[Right ventricular infarction caused by isolated right ventricular branch occlusion: a case report]

It is rare to observe right ventricular infarction caused by isolated right ventricular branch occlusion. Isolated right ventricular infarction accounts for less than three percent of all cases of infarction. Generally, it is associated with occlusion of a non dominant right coronary artery or of a right ventricular branch. ECG can be misleading with ST segment elevation in anterior leads. We describe a patient admitted for chest pain with ST segment elevation in leads V1 to V3 associated with ST segment elevation in leads V3R and V4R. Coronary angiography demonstrated isolated total occlusion of the right ventricular branch. Thus, right precordial leads need to be done in every patient presenting with ST segment elevation in precordial leads V1 to V3 and not only in inferior myocardial infarction.

[A case of chest trauma-induced acute myocardial infarction]

The occurrence of an acute myocardial infarction (MI) after chest trauma is a rare complication. We report a case of a 58-year-old man presenting with an acute anterolateral MI secondary to blunt chest trauma. Coronary angiography revealed a non significant lesion of a first diagonal branch without any atherosclerosis lesion on coronary artery. He was conservatively managed and resulted in a good prognosis. Based on this case, we discuss the path physiologic mechanism of MI following chest trauma.

[Assessement of home blood pressure with a monitor including MAM technology: comparison with the standard monitor]

OBJECTIVES

To compare two periods of three days of home blood pressure monitoring (HBPM) using two different monitors with one including MAM (microlife average mode) technology.

METHODS

In 152 hypertensive subjects referred to hypertension specialists, a self-measurement of blood pressure was performed sequentially with an Omron M6 (arm cuff, A/A, BHS validation) or Microlife BP-3AC1 with the MAM technology. Each patient recorded home blood pressure during two periods of 3 days with 3 measures in the morning and 3 in the evening. Order for use of each monitor was randomised. BP values were reported on a standardized document.

RESULTS

In this population, aged 60 +/- 14 years, with 57% of men and a mean blood pressure of 150 +/- 21/84 +/- 21 mmHg, the home blood pressure values were 141.5 +/- 18.7/79.9 +/- 9.6 mmHg with the OMRON monitor and 138.2 +/- 17.1/79.9 +/- 10.1 mmHg with the Microlife monitor. Values between the two monitors differed about 5 mmHg for the mean SBP and about 2.8 mmHg for the mean DBP. The mean HBPM values does not differ between the two methods for more than 2.5 mmHg, 5 mmHg, 10 mmHg and 15 mmHg in 29%, 49%, 80% and 90% for SBP and in 42%, 76%, 94% and 98% for DBP respectively.

CONCLUSIONS

For most of patients, mean SBP/DBP obtained with home blood pressure Measurement during three days are comparable when using monitor operated with MAM technology or not.

[Hemodynamic instability and long-term lithium therapy]

Lithium is known to be responsible for many adverse events on the cardiovascular system. Among these events, it was experimentally noted that lithium could block the action of catecholamines on myocardium. The authors report the case of a patient under lithium therapy developing a myocardial infarction secondarily complicated of a severe cardiac failure. The inotropic support essential to balance hemodynamic could be raised only after lithium's stop. This example could be a clinical translation of the experimental effect previously observed.

[Education for chronic cardiologic diseases in a transversal multidisciplinary unit: the experience of a general hospital center]

Treatments for congestive heart failure, hypertension and cardiovascular risk have significantly changed and have become more complex. The have also become more and more effective thanks to the results of great clinical studies that have enabled European and North-American societies to issues recommendations. The observance of the pharmacological and non-pharmacological treatments requires the education of patients and their family following guidelines that have been clearly defined by the European Society of Cardiology. This education, in which the technic of communication is very important, is common to a lot of chronic diseases and requires adequate material and human resources in order to have an optimal quality of treatment. In a society in which spending is on rise, getting such resources is not easy. However, putting in common resources of several departments can be a good solution. The experience of the Hospital Center of Douai (France) lead to the creation of a Transversal Education Unit at the end of the year 2003. This unit centralizes the efforts of several departments of care like pneumology, pediatrics, diabetology, nutrition and cardiology and allows patients suffering from co-morbidities to have access to various programs of this unit.

[Systolic blood pressures are not comparable when home blood pressure is measured with a wrist or an arm validated monitor]

OBJECTIVES

To compare home blood pressure values obtained with two validated OMRON (wrist or arm) monitors used sequentially in the same subject.

METHODS

In 265 hypertensive subjects referred to hypertension specialists, a self measurement of blood pressure was performed sequentially with an OMRON M4-I (arm cuff, A/A, BHS validation) or OMRON RX-I (wrist cuff, B/B, BHS validation). Each patient recorded home blood pressure during two periods of 4 days with 3 measures in the morning and 3 in the evening. Order for use of each monitor was randomised. With wrist devices, subjects were advised to keep the arm at heart level during measurements. BP values were reported on a standardized document. Patients were asked by a questionnaire about the tolerance and feasibility of the 2 methods.

RESULTS

In this population, aged 59 +/- 14 years, with 60% of men and a mean blood pressure of 152 +/- 21 / 86 +/- 14 mmHg, the home blood pressure values were 143 +/- 20/81 +/- 11 mmHg with the arm monitor and 135 +/- 10 / 80 +/- 11 mmHg with the wrist monitor. Mean SBP adjusted on age, initial blood pressure level and period order was significantly lower when home blood pressure monitoring has been recorded with a wrist monitor as compared to an arm monitor (p < 0.001). Self measurement of blood pressure was felt as easy in 92% with the arm monitor and in 96% with the wrist monitor (p < 0.05). Self measurement of blood pressure was felt as constraining in 14% with the arm monitor and in 7% with the wrist monitor (p < 0.01). The feasibility between the two devices was good with none of the value missing in 86% with the arm monitor and in 85% with the wrist monitor. The missing values were in 56% the fourth day.

CONCLUSION

Despite the use of two validated monitors, mean SBP is significantly lower when home blood pressure monitoring is recorded with a wrist monitor as compared to an arm monitor. Uncertainty in the arm position with the use of wrist device could explain these results. When advising home blood pressure monitoring, care should be taken to recommend only the use of validated devices and to prefer the use of arm devices in order to avoid the uncertainty of an inadequate utilisation.

[Reflux nephropathy and arterial hypertension]

This case-report emphasizes an uncommon cause of hypertension in an adolescent: reflux nephropathy. Reflux nephropathy is a frequent hypertension and renal failure etiology. Medical treatment is unknown from cardiologist.

[Pacemaker syndrome after dual-chamber implantation: consequence of a very long atrial activation delay]

Many circumstances, generally occurring in inappropriate device's adjustment or in specific myocardial conduction's disturbances, can result in dual chamber indications in pace maker syndromes. Our case report is about a man implanted with a dual chamber device with a dilated right atrium and intra atrial conduction delay resulting in a delayed post pacing atrial activation time. The consequence was an atrial contraction occurring during closed atrioventricular valves.

[Clinical significant of serum chromogranin A levels for diagnosing pheochromocytoma in hypertensive patients]

OBJECTIVE

CMA is a widespread glycoprotein located in the secretory vesicles of neuroendocrine cells and is co-released with peptides and biogenic amines into the circulation. The present study set out to investigate the clinical utility of assessing serum CGA levels in comparison with the urinary KTCO and their urinary metabolites concentrations, which are to date the gold standard validated diagnostic test.

METHODS

From January 2000 to June 2001, 202 consecutive patients, aged 53 +/- 12.7, 102 males, were admitted to our department for a hypertension evaluation. Blood samples for measurements of plasma concentrations of chromogranin A were collected and serum CGA levels were quantified by RIA technique (RIACT). This radioimmunometric technique consisted in using 2 monoclonal antibodies directed to 2 specific antigenic domains of the middle portion of the CGA. The fixed threshold value for identifying positive results was, set at 100 ng/ml according to previous studies.

RESULTS

No pheochomocytoma was diagnosed by conventional urinary KTCO essay. Of the 202 CGA blood samples, 32 turned out to be positive, due to commonly encountered false positive causes (inhibitor of the pump with protons, corticotherapy, hypergastrinemia, chronic renal insufficiency, respectively, in 11, 2, 1, 18 cases). The CGA plasma concentration averaged 77 +/- 77 mg/ml and 203 +/- 125 ng/ml in the CGA subgroup over the threshold value.

CONCLUSION

The reliability of immunoradiometric serum CGA concentrations appeared according to this work to be comparable to that of the urinary KTCO levels and their urinary metabolites in hypertensives. Moreover, it solely requires a simple, easily done blood taking, less expensive than urinary KTCO collection. Besides, no antihypertensive drugs interfered with the analysis of CGA levels. However, some false positive results have to be mentioned in the presence of renal impairment, hypergastrinemia, corticotherapy, inhibitor of the pump with protons.

[Management of essential arterial hypertension and cardiovascular risk levels. Observation in general medicine: national PHENOMEN study. Evaluation and stratification of cardiovascular risk based on the 2000 ANAES recommendations in a population of hypertensive patients]

OBJECTIVE

To define the prevalence of cardiovascular risk (CVR) levels in a population of hypertensive patients (whether treated or not) monitored by General Practitioners, using the stratification system proposed by the ANAES in 2000.

METHODS

Between January and July 2001, a nation-wide survey was carried out based on a representative sample of 8,177 General Practitioners spread evenly throughout all of the 22 administrative regions in France. The evaluation of CVR levels took into account blood pressure readings as well as CVR factors and indicators.

RESULTS

This survey covered 16,358 patients (53.2% men, 46% women; mean age = 62.5 +/- 11.9 years; BMI = 27.3 +/- 4.5 kg/m2) with a mean history of hypertension of 7 +/- 7 years. The most common CVR factors were dyslipidemia (59.5%), smoking (19%) and diabetes (16%). Concomitant target organ damage was recorded in 17% and heart disease in 21.8%. One patient in four had more than three CVR factors; respectively 56.5%, 30.9% and 12.5% of the patients had mild, moderate or severe hypertension. More than 50% of the patients were classified as being at "high" or "very high" CV risk. The distribution of risk levels was similar throughout the country with a North-South gradient of the high/very high levels. Only 17% of the patients being treated had completely normal blood pressure (< 140/190 mmHg), although 19% more count as normal if the limit values are included.

CONCLUSION

The main objective of this large-scale, nation-wide epidemiological survey was to evaluate how well CVR is being managed in a representative sample of patients with high blood pressure. In general, none of the risk factors is adequately controlled, especially in populations considered as being at high CVR. Moreover, the notion of CVR has only been partially assimilated by General Practitioners.

[Sexual dysfunction in treated hypertensive patients. Results of a national survey]

OBJECTIVES

To evaluate, using an self-administered questionnaire, the characteristics of sexual function in treated hypertensives.

METHODS

In 459 hypertensive subjects, aged of 59 +/- 12 years, living in France and referred to hypertension specialists, a self-administered questionnaire evaluating quality of life and antihypertensive treatment was given before the consultation. Several questions focused on the quality of sexual function since the last 12 months (interest for sexuality, sexual pleasure, quality of erection). Details on antihypertensive treatments and cardiovascular characteristics were obtained from medical records. Antihypertensive treatments were prescribed since more than 10 years for 39% of subjects, since 5-10 years for 25%, since 1-5 years for 26%, and since less than 1 year for 10%.

RESULTS

In this population of treated hypertensives, blood pressure level was higher in men than in women (145 +/- 22/86 +/- 13 vs 135 +/- 25/76 +/- 15; p < 0.01). In the questionnaire, the section with sexual function questions was filled out extensively in 92% of men (248/268), but only in 74% of women (142/191). Sexual disturbance was declared by 38% of cases (148/390), but rate was significantly higher in men as compared to women (49% vs 18%; p < 0.01). In men, these modifications were characterised by an interest for sexuality decreased for 58%, unchanged for 41% and increased for 1%. Sexual pleasure was decreased for 49%, unchanged for 50%, and increased for 1%. Quality of erection was modified in 45%. The erections were less frequent for 31%, less durable for 19% and impossible for 11%. In women, interest for sexuality was decreased for 41% and unchanged for 59%, sexual pleasure was decreased for 34% and unchanged for 66%. Logistic regression analysis indicates that gender (p < 0.001), greater number of antihypertensive tablets (p < 0.01), prescription of diuretics (p = 0.03) and presence of coronaropathy (p = 0.01) were independent determinants for sexual disturbance in treated hypertensives.

CONCLUSION

This study indicates that sexual disturbance is declared by 38% of patients treated for hypertension. Because complaints are more frequent in men, treated with multiple medications including a diuretic, a specific interrogation should be proposed more regularly in these patients in order to detect and to deal with, if possible, sexual disability.

[Renovaascular hypertension and Von Recklinghausen neurofibromatosis]

This clinical case illustrates the diagnosis of a secondary cause of hypertension in a patient with Von Recklinghausen's disease. The hypertension resulted from a complex malformation of the right renal artery and dysplasic stenosis of the left inferior polar artery treated successfully by simple angioplasty. This case illustrates the high proportion of vascular (renal artery dysplasia, coarctation of the aorta) and endocrine (pheochromocytoma) causes of hypertension in patients with neurofibromatosis.

[Are demographic characteristics of hypertensive patients different with renal artery stenosis?]

Atheromatous renal disease is more and more involved in end stage renal failure in polyatheromatous patients. The goal of this work was to study the demographic differences between hypertensive patients with renal artery stenosis (RAS) or without RAS.

METHOD

Between November 1995 and July 1997, 49 hypertensive patients were included consecutively for a suspicion of RAS. Age, sex, hypertension history, tabagism, cardiovascular heredity, body mass index, diabetes history, hypercholesterolemia, kalmia, serum creatinine, creatinine clearance, systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure (PP) were studied. A renal echo-doppler and a renal TDM were performed in all patients. A renal arteriography was performed in 23 patients with a RAS suspicion after the two morphologic exams. The demographic characteristics of both clinical groups control (group 1) and patients with unilateral RAS (group 2), were compared.

STATISTICS

Descriptive analysis, Wilcoxon test, Khi 2 test, spearman correlation (p < 0.05).

RESULTS

Group 2 patients were significantly older than group 1 patients (p = 0.008) with a mean age difference of 8 years. Creatinine clearance was lower in patients suffering from RAS with a mean difference of 23 mL/min between groups 1 and 2 (p = 0.0007) but we also had to take into account the negative correlation existing between creatinine clearance and age (r = 0.63; p = 0.0001) when interpreting these results. The DBP was lower (p = 0.03) and the PP higher (p = 0.01) in group 2. The SBP was higher in group 2 but this result was not significant. Mean differences in SBP and PP between group 1 and group 2 were 6 mmHg and 15 mm Hg respectively. Smoking was more common in group 2 (p = 0.04). The history of hypertension, cardiovascular heredity, sex ratio (M/F), body mass index and prevalence of diabetic were comparable between the two clinical groups.

CONCLUSION

Although there were demographic differences between the two clinical groups, no clinical or biological variable could be used alone to identify which patients suffered from renal stenosis, because the distribution of these variables did not differ significantly between the two groups and the effective was small. Then, we thought that Krijnen's predictive rule is interesting in the screening of hypertensive patients with RAS suspicion.

[Method of studying renal morphology in hypertensive patients with and without renal artery stenosis]

Although the size of the kidney is still the most commonly used as morphological parameter, it is not enough sensitive for early detection of ischemic nephropathy.

PURPOSE

To study a novel method of renal morphology analysis using spiral computed tomography angiography (CTA) in hypertensive patients with or without unilateral atheromatous renal artery stenosis (RAS).

METHODS

Forty-nine hypertensive patients suspected RAS underwent spiral CTA. Arteriography showed significant RAS in 26 patients. Renal length, 3 upper and 3 lower cortical thicknesses were measured in 46 control kidneys (C) i.e. 23 patients without RAS (group 1), in 26 stenosed (S) and in 26 opposite kidneys (OPP) i.e. 26 patients with unilateral RAS (group 2). Mean cortical thickness (MCT), cortical area (CA), medullary length (ML) were calculated in the same groups. The reproducibility and agreement of measurements were investigated in two groups. The demographic parameters (age, sex, bodymass index, and history of hypertension) were correlated with morphological parameters in group 1.

RESULTS

The reproducibility and agreement of measurements were confirmed (R2 = 0.53 to 0.93) except for anterosuperior thickness. The C kidneys were of comparable morphology: MCT (mm) = 9.1 +/- 0.6; 9.2 +/- 1.0, CA (mm2) = 950 +/- 119; 934 +/- 157, ML (mm) = 85 +/- 11. In group of Opp kidneys, MCT = 7.9 +/- 1.4 mm, CA = 806 +/- 210 mm2, ML = 84 +/- 13 mm. In group of S kidneys, MCT = 6.6 +/- 1.6 mm, CA = 612 +/- 193 mm2, ML = 77 +/- 14 mm. Demographic parameters were not correlated to renal morphology.

CONCLUSION

Spiral CTA is a suitable method to study renal morphology. Cortical thickness and medullary length could be used to obtain a reliable diagnosis of early ischemic nephropathy.

[Better understanding of atheromatous ischemic renal vascular disease]

Atheromatous ischaemic renal vascular disease (AIRVD) comprises ischaemic renal disease, atheromatous disease of the large arteries and intra-renal atheromatosis. Cholesterol emboli and lesions of nephroangiosclerosis are often associated, affecting the two kidneys. It is an increasingly common cause of chronic renal failure in an aging population, affecting 12 to 14% of new patients requiring dialysis in the United States. Atheromatous stenoses are very progressive with a risk of renal atrophy; they are a marker of polyvascular disease, often detected during other angiographic investigation. Hypertension secondary to the stenosis, still incorrectly called renovascular hypertension, is, however rare, affecting less than 0.5% of hypertensives. For economic reasons, it is important to select patients who need complementary investigation. In view of the absence of specific signs of the pathology, the "presumptive" diagnosis is based on a range of clinical and biological results, especially in a high risk context. The method of investigation varies from team to team, depending on the availability of equipment, the experience of the operators and the patient himself. Duplex Doppler, spiral angioscan and magnetic resonance angiography are the most pertinent investigations for the management of AIRVD. When the diagnosis of renal artery stenosis has been made, the problem of revascularisation, the objective of which is to preserve or restore the functional nephronic mass, has to be treated to prevent progression to end stage renal failure. Although epidemiological and physiopathological evidence is in favour of revascularisation, only renal salvage procedures are imperative. Apart from these indications, the clinical benefits of revascularisation have not yet been demonstrated. In all cases, the control of associated risk factors is essential to maintain the success of revascularisation and slow down the progression of atheromatous disease.

Susceptibility to provoked cerebral infarction is not increased in a rat model of pharmacologically-induced hypertension despite endothelial dysfunction

An increase in susceptibility to provoked stroke has been described in a genetically-determined rat model of hypertension. We investigated whether the susceptibility to provoked cerebral ischaemia was also increased in a rat model of pharmacologically-induced hypertension with endothelial dysfunction. Chronic inhibition of nitric oxide synthase induced by N(omega)-nitro-L-arginine methyl ester (L-NAME) administration (50 or 75 mg.kg(-1) x day(-1)) in drinking water for 6 weeks caused a sustained hypertension, comparable in the two groups. Endothelium-dependent relaxation induced by acetylcholine or A23187 was significantly, and dose-dependently, impaired in rats receiving L-NAME, as proven by a decrease in maximal relaxation and increase of EC50, as compared to control. Endothelium-independent relaxation induced by sodium nitroprusside was not different in the three groups. Aortic media area was significantly, and dose-dependently, increased following chronic nitric oxide inhibition. Cerebral infarct volumes were not increased in L-NAME-treated groups independently of the level of endothelial dysfunction induced by chronic L-NAME administration. These data demonstrate that susceptibility to cerebral infarction was not increased in a non-genetically determined hypertension model in spite of the development of endothelial dysfunction and vascular structure alterations.