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Left ventricular hypertrophy (LVH) is a recognized independent risk factor for cardiovascular morbidity and mortality. The purpose of this study was to assess the determinants of left ventricular mass index (LVMI), according to the presence or absence of silent myocardial ischaemia (SMI), in diabetic patients with at least two additional risk factors but with no known coronary artery disease. Eighty diabetic patients (14 Type 1 and 66 Type 2) were studied, and LVMI was measured echocardiographically. Three non-invasive tests (the ECG stress test, thallium-201 myocardial scintigraphy with intravenous dipyridamole infusion, and ambulatory 48-h ECG monitoring) were performed on all patients. Forty-five percent of patients had LVH (LVMIor = 110 g/m2 in men andor = 106 g/m2 in women). Twenty-six patients (37%) had SMI assessed on at least one of the non-invasive tests, 7 of whom had significant coronary stenoses on angiography. LVMI was significantly higher in patients with coronary stenoses on angiography than in those with SMI but without coronary stenoses or in those without SMI (p0.05), and was correlated with systolic blood pressure. In patients free of SMI, LVMI correlated with creatininemia. In patients with SMI and normal coronary arteries on angiography, LVMI correlated with the waist/hip girth ratio, the log urinary albumin excretion rate and the red blood cell filtration index (a rigidity index). This study suggests that LVH is very frequent in diabetic patients and that the main factor contributing to the increase of LVMI differs according to the presence or absence of SMI and coronary stenoses: volume load in patients free of SMI, microcirculatory disorders in those with SMI but with normal coronary arteries, and blood pressure in those with coronary stenoses.

The purpose of this study was to evaluate the ability of three noninvasive techniques to detect silent myocardial ischaemia and analyse the factors associated with this condition, particularly left ventricular hypertrophy, in diabetic patients. An ECG stress test, a thallium-201 myocardial scintigraphy with dipyridamole intravenous infusion, ambulatory 48 h ECG monitoring and an echocardiographic study were performed in 92 diabetic patients without cardiac symptoms but withor = 2 additional cardiovascular risk factors. At least one of these tests was positive in 28 patients (30.4%), suggesting silent myocardial ischaemia. Twenty-four of these patients had a coronary angiography which showed significant coronary stenosis in only 9 cases. An accurate echocardiographic tracing was obtained in 79 patients, particularly in 7 of the 9 with coronary stenosis. Left ventricular hypertrophy was detected in 34 patients, 6 of whom had coronary stenosis. In patients with left ventricular hypertrophy, the positive predictive values of myocardial scintigraphy and the ECG stress test were respectively 50% and 100%, as compared to only 33% and 11% in those without hypertrophy. In summary, coronary stenoses were found in10% of asymptomatic diabetic patients withor = 2 cardiovascular risk factors, but more frequently in individuals with left ventricular hypertrophy. Thus, silent myocardial ischaemia should be searched for first in diabetic patients with hypertrophy, for which the stress test was the most accurate detection method in this study.

The influence of classical atherosclerosis risk factors (male sex, smoking, hypercholesterolemia, diabetes, overweight and hypertension on peri-hospital mortality and morbidity were studied in 83 patients (68 men and 15 women) aged 63 +/- 13 years and undergoing peripheral arterial surgery. None of these factors was statistically correlated with peri-operative complications with the exception of hypertension but the correlation was slight (0.5 less than p less than 0.10). In contrast, there was a powerful statistical (p less than 0.0003) link between age and morbidity and mortality associated with this type of surgery.

From October 1983 to January 1985, 46 patients (38 men and 8 women; mean age 60 years, range 37-83) underwent peripheral vascular surgery either of the internal carotid artery or of arteries of the lower limbs. All patients had thorough clinical examination, ECG and thallium dipyridamole myocardial scanning before operation, as a result of which they were divided into 20 with, and 26 without chronic ischemic heart disease. Three major cardiac events were noted during or following a period of one month after surgery: two deaths due to a cardiac ischemic event and one post-operative unstable angina pectoris. The three patients with these complications were classified in the coronary group (NS). When the patients were reclassified according to the presence or absence of thallium redistribution on serial images after dipyridamole, 14 had redistribution and 32 had no redistribution. The three major cardiac events were found to have occurred in the group with redistribution (P less than 0.04). Our study suggests that patients with redistribution have a high incidence of postoperative ischemic events. They should be considered for a particular pre-operative coronary management to avoid post-operative major cardiac events and to improve survival.

The ambulant recording of the electrocardiogram by the Holter technique has become one of the non invasive examinations widely used in two indications: paroxysmal arrhythmias and coronary disease. However, the technical limitations of the method and the occasionally improper extension of the indications of Holter recording lead to disappointing results. The aim of this work is an estimation of the usefulness of Holter as a function of the desired information by a statistical study. Of 646 consecutive recordings, 200 were taken at random; 169 usable ones were classed in 7 categories according to the clinical requirement; the overall usefulness amounts to 27.5 percent of the cases in which Holter permits a diagnosis. As far as paroxysmal disturbances of rhythm are concerned, Holter is more efficacious than the standard electrocardiogram. However, the efficiency of the method is low: 17.4 percent of cases when it was required to find a cardiac arrhythmia causing a cerebral vascular accident, and even lower, 5.1 percent, when a malaise was concerned. In 20 percent of the cases was a useful tool in diagnosing thoracic pain. In 9.5 percent of the cases the tracings were not interpretable owing to their poor quality. These findings urge more rigor in the choice of indications and a better control of technical problems if the efficacy of the method is to be improved.

Twelve years after mediastinal irradiation for Hodgkin's disease, a 38-years old man developed an infra-hisian atrioventricular block with syncopes. The rarity of this complication of radiotherapy is emphasized. A review of the literature yielded only 6 cases of atrioventricular block associated with cobalt therapy; a pathological examination was performed in two of these patients and an electrophysiological study in two others.

From October 1983 to January 1985, 46 patients (38 men and 8 women; average age, 60 years; range, 37 to 83 years) underwent peripheral vascular surgery of either the internal carotid artery or the arteries of the lower limbs. Each patient had a thorough clinical examination, an ECG, and a dipyridamole-thallium-201 myocardial scan before operation. On the basis of results, they were divided into two groups: 20 patients with and 26 patients without chronic ischemic heart disease. Three major cardiac events were noted during or after a period of 1 month after surgery: There were two deaths due to cardiac ischemic events and one patient had postoperative unstable angina pectoris. These three patients were classified in the coronary group (NS). When the patients were classified on the basis of whether or not there was thallium redistribution on serial images after infusion of dipyridamole, 14 with redistribution and 32 without redistribution were noted. The three patients who had major cardiac events were in the former group (p less than 0.04). Our data suggest that patients in whom redistribution occurs have a high incidence of postoperative ischemic events. These patients should be considered for particular preoperative coronary care to avoid major postoperative cardiac events and to increase chances of survival.

Twenty-seven patients were diagnosed as having dilated cardiomyopathies, based on increases in the cardiothoracic index greater than 0.50, in the diastolic and systolic diameters of the left ventricle, and in the telediastolic volume of the left ventricle, which was indexed by body surface determined by contrast ventriculography. They underwent gallium 67 scintigraphic examination of the myocardium, in order to non-invasively detect the presence of an inflammatory infiltrate. Fifteen of them also had endomyocardial biopsies and all had virology check-up. The results were disappointing. Only in one case was the scintigraphic image undeniably positive; in 20 other patients the findings were dubious or negative. This technique did not demonstrate the presence of an inflammatory infiltrate and thus we could not establish an association between myocarditis and dilated cardiomyopathy.

It has been hypothesized that dilated cardiomyopathy (DCM) is of dysimmune origin. Conventional immunological studies have provided no evidence that a primary disregulation of immune mechanisms is involved. In the present study, the possibility of an individual predisposition to DCM resting on a preferential distribution of HLA system antigens has been investigated. Typing of the HLA system antigens A and B was performed in a group of 38 DCM patients who were heavy drinkers. The results were compared with those obtained in: (a) 57 alcoholic patients without cardiopathy, and (b) a population of 306 healthy subjects. All subjects were caucasians. Compared with alcoholic patients without cardiac disease, DCM patients had a prevalence of B8 allele. The relative risk of developing DCM was 2.83 in the presence of the B8 antigen. This result suggests a genetic predisposition to DCM: the B8 allele, prevalent among our patients, is associated with the phenotype of numerous autoimmune diseases. This study therefore supports the theory that DCM is of dysimmune origin, but this must be confirmed by further investigations conducted on a larger number of cases.

Forty-nine diabetic patients (26 type I and 23 type II), free of cardiovascular disease symptoms, were compared with 32 controls in a noninvasive study of left ventricular (LV) function. Absence of ischemic cardiopathy was confirmed by routine investigations and an exercise electrocardiogram using 12 leads with a thallium-201 myocardial scintigraphy. Diabetic patients had (1) a significantly prolonged mean isovolumetric relaxation time (IVRT) assessed by M-mode echocardiography and phonomechanography; (2) a significantly reduced E-F slope; (3) an increased mean Weissler index (pre-ejection period/LV ejection time). The IVRT and E-F slope abnormalities reflect increased myocardial stiffness and impaired LV compliance. The increased Weissler index reflects impaired myocardial contractility. These abnormalities were not related to sex, age, duration of diabetes or to the presence or extent of complications. No significant difference was found between diabetic patients and controls for mean diastolic and systolic LV diameters, thickness of the posterior wall or of the interventricular septum, assessed by echocardiography, or for the ejection fraction, determined by radionuclide angiocardiography. Finally, more than half of the patients with a frankly abnormal IVRT, Weissler index and E-F slope had had diabetes for less than 5 years, some even less than 2 years, without complications. These data show: (1) evidence of LV dysfunction specific to diabetes and unrelated to ischemic cardiopathy and hypertension; (2) the possible involvement of a metabolic factor in this early asymptomatic LV abnormality rather than microangiopathy.

Striated skeletal muscle from 20 patients with primary cardiomyopathies were examined histologically by light microscopy. The average age of the patients was 51 years (range 34-71 yr). Seventeen of them (16 men, 1 woman) had dilated cardiomyopathy, 9 of which were associated with chronic alcoholism, and 3 men had hypertrophic cardiomyopathy. All underwent routine peripheral muscle biopsies, without clinical or biological signs of neuromuscular involvement. Minor anomalies were observed in the dilated cardiomyopathy patients: 4 in chronic alcoholics and 1 in a diabetic patient. All 3 biopsies were normal in the hypertrophic cardiomyopathy group. Comparison of these results and those reported in the literature showed that our limited findings were not only due to the study protocol and that the histological lesions were not specific to cardiomyopathy.

A case of acquired immunodeficiency syndrome associated with myocarditis is reported. The myocarditis was peculiar in that it heralded the syndrome and followed a subacute course. It was most probably of infectious origin, although no pathogen has positively been identified; it may have been caused by a cytomegalovirus or even by the human immunodeficiency virus itself on a background of genetic predisposition. This case shows that while cardiologists are concerned with cardiac disorders occurring during AIDS, they must also consider the possibility of AIDS when confronted with a myocarditis.

In order to test the hypothesis of the role of a suppressor/cytotoxic T lymphocyte deficit in the pathogenesis of dilated cardiomyopathies (DCM), 20 patients (11 alcoholic-A; 9 primary-P) were compared with 24 normal controls (N) and 10 patients with chronic cardiac failure (CCF). The percentage of OKT 3, a global assessment of the T lymphocytes, did not differ significantly between the groups. The percentage of OKT 4 (helper T lymphocytes) was significantly lower in DCM (43 +/- 8.1 p. 100) compared to N (51.92 +/- 8.1 p. 100), p less than 0.001. The percentage of OKT 4 was also lower in CCF (45.3 +/- 3.91 p. 100) compared to N (p less than 0.05). There was a very significant decrease in the percentage of OKT 8 (suppressor/cytotoxic T lymphocytes) in DCM (17.23 +/- 4.78 p. 100) compared to N (26.42 +/- 5.72 p. 100) (p less than 10(-8)). A reduction of OKT 8 was also observed in CCF compared to N (p less than 0.05). The ratio of OKT 4/OKT 8 was significantly higher in DCM (2.7 +/- 0.97) compared to N (2.08 +/- 0.6) (p less than 0.05). This difference was not observed in CCF (2.19 +/- 0.48). There were no differences between DCM A and P. These results indicate that chronic cardiac failure is associated with an equal reduction in the percentage of OKT 4 and OKT 8 lymphocytes. Dilated cardiomyopathy is associated with a large reduction in the OKT 4 and especially in the of OKT 8 with a statistically significant increase in the OKT 4/OKT 8 ratio. Although chronic cardiac failure seems to affect lymphocytes, these results are compatible with a deficit of suppressor/cytotoxic T lymphocytes in dilated cardiomyopathies.

Between November, 1978 and August, 1983, 22 patients aged from 28 to 65 years with idiopathic dilated cardiomyopathy diagnosed on the basis of clinical and haemodynamic criteria were investigated. All these patients, who consumed alcohol in excessive amounts, were followed up for 1 to 58 months. The overall mortality rate was 10 p. 100 at 4 months and 25 p. 100 at 58 months. Six patients were clinically improved with reduction of heart size (group A); 10 patients showed deterioration with 3 deaths (group C) and 6 patients followed an intermediate course (group B). When the characteristics of the groups were evaluated, it was found that compared to group C patients those in groups A and B had a lower cardiothoracic ratio: 0.56 +/- 0.04 (B) vs 0.64 +/- 0.06 (C) (P less than 0.02), a lower indexed end-diastolic diameter and systolic diameter on TM echo: 3.20 +/- 0.50 cm/m2 (A) vs 4.13 +/- 0.39 cm/m2 (C) (P less than 0.02), and 2.72 +/- 0.37 cm/m2 (A) vs 3.57 +/- 0.47 cm/m2 (C) (P less than 0.02) respectively, and a lower indexed end-diastolic volume as evaluated by angiography: 121 +/- 61 ml/m2 (A) vs 202 +/- 65 ml/m2 (C) (P less than 0.06). Dilated cardiomyopathy associated with excessive alcohol consumption has a better prognosis when the patients stop drinking and when their heart dilatation is mild to moderate.

Apparently primary dilated cardiomyopathy poses a difficult aetiological problem. There is epidemiological, biological and histological evidence that some of them are the long-term results of acute myocarditis especially due to Coksackie virus. In order to establish whether cytomegalovirus infection could also have the same consequences 67 cases of dilated cardiomyopathy were reviewed to look for inflammatory changes and CMV serology. The results indicate a possible link between acute CMV myocarditis and dilated cardiomyopathy (7 p. 100 of cases) but this is difficult to prove in the chronic stage of the disease.

49 diabetics (D) (26 IDD and 23 NIDD) were compared to 32 controls (C). Absence of ischemic cardiopathy (IC) was confirmed by routine investigations and noninvasive cardiovascular techniques, including an exercise ECG using 12 leads and a thallium 201 scintigraphy. Our results show: a) a prolonged mean isovolumetric relaxation time (IVRT) as studied by the M mode echocardiography and phonomechanography: D = 0,10 sec +/- 0,04; C = 0,05 sec +/- 0,02; p less than 0,0001; b) a reduced mean EF slope: D = 97,48 +/- 37,08 mm / sec; C = 125,68 +/- 34,35; p less than 0,005; c) a high mean Weissler index (ratio of PEP to LVET): D = 40 +/- 0,08; C = 33 +/- 0,05; p less than 0,01. IVRT and EF slope abnormalities are related to increased myocardial stiffness and impaired LV compliance. In the absence of changes in preload and afterload, the high Weissler index reflects impaired contractility of the myocardium. These abnormalities are related neither to the duration of diabetes nor to the presence or severity of the complications. With the M mode echocardiography, mean diastolic and systolic thickness of the septum is greater in D with retinopathy than in C (p less than 0,005 and p less than 0,03 respectively); mean diastolic and systolic thickness of the posterior wall is greater in NIDD than in C (p less than 0,001 and p less than 0,025). We conclude that there is evidence of left ventricular functional abnormalities specific to diabetes and unrelated to IC and hypertension. Our findings support the hypothesis that they may be due to metabolic disorders and/or myocardial microangiopathy.

In order to detect evidence of cardiac autonomic neuropathy, 24-hour continuous electrocardiographic monitoring was carried out on fifty-one diabetic patients (thirty-one IDD, twenty NIDD) and twenty-two healthy controls taking no treatment which could alter the heart rate. In the diabetic patients the minimum 24-hour heart-rate and the mean sleeping heart rate were significantly higher, and the maximum 24-hour heart rate and the ratio [(maximum-minimum heart rates)/minimum heart rate] were significantly lower. Evidence in one diabetic of cardiac autonomic neuropathy was found only as the difference (maximum-minimum heart rates). This index was found to be below 38/min (mean-2 SD of the controls) in seven diabetics, but only one of the nine diabetics with signs of autonomic neuropathy had this abnormal index. The mean values for the minimum and the mean sleeping heart rates were high in the IDD with or without signs of peripheral neuropathy and without signs of autonomic neuropathy but were not high in IDD with signs of autonomic neuropathy. These findings suggest the presence of cardiac autonomic neuropathy in diabetics. However, the possibility of insulin-induced tachycardia should be considered this tachycardia is probably related to stimulation of the sympathetic nervous system, which would explain the absence of abnormalities in IDD with autonomic neuropathy.

A forty year old man with malignant pheochromocytoma of Zuckerkandl's body is reported. The case history is a severe hypertension with acute episodes, tachycardia and psychiatric disorders. The tumor extra adrenal site was got by abdominal scanning and its malignant type was demonstrated by pathological study and metastasis of lymph nodes occurring 4 months after surgery. The surgical treatment was associated to antimitotic and alpha blocking therapy. Clinical and biological status is still good after a twelve months follow-up.