Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study)

BACKGROUND

In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.

METHODS

The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.

RESULTS

Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.

CONCLUSION

Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

[A randomized double-blind trial comparing cibenzoline and disopyramide in the prevention of recurrences of atrial tachyarrhythmia]

The aim of this multicenter, randomised, double-blind trial was to compare the efficacy and tolerance of oral disopyramide (D: 250 mg slow release twice daily) compared with cibenzoline (C: 130 mg twice daily) in the prevention of recurrences of atrial arrhythmias over a 6 month period. Sixty patients (mean age: 62 +/- 14 years; 37 men, 23 women; cardiac disease in 60% of cases) were randomised to two groups: C (N = 31) and D (N = 29). The commonest arrhythmia was atrial fibrillation (83%). The arrhythmia was recent (< 3 months) in 41% of patients and present for more than one year in 38% of patients. Sixteen patients of Group C (52%) and 11 of Group D (38%) had recurrences after an average of 79 +/- 58 days for Group C and 58 +/- 40 days for Group D (p = NS). The probability of absence of recurrence at 6 months was 36 +/- 11% in Group C and 55 +/- 10% in Group D (p = NS). Four patients in Group C (13%) and 13 patients in Group D (45%) had at least one unwanted side-effect (p = 0.009). Treatment was stopped because of side-effects in 2 patients in group C (6%) and 6 patients in Group D (21%). These results show that cibenzoline has a comparable efficacy for the prevention of recurrence of atrial tachyarrhythmia and is significantly better tolerated than disopyramide. This differences is mainly related to the marked anticholinergic effects of disopyramide.

[Study of the efficacy and tolerability of oral administration of cibenzoline in the prevention of recurrence of symptomatic atrial fibrillation]

The efficacy and safety of oral cibenzoline were evaluated in 42 patients aged 67 +/- 7 (55-80) and with recurrent symptomatic atrial fibrillation for at least a year and for which at least one previous anti-arrhythmic agent had been stopped for inefficacy or intolerance. Cibenzoline was administered for 6 months at the dose of 260 to 390 mg per day in patients aged under 70, with the possibility of reducing this dose in those aged over 70. Clinical, electrocardiographic and 24-hour Holter evaluation took place at inclusion and after 3 and 6 months' treatment or at the time of trial termination for documented recurrence (atrial arrhythmia persisting for 60 seconds or more). The mean duration of atrial fibrillation was 5.6 +/- 5 years (1-26). It was related to ischemic (22%), valvular (17%), hypertensive (17%), hypertrophic (7%) or dilated (7%) heart disease. No etiology was found in 45% of cases. All patients had taken at least one anti-arrhythmic agent in the past (mean of 2 drugs, range 1 to 6). All patients were symptomatic, the commonest symptoms being palpitations (82%), chest pain (28%), feelings of vertigo (11%) or episodes of acute dyspnea (9%). Thirteen patients (31%) had a documented recurrence (> 60 seconds) during the six months of the trial. Recurrence occurred during the first months of treatment in the majority of patients (11 out of 13). The number of symptomatic patients decreased considerably during treatment with cibenzoline, with the disappearance of palpitations in 83% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Selective coronary angiography in children. Technic and indications]

Non-selective opacification of the coronary arteries is often adequate for practical purposes in children, especially for studying the coronary circulation before operating congenital heart disease. However, selective coronary angiography is essential to demonstrate some abnormalities of distribution poorly visualised by the non-selective method and especially in cases of coronary anomalies or acquired coronary disease before procedures of reimplantation of revascularisation. The indications must be carefully considered and the technique particularly adapted using paediatric catheters and trained personnel skilled in retrograde arterial catheterisation in children. 51 selective coronary angiographies were carried out in 47 children 1 to 13 years old, including 12 children under 3 years of age. In 33 cases (23 Fallot's tetralogy the object was to detect coronary abnormalities not observed on non-selective opacification (3 LAD arteries arising from the right coronary, 1 single coronary artery) or to determine their anatomical relationships in complex cardiac malformations (5 cases). There were 5 cases of isolated congenital or acquired coronary disease with signs of ischaemic heart disease in 3 cases (LAD arising from the pulmonary artery and antero-septal infarction, calcified aneurysms and antero-lateral infarction in Kawasaki disease, pseudoxanthoma elastica with multiple coronary stenosis and severe angina). The investigation was indicated for complications of cardiac surgery in 2 children and in 4 cases selective coronary angiography was performed to assess the results of coronary reimplantation.

[Abnormal origin of the anterior interventricular artery from the pulmonary artery responsible for a postinfarction left ventricular aneurysm in a 6-year-old girl]

The isolated abnormal origin of the anterior interventricular artery from the pulmonary artery with the circumflex artery, arising normally from the right coronary artery and implanting in the aorta is much less common than the origin of a common left coronary trunk from the pulmonary artery. The first condition is also better tolerated than the second. In the present case, the clinical tolerance was excellent, but there was, nevertheless, a complicated antero-apical necrosis of a left ventricular aneurysm, which was successfully resected at the same time as the reimplantation of the anterior interventricular artery into the aorta. The patency of the anastomosis was subsequently confirmed.

[Importance of the exercise test in the follow-up of surgically treated congenital aortic stenoses]

Sixty four children with isolated congenital aortic stenosis (39 valvular, 16 fixed subvalvular, 4 supravalvular and 5 multiple) were operated at a mean age of 11,5 years. Valve repair was possible in all but three patients who had to undergo valvular replacement. Myotomy was associated in 18 cases (28 p. 100). The mean systolic pressure gradient was 79,9 mmHg (+/- 17,8); there was associated aortic regurgitation in 21 patients but this was minimal except in one case. Twenty children (31 p. 100) had symptoms on effort and the basal ECG showed ST-T wave changes in the left precordial leads in 30 cases (47 p. 100). Several preoperative exercise ECGs were performed in 29 patients without ST-T changes on the resting ECG. The exercise ECG was positive in 15 patients, providing one of the arguments for surgery; a poor blood pressure response to exercise was observed in 12 patients with a negative test. Out of the 28 patients with a positive preoperative exercise ECG, 7 (25 p. 100) went on having a positive result after surgery (p less than 0,05). The maximal heart rate was not significantly higher after surgery but the total work was significantly greater (p less than 0,01) and the increase in systolic blood pressure was even more significant (p less than 0,001). Out of 14 patients undergoing repeat catheterisation for a continuing positive exercise ECG or for ST-T wave changes on the resting ECG, there were 6 residual severe stenoses, 3 severe aortic regurgitations, 3 hypertrophic cardiomyopathies which were obstructive in 2 cases. The exercise ECG is a means of appreciating the consequences of the stenosis which are the cause of the complications (myocardial ischemia and poor blood pressure adaptation). This justifies its use in assessing the surgical indications and for the follow-up of the surgical result. A persistantly positive exercise ECG and continuing ST-T wave changes on the resting ECG are signs of a poor surgical result and hemodynamic revaluation should be considered; besides severe postoperative aortic regurgitation, residual or recurrent stenosis and, above all, asymmetric septal hypertrophy, obstructive or not, are the main causes of poor postoperative results.

[Cardiovascular malformations associated with tetralogy of Fallot. Apropos of a series of 250 cases of tetralogy of Fallot]

This study was undertaken in 39 patients with Fallot's tetralogy associated with one or more cardiovascular malformations. Some common anomalies, simple anatomical variations were excluded (right sided aortic arch, patent foramen ovale). Out of a total of 48 anomalies (6 children had 2, 3 or 4 associated malformations) there were 5 anomalous systemic venous drainages (including 4 supernumerary left superior vena cava), 8 secundum atrial septal defects (including one multiperforated defect), 2 muscular ventricular septal defects, 7 atrioventricular canals (5 in mongol children); 1 tricuspid hypoplasia, 1 absent left pulmonary artery, 1 mitral valve prolapse, 1 obstructive cardiomyopathy, 10 coronary anomalies (including 5 ectopic left anterior descending arteries arising from the right coronary artery), 8 patent ductus arteriosus (arising from the left subclavian in 4 cases of right aortic arch), 3 retro oesophageal subclavian arteries and one congenital subclavian steal syndrome. The incidence of associated malformations was 15 p. 100, but values of up to 30 p. 100 have been reported mainly in anatomical studies. The authors emphasise the diagnostic and therapeutic implications of these associated malformations. In most cases, especially Fallot's tetralogy with an endocardial cushion defect, 2D echocardiography proved to be an essential diagnostic tool. Catheter studies, however, remain necessary, especially for the detection of aortic and coronary anomalies: selective coronary angiography is sometimes required. Difficult surgical problems are mainly encountered when the associated anomaly has not been diagnosed preoperatively. Although the variations of systemic venous drainage are not of great importance, those of the aortic arch can influence the technique of palliative procedures. Muscular VSD must not be missed. Tricuspid hypoplasia may pose a complex surgical problem. Malformations of the left heart which are sometimes unrecognised, aggravate the situation considerably. The association of Fallot's tetralogy and atrioventricular canal can now be corrected under good conditions. Finally, variations in the coronary anatomy must be documented meticulously as they may contraindicate early complete repair.

[The exercise test in congenital aortic stenosis]

Exercise tests can be carried out without risk in a child or young adult with asymptomatic congenital aortic stenosis. In such a case, the ECG at rest gives only a very poor indication of the severity of the stenosis, which often becomes worse with age. The only sinister findings is that of repolarisation defects, which are almost always absent at rest. Exercise, by causing an imbalance between myocardial oxygen consumption and oxygen transport, will cause "ischaemic" signs to appear on the ECG. At the same time, the absence of compensation of pressure is a very important sign of poor tolerance; the test can usefully be concluded by using a floating catheter to measure the pulmonary capillary pressure. The correlation between a positive test and the stenotic pressure gradient, measured on catheterisation at rest, is good; but "negative" tests may be found in certain cases with a tight stenosis, especially if maximal rate could not be reached. In cases of stenoses which were initially mild or moderate, this test is very useful as a follow-up procedure, as such stenoses may become worse with age and require surgical correction. It is also useful for assessing the results of surgery, and of rehabilitation.