The carotid sinus syndrome is a well-known cause of syncope: the cardio-inhibitory forms are the easiest to diagnose and probably the easiest to treat. However, the vasodepressive forms are as common but their outcome is mainly unknown. Eight hundred and fifty-three patients underwent endocavitary electrophysiological studies with invasive blood pressure measurement for unexplained syncope between October 1984 and January 1990. A carotid sinus syndrome was diagnosed in 215 cases. Fifty-two patients (24.2%) had a cardio-inhibitory form (ventricular standstill > or = 3 s during carotid sinus massage), 40 (18.6%) had a pure vasodepressive form (isolated fall of systolic blood pressure > 50 mmHg during massage) and 123 patients (57.2%) had a mixed form. The average age was 74.1 +/- 9.7 years with no difference between the different forms. A number of parameters was different on the cardio-inhibitory and vasodepressive forms: the number of men (75.6 vas 24.4%; p < 0.05) and the number of syncopes (83.3 vs 60%; p < 0.02) were greater in the cardio-inhibitory form; the vasodepressive forms were more often associated with a history of transient ischaemic attacks (15 vs 0%), a poor cardiovascular status (hypertension: 47.5 vs 15.7%; p < 0.01), coronary artery disease (47.5 vs 25.5%; p < 0.05), cardiac failure (27.5 vs 11.7%; p < 0.05), induction of sustained supraventricular tachycardia (50 vs 23.5%; p < 0.05) and a greater pacemaker effect (53.6 vs 34.8 mmHg; p < 0.01); of the 191 patients (84.9% of the population) followed up for an average of 21.2 months, 168 received treatment: implantation of a cardiac pacemaker in 108 patients, reduction of antihypertensive and/or potentially bradycardia-inducing drugs in 30 patients, prescription of antiarrhythmic therapy, in 30 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The case of a 53-year-old patient with scapulo-humero-peroneal wasting, early flexion contractures of the elbows and ankles, abnormal cardiac conduction and probable X-related heredity is reported. Histology was suggestive of a primary and very slowly progressive muscular disorder. CT scan revealed fatty muscle degeneration which was more extensive than suggested by clinical findings. Electrophysiological studies revealed right atrial paralysis, left atrial tachycardia and supra and, above all, infra-His block. Sustained episodes of ventricular tachycardia, an anomaly described only rarely in pathology of this type, occurred some time after the fitting of a permanent pacemaker. The originality of this case of Emery-Dreifuss progressive muscular dystrophy lies in the usefulness of muscle CT scan and the existence of life-threatening arrhythmias.

The authors undertook a prospective electrophysiological study of 950 patients: 53 subjects considered to be "controls" since they were free of any history of syncope or faintness were identified, as well as 39 symptomatic subjects with a strong suspicion of sinus dysfunction, since no other detectable cause of fainting episodes was found by extracardiac investigation, 24 hour ECG nor electrophysiology. Following the creation of a computerised tool enabling not only the entry of indirect tests, processing, averaging of results, printing and memorization, but also assistance in interpretation, several electrophysiological parameters were used: heart rate and existence of sinus arrhythmia, Strauss tests with adjusted data or not, effective nodal refractory period, Guize, Narula and Mandel tests, and an atropine (0.03 mg/kg) test which was performed only in the symptomatic group. These tests were studied by single-variate and correlative analysis to define their normal ranges, their critical values and their dependence or independence. The performance of each test (i.e. its efficiency, and the specificity and sensitivity of each critical value) was measured. Tests found to be most useful (specificity and efficiency > 90%) were as follows: Mandel test = CSRT > or = 534 ms, Narula test = TECASA > or = 339 ms, heart rate < or = 55/min, type II, IIa and chaotic Strauss curve associated with a pathological Guize test. The combination of these tests in this algorithm resulted in an increase in sensitivity to 84%, at the price of a very moderate fall in specificity to 87%.(ABSTRACT TRUNCATED AT 250 WORDS)

Single ventricular stimulation induces haemodynamic disturbances, the best known of which is the pacemaker syndrome. In order to assess the prevalence and severity of these abnormalities, invasive blood pressure monitoring was performed in 396 consecutive patients undergoing endocavitary electrophysiological investigations : a decrease in systolic blood pressure at a rate near to that of the spontaneous rhythm defines the pacemaker syndrome. It is maximal after 3 to 5 beats of equivalent intensity with or without retrograde conduction. The pacemaker syndrome is greater in hypertensive and coronary patients than in subjects with healthy hearts (- 44.2 mmHg and - 37.2 mmHg versus - 33 mmHg, p < 0.001 and p < 0.04). It is less pronounced in cases of cardiac failure (- 31.8 mmHg). The pacemaker syndrome increases in intensity with age (- 44.3 mmHg after 80 years of age versus - 23.1 mmHg in subjects under 50 years of age; p < 0.001).Two electrophysiological abnormalities are associated with an increased pacemaker syndrome even in apparently normal hearts: sustained induced supraventricular tachycardia (- 34.2 mmHg versus - 26 mmHg, p < 0.002), mixed carotid sinus syndromes (- 38 mmHg) and pure vasodepressive syndromes (- 48.5 mmHg, p < 0.001).The study of the pacemaker syndrome is useful for three reasons: - the detection of another cardiac abnormality in cases of sustained induced supraventricular tachycardia, even in an apparently healthy heart; - to assess the presence of a second haemodynamic abnormality independant of the vagal effect in cases of carotid sinus syndrome with vasodepression; - finally, to identify the patients at high risk of a pacemaker syndrome.

Thirty-seven patients presenting with electro-induced supraventricular arrhythmia sustained for more than 10 min or symptomatic received an intravenous injection of flecainide acetate (1.5 mg/kg; 10 mg/min). There were 24 cases of atrial fibrillation, 13 of atrial tachysystole with more than 180 beats per minute. Electrophysiological exploration was carried out for syncope (13 cases), lipothymia with palpitations (11 cases) or without palpitations (8 cases), or for a stroke of unknown origin. The induced arrhythmia was the only electrophysiological abnormality in 57% of cases. A return of sinus rhythm was obtained in 70% of cases during the injection (1 2 cases) or shortly after the end of the injection (14 patients). Safety was good, with the exception of the onset of two junctional rhythms and one case of non-syncopal monomorphic ventricular tachycardia. After an initial reduction, the PR, QRS, PA and HV intervals were significantly longer than baseline, whereas the AH space and the systolic blood pressure remained virtually unchanged. Thus the provision of IV flecainide acetate can only be beneficial in carrying out study protocols of abnormalities of the atrial substrate.

Thirty-seven patients presenting with electro-induced supraventricular arrhythmia sustained for more than 10 min or symptomatic received an intravenous injection of flecainide acetate (1.5 mg/kg; 10 mg/min). There were 24 cases of atrial fibrillation, 13 of atrial tachysystole with more than 180 beats per minute. Electrophysiological exploration was carried out for syncope (13 cases), lipothymia with palpitations (11 cases) or without palpitations (8 cases), or for a stroke of unknown origin. The induced arrhythmia was the only electrophysiological abnormality in 57% of cases. A return of sinus rhythm was obtained in 70% of cases during the injection (12 cases) or shortly after the end of the injection (14 patients). Safety was good, with the exception of the onset of two junctional rhythms and one case of non-syncopal monomorphic ventricular tachycardia. After an initial reduction, the PR, QRS, PA and HV intervals were significantly longer than baseline, whereas the AH space and the systolic blood pressure remained virtually unchanged. Thus the provision of IV flecainide acetate can only be beneficial in carrying out study protocols of abnormalities of the atrial substrate.

Single ventricular stimulation induces haemodynamic disturbances, the best known of which is the pacemaker syndrome. In order to assess the prevalence and severity of these abnormalities, invasive blood pressure monitoring was performed in 396 consecutive patients undergoing endocavitary electrophysiological investigations: a decrease in systolic blood pressure at a rate near to that of the spontaneous rhythm defines the pacemaker syndrome. It is maximal after 3 to 5 beats of equivalent intensity with or without retrograde conduction. The pacemaker syndrome is greater in hypertensive and coronary patients than in subjects with healthy hearts (-44.2 mmHg and -37.2 mmHg versus -33 mmHg, p < 0.001 and p < 0.04). It is less pronounced in cases of cardiac failure (-31.8 mmHg). The pacemaker syndrome increases in intensity with age (-44.3 mmHg after 80 years of age versus -23.1 mmHg in subjects under 50 years of age; p < 0.001). Two electrophysiological abnormalities are associated with an increased pacemaker syndrome even in apparently normal hearts: sustained induced supraventricular tachycardia (-34.2 mmHg versus -26 mmHg, p < 0.002), mixed carotid sinus syndromes (-38 mmHg) and pure vasodepressive syndromes (-48.5 mmHg, p < 0.001). The study of the pacemaker syndrome is useful for three reasons: the detection of another cardiac abnormality in cases of sustained induced supraventricular tachycardia, even in an apparently healthy heart; to assess the presence of a second haemodynamic abnormality independent of the vagal effect in cases of carotid sinus syndrome with vasodepression; finally, to identify the patients at high risk of a pacemaker syndrome.

Oral anticoagulants (OC) prevent the activation by carboxylation of coagulation proteins. However this action also affects osteocalcin, or bone Gla-protein, a parameter of bone remodelling. Phosphorus and calcium metabolism, osteocalcin levels and bone mineral content were studied in twelve men aged under 60, and who had been taking OC for more than a year, in comparison with a paired group of nine controls with the same cardiovascular pathology but not taking anticoagulants. Osteocalcin levels were lower in the OC group (3.44 ng/ml) than in the control group (5.88 ng/ml) (p = 0.01). There was no significant difference in other phosphorus/calcium balance parameters nor in bone density between the two groups. No evidence was found of any osteopathy in the OC group, but the decrease in serum osteocalcin could result either from inhibition of its secretion or of its carboxylation, or from an action on the osteoblast.

109 subjects aged 70 years (58 women, 51 men; average age 77 years) were hospitalized in the CICU (Cardiology Intensive Care Unit) over the period stretching from 1984 to 1986. The average length of stay in the CICU was 1 week, completed by an average stay of 5 days in the cardiology department. 100 per cent of the patients were followed up. Of the clinical parameters made evident by this study, the authors note that hypertension was the predominant risk factor (52.2 per cent); a history of coronary disease was noted in 60.5 per cent; 26.6 per cent of the patients were hospitalized before the 6th hour, chest pain being typical in 78 per cent versus painless in 11 per cent of patients; topographically, the infarction was anterior in 55 per cent, posterior in 40.4 per cent, and around the circumference in 4.6 per cent of cases; 80.8 per cent of the infarctions were transmural versus 19.2 per cent of infarctions without the Q wave--the latter accounted for a higher hospital mortality rate (38 per cent versus 27.3 per cent). The main complications were disturbances in rhythm (60.6 per cent) and LVI (56.9 per cent). Complications on the form of infections were noted in 15.6 per cent. Apart from the usual indicators of severity (cardiogenic shock, VF, LVI), infarction of the RV and AF had a serious effect on the prognosis. latrogenic disease accounted for 18.9 per cent. From the point of view of prognosis, hospital mortality was 30 per cent; mortality after one year was 44 per cent and 47.7 per cent after 2 years (in a group of 76 subjects).(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report a case of infectious spondylodiscitis revealing a staphylococcal endocarditis in a patient with a Carpentier aortic heterograft. This case, along with 60 descriptions from the literature, has enabled them to specify the characteristics of occurrence of endocarditis during a spondylodiscitis. The clinical factors in favor of this association are: a pre-existing cardiopathy, an oral port of entry, occurrence of other rheumatoid manifestations, even more the presence of complications of endocarditis. The laboratory factors in favor of an association are: discovery of an inflammatory anemia, of circulating immune complexes, of a cryoglobulinemia, of a rheumatoid factor, of hematuria. But it is mostly the demonstration of streptococcus in blood cultures and other samples that should be an indication to search for an endocarditis, the course of which dominates the prognosis.

A prospective study based on intracavitary electrophysiological exploration coupled with invasive arterial pressure monitoring was conducted in 245 patients aged 70.2 +/- 13 years who had experienced syncopes and/or lipothymias of uncertain origin. The study showed that 63 patients (25.7 p. 100) had carotid sinus syndrome (CSS). The syndrome was of the vagal type (cardiac inhibition) in 27 p. 100 of the cases, of the depressor type (vasodepression) in 22 p. 100 of the cases and mixed in 51 p. 100 of the cases with the two types of pathological response: electrophysiological and haemodynamic. Compared with the remaining 182 patients, these 63 patients were more frequently male (63.5 p. 100, p less than 0.01), of the same age (71.7 years, NS) and more symptomatic, meaning that syncopes occurred in 80 p. 100 of the cases and that their number per patient was higher (2.92, p less than 0.01). A predisposing factor (usually a vagal predominance) was found in 26.9 p. 100 of the cases. In 30 p. 100 of the patients CSS was associated with a sinus node disease or with disorders of atrioventricular conduction. Another haemodynamic abnormality often associated with CSS was a more pronounced (-38.7 mmHg, p less than 0.01) and more frequent (68 p. 100, p less than 0.01) pacemaker effect. 62 p. 100 of patients with mixed CSS had an increase in systolic arterial pressure during vagogenic manoeuvres with DDD mode stimulation as compared with the VVI mode stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

100 patients, from three internal medicine departments, were the subject of a retrospective study concerning the clinical manifestations and the evolution of Horton's disease. The mean age is 71 years, with a 2/1 female predominance. A temporal artery biopsy was obtained in all cases. Besides the prevalence of clinical symptoms (headaches: 80 p. cent; weight loss: 78 p. cent; fever: 65 p. cent; local inflammation: 52 p. cent, frequent pseudo-polyarthritis: 40 p. cent and sometimes severe ocular localizations (11 p. cent blindness), other signs should be emphasized: muscular pain (49%), skin hyperesthesias (37%), painful jaw (33%), etc. The inflammatory syndrome dominates the biological picture (96%); the alkaline phosphatases are increased in 37 p. cent of cases. Temporal artery biopsy was positive in 82 p. cent of cases, which confirms the excellent sensitivity of this test, preceded by a Doppler study in only 28 cases. Extension of the inflammatory process to the large vessels was demonstrated 8 times, on clinical data. Finally, the mean length of the steroid treatment was two years with 14 relapses and 8 deaths.

A case of myxoid liposarcoma of the left atrium in a 35-year old man is reported. The tumour, revealed by an atrial flutter, was excised. The patient died 13 months later, with multiple metastases. A review of the literature yielded only 7 cases of primary liposarcoma of the heart, including 4 which were surgically treated. This confirms the extreme rarity of a tumour which has a very poor prognosis due to recurrence in situ or metastatic spread.