[Show abstract][Hide abstract] ABSTRACT: Observational studies document the inverse relationship between cardiovascular disease (CVD) and moderate alcohol intake. However, the causal role for alcohol in cardioprotection remains uncertain as such protection may be caused by confounders and misclassification. The aim of our study was to evaluate potential confounders, which may contribute to putative cardioprotection by alcohol.
We evaluated clinical and biological characteristics, including cardiovascular (CV) risk factors and health status, of 149,773 subjects undergoing examination at our Center for CVD Prevention (The Urban Paris-Ile-de-France Cohort). The subjects were divided into four groups according to alcohol consumption: never, low (<or=10 g/day), moderate (10-30 g/day) and high (>30 g/day); former drinkers were analyzed as a separate group.
After adjustment for age, moderate male drinkers were more likely to display clinical and biological characteristics associated with lower CV risk, including low body mass index, heart rate, pulse pressure, fasting triglycerides, fasting glucose, stress and depression scores together with superior subjective health status, respiratory function, social status and physical activity. Moderate female drinkers equally displayed low waist circumference, blood pressure and fasting triglycerides and low-density lipoprotein-cholesterol. Alcohol intake was strongly associated with plasma high-density lipoprotein-cholesterol in both sexes. Multivariate analysis confirmed that moderate and low drinkers displayed better health status than did never drinkers. Importantly, few factors were causally related to alcohol intake.
Moderate alcohol drinkers display a more favorable clinical and biological profile, consistent with lower CV risk as compared with nondrinkers and heavy drinkers. Therefore, moderate alcohol consumption may represent a marker of higher social level, superior health status and lower CV risk.
Full-text · Article · Jun 2010 · European journal of clinical nutrition
[Show abstract][Hide abstract] ABSTRACT: Objectif
Les sujets en situation de précarité socio-économique ont une incidence accrue du diabète et de ses complications.
L’objectif de ce travail a été d’évaluer le risque du diabète chez les précaires en tenant compte des facteurs de confusion.
Patients et Méthodes
32 435 hommes et 16 378 femmes (35–80 ans), venus pour bilan de santé (Centre IPC, Paris), de janvier 2003 à décembre 2006. La précarité socio-économique était définie par le score EPICES validé par le Centre Technique d’Appui et de Formation pour les Centres d’examens de santé (BEH, 2006). Les sujets définis comme « Précaires » appartenaient au cinquième quintile. Le diabète était défini comme : Diabète connu et/ou traité ou diabète dépisté par un taux de glycémie ε1,26 g/l.
Entre 35 à 59 ans, la prévalence du diabète est de 6% chez les précaires et de 1% chez les non précaires pour atteindre respectivement 17% et 4% de 60 à 80 ans. Quel que soit le statut glycémique les facteurs de risque cardiovasculaires sont augmentés chez les précaires. Par rapport aux sujets non précaires en tenant compte de l’âge, de l’IMC, du tour de taille, des scores de stress et de dépression, le risque (Odds ratio) d’être diabétique chez les sujets précaires est de 4,2 (3,3–5,4) et 5,2 (3,3–8,3) respectivement chez les hommes et les femmes de 35–59 ans, et de 3,5 (2,4–5,2) et 2,2 (1,1–4,3) chez les 60–80 ans.
la situation de précarité socio-économique influence, fortement et indépendamment de facteurs de confusion, le risque d’être diabétique. Ceci incite à renforcer la prévention de ces populations.
No preview · Article · Mar 2010 · Diabetes & Metabolism
[Show abstract][Hide abstract] ABSTRACT: Increased risk for cardiovascular morbidity and mortality has been related to both lung function impairment and metabolic syndrome. Data on the relationship between lung function and metabolic syndrome are sparse.
To investigate risk for lung function impairment according to metabolic syndrome traits.
This cross-sectional population-based study included 121,965 men and women examined at the Paris Investigations Préventives et Cliniques Center between 1999 and 2006. The lower limit of normal was used to define lung function impairment (FEV(1) or FVC < lower limit of normal). Metabolic syndrome was assessed according to the American Heart Association/National Heart, Lung, and Blood Institute statement.
We used a logistic regression model and principal component analysis to investigate the differential associations between lung function impairment and specific components of metabolic syndrome. Lung function impairment was associated with metabolic syndrome (prevalence = 15.0%) independently of age, sex, smoking status, alcohol consumption, educational level, body mass index, leisure-time physical activity, and cardiovascular disease history (odds ratio [OR] [95% confidence interval], 1.28 [1.20-1.37] and OR, 1.41 [1.31-1.51] for FEV(1) and FVC, respectively). Three factors were identified from factor analysis: "lipids" (low high-density lipoprotein cholesterol, high triglycerides), "glucose-blood pressure" (high fasting glycemia, high blood pressure), and "abdominal obesity" (large waist circumference). All factors were inversely related to lung function, but abdominal obesity was the strongest predictor of lung function impairment (OR, 1.94 [1.80-2.09] and OR, 2.11 [1.95-2.29], for FEV(1) and FVC, respectively). Similar results were obtained for women and men.
We found a positive independent relationship between lung function impairment and metabolic syndrome in both sexes, predominantly due to abdominal obesity. Further studies are required to clarify the underlying mechanisms.
Full-text · Article · Feb 2009 · American Journal of Respiratory and Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: Limited knowledge exists on vascular risk factors, body height and weight in patients with spontaneous cervical artery dissection (sCAD).
In this case-control study, major vascular risk factors, body weight, body height and body mass index (BMI) of 239 patients obtained from a prospective hospital-based sCAD registry were compared with 516 age- and sex-matched healthy controls undergoing systematic health examinations in the Clinical and Preventive Investigations Center, Paris. Gender-specific analyses were performed.
The mean body height was higher in sCAD patients than in controls (171.3 cm (SD 8.6) vs 167.7 cm (8.9); p<0.0001) and sCAD patients had a significantly lower mean body weight (67.5 (12.2) kg vs 69.3 (14.6) kg; p<0.001) and mean BMI (22.9 (3.3) kg/m2 vs 24.5 (4.2) kg/m2; p<0.0001) than controls. The overall frequency of hypertension, diabetes, current smoking, past smoking and hypercholesterolaemia did not differ significantly between sCAD patients and controls. The mean total plasma cholesterol level was identical in both groups (5.5 mmol/l, SD 1.1). Gender specific subgroup analyses showed similar results for men and women.
Patients with sCAD had a higher body height and a lower body weight and BMI than controls, while major vascular risk factors were similar in sCAD patients and controls.
Full-text · Article · Feb 2009 · Journal of neurology, neurosurgery, and psychiatry
[Show abstract][Hide abstract] ABSTRACT: Socio-economically deprived subjects are reported to have an increased risk of diabetes and related complications. The aim of this study was to confirm this relation in a large French population. The study subjects consisted of 32,435 men and 16,378 women aged from 35 to 80 years who had a free health checkup at the IPC Center (Investigations Preventives et Cliniques, Paris-Ile de France) between January 2003 and December 2006. Socio-economic deprivation was evaluated by using the EPICES approach (Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé de France). Socio-economically deprived subjects were defined as those with scores in the 5th quintile. The prevalence of diabetes among deprived men and women was respectively 6% and 7% at age 35-59 years, and 18% and 15% at age 60-80 years. The prevalence of diabetes increased with level of deprivation. Compared to the 1st quintile of the EPICES score distribution, diabetes was three to eight times more frequent in the 5th quintile. After taking into account age, the body mass index, waist circumference, and anxiety and depression, the risk that deprived subjects would be diabetic (odds ratio) was respectively 4.2 and 5.2 for men and women aged 35-39 years, and 3.5 and 2.2 for those aged 60-80 years. The following cardiovascular risk markers were significantly higher or more frequent among deprived subjects: body mass, abdominal obesity, high blood pressure and the metabolic syndrome in women; and lower HDL cholesterol, higher triglyceride levels, proteinuria, a higher heart rate and additional ECG abnormalities in both men and women. Other indicators of poor health were also more frequent among deprived subjects, including anxiety and depression, smoking (among men), elevated gamma-GT and alkaline phosphatase levels, lung vital capacity, visual disorders, and dental plaque. Finally, deprived subjects also had more limited access to health care. Thus, socio-economic status markedly influences the risk of diabetes, independently of confounding factors. Several markers of cardiovascular risk and poor health were significantly more frequent among socio-economically deprived subjects, who also had more limited access to health care.
No preview · Article · Jan 2009 · Bulletin de l'Académie nationale de médecine
[Show abstract][Hide abstract] ABSTRACT: Metabolic syndrome is defined as an association of central obesity and several other cardiometabolic risk factors. Dysfunctional visceral adipose tissue and inflammatory status appear to be involved in its genesis. New definitions have decreased the threshold for glycaemia and one has lowered the threshold for waist circumference, leading to an increase in the prevalence of metabolic syndrome. However, the impact on mortality with these new definitions is lower than with the National Cholesterol Education Program-Adult Treatment Panel III 2001 definition. An increase in waist circumference, along with increased glycaemia, triglycerides and/or blood pressure is more highly associated with an increased risk of mortality than are other associations, while a decrease in high density lipoprotein cholesterol increases risk of coronary heart disease. The risk of sudden death and stroke is particularly notable with metabolic syndrome. Metabolic syndrome is associated with an increase in heart rate, pulse pressure, arterial stiffness and left ventricular hypertrophy, impairment of diastolic function, enlargement of the left atrium and atrial fibrillation. In the 2007 European recommendations for the management of high blood pressure, metabolic syndrome is now taken into consideration for both risk stratification and in selecting the optimal therapeutic strategy for arterial hypertension.
Full-text · Article · Oct 2008 · Archives of Cardiovascular Diseases
[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to assess the risk of all-cause and cardiovascular disease (CVD) mortality in subjects identified as having metabolic syndrome (MS) using either the recent International Diabetes Federation (IDF) definition or the revised National Cholesterol Educational Program (NCEP-R) definition, but not the original NCEP (2001) definition. The study population was composed of 84,730 men and women without CVD aged > or =40 years who had a health checkup at the IPC Center. Follow-up for mortality was 4.7 +/-1.7 years. Prevalences of MS were 9.6%, 21.6%, and 16.5% according to the NCEP, IDF, and NCEP-R definitions, respectively. Compared with subjects without MS, risks of all-cause mortality associated with MS were 1.63 (95% confidence interval [CI] 1.38 to 1.93) with the NCEP, 1.25 (95% CI 1.09 to 1.45) with the IDF, and 1.32 (95% CI 1.13 to 1.53) with the NCEP-R, and risks of CVD mortality were 2.05 (95% CI 1.28 to 3.28), 1.77 (95% CI 1.18 to 2.64), and 1.64 (95% CI 1.08 to 2.50), respectively. In subjects with MS detected using the IDF and NCEP-R definitions, but not the NCEP definition, risks of all-cause mortality were 1.07 (95% CI 0.89 to 1.28) and 0.92 (95% CI 0.73 to 1.18) and 1.42 (95% CI 0.86 to 2.34) and 1.07 (95% CI 0.55 to 2.09) for CVD mortality, respectively. In conclusion, in a large French population, the recent definitions of MS almost double the prevalence compared with the original definition. Subjects identified as having MS using only the recent definitions and not the original definition did not have higher rates of all-cause and CVD mortality compared with subjects without MS during follow-up.
Full-text · Article · Jul 2008 · The American Journal of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Balance and gait are essential to maintain physical autonomy, particularly in elderly people. Thus the detection of risk factors of balance and gait impairment appears necessary in order to prevent falls and dependency. The objective of this study was to analyze the impact of demographic, social, clinical, psychological, and biological parameters on the decline in balance and gait assessed by the Tinetti test (TT) after a two-year follow-up.
This prospective study was conducted among community-living, young elderly volunteers in the centre "Investigations Preventives et Cliniques" and "Observatoire De l'Age" (Paris, France). Three hundred and forty-four participants aged 63.5 on average were enrolled and performed the TT twice, once at inclusion and again two years later. After the two-year follow-up, two groups were constituted according to whether or not there was a decrease in the TT score: the "TT no-deterioration" group comprised subjects with a decrease of less than two points and the "TT deterioration" group comprised those with a decrease of two points or more. Selected demographic, social, clinical, psychological, and biological parameters for the two groups were then compared.
Statistical analysis showed that female sex, advanced age, high body mass index, osteoarticular pain, and a high level of anxiety all have a negative impact on TT score.
Knowledge of predictive factors of the onset or worsening of balance and gait disorders could allow clinicians to detect young elderly people who should benefit from a specific prevention program.
Full-text · Article · Jul 2008 · Medical science monitor: international medical journal of experimental and clinical research
[Show abstract][Hide abstract] ABSTRACT: Few data are available on the impact of the metabolic syndrome on all-cause mortality risk according to the presence of hypertension. Our aim was to evaluate the 5-year impact of the metabolic syndrome, according to blood pressure status, on all-cause mortality risk in a large French population.
The study population included 39 998 men and 20 756 women with no personal history of cardiovascular disease, who had a health check-up at the IPC Center (Paris, France) between 1999 and 2002, and who were followed up for 4.7 +/- 1.2 years. The metabolic syndrome was defined according to the National Cholesterol Educational Program classification (2001). Cox regression models were used to evaluate risk of all-cause mortality after adjustment for age, sex, classical risk factors and socioeconomic categories. Subjects were classified according to blood pressure status: hypertensive subject (systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg or treatment) and normotensive subject.
The risk of all-cause mortality associated with the metabolic syndrome was 1.50 (1.24-1.82) [hazard ratio (HR) (95% confidence interval)]. The risk of all-cause mortality associated with the presence of hypertension was 1.60 (1.38-1.85). During the 4.7 years of follow-up, the impact of the metabolic syndrome was similar among normotensive and hypertensive subjects [HR: 1.09 (0.68-1.75) and 1.40 (1.13-1.74), respectively, P for interaction = 0.35].
The findings from this study show that, in a large middle-aged French population, the metabolic syndrome has the same deleterious impact on all-cause mortality in hypertensive subjects and normotensive subjects.
No preview · Article · Jul 2008 · Journal of Hypertension
[Show abstract][Hide abstract] ABSTRACT: Sudden death is a major problem in public health, affecting around 50 000 people a year in France. The prognosis for cardiac arrest is abysmal because for every minute lost the chances of survival diminish by 10%. The aim of this work was to prospectively evaluate the characteristics of cardiac arrest victims across an entire 6000 km? area, the Seine-et-Marne district, distinguished by the paradox of lying just outside the capital whilst actually being semi-rural, and to determine the current methods of dealing with this emergency. The DEFI 77 prospective epidemiological survey was carried out with the collaboration of the SAMU emergency medical service, the SDIS fire/ambulance service, the general hospitals and the Paris-Ile-de-France cardiological association. Between January 2001 and December 2005 there were 2001 cardiac arrests (mean age 68 +/- 20 years, 67% male) at home in 80% of cases. The arrest was in front of a witness in 72% of cases, but they performed resuscitation in only 14.3% of cases. The SAMU and SMUR emergency medical services attempted cardio-pulmonary resuscitation in 78% of cases. In 29% of cases, one or more external electric shocks were carried out, using a semi-automatic defibrillator 79% of the time. Only 11.5% of patients arrived at the emergency department alive, the overall hospital survival rate being less than 2%. Only eight patients subsequently underwent automatic defibrillator implantation. The results of this observational study are to a large extent explained by an extremely long delay (12 minutes) before help was called for, the delay between the call and the arrival of medical assistance (9.5 +/- 4 min), the low percentage of active witnesses, and the variability in management (invasive in particular). In conclusion, at the dawn of the third millennium the prognosis of cardiac arrest remains very poor and fully justifies educating the general public about calling for help early and about actions that can save lives, particularly external cardiac massage before the arrival of the emergency services, as well as the benefits of using automated external defibrillators.
No preview · Article · Nov 2007 · Archives des maladies du coeur et des vaisseaux
[Show abstract][Hide abstract] ABSTRACT: In acute heart failure syndromes (AHFS), the prognostic value of left ventricular ejection fraction (LVEF), although widely accepted, has been recently challenged. In contrast, blood pressure is increasingly gaining ground over LVEF as predictor of mortality. Therefore, it is not clear whether both LVEF and mean arterial pressure (MAP) are independent risk factors in patients with AHFS.
The EFICA study enrolled 581 AHFS patients admitted to 60 CCU/ICUs. Survival at 4 weeks was analyzed for all cases with echocardiographic LVEF available on admission (n=355). Four-week mortality was 23%. Multivariable analysis identified lower LVEF, lower MAP and serum creatinine >1.5 mg/dl as independent correlates of mortality (respectively, OR: 1.27 per 10% decrease, CI: 1.05-1.53, p=0.012; OR: 1.30 per 10 mmHg decrease, CI: 1.15-1.48, p<0.0001; OR: 2.84, CI: 1.64-4.93, p=0.0002). LVEF interacted significantly with MAP (p<0.0001) and the subgroup analysis showed that reduced LVEF was a strong risk factor in patients with MAP <or=90 mmHg (OR: 2.73, CI: 1.23-5.98, p=0.01) but did not reach statistical significance in patients with MAP >90 mmHg.
Both LVEF and MAP are important predictors of death in severe AHFS. LVEF can provide additional prognostic information on top of MAP but mainly in patients with low MAP (<or=90 mmHg) at admission.
Full-text · Article · Oct 2007 · European Journal of Heart Failure
[Show abstract][Hide abstract] ABSTRACT: The aim was to evaluate the impact of specific component combinations of the metabolic syndrome on all-cause mortality risk in a large French cohort.
The population was composed of 39,998 men (aged 52.6 +/- 8.3 years) and 20,756 women (aged 54.7 +/- 9.2 years) who were examined at the Investigations Préventives et Cliniques Center from 1999 to 2002. Mean follow-up was 3.57 +/- 1.12 years. Metabolic syndrome was defined according to three definitions: the National Cholesterol Educational Program (NCEP 2001), the revised NCEP (NCEP-R; American Heart Association/National Heart, Lung, and Blood Institute 2005), and the International Diabetes Federation (IDF 2005). Subjects with metabolic syndrome were compared with subjects without metabolic syndrome and with subjects with no metabolic syndrome components using Cox regression models.
The prevalence of metabolic syndrome increased from 10.3% (NCEP) to 17.7% (NCEP-R) and 23.4% (IDF). After adjustment for age, sex, classical risk factors, and socioprofessional categories, and compared with subjects without metabolic syndrome, the risk of all-cause mortality was 1.79 (95% CI 1.35-2.38), 1.46 (1.14-1.88), and 1.32 (1.04-1.67) with the NCEP, NCEP-R, and IDF definitions, respectively. Among the combinations significantly associated with all-cause mortality, the following three-component combinations and the four-component combination were more highly significant than other combinations (P < 0.05): elevated waist circumference plus elevated glucose, plus either elevated blood pressure or elevated triglycerides, and the combination of all four of these.
In a large middle-aged French population, four specific components of metabolic syndrome are associated with a much higher mortality risk. These results may have a significant impact on detecting high-risk subjects suffering from metabolic disorders and underline the fact that metabolic syndrome is a nonhomogeneous syndrome.
[Show abstract][Hide abstract] ABSTRACT: The EVADEF registry enrolled 2296 patients implanted with a defibrillator between june 2001 and june 2003 and followed up 24 months. Their main characteristics were the following: their mean age was 60±15 years, they were male in 86 %. Their left ventricular ejection fraction was 38.9 ± 15.9 %. They were in NYHA class I or II for 83.8% of them, in class III for 14.7% and in class IV for only 1.5%. Secondary prevention indications concerned 82.1%, primary prevention 18.3%. Underlying cardiopathies were coronary artery disease in 61.3%, dilated cardiomyopathies in 15.9%. In a group of 7.1% there was no underlying heart disease. The implanted devices were VVI in 48.3%, DDD in 42.9%, biventricular pacemaker with defibrillator in 8.3% and dual defibrillator in 0.5%. Periprocedure complications concerned 13.8%. The most frequently reported was the presence of an haematoma. Periprocedure mortality concerned 8 patients, i.e. 0.3% of the total cohort. Mortality was 7.2% at 1 year and 11.3% at 2 years. Among the 274 deaths, a majority was due to heart failure (42%), arrhythmic storms represented only 6.2% of deaths. Hopefully it is likely that in the future association of cardiac resynchronization therapy to defibrillator will be able to decrease this death rate due to heart failure.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the cardiovascular prognosis of 1845 Diabetic Patients (DP) and 6443 Non-Diabetic Patients (NDP) in secondary prevention.
Patients were recruited prospectively if they had had a previous history of ischemic stroke or acute coronary syndrome (ACS) i.e. Myocardial Infarction (MI) or Unstable Angina (UA) within a period of five years preceding inclusion. For each patient, the number of hospitalizations and vital status were recorded each month over a 6-month period (mean follow-up: 4.8 months).
306 patients (9.5/100--person years; 95% CI, 8.5 to 10.6) had undergone at least one subsequent event (hospitalization for ACS, ischemic stroke, or cardiovascular death). A majority of these events were non-fatal ACS (n=248). The cumulative incidence rate of subsequent events was higher in DP: 12.6/100- person years (10.0 to 15.2) than in NDP: 8.6/100--person years (7.5 to 9.8). DP were significantly at higher risk of subsequent cardiovascular events (OR: 1.34; P=0.025) after adjustment for confounding factors. 93% of coronary DP and NDP underwent a recurrent event affecting the same location. When the index episode was a stroke, 71% of DP had a subsequent stroke vs. 47% of NDP.
in secondary prevention, the risk of mortality and subsequent vascular events is independently higher in French DP than in NDP. The locations affected by each type of subsequent cardiovascular event seemed correlated to the baseline diagnosis, whatever the diabetic status, even when the frequency of subsequent strokes increased (not significantly) in DP when compared to NDP.
No preview · Article · Dec 2006 · Diabetes & Metabolism
[Show abstract][Hide abstract] ABSTRACT: We examined the prevalence of atrial fibrillation (AF) in a large French population according to age, risk factors, all-cause mortality, and cardiovascular and cerebrovascular mortality. The study population was composed of 98,961 men and 55,109 women over 30 years of age who had a free medical checkup at the IPC Center (Centre d'Investigations Préventives et Cliniques). Routine electrocardiograms revealed the presence of AF in 235 men (mean age 60.2 +/- 10.3 years) and 63 women (mean age 62.5 +/- 9.1 years). Mean follow-up was 15.2 years. The relative risk of death [Hazard Ratio (95% CI)] was determined with a Cox regression model. The prevalence of AF increased strongly with age in both genders and was higher among men. Before 50 years of age, AF was present in 0.05% of men and 0.01% of women, compared to 6.5% and 5.2%, respectively, in over-80s. After adjustment for age, factors significantly associated with AF were cardiopathy [Odds Ratio (OR) = 3.2 (2.3-4.5) among men and 4.9 (2.5-9.5) among women], hypertension [OR = 1.4 (1.1-1.9) in men and 2.2 (1.2-3.9) in women], overweight [OR = 2.2 (1.4-3.2) in men and 2.3 (1.0-5. 1) in women], ventilatory failure [OR = 1.4 (0.9-2.2) in men and 4.9 (2.4-10) in women], diabetes [OR = 1.7 (1.1-2.5) in men] and alcohol consumption [OR = 1.7 (1.2-2.4) in men]. The relative risk of death was then adjusted for age, cardiopathy, left venticular hypertrophy, blood pressure, cholesterol, glycemia, body mass index, smoking, alcohol, and vital capacity. The HR of all-cause mortality was 1.5 (1.0-2.0) in men and 1.8 (1.0-3.3) in women. The HR of cardiovascular mortality was 2.2 (1.2-3.1) in men and 3.4 (1.5-7. 7) in women, while for stroke-related mortality it was 2.0 (0.7-4.3) in men and 4.5 (1.3-16) in women. No association was found between AF and non-cardiovascular mortality in either men or women. The risk of death among men without cardiopathy or hypertension, after adjustment for the other risk factors, was not significantly increased (overall mortality 1.1 (0.5-2.0), cardiovascular mortality 1.4 (0.6-2.9)). In contrast, men with cardiopathy or hypertension had an adjusted HR of 1.7 (1.1-2.8) for overall mortality and 2.6 (1.3-5.3) for cardiovascular mortality. In conclusion, after adjustment for all risk factors, the AF-related relative risk of overall mortality and of cardiovascular mortality was higher among women than among men, especially for cerebrovascular mortality. AF was not an independent risk factor for death among men free of cardiopathy and hypertension.
No preview · Article · Nov 2006 · Bulletin de l'Académie nationale de médecine