RESUMEN
Implantable cardioverter-defibrillators (ICD) have emerged as a major treatment for life threatening ventricular arrhythmias. This technique is available in France in all the university hospitals and, with the favor of the new regulation, in some qualified private centers. However, ICD implantation and follow-up in a non-university hospital is infrequent. This study reports long-term results following ICD implantation in 152 patients (age 61+/-13 years). The vast majority (49%) of the patients were implanted for post-infarction ventricular tachycardia and 17% in primary prevention for left ventricular dysfunction. An appropriate therapy was delivered in 83 patients including 68 (81%) treated by antitachycardia pacing without the need for a cardioversion shock. An inappropriate shock was observed in 13 patients (9%). Because of iterative shocks, catheter radiofrequency ablation was proposed among 9 patients, with a success in 8. In conclusion, the technique of the implantable defibrillator can be performed in a non-university hospital with acceptable results. The increase in the ICD number in France implies that there is a need for collaboration between non-university and university hospitals in managing routine and emergency follow-up.
Asunto(s)
Arritmias Cardíacas/terapia , Desfibriladores Implantables , Adolescente , Adulto , Anciano , Desfibriladores Implantables/efectos adversos , Femenino , Estudios de Seguimiento , Hospitales Generales , Humanos , Masculino , Persona de Mediana Edad , Taquicardia Ventricular/terapia , Resultado del Tratamiento , Disfunción Ventricular Izquierda/terapiaRESUMEN
Syncope or presyncope related to adverse drug reactions are well-known. On the other hand, little is known about the specific role of different drugs. Over one six year period, 1611 patients were referred in our hospital for syncope or presyncope, including 688 in the cardiology department. Among these patients, 420 were 70 years old or more. The search for an adverse drug reaction was systematic, with the help of the French method for causality of adverse drug reaction: knowledge of "extrinsic" criteria (bibliographical data relating to the drug involved); moreover, score on the basis of "intrinsic", chronological and symptomatic criteria. Seventy five patients (11% of the group with syncope leading to admission in cardiology department) were thus retained: score = I2, "possible adverse drug reaction", for 28 patients (37%); score = I3, "probable adverse drug reaction", for 47 patients (63%). Score I4, "definite adverse drug reaction" was not used since it required the readministration of the drug to prove the iatrogenic effect. Average age was 78 years, with a female majority of 69%. Seventy two patients (96%) had previous cardiovascular disease, 37 (50%) previously experienced syncope or presyncope. In addition to the basic assessment, a Holter recording was performed among 56 patients, finding a drug-induced arrhythmia in three cases. In the majority of the patients (59 patients, 79%), the adverse drug reaction consisted of hypotension, clinically obvious in 49 cases. In ten cases, vasovagal syndrome facilitated by the drugs was diagnosed by a tilt-test. The other side effects were eight rhythm disorders and eight severe metabolic disorders. The treatments were always multiple. The involved drug was a cardiovascular therapy in 66% of the cases. The other drug classes were primarily represented by uroselective alpha 1-adrenergic blocking drugs (12%) and psychotropic ones (22%). Among the cardiovascular treatments, ACE inhibitors and diuretics, generally in association, were involved (59%). This study confirms the role for antihypertensive drugs in iatrogenic syncope, its great frequency in elderly patients but also the responsibility of another drug class less often reported, the uroselective alpha 1-adrenergic blocking drugs.
Asunto(s)
Mareo/inducido químicamente , Síncope/inducido químicamente , Anciano , Femenino , Humanos , Enfermedad Iatrogénica , Masculino , Estudios ProspectivosRESUMEN
Several publications over the last ten years have addressed the problem of genetic mutation coding platelet membrane glycoproteins and thrombotic arterial disease. The principal polymorphisms studied are those of glycoproteins GPIIIa, GPIb and the GPIa-IIa complex. The relationships of each of these polymorphisms and myocardial infarction or coronary artery disease are reported and are often subject to controversy. The polymorphism PLA2 of the GPIIIa has been shown to be a risk factor for infarction in young people, especially when associated with cigarette smoking. Its role in triggering myocardial infarction or in the severity of coronary artery disease is not so clear in the general population. Two types of polymorphism concerning the GPIb and that of the GPIa-IIa complex should also predispose to early coronary thrombotic complications. In addition, the study of these platelet polymorphisms gives a better insight into individual sensitivity to platelet antiaggregant therapy.
Asunto(s)
Enfermedad de la Arteria Coronaria/genética , Predisposición Genética a la Enfermedad , Infarto del Miocardio/genética , Glicoproteínas de Membrana Plaquetaria/genética , Polimorfismo Genético , Adulto , Edad de Inicio , Anciano , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/patología , Humanos , Persona de Mediana Edad , Infarto del Miocardio/etiología , Infarto del Miocardio/patología , Factores de RiesgoRESUMEN
BACKGROUND: Acetylsalicylic acid, or aspirin, is widely used in secondary prevention of coronary artery diseases, but the inhibition of platelet aggregation is not uniform in all individuals. OBJECTIVE: To investigate the prevalence of aspirin resistance at rest and during exercise in coronary artery disease patients. MATERIALS AND METHODS: Fifty patients with stable coronary artery disease were prospectively studied. All patients received aspirin (75-300 mg/day for >1 month) and no other antiplatelet therapy. Aspirin resistance was studied, at rest and immediately after a stress test, using the standardized platelet function analyzer (PFA-100(R), Dade-Behring). Aspirin resistance was defined as a normal collagen/epinephrine closure time (<186 s). RESULTS: Ten patients (20%) were aspirin-resistant at rest. Out of the 40 patients who were aspirin-sensitive at rest, 9 (22%) were aspirin-resistant immediately after the exercise stress test. There were no differences in aspirin sensitivity regarding gender, age, diabetes, hypertension, dyslipidemia, platelet count, medical treatment or number of the coronary arteries involved. CONCLUSIONS: Aspirin resistance is detected, at rest, in 20% of our patients with stable coronary artery disease. Aspirin treatment does not seem to protect against exercise-induced platelet activation in 22% of such patients, despite aspirin sensitivity at rest.
Asunto(s)
Aspirina/farmacología , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/farmacología , Agregación Plaquetaria/efectos de los fármacos , Anciano , Enfermedad de la Arteria Coronaria/prevención & control , Resistencia a Medicamentos , Prueba de Esfuerzo , Femenino , Humanos , Técnicas In Vitro , Masculino , Persona de Mediana Edad , Activación Plaquetaria/efectos de los fármacos , Pruebas de Función Plaquetaria , DescansoRESUMEN
UNLABELLED: This study assessed the clinical or echographic factors predisposing to dynamic left ventricular obstruction (LVO) during dobutamine echocardiography (DE) in patients with angina-like chest pain but without coronary artery disease (CAD). DE is an effective technique for the noninvasive diagnosis of underlying CAD. During DE, an LVO is not unusual in ischemic patients. METHODS: DE (5-40 microg/kg/min) was performed in 52 consecutive patients with angina-like chest pain and normal coronary angiogram. Mean (standard deviation) age was 61 +/- 10 years (27 men, 25 women). Dobutamine-induced LVO was defined as a new intracavitary flow acceleration of at least 3 msec in the left ventricle. RESULTS: Dynamic LVO was observed during DE in 20 (38%) of the 52 patients and was not related to clinical or baseline echocardiographic parameters. The chronotropic response and the systolic blood pressure during DE were higher in the group with LVO (P < 0.03 and P < 0.05, respectively). Appearance of chest pain during the test was also more frequent when LVO occurred (P < 0.02). CONCLUSION: Dynamic LVO is common during DE in a population of patients with angina-like chest pain without epicardial CAD and is associated with a higher hemodynamic responsiveness to dobutamine.
Asunto(s)
Agonistas Adrenérgicos beta/efectos adversos , Angiografía Coronaria , Dobutamina/efectos adversos , Ecocardiografía , Obstrucción del Flujo Ventricular Externo/inducido químicamente , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Angina de Pecho/diagnóstico por imagen , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Right atrial isthmus block is currently accepted as a success criterion of atrial flutter ablation. An electrophysiological study performed days after the ablation procedure may show recovery of conduction across the isthmus in some patients, followed by arrhythmia recurrence. However, few data are available on the time course of this recovery and on the monitoring of isthmus conduction at the end of the ablation procedure as a means of increasing the success rate of the procedure. Radiofrequency (RF) catheter ablation was performed in 28 men and 7 women (mean age = 65 +/- 11 years) presenting with common or clockwise atrial flutter (AFL) resistant to 2.9 +/- 1.8 antiarrhythmic drugs. Underlying heart disease was present in 13 patients. The ablation procedure was performed with an 8-mm-tip catheter, by several 45-second applications at a target temperature of 65 degrees C, directed to the isthmus between tricuspid annulus and inferior vena cava. Bidirectional isthmus block (BDB) was created with 4-24 RF applications in all but one patient. Special attention was paid to exclude incomplete block by meticulous mapping during pacing at the coronary sinus os and at the low lateral right atrium every 5 minutes for 20 minutes thereafter. Conduction recovered across the isthmus in 5 patients at 10, 10, 12, 15, and 16 minutes, respectively, and further RF applications were needed to obtain stable block. At a follow-up of 17 +/- 10 months, AFL occurred in the patient without, and in one patient with BDB. Thirty-three of the 34 patients (97%) with persistent BDB remained free of arrhythmia recurrence. This study showed that conduction resumed across the isthmus within 20 minutes, after AFL ablation in 15% of the patients. The long-term results of the procedure can be optimized by ascertaining the persistence of BDB during that period of time.
Asunto(s)
Aleteo Atrial/fisiopatología , Aleteo Atrial/cirugía , Ablación por Catéter/métodos , Atrios Cardíacos/fisiopatología , Sistema de Conducción Cardíaco/fisiopatología , Adulto , Anciano , Femenino , Estudios de Seguimiento , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Resultado del TratamientoRESUMEN
Despite the development of non-invasive diagnostic techniques, the absence of significant coronary stenosis is observed in 10 to 30% of coronary angiographic studies. The authors report the survival and functional status at 6 years of 172 consecutive patients with symptoms of angina without significant angiographic coronary stenosis. The average age was 60.8 years with a sex ratio of 1.1 and chest pain as the indication for coronary angiography in over 90% of cases. The global mortality after an average of 75.6 months follow-up was 11%, lower in women (8.5%) than in men (13.3%) with an annual mortality of 16.3 per thousand. Sudden death was observed in 4 patients and a third of deaths was of cardiac origin. The persistence of symptoms was reported by 58% of patients, mainly atypical chest pain. Despite the result of coronary angiography, nearly half of the patients were followed up annually by a cardiologist, two thirds remained on anti-anginal therapy, 20% were treated by psychotropic agents and hospital admission to the cardiology department was required in 22% of cases during follow-up. None of the patients had myocardial infarction. Survival and myocardial function after normal coronary angiography therefore appear to be good in contrast with the functional status of these patients.