Dépistage opportuniste de l’anévrysme de l’aorte abdominale lors de l’échocardiographie chez le patient coronarien : utile ou futile ?

Abdominal aortic aneurysm is a chronic degenerative disease that is usually silent until rupture occurs and this complication is still associated in contemporary era with a high rate of mortality. Screening programmes for abdominal aortic aneurysm have been shown to be effective in reducing global mortality in the screened population but these programmes are poorly implemented in the Western countries. As coronary artery disease and abdominal aorta aneurysmal disease share many risk factors, the cardiologist is centrally positioned in the screening strategy, not only to identify patients with higher risk of developing abdominal aortic aneurysm, but also to perform an opportunistic screening during echocardiography. This paper summarises evidence about the feasibility, indications, modalities, benefits and risks related to the opportunistic screening for abdominal aortic aneurysm during echocardiography with a particular emphasis on the population of patients with coronary artery disease.     

L’hypo-albuminémie contribue-t-elle à l’aggravation de l’insuffisance cardiaque ?

BackgroundHypoalbuminemia has now emerged as a powerful prognosticator in heart failure regardless of age, clinical presentation, left ventricular ejection fraction and usual prognostic markers. Growing evidence is that this prognostic value persists after adjusting for causative factors for hypoalbuminemia such as malnutrition, inflammation and liver dysfunction.ObjectiveTo address the prognostic relevance of hypoalbuminemia in frail elderly patients with well-characterized cardiogenic pulmonary edema at high risk for adverse outcome, beyond causative factors for low serum albumin levels. Serum albumin was measured after clinical stabilization to avoid hypervolemia.ResultsIn all, 67 patients with a mean age of 86 years were included. Hospital mortality was 30%. Patients who died and who survived were similar in age, ejection fraction, BNP concentration, serum creatinine, serum hemoglobin, total bilirubin and prealbumin. Patients who died had lower serum albumin levels (P < 0.001), higher blood urea nitrogen (P = 0.03) and higher C-reactive protein (P = 0.02). In multivariate analysis, serum albumin was the sole independent predictor of hospital death (P < 0.01), after adjusting for malnutrition (prealbumin P = ns), inflammation (C-reactive protein P = ns) and liver dysfunction (total bilirubin P = ns).ConclusionSerum albumin is a powerful prognosticator in frail elderly patients with acute cardiogenic pulmonary edema even after adjusting for main causative factors. These results suggest that hypoalbuminemia may contribute to the worsening of heart failure given the physiological properties of serum albumin that includes antioxidant activity and plasma colloid osmotic pressure action. Further studies are critically needed to address the relevance of prevention and correction of hypoalbuminemia in heart failure.     

Uvéites sarcoïdosiques : regards croisés de l’ophtalmologiste et de l’interniste

Sarcoidosis is one of the leading causes of inflammatory eye disease. All ocular structures can be affected, but uveitis is the main manifestation responsible for vision loss in ocular sarcoidosis. Typical sarcoid anterior uveitis presents with mutton-fat keratic precipitates, iris nodules, and posterior synechiae. Posterior involvement includes vitritis, vasculitis, and choroidal lesions. Cystoid macular edema is the most important and sight-threatening consequence of sarcoid uveitis. Patients with clinically isolated uveitis at diagnosis rarely develop other organ involvement. Even though, ocular sarcoidosis can have a severe impact on visual prognosis, early diagnosis and a wider range of available therapies (including intravitreal implants) have lessened the functional impact of the disease, particularly in the last decade. Corticosteroids are the cornerstone of treatment for sarcoidosis, but up to 30% of patients achieve remission with requiring high-dose systemic steroids. In these cases, the use of steroid-sparing immunosuppressive therapy (such as methotrexate) is unavoidable. Among these immunosuppressive treatments, anti TNF-α drugs have been a revolution in the management of non-infectious uveitis.     

Niveau d’activité physique et contrôle ambulatoire de l’hypertension artérielle. Résultats de l’étude pilote « Acti-HTA »

While physical activity (PA) is recommended for high blood pressure management, the level of PA practice of hypertensive patients remains unclear. We aimed to assess the association between the level of both PA and blood pressure of individuals consulting in 9 hypertension specialist centres. Eighty-five hypertensive patients were included (59 ± 14 years, 61% men, 12% smokers, 29% with diabetes). Following their consultation, they performed home blood pressure measurement (HBPM) over 7 days (2 in the morning + 2 in the evening), they wrote in a dedicated form their daily activities to estimate the additional caloric expenditure using Acti-MET device (built from International physical Activity Questionnaire [IPAQ]). Thus, patients completed a self-administered questionnaire “score of Dijon” (distinguishing active subjects with a score > 20/30, from sedentary < 10/30). Subjects with normal HBPM value (< 135/85 mm Hg) (55% of them) compared to those with high HBPM were older, had a non-significant trend towards higher weekly caloric expenditure (4959 ± 5045 kcal/week vs. 4048 ± 4199 kcal/week, P = 0.3755) and score of Dijon (19.44 ± 5.81 vs. 18.00 ± 4.32, P = 0.2094) with a higher proportion of “active” subjects (48.9% vs. 34.2%, P = 0.1773). In conclusion, our results demonstrate a “tendency” to a higher level of reported PA for subjects whose hypertension was controlled. This encourages us to continue with a study that would include more subjects, which would assess PA level using an objective method such as wearing an accelerometer sensor.     

Dépistage et facteurs de risque des calcifications cardiaques chez l’hémodialysé : apport du scanner multi-coupe ultra-rapide et de l’échocardiographie transthoracique

IntroductionCardiovascular disease is the first leading cause of death in hemodialysis patients. In this population, cardiovascular calcifications occur at an earlier age and progress faster than in general population.Patients and methodsIn order to determine the prevalence and risk factors of cardiac calcifications, 49 patients on chronic hemodialysis were screened in the coronary arteries and cardiac valves by the 64 multi-slice ultra-fast CT and the transthoracic echocardiography. Different clinical and biological parameters were studied by the SPSS 10.0 statistical software to determine risk factors.ResultCardiac calcifications were identified in 81.6% of cases in at least one of the two studied sites. The coronary artery involvement was more common than valvular and concerned 69.4% of cases. The mean Agatston coronary artery calcium score (ACACS) was 331.1 and 522.2 in coronary patients and was correlated to alteration of systolic function of LV (r = −0.287, P = 0.045). The severity of CACS was positively correlated with age (r = 0.332, P = 0.02). Coronary calcifications were associated with cardiovascular risk common to those of the general population (age, male sex, systolic blood pressure, diabetes, history of ischemic heart disease), but also to a lesser quality of dialysis. Valvular calcifications were present in 49% of cases and were correlated with left ventricular hypertrophy (P = 0.006). The exclusive involvement of the aortic valve was the most common valvular abnormality. Phosphocalcic and lipid parameters, levels of hemoglobin, CRP and uric acid did not predisposed to cardiac calcifications in our patients.DiscussionIn hemodialysis patients, the pathogenesis of cardiovascular calcification is complex and cannot be attributed to a passive process. This process involves several factors that can promote or inhibit calcification. The new multi-slice ultra-fast scanner is a very sensitive method for topographic and quantitative assessment of coronary calcification and is a better alternative to invasive techniques.ConclusionOur study confirms the high prevalence of cardiac calcification in hemodialysis, and highlights the importance of early screening and treatment of predisposing factors.     

Incidence de l’hypertension artérielle dans la population française de plus de 60 ans

ObjectiveTo evaluate incidence and determinants of arterial hypertension after 60 years.MethodsFour thousand nine hundred and forty one subjects aged 60 years or above (2505 men: 64.2 ± 4.2 years; 2436 women: 64.8 ± 4.3 years) were explored two times at the IPC center, Paris, between 1992 and 2007, and were normotensive at the first visit (V1): systolic BP (SBP) less than 140 mmHg and diastolic BP (DBP) less than 90 mmHg without treatment. The delay between the two visits was 5.8 ± 2.2 years. At the second visit, population was analysed as normotensives and hypertensives. An age-adjusted Anova compared groups.ResultsIn men, incidence of hypertension is 41.5% and 25.9% for isolated systolic hypertension. In women, incidences were 37.8% and 27.8% respectively. Baseline characteristics for V2-hypertensives showed higher SBP, DBP, BMI, heart rate, glycemia, ECG abnormalities thanV2-normotensives but they had lower physical activity. The determinants of hypertension were: SBP, age, BMI, DBP, glycemia, and lack of physical activity for this age class.ConclusionFrom 60 years old, 6-year incidence of hypertension is about 40% and 26% for isolated systolic hypertension, this latter being higher in women. Regular physical activity is protective.