[Efficacy and acceptability of lercanidipine are not age dependent in patients with essential hypertension: the AGATE study]. / Efficacité et la tolérance de la lercanidipine ne sont pas liées à l'âge des patients hypertendus: étude AGATE.

UNLABELLED: Calcium channel blockers (CCB) are known to be more efficacious and better tolerated in elderly patients. Lercanidipine is a highly lipophilic CCB with a specific safety profile linked to its pharmacokinetics. OBJECTIVES: To evaluate and compare the efficacy and safety of lercanidipine according to age. METHODS: Two groups of hypertensive patients (G1: aged < 65, G2: aged > or = 65) entered an open study conducted over 56 days. All received lercanidipine 10 mg/d (monotherapy or add-on), titrated to 20 mg/d if blood pressure (BP) was not controlled at D28. BP was measured using a semi-automatic device at doctor's office (three measurements at 1-min intervals) and at home by the patient himself (three measurements in the morning and in the evening at 1-min intervals over the 7 days before D0 and D56). RESULTS: Seven hundred and fifty-six patients entered the study. Thirty-eight patients dropped out prematurely and 30 were excluded because they were normotensive; 691 patients (G1 n = 375, G2 n = 316) were kept for analysis. At the end of the study, 507 patients were treated with lercanidipine alone (10 mg/d n = 221, 20 mg/d n = 286) and 184 with a combination including lercanidipine (10 mg/d n = 91, 20 mg/d n = 93). Efficacy was not different between the groups excepted home pulse pressure which decreased more in G2. In the office, SBP decreased by 17 and 21 mmHg, respectively, for G1 and G2, and DBP by 9 and 10 mmHg. The prevalence of leg edema was not different between G1 and G2 and was particularly low in both groups (3%). CONCLUSION: Lercanidipine was as efficacious and well tolerated in younger patients as in elderly patients.

[Asymptomatic carotid stenoses. A cardiologist's viewpoint]. / Sténoses carotidiennes asymptomatiques.

Cardiologist work is undergoing profound changes. He is in charge of the prevention and treatment of atherothrombotic disease. Preoperative evaluation of global cardiovascular risk is of paramount importance to choose between medical, surgical or interventional treatment. Furthermore, because the cardiologist has extensive experience with coronary angioplasty, he will have an essential role in carotid angioplasty.

[Pulmonary hypertension screening in systemic scleroderma: a cohort study of 67 patients]. / Dépistage de l'hypertension artérielle pulmonaire au cours de la sclérodermie systémique: étude d'une cohorte de 67 patients.

PURPOSE: Pulmonary hypertension is a severe complication of systemic sclerosis and has emerged as a major cause of morbidity and mortality in this condition. Treatment is all the more efficient as pulmonary hypertension is early diagnosed. A good knowledge of the clinical, biological and functional features of pulmonary hypertension in systemic sclerosis is therefore necessary to suspect and to diagnose pulmonary hypertension as early as possible. METHODS: Sixty seven patients with systemic sclerosis were retrospectively studied. We compared clinical, immunological, functional (spirometry) and morphological (pulmonary fibrosis) features according to the presence (n = 25) and the characteristic of pulmonary hypertension (isolated or secondary) or the absence (n = 42) of pulmonary hypertension, assessed by Doppler echocardiography. RESULTS: CREST syndrome (calcinosis, Raynaud's phenomenon, oesophageal involvement, sclerodactyly and telangiectasia) was more frequent in patients with isolated pulmonary hypertension than in patients without PH (72.7% vs 28.5%, P < 0.05; odds-ratio [OR] = 6.6) and dyspnea was more severe (P < 0.001; OR = 11.4). The age at time of pulmonary hypertension diagnosis was higher in patients with secondary pulmonary hypertension than in patients with isolated from (median: 62.5 years (range: 32-35) vs 53 years (range: 37-85), P < 0.05). Patients with isolated pulmonary hypertension had anticardiolipin antibodies more frequently than patients without pulmonary hypertension (72.7% vs 35.7%, P < 0.05). Isolated reduction of diffusing capacity was preferentially observed among patients with isolated pulmonary hypertension than among those without pulmonary hypertension. A linear relation between systolic pulmonary artery pressure values and diffusing capacity values (r = 0.72, P < 0.01) was found. Isolated reduction of diffusing capacity was more frequent in patients with isolated pulmonary hypertension than in patients without pulmonary hypertension (63.6% vs 14.3%, P < 0.001; OR = 10.5). CONCLUSION: The severity of pulmonary hypertension in systemic sclerosis justifies a systematic screening by Doppler echocardiography and diffusing capacity measurement. Our results allow us to better define the characteristics of sclerodermic patients with isolated or secondary pulmonary hypertension. The search for pulmonary hypertension should be repeated with time and clinicians should be particularly vigilant in the case of a patient presenting these characteristics.

Aerosolized iloprost in CREST syndrome related pulmonary hypertension.

OBJECTIVE: To assess the outcome of patients with CREST syndrome associated severe pulmonary hypertension treated by aerosolized iloprost in a noncomparative study. METHODS: Five patients with CREST syndrome associated severe pulmonary hypertension were treated with 100 microg/day of aerosolized iloprost. New York Heart Association functional class and exercise tolerance (6 min walk test) were assessed at baseline, after one month, and then every 6 months. A right heart catheterization was performed at baseline in all but one patient. Systolic pulmonary artery pressure (PAP) was measured with Doppler echocardiography after one month and every 6 months. RESULTS: The mean followup was 13.2 +/- 8.8 months (median 6, range 6-24). Subjective quality of life improved in all patients. NYHA functional class decreased from Class III to II in 3 patients, from Class III to I in one patient, and from Class IV to III in one patient. At 6 months, the distance walked in 6 min had increased from 352 +/- 48 to 437 +/- 56 m (p = 0.06). At one month the mean systolic PAP was 58 +/- 13 vs 81 +/- 9 mm Hg at baseline (p = 0.04). At 6 months the mean systolic PAP was 57 +/- 13 mm Hg (p = 0.06). The improvement of both clinical and hemodynamic status was maintained in the 2 patients treated for 2 years. Neither adverse effects nor need to increase the daily dose of iloprost were observed. One patient died of right heart failure and one patient did not experience any improvement of exercise tolerance and hemodynamics. CONCLUSION: Aerosolized iloprost might be potentially useful as treatment for CREST syndrome associated pulmonary hypertension. However, patients who could benefit from this treatment will probably have to undergo careful criteria selection.

Echocardiographic follow-up after Ross procedure in 100 patients.

The Ross procedure could provide an ideal aortic valve replacement method in children and young adults. We evaluated midterm echocardiographic results to assess pulmonary homograft function as well as pulmonary autograft dimensions and function. In all, 105 patients (26 women and 79 men) underwent the Ross procedure; median age at implant was 29 years. All patients underwent free root replacement. Transvalvular gradients and autograft dimensions were measured at 3 levels (annulus, sinuses of Valsalva, and proximal aorta) at discharge, at 6 months, and annually thereafter. Perioperative mortality was 4.7%. The mean period for echocardiographic follow-up in 100 patients was 32.7 months (range 0.5 to 7 years), during which 4 noncardiac-related deaths occurred. Two patients underwent late reintervention. No moderate or severe regurgitation was recorded. There was 1 case of mild homograft regurgitation and 4 of mild autograft regurgitation at late follow-up. Autograft peak gradients were low and reproducible (5 +/- 2.8 mm Hg at discharge vs 5.5 +/- 3.5 mm Hg at last follow-up, p = NS). Homograft peak gradients increased significantly without severe obstruction (7.8 +/- 5.7 mm Hg at discharge vs 15.8 +/- 9.2 mm Hg at last follow-up). The diameter of the autograft annulus was stable during follow-up, whereas autograft dimensions at sinuses and proximal aorta increased significantly. One group of patients was identified with sinus diameter increases >20% (group A). The 90 remaining patients were classified into group B. The only parameter significantly different between the 2 groups was the sinus diameters measured at discharge (1.74 cm/m2 (group A) vs 1.92 cm/m2 (group B); p = 0.036). In 100 patients and with echocardiographic follow-up for up to 7 years, the Ross procedure showed excellent results. For 10% of patients, we observed a 20% dilation of sinus diameters, but in only 3 patients (3%) was this beyond the upper normal limit.

[Post-embolic chronic pulmonary heart disease: a case report]. / Coeur pulmonaire chronique post-embolique: à propos d'une observation.

Echocardiography and pulmonary scintigraphy demonstrated post-embolic chronic cor pulmonale in a six-year-old woman presenting with dyspnoea. The patient's symptoms deteriorated during subsequent thromboembolic episodes, despite treatment consisting of oral anticoagulants and diuretics. After discussing the pathophysiology and diagnostic methods, the authors emphasize the limits of medical treatment of post-embolic chronic cor pulmonale and the value of two surgical treatments: thromboendarterectomy and lung transplantation. They also recall the precise selection criteria for lung transplantation.

Mitral valve strands and the risk of ischemic stroke in elderly patients. The French Study of Aortic Plaques in Stroke (FAPS) Investigators.

BACKGROUND AND PURPOSE: Strands are thin and filamentous attachments on the cardiac valves shown by transesophageal echocardiography. Their nature and their potential for embolization are largely unknown. The objective was to estimate the risk of brain infarction in patients with mitral valve strands. METHODS: Using transesophageal echocardiography, we compared the frequency of strands on native mitral valves in 284 consecutive patients admitted with brain infarction and 276 control patients, all older than 60 years. In a second part, case subjects were followed up over a 2- to 4-year period, and the risk of recurrence of brain infarction was estimated in patients with and without strands. RESULTS: In the case-control study, mitral valve strands were found in 22.5% of the case patients and in 12.1% of the control subjects. In case subjects, mitral valve strands were more frequent in those with mitral valve dystrophy (52.4% versus 37.4%; P = .03). Strands were not associated with mitral valve prolapse, annular calcifications, or left atrial spontaneous echocardiographic contrast. After adjustment for age, sex, and mitral valve dystrophy, the odds ratio for ischemic stroke among patients with mitral strands was 2.2 (95% confidence interval, 1.4 to 3.6; P = .005). The frequency of strands was not different in patients with a known cause of brain infarction (24.4%) from that in patients with no other apparent cause (20.9%). During 646 per 100 person-years of follow-up, the incidence of recurrent brain infarction was 6.0 person-years in patients with strands and 4.2 in those without. In the Cox analysis, including potential confounders and poststroke treatment, mitral valve strands did not appear as independent predictors of recurrent brain infarction (relative risk, 1.3; 95% confidence interval, 0.5 to 3.0; P = .54). CONCLUSIONS: The present study shows an independent association between mitral valve strands and the risk of brain infarction. However, the lack of an increased relative risk of recurrence raises doubts about the potential causal relation with brain infarction in patients aged 60 years or older.

Incidence and prognosis of embolic events and metastatic infections in infective endocarditis.

AIMS: In infective endocarditis, the true incidence of embolic events and metastatic infections remains unknown probably because a large number of events are asymptomatic. The consequences of the prognosis of such events have never been evaluated by a prospective follow-up. This study aimed to assess the incidence of symptomatic or asymptomatic embolic events and metastatic infections in definite infective endocarditis and to determine whether these events carry a risk of mortality. METHODS AND RESULTS: From January 1991 to December 1993, 102 patients with suspected or known infective endocarditis were referred to our institution. Among them, we selected 68 patients (50 males, 18 females, mean age = 52.7 years) exhibiting definite infective endocarditis according to the Duke University criteria. Blood cultures were positive in 49 cases (72%). Echocardiography revealed valvular vegetations in 55 cases (81%). Irrespective of the clinical presentation, patients were examined radiologically by cerebral computed tomography scanning (n = 60), magnetic resonance imaging (n = 3), abdominal computed tomography scanning (n = 32) or abdominal echocardiography (n = 20). Depending on the symptoms, thoracic computed tomography scanning (n = 22), pulmonary angiography (n = 2), ventilation-perfusion scintigraphy (n = 4), or gallium citrate radionuclide scanning (n = 7) were also performed. All patients were prospectively followed-up for a mean period of 21.4 +/- 17.5 months. In 35 patients (51%), 51 embolic or metastatic events were revealed, involving the central nervous system (n = 23), spleen (n = 7), kidney (n = 5), lung (n = 5), liver (n = 4), bone and joint (n = 4), iliac (n = 2) or mesenteric (n = 1) arteries. During the hospital stay, the mortality rate was higher in patients exhibiting embolic or metastatic events (20 vs 12%), but the difference did not reach statistical significance. Kaplan-Meier analysis demonstrated no difference in long-term follow-up. CONCLUSION: Our data suggest that embolic or metastatic events had a high incidence (51%) during infective endocarditis, but were not associated with significant attributable mortality.

Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management.

BACKGROUND: Endocarditis related to pacemaker (PM)-lead infection is a rare but serious complication of permanent transvenous pacing. To determine in which situations the diagnosis should be evoked and to determine optimal management, we reviewed our experience with endocarditis related to PM-lead infection. METHODS AND RESULTS: Fifty-two patients were admitted for endocarditis related to PM-lead infection. The presentation was acute in 14 patients, with onset of symptoms in the first 6 weeks after the last procedure on the implant site, and chronic in 38 patients. Fever occurred in 86.5%. Clinical and/or radiological evidences of pulmonary involvement were observed in 38.4%. Pulmonary scintigraphy disclosed pulmonary infarcts in 31.2%. Local complications were found in 51.9%. Elevated C-reactive protein was found in 96.2%. A germ was isolated in 88.4% of patients and was a Staphylococcus in 93.5%. Transthoracic echocardiography demonstrated vegetations in only 23% of patients, whereas transesophageal echocardiography disclosed abnormal appearances on the PM lead in 94%. We systematically tried to ablate all the material. Two techniques were used: percutaneous ablation or surgical removal during extracorporeal circulation. All patients were treated with antibiotics after removal of the infected material. Two patients died before lead removal and 2 after surgical removal; the predischarge mortality was 7.6%, and the overall mortality was 26.9% after a follow-up of 20.1+/-13 months. CONCLUSIONS: The diagnosis of endocarditis related to PM-lead infection should be suspected in the presence of fever, complications, or pulmonary lesions after PM insertion. Transesophageal echocardiography should be performed to look for vegetations. Staphylococci are involved in the majority of these infections. The endocardial system must be entirely removed and appropriate antibiotic therapy pursued for 6 weeks.

Multiple cerebral infarcts associated with an atrial septal aneurysm. Superimposed thrombus detected by transesophageal echocardiography.

The authors describe the case of a patient referred for evaluation of multiinfarct dementia. Conventional echocardiography revealed an aneurysm of the interatrial septum. A transesophageal echocardiogram demonstrated superimposed thrombus. This rare cause of systemic emboli can be diagnosed only by transesophageal echocardiography and is of major interest to avoid recurrence of ischemic strokes.

Higher prevalence of atrial septal aneurysms in patients with ischemic stroke of unknown cause.

Atrial septal aneurysms (ASA) are frequent findings on transesophageal echocardiographies. Whether they are more frequent in patients with cerebral ischemia of unknown cause remains unclear. We investigated this question in 154 consecutive patients with an ischemic stroke or transient ischemic attack. The 16 patients with ASA were younger, less likely to have arterial hypertension and more likely to have a patent foramen ovale (PFO) or an unknown cause of stroke, but they did not differ for number and side of infarcts, other demographic data and vascular risk factors. Patients with ASA unassociated to PFO were also more likely to have an unknown cause of stroke. These findings lead to the hypothesis that ASA might be sources of cerebral emboli.

[Cardiac complications in adult onset Still disease: from pericarditis to tamponade as manifestations]. / Complications cardiaques de la maladie de Still de l'adulte: de la péricardite à la tamponade parfois révélatrice.

Pericarditis is a common manifestation of adult still's diseases (ASD), observed in 20% to 3% cases. Pericardial tamponade is more seldom, less than ten cases have been reported in the literature. We reported two observations of patients with ASD and pericardial tamponade above a series of 18 patients with ASD, in one case revealed the disease. The first patient was a 32-year-old women and had fever, arthritis, high white blood cell count and developed pericardial tamponade. The evolution was favourable with bolus of methylprednisolone. In the second case, cardiac tamponade occurred several years after the onset of the disease. Surgical drainage was first required (800 ml) because of inefficacity of oral prednisone. A dramatic improvement was observed after bolus of methylprednisolone. In conclusion pericardial tamponade is a seldom but sometimes the first manifestation of ASD and may required in first intention bolus of methylprednisolone.

Treatment of recurrent pericarditis with colchicine.

Corticosteroid therapy, because of its frequent and severe side effects should be avoided if possible, and colchicine may be an effective substitute in steroid-dependent recurrent pericarditis. The aim of our study was to assess the usefulness of colchicine in recurrent pericarditis before initiating corticosteroid treatment. Nineteen consecutive patients (10 males, nine females, age 46 +/- 7 years) with recurrent pericarditis (two episodes or more) were included in this prospective open-label study. Before the study, the patients suffered a total of 57 episodes of pericarditis (mean = 3.0 +/- 0.5 episodes.patient-1) despite the use of non-steroidal anti-inflammatory drugs. The mean interval time between the episodes was 7.3 +/- 5.3 months. Colchicine was given at a loading dose of 3 mg and a maintenance dose of 1 mg daily (for 1 to 27 months (mean = 7.7). During the clinical follow-up, the efficacy was estimated by the occurrence of new episodes of pericarditis and by the need for corticosteroid treatment. No recurrence occurred in 14 out of the 19 patients (74%) during a follow-up of 37.4 +/- 6.5 months. In four out of the 19 patients (21%), five recurrences occurred, which resolved without corticosteroids. Follow-up at 23.8 +/- 12.7 months was free of further recurrence. Only one patient (5%) had several recurrences and required corticosteroids for chronic rheumatism. Tolerance was good except for two cases of diarrhoea, one case of hypothyroidism due to associated long-term antidiarrhoeal therapy (containing iodine), and one case of mild leucopenia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of embolic cerebrovascular complication: contribution of transesophageal echography]. / Le bilan d'un accident vasculaire cérébral embolique: apport de l'échographie transoesophagienne.

Ischemic cerebrovascular accidents are classically attributed to an embolism of cardiac origin in 15% of cases. This longstanding concept is questioned by trans-esophageal echocardiography (TEE). The incidence of anomalies which could be the origin of a cerebral embolism involves more than 50% of cases in certain series. The superiority of TEE over trans-thoracic echocardiography (TTE) emerges in particular when certain abnormalities such as an intra-atrial thrombus, spontaneous atrial contrast, an intra-aortic atherosclerotic plaque, a patent foramen ovale or an aneurysm of the inter-atrial septum are sought. The high incidence of such abnormalities in a population having sustained an ischemic cerebrovascular accident is not sufficient to establish a cause-and-effect relationship between the abnormality and the cerebral event. Certain abnormalities are commonly associated with each other or with emboligenic arrhythmias (atrial fibrillation). Studies hence remain required to determine the respective responsibilities of these various abnormalities and stratify their embolic risk by defining certain risk factors. While awaiting the result of such studies, it would seem valid to suggest the more routine use of TEE in the investigation of ischemic cerebrovascular accidents in young patients free of clinically obvious heart disease, and this regardless of the result of TTE.

Intracardiac hemodynamics in man during short periods of head-down and head-up tilt.

The intracardiac hemodynamic responses to short periods of 70 degrees head-down and head-up tilts were studied in 12 normal male subjects, ages 19-24 years. Echo-Doppler techniques were used to measure the transmitral and transaortic flow velocities as well as cardiac index, and to evaluate the peripheral impedance. Head-down tilt (HDT) rapidly induced an increase (9.7%, p < 0.05) in the early passive filling of the left ventricle (ME peak of the transmitral flow velocity curve) and in transaortic flow velocity (8%, p < 0.05), as well as in cardiac output (6%, p < 0.05). In spite of a peripheral vasodilation, the blood pressure increased (7%, p < 0.05 for the systolic; 15%, p < 0.01 for the diastolic) and remained at a high level for the 5 min of the experiment. Head-up tilt (HUT) induced inverse responses; i.e., a large initial decrease in the transmitral (-15%, p < 0.05) and transaortic (-16%, p < 0.001) flows. The shape of the arterial peripheral flow indicated an increased vascular impedance. After a short drop, the blood pressure rapidly recovered a level statistically close to that of the pretest. In both cases, tachycardia occurred. We conclude that, in man, the cardiac responses to the changes in posture appear to be related more to the passive changes in ventricular filling due to the blood shift than to the nervous regulation by the arterial baroreflexes, whereas these reflexes mainly act in the control of the vascular impedance.

Congenital high flow coronary cameral fistula in an 81-year-old woman: management problems.

An 81-year-old woman presenting with severe congestive heart failure was found to have a congenital right coronary fistula draining into the superior vena cava. The diagnosis was suspected on transthoracic two-dimensional echo-Doppler study and confirmed with coronary angiography. Transesophageal echocardiography and magnetic resonance imaging were nondiagnostic. An attempt to close the fistula with transcatheter embolization using a detachable latex balloon was unsuccessful because of the very large size of the fistula. Follow-up showed a favorable outcome with medical therapy. Despite the advent of more recent diagnostic and therapeutic techniques, management of such large fistulae remains unresolved.

[Left intraventricular gradients measured by Doppler echocardiography at rest, during exercise and during isoproterenol test in hypertrophic cardiomyopathy]. / Gradients intraventriculaires gauches, mesurés par échocardiographie Doppler au repos, à l'effort et lors d'un test à l'isoprotérénol, au cours de la cardiomyopathie hypertrophique.

Doppler echocardiography has been shown to be an accurate method of assessing left ventricular outflow obstruction in hypertrophic cardiomyopathy (HCM). One of the characteristics of this pressure gradient is its variability and, therefore, we measured this parameter during dynamic exercise testing in 33 patients. The results were compared with those recorded during isoproterenol infusion, the reference stress test for patients with HCM. Submaximal exercise in the recumbent position is usually well tolerated and resulted in a 43% increase in heart rate and a 47% increase in pressure gradient. There was a significant correlation between resting and exercise outflow obstruction (r = 0.90; p = 0.001). Moreover, exercise echo revealed obstruction in 26% of patients without resting pressure gradients (latent obstruction). The interpretation of results obtained with isoproterenol infusion is more difficult: this test resulted in an important increase in the left ventricular pressure gradient (231%) and "revealed" obstruction in 84% of cases. Therefore, we believe that exercise is more physiological and better tolerated than isoproterenol stress infusion and should be adopted as the investigation of choice in HCM even without obstruction at rest. If it is not possible to perform the exercise or no outflow tract obstruction can be demonstrated, an isoproterenol infusion may be used but this is not always well tolerated and the results should be interpreted with caution.