[Sensitization of tilt-table testing for syncope of unknown etiology: which drug to use?]. / Quel agent pharmacologique utiliser pour la sensibilisation du test d'inclinaison dans l'evaluation des syncopes d'origine indéterminée?

OBJECTIVE: The sensitivity of tilt-table testing in the diagnosis of vasovagal syncope is between 30% and 50% only. The most common method currently used to improve the sensitivity of the test is the administration of isoproterenol i.v. However, this method is difficult to perform and time consuming. The objective of our study was to compare sublingual trinitrin administration to i.v. isoproterenol during tilt-table testing. METHODS: We analyzed the results of 257 consecutive patients referred for tilt testing. Patients who had a negative test received either a ten minutes infusion of i.v. isoproterenol at the dose of 4 mcg/kg/min, or 0.4 mg of trinitrin given sublingually. RESULTS: Two hundred (and) fifty-seven patients underwent tilt-table testing. In the first group (isoproterenol group), 42 patients (39%) had a spontaneous positive tilt test, compared to 45 patients (31%) in the trinitrin group (P = NS). After sensitization, 24 additional patients (22%) had a positive test in the isoproterenol group vs 55 patients (37%) in the trinitrin group (P = NS). The total number of positive tests was 66 (61%) in the isoproterenol group compared to 100 (68%) in the trinitrin group (P = NS). CONCLUSION: Sublingual trinitrin is at least as good as IV isoproterenol during tilt-table testing. Because trinitrin is simpler to use and because its administration is much faster than isoproterenol, it should be recommended as the drug of choice to improve the sensitivity of tilt-table testing.

In-hospital mortality after acute myocardial infarction in Lebanon: incidence, associations, and influence of newer treatment regimens.

PURPOSE: To study the incidence of in-hospital mortality following acute myocardial infarction in Lebanon, and its relationship to demographic, clinical variables, and therapeutic strategies. PATIENTS & METHODS: Consecutive admissions due to myocardial infarction to 18 medical centers in various regions of Lebanon were entered into the Lebanese Myocardial Infarction Study, conducted between January and July 1996. Information was obtained on age, gender, time of onset of symptoms, delay to hospital arrival, mode of transport, and coronary risk factor analysis. The patients were followed up in hospital for analysis of modes of therapy, complications and mortality. RESULTS: There were 44 in-hospital deaths among the 433 admissions (10.2%), which is a rate lower than those previously reported from Lebanon. Less than half the patients presented within 6 hours of onset of symptoms and only 28% received thrombolytic therapy. The mortality rate was higher in older age groups, those presenting with cardiogenic shock or pulmonary edema, those with a history of angina, infarction or heart failure, and those who developed recurrent ischemia or infarction during their hospital stay. Furthermore, occurrence of ventricular arrhythmias, mechanical complications, congestive heart failure and left bundle branch block was associated with a higher mortality rate. Treatment with angiotensin converting enzyme inhibitors, beta-blockers, aspirin, heparin, nitrates and thrombolytics significantly reduced mortality rates. CONCLUSIONS: The results reveal improvement in the survival of patients after acute myocardial infarction to values similar to those reported from Western countries. Further effort should be expended to enhance early arrival to the hospital, increased thrombolytic therapy and to implement treatment strategies supported by large clinical trials such as use of aspirin, ACE inhibitors and beta-blockers.

Gender differences in the diagnosis and treatment of acute myocardial infarction in Lebanon.

PURPOSE: To study the gender differences in presentation, diagnosis and treatment of acute myocardial infarction in Lebanon. MATERIAL & METHODS: Consecutive admissions due to myocardial infarction to 18 medical centers in various regions of Lebanon were entered into the Lebanese Myocardial Infarction Study, conducted between January and July 1996. Information was obtained on age, gender, time of onset of symptoms, delay to hospital arrival, mode of transport, and coronary risk factor analysis. The patients were followed up in hospital for analysis of modes of therapy, complications and mortality. RESULTS: Of 433 admissions, 99 were female. Compared to men, women were older, presented later, smoked less but tended to have a higher frequency of hypertension. The other coronary risk factors were similarly prevalent in males and females. Inotropic agents were used more commonly in females but thrombolytics were used less so. Women tended to develop more heart failure and had significantly higher incidence of recurrent ischemia or myocardial infarction, high level atrioventricular block and atrial arrhythmias. The overall mortality rate was higher in females than in males (16.2% vs. 8.1%, P = 0.037). CONCLUSIONS: The results reveal similarities between gender differences among Lebanese and Western populations. The higher mortality rate in women may relate to the late arrival to hospital, the older age and the more frequent complications. This emphasizes the need to educate women about coronary risk and to urge them to seek early medical care.

[Value of transesophageal echocardiography in the diagnosis of peripheral embolic event]. / Interet de l'echocardiographie transoesophagienne dans le bilan d'un accident embolique peripherique.

Ischemic cerebro-vascular events are in 15% of cases secondary to a cardiac embolus. The prevalence of echocardiographic anomalies, susceptible of being at the origin of a cerebral embolus may reach 50%. Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) in the detection of a thrombus of the left atrial appendage, spontaneous echocontrast, intra-aortic atherosclerotic plaque lesion, patent foramen ovale or an atrial septal aneurysm. The high prevalence of these anomalies in a population who presented an ischemic cerebrovascular accident does not suffice to establish a causal relationship between the anomaly and the cerebral event. Further studies seem to be necessary to establish the responsibility of these different anomalies and determine their embolic risk, by defining certain risk factors. Pending the results of such studies, TEE should be indicated more systematically in the case of an ischemic cerebrovascular accident of the young patient without a clinically evident cardiopathy, independently of the results of TTE.

[Spontaneous closure of a coronary fistula between the left anterior descending artery and the pulmonary artery. Apropos of a case]. / Fermeture spontanée d'une fistule coronaire entre l'interventriculaire antérieure et l'artère pulmonaire. A propos d'un cas.

A 35-year-old man presented with a coronary fistula between the left anterior descending artery (LAD) and the pulmonary artery trunk. Coronary angiography, performed after an inferior infarct, showed occlusion of the posterior descending artery, complete closure of the fistula and good visualization of the LAD. The authors emphasise the association of coronary fistula and coronary atherosclerosis and the ultrasonographic surveillance designed to follow the course of these fistulas and to detect possible spontaneous closures.

[First Lebanese series of percutaneous mitral commissurotomies]. / La première série libanaise de commissurotomie mitrale percutanée.

From January 1993 to January 1994, we realized at Risk Hospital 11 percutaneous mitral commissurotomies (PMC). This first Lebanese series comprised 9 women and 2 men. The mean age was 36 y (18-73 y). Ten patients were en class III of the NYHA and one in class IV (pregnant woman on the end of the 7th month). The predilatation evaluation was done by transthoracic echocardiography for the just 2 patients and by transthoracic with transesophageal multiplane echocardiography for the 9 others. The mean gradient was at 20 mmHg (10-24 mmHg) and the mean mitral area at 1 cm2 (0.65-1.5 cm2). We used the Inoue balloon for all these procedures with a stepwise technique and a color echo-doppler control between inflations. We obtain bicommissural opening in 8 patients and unicommissural opening in 3 patients. The mean gradient post dilatation was at 4 mmHg (3-8 mmHg) and the mean mitral area at 2.3 cm2 (1.5-2.8 cm2). No mitral regurgitation > 2/4 was noted. After a general review, we concluded the PMC is at present the treatment of choice of non or discrete calcified mitral stenosis and this procedure has to be taken on charge by the Ministry of Health in Lebanon.

[Coronary artery-cardiac fistulas. Review of the literature. Two accidentally discovered cases]. / Les fistules coronaro-cardiaques. Revue de la littérature. A propos de deux cas de découverte fortuite.

We report two cases of coronary artery fistula discovered accidentally during coronary-angiography. One case between the left anterior descending and the pulmonary artery and another case between the circumflex and the left ventricule. Both cases were associated with hypertrophic cardiomyopathy. There was a spontaneous closure of the fistula in the first case. A brief review of the literature is presented because this anomaly is being discovered frequently because of the possibility of diagnosis with transesophageal echocardiography.

[Complications of single chamber pacemakers (pacemaker syndrome). Short-term and long-term follow-up of 278 patients]. / Complications de la stimulation cardiaque monochambre (syndrome de pacemaker). Suivi de 278 patients à moyen et long terme.

OBJECTIVES: To assess complications of single chamber pacemaker VVI. MATERIALS AND METHODS: We reviewed the medical files of 278 patients implanted with VVI pacemaker at Saint Joseph Hospital, Bawchrieh, Lebanon, between 1978 and 1988. We looked for complications that have been reported by the patients. We compared these complications to different factors: age, indication, retrograde conduction ECG aspect before implant. RESULTS: 36 patients (12.9%) reported at least once one of these complications: fatigue, headache, neck pain, palpitations, confusion, dyspnea, angina, chest pain, pulmonary oedema, pedal oedema, atrial fibrillation, cerebrovascular accident. These complications were more frequent when the indication was an atrial disease compared to AV Block. The retrograde conduction was frequent in patient with complications. Heart failure was aggravated by stimulation, but not induced by it. CONCLUSIONS: The single chamber VVI is complicated by symptoms which could be minor, moderate and major. VVI is an acceptable mode of stimulation when the indication is AV block. The dual chamber pacemaker should consider the cost-effectiveness.

[Constrictive pericarditis after aortocoronary bypass. Apropos of a case]. / Péricardite constrictive après pontage aorto-coranarien. A propos d'un cas.

We report a case of pericarditis following aorto-coronary by-pass surgery which gradually developed into chronic constrictive pericarditis. The disease was a long time ignored because symptoms are not specific. In our case the clinical presentation looked like a cirrhosis especially that our patient developed an hepatitis after blood transfusion. In this occasion criteria of diagnostic are reminded. Hemodynamic investigation is still the best method of diagnosis and the only treatment is surgical and consists of pericardial decortication.