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Ten healthy male volunteers performed maximal exercise tests on a bicycle ergometer. A control reading was obtained; at a second session propranolol 80 mg was given, and then placebo, 100 mg or 200 mg AQ-A 39 were administered in a randomised double-blind manner. At peak exercise, the heart rate averaged 191.6 beats/min during the control test, 185.8 beats/min after placebo, 172.4 beats/min with 100 mg of AQ- A 39 (-10%), 166.0 (beats/min) with 200 mg of AQ-A 39 (-13.4%); with 80 mg of propranolol, the heart rate averaged 132.8 beats/min and the workload accomplished was substantially lower than that accomplished with AQ-A 39 and placebo which remained the same as in the control test. No effect on blood pressure was observed. The rate pressure product was significantly reduced with AQ-A 39. [ABSTRACT FROM AUTHOR]

We report a case of atrioventricular (AV) block diagnosed 28 years ago compensated by a functional accessory pathway. During follow-up, the accessory pathway conduction properties at rest deteriorated while the refractory properties were unchanged. At 46 years, the patient became symptomatic from bradycardia and a dual-chamber pacemaker was implanted. Although rare, concealed AV block due to an accessory pathway has to be recognized before radiofrequency ablation.

The particularities of exercise tests in athletes concern mainly the exertion protocols adapted to their increased physical capacities and the interpretation of ECG tracing which can sometimes be very special at rest and also misleading during exercise. In the great majority of cases, the test used is both cardiac and pulmonary, in order to assess the aerobic capacities, the maximal aerobic power, and the determination of ventilation thresholds (programming and follow-up of training...). More infrequently, the test is used to detect cardiovascular diseases, especially during a longitudinal follow-up of high-level athletes, or to exclude it in case of cardiovascular symptoms, atypical resting ECG or even in case of suspicion of disease (arrhythmia, cardiac chamber hypertrophy or dilation at echocardiography). In more aged sportsmen (athletes masters), exercise tests performed are usually required for screening coronary heart disease. In this case the test protocols should be more adapted for screening than for the assessment of sportive capacities.

No study has shown that moderate wine consumption has any adverse effect on cardiovascular risk. Binge drinking induces a risk of thrombosis. The continuation of moderate wine consumption is reasonable and probably beneficial as secondary prevention. Polyphenols are antioxidants, antiaggregants, and NO donors; they increase HDL cholesterol levels. Moderate wine consumption appears to protect cognitive function in the elderly.

The authors report the case of a woman with an acute myocardial infarction in whom coronary angiography performed a few hours earlier was completely normal. Transoesophageal echocardiography showed two thrombi in the left atrial appendage confirming the thromboembolic mechanism of this infarct.

Objective: The study aimed to assess, at trough plasma concentration, the anti-ischemic and antianginal efficacy and tolerability of trimetazidine modified release (MR) 35 mg taken twice daily by patients with stable angina pectoris., Design: This multicenter, randomized, double-blind, placebo-controlled, international study started with a run-in period of 3 weeks with atenolol 50 mg/day and placebo, followed by a 6-month treatment period with once daily atenolol 50 mg and twice daily trimetazidine MR 35 mg or placebo., Patients: The study involved 223 patients with stable angina pectoris (class II or III of the Canadian Cardiovascular Society [CCS] classification). 180 patients were analyzed in the full analysis set (FAS) following the intention to treat principle (ITT) and 167 patients were analyzed in the per protocol set (PPS). The PPS data are presented here., Interventions: Two exercise tolerance tests (ETTs) were performed during the run-in period in order to assess the stability of exercise tolerance before angina pectoris and significant ST segment depression. Efficacy was assessed by a third ETT performed after 8 weeks of treatment, at trough, 12 hours after the intake of the drug. Safety was evaluated over the 6-month duration of the study., Main Outcomes Measures: Time to 1 mm ST segment depression., Results: Time to 1 mm ST segment depression was increased by 44 seconds more in the trimetazidine MR 35 mg group than in the placebo group (p = 0.005). A significant difference was also evidenced for the time to onset of angina pectoris (p = 0.049) and for the reason for stopping the exercise (p = 0.02). No difference between groups was found for safety parameters., Conclusion: This study demonstrates the anti-ischemic and antianginal efficacy of trimetazidine MR 35 mg twice daily at trough plasma concentrations in patients with stable angina pectoris receiving atenolol 50 mg/day. Furthermore, the drug is well tolerated over 6 months.

After a review of the different central and peripherical factors limiting exercise capacity in chronic heart failure, the authors report the mechanisms of these increment with exercise training. The different indications for clinical training techniques of segmental training on a specific bench are discussed; but it appears that both aerobic and repetitive weight programs seem to have short term favorable and complementary effects.

Exercise tolerance tests in athletes are usually performed to evaluate aerobic exertion capacity and to plan training. They are based on simultaneous measurement of expired gases (determination of ventilation threshold and of VO2max). They can also be used to seek a possible cardiovascular anomaly, particularly in case of clinical symptoms or anomalies on auscultation; findings based on electrocardiography (rhythm, repolarisation, etc.) and on blood pressure readings, however, can lead to suspicion of an early anomaly and direct complementary investigation.

Unlabelled: Between 1980 and 1995, we observed twenty-five patients (22 males, 3 females) at the mean age of 50.6 +/- 13 years, without previous myocardial infarction who presented exercise induced ST elevation on a bicycle stress test., Methods: Significant ST elevation was defined as a > or = 1 mm change present in > or = 1 lead measured 0.08 sec after the J point and in 3 consecutive beats. All patients have undergone coronary angiography in the days following the exercise test., Results: Most of patients (56%) presented a history of typical angina that was either purely exertional (8 pts) or also occurred at rest (6 pts). Others (36%) had non typical angina or no angina (8%); 78% of pts were smokers. Sixteen patients (group I) had ST elevation during exercise (exercise duration: 7.6 +/- 4 min; peak heart rate: 135.5 +/- 29 batt/min; ST = 3.5 +/- 1.5 mm) and nine (group II) during the recovery phase (exercise duration 16.3 +/- 1.6 min; p < 0.05; peak heart rate 168 +/- 22 batt/min; p < 0.05; ST: 5.8 +/- 3 mm; p < 0.05). In group I, 1 patient had no vessel disease, 12 had one vessel disease, 3 had multivessel disease with 6 cases of hypersevere coronary stenose (> 90%). In group II, 4 patients had normal coronary arteries, there was one vessel coronary artery disease in 4 patients and multivessel in one subject, without hypersevere coronary stenosis. Correlation between anatomic location of stenosis and electrocardiographic ST elevation was excellent, particularly in case of single vessel disease (100%). All patients underwent one or more new exercise tests after therapeutic intervention (surgery n = 3; angioplasty n = 7; medical treatment n = 15), only 2 patients had persistent exercise induced ST elevation. During follow-up (5 +/- 3 years), 3 patients died (2 cardiac deaths) and 3 had recurrent angina controlled by new treatment., Conclusion: Exercise-induced ST elevation is a rare phenomenon in patients without prior myocardial infarction. When occurring purely during exercise, coronary lesions are frequent and often servere, in the other hand ST elevation of the recovery phase is frequently associate with normal arteries or less severe lesions. In most cases, revascularisation or medical therapy can abolish clinical and electrocardiographic abnormalities.

We describe the occurrence of acute myocardial infarction during transesophageal echocardiography (TEE) in a patient with atrial fibrillation and underestimated angina. Such a case has not been previously reported in the literature. This case illustrates one of the possible complications of TEE, leading us to suggest systematic sedation in patients with angina in whom TEE is envisaged.

Iatrogenic third degree atrioventricular block due to alpha interferon is rare. The authors present a case which occurred with low dosage, regressed when treatment was withdrawn and reappeared when treatment was reintroduced. The physiopathological mechanism of disease of the conduction pathways and its general cardiotoxicity is not yet understood. The secondary effects of this increasingly widely used anti-tumoral and anti-infectious drug should be recognised in order to prevent them. Initial cardiological investigation and follow-up are indicated to ensure this prevention.

This report describes two patients with atrial fibrillation in whom an implanted CHORUS DDD pacemaker programmed to the DDI mode produced an irregular ventricular stimulation rate. The lower rate timing of these devices is atrial-based only when an atrial event opens an AV interval shorter than the programmed AV delay. In the DDI mode, if Api represents the time when an atrial paced event (Ap) would have occurred if it had not been inhibited by a previous atrial sensed event (As), then Api-Vp constitutes the implied AV interval where Vp is a paced ventricular event. Although the As-Vp interval (As-Api + Api-Vp) generates an atrial refractory period during its entire duration, the pacemaker can sense an atrial event (AR) during the implied AV interval. AR cannot start another AV delay, but it can initiate the atrial-based lower rate interval. This timing mechanism can cause irregular prolongation of Vp-Vp intervals to a value longer than the programmed lower interval with a maximal extension equal to the programmed AV delay. Such behavior of the CHORUS pacemaker should not be interpreted as malfunction.

The aim of rehabilitation is to improve exercise capacity and, thereby, the autonomy of patients with cardiac failure. For many years, these patients were considered inapt to perform physical exercise and they are in the same situation at the dawn of the year 2000 as patients with myocardial infarction forty years ago. The symptoms of cardiac failure (dyspnoea of effort and muscular fatigue) are not only the consequence of pulmonary hypertension and decreased muscular perfusion. Prolonged interruption of exercise and long stays in bed or in a chair lead to anatomical and functional amyotrophy, which, in turns, incites to further inactivity. Deconditioned respiratory muscles cannot tolerate the increased load of hyperventilation. Neurohormonal changes cause vasoconstriction which reduces muscular perfusion. Physical training can significantly improve these abnormalities, though it does not seem to have a measurable effect on cardiac function; based on segmental work which enables performance of substantial efforts with a minimum of haemodynamic changes, it provides a 20 to 30% gain in capacity, mainly increasing the duration of submaximal exercise rather than maximum performance. Muscular fatigue is the symptom which is the most improved. Unfortunately the organisation, which is more difficult than in the post-infarction period, and the generalisation of the practice of long-term, well adapted physical training remains marginal although hundreds of thousands of patients could benefit; more than the inertia of the official instances concerning anything related to cardiac rehabilitation, it is the lack of interest shown by cardiologists and the absence of flexible structures within the health care organisation for elderly people which are responsible.

The growing numbers of elderly and cardiac patients are the consequence of progress in the prevention of the complications of coronary artery and valvular heart disease by surgery and revascularisation and improved treatment of hypertension which delays target organ complications by at least fifteen years. The elderly are particularly exposed to surgical risk: nearly half the patients with ischaemic heart disease die of cancer; a high proportion of elderly people require orthopaedic surgery either as an emergency (fractured femur) or as a standard procedure (knee surgery); nearly a quarter of patients requiring peripheral vascular surgery have coronary artery disease which may be silent. A preoperative consultation with the anaesthetist has been made compulsory, except in emergencies, giving time for preoperative investigations. The decrees of the Court of Cassation have also affected the traditional relationship of trust between patients and their doctors, leading to an increase in the cost of preoperative investigations without an accurate assessment of their benefits with regards to postoperative complications and the cost that they entail. Contrary to present tendencies reflected in the literature, the screening of risks should be simplified: clinical history and examination and resting ECG, often completed by stress testing, are sufficient in the large majority of cases. More importance should be attributed to the functional status than to the lesions. When the cardiac disease is asymptomatic, the chances are that it will remain so during and after surgery.... The main difficulty is not in identifying high risk patients: it is preventing cardiovascular events when surgery is unavoidable. The experience and collaboration between the quartet of anaesthetist, surgeon, cardiologist and general practitioner, are much more useful than the very incomplete bibliographical data concerning this side of the problem.

Delivery of a balloon-expandable stent was complicated by a systemic embolisation. The radio-opaque stent was lost in the descending aorta, but then removed by using a loop basket intravascular retriever set without any peripheral arterial complication.

Effort tolerance is reduced after correction of Tetralogy of Fallot. This prospective study investigated the cardiorespiratory response and the chronotropic function (mean follow-up 11.1 years) of 70 patients (43 boys and 27 girls) with an average age of 14.9 +/- 7.2 years (group 1) compared with 65 normal, sedentary subjects paired red for age and gender (group 2). All underwent exercise testing (Bruce protocol) with measurement of respiratory gases. Quantification of pulmonary regurgitation was performed by Doppler echocardiography. The chronotropic response to exercise was assessed by calculating the mean of slopes established by chronotropic metabolic relationship of Wilkoff. The cardiorespiratory response to exercise was abnormal in group 1: the duration of exercise (11.3 vs 13.6 min; p = 0.005), peak VO2 (35.5 vs 46 ml/min/kg; p < 0.001) and anareobic threshold (8.3 vs 9.2 min; p = 0.001) were decreased. Maximal heart rate (172 vs 190bpm; p < 0.001) and the mean of the metabolic-chronotropic slopes (0.68 vs 0.83; p < 0.001) were decreased in the patient group, showing abnormal chronotropic response to exercise. The latter seemed to be related to the severity of pulmonary regurgitation. The duration of exercise (10.6 vs 11.5 min; p = 0.001), peak VO2 (33 vs 37 ml/min/kg; p < 0.001), maximal heart rate (161 vs 177 bpm; p = 0.002) and the mean of the slopes of the metabolic-chronotropic relationship (0.59 vs 0.72; p < 0.001) were decreased in patients with moderate to severe pulmonary regurgitation. This study shows that significant pulmonary regurgitation is responsible for a poor cardiorespiratory response to exercise and for an abnormal chronotropic response which seems to be multifactorial but probably related to an adaptation favouring left ventricular filling during exercise.

This study assessed the diagnostic value of two new electrocardiographic criteria of coronary artery disease: the ST/HR index and the slope of the linear relationship between ST segment changes and the heart rate during the first three minutes of the post-exercise recovery period. These two criteria were compared to the standard criteria (> or = 1 mm horizontal or descending ST depression or > or = 2 mm ascending ST depression) to Detrano's ST/HR exercise index (> 1.6 microV/bpm in coronary patient), the exercise ST/HR slope (> or = 2.4 microV/bpm in coronary patients) and the exercise recovery loop (clockwise in normal and anticlockwise in coronary patients) in 88 subjects investigated for suspected coronary artery disease who underwent a computerised exercise stress test and coronary angiography (25 single vessel, 21 double vessel, 20 triple vessel disease; 22 with no significant coronary disease). The ROC identified thresholds of abnormality of the ST/HR recovery index at > or = 2.1 microV/bpm and of the ST/HR recovery slope at > or = 2.52 microV/bpm. Global comparison of the areas under the ROC showed the diagnostic superiority of the exercise ST/HR indices (0.96) over the standard criteria (0.92) and recovery indices (0.86) but without statistically significant values (p = 0.65 and p = 0.15 respectively). The ST/HR index and slope during recovery identify coronary disease with a diagnostic accuracy of 80% and 77% respectively which is similar to that (84%) of the standard ST criteria. The exercise-recovery loop was less accurate (64%).

Exercise capacity in cardiac transplanted patients has been reported to remain decreased in some studies; however, functional results after transplantation may vary, ranging from modest to spectacular improvement. The aim of the study was to quantify exercise capacity in a large series of transplanted patients and to search for factor predictive of a good functional result. Eighty-five patients (mean 52.1 +/- 11.8 years) underwent exercise testing with respiratory gas exchange measurements 1 to 100 months after transplantation. Mean performance was 112.4 +/- 33 W with a peak VO2 of 21.1 +/- 6 ml.min-1.kg-1. Heart rate was 103 +/- 14 at rest, reaching 142 +/- 22 beats.min-1 at the end of exercising. In univariate analysis, maximal or submaximal aerobic capacity parameters were strongly correlated with chronotropic reserve (r = 0.63; P < 0.001) without correlation with cold ischaemic time, number of rejection episodes or right bundle branch block. In multiple regression analysis, chronotropic reserve, time from transplantation, age of donor and age of patient were proved to be the variables best correlated with peak VO2. Our study confirms the persistence of a large decrease in aerobic functional capacity despite cardiac transplantation; limited exercise capacity does not improve over time, and is limited not only by the patient's age but by that of the donor, and especially by chronotropic reserve.

The use of sublingual nitroglycerin in the stress test is a precious tool in everyday clinical cardiology. It has several indications in this context: 1) Confirmation of the diagnosis of myocardial ischaemia by eliminating a large number of false-positives with no marked variation of ST depression and performance after sublingual nitroglycerin in contrast with patients presenting authentic myocardial ischaemia on effort. 2) Teaching of the preventive and opportunistic use of nitroglycerin before intense effort and before physical training which, in the long-term, is one of the most effective treatments of exertional angina pectoris. 3) Demonstration of potentiation of the effect of certain antianginal drugs such as beta-blockers. 4) In therapeutic trials, the stress test performed with sublingual nitroglycerin is used as a reference and to select patients capable of a fairly marked progression, so that they can be included in a protocol. It has the advantage of demonstrating a functionally measurable improvement of the stress test with an appropriate drug. 5) Progression with sublingual nitroglycerin during the stress test is related to regression of ischaemia i.e. restoration of functional viability of hibernating or shocked ischaemic segments of myocardium. It is probably the only realistic way to predict possible improvement after revascularization compared to other tests, which may be over-sensitive, as they detect zones with little capacity of regaining a viability which really contributes to cardiac output on exertion.

In patients taking flecainide, exercise-induced arrhythmias are believed to be related to QRS widening at rest and during exercise. Our aim was to determine, retrospectively, predictive factors of flecainide-induced (a) QRS widening at rest and during exercise, and (b) proarrhythmia (PA) during exercise. Flecainide was administered to 119 patients for atrial and/or ventricular arrhythmias who performed a maximal treadmill test. A total of 63 patients had a normal heart (defined by the absence of structural heart disease and an ejection fraction ≥ 55% by echocardiography and/or cardiac catheterisation), 26 had coronaropathy, 18 valvulopathy and 3 had both, and 7 had dilated and 2 hypertrophic cardiomyopathy. The mean dosage of flecainide was 190 or 200 ± 10 mg/day. Previous myocardial infarction (MI) was a predictive variable of flecainide-induced QRS widening at rest (p = 0.04). During exercise, the risk factors of QRS widening were previous MI (p = 0.008), angina without previous MI (p = 0.009), structural heart disease (p = 0.001) and a bundle branch block at rest (p = 0.01). PA on exercise occurred in 7 patients. Structural heart disease (p = 0.04) and an impaired left ventricular ejection fraction (LVEF) [p = 0.02] were predictive variables of PA. All patients with left ventricular dysfunction and PA had a QRS widening with flecainide at rest ≥ 25%. The risk factors of QRS widening at rest and during exercise with flecainide were distinct from those of PA on exercise. In patients with an impaired LVEF, a flecainide-induced QRS widening of 25% at rest was the threshold value beyond which there was a high risk of PA during exercise. This study was retrospective and not a double-blind trial, therefore the results need to be corroborated in a prospectively designed trial.

After a Senning procedure for transposition of the great arteries (TGA), systolic dysfunction of the right ventricle (RV) is common. Pre and peroperative chronicale hypoxia may be the cause of this ventricular myocardial alteration. In order to detect abnormalities of myocardial viability and to study their relationship to RV function, the authors studied 41 patients (pts), 11.3 +/- 3 years after a Senning procedure. All patients underwent myocardial scintigraphy of the RV under basal conditions. 1 hour after injection of 1.5 mCi of Thallium 201. The RV ejection fraction (n = 41) and at peak effort (n = 25). Exercise ability and aerobic capacity were assessed by exercise testing (Bruce) with gas exchange measurement and compared with 41 normal matched subjects. The cardiorespiratory response to exercise was altered in the Senning group : duration of effort (10.5 +/- 2 vs 13.2 +/- 2 min; p < 0.0001), peak VO2 (33 +/- 5 vs 44.4 +/- 6 ml/min/kg; p < 0.0001), anaerobic threshold (6 +/- 1 vs 8.4 +/- 1.9 min; p < 0.05) were lower compared to controls. Abnormalities of RV viability were observed in 18/41 pts (44%), moderate in 12 cases and severe in 6 cases. Resting and exercise RVEF were significantly lower in patients with myocardial defects (45 +/- 5 vs 51 +/- 7%; p < 0.0005, and 49 +/- 9 vs 58 +/- 9%; p < 0.05 respectively). In conclusion, after the Senning procedure for TGA, scintigraphic abnormalities of the systemic ventricule are common and associated with an alteration of systolic function at rest and on exercise.

Background: Haemodynamic measurements taken at rest and during exercise showed that percutaneous transvenous mitral commissurotomy results in both acute and long-term improvement. However, the time lag before there is an increase in exercise and in peak oxygen uptake appears to be delayed and irregular., Patients and Methods: To assess the potential of physical training to restore better physical capacity after percutaneous transvenous mitral commissurotomy, 26 patients with mitral stenosis were studied after the procedure. The group was split into two. Thirteen underwent a 3-month rehabilitation programme, and the other 13, who did not, acted as controls., Results: The mitral valve orifice area increased similarly, from 1.12 +/- 0.17 to 1.88 +/- 0.28 cm2 in the training group and from 1.04 +/- 0.16 to 1.88 +/- 0.19 cm2 in the control group. Cardiopulmonary parameters were similar before percutaneous transvenous mitral commissurotomy (peak VO2: 19.9 +/- 2.4 vs 18.9 +/- 4.5 ml. min-1.kg-1; peak workload: 94.6 +/- 29.3 vs 96.1 +/- 25 watts; VO2 at anaerobic threshold: 17 +/- 3.4 vs 16.1 +/- 5.2 ml.min-1.kg-1; all P = ns). Three months later the results were higher in the training group 1 (peak VO2: 26.6 +/- 4.7 vs 21.6 +/- 3.8 ml.min-1.kg-1, P = 0.03; peak workload: 125.4 +/- 26.6 vs 108.5 +/- 23 watts, P = 0.03; VO2 at anaerobic threshold: 19.6 +/- 5.8 vs 15.8 +/- 2.9 ml.min-1.kg-1; P = 0.02)., Conclusion: These results indicate that patients should take up exercise after successful percutaneous transvenous mitral commissurotomy for better functional improvement.

Study Objectives: This study reports on the cardiorespiratory response to graded exercise in patients after venous switch operation for transposition of the great arteries., Design: Several small studies have documented a diminished exercise tolerance after Mustard repair for transposition of the great arteries, little information exists, however, about long-term cardiorespiratory exercise performance in patients who have had the Senning procedure., Patients: This prospective study reports on the serial long-term (mean, 11 +/- 2.8 years) cardiopulmonary exercise performance of 43 patients (age, 12 +/- 3.1 years) who underwent a Senning procedure, with no significant postoperative abnormalities. Forty-three matched healthy children were also studied as a control group., Measurements and Results: All underwent exercise testing (Bruce protocol) with metabolic gas exchange to determine parameters at 3 min, anaerobic threshold, similar heart rate (150 beats/min), and peak exercise. Time of exercise was 10.5 +/- 1.9 min in patients and 13.4 +/- 2 min in control subjects (p = 0.0001). Overall, patients reached 73% of peak oxygen uptake achieved by control subjects (32.6 +/- 5.6 vs 44.7 +/- 6 mL/kg/min). Chronotropic response (188 +/- 15.7 vs 166.5 +/- 19.6 beats/min [p = 0.0001]) and oxygen pulse (7.4 +/- 2.9 vs 10.7 +/- 4.2 mL/beat [p = 0.0002]) were lower in patients at peak exercise. Patients had a greater respiratory response to exercise: both respiratory rate and ventilatory equivalent for carbon dioxide were significantly higher at all stages of exercise. Exercise capacity assessed by peak oxygen uptake was correlated with time elapsed since surgical repair (r = 0.48; p = 0.001)., Conclusions: It is concluded that even in asymptomatic patients, exercise endurance and respiratory response are generally altered as much as 11 +/- 2.8 years after venous switch operation, although early surgical repair is predictive of a better long-term functional result.

The authors report the case of an elderly sportsman presenting with the electrical signs of the syndrome described by Brugada. The absence of any serious clinical events in this patient questions the pejorative prognosis usually reported and the specific identity of this syndrome in relation to right ventricular arrhythmogenic dysplasia.