Digital stress echocardiography (DSE) with dobutamine infusion has recently emerged as an attractive alternative to exercise stress testing for evaluating coronary artery disease. DSE seems particularly useful in the diagnosis or the assessment of ischemia in patients unable to exercise or when the test is difficult to interpret. DSE has also proved to be useful in patients undergoing preoperative evaluation of cardiac risk. The assessment of residual myocardial viability in patients with previous myocardial infarction is another promising development. After a description of the methodology of dobutamine stress echocardiography, this article reviews the experience obtained to date with this technique in the diagnosis and the evaluation of coronary artery disease.

The pathogenic mechanism of unstable angina, a clinical expression of coronary heart disease, is similar to that of myocardial infarction. The main event is the instability of the atheromatous plaque adhering to the coronary intima leading to thrombosis and occlusion. Clinical manifestations can be severe since fatal or non-fatal myocardial infarction occurs in 3.9% and 5.4% of the case respectively. Adapted medical treatment can stabilize the situation in most patients, justifying early preventive treatment. Moreover, it has been estimated that a premonitory phase of angina had gone unnoticed or undiagnosed in one-half of all myocardial infarcts. In nearly all patients with unstable angina, coronarography is of major importance for rapidly defining an adapted therapeutic strategy. Myocardial revascularization (especially by angioplasty) is often needed to limit the risk of major cardiac events occurring within a short or moderate delay. Unfortunately, these procedures carry a supplementary risk of thrombosis. Thus the emphasis placed on measures capable of improving the anti-thrombotic risk in unstable angina by using new antiplatelet agents, or for certain patients at high risk of a major cardiac event, antithrombosis agents. Finally, the search for compounds capable of stabilizing the previously formed atheromatous plaque (and thus avoiding rupture) is a prime objective for an overall management strategy for patients with coronary heart disease.

Digital stress echocardiography (DSE) with dobutamine infusion has recently emerged as an attractive alternative to exercise stress testing for evaluating coronary artery disease, DSE seems particularly useful in the diagnosis or the assessment of ischemia in patients unable to exercise or when the test is difficult to interpret. DSE has also proved to be useful in patients undergoing preoperative evaluation of cardiac risk The assessment of residual myocardial viability in patients with previous myocardial infarction is another promising development. After a description of tire methodology of dobutamine stress echocardiography this article reviews the experience obtained to date with this technique in the diagnosis and the evaluation of coronary artery disease.

The pathogenic mechanism of unstable angina, a clinical expression of coronary heart disease, is similar to that of myocardial infarction. The main event is the instability of the atheromatous plaque adhering to the coronary intima leading to thrombosis and occlusion. Clinical manifestations can be severe since fatal or non-fatal myocardial infarction occurs in 3.9% and 5.4% of the cases respectively. Adapted medical treatment can stabilize the situation in most patients, justifying early preventive treatment. Moreover, it has been estimated that a premonitory phase of angina had gone unnoticed or undiagnosed in one-half of all myocardial infarcts. In nearly an patients with unstable angina, coronarography is of major importance for rapidly defining an adapted therapeutic strategy. Myocardial revascularization (especially by angioplasty) is often needed to limit the risk of major cardiac events occurring within a short or moderate delay. Unfortunately, these procedures carry a supplementary risk of thrombosis. Thus the emphasis placed on measures capable of improving the anti-thrombotic risk in unstable angina by using new antiplatelet agents, or for certain patients at high risk of a major cardiac event, antithrombosis agents. Finally, the search for compounds capable of stabilizing the previously formed atheromatous plaque (and thus avoiding rupture) is a prime objective for an overall management strategy for patients with coronary heart disease.

Les analyses de la cinetique segmentaire au cours d'un test de provocation ont ete proposees pour le depistage de l'ischemie myocardique. La valeur diagnostique de ces tests est encore controversee. La cinetique segmentaire de 28 patients coronarographies apres infarctus inferieur transmural a ete evaluee par angioscintigraphie d'effort. Cette methode apparait reproductible et sensible mais sa specificite est moyenne. Elle est limitee par la difficulte d'identifier l'artere responsable de l'apparition des troubles de la cinetique. Ceci est essentiellement du a la possibilite de recouvrements vasculaires de territoires adjacents. Le depistage des lesions circonflexes s'avere particulierement delicat

The authors report the case of a right ventricular metastasis presenting with ventricular tachycardia and underline the usual diagnostic problems of secondary cardiac tumours, the symptoms of which are often unspecific and late. The appearance of a cardiac arrhythmia in the absence of known cardiac disease should raise the possibility of a cardiac metastasis in patients with malignant disease. The reported case also illustrates the diagnostic value of non-invasive cardiac imaging techniques (echocardiography and ultra-fast computerised tomography) in this context.

Les analyses de la cinetique segmentaire au cours d'un test de provocation ont ete proposees pour le depistage de l'ischemie myocardique. La valeur diagnostique de ces tests est encore controversee. La cinetique segmentaire de 28 patients coronarographies apres infarctus inferieur transmural a ete evaluee par angioscintigraphie d'effort. Cette methode apparait reproductible et sensible mais sa specificite est moyenne. Elle est limitee par la difficulte d'identifier l'artere responsable de l'apparition des troubles de la cinetique. Ceci est essentiellement du a la possibilite de recouvrements vasculaires de territoires adjacents. Le depistage des lesions circonflexes s'avere particulierement delicat

The authors report the case of a right ventricular metastasis presenting with ventricular tachycardia and underline the usual diagnostic problems of secondary cardiac tumours, the symptoms of which are often unspecific and late. The appearance of a cardiac arrhythmia in the absence of known cardiac disease should raise the possibility of a cardiac metastasis in patients with malignant disease. The reported case also illustrates the diagnostic value of non-invasive cardiac imaging techniques (echocardiography and ultra-fast computerised tomography) in this context.

Vascular damage during intervertebral disc surgery is uncommon. It sometimes leads to the formation of an arteriovenous fistula and about one hundred cases have been reported in the literature. The diagnosis is often early, with signs of venous hypertension predominating. The authors report a case of arteriovenous fistula presenting late as apparently primary congestive cardiac failure. The mechanisms of this condition were demonstrated during preoperative instrumental manoeuvres. Surgical correction is the only treatment alternative. Repair must be arterial and venous, most often using prosthetic material. This generally enables total and permanent recovery, but overall mortality in pathology of this type is not nil.

Les auteurs rapportent un cas de pericardite toxoplasmique chez un homme de 20 ans non immunodeprime, d'evolution favorable sous traitement antiparasite specifique. La localisation pericardique de la toxoplasmose est exceptionnelle et survient sans necessite d'une immunodepression associee. Elle realise en regle un tableau de pericardite aigue banale, le diagnostic etant assure par l'association d'une serologie toxoplasmique positive (positivite des IgM ou taux ascendant d'IgG) et l'absence d'autre etiologie prouvee. L'isolement du parasite par examen direct ou inoculation a l'animal est tres rare

Voluntary sequential ambulatory recording is a diagnostic method of recording per-critical electrocardiographs in symptomatic patients with the aid of a portable solid-state technology recorder. In order to assess the value of this technique in the detection of arrhythmias, a multicenter study was performed in 1,287 symptomatic patients suspected of having paroxysmal arrhythmias (palpitations in 86.5% of cases). The quality of the sequential ambulatory recording was judged to be good in 54.9% and mediocre in 40.2% of cases: only 4.9% of recordings were uninterpretable. This technique allowed identification of a cardiac arrhythmia related to symptoms in 42.5% of the 1,091 cases which were analysed; sustained supraventricular tachycardia (11.7%), ventricular extrasystoles (14.9%) and simple sinus tachycardia (9.5%) were the principal abnormalities. The per-critical recording was negative in 57.5% of patients, suggesting a purely functional origin of symptoms in these cases. Atrial fibrillation was more common in hypertensive patients (11.3% vs 5.5% in normotensives, p less than 0.01) as were ventricular extrasystoles (23.1% vs 13% in normotensives, p less than 0.001). Voluntary sequential ambulatory recording seems to be a technique well adapted to the detection of symptomatic arrhythmias and a useful complement to Holter recording.

A case of pericarditis due to toxoplasmosis in a 20 year old non-immune depressed man with a favourable outcome with specific antiparasitic treatment is reported. Pericarditis is rare in toxoplasmosis and does not require an associated immune deficiency. The clinical presentation is that of acute benign pericarditis, the diagnosis depending on positive toxoplasmosis serology (positive IgM or increasing IgG antibody titres) and the absence of another obvious cause. Isolation of the parasite by direct examination or animal inoculation is very rare. The spontaneous evolution is to pericardial constriction whilst specific antibiotic therapy (sulfadiazine-pyrimethamine) leads to a rapid cure in most cases. This underlines the necessity of searching for toxoplasmosis in patients with unexplained pericarditis.

Voluntary sequential ambulatory recording is a diagnostic method of recording per-critical electrocardiographs in symptomatic patients with the aid of a portable solid-state technology recorder.In order to assess the value of this technique in the detection of arrhythmias, a multicenter study was performed in 1 287 symptomatic patients suspected of having paroxysmal arrhythmias (palpitations in 86.5% of cases).The quality of the sequential ambulatory recording was judged to be good in 54.9 % and mediocre in 40.2 % of cases : only 4.9 % of recordings were uninterpretable. This technique allowed identification of a cardiac arrhythmia related to symptoms in 42.5 % of the 1 091 cases which were analysed ; sustained supraventricular tachycardia (11.7 %), ventricular extrasystoles (14.9 %) and simple sinus tachycardia (9.5 %) were the principal abnormalities. The per-critical recording was negative in 57.5 % of patients, suggesting a purely functional origin of symptoms in these cases. Atrial fibrillation was more common in hypertensive patients (11.3 % vs 5.5 % in normotensive, p < 0.01) as were ventricular extrasystoles (23.1 % vs 13 % in normotensives, p < 0.001).Voluntary sequential ambulatory recording seems to be a technique well adapted to the detection of symptomatic arrhythmias and a useful complement to Holter recording.