[Frequency and detection rate of silent myocardial ischemia by Holter monitoring in patients with stable coronary insufficiency under treatment. Study of 95,725 recorded hours]. / Fréquence et taux de dépistage de l'ischémie myocardique silencieuse en fonction de la durée du Holter chez les coronariens stables sous traitement. Etude sur 95,725 heures d'enregistrement.

AIM OF THE STUDY: To determine in standard living conditions the circadian variation of the symptomatic and silent electrocardiographic ischaemia in patients with chronic stable coronary insufficiency. To evaluate the influence of the past history of the patients on the circadian variations of the symptomatic and silent ischaemic events. METHODS: The patients included in the study presented with stable angina pectoris and have undergone a 96 hours Ambulatory ECG (AECG) monitoring with a low-weight and compact material which did not modify their daily activities (R-test). The system records the trace that the patient has initiated it himself following the onset of symptoms and makes possible to distinguish between silent and symptomatic ischaemia. The same experienced cardiologist validated all the AECG records. RESULTS: 1,022 patients aged 64.6 +/- 11.0 years suffering of coronary insufficiency from 5.8 +/- 6.0 years have undergone an electrocardiographic record by an R-test for a total duration of 95,725 hours. Of the 1,022 records, 3,258 ischaemic events have been validated: 295 (9.1%) were symptomatic and 2,963 (90.9%) were silent which correspond to a ratio of 1 versus 9 while this ratio is usually described as 1 versus 4. By 26.5% (n = 271) of the patients, ischaemia have been detected and among them more than a half (54.6%, n = 148) were presenting only silent ischaemia. Of these patients who present silent ischaemia, it was recorded during the first 24 hours by only 63.7% of them which is the usual duration of an ambulatory ECG monitoring. This percentage increases to 83.1% after 48 hours and to 94.1% after 72 hours. CONCLUSION: By more than one third (36.3%) of the patients with stable coronary insufficiency, an ambulatory ECG monitoring recorded during only 24 hours is insufficient to detect a silent ischaemia which will happen later. A record duration of 48 hours reduces this risk to 20% of the patients and of 72 hours to less than 5%.

[Frequency of silent and painful ischemia in patients with treated stable coronary insufficiency]. / Etude de la fréquence des ischémies silencieuses et douloureuses chez les patients présentant une insuffisance coronaire stable traitée.

The present study was aimed at determining the frequency and circadian variations in symptomatic or silent myocardial ischemia in ambulatory patients with stable coronary disease. A comparative analysis was then made of the recordings on symptomatic and asymptomatic patients according to their medical history. Three hundred and twenty-one cardiologists recruited a total of 1,088 patients who were monitored for 4 days with a new type of electrocardiographic recorder. The patients were able to voluntarily start up the recorder in the case of cardiac discomfort or pain. The results showed that over a total recording period of 95,725 hours, the following data, which were validated by an experienced cardiologist, were obtained: 3,258 ischemic episodes, 2,963 (or 91%) of which were cases of silent ischemia, and 295 (or 9%) which were symptomatic. All the ischemic episodes involved a limited number of subjects, i.e., 271 patients. Of these, 148 (54.6%) were completely asymptomatic; only 63% of these patients with silent ischemia would have been detected if the recording had just lasted 24 hours. Moreover, the medical history showed a correlation between certain factors (such as poorly managed arterial hypertension, cardiac insufficiency, renal failure, arteritis of the lower limbs, and a waist-hip relation of over one in men) and an increase in the number of cases of silent ischemia. However, no single factor was found to be linked more to silent ischemia than to symptomatic ischemia. This investigation therefore shows the significant numeric incidence of silent ischemia. It raises the question of the need to prescribe treatment in at-risk subjects which includes recordings of long duration, so that silent ischemia, which may increase the risk of mortality, can be more readily detected.

[Atheroma and fish oils]. / Athérome et huiles de poisson.

The reduction in cardiovascular mortality and morbidity observed over the last decade may be considered to be largely the result of the prevention of lipid disorders. The beneficial effects of diet and increased consumption of unsaturated fatty acids on ischaemic heart disease is a generally accepted concept. The low death rate from coronary artery disease amongst Greenland eskimos who eat a lot of fish has been confirmed by epidemiological studies of other large fish eating populations like the Japanese. The results reported by Bang and Dyerberg have been confirmed by the Zutphen study undertaken by Kromhout in the Netherlands. Fish oil act by the intermediary of the omega-3 fatty acids. Fish oil is rich in high unsaturated omega-3 fatty acids, the most important one being eicosapentaenoic (EPA) and docosahexaenoic acids (DHA). On the basis of epidemiological studies and clinical and experimental observations, it would appear that the consumption of marine polyunsaturated fatty acids has at least a preventive effect on phenomena of atherosclerosis and thrombosis. Their efficacy on the regression or stabilisation of the atheromatous plaque has not been demonstrated. The sites of action are multiple: decreased platelet aggregation; inhibition of thromboxane A2 production; reduction of triglyceride and VLDL concentration; improved blood rheology; action on the endothelium and proliferation of the intimal cells, vascular tone and vasomotricity. The importance of cardiovascular mortality and the hopes raised by clinical and epidemiological trials justify the pursuit of complementary studies on the efficacy and modes of action of marine polyunsaturated omega-3 fatty acids.

[2 cases of agenesis of the left coronary trunk in adults]. / Deux observations d'agénésie du tronc coronaire gauche chez l'adulte.

Agenesis of the left main coronary artery is a congenital condition the prognosis of which is reputed to be good in adults, provided no associated heart disease is present. The first case reported here illustrates the benign character of the anomaly. In contrast, the second case shows that when associated with proximal atheromatous stenosis of the single right coronary artery the anomaly may have catastrophic consequences. The anatomical variants and morbid associations of left main coronary artery agenesis are described.

[Prognostic factors in dilated cardiomyopathies]. / Facteurs pronostiques des cardiomyopathies dilatées.

One hundred and sixteen patients (mean age 46 years) with dilated cardiomyopathy documented by haemodynamic investigations and angiography with normal coronary arteriography were followed up for a mean period of 29 +/- 19 months. During that period, 36% of the patients died after a follow-up of 30 +/- 20 months. The actuarial death rates were 15% at 2 years, 45% at 6 years and 60% at 10 years. The main factors predictive of survival at 10 years were the clinical and haemodynamic markers of left heart failure. The death rate was multiplied by 1.6 in patients in stages III or IV of the NYHA classification (83% vs 51%, p less than 0.01), by 2.6 in patients with left ventricular end-diastolic pressure above 15 mmHg (73% vs 29%, p less than 0.01), by 2.2 when the indexed end-diastolic volume rose above 200 ml/m2 (75% vs 35%, p less than 0.01), by 2.2 when the left ventricular ejection fraction was below 40% (75% vs 35%, p less than 0.05) and by 2.6 when angiographic mitral valve regurgitation was present (75% vs 34%, p less than 0.01). The death rate at 9 years was 2.3 times higher in patients with left bundle branch block (72% vs 36%, p less than 0.05). A cardiothoracic index over 0.60 proved to be of poor prognosis at one year (death rate: 19%). While alcoholism played no part in the prognosis, the death rate in smokers was consistently higher than in non smokers (56% vs 32% at 6 years, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Syncope with a rare etiology, cardiac hydatidosis]. / Syncopes d'étiologie rare, hydatidose cardiaque.

A case of left ventricular hydatid disease causing mitral insufficiency and revealed by accelerated idioventricular rhythm (AIVR) is reported. The traditional and more recent diagnostic procedures including echocardiography and immunology are reviewed. The persistence of AIVR and mitral insufficiency after excision of the cyst are discussed with respect to the surgical treatment.

[The clinical diagnosis of aorto-coronary bypass occlusion (author's transl)]. / Le diagnostic clinique d'occlusion des pontages aorto-coronaires.

The clinical profile of aorto-coronary bypass occlusion was drawn from a study of 49 patients with 56 occluded bypasses and 69 patients with 123 patent bypasses. All patients had undergone postoperative coronary arteriography or post-mortem examination. An anatomical cause of occlusion was retrospectively detected on the basis of pre-operative arteriographic findings or operation records in 82% of the cases, and on account of post-operative myocardial infraction (particularly significant when of late occurrence), residual angina and positive exercise tolerance test in 35%, 55% and 40% respectively of the cases. The last three criteria are of absolute diagnostic value when the arterial defects have been fully corrected by surgery.

[Changes in the exercise electrocardiogram after aortocoronary bypass. Long-term results in 50 patients]. / Evolution de l'électrocardiogramme d'effort après pontage aorto-coronaire. Résultats à long terme chez 50 patients.

A comparative study of exercise electrocardiogrammes before and after aorto-coronary bypass surgery was carried out in 50 patients over a 2 year period. Coronary arteriography was used to assess the chirurgical results qualitatively ((electrocardiographic appearances) and quantitatively (work capacity and effort tolerance) with respect to the coronary lesions and permeability of the aorto-coronary vein grafts. Exercise electrocardiography has a place in the follow up of patients with aorto-coronary bypass grafts but it only gives information on the permeability of the grafts if all the significant stenosis are bypassed at surgery.

[Long-term results of aortocoronary bypass. 1. Clinical aspects]. / Résultats à long terme des pontages aorto-coronaires. 1. Aspects cliniques.

Eighty patients undergoing one or several aorto-coronary bypass graft procedures had longterm clinical and arteriographic follow-up (mean follow-up period of two years, extremes 1 and 6 years). The indication fort operation in these patients was unstable angina in 39 (49%), threatened infarction in 16 (20%), Prinzmetal's angina in 8 (10%), and stable but incapacitating angina in 17 (21%). Significant lesions involved the three coronary trunks in 49 cases, two trunks in 25 cases, and one trunk in 6 cases. The longterm clinical results were excellent in 65% of cases, and fair in 26%; the procedure failed in 9% of cases. Angina pectoris either disappeared or improved in 96% of cases. After operation, myocardial infarctions occurred in 11 cases (14%), 7 of which were early and 4 late with a delay of 1 to 4 years. The pre-operative cardiac failure disappeared or decreased in 13 cases out of 16. Finally the quality of the clinical results does not seem to be influenced by the various indications for operation with the exception of Prinzmetal's angina, where the results have been excellent in all cases (8 cases out of 8).

[Long-term results of aortocoronary bypass. 2 Angiographic aspects]. / Résultats à long terme des pontages aorto-coronaires. 2. Aspects angiographiques.

Follow-up arteriograms carried out between one and six years (mean follow-up period two years) in 80 cases of aorto-coronary bypass graft procedures showed a good correlation between the quality of the clinical results obtained -- as detailed in the first part of this article -- and a larger proportion of patent grafts: 82% of 130 grafts had remained patent, and 94% of patients have all or some of their grafts patent. Late occlusion of the grafts is rare, and does not appear to be influenced by abnormalities of the graft found at early follow-up, these abnormalities being fairly stable. These follow-up have especially shown the good correlation between the quality of the clinical results and the functional status of the coronary network in the long term, a function not only of the permeability of the grafts which have been carried out, but also of the complete or incomplete correction of the lesions of the three coronary trunks. Such a complete procedure which was carried out or could have been carried out in only 30% of the total patients, was then successful in 94% undergoing it. The clinical results should therefore lead us to carry out operations which remove the lesions as completely as possible.

[Coronary stenosis in angina pectoris with normal resting electrocardiogram]. / Les sténoses coronaires de l'angine de poitrine avec électrocardiogramme normal au repos.

The arteriographic abnormalities found in 104 patients with typical angina pectoris and an electrocardiogram at rest which was normal at the time of arteriography were compared with those of 238 cases with typical angina pectoris, but with an abnormal electrocardiogram (127 having ST/T changes, 111 having transmural necrosis). There was no major difference between the two groups as far as the degree of coronary stenosis was concerned, nor in its extent and distribution. However, by comparison with the group with an abnormal electrocardiogram, very tight stenoses of the three trunks or of one trunk alone were slightly less common in the patients with a normal electrocardiogram; also, for each of the three trunks, the index of the lesion was slightly less raised, and the circumflex and right coronary arteries were slightly less commonly, affected, although the difference was not usually great enough to achieve significance. The action of the left ventricle and/or the value of left ventricular end-diastolic pressure were, however, manifestly better conserved in those with a normal electrocardiogram (p less than 0.001). An aorta-coronary bypass graft is more likely to be indicated in this group of patients.