Michel Bellorini

Short-term effects of sinus rhythm restoration in patients with lone atrial fibrillation: a hormonal study.

It is well known that atrial fibrillation can lead to heart failure, and is attributed to rapid ventricular rate (tachycardia‐induced cardiomyopathy). Some recent studies suggest the possible existence of an intrinsic left‐ventricular factor related to atrial fibrillation, irrespective of other elements. In order to demonstrate the implication of this factor, we measured B‐type Natriuretic Peptide, known as a functional marker of left‐ventricular dysfunction, in 40 consecutive patients with chronic non‐valvular atrial fibrillation, with low ventricular rate and absence of clinical heart failure or echocardiographic left‐ventricular dysfunction. In all patients, Brain Natriuretic Peptide (BNP) plasma level was high and dramatically decreased 24 h after external electrical cardioversion (61.4 pg/ml before cardioversion, 23.5 pg/ml 1 day after cardioversion, P<0.002). Our study demonstrates that atrial fibrillation, in absence of high ventricular rate, induces an asymptomatic cardiac alteration that is not detectable by echocardiography.

Bedside B-type natriuretic peptide and functional capacity in chronic heart failure.

To determine if B‐type natriuretic peptide (BNP) measurement could be useful in determination of functional capacity in patients suffering from chronic heart failure.

Myocardial contractile reserve under low doses of dobutamine and improvement of left ventricular ejection fraction with treatment by carvedilol.

To examine the ability of myocardial contractile reserve (MCR) assessment to predict the improvement of left ventricular ejection fraction with treatment by carvedilol, a prospective study was undertaken in 85 patients with chronic heart failure and left ventricular ejection fraction <45%. Low dose dobutamine echocardiography (DSE), a 6‐min walk test and measured brain natriuretic peptide (BNP) were assessed in all the patients. Patients were separated into two groups. Group A were patients without any myocardial reserve and group B patients with a myocardial contractile reserve defined as an increment of more than 20% of the resting left ventricular ejection fraction during dobutamine infusion. The two groups differed for percentage of ischemic cardiomyopathy (67.8 in group A vs. 29.7% in group B P‐0.028), 6‐min walk test performance (respectively, 343 vs. 415 meters P<0.05) and BNP plasma levels (respectively, 184.5 vs. 70.1 P<0.02) but not for left ventricular ejection fraction or NYHA class. During DSE, MCR and heart rate variation was higher in group B than in group A. At the end of the follow up, LVEF increased and NYHA class decreased in group B but not in group A. In multivariate analysis the existence of MCR could predict the improvement of LVEF with treatment by carvedilol. In our study, studying MCR could help to predict patients who will improve their LVEF with carvedilol prior to the administration of the treatment.

Impact of heart failure management unit on heart failure-related readmission rate and mortality

BACKGROUND Heart failure is the leading cause of hospital admissions and an economic burden. In accordance with European guidelines, a dedicated heart failure unit was created in René Dubos Hospital (Pontoise, France) in 2002. AIM To evaluate the impact of an in-hospital heart failure management unit on heart failure prognosis. METHODS We conducted a descriptive study of all-cause in-hospital mortality and heart failure related readmission rates in the year after the first admission for heart failure, from January 1997 to December 2007. The Chi(2) test, a trend test and linear regression were performed. RESULTS There were no significant differences in patient characteristics (age, sex, diabetes mellitus, left ventricular ejection fraction<45%) other than renal insufficiency, in patients admitted for heart failure from 1997 to 2007. After the creation of the heart failure unit, we observed a significant decrease in heart failure related readmission rate from 21.7% in 2002 to 15.6% in 2007 (p<0.0001), whereas there was no difference in this rate before the creation of the unit (34.3% in 1997 and in 2001; p=0.90). All-cause in-hospital mortality rate decreased from 9.3% in 1997 to 5.1% in 2007 (p<0.0001) and showed a tendency to decrease after the creation of the heart failure unit (p=0.06). CONCLUSION Heart failure related readmission rates in new patients in the year after the first admission for heart failure reduced dramatically after the creation of the heart failure unit. All-cause in-hospital mortality in heart failure patients decreased over the 10-year study period.

Unités d'insuffisance cardiaque. Concept, organisation, résultats

Resume L’insuffisance cardiaque est une maladie au pronostic sombre et dont l’evolution est emaillee de nombreuses rehospitalisations. En depit de progres importants realises dans cette pathologie en particulier sur le plan pharmacologique, le taux de readmission apres une premiere decompensation reste eleve. Certains auteurs ont mis en avant l’effet benefique d’un changement de l’organisation de la prise en charge de l’insuffisance cardiaque sur la morbide mortalite et le cout induit par ces patients. C’est ce type d’organisation concertee de l’insuffisance cardiaque que nous avons developpe depuis de nombreuses annees au centre hospitalier de Pontoise pour acceder finalement a la mise en place d’une unite therapeutique d’insuffisance cardiaque de 10 lits. Cette unite repose sur un concept associant une equipe specialement consacree a l’insuffisance cardiaque, la mise en place d’une demarche educative destinee aux patients et a leurs proches et une evaluation reguliere.

105 Implementation of patients reaction is better than implementation of knowledge in Heart failure patients

Heart failure remains a disease with poor prognosis despite the therapeutic advances of recent decades. Nearly a third of hospital admissions are due to errors in dietetics follow up or therapeutic monitoring. Therapeutic education of patients with heart failure is growing fast in France. For the “Haute autorite de sante” (HAS), evaluation of education programs is an essential element in the same way that the educational diagnosis and interactivity. We wanted to determine what the assessment could predict the onset of the test combined death and hospitalization for heart failure. We included 398 patients with systolic heart failure who received a therapeutic education between 2003 and 2008. The program involved an educational diagnosis individual training sessions with the disease, sessions Implementation situation, self-physical and dietary. During this educational process, patients filled a questionnaire initial knowledge (Q1) and a questionnaire at the end of training (Q2) and one year of it (Q3). They also fulfilled a clinical case assessment and post training within one year. The average age of patients was 65 (± 4), LVEF of 34 (± 4), the average BNP of 235 (± 346). There is no correlation between the scores of knowledge questionnaires and questionnaires of clinical cases. In ROC curve there is no cut off for predicting the occurrence of a major event. In survival curve there is no difference between patients having a response greater than the median at questionnaire1, 2 or 3. however patients with a clinical performance at post training clinical cases above the median had an event-free survival significantly better than those with a response below the median (p Conclusion The evaluation of the reactions of patients with clinical cases is greater than the simple evaluation of the knowledge of patients in terms of predicting survival without hospitalization for heart failure.

La recherche clinique au sein des centres hospitaliers généraux…: …ou comment faire de la science sans (le faire) savoir…

Resume La recherche medicale est un element important de l’art medical et du service rendu aux patients. Des etudes scientifiques peuvent et doivent etre menees ou dirigees par des centres hospitaliers generaux mais cela implique de nombreuses collaborations en particulier avec des structures universitaires. Meme si cela est parfois difficile, l’amelioration de la connaissance medicale par les publications et les communications doit etre le but final de toute recherche.