[Survival in acute myocardial infarction in a group of 369 patients consecutively admitted between 1988 and 1992. Analysis of risk factors and medical procedure]. / Survie dans l'infarctus du myocarde au stade aigu dans un groupe de 369 patients admis consécutivement entre 1988 et 1992. Analyse des facteurs de risques et de la pratique médicale.

A retrospective analysis without exclusion of 369 consecutive cases of myocardial infarction admitted between January 1988 and March 1992 studied the risk factors, previous medical history and treatment in this period during which medical practice seemed to be standardised with acknowledged benefits of thrombolysis, beta-blockade and aspirin therapy. The population observed is divided in three age groups (< 65, > 65 < 75 and > 75). A Cox model multivariate analysis for age, sex, diabetes, hypertension, hypercholesterolaemia, tobacco smoking, previous infarction, coronary artery disease and cardiac failure underlined the risk related to age which was 3.2 for patients 65-75 years of age and 4 for patients over 75 years of age. The risk was high in women (1.4), diabetes (1.5) and previous infarction (1.7). The excess mortality of the elderly age groups could also have been related to medical management as the most effective treatments were less commonly used. Thrombolysis was used in 44% of patients under 65 years of age but in only 9.7% of patients over 75 years; betablockers were prescribed in 77.6% of the younger but only in 27.4% of the older patients. The same tendency was observed in the administration of aspirin, with 81.6% receiving this drug in the younger patients compared to only 61% in older patients. Differences in survival at 6 months according to age (93.6%, 74% and 54.9%) show that there is a clearly defined therapeutic objective over 65 years of age with a large field of action and a probability of significant improvement in mortality and morbidity.

[Aneurysm of the interatrial septum. Apropos of a retrospective study of 41 cases]. / Anévrysme du septum interauriculaire. A partir d'une série rétrospective de 41 cas.

The authors undertook a retrospective study of 41 patients in whom an atrial septal aneurysm (ASA) had been diagnosed at transoesophageal echocardiography performed for ischaemic cerebrovascular events in 26 cases. No significant differences in this size, thickness or mobility of the ASA or the associated cardiac abnormalities were demonstrated in this context. However, patients presenting with cerebrovascular accidents were older, had several cardiovascular risk factors and more cardiac arrhythmias. These arrhythmias were usually related to other cardiac pathology such as ventricular hypertrophy or chronic cor pulmonale. Moreover, the probability of the cerebrovascular accident being related to the ASA was only acknowledged in 11 cases. These results mean a certain degree of discretion in diagnostic investigation and therapeutic management of these cases.

A case of recurrent benign pericarditis treated by colchicine.

After five recurrences of idiopathic pericarditis over a period of 8 months on steroidal anti-inflammatory therapy, a splenectomized patient aged 31 years benefited from treatment with colchicine. He was treated for one year without any recurrence. A relapse occurred 6, 7 and 17 months after having stopped the drug. This observation raises the question whether colchicine might be beneficial in recurrent benign pericarditis with or without corticodependence and have a prophylactic action against recurrences.

[Left ventricular diastolic function in hypertensive heart diseases. Comparison of results obtained by echocardiography and mechanocardiography]. / Fonction diastolique ventriculaire gauche dans la cardiopathie hypertensive. Comparaison des résultats obtenus par l'échocardiographie et les mécanocardiogrammes.

Usefulness of computerized mechanocardiography and echocardiography in the bedside diagnosis of impaired left ventricular diastolic function is established in a study comparing 17 hypertensive cardiomyopathy patients and 17 hypertrophic obstructive patients to 20 control. The echocardiographic study involves the ratio A/E obtained from the diastolic motion of the mitral valve and max DD/dtN, the peak rate of maximal diastolic dimension change. Both measurements allow statistical differentiation between pathological conditions and the control. The mechanocardiographic evaluation of left ventricular diastolic function provides easily three different parameters of diastolic function: isovolumic relaxation by the interval B2 alpha-0 or by t-dr/dt and the ratio dr/dt/A2, left ventricular stiffness by the A/H ratio and TRR the time of rapid filling. The mechanocardiographic indices allow clear distinction between the control group and the hypertrophic conditions for all the measured parameters giving evidence for an increased isovolumic relaxation period with a reduced velocity of relaxation, an increase in left ventricular stiffness and in the case of the hypertrophic obstructive cardiomyopathy, a prolonged time of rapid filling.

Mechanocardiographic evaluation of left ventricular diastolic function in hypertrophic cardiomyopathy and hypertensive cardiomyopathy.

Usefulness of computerized mechanocardiography and echocardiography in the diagnosis of impaired left ventricular diastolic function is shown in a study comparing 17 hypertrophic obstructive cardiomyopathy and 17 hypertensive cardiomyopathy patients to 20 normal subjects. Mechanocardiography allows the evaluation of three different parameters of diastolic function: isovolumic relaxation evaluated by S2a-O or better by t-dr/dt and dr/dt/A2 ratio, left ventricular compliance by the A/H ratio and time of rapid filling. All the parameters are impaired in both pathological populations. Isovolumic relaxation being more depressed in hypertensive cardiomyopathy and duration of rapid filling being prolonged especially in the hypertrophic obstructive cardiomyopathy patients. Although the differences are small indicating only trends computerized mechanocardiography gives some evidence for difference in the alteration of diastolic function in hypertrophic obstructive cardiomyopathy and hypertensive cardiomyopathy.

[Hypertrophic obstructive cardiomyopathy in elderly patients. Retrospective study of 23 cases]. / Myocardiopathie hypertrophique et obstructive chez le sujet âgé. Etude rétrospective de 23 observations.

This retrospective study was based on data obtained from 23 patients over 65 years old (72 +/- 1.04 years) with hypertrophic obstructive cardiomyopathy followed up for 3 years (37.2 +/- 5.4 months) in whom the diagnosis was established essentially on phonomechanographic and echocardiographic criteria under basal conditions or during pharmacodynamic stress testing when the initial examination was inconclusive. Under these conditions, diagnostic catheterisation was only required in 9 cases. The incidence of this disease seems to be substantially underestimated in this age group; clinical symptoms and ECG or chest X-ray changes are often attributed to other pathologies if these patients are not thoroughly investigated. In our experience, patients over 65 years represent 20 per cent of the total population of hypertrophic obstructive cardiomyopathy admitted to our Department during the 6 years' study period. Accurate diagnosis is important because of the therapeutic implications; digitalis and vasodilator therapy especially with nitrate derivatives are poorly tolerated by these patients. Betablockers and verapamil seem to be beneficial, judged on the decrease in the number of symptomatic patients when given these drugs. Only one of the 3 deaths observed in the 20 patients followed-up was attributed to cardiac causes, which seems to confirm the lower mortality rate in older patients with this condition.

[Importance of magnetic resonance imaging in myocardial infarct]. / Apport de l'imagerie par résonance magnétique dans l'infarctus du myocarde.

Imagery by magnetic resonance (IMR) represents a new modality of medical imagery based on the interaction between the magnetic fields produced by radio-frequency waves and living substance. IMR finds an interesting application in the study of different stages of myocardial infarction. In 30 cases of myocardial infarction IMR was compared with thallium tomoscintigraphy and echocardiography. In the acute stage, myomalacia appears in IMR as a superbrilliant zone, and in the chronic stage parietal thinning and dyskinesias are apparent. Intraventricular thromboses, but also hemostasis in aneurysmatic or akinetic sites are visualised as a high-intensity signal within these areas. IMR represents therefore a new means of evaluation of size and evolution of the necrosis. This procedure provides also functional informations about the contraction and flow anomalies.

Acute hemodynamic effects of piroximone (MDL 19,205) in patients with moderate congestive heart failure: comparison with sodium nitroprusside.

Piroximone (MDL 19,205), a new imidazolone derivative, was given intravenously to 14 patients with congestive heart failure (NYHA class II-III), while under constant daily doses of digitalis and diuretics. In the first 3 patients, we determined the dose safely eliciting a favorable hemodynamic response. The subsequent 11 patients received 1 mg/kg of piroximone intravenously, and the hemodynamic effects were compared with those of sodium nitroprusside (SN) at a dose-lowering mean blood pressure by 10-20 mm Hg. Piroximone increased heart rate (13.2 +/- 2.0 beats/min, mean +/- SEM) and lowered mean arterial pressure (9 +/- 2.3 mm Hg). Both agents reduced similarly wedge pressure (6.5 +/- 2.9 and 9 +/- 2.9 mm Hg, respectively, for SN and piroximone) and total peripheral resistance. Cardiac index was increased less by SN (15%) than piroximone (48%) (p less than 0.001), and stroke work index significantly enhanced only by piroximone (p less than 0.001). The changes in loading conditions induced by the two agents being similar, it is likely that piroximone not only acts by peripheral vasodilation, but also possesses positive inotropic properties. Myocardial oxygen demand, assessed indirectly by tension-time index, was not affected by piroximone. Thus, piroximone appears to combine well-balanced vasodilator and inotropic properties which make this new agent potentially very useful for the management of congestive heart failure.

[Obstructive myocardiopathy in the elderly. A retrospective study of 18 cases]. / Myocardiopathie obstructive chez le sujet âgé. Etude rétrospective de 18 observations.

From a retrospective study of 18 cases of obstructive cardiomyopathy in elderly people collected over a 5-year period, it appears that the incidence of the disease is probably underestimated. It seems to vary in severity, but only one-third of the patients present suggestive clinical symptoms associated with an obvious obstructive syndrome. The best diagnostic method is phonomechanography, which is easy to perform, systematically completed by a pharmaco-dynamic test. Hyperkinesia and disorders of cardiac compliance add useful specific data to the clinical picture. Echocardiography provides information on cardiac anatomy and on the obstructive mechanism. Left ventricular function tests are of particular interest in these old-age patients with cardiopathy. In our opinion, the two non-invasive methods are sufficient for a firm diagnosis, even when some criteria, notably ultrasonic, are lacking. Once the condition is diagnosed, the patient should be put on beta-blockers or calcium inhibitors, such as verapamil, which constitute an effective treatment.

[Left intraventricular thrombosis. From diagnosis to treatment]. / Thrombose intraventriculaire gauche. Du diagnostic au traitement.

Left ventricular thrombi are the source of much concern in numerous conditions affecting the ventricles. Refinement in echocardiographic and isotopic techniques is enabling earlier diagnosis and a more rational approach to therapy. These thrombi occur very frequently, and are most often asymptomatic (more than 2 to 3 times out of 4), and their natural course is not well known. Recent studies have dealt with acute ischemic cardiopathies, but these should not obscure the fact that thrombi occur with similar frequency in chronic conditions, in particular, hypokinetic cardiomyopathies. Three recent cases emphasize this, demonstrate the frequency of these thrombi, and help illustrate available diagnostic methods and a practical approach to this condition. These recent developments only confirm the importance of effective anticoagulation in all patients at risk and the necessity of optimal treatment with inotropic agents which do not suppress thrombus formation, but appear to prevent their complications.

Mechanocardiography in evaluation of left ventricular function. Relevance of combined study of apex cardiogram and systolic time intervals in diagnosis of cardiomyopathies.

The study of left ventricular performance by means of systolic time intervals, especially represented by the PEP/LVET ratio and indices drawn from the first derivative of the apex cardiogram, makes possible a good approach to the functional anomalies of patients suffering from hypokinetic cardiomyopathies or hyperkinetic conditions of obstructive or unobstructive hypertrophic cardiomyopathies and of patients with hyperthyroid conditions. In hypokinetic states, the sensitivity and the specificity of the PEP/LVET ratio proved to be good, as was the case for indices taken from the first derivative of the apex cardiogram. However, the sensitivity and the specificity of the cardiogram were much better in the detection and evaluation of hyperkinetic conditions, hypertrophic cardiopathies or hyperthyroiditis. By providing the elements required for analysis of isometric contraction through indices drawn from the first derivative of the apex cardiogram and from the ejection phase, through the PEP/LVET ratio, and by adding exploitation of the diastolic phase, in particular through the A/H ratio exploring diastolic compliance, mechanocardiograms allow an all-round, quasi-physiopathological approach to disorders of left ventricular function during cardiomyopathies.

[Phonomechanographic evaluation of left ventricular function in hyperthyroid states]. / Evaluation phonomécanographique de la fonction ventriculaire gauche dans les états hyperthyroïdiens.

Hyperthyroidism is associated with a hyperkinetic syndrome, the mechanisms of which are not fully understood but which include an increase in heart rate, a reduction in systemic arterial resistance and a debatable increase in myocardial contractility. The limitations of radioimmunological assay of the hormonal mediators underline the diagnostic value of an atraumatic method of quantifying left ventricular systolic function. In view of the variable sensitivity of phonomechanographic and echocardiographic indices with respect to changes in heart rate, pre- and after load, we studied apex cardiographic indices during the phase of isovolumetric contraction. Fifty-eight patients with hyperthyroidism but without patent cardiovascular disease were divided into two subgroups: Grave's disease: 38 cases, and toxic adenoma: 22 cases. The results of the measurements of systolic time intervals and the calculation of "indices of contractility" obtained from the apex cardiogram and its first derivative, were compared with those of 36 young, normal subjects. The results show that: the pre-ejection period of the study population was much shorter than normal (65,7 ms +/- 2,5 vs 84,6 ms +/- 3,4; p less than 0,001); this was clearly related to the chronotropic factor (p less than 0,05). The pre-ejection/ejection period ratio did not differentiate hyperthyroid from normal subjects (0,265 vs 0,283, p greater than 0,20), except in Graves' disease (0,249, p less than 0,02). On the other hand, measurements made from the apex cardiogram showed significant differences in both types of hyperthyroidism. (Formula: see text). In conclusion, phonomechanography may be used to quantify the increase in left ventricular function in hyperthyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)

[Semi-automatic acquisition and processing of mechanocardiograms]. / Acquisition et traitement semi-automatique des mécanocardiogrammes.

Like echocardiography and radio-isotope techniques, mechanocardiography has a special place in the evaluation of left ventricular function in heart disease. This recognized technique can be easily performed by clinicians or pharmacologists or in aerospace medicine. A programme has been developed from micro-processor material (HP 9845 S - SP 9835 - HP 6940 B multi-programmer) already in use in the department. After sampling at 700 Hz and quantification, this programme can reproduce a complete mechanocardiographic tracing consisting of ECG, phonocardiogram, carotidogram and apexogram . The first derivative of the apex cardiogram is calculated numerically and visualized. The characteristic events of the systolic phase of the apex cardiogram are then checked manually or semi-automatically by the operator. After confirmation, the calculations are performed and are edited with the tracings. This system eliminates the need for a recorder, as the tracings can be stored on cassette or diskette and recalled later for statistical analysis. These programmes make the interpretation of the mechanocardiographic tracings considerably simpler and faster.

[Evaluation of left ventricular function and regional kinetics following myocardial infarction. Comparative study of angiocardiography, echography and radionuclide angiography]. / Evaluation de la fonction ventriculaire gauche et de la cinétique segmentaire dans les suites de l'infarctus du myocarde. Etude comparative entre les données de l'angiocardiographie, de l'échographie et de la scintigraphie cavitaire à l'équilibre.

Left ventricular function and regional wall motion were studied three weeks after a myocardial infarction in 25 patients who had undergone L.V. monoplane cineangiography. The patients were studied by echocardiography (TM and 2D) and radionuclide angiography. Evaluation of global ejection fraction provides evidence of a close correlation between left ventricular angiography and radionuclide examination (r= 0.79). Measurement of ejection fraction by echocardiography (TM) remains clearly correlated with the same evaluation by angiography (r = 0.68). The correlations are markedly increased in the patients without significant wall motion defects (r = 0.87 for radionuclide angiography and r = 0.82 for echographic measurement). Sensitivity in the detection of L.V. aneurysms is excellent with our method of radionuclide examination (12/13) and can be compared with angiography (12/13). Two-dimensional echocardiography performed on a routine basis is less sensitive than radionuclide angiography in this diagnosis (4/13).

Hemodynamic effects of MDL 17,043, a new cardiotonic agent, in patients with congestive heart failure: comparison with sodium nitroprusside.

MDL 17,043 (MDL), a new cardiotonic agent, was given intravenously at a single dose of 0.5 mg/kg to 14 patients with congestive heart failure (stages II-III). The mean half-life of plasma elimination of the parent compound determined in eight subjects was 81 min. MDL is rapidly metabolized to the sulfoxide with a maximum plasma metabolite concentration reached at 15 min after parent drug infusion and a metabolite half-life of 164 min. In eight patients, the hemodynamic effects of MDL were compared with those of sodium nitroprusside (SN) given at a dose lowering mean blood pressure by 20 mm Hg. Both agents increased cardiac output (p less than 0.001 for MDL, p = 0.06 for SN) and decreased total peripheral resistance values (p less than 0.001 for both) and left ventricular end-diastolic pressure (wedge pressure) (p less than 0.001 for MDL, p less than 0.01 for SN). However, MDL was able to increase left ventricular stroke work, whereas SN failed. As both agents induced comparable changes in loading conditions, it can be assumed that MDL not only acts by peripheral vasodilation but also has a direct positive inotropic action on the heart muscle. Myocardial oxygen uptake, assessed indirectly by tension-time index, was not affected by MDL (p greater than 0.2) despite the improvement in myocardial contractile state, thus making this new agent suitable for the treatment of congestive heart failure secondary to ischemic heart disease.

[Phonomechanography: a premature requiem]. / Phonomécanographie: un requiem prématuré.

The value of phonomechanographic recordings has been contested in recent years. This seems to be the result of the upsurge in other non-invasive methods of investigating cardiac diseases and left ventricular function such as those based on ultrasound, pulsed Doppler or radioisotopes. Far from opposing these techniques, phonocardiography has benefited from their comparison and association which have validated the systolic time and amplitude indices previously used empirically. This validation justifies maintaining and developing phonomechanographic recordings. Whilst recognising their limits, five of their main advantages are emphasised. As a true extension of our senses and complementary to the human ear phonomechanography is, foremost, the continuation of clinical examination and an unique and ideal instrument for teaching cardiac auscultation. By confirming and explaining the nature of an auscultatory abnormality, recording the morphology and timing of the arterial and venous pulses and of the apex beat, phonomechanography participates in the positive and etiological diagnosis of various conditions and even provides a semiquantitative assessment in some diseases. Left ventricular function may be assessed by measuring the systolic time intervals and by quantifying the systolic apical impulse. This appreciation based on the period of isovolumic contraction is complementary to echocardiographic assessments of LV function which are calculated during the ejection period. Only by combining the various non-invasive methods can the weakness and practical limitations of each particular method be avoided. Finally, as the reliability of systolic time and amplitude indices have been validated, the relative ease of their determination and their economic advantages must be emphasised.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bacterial endocarditis and mitral valve prolapse]. / Endocardite bactérienne et prolapsus valvulaire mitral.

The suspected diagnosis of bacterial endocarditis is based on a presumption. Over the last few years, ultrasound, which can identify valvular lesions and their repercussions, has established itself as a supplementary diagnostic tool in the early stages of this disease. The existence of false negatives should not be underestimated, but one must also be aware of the possibility of false positives. These false positives are mostly due to mitral valve prolapse. An unusual cas serves as an illustration of the potential diagnostic difficulties of this association and confirms the value of the ultrasound examination, provided it is performed under optimal conditions and repeatedly. However, the abnormalities of ventricular kinetics in the course of mitral valve prolapse limit the evaluation of the haemodynamic repercussions of the regurgitation. The authors stress the supplementary contribution of phonomechanographic examinations. In this particular case, they gave an idea of the severity of the mitral leak and of its recent onset and they strongly suggested the integrity of left ventricular function and the presence of major valvular dysplasia.