Is the gap between guidelines and clinical practice in heart failure treatment being filled? Insights from the IMPACT RECO survey.

BACKGROUND: Recent registries have shown that recommended drugs for the treatment of chronic heart failure (CHF) are under-prescribed in daily practice. AIMS: To determine prescription rates of CHF drugs, and to assess predictive factors for drug prescription using data from a large panel of French cardiologists. METHODS AND RESULTS: We included 1919 outpatients, with NYHA class II-IV heart failure and a left ventricular ejection fraction <40%. The most frequently prescribed drugs were diuretics (83%), angiotensin converting enzyme inhibitors (ACE-I) (71%), beta-blockers (65%), spironolactone (35%) and angiotensin receptor blockers (ARB) (21%); 61% of patients received a combination of a beta-blocker and an ACE-I or ARB. Target doses were reached in 49% of the patients for ACE-I, but in only 18% for beta-blockers and in 9% for ARBs. Multivariate analyses showed that age >75 years was an independent factor associated with under-prescription of ACE-I-ARBs, beta-blockers or spironolactone. Renal failure was associated with a lower prescription of ACE-I-ARB and spironolactone, and asthma was a predictor of under-prescription of beta-blockers. CONCLUSIONS: In this contemporary survey, prescription rates of CHF drugs were higher than previously reported. However, dosages were lower than those recommended in guidelines. Age remained an independent predictor of under-prescription of CHF drugs.

Comparative effects of bisoprolol and nitrendipine on exercise capacity in hypertensive patients with regular physical activity.

The aim of this study was to evaluate the long-term effects of administering bisoprolol compared with nitrendipine on the duration of the exercise tolerated by male and female patients, aged 18-65 years, having mild to moderate hypertension and taking regular exercise. In this double-blind, randomized prospective study, 96 patients (85 men and 11 women, 48+/-10 years) formed two groups: 49 in the bisoprolol group, and 47 in the nitrendipine group. After a washout period of 14 days, either 10 mg of bisoprolol or 20 mg of nitrendipine was given daily over a treatment period of 12 weeks. During the treatment period, the stability of the physical training was monitored weekly by using a questionnaire. The results of two maximal triangular exercise tolerance tests (ETTs) on an ergometric bicycle performed at D0 under placebo and at D84 under active treatment were compared. No statistical difference was observed between both groups, concerning age, gender, morphologic characteristics, resting cardiovascular parameters, or physical training. Both groups maintained the same training level throughout the study. No significant differences between the groups were noted for duration of ETT [D0 892+/-284 s, D84, 919+/-267 s (NS) vs. D0 929+/-290 s, D84 904+/-324 s (NS)], or maximal work load [D0 190+/-49 W, D84 197+/-48 W (NS) vs. D0 198+/-49 W, D84 196+/-55 W (NS)]. On the other hand, both groups differed in maximal systolic blood pressure [D0 239+/-24 mm Hg, D84 215+/-22 mm Hg (p<0.001) vs. D0 237+/-24 mm Hg, D84 222+/-27 mm Hg (p<0.05)] (p = 0.05), and maximal pulse rate during exercise [141+/-18 vs. 163+/-17] (p<0.001), albeit not in maximal diastolic blood pressure [D0 113+/-13 mm Hg, D84 106+/-17 mm Hg (p<0.05) vs. D0 112+/-13 mm Hg, D84 104+/-15 mm Hg (p<0.05)]. The patient's own perception of the maximal effort (Borg scale) was not significantly different in either of the groups (placebo vs. treatment). Overall, in a population of hypertensive patients taking regular exercise, long-term treatment with bisoprolol produced no significant changes in the duration of peak effort, maximal workload, or the effort perceived by the patients themselves. The effects of regular exercise were comparable in both groups (bisoprolol or nitrendipine). Because previous studies have shown that dihydropyridines do not modify exercise performance in hypertensive patients, it may be concluded that the antihypertensive therapy with bisoprolol is well tolerated in a population of active hypertensive patients during dynamic exercise.

Vascular and cardiac remodeling in world class professional cyclists.

BACKGROUND: Numerous studies have demonstrated that left ventricular (LV) hypertrophy is often associated with conditioning. METHODS AND RESULTS: The aim of the study was to evaluate cardiac and carotid artery changes induced by professional cycling. We collected M-mode left ventricle and B-mode right common carotid artery data from 149 male professional cyclists before the 1995 "Tour de France" race and 52 male control subjects. LV mass indexed to body surface area in cyclists was double that in control subjects, with no overlap of 95% confidence intervals (cyclists 100.9 to 187 g/m2 and control subjects 51.8 to 96.3 g/m2). Both mean arterial diameter and mean arterial diastolic intima-media thickness (IMT) were 13% higher in cyclists than in control subjects, with overlap of 95% confidence intervals (for arterial IMT 0.45 to 0.65 mm in cyclists and 0.38 to 0.60 mm in control subjects). CONCLUSIONS: Our results suggest that intense cycling has an effect on the cardiovascular system, more pronounced on the left ventricle and less pronounced on large arteries. Nevertheless, athletic training should be considered as a potential determinant of carotid modification.

[Evaluation by Doppler echocardiography of systolic and diastolic functions of the left ventricle of the athlete's heart]. / Evaluation par échocardiographie Doppler des fonctions systolique et diastolique du ventricule gauche due coeur d'athléte.

A doppler-echocardiographuc study of left ventricular hypertrophy and systolic functions was performed in 99 professional cyclists and 26 age, body surface and blood pressure-matched controls. The following T-mode echocardiographic parameters were determined: wall thickness and cavitary diameter, left ventricular mass (LVM), fibre shortening fraction (FSF) and ejection fraction (EF). The following doppler parameters were measured at the annulus (a) and tip (p) of the mitral valve leaflets: protodiastolic velocity peak (E), velocity peak during atrial systole (A) and A/E ratio. Compared with controls, the cyclists showed a significant increase of LVM (305 +/- 53 vs 174 +/- 41 g, p less than 0.0001) and of the h/R ratio of mean wall thickness (h) to cavitary radius (R) (0.40 +/- 0.04 vs 0.35 +/- 0.06, p less than 0.001). There was no significant difference between the two groups as regards FSF, EF and protodiastolic filling peak (E). In contrast, subjects in the cyclist group showed a significant increase of Ap (0.39 +/- 0.07 vs 0.47 +/- 0.09, p less than 0.001), Aa (0.36 +/- 0.07 vs 0.41 +/- 0.08, p less than 0.01) and A/Ep (0.54 +/- 0.12 vs 0.62 vs 0.62 +/- 0.11, p less than 0.0001). It is concluded that professional cyclists have an increase in size of their left ventricle and that repercussions of this enlargement on ventricular filling only appear during the atrial systole and are related to a slower heart rate.

[Physiological limits of variations in heart rate measured by the Holter method in 134 normal subjects]. / Etude des limites physiologiques des variations de la fréquence cardiaque par la méthode de Holter chez 134 sujets normaux.

Ambulatory 24 hour electrocardiography by the Holter method was carried out in 134 normal subjects (59 men, 75 women, mean age: 42.5 +/- 14 years). The average heart rate over 24 hours was 75 +/- 9 bpm, 82 +/- 10 bpm during the daytime and 64 +/- 8 bpm at night. Maximal and minimal momentary variations (over 5 minutes) were small during the night (+23% and -7%) and greater during the daytime (+47% and -16%). The heart rate slowed progressively over a two hour period before going to bed an increased progressively over a three hour period, reaching a peak and then slightly falling before getting up. The average heart rates of women were faster than in men (+5 bpm). The average heart rate fell with age from 30 years onwards (-0.4 bpm per year). Tobacco consumption did not seem to affect the heart rate. Supraventricular extrasystoles were observed in 68% of subjects during the day, and in 50% during the night; ventricular extrasystoles occurred in 42% of subjects by day and in 23% by night. Only 22% of subjects had no extrasystolic activity. Tobacco consumption and sex were unrelated to the incidence and frequency of extrasystoles. On the other hand, the incidence and frequency of extrasystoles were very significantly related to age.

[Retrospective analysis of a series of 330 Holter recordings. Diagnostic value of the method and correlation with symptomology]. / Analyse rétrospective d'une série de 330 enregistrements de Holter. Valeur diagnostique de la méthode et corrélation avec la symptomatologie.

We have studied a series of 330 Holter recordings (HR) (including 5 double observations) 189 men and 136 women, mean age 58,4 years Old. The analysis of this series shows that: --105 HR were performed on patients with focal ischemia attacks of suputed embolic origin; the HRT was positive in 35 patients (33 p. 100) with 25 supraventricular arrhythmias (SVA) 16 ventricular arrhythmias, associated in 9 cases, and 3 conduction blocks second degrees type 2. These arrhythmias are rare in patients under 40, increasing with age, and reaching 53 p. 100 in patients greater than 70 years. --86 HR were performed in ischemic heart disease (IHD): 52 HR for ST segment analysis, positive in 5 cases, and coexisting with chest pain in 4 cases; 34 HR for detecting arrhythmias in IHD, positive in 18 cases with 14 VA and 4 SVA. In 83 p. 100 the arrhythmias occur without IHD. They were positive in 70 cases, with 49 SVA, 34 VA, associated in 17 cases, and 4 blocks second degrees type 2. --10 cardiomyopathies were recorded; the HR was positive in 6, with 4 SVA, 3 VA associated in 1 case. --8 mitral valve prolapses were recorded with 5 VA and 1 SVA. In conclusion, the HR was positive in 45 p. 100 of the cases, and show especially the great incidence of asymptomatic VA in patients with IHD.

[Holter monitoring in patients with focal cerebral ischaemic attacks (author's transl)]. / L'enregistrement de Holter dans les accidents ischémiques cérébraux.

One hundred patients with focal cerebral ischaemic attacks of suspected embolic origin were investigated by Holter monitoring to determine whether paroxysmal arrhythmia may have been responsible for the episodes. There were 57 men and 43 women aged from 16 to 79 years (mean 50 years). Ninety-seven had residual focal neurological deficits and 3 had transient ischaemic attacks. The neurological lesions were verified by cerebral angiography in 68. Twenty-one had arterial hypertension and 9 had old myocardial infarction or angina. Nine had a history of palpitations. None had cardiac valve disease. All patients were in sinus rhythm, 4 had ventricular extrasystoles on routine ECG, and 4 had supraventricular extrasystoles. None of the patients were receiving anti-arrythmic drugs at the time of investigation. Holter monitoring was performed for 18 hours in 91 cases and for 24-54 hours in the remaining ones. The interval between the cerebral ischaemic attack and the monitoring was less than one month (mean 20 days) for 50 patients and longer for the others. Cardiac arrythmias were found in 36 patients. Sixteen had more than 10 supraventricular extrasystoles per hour, 13 had runs of 3 to 8 beats of supraventricular tachycardia, 1 had an episode of atrial fibrillation. Eighteen subjects had more than 5 ventricular extrasystoles per hour, 1 had accelerated ventricular rhythm, 2 had runs of 4 to 7 beats of ventricular tachycardia. Two patients had second degree A.V. block. None had palpitations during monitoring. Arrythmias were increasingly frequent with age. Our findings are similar to those obtained with monitoring in ambulatory asympatomatic subjects of the same age without apparent heart diseases reported by other authors. On the other hand, the frequency of arrythmia was unrelated to the time elapsed between the ischaemic attack and Holter monitoring. In conclusion, Holter monitoring performed several weeks after suspected cerebral embolism failed to reveal arrythmias likely to be responsible for a focal cerebral ischaemic attack.

[Intervention among patients with right bundle branch block and left anterior hemiblock. Operatory risk (author's transl)]. / Intervention chez des patients porteurs d'un bibloc asymptomatique. Le risque opératoire.

In order to assess the risk of advanced heart block during anesthesia in patients with right bundle branch block and left anterior hemiblock, 35 consecutive patients were monitored throughout the pre-, intra- and postoperative period. As conventional ECG monitoring may only detect advanced atrioventricular block, patients were monitored according to the Holter method which can easily detect even minor changes of atrioventricular conduction namely slight increased PR interval or dropped P wave. All patients were asymptomatic, in normal sinus rhythm without second degree AV block. Surgical procedures were performed under general anesthesia (n = 15) and epidural anesthesia using lidocaine (n = 20). No episode of second or third degree atrioventricular block occurred. The only modifications observed were rare and transient increase of PR, occurring during surgical procedures in 5 patients, always associated with a sinus bradycardia. They immediately regressed at the termination of the sinus bradycardia either spontaneously or following atropine injection, strongly suggesting the responsability of increased vagal tone. Thus general or epidural anesthesia did not compromise infranodal conduction in any of the observed patients. These data indicate that anesthesia can be safely used without prophylactic preoperative insertion of pacemakers in patients with asymptomatic chronic right bundle branch block and left anterior hemi-block.