Takotsubo cardiomyopathy induced during dobutamine stress echocardiography: an exhaustive review

Funding Acknowledgements

Type of funding sources: None.

Introduction. Takotsubo cardiomyopathy (TTC) mimics an acute coronary syndrome and corresponds to an acute reversible stress-induced cardiomyopathy. Dobutamine Stress Echocardiography (DSE) has been widely used for more than 30 years and is considered as one of the gold standard non-invasive test to detect myocardial ischemia. DSE responsible for a TTC is a rare clinical entity.

Purpose. Dobutamine induced takotsubo Cardiomyopathy (TTC-DSE) is an exceptional situation. We systematically search for TTC-DSE observations to analyse the specific characteristics of such a cohort.

Methods and Results.  We conducted an extensive search in Medline, and the Cochrane Central Registry of Controlled Trials, using the key words "acute cardiomyopathy, takotsubo syndrome and DSE". File selection was based on the following criteria : (a) occurrence of TTC during DSE, (b) Mayo Clinic criteria (1) associating transient left ventricular systolic dysfunction, absence of significant coronary stenosis, ST-T abnormalities on EKG, moderate troponin elevation, and absence of pheochromocytoma or myocarditis. We identified 30 clinical observations of TTC-DSE published between 2006 and 2019, mostly from USA and Europe publications. Symptoms appear at high dobutamine dosages (30 or 40 gammas/kg/min: 24/30), rarely during recovery (4/30). These patients have the typical features of TTC : (1) strong predominance of a female population (26 women; 86.7%), aged over 50 years (24; 93.3%); (2) depression and/or anxiety (8 pts; 26.7%);  (3) ECG: ST elevation (21 pts; 70 %), ST depression (2 pts), no ST change (4 pts), and left conduction block (3 pts); (4) emergency coronary angiography without significant coronary lesion; (5) angiographic left ventricular ejection fraction (LVEF), calculated in 18/30pts : < 40% for 14/18 pts; (6) segmental LV impairment (echo or angio): apical n = 17 (77.3%); mid-ventricular n = 3 (13.6%); reverse n = 2 (9%) and unspecified (8 pts); (7) low peak of Troponin: 2.65 ± 2.04 ng/ml; (8) one death from an acute heart failure (old lady 86 years age, with intra ventricular gradient), and rapid recovery of LVEF in other patients (29 pts). Despite the heterogeinity in TTC-DSE patients and large cohort of patients in the TTC publications, TTC-DSE and TTC patients have comparable caracteristics.

Conclusion. TTC-DSE is an exceptional, but severe complication of DSE. It provides a unique opportunity to observe TTC in the acute phase. These observational studies show a similar profile between TTC-DSE and TTC patients. Mortality remains low in TTC-DSE cohort, probably because of prompt interruption of the test. Rapid recovery of LV function is consistent. High level of sympathetic stimulation secondary to dobutamine infusion, and frequent anxiety associated with DSE, are probably the major determinants of TTC-DSE. However, the rarity of the TTC-DSE, compared to the widespread daily practice of DSE in echo-laboratories, remains unexplained.

[Management of sudden death in a semi-rural district, Seine-et-Marne: the DEFI 77 study]

Sudden death is a major problem in public health, affecting around 50 000 people a year in France. The prognosis for cardiac arrest is abysmal because for every minute lost the chances of survival diminish by 10%. The aim of this work was to prospectively evaluate the characteristics of cardiac arrest victims across an entire 6000 km? area, the Seine-et-Marne district, distinguished by the paradox of lying just outside the capital whilst actually being semi-rural, and to determine the current methods of dealing with this emergency. The DEFI 77 prospective epidemiological survey was carried out with the collaboration of the SAMU emergency medical service, the SDIS fire/ambulance service, the general hospitals and the Paris-Ile-de-France cardiological association. Between January 2001 and December 2005 there were 2001 cardiac arrests (mean age 68 +/- 20 years, 67% male) at home in 80% of cases. The arrest was in front of a witness in 72% of cases, but they performed resuscitation in only 14.3% of cases. The SAMU and SMUR emergency medical services attempted cardio-pulmonary resuscitation in 78% of cases. In 29% of cases, one or more external electric shocks were carried out, using a semi-automatic defibrillator 79% of the time. Only 11.5% of patients arrived at the emergency department alive, the overall hospital survival rate being less than 2%. Only eight patients subsequently underwent automatic defibrillator implantation. The results of this observational study are to a large extent explained by an extremely long delay (12 minutes) before help was called for, the delay between the call and the arrival of medical assistance (9.5 +/- 4 min), the low percentage of active witnesses, and the variability in management (invasive in particular). In conclusion, at the dawn of the third millennium the prognosis of cardiac arrest remains very poor and fully justifies educating the general public about calling for help early and about actions that can save lives, particularly external cardiac massage before the arrival of the emergency services, as well as the benefits of using automated external defibrillators.

Rheological and flow properties of blood investigated by ultrasound

Ultrasonic waves of 1-15 MHz frequencies easily propagate through soft biological tissues, thus providing qualitative and quantitative information on mechanical and flow properties of blood and red blood cell (RBC) suspensions. Two types of techniques allow to investigate blood behaviors: echographic devices via amplitude detection and Doppler effect based devices via frequency detection of the ultrasonic signal. When ever B mode serves to construct images of tissue slabs from the ultrasonic backscattering coefficient and can give qualitative information on the mechanical properties of blood, A-mode allows to quantify the ultrasonic backscattering coefficient. Ultrasonic Doppler modes also provide both qualitative and quantitative information on blood flow velocity: continuous and pulsed Doppler modes provide curves of blood flow versus time when color Doppler and power Doppler imaging visualize blood flowing in human vessels. Association of echographic and Doppler modes to investigate simultaneously structure and velocity of blood is commercially available. Some examples of results given by such ultrasonic techniques that contribute to characterize, both in vitro and in vivo, structure and flow properties of blood or red blood cell (RBC) suspensions are presented.

[Angioplasty of intra-stent restenosis of a saphenous graft complicated by massive embolism]

The main risk of angioplasty of saphenous vein aortocoronary bypass grafts is myocardial infarction by distal embolism, explaining the introduction of systems of distal protection with encouraging results. Although embolism of an atheromatous stenosis is classical, that of intra-stent restenosis is exceptional. The authors report a very unusual case of atheromatous and/or thrombotic embolism occurring during angioplasty of an intra-stent restenosis which was recovered by a micropore filter system.

Anticoagulant (fluindione)-aspirin combination in patients with high-risk atrial fibrillation. A randomized trial (Fluindione, Fibrillation Auriculaire, Aspirin et Contraste Spontané; FFAACS)

BACKGROUND

A combination of low-dose aspirin with anticoagulants may provide better protection against thromboembolic events compared to anticoagulants alone in high-risk patients with atrial fibrillation.

OBJECTIVE

Evaluation of the preventive efficacy against nonfatal thromboembolic events and vascular deaths of the combination of the oral anticoagulant fluindione and aspirin (100 mg) in patients with high-risk atrial fibrillation.

METHODS

A multicenter, placebo-controlled, double-blind, randomized trial was conducted at 49 investigating centers in France. Atrial fibrillation patients with a previous thromboembolic event or older than 65 years and with either a history of hypertension, a recent episode of heart failure or decreased left ventricular function were included in the study. Patients were treated with fluindione plus placebo (i.e. anticoagulant alone) or fluindione plus aspirin (i.e. combination therapy), with an international normalized ratio target of between 2 and 2.6. The combined primary endpoint was stroke (ischemic or hemorrhagic), myocardial infarction, systemic arterial emboli or vascular death. The secondary endpoint was the incidence of hemorrhagic complications.

RESULTS

The 157 participants (average age 74 years; 52% women; 42% with paroxysmal atrial fibrillation) were followed for an average of 0.84 years. Three nonfatal thromboembolic events were observed (1 in the anticoagulation group, 2 in the combination group) and 6 patients died (3 in the anticoagulation group, 3 in the combination group), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe hemorrhagic complications (1 in the anticoagulation group, 2 in the combination group). Nonfatal hemorrhagic complications occurred more often in the combination group (n = 10, 13.1%) compared to the anticoagulation group (n = 1, 1.2%) (p = 0.003).

CONCLUSION

The combination of aspirin with anticoagulant is associated with increased bleeding in elderly atrial fibrillation patients. The effect on thromboembolism and the overall balance of benefit to risk could not be accurately assessed in this study due to the limited number of ischemic events.

[Prognostic value of normal coronary angiography]

Coronary angiography is the "gold standard" for coronary artery disease (CAD). It is considered either normal or subnormal without any lesion (endocoronary echography often demonstrates atheroma), or in presence of a < 50% stenosis. Nevertheless, the risk of plaque rupture is not well correlated with the degree stenosis. Despite the frequent presence of non-significant atheroma, is a normal coronarography really of a good prognosis? Between January and September 1997, 136 of 600 (22.6%) angiographies were considered as normal. The indications were: "CAD suspicion" (n = 77), "preoperative angiography of valvulopathy" (n = 38), and "angioplasty control" (n = 22). The arteries were strictly normal for 86 patients (63%) and a < 50% stenosis was found in 50 patients (37%); 108 patients (80.1%) were followed for 18 +/- 3 months: eight non coronary deaths were reported: four postoperative deaths in "valvular group", two pulmonary embolisms and two pulmonary neoplasm's in "CAD suspicion group". No myocardial infarction was reported and one unstable angina was documented. Despite the frequency of non-significant atheroma, an acute coronary syndrome exceptionally complicates a "normal" coronarography.

[Hemostasis disturbances in myocardial ischemia]

In this article, a description has been given of the close connection between coronary atherosclerosis and the onset of thrombosis. The hemostatic factors examined in this study are implicated both in the pathology of acute coronary syndromes and in the prognosis of ischemic heart disease. Amongst other factors, the role of the following has been investigated: platelets, thromboxane A2 and prostacyclin, von Willebrand factor, factor VII and tissue factor, thrombin, fibrinogen tissue plasminogen activator and plasminogen activator inhibitor. It is concluded that endothelial dysfunction in coronary atherosclerosis is the most frequent cause of disturbances in hemostatic function.

[Silent ischemic cardiopathy: which diabetics to examine?]

Non-Invasive coronary investigations are positive in 12 to 52% (average 22%) of type II diabetics, and 11 to 30% (average 17%) of type i diabetics. These statistics vary according to bias of recruitment. Haemodynamic lesions are found at coronary angiography in 35 to 80% of patients who have at least one positive non-invasive investigation. Nine to 12% of diabetics have silent myocardial ischaemia (SMI) confirmed by coronary angiography, compared with 1.3 to 5.3% of non-diabetic controls paired for age and sex. The higher frequency of SMI in diabetics seems to be mostly due to the increased frequency of ischaemic heart disease in diabetics. The importance of cardiac autonomic neuropathy (CAN) in SMI is controversial. The risk factors associated with SMI are those usually associated with coronary artery disease: age, masculine gender, hypercholesterolaemia, hypertriglyceridaemia, hypertension, smoking, a family history of cardiovascular disease, insulin therapy (for type II diabetes), proteinuria, retinopathy, peripheral occlusive arterial disease.... The French recommendations for investigating SMI seem to be contradictory. A single risk score in a given patient could help codify the investigation of SMI in diabetics, but this type of score has not yet been validated.

[Study of combined anticoagulant (fluindione)-aspirin therapy in patients with atrial fibrillation at high risk for thromboembolic complications. A randomized trial (FFAACS)]

BACKGROUND

A combination of low-dose aspirin (A) and anticoagulation (AC) may provide better protection against thromboembolic events compared with AC alone in high-risk patients with atrial fibrillation (AF).

METHODS

We performed a multicentric placebo-controlled double blind-trial to test the preventive efficacy against thromboembolic events of the addition of aspirin (A) (100 mg) or placebo (P) to anticoagulant treatment in patients with high-risk atrial fibrillation. A total of 157 patients were included, with atrial fibrillation and previous thromboembolic event or older than 65 years with either a history of hypertension, a recent episode of heart failure or a left ventricular dysfunction. All patients received fluindione (F) and P or F and A, with an INR target between 2 and 2.6. The primary endpoint was a combined endpoint of stroke (ischaemic or haemorrhagic), myocardial infarction, systemic arterial emboli or vascular death.

RESULTS

The study had to be stopped prematurely owing to a too low recruitment rate. During follow-up (0.84 years) 3 non-fatal thromboembolic events were recorded (1P, 2A) and 6 patients died (3P, 3A), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe haemorrhagic complications (1P, 2A). Non-fatal haemorrhagic complications occurred more often in group A (n = 10, 13.1 pour cent) compared with group P (n = 1, 1.2 pour cent), p = 0.003.

CONCLUSION

The FFAACS study was not able to show any therapeutic benefit from the addition of aspirin to anticoagulant in patients with high-risk AF. Such a combination increased the incidence rate of bleeding complications, which therefore greatly reduces its potential overall benefit.

[Treatment of aorto-coronary saphenous vein bypass lesions: pros and cons of angioplasty]

Heart patients who have undergone a coronary bypass may present with renewed myocardial ischemia, often connected with bypass dysfunction. The saphenous bypass is the most frequently implicated, and palliative revascularization may be envisaged, either by further bypass surgery, or by angioplasty. The latter approach has been developed since the beginning of the 1980s, and since that time there has been considerable technical and pharmacological progress in performing this type of graft. However the indications for angioplasty and its comparison with reoperation remain controversial. In the present study, it therefore seemed pertinent to include the respective opinions of two experts in the field of angioplasty and coronary bypass surgery.

Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients

AIMS

We evaluated echo-guided pericardiocentesis with contrast study in cardiac tamponade management.

PATIENTS AND METHODS

From 1982 to 1998 we performed pericardiocentesis in 110 patients (56 +/- 14 years old). Subxiphoid approach was used in 109. Cardiac tamponade was idiopathic (n = 16), secondary to malignant disease (n = 50) and miscellaneous disorders (n = 44).

RESULTS

Pericardial fluid was bloody (n=75), serous (n = 29) or turbid (n = 6). Mean volume of fluid removed was 585 +/- 370 ml. When prolonged drainage (60 +/- 26 h) was used (n = 41), total effusion volume was 850 +/- 340 ml. Eleven deaths were observed during the early period following pericardiocentesis. No relation with procedure was demonstrated by autopsy in 10, and death always occurred in critically-ill patients (five malignant diseases, five cardiac ruptures and one septic shock). Other complications were: right ventricular puncture (n = 11) with deleterious effect in one, vasovagal hypotension (n = 6) and paroxysmal arrhythmia (n = 6). Surgical drainage was mandatory in 19 patients. It had to be done as an emergency (within 6 h), because of failure of the procedure in four patients. In 14 patients without prolonged drainage a delayed surgical evacuation was indicated, because of persistent (n = 3) or recurrent (n = 11) cardiac tamponade. Only one surgical procedure was required after prolonged drainage.

CONCLUSIONS

Echo-guided pericardiocentesis with contrast study is an effective technique which reduces the risk of cardiac tamponade management. It should be considered in patients with critical haemodynamic condition or advanced malignancy, and in patients with poor short-term prognosis.

[Aneurysm of the sinus of Valsalva. Apropos of a case of right intra-atrial rupture]

An unusual systolo-diastolic heart murmur was discovered fortuitously in a 39-year-old man undergoing a routine check-up. Transesophageal echocardiography gave the diagnosis of Valsalva sinus aneurysm ruptured into the right atrium. Cardiac surgery was successful. We reviewed the literature on this unusual condition, focusing on the pathophysiological, clinical, diagnostic and therapeutic aspects. Transesophageal echocardiography provides the diagnosis.

Predictors of medical events in patients enrolled in the cardiac insufficiency bisoprolol study (CIBIS): a study of the interactions between beta-blocker therapy and occurrence of critical events using analysis of competitive risks

BACKGROUND

The risk of occurrence of medical events in a clinical trial is competitive in nature; that is, in a given patient the risk of having a critical event depends on the amount of time elapsed since random assignment and on the previous events that may have occurred in the patient. The purpose of this study was to examine the relations between baseline variables, the interactions between treatment, bisoprolol, or placebo, and the occurrence of critical events during the CIBIS trial, a mortality and morbidity trial of beta-blockade in patients with heart failure.

METHODS AND RESULTS

A Cox model for censored data was used to analyze the relations between baseline variables, total deaths, permanent treatment withdrawals, nonlethal cardiovascular events, and their interactions with bisoprolol or placebo. We examined the influence of treatment on the occurrence of deaths, permanent treatment withdrawals, and nonlethal cardiovascular events by using the technique of event history analysis, which takes into account competitive risks between events. Compared with placebo, bisoprolol reduced mortality rates in patients with a left ventricular ejection fraction < or =20% (relative risk [RR] 0.49; 95% confidence interval [CI] 0.27 to 0.88; P =.02). In patients whose baseline heart rate was in the upper tertile of distribution, permanent treatment withdrawals were less frequent in patients randomly assigned to bisoprolol than in patients randomly assigned to placebo (RR 0.50; 95% CI 0.28 to 0.88; P =.02). Bisoprolol reduced the incidence of nonlethal cardiac events in patients in whom heart failure was present for at least 4 years (RR 0.44; 95% CI 0.27 to 0.71; P <.01). Event history analysis revealed that among patients who died under treatment after having at least 1 nonlethal cardiovascular event, 20 patients were treated with placebo but only 7 patients were treated with bisoprolol (RR 0.41; 95% CI 0.17 to 0.98; P <.05).

CONCLUSIONS

Some patients with heart failure derive more benefit from beta-blocker therapy than others. In the CIBIS trial, they are those patients with the lower left ventricular ejection fractions and those who have nonlethal cardiovascular events but in whom beta-blocker therapy is not permanently discontinued.

[Cardiac tamponade]

Cardiac tamponade is an emergency situation. Diagnosis is to be suspected when an elevation of systemic venous pressure, a decline in systemic arterial pressure and a clinical context of neoplasia or recent acute pericarditis are associated. Transthoracic echocardiogram is the gold-standard of diagnosis, and allows the accurate diagnosis of a large pericardial effusion: precise localisation and haemodynamic evaluation are needed before therapeutic decision. Pericardiocentesis is the only appropriate treatment. Surgical procedure, or less traumatic echo-guided pericardiocentesis, provide rapid haemodynamic relief of symptoms. Prognosis is determined by aetiology.

[Immediate collateral coronary circulation after a methylergometrin test]

The development of a collateral coronary circulation has been well studied by angiography in two main clinical situations: myocardial infarction (by durable coronary occlusion) and angina (due to significant coronary artery stenosis), but only rarely in spastic angina. The authors report the case of severe spasm at the site of non-significant stenosis after a methylergometrine test, with immediate contro-lateral collateral circulation in a patient with a short history of spastic angina without myocardial infarction. This observation demonstrates that collateral circulation may develop very rapidly in spastic angina (without basal ischaemia in the absence of significant coronary stenosis), because this patient only had seven ten-minute episodes of clinical ischaemia. As collateral circulation may mask clinical and electrical signs in spastic angina, this case suggests that angiographic control should be systematic during the methylergometrine test.

[Thoracic radiodermatitis in interventional cardiology. Apropos of 6 cases]

The aim of this study is to describe thoracic radiodermatitis, a rare but not to be forgotten complication of interventional cardiology. The appearances are variable, from often oval-shaped erythema to cutaneous necrosis, with risk of chronic ulceration and malignant degeneration. The authors report 6 cases observed in 1997 after coronary angioplasty. Complex and long procedures are the main causes of this complication. Prevention requires a contribution from all the medical cardiological team, for the diagnosis, determining the indication of the type of revascularisation and for limiting the dose of X-radiation administered.

Feasibility of routine transradial coronary angiography: a single operator's experience

The aims of this study were to assess the feasibility of routine transradial coronary angiography in a standard population of patients with presumed coronary artery disease over a period of time long enough to allow for technical evolution and evaluation of a single operator's learning curve, and to provide data for a randomized comparison versus the femoral approach. Between June 1994 and March 1997, transradial angiography was attempted in 1,000 patients. Approximately 25% of these patients were excluded because of an abnormal Allen test. Except in the case of acute myocardial infarction, there was no selection based on symptoms, age, sex, weight or size in the absence of double internal mammary artery bypass graft operation or simultaneous right heart catheterization. Symptoms and angiographic results were typical of a standard population. The right radial approach was used in 95% of the cases for ease of handling and comfort of a right-handed operator. Radial artery puncture and catheterization success was obtained in 97.6% of the cases; the left coronary artery was selectively catheterized in 100%, right coronary artery in 98%, left ventricle in 96.9%, mammary artery grafts in 100% and saphenous grafts in 97.2%. Average procedure duration was 18 +/- 9 minutes, and decreased progressively with experience and catheter strategies. The optimal catheter selection would seem to be a single catheter, either left Amplatz or Champ, for both coronary arteries. Two coronary complications and 3 transient neurological complications occurred, but no clinically significant vascular complications requiring surgery or transfusion were reported. Transradial angiography seems to be a routine approach that should now be compared with the femoral approach and supersede the brachial approach whenever possible.

[CREST syndrome presenting as pulmonary hypertension]

The authors report the case of a 62-year-old patient complaining of recent onset of disabling breathlessness on exertion, and presenting clinical signs of previously undiagnosed scleroderma. Echocardiography revealed a diagnosis of precapillary pulmonary hypertension (74/14 mmHg) (PHT), with no pulmonary cause revealed by pulmonary ventilation-perfusion scintigraphy or by thoracic fine section computed tomography. The diagnosis of PHT in the context of circumscribed scleroderma was confirmed by x-rays of the hands, capillaroscopy, oesophageal investigations and positive anticentromere antinuclear antibodies. The clinical course was marked by rapid deterioration of the symptoms, requiring treatment with prostacyclin by continuous intravenous infusion. The appearance of PHT in a context of circumscribed scleroderma, usually a relatively benign disease, is a rare, late event, exceptionally revealing the disease, as in this case, and indicating a very unfavourable prognosis.

[Tamponade in patients with systolic left ventricular dysfunction. An atypical presentation]

BACKGROUND

Left ventricular failure has been described following surgery due to localized compression of the left ventricle and in case of diastolic left ventricular dysfunction after pericardiotomy or pericardiocentesis.

CASE REPORTS

Global heart failure was observed in 3 patients with dilated cardiopathy who developed tamponade. Systolic left ventricular dysfunction was caused by ischemic heart disease in one patient and secondary to anthracyclin chemotherapy in the two others. The effusion was successfully removed with pericardiocentesis in all three cases. No specific complications were observed.

DISCUSSION

Although exceptional, tamponade may occur in patients with signs of left ventricular failure.

[Coronary angiography by a radial artery approach: feasibility, learning curve. One operator's experience]

The aim of this study was to assess the feasibility of the radial artery approach for coronary angiography in a standard population of presumed coronary patients and to continue the assessment for a sufficiently long period of time to perfect the technique, evaluate the learning curve and prepare a randomised comparison with the femoral approach. The radial artery was used for coronary angiography in 800 patients after exclusion of about 25% of patients, mainly because of a negative Allen's maneuver. With the exception of acute myocardial infarction, there was no selection based on symptoms and transradial catheterisation was attempted irrespective of age, sex, weight or height. The representative nature of the study population was confirmed by the results of the procedure (normal: 20%, single vessel disease: 30%, double vessel disease: 26%, triple vessel disease: 18% and left main disease: 5.4%). The right radial artery was used in 94% of cases. Successful radial puncture/catheterisation was obtained in 97% of cases: 100% of left coronary arteries and 99% of right coronary arteries were catheterised, the left ventricle in 98% of cases, the internal mammary arteries in 100%, and venous bypass grafts in 95%. The average duration of the whole procedure was 19 +/- 9 minutes. This decreased regularly with operator experience and judicious choice of catheters. The best choice seemed to be a single catheter for both coronary arteries, either an Amplatz or a Champ catheter. There were two probably avoidable coronary complications and two transient neurological events but no clinically significant vascular complication. The radial artery seemed to be a good approach for routine coronary angiography and may now be compared with the femoral approach. It should help expand the practice of ambulatory coronary angiography.

[Evaluation of echo-guided pericardiocentesis in cardiac tamponade]

Between April 1982 and December 1995, 78 consecutive patients with an average age of 57 +/- 13 years underwent echo-guided pericardiocentesis in the intensive care unit for poorly tolerated pericardial effusions. The patients were admitted to the cardiology departments of Ambroise-Paré Hospital at Boulogne (n = 44). Gilles-de-Corbeil Hospital at Corbeil-Essonnes (n = 31) and Val-de-Grâce Hospital in Paris (n = 3). The underlying aetiologies were malignant disease (n = 31), idiopathic (n = 13), post-surgery (n = 7), infection (n = 7), autoimmune (n = 6), post-radiotherapy (n = 6), post-myocardial infarction (n = 3), chronic renal failure (n = 3) and coagulation defects (n = 2). Pericardial puncture was undertaken by the subxiphoid (n = 77) or left parasternal (n = 1) approaches under guidance of echocardiography. Intra-pericardial contrast was used to verify the position of the catheter. The average volume of liquid drained was 580 +/- 390 mL. After pericardiocentesis, continuous drainage was continued in 17 patients for an average duration of 63 +/- 29 hours. The total average volume was 750 +/- 330 mL. The major complications were a) three deaths during the puncture, not caused by the procedure after post-mortem study, b) ten right ventricular punctures with no consequences in 9 cases, c) two cases of shock, one of which was due to a pre-existing septicaemia of pulmonary origin, d) two non-sustained ventricular arrhythmias. The minor incidents were six vasovagal syndromes during the procedure and four paroxysmal supraventricular arrhythmias. Emergency surgical drainage was required (n = 3) for a failed procedure and late surgical drainage (n = 12) for persistence or recurrence of the effusion. No surgical drainage was required in the 17 patients placed under continuous aspiration. Echo-guided pericardiocentesis is a simple procedure and provides rapid haemodynamic relief in subjects generally in serious condition. Continuous aspiration may help avoid the need for surgical drainage for persistence or recurrence of the effusion.

Prognostic value of bisoprolol-induced hemodynamic effects in heart failure during the Cardiac Insufficiency BIsoprolol Study (CIBIS)

BACKGROUND

To further evaluate the mechanism of beta-blocker-induced benefits in heart failure, the relationships between bisoprolol-induced hemodynamic effects and survival were studied during the Cardiac Insufficiency BIsoprolol Study (CIBIS).

METHODS AND RESULTS

In 557 patients studied, bisoprolol significantly reduced heart rate (-16.3+/-15.3 versus -1.6+/-13.4 bpm, respectively; P<.001) compared with placebo at 2 months after inclusion in the study. Heart rate change over time had the highest predictive value for survival (P<.01). Left ventricular fractional shortening (LVFS) significantly increased in the bisoprolol group compared with the placebo group 5 months after inclusion (+0.04+/-0.06 versus -0.001+/-0.05, respectively; P<.001; n=160). LVFS change over time was also significantly correlated with further survival (P<.02 by Cox analysis). Using a nonparametric approach, we demonstrated a significant interaction between study treatment group and LVFS over time. Patients who demonstrated improvement of LVFS over time (82% and 51% of patients in the bisoprolol and the placebo groups, respectively; P<.02) were at lower risk, but the hazard did not further decrease with a further increase of fractional shortening, and there was no significant difference between study treatment groups. Finally, it could be demonstrated that each of the three factors (heart rate change over time, LVFS change over time, and bisoprolol treatment) made a specific contribution to mortality rate.

CONCLUSIONS

Preservation of left ventricular function appears to play a key role in the bisoprolol-induced beneficial effects on prognosis in heart failure. Short-term beta-blocker-induced cardiac effects could provide a means to identify those patients who will experience improved survival over the long term.

[Ultrasound-guided pericardial drainage. Experience in 34 consecutive patients]

OBJECTIVES

Transthoracic echoguided puncture of the pericardium can be an alternative to surgical drainage. We report our experience with this technique acquired over the last 11 years.

PATIENTS AND METHODS

From January 1984 to September 1995, 34 consecutive patients in the cardiology intensive care unit (mean age 56.5 +/- 13 years) underwent echoguided pericardial puncture for poorly tolerated pericardial effusion. The underlying cause was neoplasia (n = 22), idiopathic disease (n = 5), autoimmune disease (n = 2), post-surgical complication (n = 2 including 1 on hemodialysis), infection (n = 1), antivitamin K therapy (n = 1) and disseminated vascular coagulation (n = 1). The subxyphoid (n = 33) or left parasternal (n = 1) route was used under echographic guidance. Intrapericardial contrast allowed verification of the catheter position. The mean quantity of fluid removed was 585 +/- 390 ml. The fluid was hemorrhagic (n = 19), clear (n = 10) or serohematic (n = 4). Aspiration was continued in 16 patients after the initial puncture for a mean 64 hours. The mean total volume of fluid was 750 +/- 330 ml.

RESULTS

There was one death during puncture which was found to be unrelated to the procedure after anatomic verification. In two cases, the left ventride was punctured without any consequence. Collapsus occurred during puncture in 2 patients with pulmonary sepsis. Minor incidents were: 6 vasovagal syndromes at puncture with paroxysmal supraventricular rhythm disorder during aspiration. Prior to 1988, surgical drainage was required in 5 patients for persistent or recurrent effusion. Since that time, continuous aspiration has been used in all patients and no surgical drainage has been required. Short-term prognosis depends on the underlying cause (6 deaths at 1 month).

CONCLUSION

Echoguided pericardial puncture is a simple procedure which rapidly improves cardiac hemodynamics in these particularly fracle patients. Continuous aspiration avoids subsequent surgical drainage for persistent or recurrent effusion.

[Right retroauricular hematoma of late manifestation. Contribution of cardiac imaging]

Right intrapericardial retroatrial haematomas are usually discovered in an acute context of tamponade, following cardiac surgery. The original feature of this case was the asymptomatic nature of a right retroatrial haematoma, after surgical closure of an ostium secundum atrial septal defect, with a free interval of more than 20 years between the surgical procedure and the first relatively minor symptoms, consisting of supraventricular arrhythmias. It can be difficult to determine the intra- or extra-atrial topography of a right-sided mass by transthoracic echocardiography. On the other hand, transoesophageal echocardiography and ultrafast CT can provide a precise topographic diagnosis and appear to be complementary to assess the nature of pericardial masses.

[Cibenzoline versus propafenone by the oral route for preventing recurrence of atrial arrhythmia: multicenter, randomized, double-blind study]

This multicentre, randomized, double-blind study, conducted in parallel groups, was designed to compare the efficacy and safety of cibenzoline (C) and oral propafenone (P) in the prevention of recurrent atrial arrhythmias (M) over a 6-month period. Patients of either sex with reduced atrial fibrillation or flutter and predominantly in sinus rhythm (> 50%), with a left ventricular shortening fraction greater than or equal to 20% and not receiving any antiarrhythmic treatment were included. Patients presenting severe conduction disorders, severe heart failure (NYHA class III or IV), marked hypotension or recent myocardial infarction were not included. Treatments were administered at the dosage of one tablet twice a day, i.e. 260 mg/day of cibenzoline or 600 mg/day of propafenone. This dosage was reduced by one half in elderly patients (> 70 years). Patients were seen on inclusion (Dzero), and at the third and sixth months or in the case of recurrence of symptoms. Recurrent arrhythmias were assessed by ECG and 24-hour Holter monitoring and according to the symptoms experienced by the patients. Sixty-five patients, 36 men and 29 women, between the ages of 34 to 86 years and presenting an atrial arrhythmia-atrial fibrillation (80%) or atrial flutter (20%)-were included in the trial: 34 patients received cibenzoline and 31 received propafenone. The arrhythmia had already been treated in 78% of cases. Its aetiology was related to hypertensive heart disease (32%), valvular heart disease (8%), other (17%) or idiopathic (43%). The arrhythmia was symptomatic in 91% of patients on inclusion. The ultrasonographic left ventricular shortening fraction was 32.8 +/- 8.1% in group C and 32.6 +/- 6.4% in group P. The two groups were comparable before treatment. The efficacy of the two treatments was comparable: no significant difference in the number of recurrences was demonstrated: 11 patients treated with C and 12 patients treated with P; cumulative percentages of patients without recurrence with good tolerance of treatment (Kaplan-Meier acturial curves) at 6 months were 55.9% with C and 48.4% with P(NS); probability of no recurrence at 6 months (0.63 +/- 0.09 in group C and 0.57 +/- 0.09 in group P); mean time to recurrence (53.4 +/- 44.3 days in group C and 61.6 +/- 35.3 days in group P). Adverse events leading to discontinuation of treatment occurred in 4 patients from each group, and one proarrhythmic effect at 6 months in a patient in group P. The treatments were well tolerated in the majority of cases: there was no significant difference in the number of patients presenting at least one adverse event: 9(26.5%) in group C, 11(35.5%) in group P. Most events were considered to be mild or moderate. The effects of the two treatments on the course of blood pressure, heart rate, PR interval and QT interval calculated at 3 and 6 months compared to DO were not statistically different. The QRS interval increased to a significantly greater extent in group C that in group P (p = 0.02 at 3 months; p = 0.0005 at 6 months). No significant difference was observed between the two groups for the course of laboratory parameters at 3 and 6 months compared to DO in the patients present at these three visits. Cibenzoline can therefore constitute a good alternative to propafenone in the prevention of symptomatic recurrences of atrial tachyarrhythmias. The preferential use of one or other treatment can be guided by individual factors, including tolerance.

[Spontaneous intracardiac contrast and embolic risk]

Spontaneous contrast in the form of smokey echos in the cardiac chambers is considered to be a risk factor for thromboembolism. The aggregation of red blood cells results in larger target which diffuse a measurable in vitro ultrasonic signal. The phenomenon of erythrocytic aggregation is dependent on the red cells themselves, the plasma fibrinogen and conditions of blood flow. The other constituents of the blood only reflect a small amount of ultrasound, usually undetectable. Transoesophageal echocardiography with high frequency transducers (5 MHz) positioned in close proximity to the cardiac chambers, has become the reference method for detecting spontaneous contrast. This phenomenon is almost exclusively observed in the left atrium and left auricle and rarely in the other cardiac chambers or descending aorta. In pathological situations, spontaneous contrast is essentially implicated in two conditions: mitral valve obstacles and non-valvular atrial fibrillation. Conversely, moderate to severe mitral regurgitation is a negative predictive factor of spontaneous contrast. However, a purely qualitative appreciation of spontaneous contrast which may be influenced by the gain setting and technical specifications of the echocardiograph, and the subjectivity of the operator, is an important limitation. Therefore, the identification of quantitative markers of spontaneous contrats and new therapeutic antithrombotic protocols remain essential.

[Reduction of atrial fibrillation. New concepts, new strategies]

Restoring sinus rhythm is patients with non-valvular atrial fibrillation has two objectives: restore haemodynamic performance and reduce the risk of thromboembolism. Whether the cardioversion is spontaneous or induced with drugs or electroshock, the process itself carries the risk of systemic embolism attributed to the transitory inactivity of the left atrium. Current practice of giving anticoagulants at least 4 weeks before electric cardioversion is a compromise between the embolic risk of cardioversion estimated at 0.4 to 0.8% and haemorrhagic complications related to low blood coagulability estimated at about 1% per year. The advent of transoesophageal echography has made it possible to study the atrium in detail in search of thrombi. The result has been a revolution in our concepts and therapeutic approach to atrial fibrillation and cardioversion. Recent studies have shown that "rapid cardioversion" associated with minimal 48-hour anticoagulation with heparin IV and transoesophageal echography to eliminate a thrombus in the atrium and/or the atrial appendage can be proposed without increasing the risk of embolism. Besides simplifying the therapeutic protocols (but at the cost of the semiinvasive nature of the transoesophageal echocardiography), this method also has the merit of restoring atrial function rapidly, particularly in cases of recent onset arrhythmia.

Atrial septal aneurysm. Morphological characteristics in a large population: pathological associations. A French multicenter study on 259 patients investigated by transoesophageal echocardiography

A strong association between interatrial septal aneurysm (IASA) and stroke has recently led many authors to consider IASA as a potential cardiac source of embolism. We studied the morphological characteristics and main associations of IASA in a large cooperative study based on transoesophageal echocardiographic examinations; 259 IASA were studied in 134 men and 125 women with a mean age of 59 +/- 15 years. Fifty-five percent of IASA were found to overlap the commonly described fossa ovalis region. IASA protruded into the right atrium in 90% of the cases. They appeared thin in 81% of the patients and highly mobile in 79%. Fifty-eight percent of patients had a history of systemic embolic events, while an atrial septal shunt was detected in 61% of the patients. In patients with an embolic event, only the mobility of IASA was significantly higher than in those with no embolic event. In nine cases a pulmonary embolism was associated with arterial embolism. Furthermore, we reported three cases of paradoxical embolism. However, the true demonstration of a thrombus within the IASA was quite rare.

CONCLUSION

IASA is probably an important risk factor for stroke. In patients with IASA and a history of embolic events, IASA may enhance migration of a thrombus constituted in situ or transiting through it. Marked mobility of IASA may also increase the risk of peripheral embolus.

[Comparative effects of cibenzoline and hydroquinidine in the prevention of auricular fibrillation. A randomized double-blind study]

The objective of this study was to compare the efficacy and safety of cibenzoline (130 mg twice a day) and sustained-release hydroquinidine (300 mg twice a day) in the prevention of recurrent atrial fibrillation (AF). This randomized double-blind study was conducted in 87 patients, with a mean age of 62 years, presenting with a history of AF for 72 hours to a maximum of 3 years. After restoration of sinus rhythm, in order for the subjects to be included in the study, echocardiography had to reveal a left ventricular shortening fraction of more than 20%. Patients were followed for one year by clinical examination, ECG and 24-hour Holter monitoring performed 7 days after inclusion, then after 3, 6, 9 and 12 months. The two groups, treated with either cibenzoline (n = 40) or hydroquinidine (n = 44), were comparable. The AF recurrence rates with cibenzoline or hydroquinidine were 34.9% had 36.4% at 6 months, and 41.9% and 43.2% at 12 months, respectively (NS). Most recurrences occurred during the first month. Adverse effects were reported in 10 patients (23.3%) with cibenzoline and 12 patients (27.3%) with hydroquinidine. They led to discontinuation of treatment in 6 patients (14%) treated with cibenzoline and 5 patients (11.4%) treated with hydroquinidine. Serious adverse events included one death from hypoglycaemic coma and one case of persistent ventricular tachycardia with hydroquinidine. In conclusion, oral cibenzoline demonstrated the same antiarrhythmic activity as hydroquinidine in the long-term prevention of recurrent atrial fibrillation, with a similar degree of safety. This drug can therefore constitute an alternative to conventional antiarrhythmics in this context.

[Transesophageal echography and left intraventricular echo-contrast. Complete regression of a large thrombus of the left ventricle with anticoagulant therapy]

The authors report the case of a 69 year old man with a large left ventricular thrombosis complicating anterior myocardial infarction occurring three years previously for which anticoagulant therapy had to be withdrawn. The discussion is based around the large size of the thrombus, its complete regression with anticoagulant therapy (heparin and coumarin-derivative) and also around the detection of spontaneous echo contrast in the left ventricle by transoesophageal echocardiography. This case underlines the probable risk of withdrawing anticoagulant therapy in patients with severe left ventricular dysfunction and left ventricular spontaneous contrast.

[Is sudden reperfusion more arrhythmogenic during thrombolysis for myocardial infarction?]

The object of this study was to analyse ventricular arrhythmias occurring during intravenous thrombolysis for acute myocardial infarction with respect to ST segment changes on 24 hour Holter ECG monitoring initiated at the same time as thrombolytic therapy and on repeated 12 lead electrocardiogrammes. Forty-one patients in whom the infarct-related artery was patent at coronary angiography carried out 30.5 +/- 3.1 hours (< or = 24 hours in 59% of cases) after the onset of chest pain were included. The time to normalisation of the ST segment was defined as the interval between maximum ST elevation to a steady state and helped identify rapid (< or = 60 minutes, n = 13) from intermediate (60-180 minutes, n = 15) and slow (> 180 minutes, n = 13) reperfusion. The incidence of ventricular arrhythmias was the same in all three groups, except for prolonged ventricular tachycardias (> 15 complexes): 69%, 13% and 15% respectively (p = 0.002). The number of arrhythmias was greater when the ST segment changes were rapid than when they were intermediate or slow. This was true for ventricular extrasystoles (p < 0.05), accelerated idioventricular rhythms (p < 0.05), early (< or = 6 hours from onset of thrombolysis) accelerated idioventricular rhythms (p < 0.01) and ventricular tachycardias (p < 0.05). Therefore, the number of ventricular arrhythmias seems to be related to the speed of ST segment change, suggesting that more sudden reperfusion is more arrhythmogenic.

[Reperfusion arrhythmia]

Reperfusion arrhythmias were described from the first trials of intracoronary thrombolysis for myocardial infarction. The prevalence of ventricular fibrillation during intravenous thrombolysis is low (< 7%) and comparable to that observed with classical treatment. Holter recording shows that ventricular tachycardia and accelerated idioventricular rhythms occur in over 80% of cases. These arrhythmias are generally well tolerated and do not require specific therapy. A bradycardia-hypotension syndrome is observed in about a quarter of reperfused patients, nearly always in inferior wall infarction. It normally resolves spontaneously or after atropine or vascular filling. Reperfusion is associated with a clearcut increase in the number of episodes of arrhythmia. Some arrhythmias such as sustained ventricular tachycardia, early accelerated idioventricular rhythms (occurring in the first 6 hours) or the bradycardia-hypotension syndrome may be considered as non-invasive criteria of reperfusion. More severe ischemia and sudden reperfusion favour the arrhythmogenicity of reperfusion in the animal. Recent data suggest that this may be the case in the clinical context. In some uncontrolled studies, lidocaine, betablockers and aspirin did not affect the prevalence of the arrhythmias. Preliminary trials indicate that flunarizine and captopril may reduce the incidence of reperfusion arrhythmias in man. Ventricular arrhythmias and myocardial stunning could be the result of sa single phenomenon (the extent of the ischemic lesions or reperfusion lesions). Studies currently under way should clarify the relationship between the incidence of arrhythmias, the severity of stunning and myocardial recovery. Protocols evaluating therapeutic interventions on the reperfusate should include Holter monitoring.

[Treatment of chronic ventricular extrasystole by propafenone (600 mg/d) in 2 or 3 daily doses]

The efficacy of propafenone by oral route in the treatment of chronic ventricular extrasystoles (VES) was investigated in 14 subjects in the context of a multicenter evaluation carried out double blind and using a crossover sequence. The purpose of this study was to compare the antiarrhythmic efficacy of a dose of 600 mg/d of propafenone randomly divided into two or three subdoses. After carrying out two Holter recordings (< 15 days) the patients presenting with chronic (< or = 100 VES/H) and stable (interindividual variability > or = 30%) ventricular extrasystoles were included. The treatment period consisted of two 8-day courses divided by a placebo period and carried out following a crossover mode. The efficacy of treatment was defined as a reduction in the VES by at least 70% relative to the second Holter during the inclusion period which was used as the reference period. Fourteen patients (57.2 +/- 18.2 years) from eight cardiological centers (eight with heart disease) were included. In general, propafenone at a dose of 600 mg/d bid or tid significantly reduced the total number of VES by about 65%: 15,239 +/- 2,663 VES/24 h (baseline) to 5,238 +/- 2,746 VES/24 h (bid) and 5,765 +/- 2683 VES/24 h (tid); p < 0.0001, with no significant difference between the bid and tid treatments. Individually, 8 patients (57%) responded during the bid treatment, 7 patients (50%) during the tid treatment and 6 patients during both treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Is arrhythmogenicity related to the speed of reperfusion during thrombolysis for myocardial infarction?

The objective of this study was to relate the number of ventricular arrhythmias (VA) to the normalization time of the ST segment during thrombolysis for acute myocardial infarction. The 24 h Holter recordings, begun on start of intravenous thrombolytic therapy, and the 12-lead electrocardiograms of 41 patients with a patent infarct-related artery according to coronary angiography were analysed. The mean time from onset of chest pain to angiography was 30.5 +/- 3.1 h, < or = 24 h in 59%. The normalization time of the ST segment, assessed by the time of decrease of ST segment elevation from start of Holter recording to normal or steady state was < or = 60 min in 13 patients (group 1), 60 to 180 min in 15 patients (group 2) and > 180 min in 13 patients (group 3). The incidence of VA was similar in all groups, except for ventricular tachycardias (VT) > 15 beats (group 1:69%, group 2:13%, group 3:15%, P = 0.002). The frequency of accelerated idioventricular rhythms (AIVR), early AIVR (< or = 6 h) and of VT was significantly higher in group 1 than in group 3 with a 8-, 30- and 6-fold increase, respectively (back transformed mean). We conclude that the number of VAs is related to the normalization time of the ST segment during reperfusion. This may suggest that faster reflow is more arrhythmogenic.

[Holter monitoring of ventricular arrhythmia during the 24 first hours of myocardial infarction treated with intravenous thrombolysis]

The aim of this study was to assess ventricular arrhythmias after intravenous thrombolysis for acute myocardial infarction and to determine their relationship with coronary artery patency. A 24 hour Holter recording was started 3.1 +/- 0.2 hours after the onset of pain in 40 patients (age 54 +/- 1.6 years, 42.5% anterior infarcts) treated by streptokinase (42.5%) or tissue plasminogen activator (57.5%) within 3.3 +/- 0.2 hours of the beginning of symptoms. The arrhythmias were analysed on a Marquette 8000 computer. Coronary angiography was systematic and was performed 26.7 +/- 2.5 hours (within 4 hours in 60% of patients) after the onset of pain to define coronary artery patency (TIMI 2 and 3: 72.5%) or occlusion (TIMI 0 or 1: 27.5%). Ventricular arrhythmias were common and generally well tolerated (one defibrillation for ventricular fibrillation). Accelerated idioventricular rhythms and ventricular tachycardias were equally prevalent in patients with patent arteries (90% and 83%) as with occluded arteries (82% and 73%). The prevalence of sustained ventricular tachycardias (> 15 complexes) and of early accelerated idioventricular rhythms (< or = 6 hours) was significantly higher in patients with patent coronary arteries: 38% versus 0% (p < 0.05) and 76% versus 18% (p < 0.01). These arrhythmias may be considered to be non-invasive markers of early coronary reperfusion, with a sensitivity of 38 and 76% and a specificity of 100 and 82%. Coronary patency was associated with higher numbers of ventricular extrasystoles, ventricular tachycardias and accelerated idioventricular rhythms by a factor of 14, 13 and 32 respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early hospital discharge after uncomplicated myocardial infarction: strategies]

Considerable advances have been seen in recent years in the diagnostic and therapeutic management of myocardial infarction. Furthermore, approximately 50% of patients hospitalised for a myocardial infarction have shown no evidence of any complication by the 3rd day of the disease. With this in mind, the authors show that early discharge from hospital at the end of the first week is possible in perfect safety for the majority of these patients, most often treated by thrombolysis, based upon precise knowledge of the severity of arterial disease and of left ventricular function, and the detection of any residual ischemia or possible rhythm disturbances. Only patients with three vessel disease have a higher risk of residual angina and should theoretically be excluded from such programmes. Ambulatory rehabilitation is an essential adjuvant, contributing to a faster return to work and a decrease in health care costs.

[Large thrombus in the left atrium and rheumatic mitral stenosis. Value of cardiac imaging]

Thromboses in the left atrium, which are a commonplace complication of mitral stenoses with major dilatation of the left atrium lead to a major risk of systemic embolism. It is important to discover them, because they constitute a contraindication to mitral valvuloplasty. The authors report the case of a large left intra-atrial thrombus complicating a pure, tight, mitral stenosis. They also highlight the value of new medical imaging techniques in cardiology: chest CT scan, nuclear magnetic resonance and cardiac scintigraphy. Subsequently, transesophageal cardiac ultrasound, not available in France at the time for this patient, has become the reference method for visualizing and detecting left intra-atrial thrombi.

Holter recording of ventricular arrhythmias during intravenous thrombolysis for acute myocardial infarction

Ventricular arrhythmias during thrombolysis for acute myocardial infarction and their relation to coronary artery patency were examined. Twenty-four-hour Holter monitoring was begun 3.1 +/- 0.2 hours after onset of pain in 40 patients (age 54 +/- 1.6 years; anterior infarction 42.5%) treated with streptokinase (42.5%) or recombinant tissue-type plasminogen activator (57.5%) (delay from pain 3.3 +/- 0.2 hours). A Marquette 8000 computer was used for Holter analysis. The infarct-related artery was considered as patent (72.5%) or non-patent (27.5%) according to coronary angiography (delay from pain 26.7 +/- 2.5 hours; 60% less than 24 hours). Ventricular arrhythmias were present in all patients. Tolerance was good (1 cardioversion for ventricular fibrillation). The incidence of accelerated idioventricular rhythm was not different between patients with a patent and nonpatent artery (90 vs 82%), nor for ventricular tachycardia (VT) (83 vs 73%). Coronary artery patency was associated with a 14-, 13- and 32-fold increase of ventricular premature complexes, VT and accelerated idioventricular rhythms, respectively. The increased incidence of sustained VT (patent 38%; nonpatent 0%; p less than 0.05) and early (before the first 6 hours) accelerated idioventricular rhythm (patent 76%; nonpatent 18%; p less than 0.01) associated with artery patency suggests that these arrhythmias may be noninvasive diagnostic criteria for reperfusion (sensitivity 38 vs 76%, and specificity 100 vs 82%). A positive correlation was found between the frequency of ventricular premature complexes and VT, and peak creatine kinase.

French multicenter trial of anistreplase versus heparin in acute myocardial infarction

Eighty-four patients aged less than 71 years with less than 4-hour duration acute myocardial infarction (AMI) were randomized in a multicenter study to 30 U anistreplase or heparin (single injection of 6500 IU followed by 1000 IU/hr). Early reperfusion was assessed from ECG changes (50% of sum ST decrease 2 hours postdosing) and the CK release profile (CK peak less than 16 hours after onset of symptoms, CK slope greater than 10%/hr). Reperfusion rates in patients meeting at least two criteria of reperfusion were 62.5% on anistreplase versus 27.5% on heparin. On delayed angiogram (13.7 +/- 3.4 days), patency rates were 66% with anistreplase versus 47% (NS) with heparin in 76 patients. Global LVF was similar in both groups. With anistreplase, the mean lowest fibrinogen level was 0.43 +/- 0.55 g/l, plasminogen was 20 +/- 9%, and the highest F.D.P. was 1447 +/- 548 micrograms/ml. All values recovered by hour 48. In-hospital and 1-year follow-up mortality was 7.2% (three patients) with anistreplase versus 10.2% (four patients) with heparin. Bleeding occurred in 9.7% and 5.1% of the patients (NS), respectively. No intracranial hemorrhage occurred. Thus, with combined clinical criteria or reperfusion, anistreplase is twice as efficient as heparin, has a good tolerance, and is easy to use as a single injection.