[Prognostic factors in dilated cardiomyopathy]. / Etude des facteurs pronostiques des cardiomyopathies dilatées.

Thirty-eight patients, 27 men and 11 women, mean age 49 +/- 12 yr, suffering from dilated cardiomyopathy were included in this prospective study of prognostic factors. Twenty-two subjects admitted heavy alcohol consumption (greater than 80 g/d, for at least 10 yr). The survival rates for 2, 5 and 7 yr were 87, 35 and less than 20%, respectively. Prognostic factors were evaluated in 34 (22 alcoholic and 12 non-alcoholic) patients: 10 improved or were cured, as determined clinically, radiologically and echocardiographically (group 1); 24 deteriorated, 13 of whom died (group 2). Statistically significant values for group 1 versus group 2 were: echocardiographic left ventricular (LV) end diastolic diameter (3.50 +/- 0.80 vs 4.02 +/- 0.5 cm/m2, p less than 0.026) and LV end systolic diameter (2.97 +/- 0.65 vs 3.43 +/- 0.53 cm/m2, p less than 0.02); hemodynamic LV systolic pressure (113.9 +/- 15 vs 101.82 +/- 17.36 mm Hg, p = 0.045); angiographic LV end diastolic volume (137.8 +/- 57.44 vs 177.85 +/- 55.45 ml/m2, p = 0.057), LV end systolic volume 93 +/- 53.5 s 139.28 +/- 48.99 ml/m2, p less than or equal to 0.036), ejection fraction 0.36 +/- 0.16 vs 0.22 +/- 0.7%, p less than or equal to 0.006) and velocity of fiber shortening (0.79 +/- 0.53 vs 0.36 +/- 0.3 circ/s, p = 0.036). Other electrical, radiological and hemodynamic parameters were not significant and alcohol consumption did not influence the prognosis. The severity of LV functional impairment appears to be the major determinant of a poor prognosis and reduced survival in idiopathic and alcoholic cardiomyopathies.

Asymptomatic diabetic cardiomyopathy: a noninvasive study.

Forty-nine diabetic patients (26 type I and 23 type II), free of cardiovascular disease symptoms, were compared with 32 controls in a noninvasive study of left ventricular (LV) function. Absence of ischemic cardiopathy was confirmed by routine investigations and an exercise electrocardiogram using 12 leads with a thallium-201 myocardial scintigraphy. Diabetic patients had (1) a significantly prolonged mean isovolumetric relaxation time (IVRT) assessed by M-mode echocardiography and phonomechanography; (2) a significantly reduced E-F slope; (3) an increased mean Weissler index (pre-ejection period/LV ejection time). The IVRT and E-F slope abnormalities reflect increased myocardial stiffness and impaired LV compliance. The increased Weissler index reflects impaired myocardial contractility. These abnormalities were not related to sex, age, duration of diabetes or to the presence or extent of complications. No significant difference was found between diabetic patients and controls for mean diastolic and systolic LV diameters, thickness of the posterior wall or of the interventricular septum, assessed by echocardiography, or for the ejection fraction, determined by radionuclide angiocardiography. Finally, more than half of the patients with a frankly abnormal IVRT, Weissler index and E-F slope had had diabetes for less than 5 years, some even less than 2 years, without complications. These data show: (1) evidence of LV dysfunction specific to diabetes and unrelated to ischemic cardiopathy and hypertension; (2) the possible involvement of a metabolic factor in this early asymptomatic LV abnormality rather than microangiopathy.

[Comparative value of 24-hour ECG monitoring and standardized maneuvers in the detection and exploration of cardiac autonomic neuropathy in diabetics]. / Intérêt comparé de l'enregistrement ECG des 24 heures et des manoeuvres standardisées dans la détection et l'exploration de la neuropathie autonome cardiaque chez le diabétique.

24-hour continuous electrocardiographic ECG monitoring and standardized tests were performed to detect cardiac autonomic neuropathy in diabetic patients. Thirty-eight patients, with a mean duration of diabetes of 10 years, twenty-five IDDM and thirteen NIDDM, and thirty-two controls, with no illness or treatment which could alter the heart rate (HR), were studied. Five standardized tests were performed. Three tests investigated parasympathetic function: variations of HR during Valsalva manoeuvre, deep breathing and standing. The other two tests investigated sympathetic function: detection of orthostatic hypotension and blood pressure response to sustained handgrip. Parasympathetic HR control was impaired in twenty-nine patients, together with impaired sympathetic cardiovascular control in seven. According to the 6 indices studied, 24-hour ECG monitoring detected abnormalities in only eight patients. Mean minimum 24-hour HR and mean sleeping HR were elevated in the group of patients whose five standardized tests were normal and in the group of patients with impairment of both parasympathetic and sympathetic cardiovascular control, but not in the group of patients with only impaired parasympathetic HR control. This study suggests that 24-hour ECG monitoring is a less sensitive test of cardiac autonomic neuropathy than standardized tests. Moreover, it shows HR abnormalities that are not specific to cardiac autonomic neuropathy.

[Abnormalities of 24 hour (Holter) ECG monitoring in diabetics: involvement of cardiac autonomic neuropathy and/or insulin therapy]. / Anomalies de l'enregistrement ECG des 24 heures (Holter) chez le diabétique: rôle de la neuropathie autonome cardiaque et/ou de l'insulinothérapie.

In order to detect evidence of cardiac autonomic neuropathy, 24-hour continuous electrocardiographic monitoring was carried out on fifty-one diabetic patients (thirty-one IDD, twenty NIDD) and twenty-two healthy controls taking no treatment which could alter the heart rate. In the diabetic patients the minimum 24-hour heart-rate and the mean sleeping heart rate were significantly higher, and the maximum 24-hour heart rate and the ratio [(maximum-minimum heart rates)/minimum heart rate] were significantly lower. Evidence in one diabetic of cardiac autonomic neuropathy was found only as the difference (maximum-minimum heart rates). This index was found to be below 38/min (mean-2 SD of the controls) in seven diabetics, but only one of the nine diabetics with signs of autonomic neuropathy had this abnormal index. The mean values for the minimum and the mean sleeping heart rates were high in the IDD with or without signs of peripheral neuropathy and without signs of autonomic neuropathy but were not high in IDD with signs of autonomic neuropathy. These findings suggest the presence of cardiac autonomic neuropathy in diabetics. However, the possibility of insulin-induced tachycardia should be considered this tachycardia is probably related to stimulation of the sympathetic nervous system, which would explain the absence of abnormalities in IDD with autonomic neuropathy.

[Existence of asymptomatic changes in left ventricular function in the diabetic. Noninvasive study]. / Existence d'altérations asymptomatiques de la fonction ventriculaire gauche chez le diabétique. Etude non invasive.

49 diabetics (D) (26 IDD and 23 NIDD) were compared to 32 controls (C). Absence of ischemic cardiopathy (IC) was confirmed by routine investigations and noninvasive cardiovascular techniques, including an exercise ECG using 12 leads and a thallium 201 scintigraphy. Our results show: a) a prolonged mean isovolumetric relaxation time (IVRT) as studied by the M mode echocardiography and phonomechanography: D = 0,10 sec +/- 0,04; C = 0,05 sec +/- 0,02; p less than 0,0001; b) a reduced mean EF slope: D = 97,48 +/- 37,08 mm / sec; C = 125,68 +/- 34,35; p less than 0,005; c) a high mean Weissler index (ratio of PEP to LVET): D = 40 +/- 0,08; C = 33 +/- 0,05; p less than 0,01. IVRT and EF slope abnormalities are related to increased myocardial stiffness and impaired LV compliance. In the absence of changes in preload and afterload, the high Weissler index reflects impaired contractility of the myocardium. These abnormalities are related neither to the duration of diabetes nor to the presence or severity of the complications. With the M mode echocardiography, mean diastolic and systolic thickness of the septum is greater in D with retinopathy than in C (p less than 0,005 and p less than 0,03 respectively); mean diastolic and systolic thickness of the posterior wall is greater in NIDD than in C (p less than 0,001 and p less than 0,025). We conclude that there is evidence of left ventricular functional abnormalities specific to diabetes and unrelated to IC and hypertension. Our findings support the hypothesis that they may be due to metabolic disorders and/or myocardial microangiopathy.