Asymptomatic polyvascular atherosclerotic disease requires a complex management strategy--case report and review of the literature.

Atherosclerosis represents a systemic disease that affects all major vascular territories. Despite advances in medical therapies to prevent atherosclerosis and better manage patients with established peripheral arterial disease (PAD), the incidence of PAD continues to increase, and associated morbidity remains high, especially as the population ages. Over the past decade, percutaneous revascularization therapies for the treatment of patients with PAD have tremendously evolved, and a great number of patients can be offered treatment options that are less invasive than traditional surgical ones. Here we are presenting the case of a 67-year-old diabetic woman with multiple cardiovascular risk factors and oligosymptomatic atherosclerotic involvement in several important territories (severe internal carotid stenosis, severe proximal left subclavian artery stenosis, critical serial stenosis in the mid-segment of the left anterior descending artery). Bilateral staged carotid artery plus left subclavian artery stenting was performed with very good results. Regarding the existence of asymptomatic one vessel coronary artery disease (CAD) with a negative exercise test our attitude was to maximize anti-ischemic medical therapy. In conclusion, the presence of multivascular atherosclerotic disease in a diabetic patient with coexisting risk factors is not surprising and it only reinforces the well known fact that we have to search for the involvement of other territories in an oligosymptomatic patient.

[Renal osteodystrophy (3); its treatment in dialysis patients]. / Ostéodystrophie rénale (3); Son traitement chez le dialysé.

The prevalence and the clinical gravity of the various histopathological varieties of renal osteodystrophy in dialysis patients depends on the severity of both the aluminium intoxication and that of hyperparathyroidism. The prevalence of bone pains, fractures and hypercalcemias are the highest in adynamic bone diseases (ABD) with severe aluminium intoxication, then in osteitis fibrosa and mixed osteopathy, in the ABD with moderate aluminium intoxication and rare in the mild lesion in spite of similar moderate aluminium intoxication. In the absence of aluminium intoxication, hypercalcemia and hyperphosphatemia prevalence is higher only when intact PTH is more that 4 times the upper limit of normal. When PTH is between 1 and 2 folds the ULN this prevalence is null and bone mineral density is the highest. 2. The low turnover aluminic bone diseases (osteomalacic or adynamic) will be cured by long term deferoxamine treatment. The hazards of such treatment justify the performance of a bone biopsy to ensure the diagnosis. Their prevention relies on adequate treatment of tapwater and definitive exclusion of long term administration of aluminum phosphate binders. 3. Non aluminic osteomalacia will be treated according to the same guidelines given for the uremic patients before dialysis. 4. Non aluminic adynamic bone disease will be cured by means aiming at stimulating PTH secretion as discontinuing 1 alpha hydroxylated vitamin D derivatives, and, if there is no hyperphosphatemia by discontinuation of calcium supplement. In case of hyperphosphatemia in dialysis patients CaCO3 doses have to be nevertheless increased after the dialysate calcium concentration (DCa) has been decreased in order to induce a negative perdialytic calcium balance for PTH secretion stimulation. In the near future substitution of CaCO3 by non calcemic non aluminic phosphate binders will suffice. 5. Osteitis fibrosa due to hyperparathyroidism will be treated first by securing an optimal vitamin D repletion (bringing plasma 25OH vitamin D around 30 and 60 ng/ml or 75-150 nmol/l) and by correcting hypocalcemia and hyperphosphatemia by CaCO3 at high doses (3-12 g/day) taken with the meals. In case of hypercalcemia dialysate calcium concentration will be decreased to correct it or, in a near future, CaCO3 will be decreased to 3 g/day and hyperphosphatemia will be controlled by non calcemic, non aluminic phosphate binders. When hyperphosphatemia is controlled whereas plasma calcium is normal or low, 1 alpha hydroxylated vitamin D derivatives can be administered. 6. Instrumental parathyroidectomy should be considered when plasma levels of intact PTH remain above 7 folds the upper limit of normal whereas hyperphosphatemia persists and hypercalcemia occurs in order to prevent thining of the corticals and subsequent fracture risk. In case of previous exposition to aluminum, a deferoxamine test and/or a bone biopsy will be performed to decide a long term DFO treatment before the parathyroidectomy in order to prevent the transformation of a mixed osteopathy into an aluminic adynamic bone disease. 7. The difficulty of hyperparathyroidism control in dialysis patients is due to poor compliance to phosphate binders and to irreversible parathyroid hyperplasia with occured before the dialysis stage. This stress the primary importance if its early prevention without iatrogenia by first CaCO3 and vitamin D repletion, as soon as the creatinine clearance decreases below 60 ml/min/1.73 m2.

[Diagnostic value of electrocardiography using dobutamine in coronary artery disease]. / Valeur diagnostique de l'électrocardiographie sous dobutamine dans l'insuffisance coronaire.

OBJECTIVES: Assess the sensitivity and specificity of electrocardiograms performed during dopamine perfusion to detect coronary artery stenosis. PATIENTS AND METHODS: One hundred three coronary artery disease patients with a coronarography were studied; 23 coronarographies were normal, 59 patients were taking a beta blocker. An exercise test was also performed in 54 cases. A dobutamine perfusion was given at increasing dosage up to 50 micrograms/kg/min, in combination with intravenous atropine if needed to obtain a heart rate close to the theoretical maximum. RESULTS: The ST segment could not be analyzed reliably in 12 patients. There was an ST depression in 32 cases, an ST elevation in 20 and an isoelectric ST in 39. The sensitivity of a positive test to detect stenosis was 67% and specificity was 83%. Test sensitivity increases with increasing number of stenotic lesions. There were no false positives in patients with an ST elevation. Results were not related to gender nor beta blocker treatment. The exercise tests were globally comparable but poorer in patients taking beta blockers. There were no notable adverse effects. CONCLUSION: Dobutamine perfusion electrocardiogram is a simple well-tolerated exploration method for the diagnosis of coronary artery disease applicable in all patients. Its diagnostic value is similar to that of the exercise test and better in patients taking beta blockers. Specificity is excellent and sensitivity is acceptable, particularly in patients with mulitvessel disease.

[Comparative effects of captopril and atenolol on lipid metabolism in hypertensive hypercholesterolemic patients treated with pravastatin. A multicenter controlled trial]. / Effets comparés du captopril et de l'aténolol sur le métabolisme lipidique chez des patients hypertendus hypercholestérolémiques traités par pravastatine. Essai multicentrique contrôlé.

OBJECTIVES: A randomized double-blind trial was conducted in hypertensive subjects with hypercholesterolemia treated with pravastatin in order to compare the effects of captopril and atenolol on lipid metabolism. METHODS: After a pre-inclusion period, 147 eligible subjects (64 men and 83 women, age range 32-74 years) were randomized into two groups and given, in a double-blind trial, either captopril (50 mg/d) or atenolol (50 mg/d) for 6 months. The controlled trial was followed by an open trial in 120 subjects for 6 more months. Laboratory tests for lipid metabolism were performed at inclusion and at 6 months. RESULTS: Control of blood pressure was satisfactory and similar in the two groups. Lipid tests were performed both in local and a centralized laboratory with good interlaboratory correlations. High density lipoprotein (HDL)-cholesterol remained unchanged in the captopril group declined slightly in the atenolol group. Total cholesterol increased moderately in both groups. Triglycerides increased somewhat in the captopril group and significantly more in the atenolol group. These results were maintained during the open trial. Most of the undesirable effects were benign and did not require treatment. CONCLUSION: The effects of captopril and of atenolol are not diminished in combination regimens with pravastatin. The antihypertensive efficacy was similar for the two treatments, but the effect on lipid metabolism was more favorable with captopril.

[Drug therapy of heart failure. What choice in 1996?]. / Les traitements medicamenteux de l'insuffisance cardiaque. Quel choix en 1996?

The mortality of heart failure remains high despite recent therapeutic progress. The objectives of treatment are to relieve symptoms, but also to improve survival. The secondary objectives are extension of the duration of effort, improvement of the ejection fraction, reduction of arrhythmias and neuroendocrine disturbances, although these criteria are not strictly related to the primary objectives. Diuretics should be used from the first symptoms, but their effect on survival has not been evaluated. Digitalis alkaloids, with no effect on survival, also improve functional signs, even in patients in sinus rhythm. All other positive inotropic agents increase mortality. Nitrates improve symptoms and, when associated with hydralazine, prolong survival. Amiodarone should be reserved to patients with dangerous arrhythmias. Angiotensin converting enzyme inhibitors have the best demonstrated effect on survival and must be used as first-line treatment. Their preventive effect on mortality is limited, except in post-infarction ventricular dysfunction. Beta-blockers, which appear very promising for the improvement of survival, functional signs and ejection fraction, are currently under evaluation. Their mechanisms of action and the choice of the most active drugs have yet to be determined.

Effect of age on systolic intervals (STI).

Weissler's corrected STI was to be used in the assessment of cardiac performance taking into account only the heart rate and sex. But there are many other determinants of STI, among them an important one is the age. In the present paper, in 422 normal adults (280 men and 142 women) divided according the age into three groups (20-29, 30-39, 40-60 years), we found significant differences concerning STIc with age, especially over 40 years old. On the other hand, in a previous paper we have found in trained athletes similar modifications of STIc as those noticed in cardiac failure. That is why we, like other authors, do not consider Weissler's STIc as valid in the assessment of cardiac performance.

Absence of increased cardiac voltage and the importance of Q vectors for the diagnosis of left ventricular hypertrophy in early stages of hypertension in patients over 40 years of age.

The quantitative VCG criteria (VCGer) for left ventricular hypertrophy (LVH) and their diagnostic power were determined in 165 hypertensive men and 86 women over 40 years of age without congestive cardiac failure in comparison with 91 normal men and 108 normal women. The patients were grouped according to the presence or absence of LVH determined by X-ray (men: 96 without and 69 with LVH, women: 41 without and 45 with LVH). The proper statistical methods were used taking into account whether their distributions were symmetrical or asymmetrical. We found some sex differences of VCG criteria. The most striking results were the lack of increased voltage, and the great sensitivity of the orientation of Q vectors to the left (Q left). Q left may be induced by: 1. a septal hypertrophy, alone or accompanied by a hypertrophy of the anterior and posterior paraseptal regions of LV wall, 2. by a subendocardial ischemia at these levels induced by the increase of intraventricular pressure, 3. by possible spatial change of the septum, 4. by all these factors acting synchronously, 5. by other, unknown factors. These VCGcr for LVH found by us are different from those in the literature, but they are valid in Romania.

New mathematical statistical methods for detecting correct echocardiographic (ECG) and vectorcardiographic (VCG) diagnosis criteria by computerization. I. The determination of the upper (Lu) and low (Ll) limits for VCG amplitudes. The multivariate analysis.

The mathematical statistical methods for the determination of the upper (Lu) and low (Ll) limits of the 95 percentile range of symmetrical and asymmetrical frequency distribution curves for electrocardiographic (ECG) or vectorcardiographic (VCG) amplitudes, ECG and VCG diagnostic criteria, and the multivariate analysis as well as the bases of their computerization-program have been presented, in order to find out the ECG and VCG diagnostic criteria. The formulae for the determination of sensitivity, specificity and performance score of the ECG and VCG diagnostic criteria, in both the above mentioned methods are presented.

Studies concerning the role of myocardial hypertrophy and of intramural tension as determinants of the increased voltage in concentric left ventricular hypertrophy.

In order to study the role of myocardial hypertrophy and of the intramural tension as determinants of the increased voltage in concentric left ventricular hypertrophy, the amplitude of intracellular action potentials in frog and rat myocardium and of monophasic action potentials recorded in dogs by suction electrodes were studied. Increased amplitudes of intracellular action potentials were seen neither in experimental LVH in rats nor during stretch in frog and rat myocardium. The increased intramural tension in dog heart during norepinephrine perfusion or in heart-lung preparation during increased peripheral resistance does not increase the amplitude of monophasic action potentials. The abrupt hypertension induced by norepinephrine is an inadequate model for the study of the effect of increased intramural tension. The increase of the voltage in LVH cannot be accounted for by the increase of action potentials of each hypertrophied fibre. Many factors cooperate in producing increased voltage of LV in LVH.