[NT-proBNP in practice: from chemistry to medicine]. / NT-proBNP en pratique "De la biologie à la clinique".

Since the introduction of routine assay for natriuretic peptides, there are a growing number of clinical applications for those new tests. Numerous studies have defined analytical characteristics and clinical interest of NT-proBNP assay. Originally limited to acute heart failure diagnosis in the emergency room, NT-proBNP assay has now a wide number of applications. This literature review presents the "state of art" of this marker, detailing NT-proBNP physiological recent knowledge and its recognized or investigated clinical applications.

[NT-proBNP in practice: from chemistry to medicine]. / NT-proBNP en pratique "de la biologie à la clinique".

Since introduction of routine assay for natriuretic peptides, there are a growing number of clinical applications for those new tests. Numerous studies have defined analytical characteristics and clinical interest of NT-proBNP assay. Originally limited to acute heart failure diagnosis in the emergency room, NT-proBNP assay has now a wide number of applications. This review presents the "state of art" of this marker, detailing NT-proBNP physiological recent knowledge and its recognized or investigated clinical applications.

Abdominal obesity is associated with ineffective control of cardiovascular risk factors in primary care in France.

AIM: Insufficient control of cardiovascular risk factors is observed in primary care. The goal of the present study was to evaluate the association of abdominal obesity with achievement of treatment targets for HbA(1c), LDL cholesterol, triglycerides, HDL cholesterol and blood pressure in primary care. METHODS: In this cross-sectional observational epidemiological study, primary-care practitioners completed a questionnaire covering demographic and socioeconomic data, medical history, drug treatment, and clinical and biological characteristics for 3351 patients (1630 men and 1721 women). Therapeutic targets were HbA(1c) <7%, LDL cholesterol <1.6g/L, triglycerides <1.5 g/L and SBP/DBP <140/90 mmHg. Multivariate analyses were performed to assess the relationship between waist circumference and a lack of cardiovascular risk-factor control. RESULTS: The patients' mean ages were 58+/-14 years and 55+/-16 years for men and women, respectively. A large waist circumference was positively and significantly (P<0.0001 for all) associated with diabetes, hypercholesterolaemia, hypertriglyceridaemia, low HDL cholesterol and hypertension. The prevalence of patients not achieving therapeutic targets increased across waist-circumference quartiles. For treated patients, the odds ratios (95% CI) (adjusted for age, gender, education, smoking status and medical specialty) for not achieving treatment targets were 17.6 (2.2-142) for triglycerides, 2.8 (1.3-6.1) for HbA(1c) and 1.4 (0.9-2.0) for blood pressure on comparisons with extreme quartiles of waist-circumference distribution. CONCLUSION: In primary care, a lack of control of triglycerides, HbA(1c) and, to a lesser extent, blood pressure increases with waist circumference independently of confounders. This suggests that abdominal obesity is associated of poor results in the treatment of diabetes and hypertriglyceridaemia.

Treatment of heart failure with preserved systolic function.

Heart failure is a major public health problem. Heart failure with preserved systolic function (HF-PSF) is a common form, which is difficult to diagnose. Results of recent studies show that HF-PSF has a poor prognosis, with an annual survival rate similar to that of heart failure with left ventricular systolic dysfunction. Despite these findings, the therapeutic management of HF-PSF is not clearly defined. We will discuss in this review of the literature the current therapeutic management of HF-PSF, including the role of precipitating factors such as hypertension, myocardial ischaemia and supraventricular arrhythmias, and the main results of epidemiological registries and randomized controlled clinical trials in this disease. Only four large therapeutic trials have assessed the impact of different classes of drugs (digoxin, angiotensin II converting enzyme inhibitors, angiotensin II receptors type I blockers and beta-blockers) on morbidity and mortality in HF-PSF. Results of these trials are disappointing. Apart from the beta-blockers, the other three classes of drugs did not show benefit on the outcome of the disease. Moreover, the results of the beta-blocker trial are controversial as a mixed population of heart failure with and without preserved systolic function was studied. Finally, the current therapeutic management of patients with HF-PSF is still based on our pathophysiological knowledge: education, low salt diet, diuretics, slowing heart rate and controlling triggering factors. Other large randomized controlled multicenter trials, which may help us in the understanding of HF-PSP and its therapeutic management, are ongoing.

[Influence of percutaneous coronary intervention in non ST-elevation acute coronary syndromes on prescription of secondary prevention medications. Data from the S-Témoin Registry]. / Prevention secondaire après syndrome coronaire aigu sans sus-décalage de ST en fonction de l'utilisation de l'angioplastie coronaire: l'étude S-Témoin.

BACKGROUND: The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry. METHODS: The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005. RESULTS: Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI. CONCLUSION: Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

Heart failure with preserved systolic function: a diagnostic algorithm for a pragmatic definition.

Heart failure is a major health problem which often concerns the elderly. Prevalence of heart failure with preserved systolic function is increasing and varies from 40 to 50%. In the literature, and in the large epidemiological studies, it is commonly designed with the term of "diastolic heart failure", even if a precise analysis of diastolic function is not performed. A diagnostic algorithm is proposed in order to better define the concept of heart failure with preserved systolic function. It consists of seven steps from symptoms and clinical signs to the echocardiographic analysis of diastolic function, in order to confirm the definition of heart failure with preserved systolic function.

[Do beta-blockers prevent coronary events in hypertensive patients?]. / Les beta-bloquants préviennent-ils les événements coronaires chez l'hypertendu?

Beta-blockers have been considered for decades as effective agents in preventing coronary events in hypertensive patients. Actually, the scrutiny of the available data arises some doubts over the real value of this pharmacological class. In primary prevention, the clinical benefits of beta-blockers are poorly documented: the studies conducted against placebo (MRC, IPPPSH...) did not show any significant differences regarding the rate of coronary events (except within non smokers); moreover, the beneficial effect of propranolol in preventing sudden deaths and silent myocardial infarctions has been reported byjust one retrospective analysis. Likewise in HAPPHY study, the comparison with diuretics did not emphasize a clear superiority of one of both classes; the better effect of metoprolol regarding overall mortality and fatal coronary events was shown in the pecular subset MAPHY, only. Furthermore, in elderly people, HEP, MRC OA and STOP studies did not find any significant effect of beta-blockers in preventing coronary events, as compared with placebo. However, SHEP study, which involved patients older than 60 years with isolated systolic hypertension receiving first a diuretic, then a beta-blocker(atenolol) in 1/4 of the cases, demonstrated a significant reduction versus placebo both in strokes and in coronary events. Finally, in UKPDS, CAPP, LIFE and CONVINCE studies, atenolol turned out to have a similar efficacy as captopril, losartan and verapamil, in preventing ischemic heart disease. Among the numerous published meta-analyses, that of Psaty pointed out the absence of a primary cardioprotective effect by beta-blockers; more recently, that of Carlberg, emphasized atenolol given alone as the first-line drug to fail in significantly reducing coronary events and strokes. In secondary prevention, some more convincing data may be found in the literature, regarding post myocardial infarction patients (meta-analyses of Staessen, 1982, Yusuf, 1985 and Soriano, 1997), as well as those with stable angina (BIP study in diabetics) or silent ischemia (ASIST study: significant reduction in number and duration of ischemic events by atenolol). Moreover, INVEST study recently showed atenolol and verapamil to have an equivalent efficacy in the hypertensive patients with stable coronary artery disease. Last, hypertension should be reminded as resulting in many cases of heart failure, a pathology where beta-blockers have clearly demonstrated their beneficial effects.

[Validation of the therapeutic role of amlodipine in 31,946 French hypertensive patients]. / Validation de l'intérêt thérapeutique de l'amlodipine dans une population française de 31,946 patients hypertendus traités en pratique de ville.

Amlodipine, a dihydropyridine calcium channel blocker (CCB), with a long duration of action, has been the subject of numerous controlled studies which showed its effectiveness and good tolerance in arterial hypertension in once-daily doses. We report the results of a large, multicentric, French, prospective phase IV study which evaluated the effectiveness and tolerance of amlodipine administered at a rate of 5 to 10 mg in only one daily dose. We also assess the evolution of the quality of life after 12 weeks of treatment among 31,946 hypertensive patients followed up to the ambulatory stage by general practitioners. The response rate--defined as the patients having had a reduction of 10 mmHg or more diastolic blood pressure--was 88%. The blood pressure standardization--defined by a diastolic blood pressure lower than 90 mmHg--was achieved for 70% of the patients. Amlodipine was administered in stand-alone therapy in 78% of the cases. The occurrence of an undesirable event was noted in the course of treatment in 12% of the patients and justified interruption of the treatment for 3.7% of the total population. The index average of quality of life was improved by the end of the 12-week treatment. This study carried out on a significant number of hypertensive patients (n = 31,946) under real prescription conditions confirms the efficacy and good tolerance of amlodipine, as has already been demonstrated in the preliminary developmental studies.

[What role to assign for calcium channel blockers in the treatment of arterial hypertension in 1997?]. / Quelle place pour les antagonistes calciques dans le traitement de l'hypertension artérielle en 1997?

What is the place of calcium channel blockers in the treatment of hypertension (HT)? And, more importantly, what is the place of any molecule recognised as being effective to reduce blood pressure figures in the treatment of HT? Beyond the hypotheses which have dominated the rational approach up until now, suggesting a possible answer to these two questions, medical practice is developing towards evidence-based medicine. This opposes two lines of logic:--that which argues that the benefit of treatment of HT is exclusively related to a reduction of blood pressure figure obtained with the use of the most effective molecule or class which is best tolerated in a given clinical context; that which argues that it is impossible to prescribe widely and indefinitely molecules whose real effect on the clinical prognosis of HT and long-term safety are unknown. This new logic no longer recognizes the reduction of blood pressure figures independently of the means used to achieve this reduction as the exclusive guarantee of the benefit of treatment and proposes that treatments which are widely prescribed must have a more detailed clinical evaluation file than that authorized by current practice. Calcium channel blockers were recently adopted as the main subject of this opposition between two logics, probably because several molecules of this class, evaluated in therapeutic trials conducted outside of the context of HT, demonstrated harmful cardiovascular effects and that case-control studies in the context of HT have indicated the possibility of extracardiac adverse effects. It therefore seems useful to try to redefine their place in the treatment of HT in the light of this recent debate and, more importantly, to extend the discussion to several principles of the pharmacological treatment of HT. Leaving current controversies to one side, this review is designed to present several elements of these opposing logics.

[Prognostic factors in dilated cardiomyopathy]. / Etude des facteurs pronostiques des cardiomyopathies dilatées.

Thirty-eight patients, 27 men and 11 women, mean age 49 +/- 12 yr, suffering from dilated cardiomyopathy were included in this prospective study of prognostic factors. Twenty-two subjects admitted heavy alcohol consumption (greater than 80 g/d, for at least 10 yr). The survival rates for 2, 5 and 7 yr were 87, 35 and less than 20%, respectively. Prognostic factors were evaluated in 34 (22 alcoholic and 12 non-alcoholic) patients: 10 improved or were cured, as determined clinically, radiologically and echocardiographically (group 1); 24 deteriorated, 13 of whom died (group 2). Statistically significant values for group 1 versus group 2 were: echocardiographic left ventricular (LV) end diastolic diameter (3.50 +/- 0.80 vs 4.02 +/- 0.5 cm/m2, p less than 0.026) and LV end systolic diameter (2.97 +/- 0.65 vs 3.43 +/- 0.53 cm/m2, p less than 0.02); hemodynamic LV systolic pressure (113.9 +/- 15 vs 101.82 +/- 17.36 mm Hg, p = 0.045); angiographic LV end diastolic volume (137.8 +/- 57.44 vs 177.85 +/- 55.45 ml/m2, p = 0.057), LV end systolic volume 93 +/- 53.5 s 139.28 +/- 48.99 ml/m2, p less than or equal to 0.036), ejection fraction 0.36 +/- 0.16 vs 0.22 +/- 0.7%, p less than or equal to 0.006) and velocity of fiber shortening (0.79 +/- 0.53 vs 0.36 +/- 0.3 circ/s, p = 0.036). Other electrical, radiological and hemodynamic parameters were not significant and alcohol consumption did not influence the prognosis. The severity of LV functional impairment appears to be the major determinant of a poor prognosis and reduced survival in idiopathic and alcoholic cardiomyopathies.

A comparison of three severity score indexes in an evaluation of serious bacterial pneumonia.

Two non specific severity scoring systems, acute physiological score (APS) and simplified acute physiological score (SAPS) are compared with a specific index (Sc) in an evaluation of 96 ICU patients with "serious" bacterial pneumonia. The three scores were measured during the first 24 h following ICU admission. There is a good correlation between APS, SAPS or Sc. Accuracy and efficiency of the non specific scoring indexes and Sc are similar. There is no statistical difference in sensitivity, specificity, positive and negative predictive values, receiver operating characteristic curves of the three indexes. Simple and reliable non specific index such as SAPS, valid for a variety of pathologies, can be used in an evaluation of mortality and comparative studies of groups of patients with serious bacterial pneumonia.