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PubMed2005

[Automobile driving and implantable defibrillators].

The consequences of implanting an automatic cardioverter defibrillator (ICD) on vehicle driving in France are poorly known. This retrospective study examined the behaviour at the wheel of ICD recipients who were recommended to abstain from driving for 3 to 6 months after device implantation. The study population included 98 patients (mean age = 59.5 +/- 14.8 years) followed for a mean of 24. +/- 23.9 months, who underwent ICD implant for ventricular tachycardia (65% of patients ventricular fibrillation (15%), syncope (8%), as part of a research protocol of myocardial cell transplantation 6%, or for primary prevention (5%). The underlying heart disease was ischemic in 59% of patients dilated cardiomyopathy in 11%,hypertrophic cardiomyopathy in 8%, valvular in 6%. Brugada syndrome in 4%, right ventricular arrhythmogenic cardiomyopathy in 2%, and miscellaneous disorders in 9% of patients. Five patients died without post mortem interrogation of the ICD. Only 28% of drivers remembered, and 13% observed, the recommended driving limitations. However, 45% (the oldest) claimed to drive prudently. During follow-up, 47% of patients received an ICD shock. Their mean it ventricular ejection fraction was 34 +/- 14%, versus 43 +/- 18% in patients who received no ICD therapy (p = 0.015). Syncope occurred in 16% who received ICD shocks. Shocks were delivered during driving in 6 patients, without consequent accident. Despite their non-observance of recommended driving limitations. ICD recipients suffered few traffic accidents. Legislation in France should reproduce the guidelines issued by European professional societies and enacted by the British laws.

Accidents, Traffic↗
PubMed1990

[Peripelvic tumors: approach and management].

The peripelvic area consists of the bony pelvis, hip joints and adjacent mesenchymal soft tissues. Malignant lesions in this area present unique diagnostic and therapeutic problems, in particular when tumor removal is involved. Between 1986 and 1988 we treated 7 females and a male, aged 8-75 years, for malignant tumors of this area. Diagnoses (histologic) included 4 cases of malignant fibrous histiocytoma, a malignant schwannoma, a Ewing sarcoma, a chondrosarcoma, and an osteosarcoma. Operations included marginal resection (4 cases), radical resection and reconstruction (2), radical resection (1), and modified hemipelvectomy (2). Adjuvant therapy consisted of radiotherapy in 1 case, chemotherapy in 2, and a combination of both in another 2. A patient who underwent radical resection and reconstruction of his left hemipelvis and hip joint died of local infection that progressed to generalized sepsis 2 months after operation. 2 patients died of recurrent disease, 3 and 30 months, respectively, after primary therapy. 1 died of myocardial infarction 20 months after the first and 3 months after the last of a series of marginal resections. 3 patients are alive and well 3-24 months following their first operation, and the fourth is doing well 24 months following first operation and 23 months after resection of lung metastases. Soft tissue sarcomas and osteosarcomas are the most frequent malignant tumors encountered in the pelvis and peripelvic areas. Their varying grades of malignancy and metastatic potential influence the approach on the one hand, while invalidity and compromised quality of life associated with tumor resection, influence it on the other.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

Pharmacological and therapeutic properties of an ideal beta-blocker.

With hindsight it is now possible to define some of the additional pharmacological characteristics which enhance the pharmacodynamic and therapeutic efficacy of a drug whose primary purpose is to antagonize competitively sympathetic stimulation of the heart. The ideal pharmacokinetic profile for a beta-blocker includes ready and unimpeded absorption; a predominantly hydrophilic distribution; a relatively long duration of pharmacological activity and alternative routes of elimination. The ideal pharmacodynamic activity of such a drug involves a number of factors, including the essential element of beta 1-adrenoceptor selectivity. In addition, moderate beta 2-adrenoceptor agonist activity and mild stimulation of myocardial contractibility afford enhanced haemodynamic efficacy. The intrinsic ability to relax vascular and bronchial smooth muscle are also highly desirable ancillary pharmacodynamic properties. From the therapeutic aspect, a drug administered with the primary objective of reducing myocardial ischaemia in patients with a coronary heart disease, or of lowering blood pressure in patients with hypertension, should not only prove effective in clinical practice, but should also be shown to have beneficial haemodynamic properties and a minimum of undesirable pharmacological effects. The unique pharmacological profile of celiprolol appears to allow fulfillment of many of these desirable objectives.

Adrenergic beta-Antagonists↗
PubMed1981

[Incidence and prognostic implication of repetitive ventricular premature contractions detected by Holter monitoring (author's transl)].

Incidence and prognostic significance of repetitive ventricular premature contractions in various cardiac diseases were evaluated retrospectively with 593 consecutive patients referred for the 24-hour continuous electrocardiographic monitoring (Holter monitoring). Primary cardiac diagnoses for 308 patients with structural heart diseases included previous myocardial infarction (MI) in 151 patients, angina pectoris in 34, congestive cardiomyopathy (COCM) in 21, valvular heart disease in 29, hypertensive heart disease (HHD) in 18, conduction disturbance in 28, and other cardiovascular abnormalities in 17 patients. Other 285 patients (48%) had no known structural heart disease. Repetitive ventricular premature contractions (VPCs) was defined as the occurrence of self-terminating two (couplet), three (triplet) or more consecutive VPCs without associated hemodynamic sequelae. Holter monitoring was done with simultaneous two-channel recordings. Repetitive VPCs were seen in 96 patients; 17% of patients with MI, 52% of COCM and 7% of no structural hart disease. Among 308 patients with structural heart disease, 91 had congestive heart failure and 42% of these had repetitive VPCs, whereas only 17% of patients without congestive heart failure had repetitive VPCs. Coronary arteriographic and ventriculographic findings were reviewed in 91 patients with previous MI. Neither the degree of coronary artery involvements nor left ventricular ejection fraction had influence on the occurrence of repetitive VPCs. Four hundreds and sixty-nine patients under the age of 69 years were followed from 6 to 36 months (mean 19 months). Thirteen patients including 5 cases with MI (4% of the cases with MI), 4 with COCM (21% of COCM) and 4 with other structural heart disease (4% of other disease) died suddenly in the follow-up period. In the patients followed, 72 had repetitive VPCs and 9 of them died suddenly. These 9 patients consisted of 4 patients with MI (25% of the cases with MI having repetitive VPCs), 4 with COCM (40% of COCM) and 1 with other structural heart disease (3% of other disease). Thus, patients with MI or COCM had higher incidence of repetitive VPCs and they are at a high risk for sudden cardiac death.

Aged↗
PubMed2006

[Secondary prevention of coronary heart disease and gender perspective in two primary healthcare centers].

BACKGROUND AND OBJECTIVE: Our goal was to describe the secondary prevention of coronary heart disease activities in two primary healthcare centers and to analyze differences according to gender. PATIENTS AND METHOD: Retrospective follow-up study (medical records audit) during one year of 187 patients discharged after one myocardial infarction to identify the use of preventive advice and treatments. RESULTS: Men had more exercise (66.7%), smoking (62.9%) and alcohol advice (20.0%) and less diet advice (62.9%) than women (34.3%, 2.9%, 0.0%, 94.3%, respectively). After one year of follow-up, there were no differences in antiplatelet therapy (99.3%), betablockers (41.4%) and statins (70.7%), yet the use of drugs with action on the renin-angiotensin system showed notable differences (men: 50.5%; women: 5.7%; P < .05). Overall, 66.6% of the men vs. 31.4 of the women received three or more treatments. There were no differences among health centers. CONCLUSIONS: Although secondary prevention seems to have improved along time, some problems remain, especially in women.

Aged↗
PubMed1992

The case for unstable angina pectoris as a primary end point in primary prevention studies.

Coronary artery disease (CAD) primary end point definitions used in previous prevention trials are reviewed, as well as trends over time for CAD mortality, incidence and hospital discharges to see if new primary end points should be considered. CAD mortality has shown a dramatic decline in the U.S. in the last 20 years, whereas the decrease in the incidence of acute myocardial infarction (AMI) is less consistent. The decline in CAD incidence and mortality has been attributed to changes in lifestyle and increased medical/surgical intervention. Hospital discharge rates for CAD have risen during the past decade. In addition, although the rate of discharge for AMI appears to have stabilized, the rates for angina, and more dramatically for unstable angina, have increased. Unstable angina made up 4% of CAD discharges in 1980, and increased to 25% of CAD discharges in 1989. Because of these trends, future trials that rely solely on AMI as a primary end point will not reflect the actual experience with CAD presentation in the U.S. Given the greater availability of methods to diagnose unstable angina more accurately, and because of its high risk pathology, it is concluded that unstable angina should receive serious consideration as a primary end point in future primary prevention trials.

Adult↗
PubMed1986

The Lipid Research Clinics Coronary Primary Prevention Trial.

The Lipid Research Clinics Coronary Primary Prevention Trial tested the efficacy of cholesterol lowering in reducing the risk of coronary heart disease in 3806 asymptomatic, middle-aged men with primary hypercholesterolaemia. The cholestyramine group experienced 8.5 and 12.6% greater reductions in total and low density lipoprotein (LDL), respectively, than those obtained in the placebo group. The cholestyramine group experienced a 19% reduction in risk (p less than 0.05) of the primary end-point of definite coronary heart disease death and/or definite non-fatal myocardial infarction. Corresponding and significant reductions were also seen for angina, development of a positive exercise test, and coronary bypass surgery. All-cause mortality was only slightly, and not significantly, reduced in the cholestyramine group, reflecting more violent and accidental deaths in the cholestyramine subjects. When the cholestyramine group was analysed separately, a 19% reduction in coronary heart disease risk was also associated with each decrement of 8% in total cholesterol. Moreover, coronary heart disease incidence in men in sustaining a fall of 25% in total cholesterol, a typical response to the prescribed dosage (24 g/day) of cholestyramine resin, was half that of men who remained at pretreatment level. The Lipid Research Clinics Coronary Primary Prevention Trial findings show that reducing total cholesterol by lowering LDL cholesterol levels, can diminish the incidence of coronary heart disease morbidity and mortality in men at high risk for the disease because of raised LDL cholesterol levels. These results have considerable importance for the prevention of coronary heart disease through cholesterol lowering, at both the clinical and public health levels.

Adult↗
PubMed2001

C-reactive protein: risk assessment in the primary prevention of atherosclerotic disease. Has the time come for including it in the risk profile?

About half of patients presenting with myocardial infarction do not have the "classic" risk factors. This has stimulated a search for other factors that may be responsible and, when present, may help to predict which patients are at greatest risk for myocardial infarction and other cardiovascular events. With improved understanding of the pathogenesis of ischemic cardiovascular disease, we have gleaned new insights into potential markers of underlying atherosclerosis and cardiovascular risk. In recent years, data suggesting that certain markers of inflammation--both systemic and local--play a key role in the development and progression of atherosclerosis, and in its final clinical complications have accumulated. Specifically, elevated levels of one systemic marker of inflammation, C-reactive protein (CRP), are associated with an increased risk of cardiovascular disease events. Among several markers of systemic inflammation, CRP shows the strongest associations with vascular events, and the addition of CRP to total cholesterol dramatically improves risk prediction. CRP fulfils most of the requirements needed to serve as a new risk factor, but still several issues await further confirmation and clarification before this marker can ultimately be included in the routine risk profile. Moreover, potentially important associations have been established between elevated CRP levels and increased efficacy of established therapies, in particular lipid-lowering therapy with statins; CRP testing may enable us to tailor expensive cardiovascular medication to the individual patient. Such an improved prescription strategy might be especially valuable in the primary care setting where the absolute cardiovascular risk is considerably lower compared to that in secondary prevention.

Biomarkers↗
PubMed2002

Percutaneous reperfusion of left main coronary disease complicated by acute myocardial infarction.

Previous studies have shown a benefit of a strategy of direct angioplasty and stenting in patients with acute myocardial infarction (AMI) complicated by early cardiogenic shock. However, few data exist for the subset of patients with left main trunk disease complicated by AMI and cardiogenic shock. We performed an analysis of patients with AMI who underwent mechanical intervention between January 1995 and December 2000. Out of 1,433 patients with ST segment elevation AMI treated with primary coronary angioplasty (PTCA), 22 patients (1.5%) had left main disease (LMD) as the culprit lesion. Baseline characteristics were age, 66 +/- 11 years; female gender, 9%; diabetes, 14%; previous myocardial infarction, 14%; mean systolic blood pressure, 77 +/- 24 mm Hg; time to treatment, 4.8 +/- 2.2 hr; TIMI 0-1, 77%; collateral flow (Rentrop grade >or= 2) 9%. The primary success rate was 91%. Primary stenting was performed in 17 patients (77%). The in-hospital mortality rate was 50%. All deaths were due to refractory shock. The 6-month survival rate was 41% +/- 1%, while the event-free survival rate was 27% +/- 10%. At 6-month follow-up, the mortality rate increased to 59%; the target vessel revascularization rate was 14%. A percutaneous mechanical intervention strategy in patients with left main disease complicated by AMI is feasible and effective, and patients discharged alive have a good mid-term prognosis.

Adult↗
PubMed1979

[Microfocal myocardial infarct as a variant of exacerbation of ischemic heart disease].

The results of long-term (3- to 4-year) follow-up of 180 patients with microfocal myocardial infarction are analysed. The difference in the course and prognosis of primary and recurrent microfocal myocardial infarction is determined. It is shown that microfocal myocardial infarction as a form of exacerbation of ischemic heart disease is characterized by a complex of syndromes differing from the typical picture of marcrofocal myocardial infarction. As compared to macrofocal myocardial infarction, the course of the disease after microfocal myocardial infarction is characterized by more frequent exacerbations of coronary insufficiency and a greater tendency toward the development of recurrent myocardial infarction. In some cases, microfocal myocardial infarction heralds the development of macrofocal myocardial infarction with a severe course and high mortality rate, which provides the grounds for the conclusion that patients with microfocal myocardial infarction have a lower coronary reserve.

Aged↗
PubMed1979

Management of the patient with myocardial infarction.

Coronary atherosclerotic heart disease and myocardial infarction constitute an epidemic in this century, mandating that the primary care physician be familiar with their recognition and management. However, in recent decades, an improved understanding of pathophysiologic alterations, an enormous advance in technology and significant accomplishments in pharmacology and operative procedures have virtually revolutionized the management of patients with myocardial infarction. Although patterns of care described in this monograph may well be obsolete a few years hence, to be superseded by safer, more precise, more efficient and more cost-effective therapeutic modalities, nevertheless basic principles underlying the management of the patient with myocardial infarction remain as appropriate guidelines. In the hospital phase, efforts should be directed toward enhancing survival, saving myocardium and restoring function. The long-term ambulatory care should be designed to maintain functional capacities, to control symptoms, to retard or arrest the atherosclerotic process thus decreasing the likelihood of recurrent myocardial infarction and/or of sudden cardiac death and to restore the patient to a normal or near-normal life style.

Acute Disease↗
PubMed2006

["Smoker's paradox" in patients with acute myocardial infarction receiving primary coronary intervention].

OBJECTIVES: Smokers with acute myocardial infarction have lower mortality rates than non-smokers despite increased risk for coronary artery disease. This study assessed the effects of smoking on complications and outcomes after acute myocardial infarction, and investigated the relationship between the clinical factors and the paradoxical effects of smoking in patients receiving primary coronary intervention. METHODS: Subjects were 367 consecutive patients with acute myocardial infarction who were admitted within 24 hr of onset and underwent successful coronary intervention, 165 (45%) of whom were smokers. RESULTS: The smoking group contained significantly more male patients, and the smoking group was significantly younger than the non-smoking group (p < 0.0001). The value of acute phase brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) were significantly lower (BNP: 250 +/- 366 vs 448 +/- 513pg/ml, p = 0.0002; ANP: 48 +/- 77 vs 74 +/- 82pg/ml, p = 0.005) in the smoking group. Peak creatine kinase time from onset was significantly earlier (12.9 +/- 9.3 vs 16.1 +/- 10.0 hr, p = 0.049) in the smoking group. Left ventricular ejection fraction in the chronic phase was significantly better in the smoking group (58 +/- 13% vs 52 +/- 14%, p = 0.03). The early ST-segment resolution rate was higher in the smoking group (81% vs 67%, p = 0.003), and there were significantly fewer patients with heart failure in the smoking group than in the non-smoking group (28% vs 41%, p = 0.01). The cardiac mortality rate during 6 months was significantly lower in the smoking group (3% vs 9%, p = 0.01). The beneficial effects of smoking on the prognosis were related with the differences in sex and age of the study group. CONCLUSIONS: The reason why smokers with acute myocardial infarction have lower mortality rates than non-smokers, the "smoker's paradox", may be related to less damage to the microvascular function after primary coronary intervention, with lower BNP and better left ventricular ejection fraction.

Aged↗
PubMed2003

Cohort study on effects of parathyroid surgery on multiple outcomes in primary hyperparathyroidism.

OBJECTIVES: To assess the effects of surgery compared with conservative treatment (no surgery) for primary hyperparathyroidism. DESIGN: Cohort study. SETTING: Nationwide Danish cohort. PARTICIPANTS: 3213 patients, mean age 61 (SD 16) years, with a diagnosis of primary hyperparathyroidism between 1980 and 1999. 1934 (60%) underwent surgery and 1279 (40%) were treated conservatively. MAIN OUTCOME MEASURES: Occurrence of fractures, osteoporosis, kidney or urinary tract stones, acute myocardial infarction, angina pectoris, cardiac arrhythmias, arterial hypertension, heart failure, stroke, acute pancreatitis, stomach or duodenal ulcers, muscle pain, malignant diseases, psychiatric disorders, and mortality. RESULTS: At diagnosis of primary hyperparathyroidism, patients who subsequently underwent surgery had a lower prevalence of previous fracture (odds ratio 0.64, 95% confidence interval 0.51 to 0.80), acute myocardial infarction (0.59, 0.42 to 0.83), stroke (0.57, 0.37 to 0.88), psychiatric disorders (0.54, 0.31 to 0.94), and painful muscle disorders (0.44, 0.26 to 0.76), whereas kidney stones (2.49, 1.93 to 3.23) and acute pancreatitis (2.77, 1.33 to 5.76) were more prevalent. After diagnosis, the risks of fractures (hazards ratio 0.69, 0.56 to 0.84) and gastric ulcers (0.59, 0.41 to 0.84) were lower in patients treated surgically than those treated conservatively. Events involving kidney or urinary tact stones were more prevalent in patients treated surgically than patients treated conservatively (1.87, 1.30 to 2.68). Mortality was lower in patients treated surgically (0.65, 0.57 to 0.73). CONCLUSIONS: Patients treated surgically for primary hyperparathyroidism have a lower prevalence of fractures and gastric ulcers than patients treated conservatively. The type of treatment had no effect on the occurrence of cardiovascular events.

Adult↗
PubMed1992

Myocardial infarction caused by cardiac microvasculopathy in a patient with the primary antiphospholipid syndrome.

Antiphospholipid antibodies occur in various clinical states, including the primary antiphospholipid syndrome. Clinical features in these conditions appear to be caused by vasculopathy associated with the presence of these antibodies. We report the case of a patient with primary antiphospholipid syndrome who experienced cardiac necrosis secondary to myocardial microvasculopathy in the absence of vasculitis. This case demonstrates unequivocally that noninflammatory myocardial microvasculopathy occurs in the primary antiphospholipid syndrome per se without any clinical or immunologic signs of systemic lupus erythematosus or other disease process. The histopathologic findings in the skin and myocardial biopsies showed a noninflammatory vasculopathy characterized by bland thrombi and lack of infiltration of the vessel wall by inflammatory cells. Ultrastructural examination of the myocardial biopsy confirmed the vascular thrombosis and endothelial activation and showed no deposits in basement membranes. The patient survived after appropriate treatment. Evidence presented here supports the concept that the vasculopathy in the antiphospholipid syndrome is distinct from other types of vascular occlusions seen in systemic lupus erythematosus. We suggest that myocardial biopsy can be crucial in showing an underlying myocardial ischemic process despite "normal" findings on coronary angiography. Results of the biopsy hastened the decision to use potentially lifesaving plasmapheresis and anticoagulation therapy in this patient.

Adult↗