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Summary Background Differences in the duration of the excitable gap along the reentry circuit during typical atrial flutter are poorly known. Aim To prospectively evaluate and compare the duration and composition of the excitable gap during typical counterclockwise atrial flutter in different parts of the circuit all around the tricuspid annulus. Methods The excitable gap was determined by introducing a premature stimulus at various sites around the tricuspid annulus during typical counterclockwise atrial flutter in 34 patients. Excitable gap was calculated as the difference between the longest resetting coupling interval and the effective atrial refractory period. Results The duration of the excitable gap, the effective atrial refractory period and the resetting coupling interval differed significantly along the tricuspid annulus. Duration of excitable gap was significantly longer at the low lateral right atrium (79 ± 22 ms) than at the cavotricuspid isthmus (66 ± 23 ms; P = 0.002). The effective atrial refractory period was significantly longer at the cavotricuspid isthmus (160 ± 26 ms) than at the high lateral right atrium (149 ± 29 ms; P = 0.004). Other locations, such as coronary sinus ostium, right atrial septum and atrial roof displayed intermediate values. Conclusion The duration of the excitable gap differed significantly along the tricuspid annulus, with a larger excitable gap at the lateral right atrium and a shorter excitable gap at the cavotricuspid isthmus, because of longer refractory periods at the isthmus.

Aims: Elderly patients are increasingly being referred for percutaneous coronary intervention (PCI), but there is a paucity of current data on the long-term outcome of elective PCI in elderly patients. We sought to define the risks facing elderly patients undergoing contemporary PCls. Methods and results: Retrospectively, in a single-centre registry, we studied the mortality and the outcome of 512 consecutive patients ≥ 75 years old who underwent PCI, between January 1 st 2000 and December 31 st 2001. Clinical endpoints included in-hospital mortality; major adverse cardiovascular and cerebrovascular events (MACCE) defined by the components of death, myocardial infarction, stroke, and repeat coronary revascularisation (target vessel revascularisation or not) by surgery or PCI, within the hospitalisation period and at long-term follow up. We compared 315 patients 75-79 years old (group I) with 197 patients ≥ 80 years old (group II). In-hospital mortality and MACCE rates were not different between the two groups. Independent predictors of in-hospital major events found by multivariate analysis were: ST-segment elevation myocardial infarction or STEMI (Odds Ratio [OR]=2.58, 95% Cl=1.15-5.78), left ventricular ejection fraction or LVEF

Background Traditional cardiovascular risk factors in the general population are usually correlated to a better prognosis in patients with chronic heart failure (HF). Most of the studies show that blood pressure variability (BPV) has noxious effect on general population but data are missing for patients with systolic HF. The aim of this study was to assess the prognostic impact of short-term blood pressure variability (BPV) in systolic HF. Methods and results We retrospectively studied 288 patients (60 ± 12 years-old; 79 % male) referred to our tertiary center of HF for the management of their systolic HF (left ventricular ejection fraction was 28 ± 9 %). All patients underwent ambulatory blood pressure monitoring (systolic BP: 110 ± 15; diastolic BP: 68 ± 10 and pulse pressure: 42 ± 11 mmHg) and the prognostic impact of BPV was collected with a mean follow-up of 4.4 ± 3.1 years. Twenty-five (9 %) patients were missing for follow-up. Among the others patients, 70 (27 %) cardiovascular events (cardiac deaths: 24 %; heart transplantation: 2 %) were recorded. By multivariate analysis BPV daytime (OR = 0.963, p = 0.033) and severe NYHA class (OR = 5.2, p

Hyperhomocysteinemia (HHcy) is a risk factor for cardiovascular disease. Homocysteine (Hcy) can generate reactive oxygen species. Oxidative stress enhances the progression of cardiovascular diseases and has long been implicated in chronic heart failure (CHF). This study was to evaluate the predictive value of plasma Hcy levels in CHF patients and to investigate the relationship with other markers.We investigated 134 adult CHF patients (males, 74%; mean age, 60.0 ± 14.8 years). Echocardiography, 6-min walk test, and determination of peak oxygen consumption (VO(2max)) were performed. Serum levels of Hcy and other markers were determined. Clinical follow-up was performed at five years.The mean Hcy level was markedly elevated in CHF patients (18.4 ± 7.83 μmol/L) vs. control subjects (12.8 ± 3.14 μmol/L; p0.01), whatever the etiology of heart failure (non-ischemic, n = 74, 17.6 ± 7.8 μmol/L; ischemic, n = 60, 19.3 ± 7.8 μmol/L). Hcy correlated negatively with VO(2max) and positively with BNP. Kaplan-Meier analysis showed that CHF patients with HHcy15 μmol/L had a significantly lower survival rate (35% vs. 56%, log-rank p0.05) than those without HHcy. Cox regression revealed that HHcy and hs-CRP were the most powerful independent predictors of mortality in patients at 5 years.HHcy is common in CHF patients and is associated with an increased risk of death at 5 years. We suggest that Hcy can be used in clinical practice as an additional risk marker in CHF patients with various medications.

The purpose of our study was to determine the clinical, angiographic, and procedural variables that predict the risk for 2-year target lesion revascularization (TLR) and other clinical events in a large cohort of patients treated with coronary stenting. Between March 1996 and March 1999, 1,340 patients were prospectively enrolled. They underwent at least one stenting procedure with one of the four coronary stent types used during this time period in our institution: Wiktor-I, Nir, Bard XT, or Tenax. Clinical follow-up was obtained for 99.1% of eligible patients (mean, 19.38 +/- 4.97 months). The overall TLR rate was 10.7% at 24 months. Two variables were independently associated with the long-term outcome: MLD post stenting and stent type. Implantation of silicon carbide-coated stents was associated with a twofold decrease in 24-month TLR (P < 0.01). The major adverse cardiac event rate at 2 years was 20.8%. Multivariate analysis showed that three parameters were predictive: diabetes (P < 0.002), recent onset of symptoms (P < 0.03), and high diffusion of coronary atherosclerosis as assessed by Gensini score (P < 0.0069). In conclusion, stent type, and particularly passive silicon carbide coating, appears to affect the 24-month TLR rate but not other major cardiac events.

Background: Management of heart failure includes β-blockade (βB) therapy and cardiac rehabilitation. The aim of this study was to compare the exercise training response of patients with congestive heart failure (CHF) receiving βB 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 βB 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 ≤.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 ≤.0001) at submaximal levels in both groups without significant differences between the groups. Conclusions: βB therapy does not impair functional improvement induced by a rehabilitation program in patients with CHF. βB therapy does not interfere with exercise training prescription if patient exercise evaluations are made at the time of therapeutic intake.

The purpose of this study was to compare the effects of stent placement with and without balloon predilatation on duration of the procedure, reduction of procedure-related costs, and clinical outcomes. Although preliminary trials of direct coronary stenting have demonstrated promising results, the lack of randomized studies with long-term follow-up has limited the critical evaluation of the role of direct stenting in the treatment of obstructive coronary artery disease. Between January and September 1999, 338 patients were randomly assigned to either direct stent implantation (DS+; 173 patients) or standard stent implantation with balloon predilatation (DS-; 165 patients). Baseline clinical and angiographic characteristics were similar in the 2 groups. Procedural success was achieved in 98.3% of patients assigned to DS+ and 97.5% of patients assigned to DS- (p = NS), with a crossover rate of 13.9%. Compared with DS-, DS+ conferred a dramatic reduction in procedure-related cost ($956.4 +/- $352.2 vs $1,164.6 +/- $383.9, p

Background: In congestive heart failure, despite activation of the sympathetic nervous system, heart rate variability parameters reflecting sympathetic modulation on sinus node are decreased. Our goal was to assess the role of beta-adrenergic sensitivity in the modulation of heart rate variability (HRV) in patients with valvular heart diseases. Methods and results: Ten patients with aortic stenosis, 10 patients with heart failure, and 12 controls were included. Baroreflex sensitivity was calculated by the sequency method. Noradrenaline plasma levels were assayed by HPLC. HRV was studied using 24-hour Holter monitoring. Cardiac beta-adrenergic receptivity was assessed by the chronotropic response to dobutamine. Right auricular samples were obtained for determination of beta-adrenergic receptor density by binding study with [125I]-iodocynaopindolol, and beta 1 and beta 2 densities, measured by competition between 125ICP binding by isoprenaline. In multivariate analysis, the dose of dobutamine that increases basal heart rate for 25 beats/min (ED25) is correlated with a parameter of global HRV: SDNN (r = 0.6, P < 0.001) and with indexes reflecting rather sympathetic modulation of HRV: SDANN (r = 0.62, P < 0.001) or SD (r = 0.47, P < 0.0001). All these relations were independent from mean NN, spontaneous baroreflex sensitivity, and noradrenaline plasma levels. No significant correlation existed between dobutamine ED25 and HRV indexes reflecting parasympathic tone. No relationship existed between HRV and beta-adrenergic receptor-binding characteristics. Conclusion: Cardiac beta-adrenergic sensitivity explored by dobutamine ED25 is an important determinant of HRV independent from mean NN, spontaneous baroreflex sensitivity, and noradrenaline plasma levels.

Aims Identification of patients with chronic heart failure at risk for sudden death remains difficult. We sought to assess the prognostic value for all-cause and sudden death of time and frequency domain measures of heart rate variability in chronic heart failure. Methods and Results We prospectively enrolled 190 patients with chronic heart failure in sinus rhythm, mean age 61±12 years, 109 (57·4%) in NYHA class II and 81 (42·6%) in classes III or IV, mean cardiothoracic ratio 57·6±6·4% and mean left ventricular ejection fraction 28·2±8·8%, 85 (45%) with ischaemic and 105 (55%) with idiopathic dilated cardiomyopathy. Time and frequency domain measures of heart rate variability were obtained from 24h Holter ECG recordings, spectral measures were averaged for calculation of daytime (1000h–1900h) and night-time (2300h–0600h) values. During follow-up (22±18 months), 55 patients died, 21 of them suddenly and two presented with a syncopal spontaneous sustained ventricular tachycardia. In multivariate analysis, independent predictors for all-cause mortality were: ischaemic heart disease, cardiothoracic ratio ≥60% and standard deviation of all normal RR intervals

Background: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 relationship between hyperinsulinemia and heart rate variability (HRV), a noninvasive tool to assess autonomic function, in obese and hypertensive subjects. Methods:24-hour 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. The patient were divided into four groups according to three parameters, body mass index (BMI > 27 kg/m2 in the men and > 25 kg/m2 in the women defined obesity), arterial pressure, and insulinemia (fasting insulinemia > 25 mUI/L defined hyperinsulinemia). Twenty-seven patients were obese, hypertensive, with hyperinsulinemia; 28 patients obese, hypertensive, without hyperinsulinemia; 12 patients nonobese, 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 among the four groups for indexes of HRV reflecting parasympathetic tone. These relations were independent of mean R-R. 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. A.N.E. 1999;4(3):316–324

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, 24h 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–IV), cardiothoracic ratio (57±7 vs 57±6%) and ejection fraction (28±8 vs 29±9%). The mean QT dispersion (66±29 vs 65±27ms), 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 cardiomyop-athy. QT dispersion was not 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 >80ms was an independent predictor of sudden death (RR: 4·9, 95% CI 1·4–16·8, P

Objective Hypertensive left ventricular hypertrophy is associated with an increased risk of arrhythmias and mortality. However, no clinical study has demonstrated a significant relationship between ventricular arrhythmias and mortality in systemic hypertension. Design and methods To evaluate the prognostic value of arrhythmogenic markers, we included, prospectively, 214 hypertensive patients aged (mean ± SD) 59.1 ± 12.8 years, without symptomatic coronary disease, myocardial infarction, systolic dysfunction or electrolyte disturbances. At inclusion, a 12-lead electrocardiogram (ECG) with QT dispersion calculation, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, echocardiography (reliable in 187 patients) and a signal-averaged ECG (125 patients) with ventricular late potentials were recorded. Results At baseline, echocardiographic left ventricular hypertrophy was found in 63 patients (33.7%). Non-sustained ventricular tachycardia (Lown class IVb) was recorded in 33 patients (16.2%) and late potentials 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, nine (4.2%) died suddenly. In univariate analysis, age, Lown class IVb and a QT dispersion > 80 ms were significantly related to global, cardiac and sudden death (P < 0.01). The left ventricular mass index was related to cardiac mortality (P = 0.002). 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 (95% confidence interval 1.2-6.0) and cardiac death 3.5-fold (95% confidence interval 1.2-9.7). Conclusion In hypertensive patients the presence of non-sustained ventricular tachycardia has prognostic value.

1. The aims of the present experiments were to define a new experimental model of pulmonary hypertension induced by a post-capillary mechanism and to assess the haemodynamic effects of nitric oxide on post-capillary pulmonary hypertension. 2. Cardiopulmonary variables of 28 male beagle dogs, anaesthetized with chloralose, 16 spontaneous breathing and 12 with assisted ventilation, were studied before and after sino-aortic denervation (SAD). The haemodynamic effects of inhaled nitric oxide (25 p.p.m., 10 min). N(omega)-nitro-L-arginine methyl ester (20 mg kg-1, i.v.), urapidil (0.5 mg kg-1-, i.v.) and propranolol (300 micrograms kg-1, i.v.) were studied after SAD. 3. SAD induced an acute and transient pulmonary hypertension, more marked in spontaneous breathing dogs. This pulmonary hypertension involved a post-capillary mechanism, secondary to the left ventricular haemodynamic effects of the acute increase of left ventricular after-load induced by systemic hypertension. In fact, the increase of mean pulmonary arterial pressure after SAD and the decrease of this parameter after urapidil or propranolol were strongly correlated with the variations of pulmonary capillary wedge pressure. Furthermore, no significant change in pulmonary vascular resistance was found after SAD or administration of alpha or beta-adrenoceptor antagonists. 4. Inhaled nitric oxide did not reverse pulmonary hypertension induced by SAD. N(omega)-nitro-L-arginine methyl ester had no significant haemodynamic effect of pulmonary circulation. 5. In conclusion, the lack of effect of inhaled nitric oxide and nitric synthase inhibitor on pulmonary circulation parameters SAD suggest that endothelium-derived oxide is not involved in the mechanisms leading to post-capillary pulmonary hypertension.

Our objective was to evaluate, in a French multicenter study, the results of implantation of Wiktor tantalum wire coronary stents in stenosed or occluded coronary vessels or in saphenous vein bypass grafts. The study was a retrospective analysis of clinical and angiographic data from patients treated with tantalum wire stent implanted at five centers. Stenting of native coronary arteries or saphenous vein bypass grafts was attempted in 272 patients after acute or threatened closure of the target vessel, or because the lesions concerned were considered to be at particularly high risk of becoming restenosed, or because the result of primary angioplasty was inadequate. Successful stent deployment was achieved in 261 95.9%) of 272 patients. The incidence of major complications such as death, myocardial infarction (MI), or a condition requiring urgent bypass surgery was 8.1%. Major vascular complications occurred in 2.6% and actually decreased with a new anticoagulant regimen. Angiographic follow-up at a mean of 6 months after stenting showed restenosis in 23.6% with a more frequent restenosis in the group with stent size equal to 3 mm than in the group with stent size superior to 3 mm (46.1% vs 13.7%, P < 0.01). Stenting with the Wiktor tantalum wire stent is an effective means of treating acute complications and suboptimal results after angioplasty. This stent seems to offer hope of a significant reduction in the rate of late restenosis in native coronary vessels, but a prospective comparison of balloon angioplasty and stenting is needed.

Incidence, characteristics and predictive factors of transient ST-segment changes after DC shock are poorly known.91 consecutive pts referred for external cardioversion of atrial fibrillation (AF) (61 men, 69±10 yo) were prospectively included. The presence of ST elevation or depression was assessed on 12 lead-ECG immediately after the first DC shock. Correlations with DC shock characteristics (monophasic/biphasic and energy), clinical variables, echocardiographic parameters, biological parameters, medications, anaesthetic drugs as well with morphological features were made.18 and 20 pts underwent 200 J or 300 J monophasic and 53 pts 200 J biphasic DC shocks. We found an incidence of 48% for ST-segment changes: 35% for ST elevation and 13% for ST depression. ST changes did not induce significant cardiac events or alter AF recurrences. ST changes were not related to energy but ST elevation was significantly more often induced by monophasic (76% vs 6%, p0.0001) and ST depression by biphasic DC shocks (26% vs 3%, p=0.01). Using multivariate analysis, independent predictors for ST elevation were the use of monophasic DC shocks, of propofol and increased CRP, while a low ejection fraction and use of biphasic DC shocks were independent predictors of ST depression.ST-segment changes after external cardioversion with DC shock are common, short living and do not carry clinical significance. They are related to the monophasic or biphasic configuration of DC shock, to the use of propofol, to the ejection fraction and to an increased CRP.

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.

Introduction: The aim of this study was to determine whether impaired adaptation of the QT interval to changes in heart rate predicts sudden death in patients with chronic heart failure (CHF). Methods: We prospectively included 175 CHF patients in sinus rhythm. QT dynamicity was evaluated by analyzing 24-h Holter recordings. The linear regression slope of QT interval measured to the apex and to the end of T wave plotted against RR intervals was calculated using a dedicated Holter algorithm. Results: Mean follow-up was 29.9±17.9 months. There were 48 deaths, of which 21 were sudden. The actuarial 3-year mortality rates were 38.4% for overall mortality and 14.1% for sudden death. Of all the parameters, an increased QTe/RR slope (>0.28) was the strongest independent predictor of sudden death (relative risk 3.47, 95% confidence interval 1.43−8.40, p=0.006). Conclusion: Increased 24-h QTe dynamicity is independently predictive of sudden death among patients with heart failure. This simple parameter may help to stratify risk and select patients who may benefit from antiarrhythmic prophylaxis.

The purpose of our study was to determine the clinical, angiographic, and procedural variables that predict the risk for 2-year target lesion revascularization (TLR) and other clinical events in a large cohort of patients treated with coronary stenting. Between March 1996 and March 1999, 1,340 patients were prospectively enrolled. They underwent at least one stenting procedure with one of the four coronary stent types used during this time period in our institution: Wiktor-I, Nir, Bard XT, or Tenax. Clinical follow-up was obtained for 99.1% of eligible patients (mean, 19.38 +/- 4.97 months). The overall TLR rate was 10.7% at 24 months. Two variables were independently associated with the long-term outcome: MLD post stenting and stent type. Implantation of silicon carbide-coated stents was associated with a twofold decrease in 24-month TLR (P0.01). The major adverse cardiac event rate at 2 years was 20.8%. Multivariate analysis showed that three parameters were predictive: diabetes (P0.002), recent onset of symptoms (P0.03), and high diffusion of coronary atherosclerosis as assessed by Gensini score (P0.0069). In conclusion, stent type, and particularly passive silicon carbide coating, appears to affect the 24-month TLR rate but not other major cardiac events.

The Tenax coronary stent is laser sculpted from high precision 316 L stainless steel using advanced production procedures. An a-Sic : H (hydrogen-rich amorphous silicon carbide) coating reduces its thrombogenicity and improves its biocomputibility. From April to July 1998, 266 stents were implanted in 241 patients (aged 62.7 ± 10.8 years) in five centers. The clinical indication for intervention was unstable angina (33.2%) and recent myocardial infarction (29.8%) in many cases. Most lesions (83.8%) had complex characteristics (Class B2 or C). The target vessel was the LAD in 42.8% and the right coronary artery in 36.8% of all cases. Four primary stent deployment failures occurred and implantation was successful in 289 (97.4%) of 266 stents. No death and no Q-wave myocardial infarction or emergency CABG occurred during hospital stay. Clinical success, defined as successful deployment without procedural or clinical event, was achieved in 230 (98.4%) of 241 patients. One-year clinical follow-up shows a low need for target lesion revascularization (17/237 [7.1%] patients) and a 15.8% rate of major adverse cardiac events (36/237 patients). The clinical and angiographic outcomes of our study suggest that the hybrid, amorphous hydrogenated silicon carbide coated design is promising and merits further evaluation in larger clinical trials. (J Interven Cardiol 2001; 14: 1–5)

In hypertensive patients, the upper and lower limits of cerebral autoregulation are shifted to higher levels. However, the dynamics of cerebral autoregulation in hypertensive patients are less well known. We compared the dynamics of cerebral autoregulation in 21 treated hypertensive patients (13 men and 8 women; mean age: 48.9+/-13.6 years) and in 21 normotensive subjects (13 men and 8 women; mean age: 51+/-14.5 years) by transcranial Doppler (TCD) of the middle cerebral artery (MCA) during the acute decrease in blood pressure induced by standing up after 2 min in squatting position. MCA maximal outline blood flow velocity (FV), blood pressure (Finapres) and end-tidal PCO2 were continuously monitored and computerised. A cerebral vascular resistance index (CR) was calculated as follows: mean arterial BP/MCA mean FV with normalised changes in CR per second during the blood pressure decrease (CR slope). The CR slope reflecting the rate of cerebral autoregulation did not differ between the two groups and within the hypertensive patients [well controlled (8 patients) and not controlled (13 patients)]. The time to maximum decrease of CR (T1) and the time to full recovery of CR after the initial drop (T2) were also similar in the two groups (controls T1: 11.3+/-3.1 s, T2: 12+/-5.9 s; hypertensive T1: 11.7+/-2.5 s, T2: 10.7+/-4.5 s) and within hypertensive patients. These findings suggest that the dynamics of cerebral autoregulation are well preserved in hypertensive patients, with no difference according to the efficiency of treatment of hypertension.

BackgroundAmbulatory blood pressure monitoring (ABPM), while used routinely in Hypertension, has rarely been applied in Chronic Heart Failure (CHF). This study was designed to assess prognostic value of ABPM data in our patients with CHF.Methods and ResultsIn this preliminary work, a retrospective analysis on 288 patients (227 men (79%), 61 women (21%)) who had received an ABPM in our Heart Failure unit between 1999 and 2006 was made. Our study population, with a mean age of 59.6 years consists of 45.2% ischemic cardiomyopathy, 42.6% idiopathic dilated cardiomyopathy, 9.3% hypertrophic cardiomyopathy, 2.9% valvular cardiomyopathy. Almost all are symptomatic (NYHA I (8.3%) II (48.2%) III (37.8%) IV (5.5%)) and average ejection fraction (EF) is 28.2%. ABPM data and patient characteristics are studied in bivariate analysis: EF correlated positively with mean pulse pressure (PP) (daytime PP: r = 0.47, p0.05). Significative difference found for 24 h-PP (p

Although stents have been implanted in human coronary arteries since 1986, the long-term angiographic outcome of coronary stenting is unknown. We performed 10-year angiographic follow-up in 8 patients who had undergone stent implantation without acute complications or 6-months' restenosis. Analysis of the changes in minimal luminal diameter within the stent and the reference vessel diameter of the stented segment at 10 years do not suggest that atherosclerosis is accelerated or prolonged beyond 6 months within coronary stents.

An insertion/deletion (I/D) polymorphism of the angiotensin I-converting enzyme (ACE) has been associated with an increased risk of coronary artery disease (CAD) and myocardial infarction (MI). However, this finding has not been fully investigated in European populations with very low CAD risk. In a case-control study on a population from Southern Europe (Toulouse, France), we evaluated the ACE I/D polymorphism in 405 men, aged 35-65 years, who underwent coronary angiography and in 357 representative control men within the same age range. We also explored associations in the patients between this polymorphism and CAD severity. The ACE genotype was not associated with the presence of either CAD or MI. The ACE genotype was not a marker for angiographically assessed CAD severity. In a sample in one of the European populations with the lowest CAD risk, ACE I/D polymorphism was not associated with an increased risk for CAD or MI and did not influence the extent of CAD.

The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting of bifurcation lesions using the "T" or "reverse Y" configuration with a Wiktor GX stent. This series demonstrates that stents can be placed with a high rate of success in coronary bifurcation lesions and the techniques described will overcome the potential limitations of coronary angioplasty in such lesions.

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). Results 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 ≥65 years, ECG strain pattern, Lown class IV b and QT interval dispersion >80 ms ( P ≤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.

This study compares the ability of intracoronary ultrasound (ICUS) to identify thrombus by means of actual criteria, with the histologic studies of tissues removed by directional atherectomy in patients treated previously with thrombolytic therapy. Coronary angiography and intravascular ultrasound imaging were performed before atherectomy in 34 patients who had received intravenous thrombolytic therapy for acute myocardial infarction a mean of 6 days before. The lesion morphology and the percentage of stenosis were defined in the angiogram. The ultrasound characteristics of the narrowing were described as intraluminal thrombus, mural thrombus, mixed plaque, and dense plaque. Thirty patients were studied. Thrombus was suspected in 8 patients on angiography. By ICUS, the presence of thrombus was predicted in 21 patients. Histologic studies of excised tissues found thrombus in 20 of the 30 patients. When ICUS was compared with histology, the true-positive rate was 80% and the false-positive rate was 50%; the true-negative rate was 50% and the false-negative rate was 20%. The correlation between observers was high. These observations suggest that ICUS may be useful in identifying fresh thrombus. The findings of this study help to confirm the criteria for diagnosing intraluminal thrombus by ICUS imaging.

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 (P0.001). 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.

IntroductionDC shock is commonly used for external cardioversion of cardiac arrhythmias. Incidence, characteristics and predictive factors of transient ST-segment changes after DC shock are poorly known.Methods91 consecutive pts referred for external cardioversion of atrial fibrillation (AFib) (61 men, 69±10 yo) were prospectively included. Duration and amplitude of ST elevation or depression were quantified on12 lead-ECG immediately after the first DC shock. Correlations with DC shock characteristics clinical variables, underlying heart disease, echocardiographic parameters, biological parameters, medications, anesthesic drugs as well with morphological features were made.Results18 and 20 pts underwent 200 J or 300 J monophasic and 53 pts 200 J biphasic DC shocks. Immediate success rate was 95%.We found an incidence of 48% for ST segment changes: 35% for ST elevation (0,81±0,44 mV) and 13% for ST depression (0,2±0,07 mV, p

Summary 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.