Search

The cardiac workup of stroke often includes a 24 hours Holter and an echocardiography looking for cardiac sources of emboli (atrial fibrillation (AF), intracardiac thrombus, mitral stenosis, recent myocardial infarction, endocarditis, dilated cardiomyopathy...) which would lead to a change of treatment (secondary prevention) aiming at decreasing the risk of recurrence. In case of a stroke with AF, the secondary prevention strategy is well defined (anticoagulants). It is less clear for the other causes. The diagnostic yield of these examinations is limited and there is a lack of consensus in their utility. This systematic review tries to sum up current guidelines. It appears that these examinations should rather be targeted than performed systematically.

Population aging has generated an increased demand for acute healthcare services in persons aged over 65, who may represent up to half of all patients treated in intensive care units (ICU). However, the number of available ICU beds is limited. Intermediate care units (IntCU) require less human and technical resources, and may represent an interesting alternative to intensive care in the geriatric population. This article describes a 10-year, single centre experience at a geriatrics IntCU in Geneva. We observed a significant reduction in in-hospital mortality after the creation of the IntCU (2000-2001) compared to the 2 years immediately preceding its inception (1998-1999).

Anemia is a frequent disease in elderly persons, but is often undertreated and misunderstood as a physiologic consequence of aging. Nevertheless, its association with some negative clinical impacts is well known and widely documented in the literature.

Considering that angina is an important symptom of coronary heart disease, exercise stress testing has proven its usefulness and remains a reference exam. Indeed, it is reasonably reliable and accessible, even for non cardiologist physicians, and provides both diagnostic as well as prognostic information. In this article, we review the key points to know about stress testing, in particular patient selection and interpretation of it results. A good comprehension of these different aspects is likely to improve patient care and to help avoid, additional tests that may be unnecessary.

Non-HACEK Gram-negative endocarditis is a rare but severe illness, and the diagnosis can be difficult to establish. Here, we report the case of a 72-year-old woman with Turner syndrome suffering from non-typhoid Salmonella endocarditis of the triscupid valve, who benefited from prompt antibiotic treatment allowing a quick and complete recovery.

Acute coronary syndrome (ACS) includes unstable angina pectoris, myocardial infarction without ST elevation and myocardial infarction with ST elevation. ACS is more frequent in the elderly than in the general population and is associated with very high morbidity and mortality. As older individuals are often excluded from clinical trials, the geriatrician needs to take care of these subjects without specific guidelines. Although older subjects (or very old subjects) represent a group at high risk of complications, they would benefit most of an aggressive coronary revascularisation procedure. Given the current state of knowledge, biological age itself should not be the only limiting criteria when considering an invasive coronary procedure, but the existing quality of life and physical conditions of the individual should also be taken into account in the global management strategy.

The management of psychotropic drugs is a daily preoccupation for geriatric psychiatrists and geriatricians alike. The lack of controlled clinical trials in very old patients (over 80 years old) often leads to empirical therapy. The multiple somatic co-morbidities of old patients, the high prevalence of potential drug-drug interactions and a wish to implement an increasingly patient centered approach all influence psychotropic drug prescription which tends to be simplified and individualized. This review is an attempt to depict the general principles and precautions we, as in-hospital geriatricians, geriatric clinical pharmacologists and geriatric psychiatrists in Geneva, Switzerland, have found helpful after many years of interaction with elderly patients and their families, and shared responsibility for the care of these very frail patients.

Left bundle branch block (LBBB) is the assumed presentation of right ventricular pacing. Paced right bundle branch block (RBBB) raises the suspicion of lead malposition. In a well placed right ventricular lead an atypical conduction pattern must be evoked. It is important to differentiate malposition from well placed ventricular lead because malposition is associated with embolic complications and may require therapeutic interventions including anticoagulation or radical lead replacement. We report the case of two patients with a paced RBBB pattern despite a well-placed right ventricular lead, as confirmed by chest X-ray and echocardiography. We discuss the etiologies and attitude to adopt when electrocardiogram (ECG) shows a paced RBBB.

Postprandial hypotension (PPH) is a clinical entity considered to affect above all elderly people with hypertension. It is equally common in diastolic heart failure, Parkinson's disease, diabetes mellitus and autonomic dysfunction. Diagnosis is based on a minimum of 20 mmHg drop of the systolic blood pressure oron a symptomatic systolic blood pressure decrease within 2 hours of the meal. Post-prandial dizziness, fatigue, syncope and falls must raise suspicion for this entity. Although more frequent than orthostatic hypotension, PPH is less searched for. Socio-economical repercussions associated to falls require a better screening of PPH in hospital and ambulatory conditions.

Atrial arrhythmias are frequent and are an important cause of heart failure aggravation or cerebrovascular accidents. They show a clear trend towards increasing incidence with age. Restoring and maintaining sinus rhythm with antiarrhythmic drugs delivers only temporary success and is prone to long term failure and/ or side effects. The treatment of atrial arrhythmias using RF catheter ablation is progressively becoming the treatment of choice because of the high percentage of successful cures achieved with relatively rare complications and no long term side effects.

The prevalence of prescription medication use among older people increases with advancing age and is related to their comorbidities. Cardiovascular medication is the medication category that is the most commonly prescribed. We retrospectively determined the repercussion of the cardiological consultation of the Hôpital de gériatrie de Genève on the cardiovascular medication. For the year 2001, 191 hospitalized patients were randomely selected and their treatment before and after the consultation was compared. The treatment was simplified after consultation considering the number of medication classes, drugs, and pills. Adverse effect (11% of consultations) is the main reason for interrupting a medication. The number of medication before consultation is an important factor to decide whether the treatment needs to be simplified. The medication cost is not modified. By simplifying treatment the cardiological consultation reduces the adverse effects of medication and probably improves therapeutic adherence. A prospective study is necessary to confirm these data and estimate their long term consequences.

The prevalence of heart failure increases with age. Although the benefit of cardiac rehabilitation has been well demonstrated, in particular for what concerns improved effort tolerance, data in the geriatric population is scarce. A supervised inpatient cardiac rehabilitation program has started in September 2004 at the Hôpital de gériatrie in Geneva. By March 2005, 34 out of 50 participants (mean age of 87 years) had completed the program. The results showed a significant increase in the distance walked at the 6-minute test (+ 68,5 m, P<0,001) and a decreased level of anxiety that facilitated the return home. It will be necessary to evaluate the impact of these encouraging results on the readmission rate and on the longterm functional capacity.

Polymedication is frequent in geriatric everyday practice and often leads to unwanted drug-drug interactions. Physicians must be aware of the potential interaction-induced with intoxications or therapeutic ineffectiveness. The clinical case presented here illustrates the importance of entertaining the possibility of such an interaction every time that the expected therapeutical effect of a substance is not reached. Our patient had refractory arterial hypertension despite taking five different antihypertensive drugs in hospital, while on carbamazepine for a facial neuralgia. This substance induces the cytochrome P450, which catalyse the metabolism of most of the antihypertensives used. After the discontinuation of carbamazepine and on tritherapy, the blood pressure profile has significantly improved.

Heart failure is at the same time a muscular and a neurohormonal disease. This explains the current therapeutic choices: in particular digitalis, ACE inhibitors, spironolactone and in certain patients even beta-blocking agents. Two different types of heart failure are distinguished today: systolic failure with pump failure and diastolic failure with deranged ventricular filling. In the elderly, the two entities occur either together or individually. A precise and early diagnosis is important for an appropriate treatment to be instituted as early as possible, even in the case of asymptomatic or subclinical heart failure.

The absence of specific clinical signs makes the diagnosis of cardiac amyloidosis difficult. Moreover, it is established that this condition, the prevalence of which increases with age, aggravates the prognosis of cardiac failure. The present study was undertaken to identify the clinical or paraclinical signs enabling more accurate diagnosis of this disease. Analysis of 2589 autopsy reports from the University Institutes of Geriatrics of Geneva between January 1972 and January 1990 recensed 58 cases of microscopic cardiac amyloidosis, but this diagnosis was not made in any of these patients before death. Of the potential indicators, the good specificity but poor sensitivity of atrial fibrillation and low voltage electrocardiogram was confirmed. On the other hand, the author's research found the association of radiological cardiomegaly and a raised erythrocyte sedimentation rate in nearly 70% of cases of cardiac amyloidosis with a false positive rate of only 10% in a control group.

An abnormal Q wave in the ECG of the elderly calls for differential diagnosis between an old myocardial infarction and left ventricular hypertrophy. The latter may be due to hypertrophic cardiomyopathy, the prognosis of which is good in the elderly. The echocardiogram is the only method which provides the correct diagnosis and helps to avoid incorrect treatment.

In cases with a history of swallow syncope, an ECG should immediately be taken during ingestion of solid or liquid food in order to determine the rhythm disturbances responsible for the syncopes. Both esophageal passage and cardiac diagnosis are indicated, since, as shown in the literature, pathologic findings are not uncommon. The triad syncope, bradyarrhythmia while swallowing is considered to be an indication for definitive electrostimulation (pacemaker implantation) unless, exceptionally, halting digitalis medication puts an end to the syncopes.

A diastolic gradient across the mitral valve is generally indicative of mitral valve stenosis. In the present study, echocardiography was used to demonstrate two less common causes of left ventricular inflow obstruction: one patient had a fibromuscular membrane beneath the valve, the other a large vegetation attached to the posterior leaflet of the mitral valve. Echocardiography proved to be the optimal imaging technique in each case.

Until recently the only means of diagnosing intracardiac thromboses were angiography and M mode and 2D echocardiography. The aim of this study was to assess the value of CAT scanning in this field and to compare it with angiography and ultrasonography. Twenty intracardiac thromboses were studied in 19 patients by CAT scanning: 14 in the left ventricle, 2 in the right ventricle, and 4 in the left atrium, one patient having both left and right ventricular intracavitary thrombosis. M mode and 2D echocardiography and angiography were carried out whenever possible. Although for different practical reasons all patients did not undergo all three investigations, CAT scanning appeared to be the most reliable diagnostic method in intracardiac thrombosis, being more specific than either angiography and ultrasonography. In addition, the therapeutic effects of anticoagulant therapy on the thrombus can be assessed and other associated pathology such as aneurysm, pericardial reaction, dilatation of the cardiac cavities, myocardial and valvular calcification can also be demonstrated.

A 25-year-old Senegalese woman with severe multivalvular disease presented with jaundice (unconjugated bilirubin) augmented by exertion without evidence of frank anemia. Following the exclusion of all other causes of hemolysis, the diagnosis of mechanical hemolysis secondary to deformed valves was established. The jaundice and laboratory evidence of hemolysis diminished markedly after placement of (Starr) aortic and mitral valve prostheses and a tricuspid commissurotomy. While chronic hemolysis due to ball or disc valve prostheses is usually clinically insignificant yet often described in the literature, hemolysis complicating non-operated valvulopathies is a rare clinical condition and, in contrast to the case presented, usually less severe than hemolysis following valve prosthesis insertion.

Two-dimensional echocardiography is complementary to the unidimensional technique. It offers the possibility of examining a wide area of the heart in real time and obtaining multiple cross-sectional views from several different chest wall transducer positions. Although generally quite accurate this new technique has some limitations, i.e. with regard to resolution of an ultrasonic image. Two-dimensional echocardiography is mainly useful for evaluation of left ventricular function and congenital heart diseases, and for diagnosis of left ventricular and auricular thrombi.

Hepatic drug metabolism influenced by genetic and environmental factors is a major source of variation in the response to a number of beta-adrenoceptor antagonists. The first study described here was carried out to define the role of a genetic determinant (debrisoquine-type oxidation polymorphism) on plasma concentration of bopindolol and its pharmacological effect. Atenolol was used as a negative and metoprolol as a positive control. In a second study, the relative potency and duration of action of bopindolol were assessed in comparison to atenolol and slow-release oxprenolol. The first study was carried out using 10 healthy volunteers (6 extensive and 4 poor metabolizers), and the second study was carried out using 12 volunteers, all of whom were extensive metabolizers. Genetic polymorphism did not influence the kinetic behavior or pharmacological effects of atenolol. The elimination of bopindolol was slightly but significantly prolonged in poor metabolizers, but this did not significantly alter the cardiac effects of the drug. In the case of metoprolol poor metabolizers showed a significant prolongation of drug elimination, and this was associated with a significant prolongation of the cardiac effects of the drug. The second study revealed that, in terms of cardiac beta-adrenoceptor blockade, 1 mg bopindolol was equipotent to 100 mg atenolol or 160 mg slow-release oxprenolol and that both bopindolol and atenolol had a longer duration of action than slow-release oxprenolol. It is concluded that bopindolol is a potent beta-adrenoceptor antagonist with a very long duration of action which shows little interindividual variability.

Wise utilization of antiarrhythmic drugs depends on a profound knowledge of their intracellular effects; however, due to widely varying individual response to such drugs, long clinical experience and a certain degree of empiricism are usually necessary. In view of the negatively inotropic effect of the majority of the antiarrhythmic drugs and the potential danger of their association, it seems advisable to recommend that benign arrhythmias should not be treated. Finally, a thorough understanding of the mechanism of complex arrhythmias is essential in selecting the appropriate medical treatment.

The object of this study was to determine whether transverse radiotomography, despite cardiac movement, could be used to visualise aortocoronary bypass grafts to confirm their patency or obstruction. The results were then compared with those of coronary angiography. 20 patients with a total of 38 grafts (18 on the left anterior descending, 8 on the circumflex and 12 on the right coronary artery) underwent tomography. 1 or 2 60 ml boluses of iodide contrast medium were injected into a fore arm vein and 3-5 films were exposed after each injection at 15 sec intervals. Coronary angiography was performed in 16 patients and the results of tomography were identical to those of coronary angiography : 23 patent and 6 occluded grafts. In one case, subtotal proximal stenosis of the left anterior descending artery allowed sufficient flow for the graft to be opacified and considered patent on tomography. The correlation between transverse radiotomography and coronary angiography was excellent. Transverse radiotomography, a non-invasive technique, is very useful in operated patients with atypical chest pain and in those with recurrent angina in whom obstruction of the graft is feared. It does not seem destined to replace control coronary angiography after bypass surgery, but it may be indicated is selected cases.

Dissection of the ascending aorta is a rare complication of aortocoronary bypass surgery. A 63-year-old man who had received a double graft was found to have dissection of the ascending aorta, which was shown angiographically four months after operation. Since the patient was asymptomatic, operation was postponed. He has been followed up regularly and two years later his condition is still satisfactory.

The relatively rare pseudotumoral lymphoid hyperplasia (benigh lymphoid or reactive lymphoreticular hyperplasia; pseudolymphoma; Castleman's disease) arises from the lymph nodes, usually in the mediastinum. The disease assumes tow histologically and clinically different forms: the first, angiofollicular, is often symptomless, while the second, lymphoplasmocytic, is sometimes associated with a marked chronic inflammatory syndrome. The etiology is unknown, but is probably a reaction of the lymphoplasmocytic system to an antigen, possibly of viral origin. Diagnosis is based on histology. Surgical treatment is curative. A rare form of this unusual disease is reported with reference to the morphological differential diagnosis; the similarities with immunoblastic lymphadenopathy are emphasized.

The diagnosis of inferior myocardial infarction was wrongly made in a patient with a history of chest pain and Q waves in Leads 3 and aVF. Despite a normal PR interval, ventricular preexcitation was suspected on the deformation of the upstroke of the QRS complex, suggestive of a delta wave. Ventricular and coronary angiography and exercise Thallium 201 myocardial scintigraphy allowed the diagnosis of myocardial infarction to be eliminated. Endocavitary electrophysiological recordings confirmed the presence of an accessory atrioventricular conduction pathway (Kent bundle) and explained the intermittent appearances of the WPW syndrome on ECG. The patient was investigated after the acute episode, and the absence of cardiac enzyme estimations at that time made the rectification of the diagnosis more difficult.

The interventricular septum was studied by biventricular angiography in 52 patients divided into 4 groups: the first group consisted of 14 normal subjects; the second of 10 patients with hypertension (9 cases) or aortic stenosis (1 case); the third, of 19 patients with echocardiographic asymmetric septal hypertrophy, and the fourth, of 9 cases of cardiomyopathy with dilatation. The following parameters were measured: septal thickness at 4 different points and mean septal thickness, the height (long axis) and surface of the septum in diastole and systole. The percentage variation was calculated. There were no significant differences between Group I and II; there was a significant difference (p less than 0,01) in the variations of septal thickness of the upper segments between Group I and III. This difference remained significant (p less than 0,05) for the variations of mean thickness between Group I (-38%) and Group III (-18%). There was also a significant difference (p less than 0,05) in the variation of height between Group I (23%) and Group IV (9%). None of the variations of septal surface reached the threshold of statistical significance between the four groups. Biventricular angiography can therefore demonstrate certain abnormalities of septal motion. In asymmetric septal hypertrophy, the variations in thickness are significantly less pronounced than in normal subjects but the motion in the longitudinal axis does not differ significantly. In cardiomyopathy with dilatation, however, the variation in septal height is the most affected parameter.

Atrial flutter with 1:1 atrioventricular conduction giving rise to a ventricular rhythm of 240/min in an 80 year old man was the first sign of the Wolff-Parkinson-White syndrome; all previous electrocardiogrammes had shown no evidence of pre-excitation. It was only on the fifth day of hospitalisation that the ECG showed a short PR interval with a delta wave. This case illustrates that: --all supraventricular arrhythmias with abnormally high ventricular rates (over 220/min in adults) should alert to the possibility of an accessory atrioventricular pathway; --rapid atrioventricular conduction may be the first sign of an accessory pathway; --the differential diagnosis lies between an accessory atrioventricular pathway and an atriohisian tract; --digitalis, which may shorten the refractory period of the accessory pathway, is contraindicated in patients with a Kent bundle.