Acute hemodynamic effects of amlodipine 15 days after a myocardial infarction in normotensive patients treated with atenolol.

The acute hemodynamic effects of 20 mg iv amlodipine were evaluated in a placebo-controlled study in 16 normotensive patients 15 +/- 1 days after an acute myocardial infarction by covariance analysis. Atenolol was given orally for at least 1 week before the study to maintain the heart rate between 50 and 60 beats/min. All patients were given two doses of 10 mg of amlodipine, or 10 ml of a placebo twice, in i.v. infusion lasting 2 minutes each. Hemodynamic data were collected during the control period and 15 minutes after each of the two amlodipine or placebo infusions. At the time of the last measurements, 15 minutes after the second amlodipine or placebo infusion, the plasma amlodipine level was 31 +/- 16 micrograms/l and the plasma atenolol level was 773 +/- 564 mu/l in the amlodipine group versus 795 +/- 916 micrograms/l in the placebo group. There were no chronotropic, dromotropic, or inotropic effects. The main hemodynamic effect was a fall in systemic vascular resistance (1548 +/- 591 dynes.sec.cm-5 to 1176 +/- 526 dynes.sec.cm-5, p = 0.045) with decreases in aortic pressure and in the left ventricular stroke work index. The left ventricular ejection fraction was 51 +/- 12% in the placebo group and 56 +/- 15% in the amlodipine group (ns) during the control period, and did not change after infusion of placebo or amlodipine. Left ventricular compliance seemed to be enhanced by amlodipine, because the end-diastolic left ventricular volume index rose from 82 +/- 11 ml/m2 to 87 +/- 11 ml/m2 (p = 0.026) 15 minutes after the beginning of the second infusion of 10 mg of amlodipine, without any change in end-diastolic left ventricular pressure. Intravenous infusion of 20 mg of amlodipine is well tolerated 15 days after acute myocardial infarction in normotensive patients without deeply depressed left ventricular systolic function and chronically treated with atenolol. The main hemodynamic effects observed are potentially useful for such patients.

[Cibenzoline versus propafenone by the oral route for preventing recurrence of atrial arrhythmia: multicenter, randomized, double-blind study]. / Cibenzoline versus propafénone par voie orale dans la prévention de la récidive des arythmies auriculaires: étude multicentrique randomisée réalisée en double aveugle.

This multicentre, randomized, double-blind study, conducted in parallel groups, was designed to compare the efficacy and safety of cibenzoline (C) and oral propafenone (P) in the prevention of recurrent atrial arrhythmias (M) over a 6-month period. Patients of either sex with reduced atrial fibrillation or flutter and predominantly in sinus rhythm (> 50%), with a left ventricular shortening fraction greater than or equal to 20% and not receiving any antiarrhythmic treatment were included. Patients presenting severe conduction disorders, severe heart failure (NYHA class III or IV), marked hypotension or recent myocardial infarction were not included. Treatments were administered at the dosage of one tablet twice a day, i.e. 260 mg/day of cibenzoline or 600 mg/day of propafenone. This dosage was reduced by one half in elderly patients (> 70 years). Patients were seen on inclusion (Dzero), and at the third and sixth months or in the case of recurrence of symptoms. Recurrent arrhythmias were assessed by ECG and 24-hour Holter monitoring and according to the symptoms experienced by the patients. Sixty-five patients, 36 men and 29 women, between the ages of 34 to 86 years and presenting an atrial arrhythmia-atrial fibrillation (80%) or atrial flutter (20%)-were included in the trial: 34 patients received cibenzoline and 31 received propafenone. The arrhythmia had already been treated in 78% of cases. Its aetiology was related to hypertensive heart disease (32%), valvular heart disease (8%), other (17%) or idiopathic (43%). The arrhythmia was symptomatic in 91% of patients on inclusion. The ultrasonographic left ventricular shortening fraction was 32.8 +/- 8.1% in group C and 32.6 +/- 6.4% in group P. The two groups were comparable before treatment. The efficacy of the two treatments was comparable: no significant difference in the number of recurrences was demonstrated: 11 patients treated with C and 12 patients treated with P; cumulative percentages of patients without recurrence with good tolerance of treatment (Kaplan-Meier acturial curves) at 6 months were 55.9% with C and 48.4% with P(NS); probability of no recurrence at 6 months (0.63 +/- 0.09 in group C and 0.57 +/- 0.09 in group P); mean time to recurrence (53.4 +/- 44.3 days in group C and 61.6 +/- 35.3 days in group P). Adverse events leading to discontinuation of treatment occurred in 4 patients from each group, and one proarrhythmic effect at 6 months in a patient in group P. The treatments were well tolerated in the majority of cases: there was no significant difference in the number of patients presenting at least one adverse event: 9(26.5%) in group C, 11(35.5%) in group P. Most events were considered to be mild or moderate. The effects of the two treatments on the course of blood pressure, heart rate, PR interval and QT interval calculated at 3 and 6 months compared to DO were not statistically different. The QRS interval increased to a significantly greater extent in group C that in group P (p = 0.02 at 3 months; p = 0.0005 at 6 months). No significant difference was observed between the two groups for the course of laboratory parameters at 3 and 6 months compared to DO in the patients present at these three visits. Cibenzoline can therefore constitute a good alternative to propafenone in the prevention of symptomatic recurrences of atrial tachyarrhythmias. The preferential use of one or other treatment can be guided by individual factors, including tolerance.

[Evaluation of amlodipine in stable effort angina. Comparison with diltiazem in terms of efficacy, tolerability and maintenance of the anti-ischemic action 24 hours after the last dose]. / Evaluation de l'amlodipine dans l'angor d'effort stable. Comparaison avec le diltiazem en termes d'efficacité, de tolérance et de maintien de l'action anti-ischémique 24 heures après la dernière prise.

83 patients were enrolled in a multicentre, randomized, open study to assess the efficacy of amlodipine in stable effort angina. Preselected patients were submitted to a one-week placebo wash-out period during which only nitrates or molsidomine were authorized. Patients were then randomized to receive either 5 mg of amlodipine as a morning dose, or 180 mg of diltiazem in three divided doses. After two weeks, the dosage was able to be increased (according to clinical efficacy) to 10 mg of amlodipine as a single dose or 240 mg of diltiazem in four divided doses. The antianginal efficacy of these two treatments was essentially evaluated in terms of the results of stress tests (ST) conducted at the end of the second week and fourth week of active treatment: and 24 hours after the last dose of the drug. The results of 63 patients who scrupulously complied with the protocol showed that amlodipine and diltiazem corrected or improved the ST parameters (time to onset and amplitude of ST depression, duration of ST, work performed). The anti-ischaemic action of amlodipine was maintained for at least 24 hours after the last dose and therefore provides better security (by covering the entire 24-hour period) and better compliance (by tolerating a dose omission of several hours).

[Myocardial infarction with normal coronary angiography. Apropos of 9 cases. A retrospective and comparative study]. / Infarctus du myocarde à coronaires angiographiquement normales. A propos de 9 cas. Etude rétrospective et comparative.

This retrospective study was designed to determine the characteristics of myocardial infarction with normal coronary arteries. The files of consecutive patients admitted to hospital for a first infarction in 1992 and 1993 were analysed. Patients younger than 70 years of age, who had undergone coronary angiography during their admission to hospital were selected. A total of 109 infarctions complied with these criteria and 9 of them were associated with angiographically normal coronary arteries. In this series, patients with angiographically normal coronaries tended to be younger than those with at least one stenotic coronary artery (47 +/- 13 years vs 55 +/- 11 years, p = 0.07). The sex ratio did not differ between the two groups. The body mass index of patients with normal coronary arteries was significantly lower (22.9 +/- 3.9 kg/m2 vs 26.3 +/- 3 kg/m2; p = 0.02). These patients more frequently reported a history of phlebitis (3/9 kg/cm2 vs 26.3 +/- 3 kg/cm2; p = 0.02). These patients more frequently reported a history of phlebitis (3/9 vs 2/100). The frequency of anterior and posterior infarctions was virtually the same. Myocardial infarction with normal coronary arteries appears to be less severe, as reflected by the creatine phosphokinase peak (867 +/- 268 IU/l vs 1921 +/- 1389 IU/l), the maximal sum of ST elevation (5 mm vs 16 +/- 12 mm; p = 0.05), the percentage of left ventricular akinesia on angiography (25.5 +/- 4 vs 38.7 +/- 11.8; p = 0.01), and the lower ventricular end-diastolic pressure (11.5 +/- 3.5 mmHg vs 38.7 +/- 11.8 mmHg; p = 0.02). Fewer complications were observed during the acute phase, with no deaths. During the subsequent follow-up, with a median of 2 years, no recurrent infarctions, no cardiac decompensation and no deaths were observed in the group with normal coronary arteries. Two patients presented an episode of angina and one developed a recurrent episode of phlebitis. In the other group of 100 patients, 12 deaths were observed during the acute period, followed subsequently by 2 other deaths, 10 episodes of recurrent angina, 2 recurrent infarctions and 12% of patients developed heart failure. In this series, infarction with normal coronary arteries therefore appears to have a good prognosis, possibly because of more limited myocardial necrosis. No abnormalities of haemostasis or coagulation were observed in these patients.

[Comparative effects of cibenzoline and hydroquinidine in the prevention of auricular fibrillation. A randomized double-blind study]. / Effets comparés de la cibenzoline et de l'hydroquinidine dans la prévention de la fibrillation auriculaire. Une étude randomisée en double aveugle.

The objective of this study was to compare the efficacy and safety of cibenzoline (130 mg twice a day) and sustained-release hydroquinidine (300 mg twice a day) in the prevention of recurrent atrial fibrillation (AF). This randomized double-blind study was conducted in 87 patients, with a mean age of 62 years, presenting with a history of AF for 72 hours to a maximum of 3 years. After restoration of sinus rhythm, in order for the subjects to be included in the study, echocardiography had to reveal a left ventricular shortening fraction of more than 20%. Patients were followed for one year by clinical examination, ECG and 24-hour Holter monitoring performed 7 days after inclusion, then after 3, 6, 9 and 12 months. The two groups, treated with either cibenzoline (n = 40) or hydroquinidine (n = 44), were comparable. The AF recurrence rates with cibenzoline or hydroquinidine were 34.9% had 36.4% at 6 months, and 41.9% and 43.2% at 12 months, respectively (NS). Most recurrences occurred during the first month. Adverse effects were reported in 10 patients (23.3%) with cibenzoline and 12 patients (27.3%) with hydroquinidine. They led to discontinuation of treatment in 6 patients (14%) treated with cibenzoline and 5 patients (11.4%) treated with hydroquinidine. Serious adverse events included one death from hypoglycaemic coma and one case of persistent ventricular tachycardia with hydroquinidine. In conclusion, oral cibenzoline demonstrated the same antiarrhythmic activity as hydroquinidine in the long-term prevention of recurrent atrial fibrillation, with a similar degree of safety. This drug can therefore constitute an alternative to conventional antiarrhythmics in this context.

High flow coronary fistula closure by percutaneous coil packing.

Few cases of transcatheter coronary fistula closure have been reported. High flow coronary fistulae are usually treated by surgery. This case report presents a 5.4 liters/min flow coronary fistula percutaneously closed by steel coils. This large flow needed the packing of 25 coils, 10-15 cm long, for its total occlusion.

Predictive value of the P wave at implantation for atrial fibrillation after VVI pacemaker implantation.

This study assesses the value of P wave measurements on the surface ECG at implantation, in the prediction of atrial fibrillation in VVI paced patients. From a consecutive series of 320 pacemaker implantations 172 VVI paced patients for symptomatic atrioventricular block (AVB) (n = 126; mean age 69 +/- 14) or sick sinus syndrome (SSS) (n = 56; mean age 68.6 +/- 12) and in sinus rhythm at implantation were used in this study. P wave duration in V1 is correlated with the incidence of atrial fibrillation during 5 years of follow-up. V1 at implantation was significantly longer (114.6 +/- 2.7 msec) in the patients who developed atrial fibrillation than in those who did not (91.9 +/- 2.7 msec) (P < 0.001). Although positive predictive accuracy increases progressively for higher V1 values for AVB and SSS, the negative predictive and diagnostic accuracy of V1 criteria were less in SSS. Application of the Bayes' theorem showed that in SSS the probability to develop atrial fibrillation is 33% for V1 < 110 msec and is for V1 < 90 msec still higher than that reported in DDD paced patients. In the AVB group the probability to develop atrial fibrillation is 8% for V1 < 110 msec and 6% for V1 < 100 msec. It seems, therefore, that atrial stimulation (AAI or DDD) is always indicated in SSS. In AVB with V1 < 100 msec, DDD pacing, if not needed for other indications, apparently does not offer much benefit in the prophylaxis of atrial fibrillation.

[P wave changes and atrial fibrillation after implantation of VVI type pacemaker]. / Modifications de l'onde P et fibrillation auriculaire après l'implantation d'un pacemaker type VVI.

The P waves of patients with VVI pacemakers were compared with those of DDD pacemakers at implantation and then regularly for 5 years. A certain number of cardiac pathologies are known to cause P wave changes. The incidence of atrial fibrillation (AF) was much higher in VVI than in DDD patients. In the VVI group, the incidence was much greater in patients paced for sinus node disease than in patients paced for AVB. Analysis of sinus P wave characteristics in 320 patients with VVI pacemakers shows progressive abnormalities of atrial function with time. The expression of this atrial dysfunction is a statistically significant prolongation of the P wave in V1 and dII and of the terminal part of the P wave in V1. The factors responsible for this abnormality and which favours the occurrence of AF are quasi-permanent pacing, the presence of retrograde conduction and an abnormality of atrial activation at the time of implantation.

Kinetics and hemodynamic effects of intravenous nicardipine modified by previous propranolol oral treatment.

Intravenous nicardipine, 5 mg, was administered in two comparable groups of eight patients with chronic coronary artery disease but no clinical signs of heart failure. One group had received no previous treatment and served as a control group, and the other had received long-term treatment with large oral doses of propranolol. Blood concentrations of nicardipine were higher, and the area under the plasma concentration curve was greater in the group previously treated by propranolol. The total clearance of nicardipine was decreased in patients taking propranolol, without a change in the half-life of the drug. Typical hemodynamic responses, namely, a decrease in aortic pressure and in arterial resistances, were greater and more lasting in patients previously treated orally by propranolol. Filling pressure remained stable in both groups. The nicardipine infusion did not induce signs of dromotropic or inotropic negative effects in either group. The greater and more lasting hemodynamic effects of nicardipine in the group previously treated orally by propranolol do not seem to be related to an overall hemodynamic action of propranolol, but are probably due to higher nicardipine plasma levels, and may be caused by a decrease in hepatic blood flow induced by propranolol, with a consequent decrease in nicardipine clearance and by a smaller nicardipine volume of distribution in the propranolol group.

Evolution of P wave characteristics after pacemaker implantation.

This study is an investigation of the long-term effects of VVI pacing on the atrium as derived from the evolution of P wave characteristics of 285 patients. The occurrence of left and right atrial disease is demonstrated as well as the evolution of left atrial hypertrophy in some cases. A comparison is made with DDD pacing and special attention is given to the progression to atrial fibrillation.

[Influence of preload changes on the filling function of the left heart ventricle studied by Doppler echocardiography]. / Influence des variations de la précharge sur la fonction de remplissage du ventricule gauche étudiée par écho-doppler.

Left ventricular filling may be studied non-invasively by Doppler echocardiographic recording of transmitral blood flow. This study reports the variations in this flow induced by changing cardiac preload by administering trinitrin or by vascular filling in 27 patients undergoing catheterisation. Left ventricular end diastolic pressure (LVEDP) was measured by the pig-tail catheter used for ventriculography. Transmitral flow was recorded by pulsed Doppler using the apical view. The parameters studied were those of the early diastolic E wave and the end diastolic A wave. The hemodynamic and echocardiographic measurements were performed under basal conditions, after trinitrin and after vascular filling. Trinitrin was given to 14 patients and led to a fall in LVEDP from 17.6 +/- 4.5 to 6.7 +/- 1.4 mmHg (p less than 0.001). The amplitude of the mitral E wave decreased and the E/A ratio fell from 0.93 +/- 0.37 to 0.71 +/- 0.32 (p less than 0.001). Thirteen patients underwent vascular filling which increased LVEDP from 10.9 +/- 5 to 27 +/- 4 mmHg (p less than 0.001). The mitral E wave increased and the E/A ratio rose from 0.96 +/- 0.32 to 1.27 +/- 0.23 (p less than 0.01). The patients received trinitrin and then underwent vascular filling. The LVEDP decreased from 16 +/- 3.9 to 8 +/- 2.9 mmHg (p less than 0.001) and then rose to 28.3 +/- 3.5 mmHg (p less than 0.001). The E/A ratio fell after trinitrin from 0.91 +/- 0.40 to 0.58 +/- 0.30 (p less than 0.01) and then rose to 1.42 +/- 0.60 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Obstructive calcification of the thoracic aorta revealed by dilated cardiomyopathy.

Obstructive calcification of the thoracic aorta appears as acquired coarctation of the aorta. The case we present is of note because it presented as a dilated cardiomyopathy. The diagnosis, suspected on chest X-ray, was confirmed by catheterization, aortic angiography and thoracic computer tomography. The patient underwent aortic endarterectomy, but died in the post-operative period. Review of the literature shows that the pathogenesis of the condition remains unclear.

[Bepridil and bundle of His block. Apropos of a case]. / Bépridil et bloc intrahisien. A propos d'un cas.

The first case of atrioventricular block located in His bundle observed during oral treatment with bepridil is reported; the block subsided when the drug was discontinued and reappeared when it was reintroduced. Electrophysiological studies performed with bepridil have shown that, as could be foreseen from its beneficial or undesirable effects, this calcium antagonist has some properties of Vaughan Williams' class I antiarrhythmic agents and alters subnodal conduction. Clinical studies indicate that in therapeutic doses this alteration has little or no significance, but it may reach clinical expression when latent of patient pre-existing disorders of conduction within or below His bundle are present.