Relationship between alcohol intake, health and social status and cardiovascular risk factors in the Urban Paris-Ile-de-France Cohort: is the cardioprotective action of alcohol a myth?

BACKGROUND/OBJECTIVES: Observational studies document the inverse relationship between cardiovascular disease (CVD) and moderate alcohol intake. However, the causal role for alcohol in cardioprotection remains uncertain as such protection may be caused by confounders and misclassification. The aim of our study was to evaluate potential confounders, which may contribute to putative cardioprotection by alcohol. SUBJECTS/METHODS: We evaluated clinical and biological characteristics, including cardiovascular (CV) risk factors and health status, of 149,773 subjects undergoing examination at our Center for CVD Prevention (The Urban Paris-Ile-de-France Cohort). The subjects were divided into four groups according to alcohol consumption: never, low (30 g/day); former drinkers were analyzed as a separate group. RESULTS: After adjustment for age, moderate male drinkers were more likely to display clinical and biological characteristics associated with lower CV risk, including low body mass index, heart rate, pulse pressure, fasting triglycerides, fasting glucose, stress and depression scores together with superior subjective health status, respiratory function, social status and physical activity. Moderate female drinkers equally displayed low waist circumference, blood pressure and fasting triglycerides and low-density lipoprotein-cholesterol. Alcohol intake was strongly associated with plasma high-density lipoprotein-cholesterol in both sexes. Multivariate analysis confirmed that moderate and low drinkers displayed better health status than did never drinkers. Importantly, few factors were causally related to alcohol intake. CONCLUSIONS: Moderate alcohol drinkers display a more favorable clinical and biological profile, consistent with lower CV risk as compared with nondrinkers and heavy drinkers. Therefore, moderate alcohol consumption may represent a marker of higher social level, superior health status and lower CV risk.

Vascular risk factors and morphometric data in cervical artery dissection: a case-control study.

BACKGROUND: Limited knowledge exists on vascular risk factors, body height and weight in patients with spontaneous cervical artery dissection (sCAD). PATIENTS AND METHODS: In this case-control study, major vascular risk factors, body weight, body height and body mass index (BMI) of 239 patients obtained from a prospective hospital-based sCAD registry were compared with 516 age- and sex-matched healthy controls undergoing systematic health examinations in the Clinical and Preventive Investigations Center, Paris. Gender-specific analyses were performed. RESULTS: The mean body height was higher in sCAD patients than in controls (171.3 cm (SD 8.6) vs 167.7 cm (8.9); p<0.0001) and sCAD patients had a significantly lower mean body weight (67.5 (12.2) kg vs 69.3 (14.6) kg; p<0.001) and mean BMI (22.9 (3.3) kg/m2 vs 24.5 (4.2) kg/m2; p<0.0001) than controls. The overall frequency of hypertension, diabetes, current smoking, past smoking and hypercholesterolaemia did not differ significantly between sCAD patients and controls. The mean total plasma cholesterol level was identical in both groups (5.5 mmol/l, SD 1.1). Gender specific subgroup analyses showed similar results for men and women. CONCLUSION: Patients with sCAD had a higher body height and a lower body weight and BMI than controls, while major vascular risk factors were similar in sCAD patients and controls.

[Management of sudden death in a semi-rural district, Seine-et-Marne: the DEFI 77 study]. / Prise en charge de la mort subite dans un département semi rural, la Seine et Marne: étude DEFI 77.

Sudden death is a major problem in public health, affecting around 50 000 people a year in France. The prognosis for cardiac arrest is abysmal because for every minute lost the chances of survival diminish by 10%. The aim of this work was to prospectively evaluate the characteristics of cardiac arrest victims across an entire 6000 km? area, the Seine-et-Marne district, distinguished by the paradox of lying just outside the capital whilst actually being semi-rural, and to determine the current methods of dealing with this emergency. The DEFI 77 prospective epidemiological survey was carried out with the collaboration of the SAMU emergency medical service, the SDIS fire/ambulance service, the general hospitals and the Paris-Ile-de-France cardiological association. Between January 2001 and December 2005 there were 2001 cardiac arrests (mean age 68 +/- 20 years, 67% male) at home in 80% of cases. The arrest was in front of a witness in 72% of cases, but they performed resuscitation in only 14.3% of cases. The SAMU and SMUR emergency medical services attempted cardio-pulmonary resuscitation in 78% of cases. In 29% of cases, one or more external electric shocks were carried out, using a semi-automatic defibrillator 79% of the time. Only 11.5% of patients arrived at the emergency department alive, the overall hospital survival rate being less than 2%. Only eight patients subsequently underwent automatic defibrillator implantation. The results of this observational study are to a large extent explained by an extremely long delay (12 minutes) before help was called for, the delay between the call and the arrival of medical assistance (9.5 +/- 4 min), the low percentage of active witnesses, and the variability in management (invasive in particular). In conclusion, at the dawn of the third millennium the prognosis of cardiac arrest remains very poor and fully justifies educating the general public about calling for help early and about actions that can save lives, particularly external cardiac massage before the arrival of the emergency services, as well as the benefits of using automated external defibrillators.

Characteristics and six-month outcomes in a cohort of 8288 diabetic and non-diabetic patients with previous history of acute coronary syndrome or stroke: the French PREVENIR 3 survey.

AIMS: To evaluate the cardiovascular prognosis of 1845 Diabetic Patients (DP) and 6443 Non-Diabetic Patients (NDP) in secondary prevention. METHODS: Patients were recruited prospectively if they had had a previous history of ischemic stroke or acute coronary syndrome (ACS) i.e. Myocardial Infarction (MI) or Unstable Angina (UA) within a period of five years preceding inclusion. For each patient, the number of hospitalizations and vital status were recorded each month over a 6-month period (mean follow-up: 4.8 months). RESULTS: 306 patients (9.5/100--person years; 95% CI, 8.5 to 10.6) had undergone at least one subsequent event (hospitalization for ACS, ischemic stroke, or cardiovascular death). A majority of these events were non-fatal ACS (n=248). The cumulative incidence rate of subsequent events was higher in DP: 12.6/100- person years (10.0 to 15.2) than in NDP: 8.6/100--person years (7.5 to 9.8). DP were significantly at higher risk of subsequent cardiovascular events (OR: 1.34; P=0.025) after adjustment for confounding factors. 93% of coronary DP and NDP underwent a recurrent event affecting the same location. When the index episode was a stroke, 71% of DP had a subsequent stroke vs. 47% of NDP. CONCLUSION: in secondary prevention, the risk of mortality and subsequent vascular events is independently higher in French DP than in NDP. The locations affected by each type of subsequent cardiovascular event seemed correlated to the baseline diagnosis, whatever the diabetic status, even when the frequency of subsequent strokes increased (not significantly) in DP when compared to NDP.

Cardiovascular risk markers associated with the metabolic syndrome in a large French population: the "SYMFONIE" study.

OBJECTIVE: The SYMFONIE study was designed to analyze the clinical and biological characteristics, and the cardiovascular risk markers, in men and women with the metabolic syndrome compared to control subjects. RESEARCH DESIGN AND METHODS: The study population included 101,697 men and women, 18 to 80 years of age, who had a health checkup at the Centre d'Investigations Preventives et Cliniques (Paris, France) between 1997 to 2002. The metabolic syndrome was defined according to the ATpiiI-NCEP 2001 criteria. RESULTS: Out of the 66,202 men (47.4+/-11.8 years) and 35,495 women (48.5+/-13.6 years) included in this population, 6761 men (10.2%) and 2155 women (6.1%) presented the metabolic syndrome. Among subjects < or =40 years of age, the prevalence of the metabolic syndrome was 5.0% in men and 2.2% in women, and rose to 14.1% and 12.0%, respectively, among men and women >70 years of age. After adjustment for age, patients with the metabolic syndrome presented higher pulse pressure (systolic minus diastolic blood pressure), higher heart rate, lower vital respiratory capacity, lower physical activity, an increase in inflammatory status assessed through leukocyte count and dental inflammation, hepatic abnormalities, and increased levels of stress and depression. CONCLUSION: In this large French population, the prevalence of the metabolic syndrome is lower than in North American and northern European populations. Patients with the metabolic syndrome present several additional hemodynamic, inflammatory and psychological risk markers which could contribute to the poor cardiovascular prognosis of these subjects.

[Survey into cardiac pacing in the Ile-de-France area for the year 2001: evaluation of indications]. / Enquête sur la stimulation cardiaque en Ile-de-France pour l'année 2001: evaluation des indications.

UNLABELLED: A survey into the implantation of cardiac pacemakers during 2001 in the Ile-de-France area was carried out by the French National Insurance Medical Service in order to evaluate performance in all centres performing more than 10 primary implantations per year. METHODS AND RESULTS: In 2001, 12 centres out of a total of 49 performed less than 50 primary implantations per year, representing 5% of the total regional activity, which was estimated to be 6414 procedures. The remaining 95% of procedures were spread evenly among 8 high-throughput centres (> 200 primary implantations per year) and 29 medium-throughput centres (50 to 200 primary implantations per year). Indications for pacing were analysed retrospectively by a team of regulatory doctors on a sample of 2176 patients with reference to the ACC/AHA/NASPE guidelines. After examination of the medical records, the indication was ranked as being class I, II or Ill (absence of indication). A valid indication was lacking in 8.2% of cases. Sinus node dysfunction represented 74.6% of the non-indications, and this classification had the predictive factors of asymptomatic dysfunction, and treatment with anti-arrhythmic or bradycardic medication. The proportion of class III interventions was significantly lower in the high-throughput centres (5.8 vs 9.9%, p < 0.05). CONCLUSION: 8.2% of primary pacing procedures were not indicated and resulted principally from asymptomatic sinus node dysfunction.

[Long-term evaluation of endocavitary cryoablation of nodal reentry]. / Evaluation à long terme de la cryoablation endocavitaire dans le traitement des réentrées nodales.

Radiofrequency ablation is the reference treatment of refractory nodal reentry. Cryoablation has the advantage of having more modulable effects and minimises the risk of permanent atrioventricular block (AVB). Its immediate efficacy seems comparable to that of radiofrequency ablation but the long-term results are not well known. Endocavitary cryoablation of the slow pathway was undertaken in 26 patients (18 women) with an average age of 47.7 +/- 72.8 years with re-entrant nodal tachycardia refractory to medical therapy. The primary success rate was 92% (24 out of 26). On average, 2.6 +/- 2.2 (1 to 10) cryoablations at - 70 degrees C were delivered and were preceded by 6.4 +/- 4.5 (1 to 16) cryomappings to locate the site of the slow pathway. During cryomapping, 8 episodes of AVB were observed in 6 patients (6 second or third degree), all of which were revertible on rewarming. No cases of permanent AVB were observed. An oesophageal stimulation test of inducibility was performed on the 4th day in 21 patients, 16 of which were not reinducible. During follow-up of 355 +/- 194 days, 22 of the 26 patients (85%) had no recurrence of the arrhythmia. Two of the 24 primary successes had a recurrence, in addition to the two primary failures. Two of the four recurrences occurred in a non-sustained form which was less disabilitating for the patient and the recurrences were controlled in the 4 patients by antiarrhythmic therapy. These results suggest that cryoablation may be a reliable and effective long-term treatment of re-entrant nodal tachycardias. If confirmed in larger series in terms of efficacy and safety, cryoablation could become the treatment of choice of re-entrant nodal tachycardia.

[Automobile driving and implantable defibrillators]. / Conduite automobile et défibrillateur implantable.

The consequences of implanting an automatic cardioverter defibrillator (ICD) on vehicle driving in France are poorly known. This retrospective study examined the behaviour at the wheel of ICD recipients who were recommended to abstain from driving for 3 to 6 months after device implantation. The study population included 98 patients (mean age = 59.5 +/- 14.8 years) followed for a mean of 24. +/- 23.9 months, who underwent ICD implant for ventricular tachycardia (65% of patients ventricular fibrillation (15%), syncope (8%), as part of a research protocol of myocardial cell transplantation 6%, or for primary prevention (5%). The underlying heart disease was ischemic in 59% of patients dilated cardiomyopathy in 11%,hypertrophic cardiomyopathy in 8%, valvular in 6%. Brugada syndrome in 4%, right ventricular arrhythmogenic cardiomyopathy in 2%, and miscellaneous disorders in 9% of patients. Five patients died without post mortem interrogation of the ICD. Only 28% of drivers remembered, and 13% observed, the recommended driving limitations. However, 45% (the oldest) claimed to drive prudently. During follow-up, 47% of patients received an ICD shock. Their mean it ventricular ejection fraction was 34 +/- 14%, versus 43 +/- 18% in patients who received no ICD therapy (p = 0.015). Syncope occurred in 16% who received ICD shocks. Shocks were delivered during driving in 6 patients, without consequent accident. Despite their non-observance of recommended driving limitations. ICD recipients suffered few traffic accidents. Legislation in France should reproduce the guidelines issued by European professional societies and enacted by the British laws.

[New energy sources for ablative methods]. / Nouvelles sources d'énergie dans les méthodes ablatives.

Radiofrequency current is the reference energy source for endocavitary ablation of arrhythmias. It is particularly well adapted for the ablation of focal arrhythmogenic substrates such as accessory pathways or foyers of automatism. Technological advances have made the lesions larger but the extension of the indications of percutaneous ablation to more complex substrates such as atrial fibrillation have justified the evaluation of alternative energies. The production of linear transmural lesions or deeper lesions which respect the parietal myocardial architecture and endocardial structure are a challenge for these energies. The capacity of functional mapping specific to cryogenics has provided this energy source with a clinical application for ablation of high risk structures whereas other energies, despite the chronicity of their experimental evaluation, are still at the stage of preliminary clinical trials with the sophisticated catheters in special indications.

[External electrical cardioversion of atrial arrhythmia: predictive criteria of success]. / Cardioversion électrique externe des troubles du rythme atriaux: critères prédictifs de succès.

AIM: Supraventricular arrhythmia is a major public health problem because of its prevalence and clinical consequences. The first step of the treatment usually consists in restoring sinusal rhythm. The aim of this study is to evaluate results and predictive factors of success of electrical cardioversion. METHODS: We studied a series of 143 consecutive electric cardioversion preformed in 131 French patients. RESULTS: The rate of successful direct current cardioversion was 91.2%. Negative predictive factors are the height body mass index and the age of arrhythmia. Atrial flutter is a predictive factor of success. These results agree with published results. Our study highlights the interest of some nonantiarrhythmic drugs received by the patient during the period before the direct current cardioversion. Thus, a spironolactone treatment appears to be a new predictive factor of the success of electrical cardioversion (success in patients treated with spironolactone: 100% vs 89% without, P = 0.04). CONCLUSIONS: Our results agree with usual predictive factors of the success of cardioversion. Nevertheless, a new approach is that of the positive effect of spironolactone on cardioversion. A prospective randomized study is necessary to confirm this result.

[Predictive criteria of early recurrence of atrial arrhythmia after reduction by electrical cardioversion]. / Critères prédictifs de récidive précoce d'un trouble du rythme atrial après réduction par choc électrique externe.

The management of atrial arrhythmias aims not only to restore sinus rhythm but also to maintain it. Ten to thirty per cent of patients have early recurrence of atrial arrhythmias, the treatment of which remains empiric. The aim of this study was to define factors predictive of early recurrence of atrial arrhythmias and the consequences on the length of hospital stay. A series of 131 patients who underwent reduction of atrial arrhythmias by electrical cardioversion was studied retrospectively. A recurrence within 24 hours was observed in 12.2% of the patients. These recurrences significantly increased the length of hospital stay (6.8+/-6.3 versus 3.6+/-3.8 days, p=0.005). This study confirms two previously reported results with respect to more long-term recurrences. In the "early recurrence" group, the duration of the atrial arrhythmia was longer (p=0.003) and there were fewer treatments with amiodarone (p=0.03). In addition, original results were obtained. In the "early recurrence" group, the patients were more often treated with furosemide (p=0.02), class Ic antiarrhythmics (p=0.007) or anaesthetised with thiopental (p=0.002) than patients without early recurrences. Experimental data explain these results. However, they require confirmation by a prospective randomised trial.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study).

BACKGROUND: In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database. METHODS: The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors. RESULTS: Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival. CONCLUSION: Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

Reproducibility of the ventricular synchronization parameters assessed by multiharmonic phase analysis of radionuclide angiography in the normal heart.

Radionuclide angiography (RNA) permits analysis of contractility and conduction abnormalities. We determined the parameters of normal ventricular synchronization, assessed the reproducibility of the technique, and compared first harmonic (1H) and third harmonic (3H) analysis. Forty-four normal subjects (28 men and 16 women) were studied. RNA was performed in left anterior oblique (LAO) and left lateral (LL) projections. The onset (To), mean time (Tm), total contraction time (Tt) for right ventricle (RV) and left ventricle (LV), interventricular time (T(RV-LV) = Tm(LV - Tm(RV)) in LAO, and the apex-to-base time (T(a-b)) in LL were measured on the histograms of the time-activity curve. Reproducibility (R) was tested by studying 26 consecutive patients with two successive RNAs. RV starts contracting 25 ms before LV (To(RV) = 29 +/- 37 ms; To(LV) = 54 +/- 39 ms; mean +/- SD) with a 37 ms longer total contraction time. T(RV-LV) is 3 +/- 16 ms. In LL projection, apex and base contract synchronously: T(a-b) = 2 +/- 16 ms. 3H analysis enlarges all duration parameters (To, Tm and Tt), but does not alter synchronization (deltaT(a-b) and deltaT(RV-LV) between 1H and 3H <1%, p = NS). Reproducibility of the duration (T(tLV) and T(tRv)) and synchronization parameters (T(a-b) and T(RV-LV)) is high (R < or = 2.2%). In conclusion, the simultaneous contraction of right and left ventricles and of apex and base can be quantified by RNA phase analysis with high reproducibility. These results, consistent with published electrophysiological data, provide the basis for further non-invasive investigations of ventricular resynchronization in patients with basal electrical or mechanical asynchrony.

Combined effects of systolic blood pressure and serum cholesterol on cardiovascular mortality in young (<55 years) men and women.

AIMS: To evaluate the combined effects of the two most frequent modifiable risk factors, systolic blood pressure and serum cholesterol, on cardiovascular and coronary mortality, in a large French population aged 18 to 55 years. METHODS AND RESULTS: We studied 108,879 men (mean age 39.1+/-9.4 years) and 84,931 women (mean age 37.3+/-10.0 years) who had a health check-up at the IPC Center between 1978 and 1988. Mortality data for a mean period of 13 years were analysed. Systolic blood pressure and cholesterol levels were classified according to the cut-points proposed by international guidelines. In men, the prevalence of high cholesterol was more than twice as high in hypertensives as in normotensives; in women, it was more than three times higher. The combination of these two risk factors has additive effects on cardiovascular disease and coronary heart disease risk. In men, a borderline elevation of both systolic blood pressure (130-139 mmHg) and cholesterol (200-239 mg x dl(-1)) leads to a three- to four-fold increase in cardiovascular disease risk. Men with systolic blood pressure >or=160 mmHg represent a small percentage (about 5%) who have a 10-fold increase in cardiovascular disease and coronary heart disease risk, especially when high cholesterol is present. In women of the same age, similar trends were observed, but the results were less significant, probably due to the low cardiovascular disease mortality rates. CONCLUSIONS: In conclusion, in French subjects under 55 years of age, a combination of high systolic blood pressure and high serum cholesterol dramatically increased cardiovascular disease and coronary heart disease risk, especially in men. A more aggressive public health policy is needed to prevent the development of risk factors in younger subjects.

[Paroxysmal atrial fibrillation in community medicine: management intentions and cost estimates]. / La fibrillation auriculaire paroxystique en médecine de ville: intentions de prise en charge et estimation du coût.

This study was undertaken to describe the declared management of atrial fibrillation in community medicine in France for patients between 50 and 80 years of age, and to estimate the total cost of treatment for Society in the year 2000. A questionnaire was sent to a sample of 306 private sector cardiologists, representative for their geographic location: 100 replies were received. Only 10% of cardiologists prescribed a treatment in patients without cardiovascular precedents who had a single regressive episode of atrial fibrillation and three quarters of them advised follow-up. This management cost an average between 228 and 296 Euros/year. When the episode of fibrillation was persistent at the time of consultation, 82% of practitioners prescribed antiarrhythmic reduction (amiodarone) after antithrombotic treatment (oral anticoagulants) followed by an antiarrhythmic therapy (class lc mainly) with an average cost of 659 to 783 Euros/year. In patients with previous cardiovascular disease, when a first episode of atrial fibrillation was present at the time of consultation, 92% of cardiologists prescribed pharmacological reduction with amiodarone, followed by long-term therapy when successful for an average cost of 755 to 1,092 Euros/year. All cardiologists requested systematic blood tests to search for thyroid complications of amiodarone with an average cost of 59 Euros/year. The costs were high, especially in chronic and recurrent pathology: the cost of treatment of the first two episodes of atrial fibrillation in the over 65 age group was 305 million Euros/year.

Pulse pressure and heart rate: independent risk factors for cancer?

In the present study, the roles of heart rate (HR) and pulse pressure (PP) on cancer mortality, after taking into account physical activity, cigarette smoking, alcohol consumption and other confounding factors or underlying disease, were examined in men. The study included 125,513 men aged 20 to 95 years who had a health check-up at the IPC Center between 1978 and 1988. HR and PP were classified into three groups: < 60, 60-80, > 80 bpm for HR and < 50, 51-64, > or = 65 mmHg for PP. Adjusted risk ratios related to the increment from one class of HR or PP to the next for all cancer mortality were 1.4 (1.2-1.5) and 1.3 (1.1-1.4), respectively. This relationship was independent of several known risk and confounding factors, especially cigarette smoking and physical activity, and could not be explained by the presence of underlying disease.

Combined effects of heart rate and pulse pressure on cardiovascular mortality according to age.

OBJECTIVES: The aim of the study was to assess the combined effects of pulse pressure (PP) and heart rate (HR) on cardiovascular mortality in a large French population. DESIGN: The study population was composed of 125,513 men and 96,301 women aged 16-95 years who had a health check-up at the IPC Center between January 1978 and December 1988. Subjects taking antihypertensive treatment were excluded. Mortality was assessed for an 8-year period. HR and PP were classified into three groups. HR groups were: < 60, 60-79 and > or = 80 beats per minute (bpm). PP groups were: < 50, 50-64 and > or = 65 mmHg. RESULTS: In men, PP and HR were both positively associated with cardiovascular mortality risk. In women, mean arterial pressure (MAP) but not PP or HR was associated with cardiovascular mortality. In men, a combined elevation of PP and HR was associated with an important increase of cardiovascular mortality risk. The group with the highest PP and the highest HR had a 4.8-fold increase in cardiovascular mortality risk as compared to the reference group (PP < 50 mmHg and HR < 60 bpm). This effect was more pronounced in younger men (5.4-fold increase) than in older men (3.7-fold increase), as compared to the reference groups of the same age. In women, the combined effects of PP and HR on cardiovascular mortality were not significant. CONCLUSION: A combined elevation of the two components of pulsatile arterial stress is associated with an important increase in cardiovascular mortality in men, especially in younger men. In women, steady-state stress (evaluated primarily by MAP), but not pulsatile stress, is an important determinant of cardiovascular mortality.

[Arrhythmic cardiomyopathy]. / Cardiomyopathie rythmique.

Arrhythmic cardiomyopathy (ACM) is a clinical entity which can be reproduced in experimental models and which corresponds to all myocardial changes induced by chronic tachycardia. It may affect the atria and/or ventricles and, in this case, occur with all types of arrhythmia. Arrhythmia complicating a cardiomyopathy is the differential diagnosis of ventricular ACM. Nevertheless, the potential deleterious haemodynamic changes of any chronic arrhythmia may aggravate pre-existing ventricular dysfunction and, therefore, should always be considered. The development of ACM is usually progressive and depends on the heart rate, but there may also be a myocardial predisposition in certain cases. ACM is an association of haemodynamic, electrophysiological, metabolic and histological changes. Regression, which is the rule, starts in the first days following control of the ventricular rhythm but continues clinically over several months. The physiopathological mechanisms of ACM are multiple and include essentially abnormal cellular calcium concentrations. The treatment is optimally the restoration and maintenance of sinus rhythm, or at least control of the ventricular rate. Because of its curative effects, selective radiofrequency ablation of the arrhythmogenic substrate is the treatment of choice when this is localised. In chronic atrial fibrillation, when sinus rhythm cannot be maintained, the control of the ventricular response at rest and on exercise depends on pharmacological treatment, and, when ineffective, on radiofrequency modification of atrioventricular conduction with optimisation of the pacing mode.

New diagnostic criteria for diabetes and coronary artery disease: insights from an angiographic study.

OBJECTIVES: The goal of this research was to study coronary atherosclerosis in patients with type 2 diabetes compared with patients without diabetes according to the new definition of diabetes advocated by the American Diabetes Association in 1997. BACKGROUND: Patients with diabetes (fasting plasma glucose above 7.0 mM/L) have a higher risk of cardiovascular death. The correlation with the pattern and severity of their coronary atherosclerosis, especially in the new patients with "mild" diabetes (7.0 mM/L < or = fasting plasma glucose < 7.8 mM/L), remains unclear. METHODS: A cohort of 466 patients undergoing coronary angiography but free of any previous infarction, coronary intervention and insulin therapy were prospectively recruited. Ninety-three had diabetes (fasting plasma glucose > 7.0 mM/L or hypoglycemic oral treatment). Five angiographic indexes were calculated to describe severity and extent of coronary atherosclerosis. RESULTS: Overall, patients with diabetes had more diffuse coronary atherosclerosis, a greater prevalence of mild, moderate and severe stenoses and a two-fold higher occlusion rate than patients without diabetes, even after adjustment for age, gender, body mass index, hypertension, lipid parameters, smoking, family history of cardiovascular events and ischemic symptoms. Patients with "mild diabetes" had a coronary atherosclerosis pattern more similar to patients with normal fasting plasma glucose than to patients formerly defined as diabetic according to the World Health Organization criteria, except that they had a higher prevalence of <50% stenoses. CONCLUSIONS: In patients with type 2 diabetes, those with 7.0 mM/L < or = fasting plasma glucose < 7.7 mM/L have a slightly greater prevalence of mildly severe lesions that may partly explain their higher cardiovascular event rate.