Interest of a systematic screening of comorbidities in chronic inflammatory rheumatisms

BackgroundPatients with chronic inflammatory rheumatisms (CIR) have a greater risk of cardiovascular events, infections, lung diseases and osteoporosis. European League against Rheumatisms (EULAR) recommends annual evaluation of the cardiovascular risks.MethodsA program of comorbidity screening was set up in a daily clinic of our Rheumatology department and includes:– rheumatism evaluation;– cardiovascular evaluation; clinical examination, blood tests, modified systematic coronary risk evaluation (mSCORE) calculation, vessel ultrasound and echocardiography;– lung evaluation; self-questionnaires and spirometry;– osteoporosis; bone mineral density and FRAX calculation;– check-up of vaccinal status and the recommended neoplasic screenings.ResultsNinety-two patients already benefited from this systematic screening with 83% (n=76) of rheumatoid arthritis, 11% (n=10) of spondyloarthritis, 3% (n=2) of psoriatic arthritis and 4% (n=4) of other diseases. The mean rheumatism duration was 14±9 years, the mean age was 59±11 years and 64% were women. Hypertension was diagnosed in 8.7% (n=8) of the patients; dyslipidemia in 9.8% (n=9); diabetes in 6.5% (n=6) of the patients. The echocardiography showed significant abnormalities (valvular and hypokinesia) in 9% (n=8) of the patients, a significant supra-aortic vessel stenosis was found in 4.5% (n=4) of the population and an abdominal aortic aneuvrysm was diagnosed in 5.7% (n=5). Among 92 patients, 18.4% (n=14) were estimated at high risk of lethal cardiovascular event with a mSCORE≥5 and 27.5% (n=25) patients were sent to a cardiologist to pursue further cardiovascular investigations. Among these, 8 had a myocardial scintigraphy and all were normal. Moreover, 32.6% (n=30) of the patients were estimated at risk of chronic obstructive pulmonary disease or sleep apnea syndrome and were recommended to consult pneumologist. An anti-osteoporosis drug was introduced in 12% (n=11) of the patients. The update of the vaccinations and the neoplasic screenings were prescribed for respectively 52.7% (n=48) and 35.2% (n=32) of the patients.DiscussionA daily hospitalization for comorbidity screening seems worthy with significant abnormalities discovered in 36.2% of the patients. Further investigations were recommended in 50% of the patients. Patient’ satisfaction and the effective impact of the proposed or prescribed measures are under evaluation

Réponse rénale à l'expansion volémique aiguë dans l'hyperaldostéronisme primaire [Renal response to acute volume expansion in primary hyperaldosteronism]

The exaggerated natriuretic response to extracellular fluid volume expansion (VE) observed in essential hypertension (EH) is related directly to blood pressure (BP) and indirectly to plasma renin activity (PRA). In order to evaluate the precise role of different hormonal parameters, the response to acute VE (isotonic saline, 1,800 ml IV over 3 hours) was assessed in 14 patients with primary aldosteronism (PA, surgically proven adrenal adenoma) and 18 clinically matched EH. At the time of the maneuver, BP and sodium intake were similar in the two groups, but serum potassium (2.89 +/- 0.13 vs 3.69 +/- 0.09 mmol/l), PRA (0.9 +/- 0.2 vs 3.5 +/- 0.9 ng/ml/h) and plasma aldosterone concentration (PAC, 25.9 +/- 3.8 vs 12.6 +/- 1.6 ng/dl) were significantly different. During VE, sodium excretion (UNaV) increased more in PA than in EH (98.1 +/- 15.2 vs 63.5 +/- 7.9 mmol/3 h); moreover, the slope of the regression line relating UNAVVE to UNaVcontrol was significantly steeper in PA. By contrast, the change in BP and indices of VE (hematocrit and plasma protein concentration) as well as the decrease in PRA (-45 +/- 9 vs -43 +/- 5 p. 100) and the increase in ANP (+ 65 +/- 16 vs + 69 +/- 28 p. 100) were similar in the two groups. VE left PAC unchanged in PA, whilst it decreased PAC in EH. We conclude that the natriuretic response to volume expansion is more marked in primary aldosteronism than in essential hypertension, a difference which is not explained by variations in the renin-angiotensin system or atrial natriuretic peptide

Performance et rendement du ventricule gauche chez l’hypertendu sans hypertrophie ventriculaire gauche : étude échographique par modélisation du couplage ventriculo-aortique

International audienceBecause the functional interaction between the LV and arterial systems, termed ventricular-arterial coupling, is recognized as a key determinant of LV performance, the objective of the present study was to assess the impact of uncomplicated HT without LVH on LV performance using simultaneously echocardiography and carotid tonometry. LV maximal power (PmaxVG), cardiac power output (CPO), LV efficiency (CPO/PmaxVG), input aortic and output LV elastance (Ea and Ees) were assessed in 20 normotensive control subjects (NT) and 10 patients with untreated HT. PmaxVG was calculated according to the integral of the product of LV wall stress with strain rate (as an index of gradient velocity). Cyclic variation of wall thickness and SR were measured by speckel-tracking. Ea and Ees were derived and modelized from the pressure-volume curve. No difference * Auteur correspondant. Adresse e-mail : [email protected] (B. Bonnet). in age, BMI and sex ratio was observed between NT and HT. Systolic BP (160 ± 18 vs. 119 ± 10 mmHg), LV mass (99 ± 15 vs. 76 ± 12 g/m 2), PWV (9.7 ± 2 vs. 6.9 ± 1 m/s) were significantly higher (P < 0.01) in HT when compared to NT. In HT increased of CPO and Ea was compensated by an increase of LV (15 ± 4 vs. 12 ± 3%, P < 0.02) and Ees (5.5 ± 2 vs. 4.5 ± 1.5 mmHg/mL), which are significantly elevated in HT (P < 0.05). No difference was observed in Ea/Ees between NT and HT. In conclusion at the early phase of HT, in patients without LVH, LV performance and ventricular-arterial coupling were adapted to post-load elevation. This adaptation may be the result of an increased of LV contractility.L'objectif de ce travail est d'évaluer l'impact d'une HTA modérée et non compliquée (sans HVG) sur la performance et le rendement du ventricule gauche (VG) chez l'hypertendu. L'étude échographique a porté sur 20 sujets contrôles normotendus et 10 patients présentant une HTA de découverte récente, jamais traitée et sans HVG. La puissance maximale totale du VG (PmaxVG) est calculée par l'intégrale du produit des contraintes pariétales VG avec le strain rate (SR) télésystolique (pris comme index des gradients de vitesse). Le couplage ventriculo-aortique est estimé par le rapport des élastances de sortie du VG (Ees) et d'entrée aortique (Ea) (Ea/Ees) et le transfert d'énergie du VG à l'aorte (rendement) est calculé par le rapport de la puissance d'éjection (CPO)/Pmax VG. L'âge et la répartition du sexe sont les mêmes dans les 2 groupes (NT et HT). La PAS et la masse VG et la VOP sont significativement plus élevées dans le groupe HT par rapport au groupe NT. L'augmentation du CPO et de Ea chez l'hypertendu sont compensées par une augmentation du rendement VG et de Ees qui sont significativement plus élevés chez l'hypertendu (p < 0,05). Il n'y a pas de différence significative de Ea/Ees entre les 2 groupes. En conclusion à un stade précoce de l'HTA, chez les patients sans HVG, la performance du VG est adaptée à l'élévation de la post-charge. Cette adaptation pourrait être liée à une augmentation de la contractilité VG

The QT interval: a predictor of the plasma and myocardial concentrations of amiodarone.

A study was performed to assess whether plasma and myocardial concentrations of amiodarone correlated with changes on the surface electrocardiogram. Nine patients--seven with angina and two with paroxysmal ventricular tachycardia--were treated with oral amiodarone (200-400 mg daily) for at least nine months before undergoing cardiac surgery. QT intervals were measured from lead II of the surface electrocardiograms recorded before amiodarone treatment and immediately before surgery. Patients with prominent U waves after taking amiodarone were excluded from the study. Plasma and myocardial samples were collected at the beginning of the surgical procedure for estimating plasma and myocardial concentrations using the high performance liquid chromatographic technique. Amiodarone caused a significant lengthening of the QTc interval. There was a good correlation between plasma and myocardial concentrations, and both correlated well with the percentage increase in the QTc interval. Although there was a strong correlation between the dosage given (mg/kg/day) and both plasma and myocardial concentrations, the correlation with the percentage increase in the QTc interval was weaker but still highly significant. Despite previous reports to the contrary, the findings indicate that the plasma concentration of amiodarone does correlate well with the myocardial concentration. The degree of lengthening of the QTc interval may be used clinically to estimate the myocardial concentration of amiodarone