AIM OF THE STUDY:Cardiovascular autonomic neuropathy (CAN) and early arterial stiffness are frequent complications in type 1 diabetes. The aim of our work is to study the relationships between CAN (estimated by baroreflex gain calculation) and arterial stiffness (estimated by pulsatile stress) in type 1 diabetic patients. PATIENTS AND METHODS:In a cross-sectional study, we calculated baroreflex gain and pulsatile stress in 167 type 1 diabetic patients and 160 matched non-diabetic subjects whose blood pressure was continuously monitored with a Finapres(®) device in a postural test (squatting test). The baroreflex gain was calculated by plotting the pulse intervals (R-R) against systolic blood pressure values during the transition phase from squatting to standing. Pulsatile stress was estimated by the pulse pressure×heart rate product. In a longitudinal study, the baroreflex gain and pulsatile stress were calculated before and after a mean follow-up of 79±33 months in type 1 diabetic patients. RESULTS:Cross-sectional data showed a decrease in baroreflex gain and an increase in pulsatile stress in type 1 diabetic patients versus the matched non-diabetic subjects. A significant correlation between the baroreflex gain and pulsatile stress was present. Type 1 diabetic patients with lower baroreflex gain had a higher value of pulsatile stress when compared to those with higher baroreflex gain. During follow-up, a significant reduction in baroreflex gain (but without significantly increased pulsatile stress) was observed. A univariate analysis showed that the decrease of the baroreflex gain is not correlated with the time interval between the two tests, neither type 1 diabetes duration nor mean glycated hemoglobin values, but significantly with the pulsatile stress increase. CONCLUSION:In type 1 diabetic patients, the baroreflex gain is decreased and the pulsatile stress is increased when these markers are compared to age-matched non-diabetic subjects. There is a relationship between indices of CAN and arterial stiffness. Nevertheless, the baroreflex gain (marker of CAN) is impaired earlier than the pulsatile stress in this type 1 diabetic population with inadequate glycaemic control.
Les mesures hygieno-dietetiques sont a la base de la prise en charge therapeutique de la dyslipidemie de l'obesite abdominale et des autres facteurs de risque associes a l'exces de tissu adipeux visceral. L'utilisation d'agents lipido-regulateurs est Justifiee lorsque les objectifs therapeutiques ne sont pas atteints par les seules mesures hygieno-dietetiques. De nouvelles approches therapeutiques agissant directement sur l'exces de tissu adipeux visceral et en particulier la classe des bloqueurs des recepteurs CB1, sont particulierement prometteuses pour ameliorer l'ensemble du profil lipidique des patients avec obesite abdominale.
Introduction : Un entrainement physique intense peut induire des modifications morphologiques et fonctionnelles du coeur, realisant le « coeur d'athlete ». Il peut ainsi etre responsable d'une hypertrophie ventriculaire gauche d'adaptation (HVG), qu'il est parfois difficile de differencier d'une cardiomyopathie hypertrophique (CMH) avec son risque vital. L'echocardiographie permet le plus souvent ce diagnostic differentiel, mais elle peut etre insuffisante dans les cas limites. Objectif: L'apport recent du doppler tissulaire myocardique (DTM) pour le diagnostic de CMH a ete souligne. Des valeurs normales chez les sportifs ont ete publiees, mais ces series ne concernent qu'un petit nombre d'athletes dans un petit nombre de disciplines sportives. Methodes: Nous avons donc evalue en echocardiographie avec mesure du DTM a l'anneau mitral lateral, 100 sportifs de haut niveau issus de disciplines tres diverses, afin de disposer d'une valeur moyenne de reference des velocites protodiastoliques Ea. Resultats: Le pic protodiastolique Ea est mesure a 18,2 +/- 2,7 cm/s. Le rapport E/A est evalue a 1,7 +/- 0,4. On constate pour 75 % des athletes une valeur de Ea = 17 cm/s et pour 84 % d'entre eux, le rapport E/Ea est = 6. Ea est correle positivement au rapport E/A et negativement a l'âge. Conclusion: Les athletes de haut niveau ont des velocites protodiastoliques mesurees au DTM elevees grâce a l'entrainement physique.
Objectif : Determiner la prevalence de la micro-albuminurie (MAU), depistee par une bandelette urinaire specifique, chez l'hypertendu diabetique de type 2, pris en charge en cardiologie de ville. Methodes : Depistage par le cardiologue investigateur (CI) de la MAU par bandelette semi-quantitative (donnant le rapport albumine/creatinine) chez six hypertendus diabetiques de type 2 consecutifs. La recherche de MAU a ete consideree comme fiable en cas de recherche prealable de proteinurie (bandelette classique), et sur une bandelette MAU interpretable. Resultats : Deux cent vingt deux CI ont recrute 1328 patients (65,3 % H, âge moyen 67 ± 10ans, IMC moyen 29,Z ± 4,8 kg/m 2 ). Pour 1166 patients (90,8 %), le depistage de MAU a ete considere comme fiable : 58,1 % ont une MAU (rapport alb / creat entre 30 et 300 mg/g), et 3,4 % ont une MAU manifeste (rapport alb / creat > 300 mg/g). La prevalence de MAU augmentait parallelement au grade d'HTA. Dans la population avec recherche de MAU fiable, l'analyse des facteurs de risque selon le statut de MAU montrait: PA normale HbA1c Obesite IR (Ccr 30) 60ml/min) famil. angor ACVC(%) AOMI selon (ESH) (%) (%) (%) personnel ou IdM ou AIT (%) (%) (%) (%) (%) MAU+ 9,2 7,3 ±1,3 36,9 22,0 67,9 42,3 7,4 14,0 MAU- 14,6 7,1±1,1 39,6 17,4 59,5 34,9 6,2 11,8 p 0,002 0,003 0,351 0,055 0,004 0,092 0,872 0,796 Dans le groupe MAU+, le recours a une pluritherapie pour le traitement antidiabetique (y compris l'insuline) et anti-HTA etait plus frequent. Malgre les recommandations, 30 % des patients ne beneficiaient pas d'un antiagregant, et environ 1/4 des patients (24,1 %) ne beneficiaient pas d'un traitement hypolipemiant. Conclusion: La recherche d'une proteinurie par la bandelette est bien appliquee en cardiologie de ville. La prevalence de MAU est tres elevee chez ces patients hypertendus diabetiques de type 2, qui pourrait s'expliquer par leur risque cardio-vasculaire global eleve, ainsi que l'atteste la frequence des comorbidites et facteurs de risque associes chez les patients avec MAU+, dont la PA restait moins efficacement controlee en depit d'un traitement plus intensif. La prescription d'antiagregants plaquettaires et d'hypolipemiants devrait etre optimisee.
The meta-analysis showing the benefits of physical training revisited: Taylor examined only the cardiac rehabilitation trials of exercise intervention alone (versus usual care) and demonstrated that cardiac mortality is 28 % reduced and exercise appears to have an independent mortality benefit. An economic evaluation of cardiac rehabilitation: a systematic review of 15 economic evaluations. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. But further well-designed trials are required. Pronostic value of some variables determined by exercise testing entering cardiac rehabilitation and after physical training. A beneficial effect of physical training versus usual care on BNP and neurohormones in patients with chronic heart disease. Patients on beta blockers after myocardial infarction: determination of a more accurate training heart frequency derived from the classical Karvonen's formula. The combination of trimetazidine with exercise training provides greater improvements in functional capacity, left ventricular function and the endothelium-dependent relaxation of the brachial artery than exercise training alone in patients with ischaemic cardiomyopathy referred for cardiac rehabilitation. Guidelines for resistance exercise after cardiac event: a new paradigm less restrictive, safe and efficient to accelerate patients' return to daily activities. Recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease: the result of consensus among experts from the ESC study group of sports cardiology.
The clinical pharmacological and therapeutic working group was particularly impressed by twelve recent publications relative to its various themes of interest. Two studies were made of the prognostic impact of non-observance of treatment which seems to be associated with an extra-mortality even when the treatment is placebo: the probable explanation is that the non-observance of drug therapy is also associated with the non observance of dietary/life style measures and with cognitive dysfunction associated with more severe cardiac disease. A recent study on n-acetyl-cysteine has rekindled the debate on this substance for preventing nephrotoxicity of radiological contrast used during angioplasty in high risk patients. The risks of AINS drug therapy has been reassessed. The increased risk of myocardial infarction is confirmed with celecoxib but not with "classical" AINS drugs if not prescribed for more than one year and without aspirin. With respect to lipid-lowering drugs, should statins be prescribed to attain a target value of LDL-cholesterol or to attain a given reduction in LDL-cholesterol? The death knell of fibrates has more or less been rung by the results of the FIELD study and the real value of OMEGA-3 drugs should be reassessed by good quality prospective studies. In the domain of hypertension, the recent arrival of aliskiren, the first of the antirenin drugs, is noteworthy although its role in the therapeutic strategy, remains to be defined. Finally, a comment is made on the results of the TROPHY study which suggest value in the possible prevention of hypertension with angiotensin II inhibitors in patients at risk of developing hypertension.
Objective: To determine the prevalence of microalbuminuria (MAU) detected by a specific urinary strip in type 2 diabetic hypertensive patients in metropolitan France.Method: Screening for MAU with a semi-quantitative strip measuring the albumin /creatinine ratio was performed by cardiologists (Cs) in 6 type 2 diabetic hypertensive patients. This screening method was considered reliable if a preliminary search for proteinuria was performed with a usual strip and the quality of the MAU reading was good.Results: 222 Cs screened 1,328 patients (65.3% M, average age 67 10 years, BMI 29.2 +/- 4.8 kg/m(2)). MAU screening was considered reliable for 1166 patients (90.8%): 58.1 % had MAU (alb/creat ratio between 30 and 300 mg/g), and 3.4% had manifest MAU (alb/creat ratio > 300 mg/g). The prevalence of MAU increased with the severity of hypertension. In the population with a reliable MAU screen, the analysis of risk factors according to the level of MAU yielded the following results:[GRAPHICS]In the MAU+ group, the need for multiple antidiabetic (including insulin) and antihypertensive drugs was more frequent. In contrast to current guidelines, 30% of patients did not received an antiplatelet agent, and about one fourth (24.1 %) of the patients did not benefit of a hypolipemic treatment.Conclusion: Screening for proteinuria in type 2 diabetic hypertensive patients is well performed by cardiologists. The prevalence of MAU is high in this patient population, which may be explained by their high global cardiovascular risk, illustrated by the prevalence of comorbidities and risk factors, significantly higher in the MAU+ group, with less frequent BP control despite a more aggressive antihypertensive treatment. Prescription of antiplatelet therapy and hypolipidemic agents must be optimised.
Pheochromocytomas (PH) and functional paragangliomas (FPGL) are rare causes of secondary HTA.About 25% of cases are genetically determined and so, genetic counselling and genetic testing are recommended for all patients with PH/FPGL. All patients should be offered screening for SDHB, SDHD and VHL mutations [1].Direct sequencing allowed us to identify germline point mutations and small deletions or insertions in the SDHB, SDHD and VHL genes. However, this method is unable to detect large deletions and chromosomal rearrangements. We have now adapted the QMPSF method to detect large rearrangements of the SDHD, SDHB and VHL genes. This method is based on a simultaneous amplification of multiple amplicons and their quantitative comparison by fluorescence in test samples and in controls.Among our cohort of patents from COMETE and PGL.NET networks, we have selected patients on clinical criteria (positive family history, multiple tumours, young age of onset <35 years, malignant PH) suggesting a high probability of VHL disease or of familial PH/FPGL.For all of these patients, direct sequencing was negative.At the present time, 96 French subjects were analyzed. Nine large deletions were found (9%), five in the, SDHB gene and four in the VHL gene.Now, in our laboratory Q MPSF will be used routinely to detect SDHs and VHL large deletions in order to improve the performance of the molecular characterization of PH/PGL.
Les auteurs rapportent l'observation d'un garcon qui presentait une cardiopathie complexe s'integrant dans le cadre d'un dextro-isomerisme ou syndrome d'Ivemark. A l'âge de 11 ans, apres plusieurs interventions palliatives, une derivation cavo-pulmonaire totale avec mise en place d'un tube fenestre entre la veine cave inferieure et l'artere pulmonaire droite est realisee. La fenestration a ete fermee 2 ans apres. Vers l'âge de 15 ans, une desaturation peripherique s'accentue progressivement ; le catheterisme cardiaque avec angiographie montre de tres nombreuses collaterales veino-veineuses intra-hepatiques debouchant dans une volumineuse veine sus-hepatique gauche qui se drainait dans l'oreillette droite connectee au ventricule systemique. La fistule la plus importante a ete embolisee avec un Amplatzer Septal Occluder de 20 mm, les deux autres avec un Amplatzer Duct Occluder 14 x 12 et 10 x 8. La saturation est passee de 75 a 94 %. Apres 6 mois de suivi, l'enfant est asymptomatique, la saturation systemique est de 90 %.
Introduction : Les blocs auriculo-ventriculaire complets (BAVC) isoles de l'enfant surviennent sur des coeurs d'architecture normale en l'absence d'antecedent connu susceptible d'avoir entraine le bloc. Cette etude a pour objectif de preciser le pronostic actuel de ces troubles conductifs. Methodes : Cent trente-cinq patients suivis pour BAVC isole, diagnostique avant l'âge de quinze ans, ont ete inclus dans cette etude retrospective monocentrique. Resultats : Plus de la moitie (52,6 %) des diagnostics ont ete portes en periode ante- ou neonatale, attestant de leur origine congenitale. Des symptomes etaient inauguraux de la maladie dans seulement 6,7 % des cas. La recherche d'anticorps maternels anti-Ro/La a ete effectuee chez 111 de ces patients. Positive dans 56 cas, elle etait alors associee a un diagnostic precoce, un court delai d'implantation d'un stimulateur cardiaque et la survenue d'une myocardiopathie (seize cas) ; cette derniere representant un tournant dans l'evolution de la maladie (37,5 % de mortalite a six ans). Parmi les 55 cas non associes aux anticorps, deux cas etaient familiaux et aucune etiologie n'a ete retrouvee pour les autres ; le diagnostic etait alors plus tardif, et aucune evolution vers une myocardiopathie n'a ete retrouvee. Un stimulateur cardiaque a ete implante chez 122 patients (66 epicardiques, 56 endocardiques). Conclusions : Les BAVC isoles de l'enfant ne constituent pas une entite homogene : les blocs « immunologiques " sont authentiquement congenitaux et leur pronostic reste severe, en raison d'un risque de cardiomyopathie de diagnostic parfois tardif; les autres blocs sont de diagnostic plus tardif dans l'enfance, de mecanisme encore inconnu et de bon pronostic a condition de respecter les indications de stimulations chez l'enfant.
