[Interpretation of exercise stress testing by primary care physicians]. / Interprétation du test d'effort par le médecin de premier recours.

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

[Acute coronary syndrome: guidelines and geriatrics specificity]. / Syndrome coronarien aigu: guidelines et spécificité gériatrique.

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

[Prescribing psychotropic drugs to patients aged 80 and over]. / Réflexions sur l'usage des psychotropes chez la personne très âgée.

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

[Paced right bundle branch block: what to do?]. / BLOC de branche droit électroentraîné: que faire?

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

[Postprandial hypotension: an unclear clinical entity]. / Hlypotension postprandiale: une entité méconnue.

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

[Atrial arrhythmias: mechanism, ECG feature and curative treatment]. / Arythmies auriculaires: mécanisme, présentation ECG et traitement curatif.

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

[Cardiac rehabilitation: beyond 80 year-old?]. / La réadaptation cardiaque: aussi au-delà de 80 ans?

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

[Drug-induced refractory arterial hypertension]. / Hypertension artérielle résistant au traitement: une cause médicamenteuse.

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

[Impacts of a cardiological consultation on the medical treatment of elderly patients]. / Effets d'une consultation de cardiotogie sur le traitement médicamenteux des personnes âgées: expérience d'un an.

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

[Cardiac insufficiency: therapeutic aspects in the elderly person]. / Insuffisance cardiaque: particularités thérapeutiques chez la personne âgée.

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

[Postmortem diagnosis of cardiac amyloidosis in the aged. Anatomoclinical correlation]. / Diagnostic post-mortem de l'amyloïdose cardiaque du vieillard. Corrélation anatomoclinique.

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

[Hypertrophic cardiomyopathy in the elderly]. / Cardiomyopathie hypertrophique chez le vieillard.

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

[Deglutition syncope]. / Syncopes à la déglutition.

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

[Ergometric evaluation of the cardioprotective effect of pindolol in coronary disease. Comparison of 2 galenic forms]. / Evaluation ergométrique de l'effet cardioprotecteur du pindolol dans la maladie coronaire. Comparaison de deux formes galéniques.

In a dose of 5 mg three times daily, the beta-blocker pindolol (Visken Sandoz) has been shown to provide protection against both the signs and the symptoms of myocardial ischaemia. The purpose of the present study was to ascertain whether the same degree of protection is provided by a single daily dose of a slow-release formulation containing 20 mg pindolol. - Twelve patients with confirmed coronary heart disease were included in the study, which was carried out using a bicycle ergometer. The exercise tests were performed 2 hours after drug administration and again immediately before the next dose was due. These times are assumed to correspond to the maximum and minimum plasma levels of pindolol respectively. - The results show no statistically significant difference between the 20 mg form of the drug once a day and the 5 mg form 3 times daily with regard to the effect on heart rate (HR), blood pressure (BP), the product of HR and BP, and S-T segment changes (Cohn score) either at rest, during maximum effort, or 3 minutes after exercise. - It is concluded that 20 mg slow-release pindolol once daily is an effective anti-anginal therapy similar in its properties to 5 mg 3 times daily.

Interindividual pharmacokinetic and pharmacodynamic variability of different beta blockers.

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