Diltiazem slow-release and left-ventricular hypertrophy: a volumetric approach of left ventricular mass using magnetic resonance imaging.

AIMS: This study was designed to assess the changes in left ventricular mass (LVM) in hypertensive patients with left ventricular hypertrophy under drug therapy with once-daily slow-release diltiazem. Magnetic resonance imaging (MRI) was used for this purpose because of its higher reproducibility than M-mode or two-dimensional echocardiography. METHODS: Patients suffering from essential hypertension were included if their baseline LVM index (LVMI) was > or = 105 g/m2 in male or > or = 85 g/m2 in female patients, ie, equal or higher to the median values observed in hypertensive patients in our institution. MRI consisted in a true short-axis, electrocardiogram (ECG) gated spin-echo slice acquisition at baseline, after 3 and 6 months of therapy (M0, M3, and M6). Data were stored on magnetic tapes and read subsequently under blind conditions and the control of an external auditor. RESULTS: Thirty-five patients were included. Of these, 14 patients (40%) were not previously treated. Inter- and intra-observer variability for LVMI measurement were 5.6 +/- 4.3% and 2.1 +/- 3.0%, respectively. Mean baseline LVMI was 110 +/- 16 g/m2 in male and 96 +/- 16 g/m2 in female patients. It decreased by 3.6% at M3 (P = 0.05) and by 6.0% at M6 (P = 0.02). A trend towards a greater LVMI reduction was observed in previously untreated patients. CONCLUSION: This study confirms that MRI is a reproducible technique for the measurement of LVM. It demonstrates a significant reduction in LVMI as early as the 3rd month of therapy in hypertensive patients treated with once-daily sustained release (SR) diltiazem, although baseline LVMI in the majority of participating patients was only moderately increased.

Prognostic factors of chronic heart failure in NYHA class II or III: value of invasive exercise haemodynamic data.

UNLABELLED: Various parameters have been found useful for establishing the prognosis of patients with chronic heart failure, in particular haemodynamic parameters measured at rest. However, few studies deal with the prognostic value of invasive exercise haemodynamic parameters in such patients. Our aim was to test the value of such parameters to assess the prognosis of patients with chronic heart failure in functional class II or III of the New York Heart Association. METHODS: Between December 1990 and June 1993, 50 patients fulfilled the criteria for inclusion in the study. The average age and ejection fraction of the population were 54 +/- 2 years and 20 +/- 0.5% respectively. All patients were examined clinically; their invasive haemodynamic parameters were measured at rest and during exercise, and their exercise peak VO2, validated by reaching the anaerobic threshold, was determined. They were followed up for 21.2 +/- 1.17 months (ranges 3-26 months). The assessment criteria employed were mortality and the occurrence of major events (heart failure, pulmonary oedema or severe ventricular arrhythmia). RESULTS: The population consisted of 32 men and 18 women. No gender-related differences were found. Two groups could be distinguished in terms of prognosis: G1: n = 31 living patients with no events, and G2: n = 19 deceased or with major events. G1 and G2 were comparable with regard to age, sex ratio and ejection fraction. Several of the 52 parameters tested were different in the two groups, in particular peak VO2, exercise duration, the workload developed during the cardiopulmonary test and all the invasive exercise haemodynamic parameters except heart rate (P < 0.0001). Haemodynamic parameters at rest had no prognostic value in this series. The ROC curves, the survival curves and the Cox analysis showed that exercise cardiac power output, exercise left ventricular work indices and exercise peak VO2 were the most useful factors for assessing the prognosis of patients with NYHA II or III chronic heart failure. An exercise cardiac power output < 2 watts accurately identified those patients with a short-term poor prognosis, and exercise peak VO2 was almost as accurate. To a lesser extent, the NYHA functional class was also an independent prognostic parameter during multivariate analysis. In conclusion, it appears that invasive haemodynamic parameters are best for determining the prognosis of patients with chronic heart failure. Peak VO2 can, however, be as useful. Moreover this is an easily obtainable non-invasive parameter, which makes it more useful in the evaluation and the follow up of such patients.

[4-year mortality of heart failure with intact systolic function: a retrospective studies]. / Mortalité à 4 ans de l'insuffisance cardiaque à fonction systolique conservée. Etude rétrospective.

Heart failure with normal systolic function has been recognised in 30-40% of patients investigated for congestive heart failure. The authors undertook a retrospective study of global and cardiovascular mortality at 4 years in two groups of patients with a history of congestive heart failure documented by equilibrium angioscintigraphy: group I (n = 109) with poor left ventricular systolic function (EF = 26 +/- 9%) and group II (n = 40) with normal systolic function (EF = 58 +/- 8%). The 4 year cardiovascular mortality was less in group II (21.6% vs 49%; p < 0.004) whereas the global mortality was comparable in the two groups. The only discriminating parameters for cardiovascular mortality between the two groups were age of more than 60 years and values of diastolic blood pressure exceeding 90 mmHg which were associated with a higher mortality in the group with normal systolic function. These results indicate a better prognosis in terms of cardiovascular mortality from congestive heart failure in patients with normal systolic function compared with those with poor systolic function.

Amniotic fluid embolism: a case with non-cardiogenic pulmonary edema.

We report an uncommon case of amniotic fluid embolism (AFE) in a 24-year-old woman with a 26th-week, second pregnancy. Clinical manifestations were dominated by acute respiratory distress and pulmonary edema. Recovery was complete. Early invasive hemodynamic studies showed normal function of the left ventricle with a low pulmonary artery occluded pressure. These findings are controversial to the concept of cardiogenic pulmonary edema in AFE.

[Dynamic cartography of flow patterns by cine-MRI. Presentation of the technique and preliminary results for major vessels]. / Cartographie dynamique des flux par ciné-IRM. Présentation de la technique et résultats préliminaires sur les gros vaisseaux.

The authors report the principles, experimental evaluation and clinical approach of a method for dynamic imaging of flow patterns by NMRI, based upon the phase modulation technique. The imaging method is based upon gradient echo, functioning in "cine" and "flow compensated" mode. Modifications in this sequence enable attribution to the moving spins phase of a value which is considered to be proportional to the flow rate. A map of rates is then obtained from the phase image. Calibration of this sequence in vitro has shown excellent correlations between flow rate and the phase information thus obtained: r always > 0.98 for rates up to m/s. The first results obtained in vivo for the thoracic and abdominal aorta, in 11 control subjects, show that the technique is suitable for the study of pulsatile blood flow, providing very detailed information concerning the spatial distribution of flow rates. Mean flow in the suprarenal abdominal aorta (4.6 +/- 1.6 l/min) is 32% greater than that in the inferior vena cava (3.1 +/- 1 l/min), corresponding to an estimation of portal vein flow of 1.5 l/min. Practical limitations related to the use of a resistive magnet are nevertheless stressed and the authors list the technical aspects necessary for the better clinical utilisation of this non-invasive flowmetric technique. A review of the current literature forms the basis for an assessment of the potential importance of dynamic and quantitative NMRI of flow patterns in the cardiovascular area.

[Acute myocardial infarction in patients over 70 years of age treated by immediate primary angioplasty]. / Infarctus du myocarde aigu chez les patients de plus de 70 ans traités par angioplastie primaire immédiate.

Twenty consecutive patients aged over 70, admitted for acute myocardial infarction, underwent coronary arteriography within less than 6 hours after the onset of pain to confirm the diagnosis and determine the indications for other than thrombolytic reperfusion treatment, the risk of thrombolysis seeming theoretically prohibitive. In all cases, the artery responsible was found to be obstructed and, based upon this criterion, primary reperfusion angioplasty was performed. The criterion for success of angioplasty was the reappearance of distal flow (grade > 1 of the TIMI classification--Thrombolysis in Myocardial Infarction). The reperfusion rate obtained by angioplasty was 85%. Follow-up coronary arteriography during hospitalisation (between D10 and D15) in 17 patients revealed neither restenosis nor re-occlusion. In case of successful reperfusion, left ventricular ejection fraction improved by 16% (in absolute values). Hospital mortality was 15% (6 patients were in cardiogenic shock from the time of admission). Mortality (after a follow-up of 27.3 +/- 17.5 months) was 20%. Complications of the procedure during the acute phase included one femoral hematoma and one moderate coronary dissection, with an uncomplicated outcome. Angioplasty is an effective reperfusion method in patients aged over 70, and is an alternative to thrombolysis which, in this age group, is accompanied by a risk of hemorrhagic complications, cerebral in particular. Thus angioplasty can be suggested as first line treatment in elderly patients provided they have been admitted to a unit where operational cardiology is available on a continuous basis.