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Background: Electrophysiological alterations in atrial fibrillation (AF) may be genetically based and may lead to changes in ventricular repolarization. Short QT syndrome is a rare channelopathy with abbreviated ventricular repolarization and a propensity for AF., Aims: To determine if minor unrecognized forms of short QT syndrome can explain some cases of lone AF., Methods: We prospectively compared QT intervals in 66 patients with idiopathic lone AF and 132 age- and sex-matched controls. QT intervals were measured during sinus rhythm in each of the 12 surface electrocardiogram leads and corrected using Bazett's formula (QTc). QT intervals were also corrected using other formulae. Uncorrected QT and heart rate regression lines were compared between AF patients and controls., Results: AF patients presented with a slower resting heart rate (64 ± 10 beats per minute [bpm] vs 69 ± 9 bpm; P=0.0006). QTc intervals were shorter in AF patients in 11/12 electrocardiogram leads (significant in 7/12, borderline in 2/12; mean QTc 381 ± 21 ms vs 388 ± 22 ms; P=0.02). QTc intervals were also shorter in AF patients, significantly or not, using other correction formulae. For similar heart rates, uncorrected QT intervals were shorter in patients when heart rates were greater than 70 bpm and longer when heart rates were less than 60 bpm. AF patients displayed steeper QT/heart rate regression line slopes than controls (P=0.009)., Conclusion: Heart rate is significantly slower and the rate dependence of ventricular repolarization is significantly altered in patients with lone AF compared with controls. Further study is warranted to determine if AF induces subsequent ventricular repolarization changes or if these modifications are caused by an underlying primary electrical disease., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Previous studies indicate that mortality from acute coronary syndromes is higher in women than in men, especially in case of interventional strategy., Aim: To assess whether the in-hospital mortality rate differs between genders during the first 48h after emergency percutaneous coronary intervention for ST-elevation myocardial infarction (emergency PCI-STEMI) or after non-emergency PCI., Methods: All patients treated with PCI between January 2005 and June 2008 were included. The primary endpoint was frequency of death within 48h after the PCI procedure; secondary endpoints included frequency of recurrent myocardial infarction, new PCI or coronary artery bypass graft surgery, stroke, and major vascular or renal complications. Data were analysed via logistic regression with and without propensity-score matching., Results: More than 9000 patients underwent PCI. In the emergency PCI-STEMI group (n=1753), 48-hour mortality occurred in 2.2% of men and 4.9% of women (p=0.004). However, gender disparity occurred only in elderly patients; the rate was significantly (p=0.02) higher in women (8.1%) than in men (3.3%) aged > or =75 years. There was no evidence of gender disparity in the non-emergency PCI group (n=7336) or in secondary endpoints for either PCI group. Similar results were obtained in pair analyses of men and women with matching propensity scores., Conclusions: Elderly women have a disproportionately high in-hospital mortality rate during the first 48h after emergency PCI for treatment of STEMI; however, there is no gender discrepancy in younger patients or patients of any age who receive non-emergency procedures., (2010 Elsevier Masson SAS. All rights reserved.)

Background: Previous studies have reported circadian variation in the rate of post-percutaneous coronary intervention (PCI) complications and mortality., Aim: To assess whether in-hospital outcomes during the first 48h after admission are related to the time or the day when PCI is performed., Methods: Emergency PCIs (2266 total; 1396 during regular hours and 870 during off hours) performed consecutively during a 3.5-year-period (2005-2008) were evaluated. The primary endpoint was death and the secondary endpoint was a composite score based on cardiovascular complications. The association between PCI start time and in-hospital outcome was assessed using multivariable logistic regression and propensity score analysis., Results: The patients' mean age was 64.8 years and 77.3% were men. The highest death rate was for night-time PCI (3.6%), with a 5.1% occurrence rate for PCI performed between 00:00 and 03:59, and a 3.0% occurrence rate for weekend daytime PCI compared with 1.5% for weekday daytime (regular-hours) PCI. The frequency of occurrence of other clinical events did not vary significantly throughout the day. Compared with weekday daytime PCI, the odds ratio for mortality was 2.95 for night-time PCI (95% confidence interval [CI] 1.58-6.01; p=0.0007) and 2.42 for weekend daytime PCI (95% CI 0.97-6.01; p=0.06)., Conclusion: Our study shows a significant time-dependent effect on in-hospital deaths in patients treated with emergency PCI. Healthcare organization and circadian variation of ischaemic processes could explain this variation in mortality.

Background: Interest in the role of patient education sessions for optimizing the management of heart failure (HF) is increasing. We determined whether improvements in young and elderly patients' knowledge of HF and self-care behavior could be analyzed by administering a knowledge test before and after an educational session., Methods: Stable heart failure patients (n = 115) were enrolled in a prospective cohort study from our Heart Failure educational centre in a university hospital. Patient knowledge of six major HF-related topics was assessed via a questionnaire distributed once before an educational session and twice afterward. Each answer was assigned a numerical value and the final score for each topic could range from 0 to 20. Scores >/= 15/20 were considered representative of a good level of knowledge., Results: The level of knowledge was low (9.7/20) before the educational session but was significantly higher (16.3/20) during the 1st quarter after the session, and this benefit was maintained for up to 12 months (16.6/20). Knowledge levels increased in both younger and elderly patients, and the number of patients who had a good level of knowledge also increased after the educational session., Conclusion: This study confirms that an HF knowledge test is feasible and that educational sessions improve the knowledge and self-management of both younger and elderly patients.

Background: Despite advances in procedures for percutaneous coronary intervention (PCI) and enhancement of materials and adjunctive therapy, postprocedural mortality remains a possible adverse outcome after PCI., Aims: To assess factors independently associated with in-hospital mortality in patients referred for PCI., Methods: Between January 2004 and December 2005, 4074 PCI were performed in our University Hospital, with 70 deaths registered either during the procedure or during the in-hospital stay. The 70 patients who died were age- and sex-matched with 70 controls in a case-control design study. Clinical and angiographic characteristics at hospital admission were collected from the patients' medical files., Results: The cumulative incidence rate for in-hospital mortality was 1.72%. Variables positively and significantly associated with in-hospital mortality were severe renal failure (55.7% in cases versus 12.9% in controls, p<0.0001), cardiac failure (26.1% versus 10.1%, p=0.01), ST-segment elevation myocardial infarction (STEMI) (70.6% versus 31.4%, p<0.0001), proximal coronary lesion (72.9% versus 40.0%, p<0.0001) and angiographically visible thrombus (14.3% versus 4.3%, p=0.04). Conversely, history of coronary heart disease, smoking and dyslipidemia were less frequent among cases. In multivariable analysis, the adjusted odds ratios (OR) for in-hospital death were 4.89 (95% confidence interval [CI] 1.96-12.2, p<0.001) in STEMI versus non-STEMI, 4.28 (95% CI 1.73-10.6, p<0.01) in those with a proximal coronary lesion, and 9.77 (95% CI 3.42-27.9, p<0.0001) in patients with severe renal failure., Conclusion: STEMI, proximal coronary lesion, and renal failure at admission are identified as particular settings associated with a higher probability of in-hospital mortality after PCI.

Objectives: Complete bidirectional cavo-tricuspid isthmus (CTI) block is mandatory for radio-frequency (RF) ablation of typical atrial flutter (AF). CTI block can be assessed by a simplified method using two catheters and the technique of differential pacing, but long-term results in large series are poorly known., Methods: CTI RF ablation was performed in 255 consecutive patients with typical AF, using one quadripolar catheter, and the ablation catheter, in association with the technique of differential pacing., Results: Procedural success, as defined by documentation of complete bidirectional CTI block using limited activation mapping, positive differential pacing together with termination of ongoing AF, was achieved in 80% of patients. AF recurred in 37 patients (14%) over a mean follow-up period of 15 +/- 9 months. Two hundred and forty-one patients (94%) were finally cured, with 1.1 procedures/patient. The recurrence rate was related to the achievement of complete CTI bidirectional block (12% vs. 29%, p = 0.01)., Conclusions: Long-term results of CTI ablation, employing a simplified method using the differential pacing technique, are similar to those for the standard methods using multipolar catheters. Therefore, this technique compares favorably to other established methods for such common RF procedures, especially due to its lower cost.

Objectives: We sought to assess the frequency and causes of stent thrombosis in diabetic and nondiabetic patients after implantation of sirolimus-eluting stents., Background: Safety concerns about late stent thrombosis have been raised, particularly when drug-eluting stents are used in less highly selected patients than in randomized trials., Methods: The EVASTENT study is a matched multicenter cohort registry of 1,731 patients undergoing revascularization exclusively with sirolimus stents; for each diabetic patient included (stratified as single- or multiple-vessel disease), a nondiabetic patient was subsequently included. Patients were treated with aspirin + clopidogrel for at least 3 months and were followed for 465 (range 0 to 1,062) days (1-year follow-up in 98.5%). The primary end point was a composite of stent thrombosis (according to Academic Research Consortium definitions), cardiovascular death, and nonfatal myocardial infarction (major adverse cardiac events [MACE])., Results: During follow-up, MACE occurred in 78 patients (4.5%), cardiac death in 35 (2.1%), and stent thrombosis in 45 (2.6%): 30 definite, 23 subacute, and 22 late, including 9 at >6 months. In univariate analysis, the 1-year stent thrombosis rate was 1.8 times higher in diabetic than in nondiabetic patients (3.2% vs. 1.7%; log rank p = 0.03), with diabetic patients with multiple-vessel disease experiencing the highest rate and nondiabetic single-vessel disease patients the lowest (4.3% vs. 0.8%; p < 0.001). In multivariate analysis, in addition to the interruption of antithrombotic treatment, independent stent thrombosis predictors were previous stroke, renal failure, lower ejection fraction, calcified lesion, length stented, and insulin-requiring diabetes., Conclusions: The risk of sirolimus stent thrombosis is higher for multiple-vessel disease diabetic patients.

The combination of coronary artery aneurysm and coronary artery fistula is infrequent. A saccular aneurysm of a branch of the left-circumflex coronary artery associated with multiple fistulae to the right atrium was observed on a coronary angiogram performed in a 47-year-old female. Multidetector computed tomography coronary angiography detailed the anatomy of the abnormal coronary artery. An embolization with a microcoil was performed and the aneurysm sac was excluded.

Multiple atrial septal defects can be closed by interventional catheterisation. The procedure requires an accurate morphological evaluation: number of defects, distance from their edges to the main cardiac structures, resistance of the septum. The authors report the case of a 63 year old woman presenting with cardiac failure in whom 3 atrial septal defects were diagnosed. All 3 defects were successfully closed by the implantation of two Amplatz devices. Control echocardiography at 6 months showed the occluders in a normal position with no residual shunt and the patient was asymptomatic.

The authors report a case of paroxysmal, complete atrioventricular block during an anterior acute myocardial infarction, leading to asystolia. The different possible physiopathological mechanisms are discussed, suggesting a paroxysmal nodal conduction defect, secondary to transient parasympathetic stimulation, triggered by a Bezold-Jarish type of cardiac reflex. This reflex is frequently involved in various pathologic situations or diagnostic procedures, usual in cardiology. Although it is frequently observed in inferior myocardial infarction, it can occur during an anterior acute myocardial infarction.

A 33 year old woman suffered a lateral myocardial infarction for the first time, and was treated by pre-hospital thrombolysis and secondary angioplasty on the diagonal artery. Fifteen days before the cardiac event she had undergone a left ovarian cyst excision and left salpingectomy for an ectopic pregnancy. She was a moderate smoker and had been taking a second-generation biphasic minidose oral contraceptive (ethinyl-estradiol 30-40mg and levonorgestrel 150-200 mg) for about ten years. Fifteen days before the myocardial infarction and due to the ectopic pregnancy she had changed to a combined monophasic minidose oral contraceptive pill containing ethinylestradiol (30 mg) and drospirenone (3 mg). The eventual outcome was favourable, with no complications. In this article we discuss the possible implications of the various factors (oral contraceptive, tobacco use, and surgical intervention) in this young woman with a myocardial infarction.

Each year in France, 150,000 to 180,000 new patients are the subject of prescriptions following acute coronary syndrome with or without ST segment elevation. There are two targets of the treatment, atherosclerosis, a diffuse, evolving trouble which, in this situation, is coming out of an unstable phase, and the myocardium, which has often been revascularised and has suffered deterioration of its contractile and electrophysiological characteristics to a greater or lesser extent. Prescriptions, based on proven factors and always centred on hygiene and dietary advice and the use of a combination of statins and aspirin, are adapted to suit the atherosclerotic and myocardial risk assessed for the individual patient. The prescription starts off the secondary preventive phase. It marks the first stage of the follow up, which is inevitable though of variable duration, for a disease which may evolve. It is the first step in the accompaniment of an attentive, informed patient whose confidence has been restored and who must now avoid falling into the double trap of not taking the treatment sufficiently seriously or of obsessively over-reacting.

Despite the improvement in revascularisation techniques, coronary artery disease remains the principal aetiology of cardiac failure in developed countries. The therapeutic management of cardiac failure has been improved over recent years, yet cardiac failure is still associated with significant morbidity and mortality. As cardiac transplantation lacks donors, techniques that allow myocardial regeneration represent an attractive alternative. To date, several types of cells are under study and are suitable for implantation into infarcted myocardium (myoblasts, medullary stem cells...). Following good preclinical study results, the first human cell therapy trials, using the intramyocardial route, have begun, in the course of aorto-coronary bypass surgery in patients with chronic ischaemic cardiopathy and little altered left ventricular function, and then in those with ventricular dysfunction. Different modes of administration of these cell therapy products are under study and could be envisaged in clinical situations such as just after infarction in order to improve ventricular remodelling with an intracoronary injection technique. As for every new treatment, there are numerous problems to resolve, from understanding the relevant mechanisms of cellular transplantation, to the secondary effects that it could entail. Nevertheless, cardiac cellular transplantation is expanding rapidly and with the evolution of techniques it allows a glimpse of a new field of treatment for cardiac failure.

Background: Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI)., Objectives: The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction., Methods: We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR)., Results: The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different., Conclusion: In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.

Aims: Patients suffering from coronary heart disease with ventricular systolic dysfunction present a bad prognosis and should be potentially revascularized. Up to now, surgery appeared to be the most feasible revascularization technique for such patients. Aims of this study were to assess the influence of different treatments (surgery, angioplasty or exclusively medical treatment) on clinical outcome and to establish a prognostic score practitioners to select the most appropriate therapy adapted to their patient profiles., Method: From 1995 to 2000, 492 patients were included in this cohort: 365 in the angioplasty group, 96 in the surgical group and 31 in the medical group. Kaplan Meier curves were made with a multivariate analysis to determine the significant predictive factors of mortality and major adverse cardiac events., Results: After a mean follow-up of 32 +/- 19 months, there was no statistical difference in mortality rate between the groups. However, the survival rate without MACE is higher in the surgical group, intermediate in the angioplasty group and lower in the medical group. Using the significant predictive factors of MACE in multivariate analysis, a prognostic score has been established in order to discriminate three categories of severity. For each category, angioplasty was compared with surgery in terms of the event-free-survival rate. For the two extreme categories (severe and non-severe), both treatments were equal. For the intermediate category, surgery obtained greater results., Conclusion: This prognostic score could help physicians in choosing the appropriate revascularization technique to treat patients with severe ischemic heart failure.

Background: Randomized trials comparing primary angioplasty and in-hospital fibrinolysis in acute myocardial infarction (AMI) have shown an advantage for primary angioplasty. The long-term follow-up of pre-hospital fibrinolysis followed by elective or rescue coronary angioplasty versus primary angioplasty is not well established after acute myocardial infarction. This study sought to assess the long-term clinical outcome of patients with AMI having either received pre-hospital fibrinolysis optimized by coronary angioplasty or primary angioplasty., Methods: We conducted a retrospective analysis involving 318 patients who either underwent primary angioplasty ( n = 157) or received pre-hospital fibrinolysis followed by an angioplasty (rescue or elective) ( n = 161) within 6 hours of the onset of chest pain., Results: The groups were similar regarding their baseline characteristics except for the ages. No difference was noted for in-hospital mortality (primary PTCA group: 2.48%, combined group: 2.54%; p = ns) with no increased risk of hemorrhage. The 3-year mortality was not significantly different in the two groups (9.7% vs. 4.9%; p = 0.15). Regarding major adverse cardiac events (29.5% vs. 37.5%; p = 0.23), reintervention (22.5% vs. 23.2%; p = 0.99) or target lesion revascularization (16.1% vs. 14.7%; p = 0.68), the groups were statistically similar., Conclusion: These data from real-life practice emphasize the safety and similar benefits on the long-term clinical outcome of AMI patients having undergone either pre-hospital fibrinolysis followed by angioplasty or primary angioplasty.

During chronic mechanical overload induced by hypertension, left ventricular hypertrophy predisposes to atrial and ventricular arrhythmias. Atrial arrhythmias, mainly atrial fibrillation, decrease cardiac output and increase the risk of embolism whereas ventricular arrhythmias remain the major cause of sudden death. In hypertensive patients, Holter EKG recordings frequently detect atrial or ventricular premature beats and more rarely atrial or ventricular tachycardia. In these patients, the presence of non-sustained ventricular tachycardia is considered as an independent predictor of mortality. Moreover, this non invasive method through the assessment of heart rate variability allows the study of the autonomic control of the heart, known to modulate occurrence of arrhythmias.

The role of bradykinin in the cardiovascular effects of angiotensin converting enzyme inhibitors remains difficult to establish. On their haemodynamic effects, bradykinin acts during their acute administration, participating in their vasodilatation action, while during their chronic administration they act slightly or not at all. On their trophic effects, the action of the tissue kallikrein-kinin system, suggested by the results of animal experimentation, is yet to be demonstrated in man. For their effects on cardiovascular morbidity and mortality the role of bradykinin remains under discussion. Nevertheless, besides ACE inhibitors, the other therapeutic agents which increase the levels of bradykinin, such as neutral endopeptidase inhibitors, have a significant field of development in the course of cardiovascular pathologies.

The object of this study was to assess and analyse TIMI (Thrombolysis in Myocardial Infarction) grade and secondary major cardiac events of patients with acute myocardial infarction benefiting from pre-hospital thrombolysis according to their predefined clinical and electrical "ischaemic status" (Active, Inactive, Intermediate) on admission to the coronary care unit and at the end of thrombolysis (90th minute). This single centre study was undertaken from March 1994 to August 1999 on 161 patients treated by thrombolysis by the emergency ambulance service for acute myocardial infarction (< or = 6 hours). The mean age was 56.2 +/- 11.3 years with 8.7% of women. On admission to the coronary care unit. 30.8% were classified as Inactive and 51.6% as Active. At the end of thrombolysis, 62.3% were classified as Inactive and 27.7% as Active. Nearly 93% of TIMI 3 flow was observed in Inactive patients at the 90th minute and 76.7% of TIMI < or = 2 flow in Active patients (p < 0.0001). Global hospital mortality was 2.48% but it was zero in the Inactive group at the end of thrombolysis. With an average follow-up of 26.9 +/- 15.8 months, the incidence of major cardiac events was 34.1%, including 16.1% of revascularisation of the target lesion. In multivariate analysis, predictive factors for TIMI < or = 2 at the end of thrombolysis included persistent pain, the number of leads with ST elevation and the absence of regression of ST elevation on admission to the coronary care unit. The only predictive factor for secondary major cardiac events was persistent ST elevation at the 90th minute of thrombolysis.

Background: Management of heart failure includes beta-blockade (betaB) therapy and cardiac rehabilitation. The aim of this study was to compare the exercise training response of patients with congestive heart failure (CHF) receiving betaB therapy with that of patients not receiving treatment., Methods and Results: Thirty-four consecutive patients with CHF were included in a 4-week training program at their ventilatory threshold (VT); 6 patients received betaB treatment and 18 did not. The patients underwent a cardiopulmonary exercise test before and after training. Oxygen uptake (VO(2)) at peak exercise and at VT increased in both groups (P < or =.0001) without any significant differences between the groups. The same results were found after adjustment to ejection fraction and VO(2) at the start of the training program. There was no difference in VT improvement, measured as a percentage of utilization of maximal oxygen uptake, between the groups. After training, heart rate and ventilation decreased (P < or =.0001) at submaximal levels in both groups without significant differences between the groups., Conclusions: betaB therapy does not impair functional improvement induced by a rehabilitation program in patients with CHF. betaB therapy does not interfere with exercise training prescription if patient exercise evaluations are made at the time of therapeutic intake.

Background: Previous studies of heart rate variability (HRV) in systemic hypertension have yielded conflicting results. We sought to assess the alterations of HRV in hypertensive patients with or without left ventricular hypertrophy (LVH)., Methods: 195 hypertensive patients in sinus rhythm, mean age 53 +/- 11 years, without diabetes mellitus, nor symptomatic coronary disease or systolic dysfunction, were prospectively enrolled. Echocardiographic examination allowed their subdivision in 3 groups: normal geometry (112), concentric remodeling (43) and LVH (40). Time and frequency domain measures of HRV were obtained from 24 h Holter ECG recordings in all patients as in 40 control subjects., Results: In comparison with control subjects, the 3 hypertensive groups presented a significant decrease of SDNN and total frequency power both indexes of global HRV; a significant decrease of pNN50 and high frequency power, indexes of HRV reflecting parasympathetic tone, and a significant decrease of SDANN and low frequency power, indexes reflecting sympathetic modulation of HRV. Comparisons among the three hypertensive groups showed that patients with LVH had significantly (p < 0.05) lower low frequency power (5.5 +/- 1.0 Ln m2) than patients with left ventricular normal geometry (5.9 +/- 0.8 Ln m2) or concentric remodeling (5.9 +/- 0.9 Ln m2)., Conclusion: Assessment of HRV in hypertensive patients shows a constant decrease of parasympathetic indexes and a more markedly reduction of sympathetic parameters in presence of LVH.

The authors report the case of a cardiac transplant patient with a recurrence of atrial flutter two months after electrical cardioversion and despite long-term preventive treatment with amiodarone. Early investigation for signs of rejection with 4 endomyocardial biopsies was negative. Aggravation of the haemodynamic status due to flutter with a rapid ventricular response led to an attempted radio-frequency ablation. Endocavitary mapping confirmed persistence of sinus activity in the native atrium and the presence of a circuit of type I isthmic flutter (anticlockwise circuit) in the donor atrium. Ablation by radio-frequency in the same procedure was successful. A fifth myocardial biopsy the same day finally confirmed stage 3A acute rejection. No signs of recurrent rejection or arrhythmia have been observed after 24 months' follow-up in this patient. This preliminary experience confirms the need to look for graft rejection by repeated myocardial biopsies in cardiac transplant, patients with atrial flutter and the efficacy of radio-frequency ablation in cases of resistance to conventional therapy.

Aims: Analysis of heart rate variability is a noninvasive tool that allows to study autonomic control of the heart. Several studies have shown disturbed heart rate variability in patients with chronic heart failure (CHF). We sought to assess the prognostic value of time domain measures of heart rate variability in CHF., Methods and Results: We prospectively enrolled 190 patients with CHF in sinus rhythm, mean age 61+/-12 years, 109 (57.4 %) in NYHA class II and 81 (42.6 %) in class III or IV, mean cardiothoracic ratio 57.6+/-6.4 % and mean left ventricular ejection fraction 28.2+/-8.8 %, 85 (45 %) with ischemic and 105 (55 %) with idiopathic dilated cardiomyopathy. Time domain measures of heart rate variability were obtained from 24 h Holter ECG recordings. During follow-up (22+/-18 months), 55 patients died. In multivariate analysis, independent predictors for all-cause mortality were: ischemic heart disease, cardiothoracic ratio > or =60 % and standard deviation of all normal RR intervals <67 ms (RR=2.5, 95 % CI 1.5--4.2)., Conclusions: Depressed heart rate variability has independent prognostic value in patients with CHF.

ATHEROSCLEROSIS: Currently regarded as a multifactorial disease, atherosclerosis involves several factor including: oxidized LDL, endothelial cells, macrophages, immune cells, vascular smooth muscle cells. The endothelium appears to play a key role through the production of vasomotor, antiaggregate and leukocyte antiadhesion molecules. NITRIC OXIDE: NO is one of the most important mediators of endothelial antiatherothrombotic functions. Loss of endothelial production, called "endothelial dysfunction", i.e. loss of endothelial vasorelaxing, antiaggregate and leukocyte antiadhesion properties, could lead to increased fatty streak formation and acute arterial events (thrombus formation, vascular spasm)., Animal Experiments: Although animal models strongly suggest a major role for NO in the pathophysiology of atherosclerosis, human studies with nitrates have been disappointing to date. The local effect of NO is probably closely adapted to local conditions. Therefore, massive delivery of NO as is achieved with nitrates could not repair endothelial dysfunction.

The authors report the case of an asymptomatic 32 year old man with no family history of sudden death but with ECG changes suggesting Brugada's syndrome. He underwent implantation of an automatic defibrillator after inducible syncope ventricular fibrillation had been demonstrated during electrophysiological investigation. The later occurrence of three episodes of ventricular fibrillation treated by the defibrillator confirmed a posteriori the logic of this therapeutic approach.

Physical exercise is a treatment for cardiac failure but a large range of intensities of exercise is proposed. The aims of this study were to determine the range of intensities of effort used and to individualize the intensities used. Thirty patients with stable cardiac failure (NYHA Classes II-III, age: 53 +/- 2.1 years, ejection fraction: 31 +/- 1.4%) underwent a cardiorespiratory exercise stress test before and after individualized training at the ventilatory threshold. However, before and after the training period, standard methods of calculation of the intensities at the ventilatory threshold showed individual differences greater than +/- 2 standard deviations, indicating different metabolic stimulations. After the individualized training programme, peak oxygen consumption on exercise (1679 +/- 100 vs 1487 +/- 89 ml.min-1, p = 0.0001) and at ventilatory threshold increased (1365 +/- 85 vs 1133 +/- 65 ml.min-1, p = 0.0001), the ventilatory threshold/peak exercise ratio increased (81.2 +/- 1.3 vs 76.7 +/- 1.4%, p = 0.0008), and there was a decrease in heart and ventilatory rates at submaximal metabolic levels (p = 0.0001). The authors conclude that protocols using intensity of effort at the ventilatory threshold give similar results with respect to improvement of aerobic capacity as other methods of indirect calculation, based on maximal heart rate of oxygen consumption. The value of this particular method lies in the adequation between aerobic capacity of the patient and the intensity of training. The results obtained attain the physiopathological aims of rehabilitation.

Aims: During insulin resistance, sympathetic nerve activity is increased. However insulin resistance is a common feature of obesity and essential hypertension, it is unclear if chronic hyperinsulinemia per se contributes to sympathetic overactivation. The purpose of our study was to explore++ the relationships between chronic hyperinsulinemia and heart rate variability (HRV), a non-intensive tool to assess autonomic function, in obese and hypertensive subjects., Methods: 24 hours Holter ECG for HRV time and frequency domain analysis was performed in 77 patients, mean age 53 +/- 10 years, 52 men and 25 women, free of diabetes, without beta-blockers, divided in four groups according to three parameters, body mass index (BMI > 27 kg/m2 in man and > 25 kg/m2 in woman defined obesity), arterial pressure and insulinemia (fasting insulinemia > 25 mUI/L defined hyperinsulinemia): 27 patients obese, hypertensive, with hyperinsulinemia; 28 patients obese, hypertensive, without hyperinsulinemia; 12 patients non obese, hypertensive, without hyperinsulinemia; 10 patients obese, normotensive, without hyperinsulinemia., Results: In comparison with the three other groups, patients with hyperinsulinemia showed a significant decrease (p < 0.05) of SDNN and the power of total spectrum (0.01-1 Hz) band, which are indexes of global HRV, and a significant decrease (p < 0.005) of SD and the normalized power of the low frequency (0.04-0.15 Hz) band, both indexes reflecting sympathetic modulation of HRV. In contrast, no significant difference was observed between the four groups for indexes of HRV reflecting parasympathetic tone. These relations were independent of mean RR. Fasting insulinemia was significantly (p < 0.0001) related with HRV in time domain (SDNN; r = -0.43; SD: r = -0.49) and spectral domain (total spectrum: r = -0.49; low frequency: r = -0.52)., Conclusion: Chronic hyperinsulinemia appears to be an important determinant of HRV, particularly for the indexes reflecting sympathetic influence, independent of obesity and hypertension.

Half of all deaths occurring in patients with heart failure are sudden deaths probably related to a malignant ventricular arrhythmia. The pathophysiological mechanisms of these arrhythmias are unclear, but left ventricular function, hypokalaemia accentuated by diuretics and treatments altering inotropism play a definite role. Because of the diversity of aetiologies generating heart failure, the multiplicity of fatal arrhythmias and the multifactorial origin of these arrhythmias, there is no formal marker for the risk of sudden death in patients with heart failure, at the present time. In addition to the NYHA classification and detection of episodes of syncope, assessment of these patients must be as complete as possible, at least including repeated evaluation of the ejection fraction, Holter ECG monitoring and detection of delayed ventricular potentials.

Sudden death accounts for about 35% of the mortality of cardiac failure and its incidence does not decrease with the use of angiotensin converting enzyme inhibitors. Non-sustained ventricular tachycardia on Holter monitoring, late ventricular potentials and tachycardia induced by programmed ventricular stimulation have no formal predictive value of sudden death, underlining the varied character of the mechanisms underlying sudden death during cardiac failure. Sustained ventricular tachycardia degenerating to ventricular fibrillation is only one of the rhythmic factors implicated together with inaugural ventricular fibrillation, bradyarrhythmias and electromechanical dissociation. The underlying cardiac disease plays a role in the initiation of the fatal arrhythmia. In coronary artery disease, recurrent acute ischaemia is the principal trigger factor in patients who often have triple vessel disease. This explains the fact that classic markers of arrhythmia in the post-infarction period, which are only the reflection of the arrhythmogenic substrate of ventricular tachycardia, usually due to reentry around the fibrous scar of the infarct, are not valid in patients with progressive ischaemic cardiomyopathy. The most effective antiarrhythmic treatment in this type of patient is the prevention of ischaemia, when possible. In primary dilated cardiomyopathy, the mechanism underlying sudden death could be different at each stage. In NYHA Stages I and II, ventricular tachyarrhythmias could play a major part in unexpected sudden death in patients whose stable haemodynamic status suggested a more prolonged survival. The value of an implantable defibrillator would seem to be proved in this group of patients, at least in secondary prevention. In Stages III and IV, ventricular arrhythmias only indicate the degree of ventricular dysfunction and sudden death may follow bradyarrhythmias and electromechanical dissociation due to the precarious haemodynamic status.

Objective: To assess cardiac beta-adrenoceptors (beta-AR) in an obesity-hypertension model., Methods: Six male beagle dogs (aged 35 +/- 5 months) receiving during 30 weeks a high-fat diet with 60% uncooked beef fat were compared to 6 normal beagle dogs. With right auricular and left ventricular samples we analysed cardiac beta-AR density through binding study using [125I]-cyanopindolol. beta 1 and beta 2 densities were obtained by competition with CGP 20712A. Affinity state of beta-AR was assessed by competition with isoproterenol. Noradrenaline plasma level was assayed by HPLC. Left ventricular mass (LV mass) was measured by echocardiography. Results are expressed as mean +/- SE. All comparisons were performed using a variance analysis (*: p < 0.05)., Results: Systolic blood pressure was significantly higher in obesses (245 +/- 8 vs 197 +/- 10 mmHg in controls). Diastolic blood pressure did not differed between both groups (93 +/- 3 vs 84 +/- 3 mmHg in controls). Noradrenaline plasma levels were similar in both groups (276 +/- 30 vs 235 +/- 50 pg/mL in controls). Obesses were characterized by higher LV mass (80 +/- 24 vs 67 +/- 15 g in controls*). Right auricular and left ventricular beta-AR densities were not different in obesses (57 +/- 6 and 67 +/- 4 fmoles/mg protein) and in controls (68 +/- 7 and 63 +/- 9 fmoles/mg protein). The beta 1-AR proportion was the same in obesses and controls in right auricule (63 +/- 4 vs 64 +/- 3% in controls) and left ventricule (59 +/- 3 vs 60 +/- 4% in controls). The proportion of beta-AR receptors in a high affinity state was similar in right auricular samples (69 +/- 4 vs 67 +/- 3%) in controls) but was significantly different in left ventricule (28 +/- 6 vs 74 +/- 6%) in controls)., Conclusion: Left ventricular beta-adrenoceptors came under a specific desensibilisation independent of plasma noradrenaline levels. This functional decoupling of beta-adrenoceptors may account for the progressive systolic dysfunction of hypertensive cardiomyopathy.

Aims: Identification of patients with congestive heart failure at risk of sudden death remains problematic and few data are available on the prognostic implications of QT dispersion. We sought to assess the predictive value of QT dispersion for arrhythmic events in heart failure secondary to dilated cardiomyopathy or ischaemic heart disease., Methods and Results: Twelve-lead ECGs calculated for QT dispersion, 24 h Holter ECGs and signal-averaged ECGs were prospectively recorded in 205 heart failure patients in sinus rhythm. The 86 patients with ischaemic heart disease and the 119 with dilated cardiomyopathy were not significantly different as regards NYHA grades (51 vs 49% in grades III-i.v.), cardiothoracic ratio (57 +/- 7 vs 57 +/- 6%) and ejection fraction (28 +/- 8 vs 29 +/- 9%). The mean QT dispersion (66 +/- 29 vs 65 +/- 27 ms), the frequency of non-sustained ventricular tachycardia (37 vs 38%) and ventricular late potentials (41 vs 40%) were not significantly different in patients with ischaemic or dilated cardiomyopathy. QT dispersion was significantly related to other arrhythmogenic markers. During follow-up (24 +/- 16 months), 66 patients died, 22 of them died suddenly and seven presented a spontaneous sustained ventricular tachycardia. In patients with dilated cardiomyopathy, in multivariate analysis, only a QT dispersion > 80 ms was an independent predictor of sudden death (RR: 4.9, 95% CI 1.4-16.8, P < 0.02) and arrhythmic events (RR: 4.5, 95% CI 1.5-13.5, P < 0.01). In patients with ischaemic heart disease, no studied parameter was found significantly related to sudden death or arrhythmic events., Conclusions: In congestive heart failure, abnormal QT dispersion can identify patients with dilated cardiomyopathy who are at high risk of arrhythmic events.

Objective: To evaluate the prognostic value of arrhythmogenic markers in hypertensive patients., Design: Two hundred and fourteen hypertensive patients without symptomatic coronary disease, systolic dysfunction, electrolyte disturbances or anti-arrhythmic therapy were included. Recordings were made of 12-lead standard ECGs with calculations of QT interval dispersion, 24 h Holter ECGs (204 patients), echocardiography (187 patients) and signal-averaged ECGs (125 patients)., Baseline Data: echocardiographic left ventricular hypertrophy was found in 63 patients (33.7%), non-sustained ventricular tachycardia (Lown class IV b) in 33 patients (16.2%), ventricular late potentials in 27 patients (21.6%). Mortality: after a mean follow-up of 42.4 +/- 26.8 months, global mortality was 11.2% (24 patients), cardiac mortality 7.9% (17 patients), sudden death 4.2% (nine patients). Univariate analysis: predictors of global, cardiac and sudden death were age > or = 65 years, ECG strain pattern, Lown class IV b and QT interval dispersion > 80 ms (P < or = 0.01). Left ventricular mass index was closely related to cardiac mortality (P = 0.002). Multivariate analysis: only Lown class IV b was an independent predictor of global (RR 2.6, 95% CI 1.2-6.0) and cardiac mortality (RR 3.5, 95% CI 1.2-9.7)., Conclusion: In hypertensive patients, non-sustained ventricular tachycardia has a prognostic value.

Objective: Hypertensive left ventricular hypertrophy (LVH) is associated with increased risk of arrhythmias and mortality. However, no clinical study demonstrated a significant relation between ventricular arrhythmias and mortality in systemic hypertension., Design and Methods: To evaluate the prognostic value of arrhythmogenic markers in systemic hypertension, we included between 1987 and 1993. 214 hypertensive patients, 59.1 +/- 12.8 years old, without symptomatic coronary disease, myocardial infarction, systolic dysfunction, electrolyte disturbances or antiarrhythmic therapy. At inclusion, an ECG, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, an echocardiography (reliable in 187 patients) with left ventricular mass index and ejection fraction calculation, a SAECG (125 patients, enrolled after 1988) with ventricular late potentials (LP) were recorded. QT interval dispersion (QTd) was calculated on 12 leads standard ECG and LVH was appreciated., Results: At baseline echocardiographic LVH was recorded in 63 patients (33.7%) with normal ejection fraction (75 +/- 7.4%). Non-sustained ventricular tachycardia (Lown IVb) was found in 33 pts (16.2%) and LP in 27 patients (21.6%). After a mean follow up of 42.4 +/- 26.8 months, all-cause mortality was 11.2% (24 patients); 17 patients died of cardiac causes (7.9%); of these 9 patients (4.2%) died suddenly. In univariate analysis, age, strain pattern of LVH, advanced Lown classes and abnormal QT dispersion (> 80 ms) were significantly related to global, cardiac and sudden death (p < or = 0.01). Left ventricular mass index was closely related to cardiac mortality (p = 0.002). LP failed to predict mortality. In multivariate analysis, only Lown class IVb was an independent predictor of global and cardiac mortality, increasing the risk of global death 2.6 fold [1.2-6.0] (CI 95%) and the risk of cardiac death 3.5 fold [1.2-9.7] (CI 95%)., Conclusions: In hypertensive patients the presence of non-sustained ventricular tachycardia on 24 h Holter has a prognostic value.

Computed tomography is currently the reference examination in the investigation of mediastinal tumours. We report a case of pericardial tumour revealed by transoesophageal echocardiography. This investigation immediately defined the limits of this mass and its relations with cardiac cavities and large vessels and suggested the main features of its tissue structure. However, the aetiological diagnosis is still based on CT-guided needle biopsy or investigation by mediastinoscopy or thoracotomy. Our case consisted of a non-Hodgkin lymphoma. Transoesophageal echocardiography is a non-irradiating technique, which can be performed at the patient's bed and which allows a precise assessment of the pericardial regions, especially the right pericardial regions.

Objective: To evaluate the correlation between QT interval dispersion (QTd) and ventricular arrhythmias in hypertensive patients (pts) with or without left ventricular hypertrophy (LVH). A secondary aim was to investigate correlations of QTd with other markers of arrythmogenic propensity: ventricular late potentials (LP) and heart rate variability (HRV)., Methods: We retrospectively measured the QTd on the 12 standard surface ECG leads in 230 hypertensive pts (94F, 136M; 59.6 +/- 12.7 years old). A 24 hours ECG Holter recording was performed in 218 pts and ventricular arrhythmias were appreciated using the Lown classification. Left ventricular mass was determined by echocardiography (LVM-Devereux formula) and left ventricular mass index (LVMI) were determined in 202 subjects. LP (122 pts) and HRV (55 pts) were investigated., Results: The QTd varied between 20 and 160 msec (57.8 +/- 32.7 msec). The distribution of pts classified using Lown criteria was: 29 pts (13.3%) class O; 106 pts (48.6%) class I; 8 pts (3.6%) class II; 13 pts (6%) class III; 29 pts (13.3%) class IVa; 33 pts (15.1%) class IVb; 116 pts (69.5%) had LVH determined by echocardiography. The QTd was strongly correlated with the Lown classes (p < 0.0001). The QTd was significantly broader in Lown classes III, IVa and IVb compared to classes O, I and II cumulated (p < 0.002); there was no difference concerning QTd between Lown classes III, IVa and IVb. The QTd was also correlated with the absolute number of premature ventricular depolarizations/24 hours (p = 0.02; r = 0.16). The 75 pts with an increased LVMI had significantly elevated QTd compared to pts without it (p < 0.0001). Qtd was correlated with LVMI (r = 0.37; p < 0.0001). There was no correlation between QTd and the existence of LP (which were correlated with the Lown classes; p < 0.03) and HRV parameters., Conclusion: Elevated QT interval dispersion is associated with more severe ventricular arrhythmias in hypertensive subjects with LVH. The mechanism of an increased inhomogeneity of repolarisation is probably related to the anatomic modifications induced by LVH. No significant correlation between QTd, LP and HRV was observed.

To investigate whether detection of ventricular late potentials could provide prognostic information in patients with congestive heart failure with or without bundle branch block, we prospectively obtained a signal-averaged ECG from 151 patients with congestive heart failure, using specific criteria in 57 patients with bundle branch block. Late potentials were detected in 49 patients (32.5%); their incidence was not significantly different in patients without (31%; 29 patients) or with bundle branch block (35%; 20 patients). Late potentials were present in 25 of 73 patients (34%) with idiopathic dilated cardiomyopathy, in 20 of 57 patients (35%) with ischaemic cardiomyopathy and in four of 21 patients (19%) with hypertensive heart disease (ns). Age, NYHA class, ejection fraction and use of amiodarone were not statistically different among patients with or without late potentials. In contrast, patients with late potentials had more past episodes of sustained ventricular tachycardia (8.2%; four patients) than those without late potentials (1.9%; two patients). Twenty four hour ambulatory ECGs were obtained in 135 patients (89%). Non-sustained ventricular tachycardia was not correlated with the presence of late potentials found in 45 of 88 patients (51%) without late potentials and in 29 of 47 patients (62%) with late potentials (ns). The mean follow-up was 27 +/- 12 months; 51 patients died, 31 from progressive congestive heart failure and 13 suddenly; seven prospectively had sustained ventricular tachycardia. The total mortality rate, the cardiac mortality rate and sudden death risk were not significantly related to the presence of late potentials; their incidence were respectively 35% (36 patients), 32% (33 patients) and 10% (10 patients) in patients without late potentials and 31% (15 patients), 23% (11 patients) and 6% (three patients) in those without late potentials. The incidence of sustained ventricular tachycardia during follow-up was 2% (two patients) in patients without late potentials and 10% (five patients) in those with late potentials. The incidence of sustained ventricular tachycardia experienced by the patients before the study or seen during follow-up was significantly increased in the presence of late potentials: 18% (nine patients) vs 2% (two patients) in the absence of late potentials (P < 0.001). Removal from the study of data from patients with bundle branch block, patients with severe congestive heart failure (NYHA 3 or 4) or patients taking amiodarone did not alter these results. Thus, signal-averaged ECG results only improved risk stratification for sustained ventricular tachycardia in patients with congestive heart failure and failed to identify patients at high risk for sudden death.

Inhaled nitric oxide, a selective pulmonary vasodilator, reverses hypoxic pulmonary vasoconstriction and is an effective treatment in some cases of human pulmonary hypertension. Localization of nitric oxide synthase had indicated a neural role for nitric oxide. Thus, we studied the interactions between inhaled nitric oxide and systemic and pulmonary vascular reactivity in acute neurogenic hypertension. In 6 male beagle dogs (mean weight: 15 +/- 1 kg), anesthetized by chloralose (8 cg/kg) and in spontaneous ventilation, the hemodynamic effects on systemic and pulmonary circulation of inhaled nitric oxide (12 ppm) were studied before and after acute sino-aortic denervation. The hemodynamic effects of intravenous propranolol (300 micrograms/kg) were studied after denervation. Mean arterial pressure (MAP), pulmonary capillary pressure (PCP), mean arterial pulmonary pressure (MAPP), cardiac input (CI) and oxygen venous saturation (SvO2) were measured. [table: see text] Sino-aortic denervation causes an acute and transitory pulmonary hypertension due to a double mechanism: a post-capillary hypertension (increase PCP) secondary to an increase left ventricular post-charge by systemic hypertension and a precapillary hypertension. In fact, vascular pulmonary resistances increase from 1.8 +/- 0.1 to 3.4 +/- 0.8 uW after denervation (p < 0.05). Change in pulmonary vascular reactivity induced by catecholamines is probably involved. Propranolol but not inhaled nitric oxide reverse pulmonary hypertension due to sino-aortic denervation.

Between 1977 and 1990, 64 premenopausal women, under 50 years of age (42 +/- 5.6 years), were admitted for typical acute myocardial infarction with pathological Q waves. Twenty one patients had attempted myocardial revascularisation either by intravenous thrombolysis or primary angioplasty (n = 3). All patients underwent coronary angiography with selective left ventriculography during their hospital admission. This group of 64 women was characterised by the association of coronary risk factors (2.8 per patient): smoking (89%), hyperlipidaemia (67%), diabetes (45%) and oral contraception (35%). Coronary angiography showed single vessel occlusion in 86% of patients receiving oral contraception, multiple vessel disease in 36.5% and single or double vessel disease in 31.7% of the other patients. There were 3 deaths during the hospital period (4.6%), 12 cases of left ventricular failure, 2 ventricular aneurysms, 2 operated ischaemic mitral regurgitations and 9 recurrences of pain treated by angioplasty. During follow-up (36.5 +/- 4 months), 22 patients were readmitted to hospital and there were 3 further deaths, 12 cases of persistent cardiac failure, 10 cases of latent ventricular dysfunction and 9 ischaemic reoccurrences treated by angioplasty or surgery. The results in this group of patients suffering from myocardial infarction at an unusually early age for women showed that although the mortality was similar to that observed in men of the same age (9%) there was a very high morbidity and a high risk of cardiac failure. The prognosis of myocardial infarction in women, though better than 10 years ago, should improve with immediate revascularisation, the correction of cardiovascular risk factors and the rapid application of all techniques of modern cardiology.

The purpose of the study is to make a selection of patients with left ventricular hypertrophy from Ambulatory Blood Pressure Monitoring (ABPM) values. We studied 39 patients, 23 men and 16 women, without treatment. These patients had systolic pressure > 140 mmHg and/or diastolic pressure > 90. With ABPM we measured mean systolic (MS) and diastolic (MD) pressure during the day (D) and the night (N), the percentages of systolic values (%S) > 160 mmHg and of diastolic values (%D) > 95 mmHg. With echocardiography we measured left ventricular mass index (LVMI: Devereux) and with pulsed Doppler peak of early (E) and late (A) ventricular filling and the ration A/E. We found the same amount of correlations between ABPM and echocardiographic parameters as other authors. [table: see text] The study of LVMI found a difference between groups when MD were > 140/90 (*) and A was significantly greater in patients with MSD > 140 (*). LVMI was greater in patients with MDD > 80 (*) and A was greater in patients with MSN > 120 (*). Predictive value of MSD > 140: 53% specificity: 79%. Predictive value of MSN > 120: 80% specificity: 45.8%. We concluded that the correlations between ABPM and echocardiographic disturbances are not very strong, but significant. If the predictive value of MSF is low, his specificity is rather high and conversely MSN has a good predictive value for selection of hypertrophic patients.

Ventricular arrhythmias occur with increased frequency in hypertensive patients with left ventricular hypertrophy (LVH). The aim of this work is to study the incidence of ventricular late potentials (LP) and their relation to ventricular arrhythmias in 148 hypertensive patients, 87 men and 55 women, without evidence of a coronaropathy. For each patient we carried out a signal-averaged electrocardiography, an echocardiogram to determine the LV mass index (LVMI) and the LV end-diastolic dimension (EDD), and 24 hours Holter monitoring to record ventricular arrhythmias filed according to Lown's classification. LP were considered present if the root-mean-square voltage during the last 40 ms of the QRS was: < 20 uV in absence of bundle branch block, or < or = 17 uV in presence of bundle branch block. [table: see text] The frequency of LP appears exceptional in hypertensive patients without LVH (5%) and remains uncommon in patients with concentric LVH (13%). The incidence of LP is only frequent at the end stage of hypertensive cardiopathy with eccentric LVH (48%). The severity of ventricular arrhythmias is only correlated to the presence of LP in patients with concentric LVH (p < 0.02).

The aim of the present study was to determine when a search for ventricular arrhythmias, by ambulatory electrocardiographic monitoring, is necessary in hypertensive patients. An electrocardiogram, an echocardiogram and a 24 hour Holter monitoring were recorded in 88 patients with essential hypertension. According to the results of electrocardiogram patients were subdivided into 4 groups: normal electrocardiogram, isolated left auricular hypertrophy (LAH), isolated left ventricular hypertrophy (LVH) and major ST-T wave changes. According to the degree of septal thickness (ST), patients were classed in 4 groups. [table; see text] For hypertensive patients with normal electrocardiogram, Holter monitoring is not necessary; in fact practically no complex arrhythmias is found in this group. On the contrary, for hypertensive subjects with ST-T waves changes, this investigation seems very interesting, nearly 75% of them present high-grade ventricular arrhythmias. For the patients with electrocardiographic isolated LAH or LVH, the realisation of an echocardiography permits to separate the subjects with mild LVH (ST less than 12 mm) where Holter monitoring is not necessary (81% Lown O-I) and the patients with mean or severe LVH (ST greater than or equal to 12 mm) where this investigation seems very interesting, nearly 65% of them present high-grade ventricular arrhythmias.

The authors report a new case of primary chylopericardium in an asymptomatic 26 year old male. In view of the negativity of the complementary etiological investigations a surgical subxiphoid window was performed and this confirmed the diagnosis. After failure of isolated evacuatory drainage, the patient was cured by pericardectomy. The anatomo-clinical, biochemical and diagnostic features of this condition are described based on a review of the other cases of primary chylopericardium reported in the literature. Surgical pericardectomy seems to be the only effective long term treatment.

In severe chronic congestive cardiac failure the physician has the choice of two families of positive inotropic agents, the direct sympathomimetics and the phosphodiesterase inhibitors. The aim of the study was to compare the efficacy and tolerance of enoximone and dobutamine in this indication. Twenty patients with severe chronic cardiac failure with a cardiac index of less than 2.2 l/min/m2 and pulmonary capillary pressure of over 20 mmHg were randomised into two groups in an open trial. One group received enoximone 50 micrograms/kg/min for 30 minutes then 10 micrograms/kg/min and the other received dobutamine 10 micrograms/kg/min. The two groups were comparable. Results were analysed 12 hours after starting therapy, well after the loading dose of enoximone and before the appearance of tolerance to dobutamine. Neither drug caused a significant change in heart rate or mean blood pressure. The pressure-rate product did not increase significantly with enoximone (+9.2% NS) in contrast with the dobutamine group in which a significant elevation was observed (+23.5%, p less than 0.05). The cardiac index increased with enoximone (+61.0%, p less than 0.01) and with dobutamine (+32.1%, p less than 0.02). This resulted mainly from an increase in the systolic index (+45.5%, p less than 0.05 with enoximone and +30.1%, p less than 0.05 with dobutamine). Pulmonary capillary pressure and total systemic resistance decreased with enoximone (-29.1%, p less than 0.001 and -36.7%, p less than 0.05 respectively) and with dobutamine (-23.4%, p less than 0.001 and -20.7%, p less than 0.05 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

The main objective is to determine when concentric left ventricular hypertrophy (LVH) increased ventricular ectopic activity in essential hypertension. Twenty-four hours Holter monitoring was recorded in 56 patients with essential hypertension: 20 without LVH and 36 with concentric LVH determined by echocardiography (left ventricular mass greater than 215 g). According the degree of septal thickness (ST), patients were classed in 4 groups: (formula; see text) This study allows to conclude that mean and severe concentric LVH (ST greater than or equal to 12) detected by echo are associated with a greater PVC and a higher Lown's class ventricular ectopy. The degree of ST was strong correlated with the Lown's classification (r = 0.6, p less than .0001).