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Reciprocal ST segment changes are frequent during acute inferior myocardial infarction, yet their significance remains controversial. In order to investigate the implications of these changes, the ECG obtained on admission for 83 patients with acute inferior myocardial infarction was compared with the clinical course and the results of angiographic and coronary arteriographic studies performed an average of 3 weeks after the onset of symptoms. Group 1 consisted of 59 patients with at least 1 mm of horizontal on downsloping ST segment depression in at least 1 of leads V to V. Group 2 consisted of 24 patients without precordial ST depression in this area. Group 1 patients were generally older than group 2 patients (59.6 ± 6.4 versus 54 ± 5.3 yr, P<0.01) had higher total creatine kinase (CK) levels and MB fractions (1835 ± 940 versus 875 ± 305, P < 001, 269 ± 102 versus 95 ± 35 for MB fraction) and more complications during the hospital course (80% versus 38% P<0.01) and greater left ventricular dysfunction (ejection fraction 52.2 ± 6% for group I versus 59.2±7% for group 2; cardiac index 2.75±0.41min m for group 1 versus 3.25 ± 0.3 lmin m for group 2 P<0.005). No difference was observed on biplane angiography as far as left ventricular wall kinesis was concerned. By contrast, coronary arteriography revealed more frequent left coronary artery disease in group 1 patients (84%) than in group 2 patients (37%) P<0.005, the left anterior descending and circumflex arteries being equally often affected. Finally, the persistence of ST segment depression for more than 48 hours was associated with a more severe depression of the ejection fraction than transient depression (less than 48 hours). In summary, the presence of ST segment depression in the precordial leads during the acute phase of inferior myocardial infarction was associated with greater myocardial necrosis and more frequent left coronary artery disease, thus identifying a subset of high risk patients. [ABSTRACT FROM PUBLISHER]

Objective Between July 1992 and December 1994, 16 French hospital centres, mainly cardiological, participated in a non-controlled observational study on venous thromboembolic disease. The objective of this survey was to collect data concerning the current status of pulmonary embolism and deep venous thrombosis. Patients During this period, 547 patients were included: 446 with deep venous thrombosis and 387 with pulmonary embolisms. Results Mean age of patients was 63±21 years. There were no significant differences between the sexes. Pulmonary embolism and deep venous thrombosis tended to occur more frequently during the autumn and winter. In 30% of cases, prior deep venous thrombosis or pulmonary embolism was noted. No cause was found for the condition in 47% of cases. Ultrasound (echocardiography and/or venous ultrasound) was the most frequently requested investigation. Intravenous heparin remains the most widely used treatment (76%). Oral anticoagulation was begun before day 3 in less than 31% of cases. Thrombolytic treatment was used in 20% of pulmonary embolism cases, but was rarely prescribed for deep venous thrombosis (2·2%). The hospital recurrence rate (12/547 cases) was fairly low. The search for occult malignancy, performed in 48% of cases, seems to remain one of the major concerns of physicians. The combined pulmonary embolism and deep venous thrombosis mortality rate was 4·4%, while the death rate for pulmonary embolism alone was 6·2%. [ABSTRACT FROM PUBLISHER]

Background and Objective: In patients presenting with pulmonary embolism (PE), echocardiography, in some cases, reveals mobile clots in right heart (RH) cavities. How these clots evolve after treatment, in particular after thrombolytic treatment (TT), is unknown. We sought to determine the outcome of these mobile clots in the RH during TT. Methods and Results: Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae. Conclusion: In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy. [ABSTRACT FROM AUTHOR]

Comments on a study by B. Janand-Delenne and colleagues which screened diabetic patients for myocardial ischemia. Methodology of the study; Indications of the results; Risk factors for silent myocardial ischemia.

In 20 patients who had recently had an acute myocardial infarction, we compared endocoronary electrocardiographic modifications recorded during angioplasty with thallium-201 for the detection of myocardial viability. Our data demonstrate that endocoronary electrocardiography can be an easy and reliable tool to assess viability, with sensitivity, specificity, and positive and negative predictive values of 100%, 80%, 94%, 100%, respectively. [ABSTRACT FROM AUTHOR]

Background: Elevated plasma homocysteine levels are associated with increased risk of vascular disease and of congestive heart failure (CHF), with a relationship between homocysteine values and disease severity. Hyperhomocysteinemia is a risk factor for cardiac dysfunction. In this study, the predictive value of elevated homocysteine levels was investigated in the prognosis of ischemic and non-ischemic CHF., Methods: A total of 159 patients with CHF, 89 with non-ischemic and 70 with ischemic CHF (83% males, mean age 62 years, mean ejection fraction 27%), and 119 controls (79% males, mean age 59.8 years) had fasting blood samples taken to measure plasma homocysteine, vitamin B(12) and folate levels. Coronary angiography was performed for all patients. The mean duration of follow-up was 49.6+/-36.7 months., Results: As in other studies, the mean level of homocysteinemia was significantly higher in the CHF group (15.80 micromol/L) than in the control group (10.90 micromol/L) (p=0.001) whatever the etiology (non-ischemic, 16.11+/-6.84 micromol/L; ischemic, 15.41+/-6.45 micromol/L). This result was observed without vitamin deficiency, but in patients, the mean creatinine value was moderately higher than in controls. We found a positive correlation between plasma homocysteine levels and New York Heart Association (NYHA) classification, creatinine and age. Moreover, hyperhomocysteinemia appears to be a powerful predictive factor of mortality in CHF patients (relative risk of death, 4.23; p=0.0003). In the follow-up of this study, 41.5% of patients with homocysteinemia >17 micromol/L died vs. 21.3% of patients with levels <17 micromol/L. In multivariate analysis, when homocysteine levels were adjusted for a second parameter (age, NYHA, creatinine, diabetes), the risk of death remained significant after each adjustment., Conclusions: Elevated homocysteine levels observed in CHF patients, whatever the etiology of their heart disease (ischemic or non-ischemic), were correlated with the severity of the disease. Hyperhomocysteinemia appears to be a predictive factor of mortality in CHF patients.

Unlabelled: It has been shown in clinical studies that for subjects with a low likelihood of coronary artery disease (CAD), attenuation correction (AC) improves the specificity of defect detection in the inferior wall (right coronary artery [RCA] region). The aim of this study was to investigate the effect of AC on the visual interpretation of the RCA and anteroseptal (corresponding to the left anterior descending artery [LAD]) regions in CAD patients., Methods: Fifty-six patients with suspected CAD underwent 20Tl stress/4 h-delayed imaging SPECT using a simultaneous 201Tl emission/99mTc transmission imaging protocol. Images were reconstructed using the maximum likelihood-expectation maximum algorithm without and with AC. The stress/4 h-delayed images were interpreted blindly for reversible or fixed defects in the RCA and LAD regions by three experienced physicians. Coronary angiography, electrocardiography and enzyme findings were used to establish diagnoses of ischemia or infarction, and receiver operating characteristic (ROC) analyses were performed., Results: Statistical testing of ROC curve areas showed that defect detection performance improved with AC when compared with performance without AC in the RCA region. This was mainly the result of a systematic increase in specificity of 12% or more (for any observer and any type of defect) for a similar sensitivity (no definite change in sensitivity values). However, defect detection performance significantly decreased in the LAD territory with AC images (P < 0.05) because of a systematic decrease in sensitivity of 20% or more, with no consistent change in specificity. Similar trends were observed when reversible and fixed defects were considered separately., Conclusion: AC significantly affects the visual interpretation of 201Tl stress/4 h-delayed SPECT images. This study confirmed the increase in specificity obtained with AC in the RCA territory. However, in the population considered, the studied AC was deleterious for the LAD territory assessment.

Objectives: Our aim was to confirm the poor prognosis related to thoracic aortic plaques, in particular aortic debris, diagnosed by transesophageal echocardiography (TEE) and to evaluate patients' prognosis as a function of the antithrombotic treatment., Background: Aortic atheroma (AA) has been widely studied. However, it is still not known which antithrombotic treatment should be adopted in this disease., Methods: Patients referred for TEE and diagnosed with AA were followed. All thromboembolic events and deaths were recorded during a follow-up of 22+/-10 months. The antithrombotic treatment to be adopted was left to the discretion of the practitioner in charge of the patient., Results: Aortic atheroma was found in 12% of all TEE performed and in 27.5% of TEE performed for stroke. This prevalence was higher when no other etiology existed to explain the stroke (p < 0.001). During follow-up, an end point occurred in 22.5% of patients. The more severe the AA the greater the incidence of events (p = 0.007). A higher mortality rate is shown in patients with aortic debris (p = 0.049). Compared with those treated with oral anticoagulants, patients with aortic plaques >4 mm thick treated with antiplatelets had more embolic events and combined events (p = 0.01 and p = 0.007, relative risk [RR] = 5.9, 95% confidence interval [CI] = 1.4 to 15, respectively); patients with aortic debris had more combined events and a higher mortality rate (p = 0.001, RR = 7.1, 95% CI = 1.2 to 19 and p = 0.019, RR = 9.1, 95% CI = 1.2 to 25, respectively)., Conclusions: We confirm the high incidence of vascular events and deaths in patients with AA. We have demonstrated, for the first time in this condition, a better outcome among patients treated with oral anticoagulants versus antiplatelets.

Background: The link between travel and the risk of venous thromboembolic disease (VTED) has been widely suspected. However, only cases or series of cases have been reported in the literature., Study Objectives: By means of a case-control study, we sought to confirm this relationship and to determine the main features, if any, of these posttravel VTEDs., Design: The history, in particular the history of recent travel, of 160 patients presenting in our department with VTED was scrupulously investigated. All journeys undertaken during the preceding 4 weeks and lasting > 4 h by whatever means of transport were considered. The same questionnaire was submitted to a control group., Results: When the two groups of patients are compared, a history of recent travel is found almost four times more frequently in the VTED group (p < 0.0001). The odds ratio for having a VTED in patients who traveled was 3.98 (95% confidence interval, 1.9 to 8.4). Means of travel used included the train in 2 cases, airplane in 9, and car in 28. Mean duration of travel was 5.4+/-2.1 h. These posttravel VTEDs are not confined to a specific location, seem to involve no particular predisposition, and are more often "idiopathic." This fact supports the hypothesis that travel alone can produce vein clot formation., Conclusions: A history of recent travel is a risk factor for VTED. Posttravel venous thrombotic events can occur after short journeys in patients with no other risk factors or concomitant disease

Background and Study Objective: The value of the ECG for the diagnosis of pulmonary embolism (PE) is debatable. Once the diagnosis of PE has been established, however, the ECG could allow the massive forms to be distinguished. The purpose of our study was to analyze the ECG signs in patients hospitalized for PE in a cardiology unit., Design: Taking a series of 80 consecutive patients hospitalized for PE, we analyzed the ECGs on admission and then during hospitalization. We sought to evaluate changes in ECG signs compared with angiographic and hemodynamic changes in PE., Results: T-wave inversion in the precordial leads is the most common abnormality (68%), and represents the ECG sign best correlated to the severity of the PE. Among those patients with anterior T-wave inversion, 90% had a Miller index over 50% (mean, 60 +/- 8%). Eighty-one percent had a mean pulmonary arterial pressure (PAP) over 30 mm Hg (mean, 37 +/- 8%). This subepicardial ischemic pattern is an even stronger marker of severity when it appears as early as the first day (p < 0.01). Its reversibility is correlated to the changes in PE. After thrombolysis in particular, normalization of repolarization systematically indicates mean Miller and PAP indexes of < 20% and < 20 mm Hg, respectively., Conclusions: The anterior subepicardial ischemic pattern is the most frequent ECG sign of massive PE. This parameter is easy to obtain and reflects the severity of PE. Its reversibility before the sixth day points to a good outcome or high level of therapeutic efficacy.

We evaluated the hemodynamic impact of right ventricular pacing at different stimulation frequencies. Fourteen patients with a right ventricular pacemaker (VVI pacing with retrograde P wave) but without clinical and electrocardiographic evidence of coronary artery disease underwent two equilibrium radionuclide angiographies: one under low heart rate (50/60 beats per minute) and the other under fast heart rate (90/100 beats per minute). Left ventricular global and sectorial ejection fractions, amplitude and phase images of first harmonic, and sectorial phases of left ventricle were analyzed. In twelve patients (84.7%), sectorial ejection fraction abnormalities in the left ventricular apicoseptal and inferoapical regions were observed under low heart rate, and worsened under fast heart rate, while new onset sectorial ejection fraction abnormalities under fast heart rate were observed in the other two patients with normal sectorial ejection fraction under low heart rate. Sectorial ejection fractions of left ventricular apicoseptal and inferoapical regions significantly changed between low and high heart rate (- 14.1 +/- 3.8%, p < 0.005; - 7.5 +/- 2.4%, p < 0.01 respectively). Left ventricular sectorial phases were abnormal in only two patients (14.3%) under low heart rate, and in twelve patients (84.7%) under fast heart rate. Our study confirms that left ventricular regional wall motion abnormalities during VVI pacing significantly worsen under fast heart rate in comparison to those under low heart rate.

Interatrial conduction time (IACT) and left atrial dimension (LAD) were determined in 75 patients (41 males, 34 females, mean age 78.2 +/- 7.9 years) undergoing atrioventricular (AV) stimulation. The LAD was measured by M mode echocardiography as the distance between the posterior aortic wall and the posterior left atrial wall. The IACT was determined during a transvenous dual chamber pacemaker implant done under local anesthesia (lidocaine). The spontaneous interatrial conduction time (SIACT) was measured from the intrinsic deflection (ID) of the right atrium recorded in a unipolar mode (unipolar J-shaped lead positioned in the right appendage) to the ID of the left atrium (bipolar esophageal lead, left atrial positive deflection equal to the negative one) during sinus rhythm. The right atrium then was paced at a rate slightly greater than the spontaneous one. The paced interatrial conduction time (PIACT) was measured from the stimulus artifact to the left atrial ID. The PIACT was also measured during incremental right atrial pacing (10 beats/min step increase to 180 beats/min) and, from these measurements, the maximum increase of PIACT (MIPIACT) was deduced. The LAD was measured at 39.5 +/- 8.7 mm, SIACT at 70.3 +/- 24.8 msec, PIACT at 118.8 +/- 27.9 msec, and MIPIACT at 16.5 +/- 16.4 msec. We found highly significant relationships between SIACT and LAD (P = 0.0006, r = 0.39), PIACT and LAD (P = 0.0001, r = 0.45), and MIPIACT and LAD (P = 0.0006, r = 0.38). We also noted that the LAD was greater in patients in whom MIPIACT was > 10 msec than in patients in whom the MIPIACT was negligible (P < 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate the frequency of spontaneous or rate dependent interatrial blocks, the interatrial conduction time (IACT) was studied on 100 consecutive patients (mean age 78.3 +/- 7.8 years) during a transvenous dual chamber pacemaker implant. The spontaneous interatrial conduction time (SIACT) was measured from the intrinsic deflection (ID) of the unipolar right atrial signal to the ID of the left atrial signal recorded in a bipolar way by an esophageal lead. The paced interatrial conduction time (PIACT) was measured from the stimulus artifact to the left atrial ID, when the atrium was paced at a slightly higher rate than the spontaneous rate and during incremental atrial pacing. From these measurements, the maximum increase of PIACT (MIPIACT) was deduced. In this elderly population, the PIACT was similar (117 +/- 26.9 msec) to the data in the literature. However, there were large interindividual variations that were also found in SIACT. We found a close correlation between SIACT and PIACT (P < 0.0001). PIACT was on average 50 msec longer than SIACT. SIACT increased with age (P < 0.03). The MIPIACT was 15.3 +/- 15.2 msec. In the majority of patients, the MIPIACT was > 10 msec, and even reached 90 msec in one patient. MIPIACT was longer in patients with a PIACT exceeding 110 msec (P < 0.004). Based on IACT alone, the AV interval must be lengthened on average by 50 msec when changing from atrial tracking-ventricular pacing to atrial pacing-ventricular pacing, but large individual differences must be kept in mind. Elderly people should probably have a longer AV delay.

Thallium-201 reinjection imaging improves myocardial viability detection when compared to standard 3-4-hr redistribution imaging, however, the extent of ischemic but viable myocardium is still underestimated. We tested whether the sensitivity of reinjection imaging could be increased by giving nitrates postexercise to improve blood flow during the redistribution period. Twenty patients with coronary artery disease were included, 11 of them with a recent myocardial infarction. All patients underwent two exercise/4-hr redistribution 201Tl SPECT protocols: one with reinjection alone and the other with nitrates and reinjection. In the latter case, 20 mg of Isosorbide Dinitrate were given to patients immediately after postexercise imaging. Fifteen patients had reversible defects with reinjection alone, three additional patients were defined as ischemic with nitrates/reinjection protocol. Reinjection alone identified 41 reversible segmental defects, all except one were also evaluated as reversible with nitrates/reinjection. However, among the 54 segments showing fixed defects after reinjection only, 14 (26%) presented as reversible with the nitrates/reinjection protocol. The redistribution extent (segments/patient) was 2.05 +/- 0.41 segments with reinjection alone and 2.75 +/- 0.38 (p < 0.01) with nitrates/reinjection. In 15 patients showing reversible defects with both protocols, the redistribution extent was 2.73 +/- 0.41 segments with reinjection alone and 3.20 +/- 0.40 (p < 0.05) with nitrates/reinjection. Thallium-201 SPECT with nitrates and reinjection improves the detection of ischemic but viable myocardium in comparison to SPECT with reinjection alone.

This study evaluated the correlations between left ventricular (LV) diastolic parameters assessed by equilibrium radionuclide angiography (ERNA) and heart rate (HR) through right ventricular pacing. Twelve patients with a permanent right ventricular apex pace-maker were included. Serial ERNA studies were performed under 6 sets of pacing cycle length (heart rate = 52, 62, 72, 82, 92, 104 beats/min) for each patient. The left ventricular ejection fraction was 49.9% +/- 3.1% under pacing HR of 52 bpm and 43.8% +/- 3.1% under pacing HR of 104 bpm. The peak filling rate (PFR) increased very significantly with HR (r = 0.98, P less than 0.001). When the relative changes of end-diastolic volume were taken into account, the correlation between PFR and HR remained significant (r = 0.94, P less than 0.001). The absolute time to PFR (TPFR) did not significantly change with HR, but the ratio of TPFR to cycle length strongly correlated with HR. Our study clearly demonstrates that the PFR assessed by ERNA increases and the TPFR occupies an increasing proportion of the cycle length as HR increases. Therefore, LV diastolic parameters should be normalized for HR in clinical applications. In particular, HR changes should be considered when LV diastolic parameters are used for the assessment of therapeutic interventions.