EMC - Cardiologie-Angéiologie最新文献

Pulmonary embolism is an affection that remains often unrecognized despite diagnostic and therapeutic advances in this field; it yields high rates of lethality and morbidity. The classical diagnostic approach based on pulmonary angiography tends to be replaced by more pragmatic non-invasive investigations. Perfusion-ventilation lung scan has an excellent sensitivity, but is limited by the large number of inconclusive results. Helical CT scanning, Elisa-based D-dimer measurement, lower-limb venous Doppler ultrasonography and echocardiography are used today as parts of non-invasive diagnostic strategies. Low-molecular-weight heparins proved to be more effective than unfractionated heparin in the treatment of deep-vein thrombosis. Their results are interesting in the treatment of pulmonary embolism. Oral anticoagulant therapy is introduced early in order to limit the risk for heparin associated thrombocytopenia. Its duration depends essentially on the recurrent character of the thromboembolic disease and on the possible existence of an underlying thrombophilia.

Most acquired arteriovenous fistulae (AAVF) are from traumatic origin and increasingly iatrogenic. Most frequently, they are localized to the limbs. Blood steel through the fistula has drastic local and general pathophysiological and haemodynamic consequences. Current imaging techniques perfectly identify the physiology and the three-dimensional topography of these AAVF. Surgery offers good results for limbs and trunk acquired fistula. Endovascular techniques are increasingly used to approach deep localized and high risk AAVF with promising results.

Hypertension is an under-recognized clinical entity in children. Blood pressure (BP) assessment should be one of the routine examinations in childhood and adolescence. Many particular features characterize hypertension in children: optimal BP determination in children requires the use of an appropriately sized cuff and BP measurement must be repeated for confirmation. The definition of hypertension is based on the normative distribution of BP in healthy children according to gender, height and age. It is graded to distinguish mild hypertension from confirmed or severe hypertension. Ambulatory BP monitoring may facilitate detection of borderline hypertension and treatment monitoring. Careful clinical assessment is the key for identifying predisposition to primary adult hypertension or secondary causes. Target organ abnormalities, additional cardiovascular risk factors and comorbidities have to be taken into account. High BP in childhood and primary hypertension have to be considered as risk factors for cardiovascular disease in early adulthood. Secondary hypertension is common in children with confirmed or severe hypertension and screening test should be individualized for each child. Renal or renovascular causes concern a majority of children but aortic coarctation or endocrine diseases can also be found. Symptomatic children and patients with severe hypertension require antihypertensive drug therapy. Lifestyle modifications including diet exercise and reduction of overweight remain the basic principles of the treatment in mild hypertension.

Syncope is a frequently encountered medical problem. Despite its benignity in a great proportion of patients, it raises the problem of the differential diagnosis regarding other causes of loss of consciousness (particularly neurological and psychiatric causes) and that of a precise etiological evaluation aimed at identifying patients at high risk. The diagnostic evaluation should be based primarily on complete medical history, physical examination and electrocardiogram, rather than on systematic investigations which are expensive, sometimes invasive and often useless. The aim of this chapter is to clarify the definition of syncope and to propose a diagnosis and management strategy according to recent recommendations and available diagnostic tools.

The recording of ventricular late potentials is a simple, noninvasive technique for ventricular tachycardia evaluation; it permits also the measurement of the degree of myocardial ischemia or fibrosis in various heart diseases such as right ventricular dysplasia, ischemic heart disease or dilated cardiomyopathies. Today, this technique has a more limited place due to its relatively low diagnosis value, principally for the prediction of sudden cardiac death. Late potentials are detected by the amplification and averaging of QRS complexes that may reveal an electrical activity of low amplitude occurring at the end of the QRS; they are due to the late depolarisation of pathological myocardial fibres and to the possible presence of an intra-ventricular reentry. This examination must be interpreted taking into account the clinical history and other noninvasive investigations undertaken for the evaluation of ventricular tachycardia and fibrillation. The averaged ECG used for the detection of late potentials remains important when measuring QRS duration because this technique is precise and reproducible; actually, this assessment is one of the more simple and potent signs of prognostic evaluation and follow-up of idiopathic or ischemic dilated cardiomyopathies.

Oedema is the main clinical sign of interstitial fluid inflation. Oedemas are due to increased capillary pressure, or lowered oncotic pressure, or to an increase of capillary permeability. When generalised, oedemas are located first in the lower part of the body. At more advanced stages, they can generate peritoneal, pleural and pericardial effusions, leading to general dropsy. In terms of aetiology, generalised oedemas are due to cardiac, hepatic, and renal causes. Treatment depends on the specific aetiology, but symptomatic measures such as low sodium diet and supine position are always necessary. Diuretics are often needed but their use should not be systematic, especially by self-medication. When oedemas are localised, they are usually due to a local cause involving a venous or lymphatic disorder. In these particular cases, venous contention is always recommended and diuretics are not indicated.

Peripheral artery disease is a highly prevalent manifestation of atherosclerosis that is associated with a substantial risk of illness and death and a marked reduction in ambulatory capacity and quality of life. Unfortunately, peripheral artery disease is under-treated with regard to risk factor modification, use of antiplatelet drugs, and treatment of symptoms. Patients with peripheral artery disease should be considered eligible for secondary prevention strategies, just as are patients with coronary artery disease. Aspirin or clopidogrel should be considered in all patients. Drugs that improve functional status, called vasoactive drugs, are also available. Their use should be limited to patients with intermittent claudication in whom, despite prolonged standard therapy and physical exercise, functional symptoms persist but with no need for revascularization. These treatments should be discontinued in the absence of clear amelioration of symptoms. Prostanoid agents have shown some benefits in patients with critical limb ischemia, in which no revascularisation is possible.

Lower limb treatment by contention/compression (C/C) is the cornerstone for treating and preventing chronic venous insufficiency (CVI), lymphoedema and thromboembolic diseases. Bandages and/or medical stockings are proposed in such treatment, owing to their proven or supposed mode of action on the haemodynamic disorders resulting from venous and lymphatic diseases. Nevertheless, complete knowledge of their therapeutic potential and precise evaluation of the patient's needs remain necessary to establish adequate prescription. However, this knowledge is not sufficient, because many uncertain factors should also be taken into account such as the technique for putting up the bandages by the patient himself or by an untrained nursing staff. This essay analyses the different theoretical, practical and psychological elements, with a view to better approach issues and solutions regarding a thousand-year-old therapy accepted by everyone but whose mode of action still very much (too much?) come under the so-called medical art.