) in cardiac dyspnea, respiratory dyspnea and mixed origin subjects respectively. However, the AUC was only 0.68 and 0.67 with mixed dyspnea included and excluded respectively. In the overall population, the sensitivity and specificity was 86% and 33% for a cutoff of 100 pg/mL, 48% and 73% for a cutoff of 400 pg/mL and 26% and 86% for a cutoff of 800 pg/mL. Similar results were obtained with mixed dyspnea subjects excluded. Conclusion In very old patients, BNP has a poor sensitivity and specificity for discriminating cardiac from pulmonary dyspnea. [ABSTRACT FROM AUTHOR]

Background: Left ventricular systolic function may be altered in patients with coronary artery disease with or without previous myocardial infarction (MI). However, whether left ventricular ejection fraction (LVEF) is reduced (<50%) in patients with stable coronary artery disease with normal electrocardiogram (ECG) is poorly documented. Methods and results: Echocardiography was performed in the 3119 patients with stable coronary artery disease included in the prospective multicenter INDYCE registry; 875 patients (28%) had a normal ECG. These patients (66 ± 10 years old, male: 79%, BMI: 26 ± 3) had a mean LVEF = 62 ± 8% (<40%: 1%, 40%50%: 91% of the patients). Twenty six percent of them had a previous MI. Eighty four percent of them had undergone coronary revascularisation (CABG: 20% and PCA: 68%), 19% had diabetes, 80% dyslipidemia and 56% high blood pressure; 3% of the patients had been hospitalized for acute heart failure (HF) in the previous year; 39% were symptomatic for dyspnea NYHA class 2 or 3, 14% for angina pectoris. Sixty nine percent of them received betablockers. BMI (p = 0.01), male gender (p = 0.01), dyspnea NYHA class 2–3 (p<0.0001) and hospitalization for HF in the previous year (p = 0.01) were significantly associated with LV systolic dysfunction in univariate analysis. In multiple logistic regression including all parameters with a p value <0.05 in univariate analysis, male gender (chi-2 = 9,1, p = 0.002), NYHA class 2–3 (chi-2 = 6.2, p = 0.01) and BMI (chi-2 = 6.6, p = 0.01) were independently associated with LV systolic dysfunction. Previous MI, HF decompensation, revascularisation, presence of angina pectoris were not significantly associated with LV systolic dysfunction. Conclusions: LV systolic function is significantly altered in 9% of patients with stable coronary artery disease with normal ECG in INDYCE registry. Male gender, NYHA class 2–3 and BMI seem to be independently associated with LV systolic dysfunction in this population. [Copyright &y& Elsevier]

Aims: OFICA is an observational study of characteristics, management and outcome of acute heart failure (AHF) during hospitalization as well as after discharge. Methods: A single-day snapshot was performed on 12 March 2009 in French public and privates hospitals. Investigators were encouraged to include all hospitalized patients with a diagnosis of AHF, irrespective of the time of admission. Planned hospitalizations and cardiac surgery setting were excluded. Relevant data was recorded about whole hospitalizations as well as medical journeys before inclusion and after discharge. Outcome and change in treatments will be assessed during 12 months after discharge. Results: The survey included 1817 patients in 170 centers, (77 ± 13 y, 45% females, LVEF >50% in 29% of pts). IV diuretics and inotropic drugs were used in 86 and 14% respectively. Non-invasive and invasive ventilation were used in 12 and 6% of cases. Circulatory support devices were required in 1.7% of cases. Echographic examination and coronary angiography were performed in 83 and 21% of cases respectively. At discharge, diuretics, ACE-I or ARB, betablockers and aldosterone blockers were prescribed in 84, 65, 53 and 17% of all patients, and in 88, 73, 66 and 25% of patients with LVEF ≤ 0.40. In patients with reduced LVEF, variables independently and significantly associated with the lack of ACE-I or ARB were the absence of diabetes and female gender (X2 = 9.9 and 8.5, respectively). Variables independently and significantly associated with the lack of betablockers were pulmonary disease, shock at admission, mental disorders, LVEF, severe renal failure and age (X2 = 60.2, 12.9, 11.0, 7.1, 6.9 and 5.6, respectively). Conclusion: The OFICA survey is a valuable tool for analyzing the management of AHF in the real life because of inclusion of unselected patients in different types of hospitals as well as departments. Prescription rate of betablockers was high, reaching 66% at discharge of an AHF with reduced LVEF. On the opposite, the rate of prescription of spironolactone at discharge remains low. [Copyright &y& Elsevier]

Heart failure remains a disease with poor prognosis despite the therapeutic advances of recent decades and the implementation of therapeutic education programs. Most programs of therapeutic patient education are focused on improving knowledge of patients regarding their disease or therapy. But according to the WHO definition, educational therapy aims to help patients live better with their illness. We therefore wanted to determine whether a link exists between knowledge of patients estimated by a questionnaire and its reflexes analyzed through clinical cases. We included 398 patients with systolic heart failure who received a therapeutic education between 2003 and 2008. The program involved an educational diagnosis individual and collective training sessions about the disease, sessions to learn how to react in case of emergency and in every day life, physical self rehabilitation and good nutrition. During this educational process, patients filled a questionnaire initial knowledge of 50 questions (True False) associated with open questions (Q1) and an identical questionnaire at the end of training (Q2) and one year it (Q3). They filled a clinical case assessment after the initial education sessions and one year thereafter. The average age of patients was 65 (± 4), LVEF of 34 (± 4), the average BNP of 235 (± 346). Performance is correct initial questionnaire (7% of correct answers). During the educational session patients significantly increase their average performance on test of knowledge with an increase of almost 20%. There is no correlation between the scores of knowledge questionnaires and clinical cases performance that either the initial questionnaire, after training or one year later (respectively R 0.2; 0,05,0023 all NS).There no impact of age in our cohort. Conclusion: There is no correlation between the answers to test reflexes and knowledge of heart failure patients tested through clinical cases. It is therefore advisable not to confine itself to the use of knowledge tests for the evaluation of therapeutic education programs. [Copyright &y& Elsevier]

Heart failure is a serious disease despite recent therapeutic advances. A third of hospital admissions are therefore preventable. Dietetic education about low salt cooking is crucial for these patients. Changes in lifestyle are difficult to implement and ill reflexes can take over. We wanted to determine whether reflexes towards salt were persistent 12 months after an initial training session. Methodology: 398 patients with systolic heart failure have been trained in heart failure in our center between 2003 and 2008. All have followed an education cursus focusing about low salt cooking. This education took place in the context of care, including integrated educational individual educational diagnosis, disease education, training in self rehabilitation and put into practical situations. Education and collective diet was designed to teach the patient''s autonomy concerning the management of its little salty. Reflexes of the patients were analyzed by means of questionnaires based on clinical cases and a new questionnaire was sent to the patient an average of 11 months after initial training. The percentages were analyzed using the Chi2. A p <0.05 was considered significant. Results: Mean age of patients was 65 (± 4), LVEF of 34 (± 4), the average BNP of 235 (± 346). Patient answers were higher than what was envisaged with a true response rate of 60%. (10-100%). In pre-training answers it is interesting to note that a high rate of patient considers potassium salt as a correct salt substitute and that the low salt scheme involves cooking everything with water (40% of responses). Within one year of training, the same clinical cases were asked and the answers were as good (81.5% of correct answers p<0.01 vs the initial questionnaire)) and comparable to the results after training. Conclusion: The implementation of an education in dietary salt-free diet allows sustainably improvement of heart failure patients’ reactions about the low salt regime. [Copyright &y& Elsevier]

HIV + patients have seen their survival improve with the emergence of poly antiviral therapies. However, it was recently shown that these therapies had an impact on lipid metabolism. We therefore wanted to determine what could be the impact of cardiological care systematically in this population. Methodology: We have systematically proposed to all HIV + patients to go to a cardiological consultation followed by biological analysis, echocardiography, cervical Doppler with intima media measurement. Depending on the clinical and biological data it was then proposed diagnostic tests as arterial doppler of lower limbs and stress test. We then compared these data with those of literature studies on comparable populations in terms of age and sex. Results: Of 97 patients regularly followed 77 were seen in consultation. The average age of our cohort was 49.05 5 years. 74% are active smoking on average at 15 PY, 54% are overweight (77.7 kg to 1.71 cm on average). The hip measurement is 97.3 cm. 15% have clinical lipodystrophies. 32% have hypertension (defined as PA> 140/95 on two occasions). 67% had dyslipidemia. The intima media thickness is 0.81 (Left) and right 0.82 mm for a standard 0.73 mm in our test cohort (p <0.05) and 0.75 mm as the threshold cut off in Canadian studies (p <0.05). The echocardiography proved normal in 80% of patients and in 100% of patients with BNP levels <30 pg / ml. After one year follow-up we found a lower limbs arteriopathy in 13% and an ischemic heart disease in 11% of patients which is significantly higher than expected and reported in literature. In conclusion: It seems appropriate to be able to propose to HIV + patients a cardiovascular consultation in view of their specific risk profile, due to a non detection of almost 24% of patients with atherosclerosis and of the increase of intima media size. However, echocardiography should not be systematic. [Copyright &y& Elsevier]

Background: In studies and surveys involving stable coronary artery disease (CAD) patients, the global population often seems well managed; however, the question remains to know what is the proportion of patients who benefit from every simple medical intervention improving the prognosis or showing good quality of care. Objective: To evaluate medical management of stable CAD outpatients in France by calculating a progressive quality index. Methods and Results: The INDYCE survey was conducted in a sample of 343 cardiologists in France in 2008. Each physician had to include consecutively 10 stable CAD patients (absence of acute coronary syndrome or revascularisation in the 6 months preceding enrolment). 3119 patients (male: 80%, 68±11 years old, diabetes: 24.3%, hypertension: 61.6%) were enrolled. Medical therapy was in keeping with Guidelines (antiplatelet agents (AA) : 88.4% ; statins : 85.9% ; ACE-I/ARBs : 78.8%, beta-blockers (BB) : 74.6%). Patients suffered from mild to moderate symptoms (angina : 19.2%, NYHA class 0 or I : 43.5%, NYHA class II : 46.9%, NYHA class III : 9.3% ; NYHA class IV : 0.3%). Mean rest heart rate (HR) was of 64.2±10.8 bpm, mean systolic and diastolic blood pressure (BP) of 131.8±15.4 and 75.8±8.4 mmHg respectively. However, when calculating a progressive quality index: [(1)] 44.69% of the patients received an AA + a statin + an ACE-I/ARBs + a BB [(2)] 29.79% had (1) and a systolic BP < 140 mmHg + a diastolic BP < 90 mmHg [(3)] 23.02% had (1) + (2) and a resting heart rate < 70 bpm [(4)] 12.6% had (1) + (2) + (3) and had a regular physical activity [(5)] 6.96% had (1) + (2) + (3) + (4) and had performed an exercise test during the last 12 months [(6)] 4.07% had (1) + (2) + (3) + (4) + (5) and were asymptomatic (no angina and NYHA class 0 or I) Conclusion: Stable CAD patients do not raise attention because they are often pauci-symptomatic. At a population level, they appear to be well managed. However, building a quality index allows us to show that very few of these patients benefit from every step of a simple medical management. [Copyright &y& Elsevier]

Heart failure remains a disease with poor prognosis despite the therapeutic advances of recent decades. Nearly a third of hospital admissions are due to errors in dietetics follow up or therapeutic monitoring. Therapeutic education of patients with heart failure is growing fast in France. For the “Haute autorité de santé” (HAS), evaluation of education programs is an essential element in the same way that the educational diagnosis and interactivity. We wanted to determine what the assessment could predict the onset of the test combined death and hospitalization for heart failure. We included 398 patients with systolic heart failure who received a therapeutic education between 2003 and 2008. The program involved an educational diagnosis individual training sessions with the disease, sessions Implementation situation, self-physical and dietary. During this educational process, patients filled a questionnaire initial knowledge (Q1) and a questionnaire at the end of training (Q2) and one year of it (Q3). They also fulfilled a clinical case assessment and post training within one year. The average age of patients was 65 (± 4), LVEF of 34 (± 4), the average BNP of 235 (± 346). There is no correlation between the scores of knowledge questionnaires and questionnaires of clinical cases. In ROC curve there is no cut off for predicting the occurrence of a major event. In survival curve there is no difference between patients having a response greater than the median at questionnaire1, 2 or 3. however patients with a clinical performance at post training clinical cases above the median had an event-free survival significantly better than those with a response below the median (p <0001). Conclusion: The evaluation of the reactions of patients with clinical cases is greater than the simple evaluation of the knowledge of patients in terms of predicting survival without hospitalization for heart failure. [Copyright &y& Elsevier]

Background: Heart Failure (HF) is a frequent and severe disease. Overall prognosis of systolic HF is poor, and one-year survival rate is lower than most cancers. For that reason, HF units were progressively created in cardiology departments according to the European guidelines. Aim: The aim of this study was to describe the evolution in all-cause in-hospital mortality in patients hospitalized for HF in the HF clinic created at René Dubos hospital (Pontoise, France). Methods: We conducted a descriptive study of all-cause in-hospital mortality in a whole population of 4801 patients hospitalized for HF (range per year: 248-640 patients) from January 1997 to December 2007 in our HF clinic. Chi square, test for trend and linear regression were performed. Results: Our population consisted of 2331 men (48.6%) with a mean age per year ranging from 67.8 to 75.8 years, and a percentage of patients presenting with systolic HF (LVEF<45%) of 53.8%. There were no significant differences in terms of sex, diabetes mellitus or LVEF<45%, except for age and renal insufficiency. All-cause in-hospital mortality rate for patients hospitalized for HF appeared to be significantly decreasing during ten-year follow-up (p<0.0001) (see figure). Moreover we noticed that average length of hospital stay was decreasing during ten-year follow-up (p=0.027, -0.3 day per year). Conclusion: Mortality in HF patients was confirmed to be decreasing during the last ten-year period, thereby confirming the impact of HF care management on HF prognosis. Display Omitted [Copyright &y& Elsevier]

Background: It is well recognized that left ventricular function is a crucial factor influencing management and prognosis in coronary artery disease (CAD). Little is known however about left ventricular ejection fraction (LVEF) distribution in stable CAD patients. Objective: To evaluate LVEF in stable CAD outpatients in France. Methods: The INDYCE survey was conducted in a sample of 343 cardiologists in 2008). Each physician had to include consecutively 10 stable (absence of acute coronary syndrome or revascularisation in the 6 months preceding enrolment) CAD patients. LVEF measurement (with the biplane simpson method) was the main endpoint of the survey. Results: 3 119 patients were enrolled. Medical therapy was in keeping with Guidelines. Patients suffered from mild to moderate symptoms (Table). Mean LVEF was 56 ± 11%; poor (LVEF < 40%) and moderately impaired (40 ≤ LVEF ≤ 50%) systolic ventricular function were reported in 9.6% (n = 298) and 19.8% (n = 619) of the cases respectively. 14% of the patients with LVEF < 40%, 29.4% of the patients with 40 ≤ LVEF ≤ 50% and 47.3% of the patients with LVEF > 50% were completely asymptomatic (i.e no angina and NYHA class 0 or I). Conclusion: Among stable CAD patients, even if LVEF is globally preserved, about 30% of the patients have a moderate or severe left ventricular systolic dysfunction. It can be completely asymptomatic and therefore unrecognized in some patients although it should modify prognosis and management. This suggests that regular systolic ventricular function assessment is necessary in stable CAD patients. [Copyright &y& Elsevier]