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Objectives: The QKD interval is measured between the onset of QRS on the ECG and detection of last Korotkoff sound by a microphone placed on the brachial artery while measuring BP. It is the sum of preejection time and pulse transmission time and thus is correlated to pulse wave velocity (PWV). This interval is automatically monitored with BP and HR every 15 minutes during 24 h with an ambulatory blood pressure monitoring device (Diasys integra, Novacor, France). The 96 measurements obtained allow to automatically calculate the QKD(100-60), QKD value for 100 mmHg SBP and 60 bpm HR. This indice of arterial stiffness has been shown to be linked to future cardiovascular (CV) events, independently of 24 h BP. However this interval may be abnormally prolonged in case of left bundle branch blocks (LBBB)., Methods: We tested the effects of simply removing QRS duration from QKD(100-60) value on the prediction of CV events in a population of 412 hypertensives (247 males: age = 53 +/- 14 years; office BP = 158 +/- 19/97 +/- 11 mmHg; 24 h BP = 133 +/- 17/86 +/- 11 mmHg) followed prospectively., Results: Mean follow up was 65 months, 32 pts were lost, 49 CV events occurred including 11 deaths. Cox model showed that baseline QKD(100-60) (m = 202 +/- 19; 142-254 ms) was significantly (p < 0.05) associated to events independently of age, 24h SBP and other traditional risk factors. Removing QRS duration (m = 85 +/- 10: 61-158 ms) improves the relation to events (monovariate khi2 = 38 vs 30)., Conclusion: Removing QRS duration from QKD(100-60) improves its predictive value of future CV events and allows using this method in patients with LBBB.

In patients successfully operated for coarctation of the aorta, the prevalence of hypertension is higher than that observed in the general population although the exact mechanism is not known. The hypothesis of increased arterial rigidity despite satisfactory correction of the coarctation has been proposed. The authors undertook 24 hour ambulatory blood pressure monitoring coupled with measurement of the QKD interval (pulse wave velocity) in order to evaluate the rigidity of the large arteries. These results were compared with those obtained in control patients paired with respect to gender, age, height and weight. Twenty-six patients with an average age of 14.5 +/- 2.9 years were included (age at time of surgery 6.3 +/- 3.7 years). The statistical data confirmed a higher systolic blood pressure (p<0.05) in the operated patients compared with controls. The results confirm the hypothesis of increased residual arterial rigidity in children operated for coarctation of the aorta which could predispose to secondary hypertension, especially on effort. In the long term, this could be an unquestionable cardiovascular risk factor explaining the increased cardiovascular morbid-mortality compared with the general population.

Primary hyperaldosteronism is a diagnosis which should be considered in refractory hypertension even in the absence of any hypokalaemia. Its detection relies above all on the levels of renin and aldosterone. The aldosterone/renin ratio has been proposed as the most sensitive criterium. The reference values used for the diagnosis of primary hyperaldosteronism are very variable in the literature, depending not only on the method used but also on the criteria used for their determination. In this study we evaluated the defined reference values prospectively by studying a population of patients with a Conn's adenoma treated surgically. The study included an initial retrospective period which allowed identification of 29 cases of Conn's adenoma treated surgically, and a 9 month prospective period during which 212 reports were collected. During this prospective period a further 9 cases of Conn's adenoma were detected, which were successfully treated with surgery. Analysis to discriminate the 38 Conn's adenomata from the rest showed that 3 parameters contributed significantly and independently to the diagnosis: supine plasma renin activity (ARPc), supine aldosteronaemia and the erect aldosterone/renin ratio, allowing correct classification in 88% of the cases. The reference ranges of these 3 parameters were calculated in order to give a sensitivity of 100% and the best possible specificity, therefore allowing a combined criterium involving all 3 parameters to be defined: ARPc < 0.45 ng/ml/h, supine aldosteronaemia >417 pmol/l, and erect aldosterone/renin >1180.

One could expect that malignant hypertension would belong to the history. Unfortunately, this complication has not been eradicated even though many physicians have already forgot it. The hypertension care units are still confronted to it, and even the arrival of the renin-angiotensin system blockers have changed the prognosis of those patients, an adequate management on emergency remains mandatory in order to avoid in particular the evolution to renal failure. By reporting a series of 42 patients included in a period of 7 years, we aimed to remind the presentation of this severe pattern of hypertension and the basics of its management.

In the Bordeaux cohort of never treated, uncomplicated hypertensive patients with office BP > 140/90 on at least 2 occasions, we selected those with good quality 24 H ambulatory BP measurement and LVM measured with M mode echo before any antihypertensive treatment. In this group, we studied the relationships between LVM and average 24 h systolic BP in males and females in univariate and multivariate analysis, taking into account age, weight and height. The population studied included 531 patients whose main characteristics are summarized in the table. The slope of the relationship between LVM and 24 h SBP is significantly steeper in males than in females (1.73 vs 0.58, p < 0.01). In multivariate analysis, the variable showing the higher correlation to LVM is 24 h SBP in males, weight in females. For a similar increase in BP, males hypertensive show a higher increase in LVM than females.

Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiovascular complications independently of other known risk factors. Since 1983, we have followed up a cohort of initially untreated hypertensive patients with echocardiographic measurements of left ventricular mass (LVM). We analyzed the data on 474 patients with more than five years' follow-up to assess the prognostic value of LVM and the sensitivity and specificity of the different ways to index for LVM through ROC curves. Forty patients were lost to follow-up. The mean follow-up period was 89 +/- 31 months. A cardiovascular complication was recorded in 40 individuals. There was a strong link between increased LVM and the occurrence of complications. Indexation by body surface area or height to the power 2.7 give the [table: see text] greatest area under the curve (AUC) to discriminate between patient with or without cardiovascular events. To get the same sensitivity in females and in males for the prediction of future events, lower cut-off must be used in females.

Hypertension is a cardiovascular risk factor. In addition to simple normalisation of the blood pressure, the true objective of treatment of hypertension should, therefore, be reduction of the excess risk and it is in terms of morbi-mortality that the real benefits of antihypertensive therapy should be evaluated. However, trials of morbi-mortality are long and costly so that intermediate criteria are proposed for assessing therapeutic benefits with measurement of left ventricular mass as one of the best candidates. The concept is interesting but it is essential to question its clinical pertinence. In order that an intermediary criterion be acknowledged as a substitution criterion, it has to fulfil the following conditions: it must be simple, reliable and reproducible to measure it must be modifiable by therapeutic intervention it must be closely related to the degree of risk, whichever way it changes the amplitude of its changes must provide a quantitative prediction of risk-associated changes finally, in the particular case of hypertension, the benefit of the improvement of the substitute criterion should be distinguished from the benefits due to lowering the blood pressure alone. Left ventricular mass measured by echocardiography is the most documented intermediate substitution criterion over the last 20 years. It fulfils most of the conditions of a substitute criterion. However, the relationship between its reduction with treatment and the reduction of risk, independently of the change in blood pressure, remains to be shown.

To improve the standardisation and reproductibility of echocardiographic left ventricular mass (LVM) measurements we developed a specific software for automated measurements of LV diameter (EDD) and wall thickness (ST&PWT) from M mode recordings on SVHS videotapes using a dedicated computer system lô 3.3 (lôDP, Paris, France). Images are digitalised into 640 x 580 pixels with 256 grey levels. The algorithm computes the averages grey-level over an area of 10 pixels width based on the QRS on ECG and the profile obtained is analysed in order to estimate the position of wall interfaces with 2 choices: PENN or ASE conventions. We compared lô results performed twice at 1 week interval (lô 1&2) to conventional (Man) measurement (PENN convention) by a trained echocardiographist in 50 echos performed in hypertensives. Results are mean +/- SD, no significant difference was found between lô 3.3 and Man measurements with closed correlations. The reproductibility of the measurements is significatively improved by the automated procedure as well as the time to recover the results.

Left ventricular hypertrophy is associated with a high risk of cardiovascular complications in all the populations in which it has been studied, especially in hypertensive patients. The echocardiographic measurements of left ventricular mass provides a quantitative approach to this risk, independent of the classical cardiovascular risk factors. It is very tempting to wish to replace the measurement of risk factors which, due to their great variability, are not easy to assess (blood pressure) by a marker which integrates several of them (blood pressure, age, weight, salt intake, blood viscosity, serum cholesterol ...) and their variation with respect to time. However, it is too early to recommend this practice for routine use. M mode echocardiographic measurement of left ventricular mass is relatively difficult technique feasible only in about 80% of the population. Even in the hands of experts, its reproducibility is far from perfect. Technical developments may lead to improvement. It remains to be demonstrated that the use of these values improves the management of hypertensive patients and this will not be an easy task. However the follow-up of left ventricular mass during treatment may be an alternative to trials of morbi-mortality in hypertensive patients with the advantage of requiring a shorter follow-up period and fewer patients. It also remains to be demonstrated that regression of left ventricular hypertrophy is accompanied by a corresponding reduction in cardiovascular complications.

Amoebic abscess of the liver is sometimes complicated by deep venous thrombosis but extension to the right atrium is rarely observed. The authors report the case of inferior vena caval thrombosis extending to the right atrium in a case of amoebic hepatic abscess. The patient was treated initially by antibiotherapy with metronidazole associated with intravenous anticoagulation. Rapid extension of the thrombus despite this treatment led to the initiation of thrombolysis. There were no embolic complications and the outcome was good. Apart from the rarity of this complication, this case poses the problem of the management of these patients. No previous reports of the use of thrombolysis were found in the medical literature. In the light of previous publications and the present case, the authors suggest investigation by CT scanning, echocardiography and venous Doppler ultrasonography in all cases of hepatic amoebic abscess.

Calculation of left ventricular mass by M mode echo is based on the assumption that the geometry of the left ventricle is an ellipsoid, the long axis of which is twice that of its short axis. The hypothesis in not always true and often leads to overestimation of the ventricular mass. The authors propose a method combining M mode data (end diastolic dimension, septal and posterior wall thickness) and 2D measurement of the left ventricular long axis: the left ventricular mass was measured by Devereux's and the authors' methods in 185 hypertensives. The 2D measurement of the long axis (mean: 84.7 mm) was much smaller than twice the short axis (mean: 52.3 mm) and the two measurements were poorly correlated. Measurement of the long axis was reproducible. The two methods of calculation were closely correlated (r = 0.95) but, on average, 23% lower with the authors' method. These results seem to be more closely related to ambulatory blood pressure than those of the classical method. The authors' combined method takes into account the true geometry of the left ventricle better than M mode method alone and avoids overestimation of left ventricular mass and the prevalence of excentric left ventricular hypertrophy in hypertensive patients.

We have proposed the use of the ambulatory monitoring of the timing of Korotkoff sounds (QKD interval) to assess arterial distensibility. This interval is inversely linked to pulse wave velocity. The study of its variations according to spontaneous blood pressure changes during 24 h allows to calculate indices of arterial distensibility independent of actual blood pressure. A normalized QKD100-60 is calculated as the value for a 60 batt/min heart rate and a 100 mmHg systolic blood pressure from the individual multivariate linear relationship between these 3 variables. This interval decrease with arterial distensibility. We tested the reproducibility of this method in 28 normal subjects (14 males, 14 females, aged 43 +/- 16 years) who underwent two 24 h recordings during daily routine separated by one week. Standard deviation of differences for QKD100-60 was 12 ms, the coefficient of variation 6% and the coefficient of repeatibility 24 ms. So QKD100-60 shows a good reproducibility in the same range that 24 h blood pressure means.

Ablation of the atrioventricular junction consists in creating a therapeutic AV block to facilitate the treatment of symptoms caused by atrial arrhythmias refractory to drug therapy. The technical performance of ablation has been improved by restricting the indication to atrial fibrillation, by using radiofrequency currents, by choosing a nodal rather than His bundle ablation site, and by improving the function of cardiac pacemakers (rate adapting, back-up). The functional results are excellent but the outcome is punctuated by rare cases of sudden death, the cause of which is not fully understood (dependance, ventricular arrhythmias, ...). To avoid permanent pacing, it has been suggested that atrioventricular conduction should be modulated rather than completely interrupted. Modulation of the fast pathway has been shown to be ineffective; that of the more complex, slow pathway, seems to be more promising. Although this obviates the need for a pacemaker, it does not suppress irregularity of the ventricular rhythm, the main cause of symptoms in paroxysmal atrial fibrillation and of the haemodynamic changes associated with permanent atrial fibrillation.

Left ventricular hypertrophy is an important risk factor in hypertension and the results of the HYCAR study confirm that it is possible to treat this risk factor independently of an action on the blood pressure. Should systematic echocardiography be performed in every hypertensive patient to diagnose left ventricular hypertrophy and follow up its outcome with treatment? This attitude seems to be premature for two reasons. Firstly, echocardiography, though much more sensitive than electrocardiography for diagnosing left ventricular hypertrophy, has a number of limitations. Good recordings cannot be obtained in all patients; even under the best conditions of reproducibility, the measurement of left ventricular mass is not excellent and does not allow reliable individual follow-up of treatment; even the criteria of left ventricular hypertrophy used at present are open to criticism. Secondly, it remains to be shown whether the reversibility of left ventricular hypertrophy, independently of lowering the blood pressure, improves the prognosis of the hypertensive patient. The intensive research into this problem, further stimulated by the encouraging results of the HYCAR study, should help define the role and value of echocardiography in the future management of hypertension.

Conversion to sinus rhythm (cardioversion) is recommended to prevent the haemodynamic and thromboembolic complications of atrial fibrillation. Prior anticoagulation is compulsory except in emergencies. The duration of anticoagulant therapy depends on the terrain and chronicity of the arrhythmia. Cardioversion may be proposed for the majority of patients in whom it is thought that sinus rhythm can be maintained by appropriate therapy. It may be carried out pharmacologically by oral or intravenous antiarrhythmic therapy. Amiodarone is the drug of choice. Cardioversion may also be carried out by external or internal direct current shock. The success rate of external electrical defibrillation depends on the energy administered, the site of the electrodes and a number of factors related to thoracic impedence. Internal electrical defibrillation may be performed with an endocavitary catheter or by the oesophageal approach, with few complications. The main problem resides in maintaining sinus rhythm in the long term. When this is not possible, cardioversion is useless, and therapy to slow the cardiac rhythm should be instituted.

Ambulatory monitoring of Korotkoff sounds appearance time (QKD interval) was performed during 24 hours in 131 normal subjects (85 males, 46 females, aged 14-78 years, mean 36 +/- 15 years) with a new device (Diasys 200RK, Novacor-France). This device allows simultaneous measurements of blood pressure, heart rate and QKD interval at programmed intervals, every 15 minutes in this study. For each patient we calculated the average 24th QKD interval, the QKD interval for a systolic BP of 100 mmHg and a heart rate of 60 bt/min (QKD: 100-60), and the slope (S) of the variations of the QKD interval against systolic BP and pulse pressure (PP). Results are presented for each 10 years age group (mean +/- SD).

Systolic and diastolic blood pressure profiles of 2,808 healthy subjects are reported according to age, sex and exercise protocols. The rates of increase of systolic pressures are expressed with respect to the heart rate and decrease with age. For a given sub-maximal effort the systolic blood pressure is lower in males and in the younger age groups: the diastolic blood pressure only increases significantly on exercise after 50 years of age. These variations according to age and sex were confirmed on treadmill exercise but the peak pressure values were lower. These quantitative results differ from those of previously reported studies and suggest that the diagnostic criteria of hypertension of effort should be redefined.

To optimise the regulation of rate responsive pacemakers, the authors propose standardized tests of everyday activities. Seven tests were selected with monitoring of the heart rate (HR) by telemetry every 30 seconds: two reference tests--cycloergometry: 2 steps of 3 minutes at 30 then 60 watts and a symptoms-limited Bruce protocol on the treadmill--and 5 everyday activities, walking, going upstairs, going downstairs, squats and hyperventilation. Fifteen normal subjects (65 +/- 10 years) were used to establish normal values and 10 patients implanted with a Telelctronics Meta DDDR 1250 rate responsive pacemaker with minute ventilation sensing, were studied after choice of minimal and maximal HR on clinical criteria (age, pathology). The rate response frequency (RRF) was adjusted so that the pacemaker HR was within normal values. At the beginning of each test, the sensor was hypokinetic (p = 0.01). Hyperventilation caused hyperkinesia of the sensor (p = 0.01). A good correlation was obtained between PM patients and normal subjects on walking, going up down stairs and for squats (p = NS). On cycle ergometry and treadmill, the PM remained slightly hypokinetic (p = 0.02). The study of "ideal" RRF measured at "peak exercise" as proposed by the manufacturer was only satisfactory in 1 of the 10 cases. This study confirms the value of using everyday activities for programming rate responsive pacemakers, the limitations of automatic adjustment and the need for personalized programming.

There are three fundamental mechanisms of ventricular tachycardia (VT) reentry, abnormal automaticity and triggered activity (TA) related to early or late after potentials. Reentry is certainly the mechanism of branch to branch and post-infarction VT. Early TA is responsible for Torsades de Pointes. Late TA is possibly the cause of certain verapamil-responsive VT but calcium-dependent reentry cannot be excluded. Abnormal automaticity or late TA may also play a role in catecholamine-induced VT. The development of drugs specific for the mechanism confronted with the results of programmed stimulation and mapping should improve the understanding of the mechanism of VT in each individual patient and allow more effective and better tolerated antiarrhythmic therapy.

One hundred and one consecutive patients with infectious endocarditis were examined by transthoracic (TTE) and transoesophageal echocardiography (TEE). There were 71 cases of endocarditis on native valves (N) and 30 cases of endocarditis on prosthetic valves (P). The detection of vegetations was significantly greater by TEE (93%), than by TEE (73%) on native valves but the rate of detection of endocarditis on prosthetic valves was low and identical with both methods. Out of a total of 18 abscesses, only 6 were detected by TEE compared with 15 by TEE. There were 3 false negative results by TEE: small anterior abscesses marked by the prosthesis or aortic calcifications. In addition, TEE demonstrated 3 perforations and 2 mycotic aneurysms of the mitral valve. The lesions were confirmed anatomically in 48 cases. The sensitivity of TEE was 94% and the specificity was 84.5%; the negative predictive value was 87.5%. These results show that TEE is significantly superior in the detection and morphological analysis of vegetations. It is the method of choice for the diagnosis of abscesses, especially in prosthetic valve endocarditis.

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

Objective: This multicenter study was aimed at determining whether the baseline ambulatory blood pressure (BP) level does influence the efficacy of angiotensin-converting enzyme inhibitors (CEI) and that of calcium antagonists (CA) to the same degree., Methods: The BP recordings of 236 patients with mild to moderate hypertension were reviewed: these subjects previously entered clinical trials comprising a mean 2-week placebo period and a mean 6-week active treatment phase (CEI = 115, CA = 121). The 24-hour baseline ambulatory BP was considered as high when greater than 139/87 mmHg, according to Staessen's meta-analysis., Results: In the patients with an high baseline ambulatory BP, CEI and CA have had roughly a similar effect (reduction in systolic = 9.5 +/- 7.8% vs 7.7 +/- 6.3%, NS; reduction in diastolic = 9.8 +/- 8.6% vs 8.3 +/- 5.8%, NS). Conversely, the patients with a baseline ambulatory BP level lower than or equal to 139/87 mmHg experienced a greater reduction in ambulatory BP with CEI than with CA (systolic = 7.9 +/- 7.0% vs 0.6 +/- 6.7%, p = 0.0001; diastolic: 5.0 +/- 7.4% vs 1.9 +/- 7.6%, p = 0.040). Finally, further analysis found the threshold of drug efficacy to be 120/80 and 135/85 mmHg in CEI and CA patients respectively., Conclusions: 1) CEI are more effective than CA in patients with a low ambulatory BP only. 2) The risk of a visceral hypoperfusion seems however to be limited, since CEI do not reduce diastolic ambulatory BP further, when its baseline level is lower than 80 mmHg.

The aim of this study was to analyse the velocity profile of the systolic fraction of the pulmonary venous flow (PVF) in mitral regurgitation (MR). Three velocity profiles were identified in left superior pulmonary vein. Inversion of the systolic fraction of the PVF was specific for angiographic grade 4 MR (specificity 97%, sensitivity 100%). On the other hand, a decrease in this wave is much less specific for mild MR and depends on severe factors such as left atrial pressure, size and ejection fraction and the lack of atrial systole (as in atrial fibrillation or atrioventricular block). Therefore, inversion of PVF has a good positive predictive value for severe MR, but the interpretation of attenuation of this wave should take into consideration not only the MR but also left atrial pressure and compliance.

The aim of this study was to evaluate the results of transesophageal echocardiography in the diagnosis of abnormal intraatrial echoes detected by transthoracic echocardiography. Patients with active endocarditis, mitral stenosis, and valve prostheses were excluded. The 47 patients (28 women and 19 men) were classified into 4 groups according to the results of transesophageal echocardiography. Group I: normal (7 cases), "phantom echos"; Group II: anatomical variants (9 cases), Chiari apparatus, muscular spur; Group III: pseudo-tumours (7 cases); retro-atrial haematoma, mitral valve prolapse, interatrial septal aneurysm; Group IV: cardiac masses (24 cases). This group comprises: typical myxomas (10 cases), typical thrombi (2 cases), localised atypical masses, relatively immobile and non-prolapsing: 5 myxomas, 1 metastasis, 2 thrombi. The results of this study suggest that transesophageal echocardiography is very useful in diagnosing suspected abnormal intraatrial echos observed on conventional transthoracic examination. However, the nature of the mass may remain obscure.

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

The effects of 6 months treatment with Sotalol on the blood pressure, left ventricular mass and function, were studied in patients with essential hypertension and left ventricular hypertrophy. Thirty-three patients (18 men and 15 women aged 53 +/- 11 years) were included initially and 26 were reviewed after 6 months of treatment. The left ventricular mass and function were evaluated by Doppler echocardiography and all recordings were interpreted "blind" at the end of the study by two operators. Treatment led to a significant reduction of the blood pressure (152 +/- 12/94 +/- 11 versus 166 +/- 18/100 +/- 9 mmHg) and of the heart rate (60 +/- 10 versus 76 +/- 12 beats per minute). The left ventricular mass index decreased by 8% (p less than 0.001) due to reduction in wall thickness. Resting left ventricular systolic function was unchanged. Left ventricular filling patterns improved with an increase in the E/A ratio which was reduced at the beginning of the trial.

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

Unlabelled: To better define the different forms of hypertensive heart disease, we performed 2D guided M mode echo recording of the left ventricle (LV) and Doppler assessment of LV filling in 118 newly recognised (less than 1 year) and untreated hypertensive patients (mean age +/- SD: 49 +/- 10 years, 80 males, 38 females). All recordings were read "blindly". 86 patients underwent also 24 hours BP monitoring during daily routine., Main Results: 1) The relative wall thickness (h/r) shows a normal distribution: mean = 0.39; SD = 0.08; 1st quartile = 0.33; 3rd = 0.43; 2) The septal/posterior wall ratio (ST/PWT) shows also a normal distribution: mean = 1.14; SD = 0.24; 1st quartile = 1; 3rd = 1.3; 3) Among patients with LVH (Devereux's criteria, n = 65) the 6 patients with h/r less than or equal to 0.33 are significantly different from the 18 patients with h/r greater than or equal to 0.43 for age (44 +/- 8 vs 51 +/- 10; p less than 0.03), casual (146 +/- 7 vs 166 +/- 13 mmHg; p less than 0.05) and ambulatory SBP (135 +/- 19 vs 146 +/- 16 mmHg; p less than 0.05), peak systolic stress (280 +/- 15 vs 187 +/- 31 Dynes/cm2; p less than 0.001) and E/A ratio (1.17 +/- 0.01 vs 0.94 +/- 0.27; p less than 0.05) but not for ponderal excess. 4) Patients with asymmetric LVH(ST/PWT greater than 1.3 in 22; greater than 1.5 in 10) are significantly different from patients with symmetric LVH for age (54 +/- 10 vs 47 +/- 10; p less than 0.03), diastolic diameter (51 +/- 5 vs 53 +/- 5 mm; p less than 0.02), ST (13.2 +/- 2.9 vs 10 +/- 1.9 mm; p less than 0.001) and PWT (8.9 +/- 1.5 vs 9.7 +/- 1.5 mm; p less than 0.02) but not for BP fractional shortening and LV filling., Conclusion: eccentric LVH may be found in young hypertensive patients with normal systolic function and LV filling despite high parietal stress; asymmetric LVH is more frequent in older patients in which LVH seems to develop rather on the septum than on free wall, independently of BP and without consequences on LV function.

Forty-three consecutive patients with mechanical valve prostheses underwent transthoracic and transoesophageal echocardiography for suspected thrombolic prosthetic valve dysfunction. The results of these investigations were compared with those of cineradiography and the clinical outcome. The diagnosis of thrombosis was retained in 11 of the 43 patients (10 mitral and 1 aortic valve prostheses). The transthoracic Doppler echo was clearly abnormal in 6 of the 11 cases. Transoesophageal echo was of essential value in all cases but one, showing abnormal movement of the mobile element and/or a paraprosthetic thrombus. The cineradiography gave false negative results in 6 cases. In conclusion, these cases underline the undeniable value of transoesophageal echocardiography in occlusive or non-occlusive thrombosis of a mitral valve prosthesis. This investigation should be undertaken whenever there is the least suspicion of thrombosis of the prosthesis.

Aneurysms of the sinus of Valsalva are rare and usually present with rupture communicating with the right heart cavities. Echocardiography is a powerful diagnostic tool in ruptured sinus of Valsalva aneurysms, especially the Color Doppler mode which shows abnormal, continuous flow as a mosaic of colour extending from the aortic root to the right heart cavities. The four case reports describe rupture of the right sinus of Valsalva aneurysm into the right atrium (2 cases) and the right ventricle (2 cases). Transesophageal echocardiography was performed in two cases and provided valuable information by confirming the site of rupture and the length of the diverticulum. The results illustrate the accuracy of Doppler echocardiographic techniques by the transthoracic and transoesophageal approaches in the diagnosis of ruptured sinus of Valsalva aneurysms.

The diagnosis of thrombosis of a valvular prosthesis is difficult especially in cases of partial thrombosis. The authors report 19 cases of partial thrombosis of mainly (16 cases) mechanical valve prostheses confirmed by radioscopy and treated either by reoperation or fibrinolysis. Mitral Valve Prostheses: 14 cases (6 Björk, 7 SJM, 1 Carbomedics). All but one case showed significant prolongation of the pressure half time compared with the postoperative reference value. In one case, however, the functional parameters of the prosthesis were normal; the diagnosis was made from the finding of a mobile thrombus on the ventricular surface of the prosthesis. Aortic Valve Prostheses: 5 cases (3 Björk, 1 SJM, 1 Duromedics). Continuous wave Doppler showed significant increases in the velocity of transprosthetic blood flow with respect to the postoperative reference values. Accurate analysis of the mobile elements of the prostheses was usually impossible. These results show that transthoracic Doppler echocardiography remains an excellent method of study and surveillance of mechanical valve prostheses but the limitations of the technique should be familiar to all operators.

The authors describe the echocardiographic features of 19 cases of intracardiac metastatic tumours diagnosed over a 5-year period. The cardiac appearances were very varied: pericardial effusion alone or associated with an intrapericardial tumour (9 cases), myocardial infiltration (9 cases), immobile or mobile intracavitary tumour sometimes simulating a myxoma (15 cases). In 18 out of the 19 cases, the tumour mass was hyperechogenic which made it easy to diagnose. However, in one case of right atrial tumour, the mass was hypoechogenic and the diagnosis could only be made by contrast echocardiography. This study illustrates the important role that two-dimensional echocardiography plays in the non-invasive diagnosis of intracardiac metastatic tumours but physicians should be aware of the potential pitfalls and limitations of the technique.

The diagnosis of partial thrombosis of mitral disc valve prostheses is particularly difficult because the clinical presentation is often atypical and the motion of the two hemi-discs is hard to analyse by transthoracic echocardiography. The authors report three cases of partial thrombosis of mitral double-disc valve prostheses. It was not possible to analyse the motion of the two hemi-disc correctly in any of the three patients. The mitral transprosthetic flow recorded by continuous wave Doppler was abnormal with respect to the reference postoperative recording. In addition, in one case, an abnormal echo was observed floating in the left ventricular inflow tract and was suggestive of a thrombus. Transesophageal echo showed abnormal motion of one of the hemi-discs. In two patients this consisted in immobility of the hemi-disc in the semi-closed position; in the other patient, limited excursion of the hemi-disc was recorded. Abnormal retrograde flow in the left atrium was observed in 2 cases and abnormal echoes on the atrial surface of the valve were recorded in one case. After fibrinolysis the transthoracic and transesophageal Doppler echocardiographic parameters returned to normal. These three cases underline the complementarity of transthoracic and transesophageal echocardiography in the diagnosis of dysfunction of mitral disc valve prostheses.

Ambulatory blood pressure monitorings for diagnosis purpose in non treated hypertensive patients are often performed only during day time for two reasons. First, target organ responses to hypertension, and mainly left ventricular hypertrophy, are more closely related to activity than to rest BP. Second, these automatic devices are frequently not well tolerated during sleep because of their noise during inflation of the cuff. However, 24 h BP monitoring seems of greater interest in treated hypertensive patients to control the efficiency of the treatment. As suggested by our work, incomplete lowering of BP during night may not be harmless. In a prospective study, we evaluated the relationship between BP recorded during 24 h (Spacelabs 5200) and M mode echocardiographic measurements of left ventricular mass index (LVMI) (Devereux's formula) both in non treated hypertensive patients (group A, n = 40) who had discontinued therapy at least 8 days prior to the study and in hypertensive patients treated with the same drugs for more than 3 months (group B, n = 24). More than half of these patients were receiving beta blocking agents. As previously stated day (8 h-22 h), systolic BP is better related with LVMI than clinical (C) and night (23 h-7 h) SBP in group A. In contrast, a higher correlation was found between night BP and LVMI in group B, which was significantly different from the correlation found in group A (Z test, p less than 0.05). (Table: see text). In conclusion, 24 h BP monitoring is useful in treated hypertensive patients. Inadequate lowering of BP during night time may partially account for persistent left ventricular hypertrophy in treated hypertensive patients.

Echocardiography is universally recognized as a first-line examination easy to perform at all times in patients with thoracic pain suggestive of aortic dissection. But like all diagnostic methods, it has its limitations and pitfalls. The present study, based on 29 consecutive cases, demonstrates the value of pulsed Doppler echocardiography in the diagnosis and monitoring of aortic dissection. When the echocardiographic images are typical of the disease, the Doppler technique helps evaluate the lesions (aortic insufficiency, number of patent channels), but it is mainly in cases with doubtful echocardiographic findings that the Doppler technique provides elements that clinch the diagnosis, notably by showing the presence ot two patent channels with different blood flows. In addition, we would like to draw attention to a new and useful sign: flapping ot the dissected intima when the Doppler window is over it; we observed this sign in 24 of our 29 patients.

The authors report two cases of severe non-obstructive cardiomyopathy presenting at the end of pregnancy in young women treated for long periods and at high dosage with beta 2-adrenoceptor stimulants, prescribed for threatened abortion or premature labour. The circumstances of the presentation, the clinical prescribed for threatened abortion or premature labour. The circumstances of the presentation, the clinical picture and the course towards complete recovery suggest that this might be a pathological process different from "cardiomyopathy of pregnancy" and be an "adrenergic myocarditis" induced or made worse by these drugs. The authors deduce some simple preventive measures.

Unlabelled: In a prospective study the relation of left ventricular hypertrophy and exercise versus ambulatory blood pressure was analysed in 31 patients with essential hypertension (10 females, 21 males, mean age 44 +/- 14). Hypertension is borderline and has never been treated in 8 patients, mild to moderate in 24 patients who had discontinued therapy at least 8 days prior to the study. M mode echocardiogram, bicycle exercise testing and ambulatory blood pressure monitoring (spacelabs 5200) were performed within a 7 days period. Left ventricular wass (LVM) was calculated from M. mode echo data according to Devereux's formula and used to determine a LVM index (LVM/Body surface area). Correlations between LVM index and rest (R) SBP, end exercise (EE) SBP, the average of approximatively 60 SBP recordings from 7H to 22H (A-SBP) and the average of the 5 highest (5H) SBP recordings in the day are reported: (Formula: see text). There is no significative correlation with diastolic blood pressure., Conclusion: 24H A-SBP and EE-SBP appears to correlate better with severity of LVH than does the R-SBP. The selection of the 5 highest SBP in a day do not improve the correlation compared with R-SBP.

The aim of this study was to validate an echocardiographic method of evaluating LV mass by assessing the reproducibility and comparing the results with those of angiography. 20 patients without abnormal regional wall motions or asymmetric septal hypertrophy underwent left ventriculography in the RAO plane and three successive M mode and 2D echocardiograms. Three 2D echo methods of measuring volumes and mass were used: the monoplane ellipsoid model obtained from apical views, the biplane ellipsoid model from an apical and a short axis parasternal view and the hemi-ellipsoid-cylinder model (HEC). The M mode evaluations showed good reproducibility with respect to volume (variation coefficient (VC): inter observer 9.8 p. 100 and intra patient 15.6 p. 100). The reproducibility of 2D echo measurements was much poorer (intra patient volume: VC = 34 to 45 p. 100; mass 29 to 46 p. 100). A close correlation was observed between the results of M mode echo and angiography; volume r = 0.85, SD = 60 g. With respect to the 2D method, the best results were obtained with the HEC model; volume r = 0.90, SD = 31 ml; mass r = 0.82, SD = 41 g. We suggest a method combining the M mode and 2D techniques, using a HEC model in which the long axis is obtained by 2D echocardiography and the short axis and wall thickness by M mode recordings. The following correlations with the angiographic method were obtained: volume r = 0.91, SD = 36 ml; mass r = 0.89, SD = 27 g.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal angioplasty is being more and more performed as the first choice treatment of renovascular hypertension. However, very few studies are devoted to the comparison of angioplasty versus surgery in treating renovascular hypertension and no one is prospective. A group of 25 patients with renovascular hypertension who underwent surgical treatment in the years 78-82 was compared to a group of 32 patients who underwent transluminal angioplasty in the years 82-86. Age, sex, etiology and severity of the arterial stenosis, blood pressure before treatment were similar in both groups. Average follow up was 44 +/- 33 months in the surgical group (S), 18 +/- 15 months in the angioplasty group (A). In the surgical group, we noticed one death, 20 p. 100 of major complications (thrombosis or stenosis of bypass grafts). In the angioplasty group, there was no death, 82 p. 100 of initial success, 12 p. 100 of major complications which needed surgery, 22 p. 100 of restenosis which were treated with a second angioplasty. Patients were classified as cured (BP less than 140/90 without treatment and perfect renal vascularisation) improved (BP less than 160/100 without treatment or with treatment if reduced and renal artery stenosis less than 50 p. 100), unchanged (BP greater than 160/100 and/or renal artery stenosis greater than 50 p. 100 or thrombosis). (Table: see text). Results are similar in both groups. The simplicity of the procedure, a lower cost and the absence of lethal complications are in favour of the transluminal angioplasty as the first choice treatment of renovascular hypertension.

The blood pressure pattern and variability were assessed in a population of 394 normotensive subjects (OMS) stratified by age (20 to 75 years) and sex. Ambulatory blood pressure measurements were performed with an automatic device (Spacelabs 5200) every 15 min. from 6 a.m. to 12 p.m., and every 30 min. from 0 a.m. to 6 a.m. The analysis was effected during normal daily activities (from 9 a.m. to 7 p.m.) and during night (from 11 p.m. to 7 a.m.). Blood pressure levels were higher in males than females. During daytime and nighttime, diastolic blood pressure rose with age until 59 years while SBP was not affected, except for the females older than 60 years. After this age, diastolic blood pressure decreased. No epidemiological study has provided a measure of the cardiovascular risk related to ambulatory blood pressure, so that we were unable to define true normal values. However, reference population values provided from two statistical methods: limit of the 95th upper confidence interval for the mean of limit of the 90th percentile value for the total data. These blood pressure distributions according to age and sex may allow a better approach to borderline hypertensive patients.

Aneurysms of the renal artery are seldom encountered. They present as different aetiopathological types. We report the case of a female patient who had both severe arterial hypertension and an apparently dysplastic aneurysm of the right prepyelic artery. Resection of the aneurysm failed to have the effect we expected on arterial hypertension. The relationship between arterial hypertension and aneurysm of the renal artery is discussed.

This case of an intracardiac myxoma observed in a 15 year old girl had several points of interest: the mode of presentation: the clinical signs were exclusively systemic and articular; the mode of diagnosis: 2D echocardiography demonstrated an immobile, dense mass about the size of a walnut implanted on the ventricular surface of the posterior mitral leaflet along the whole of its base and seemingly adherent to the ventricular wall; the intraventricular location of the tumour (exceptionally rare) and its mitral valve origin. The site of the tumour imposed mitral valve replacement but we were able to discuss the surgical approach using the results of echocardiography before surgery and a bioprosthesis was inserted to protect the maternal future of the patient.

Right atrial (RA) thrombosis is rare. The aim of this study was to determine their clinical and echocardiographic features and therapeutic implications. In the last 7 years, 16 RA masses were detected by 2D echocardiography. The diagnosis of thrombosis was made in 8 cases based on anatomo-pathological examination (6 cases) or their disappearance with medical treatment (2 cases). The clinical presentations were: pulmonary embolism (4 cases), anterior myocardial infarction (2 cases), Ebstein's anomaly (1 case), thrombosis of a Leveen catheter (1 case). Only 1 patient had atrial fibrillation. Two echocardiographic appearances were observed: 1) a long, very mobile thrombus floating between the RA and right ventricle (4 cases), 2) a relatively immobile mass (4 cases). The 4 patients with relatively immobile thrombi survived: 2 underwent surgery and 2 were treated medically. All cases of floating thrombi had pulmonary embolism: 2 patients underwent surgery but the postoperative course was complicated; 2 patients died suddenly before surgery. These cases show that 2D echo is the diagnostic method of choice for detection of RA thrombosis. The floating RA thrombus is a therapeutic emergency and has a poor prognosis.

Unlabelled: We reviewed the course of 240 patients with uncomplicated essential hypertension whose condition has been initially evaluated between january 1976 and february 1979 with both exercise (bicycle) and casual BP. Their outcome was evaluated in the first months of 1988. Thirty-eight patients were lost to follow up. The remaining 202 patients (67 p. 100 males, mean age at entry 43 +/- 13 years, mean casual BP at entry 161 +/- 25/98 +/- 15) had a mean follow-up of 9.5 +/- 2 years. Events retained for the analysis were myocardial infarction (n = 12), angina pectoris with positive coronarography (n = 8), stroke (n = 8), cardiac failure (n = 2) and sudden death (n = 3). We performed a stepwise discriminant analysis first with only casual and end exercise systolic and diastolic BP, then after introducing age, overweight (Lorentz's formula), duration of hypertension, Sokoloff index and cholesterolemia., Results: the analysis with only BP shown that end exercise BP was the best predictor of outcome with 64 p. 100 of the subjects correctly classified (CC). After introducing the other risk factors, the significantly discriminant variables were 1) overweight (65 p. 100 CC) 2) age, 3) end exercise systolic BP, 4) cholesterolemia. These 4 variables adequately classified 70 p. 100 of the subjects. Another analysis was performed in patients with maximal exercise test and gave the following results: 1) overweight, 2) cholesterolemia, 3) end exercise systolic BP with 77 p. 100 patients CC. In women, the pronostic value of exercise BP seems less important than in men.(ABSTRACT TRUNCATED AT 250 WORDS)

We investigate the effect of a new angiotensin-converting enzyme inhibitor: Perindopril (IRIS) on regression of left ventricular hypertrophy (LVH), coronary blood flow and mechanical performance of isolated papillary muscle in renovascular hypertensive (Goldblatt 2 kidneys-1 clip) Sprague-Dawley male rats. Sham operated rats (G1) and half of hypertensive rats (G2) were studied after 8 weeks. The other half of 8 weeks long hypertensive rats (G3) were treated during 8 weeks with Perindopril in drinking water at a dosage adjusted to maintain blood pressure (BP) measured with tail cuff method under 140 mmHg. The study of each rat included 1) coronary blood flow and resistance measurements under resting conditions and after coronary dilation by carbochrome infusion (9 mg/kg) using left atrial injection of radioactive microspheres (method of Wicker and Tarazi) 2) the study of mechanical performance of the isolated papillary muscle 3) weight of left ventricle after separation of septum and free wall whose subendocardial and subepicardial layers were counted separately. Results (mean +/- SD): (table; see text) MAP: mean pressure. LV/BW: left ventricular mass (mg) per gram of body weight; CR (C): minimal coronary resistance after carbochrome (mmHg/ml/min/100 mg); DL/Dt: peak velocity of shortening at L max preload; Vrelax: peak velocity of relaxation; THR: time of half relaxation; p less than 0.05; p less than 0.01 compared to SHAM. In this model, hypertension induced a 50 p. 100 LVH whose regression was nearly complete after 8 weeks of treatment with Perindopril. Minimal coronary resistance after carbochrome were higher in hypertensive rats compared to sham and return to normal after regression of LVH.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent work have raised the possibility of a lack of circadian blood pressure variability in secondary hypertension. To test this hypothesis, we compared 11 patients with renovascular hypertension (RVH) and 11 essential hypertensive patients (EH) matched for sex, age, body weight, height and the average level of SBP from 7 a.m. to 10 p.m. monitored every 15 minutes with a Spacelabs 5200 device. All patients had BP monitored during 24 hours, inside the hospital, after all anti-hypertensive drugs were discontinued for more than 5 days. Paired t test revealed no difference between the two groups. Differences (D - N) between average day time (7 a.m.-10 p.m.) and night time (10 p.m.-7 a.m.) systolic and diastolic BP were not different in the two groups. (Table: see text). To test the influence of BP level on circadian BP variation, we studied the correlation between the difference in day and night average SBP, as a % of average day time SBP, and the average day time SBP in 25 normal subjects and 64 hypertensive patients without treatment. A weak but significant correlation was demonstrated (r = -0.29; p less than 0.01). The higher the average day time SPB, the lower the difference between day and night. In conclusion, circadian variation of BP is not different between essential and renovascular hypertensive patients, but there is a trend to a smaller variation in patients with the higher BP.

Echocardiography seems to be the best non-invasive method for the detection of hypertensive heart disease: it shows early abnormalities of left ventricular compliance, frequently left ventricular hypertrophy and late abnormalities of myocardial contractility. These results are of paramount importance since recent epidemiological data have shown that left ventricular hypertrophy is a factor of severity and should be treated.

In patients with suspected dissection of the aorta two-dimensional echocardiography has become a fundamental complementary examination which can easily be used in emergencies. In the light of our experience and of published data, a floating dissected intima is the pathognomonic sign. However, false-negative results have been recorded in about 30% of the cases, as against 10% with angiography, computerized tomography and nuclear magnetic resonance imaging. In spite of this drawback, two-dimensional echocardiography still is a good screening examination, since dissection can almost certainly be excluded when the aorta is of normal caliber. False-positive results also constitute a diagnostic pitfall which must be well known and carefully avoided. The mechanisms of these various problems and the way they can be solved are discussed.

Pulsed Doppler-echocardiography was used to measure systemic and pulmonary blood flows in 22 patients aged from 3 months to 62 years presenting with interatrial (n = 13) or interventricular (n = 9) septal defect. Calculations were based on echographic measurements of aortic and pulmonary orifice areas and on the integral of maximal aortic and pulmonary Doppler velocity curves. Section areas or the arteries, taken as being circular, were deduced from arterial diameter measurements effected above Valsalva's sinus. Doppler velocity curves were recorded at that level, looking for maximal velocities and assuming a flat velocity profile. Blood flow ratios evaluated from Doppler-echocardiography data were compared with data provided by oximetry and showed good correlations (r = 0.92; Y = 0.71x + 0.53; SEE = 0.24). Calculations by categories of lesions showed better results in patients with interatrial septal defect (r = 0.94; Y = 0.73x + 0.507; SEE = 0.22) than in patients with interventricular septal defect (r = 0.83; Y = 0.547x + 0.75; SEE = 0.25). The main difficulties encountered in measuring Doppler-echocardiography blood flow ratios concerned accurate measurement of pulmonary artery diameter, due to problems of lateral resolution, and accurate measurement of turbulent Doppler velocimetry curves. However, this new, non-invasive technique may be useful to determine the best indications for catheterization or even surgery.