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Resume Introduction L’obesite est un fleau social. L’hypertension arterielle masquee (HTAM) est une entite de description relativement recente qui pose un probleme de diagnostic. Le but de cette etude etait de determiner les caracteristiques cliniques et paracliniques de ces patients, et identifier les facteurs predictifs de l’HTAM. Methodes Il s’agit d’une etude prospective incluant des patients obeses normo-tendus en mesure clinique. Tous ces patients ont beneficie d’une mesure ambulatoire de la pression arterielle (MAPA) pour depister une HTAM, une exploration biologique et une etude echocardiographique avec etude des deformations myocardiques. Resultats Nous avons recrute 50 patients dont l’âge moyen etait de 46,52 ± 10,4 ans. Le recueil des chiffres tensionnels en consultation avait montre une pression arterielle systolique (PAS) moyenne de 120, 8 ± 8,8 mmHg et une PA diastolique (PAD) moyenne de 75 ± 7,3 mmHg. La prevalence d’HTAM chez les adultes obeses etait de 36 % avec un profil majoritairement non dippers (38 %). L’etude des parametres echocardiographiques a retrouve que l’oreillette gauche (OG) etait dilatee chez 16 patients (32 %). Le ventricule gauche (VG) etait hypertrophie chez 32 patients (64 %). Le strain longitudinal global (SLG) du VG etait en moyenne de −18,85 ± 0,9 % et le SLG de l’OG etait en moyenne de 37,35 ± 4,5 %. Dans notre etude, le syndrome metabolique, des taux de HDL cholesterol bas, une glycemie a jeun elevee, une hyperuricemie, une dilatation de l’OG, une hypertrophie ventriculaire gauche, une dysfonction diastolique du VG et une alteration des deformations myocardiques etaient des facteurs associes a une HTAM chez les adultes obeses. Conclusion Il parait primordial de realiser un depistage de l’HTA par une mesure ambulatoire chez les patients obeses a risque qui presenteraient des facteurs associes a l’HTAM. La morbi-mortalite induite et le risque cardiovasculaire seraient non negligeables et le justifie pleinement.

Resume Introduction Malgre les progres therapeutiques, moins de la moitie des patients hypertendus sont equilibres. L’objectif de cette etude etait d’etudier les liens entre le controle tensionnel et les facteurs socioeconomiques (SE). Materiel et methodes Pour repondre a notre objectif, nous avons utilise les donnees, recueillies dans le service de cardiologie de l’hopital universitaire de Sfax, dans le cadre du registre national tunisien d’hypertension arterielle. Nous avons etudie les associations entre les variables SE (niveau scolaire, profession, couverture medicale) et un controle optimal de la pression arterielle (PAS Resultats L’âge moyen de notre population etait de 65 ans et le sexe-ratio de 0,95. Nous avons trouve, comme prevu, les facteurs cliniques et comportementaux associes a un bon equilibre tensionnel a savoir : le sexe feminin, le regime hyposode, l’observance therapeutique, et la pratique d’une activite physique reguliere. En revanche, l’obesite et le traitement par un nombre augmente d’anti-hypertenseurs ont ete associes a un mauvais controle tensionnel. L’etude de l’effet des variables socioeconomiques sur l’equilibre tensionnel trouve un gradient significatif en defaveur des categories sociales les plus defavorisees pour nos trois variables sociales dans l’analyse univariee. L’inclusion des facteurs cliniques et comportementaux dans l’analyse multivariee a attenue ces associations mais ne les a pas entierement expliquees. Conclusion Notre etude montre qu’il existe des inegalites sociales du controle de la pression arterielle. La justice sociale et l’amelioration des conditions de vie representent probablement les vraies solutions au probleme de ces inegalites sociales de sante.

Background Covid-19 vaccine was associated with several complications such as thromboembolic complications. The exact mechanism is not well established. Since covid 19 virus caused severe endothelial dysfunction, we suspect that the vaccine with a similar immunological response may cause this dysfunction. Aim To study the effect of covid-19 vaccine on endothelial function. Methods We conducted a prospective study. The endothelial function was clinically assessed using a post-occlusive reactive hyperemia protocol with finger thermal monitoring device. Endothelial quality index (EQI) was assessed at inclusion before the first dose of coronavirus vaccine and 30 days later. Results 20 patients were included in our study. Their mean age was 41 years old [23–65]. The sex ratio was 3/2. They were all healthy individuals. The Majority, 75% of our patients, have impaired their endothelial function 30 days after the first dose of covid-19 vaccine. Conclusion The Covid-19 vaccine effect on endothelial function may be responsible for its complications. Key words: Covid-19 vaccine, endothelial dysfunction

Resume Le recepteur HER2 (Human Epidermal Growth Receptor 2) est un recepteur transmembranaire a activite tyrosine kinase qui est surexprime dans 25 a 30 % des carcinomes mammaires. Son activation est associee a une exageration de la proliferation cellulaire avec une augmentation de la capacite de reparation entrainant une radioresistance accrue. Sur les tissus sains, essentiellement cardiaques, l’activation des recepteurs joue un role cardioprotecteur. Le Trastuzumab, premier anti-HER2 utilise pour traiter les patientes atteintes de cancers du sein avec surexpression des recepteurs HER2, inhibe la cascade de reaction aboutissant a la proliferation des cellules tumorales permettant ainsi de restaurer la radiosensibilite cellulaire. Cependant, l’association du Trastuzumab a la radiotherapie supprime l’effet cardioprotecteur des recepteurs HER2 sur les cellules myocardiques ce qui majore le risque de cardiotoxicite. C’est ainsi que l’association concomitante de ces deux modalites therapeutiques a longtemps ete un sujet de controverse. Les progres realises aussi bien sur le plan technique de radiotherapie que pour les moyens de detection precoce des lesions cardiaques, pourraient limiter la cardiotoxicite de cette association. Nous proposons a travers cette mise au point, une revue de la litterature sur les bases biologiques et le benefice-risque de l’association concomitante de radiotherapie et Trastuzumab dans le traitement adjuvant des cancers du sein non metastatique HER2 surexprime et nous discutons les modalites de son optimisation.

Background Contemporary registries on atrial fibrillation (AF) are scare in North African countries. Hypothesis In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal. Methods NATURE‐AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one‐year follow‐up period. All the patients with an Electrocardiogram‐documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described. Results A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA2DS2VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12‐month follow‐up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died. Conclusions NATURE‐AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.

EP after TEE represents a medico‐surgical emergency. Given the high rate of asymptomatic patients with COVID 19, the risk of contamination and the frailty of esophageal tissues, we should check coronavirus infection in every patient before TEE.

BackgroundCurrent predictive models based on biomarkers reflective of different pathways of heart failure with reduced ejection fraction (HFrEF) pathogenesis constitute a useful tool for predicting death risk among HFrEF patients. The purpose of the study was to develop a new predictive model for post-discharge mortality risk among HFrEF patients, based on a combination of clinical patients’ characteristics, N-terminal pro-B-type Natriuretic peptide (NT-proBNP) and oxidative stress markers as a potentially valuable tool for routine clinical practice.Methods116 patients with stable HFrEF were recruited in a prospective single-center study. Plasma levels of NT-proBNP and oxidative stress markers [superoxide dismutase (SOD), glutathione peroxidase (GPX), uric acid (UA), total bilirubin (TB), gamma-glutamyl transferase (GGT) and total antioxidant capacity (TAC)] were measured in the stable predischarge condition. Generalized linear model (GLM), random forest and extreme gradient boosting models were developed to predict post-discharge mortality risk using clinical and laboratory data. Through comprehensive evaluation, the most performant model was selected.ResultsDuring a median follow-up of 525 days (7–930), 33 (28%) patients died. Among the three created models, the GLM presented the best performance for post-discharge death prediction in HFrEF. The predictors included in the GLM model were age, female sex, beta blockers, NT-proBNP, left ventricular ejection fraction (LVEF), TAC levels, admission systolic blood pressure (SBP), angiotensin-converting enzyme inhibitors/angiotensin receptor II blockers (ACEI/ARBs) and UA levels. Our model had a good discriminatory power for post-discharge mortality [The area under the curve (AUC) = 74.5%]. Based on the retained model, an online calculator was developed to allow the identification of patients with heightened post-discharge death risk.ConclusionIn conclusion, we created a new and simple tool that may allow the identification of patients at heightened post-discharge mortality risk and could assist the treatment decision-making.

The transplant renal artery stenosis occurred up to 23% after kidney transplantation. Endovascular treatment has become the treatment of choice of this complication, but could be challenging in immediate postoperative anastomotic narrowing. We report the case of a adolescent with early renal graft artery stenosis located in the anastomosis and diagnosed 3 days after renal transplantation, with necessity of haemodialysis. This complication was treated by angioplasty on the 25th day, using a polymer free drug eluting stent with a good result. We discussed the precautions and technical features of this procedure.

Mixed connective tissue disease (MCTD) is characterized by a mixture of clinical features. The initial presentation is often incomplete, and the features of MCTD usually develop as the disease evolves. We present a 37‐year‐old female patient with overlapping symptoms. The most plausible diagnosis was MCTD.

ObjectiveNon-respiratory long-coronavirus disease 2019 (COVID-19) symptoms are mainly related to a long-lasting endothelial dysfunction and microcirculation impairment. We hypothesized that Sulodexide, a purified glycosaminoglycan mixture with a beneficial endothelial effect in arterial and venous peripheral diseases, may be effective in a subset of patients with long COVID-19.Approach and ResultsWe conducted a multicenter prospective quasi-experimental study. A total of 290 patients from the TUN-EndCOV study with long-COVID-19 symptoms and endothelial dysfunction were included. The endothelial function was clinically assessed using a post-occlusive reactive hyperemia protocol with finger thermal monitoring device. Endothelial quality index (EQI) was assessed at inclusion and at 21 days later. The study population was assigned to a sulodexide group (144 patients) or a no-medical treatment group (146 patients). Clinical characteristics were similar at inclusion in the two groups. Fatigue, shortness of breath, and chest pain were the most common symptoms, respectively, 54.5, 53.8, and 28.3%. At 21 days, the sulodexide group improved significantly better than the no-medical treatment group in chest pain (83.7 vs. 43.6%, p < 10−3), palpitations (85.2 vs. 52.9%, p = 0.009), and endothelial function [median delta-EQI 0.66 (0.6) vs. 0.18 (0.3); p < 10−3]. Endothelial function improvement was significantly correlated with chest pain and palpitations recovery (AUC, i.e., area under the curve = 0.66, CI [0.57– 0.75], p = 0.001 and AUC = 0.60, CI [0.51– 0.69], p = 0.03, respectively).ConclusionSulodexide significantly improves long-lasting post-COVID-19 endothelial dysfunction and alleviates chest pain and palpitations.

The coronary artery disease (CAD) is a chronic inflammatory disease involving genetic as well as environmental factors. Recent evidence suggests that the oral microbiome has a significant role in triggering atherosclerosis. The present study assessed the oral microbiome composition variation between coronary patients and healthy subjects in order to identify a potential pathogenic signature associated with CAD. We performed metagenomic profiling of salivary microbiomes by 16S ribosomal RNA (rRNA) next-generation sequencing. Oral microbiota profiling was performed for 30 individuals including 20 patients with CAD and ten healthy individuals without carotid plaques or previous stroke or myocardial infarction. We found that oral microbial communities in patients and healthy controls are represented by similar global core oral microbiome. The predominant taxa belonged to Firmicutes (genus Streptococcus, Veillonella, Granulicatella, Selenomonas), Proteobacteria (genus Neisseria, Haemophilus), Actinobacteria (genus Rothia), Bacteroidetes (genus Prevotella, Porphyromonas), and Fusobacteria (genus Fusobacterium, Leptotrichia). More than 60% relative abundance of each sample for both CAD patients and controls is represented by three major genera including Streptococcus (24.97 and 26.33%), Veillonella (21.43 and 19.91%), and Neisseria (14.23 and 15.33%). Using penalized regression analysis, the bacterial genus Eikenella was involved as the major discriminant genus for both status and Syntax score of CAD. We also reported a significant negative correlation between Syntax score and Eikenella abundance in coronary patients’ group (Spearman rho = −0.68, P=0.00094). In conclusion, the abundance of Eikenella in oral coronary patient samples compared with controls could be a prominent pathological indicator for the development of CAD.

Background This trial aimed to assess the efficacy of Atorvastatin reloading on the prevention of Contrast-induced nephropathy (CIN) in patients pre-treated with this statin and undergoing coronary catheterization. Methods This was a prospective randomized controlled study including patients on chronic atorvastatin therapy. We randomly assigned the population to the Atorvastatin Reloading group (AR group), by reloading patients with 80 mg of atorvastatin one day before and three days after the coronary procedure, and the Non-Reloading group (NR group), including patients who received their usual dose without a reloading dose. The primary endpoints were the incidence of cystatin (Cys)-based CIN and Creatinine (Scr)-based CIN. The secondary endpoints consisted of the changes in renal biomarkers (Δ biomarkers) defined as the difference between the follow-up level and the baseline level. Results Our population was assigned to the AR group (n = 56 patients) and NR group (n = 54 patients). The baseline characteristics of the 2 groups were similar. Serum creatinine (SCr)-based CIN occurred in 11.1% in the NR group, and in 8.9% in the AR group without any significant difference. Cys-based CIN occurred in 37% in the NR group and 26.8% in the AR group without any significant difference. The subgroup analysis showed that high dose reloading had significantly reduced the CYC-based CIN risk in patients with type 2 diabetes (43.5% vs 18.8%, RR = 0.43. CI 95% [0.18–0.99])). The comparison of “Δ Cystatin” and Δ eGFR between the AR and NR groups didn’t show any significant difference. However, cystatin C had significantly increased between baseline and at 24 hours in the NR group (0.96 vs 1.05, p = 0.001), but not in the AR group (0.94 vs 1.03, p = 0.206). Conclusions Our study did not find a benefit of systematic atorvastatin reloading in patients on chronic atorvastatin therapy in preventing CIN. However, it suggested that this strategy could reduce the risk of CyC-based CIN in diabetic type 2 patients.

BackgroundHypertension is the leading cause of morbi-moratlity in low, middle as well as high incomes countries. Tunisia is a developing country with a high cardiovascular profile and the prevalence of hypertension has widely increased during the last decades. Thus, we conducted this national survey on hypertension to analyze the profile of the Tunisian hypertensive patient and to assess the level of blood pressure control. MethodsNature HTN is an observational multicentric survey, including hypertensive individuals and consulting their doctors during the period of the study. The primary endpoint of our study was uncontrolled hypertension defined by a systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90mmHg. Our objective is to assess the predictors of uncontrolled hypertension in our population. Results Three hundred twenty one investigators from all the Tunisian governorates participated in the study. We enrolled 25890 patients with a female predominance (Sex ratio 1.21) and an average age 64.4±12.2 year-old. Most of individuals were treated in the public sector (74%), 39.4% of patients were diabetic, 25.8% were obese, 44.6% were overweight and 14% were smokers. Hypertension was controlled in 51.7% of cases if we consider 140/90 as BP target and only in 18.6% if we consider 130/80 as a target. The independents predictors of uncontrolled blood pressure were male sex (OR=1.09, 95%CI [1.02-1.16]), age> 65 year-old (OR=1.07, 95% CI[1.01-1.13], diabetes (OR=1.18, 95% CI [1.11-1.25], Smoking (OR=1.15, 95% CI [1.05-1.25]), Obesity (OR=1.14, 95% CI[1.07-1.21]), management in public sector (OR=1.25, 95% CI [1.16-1.34]) and Heart rate >80bpm (OR=1.59, 95% CI [1.48-1.71]). Contrarily, high educational level (OR=0.9, 95% CI [0.84-0.97], absence of history of coronary disease (OR=0.86, 95% CI [0.8-0.93]), salt restriction (OR=0.48, 95% CI [0.45-0.51]), drug compliance (OR=0.57, 95% CI[0.52-0.61]) and regular physical activity (OR=0.77, 95% CI[0.71-0.84]) are strong predictors of blood pressure control. Conclusion Nature HTN showed a remarkable improvement of blood pressure control amongst Tunisian people. The control remains low in patients with high cardiovascular profile and those treated in the public sector. A national health program based on therapeutic education, regular control and continuous giving much support to the public institutions is needed to decrease the hypertension burden affection rate in our population.

Background This study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions. Objective This study will provide us an overview of hypertension (HTN) management in Tunisia and the degree of adherence of practitioners to international recommendations. Methods This is a national observational cross-sectional multicenter study that will include patients older than 18 years with HTN for a duration of 4 weeks, managed in the public sector from primary and secondary care centers as well as patients managed in the private sector. Every participating patient signed a consent form. The study will exclude patients undergoing dialysis. The parameters that will be evaluated are demographic and anthropometric data, lifestyle habits, blood pressure levels, lipid profiles, treatment, and adherence to treatment. The data are collected via the web interface in the Dacima Clinical Suite. Results The study began on April 15, 2019 and ended on May 15, 2019. During this period, we included 25,890 patients with HTN. Data collection involved 321 investigators from 24 Tunisian districts. The investigators were doctors working in the private and public sectors. Conclusions Observational studies are extremely useful in improving the management of HTN in developing countries. Trial Registration ClinicalTrials.gov NCT04013503; https://clinicaltrials.gov/ct2/show/NCT04013503 International Registered Report Identifier (IRRID) DERR1-10.2196/21878

Background Hypertension is the leading cause of morbi-mortality in our country. Thus, we conducted this national survey on hypertension to analyze the profile of the Tunisian hypertensive patient and to assess the level of blood pressure control. Methods Nature HTN is an observational multicentric survey, including hypertensive individuals and consulting their doctors during the period of the study. Blood pressure measurements were conducted during consultation, using a standardized auscultatory or oscillometric sphygmomanometer after at least 15 min of rest. The diagnosis of new hypertension is based on the 2018 ESC/ESH criteria. The primary endpoint of our study was uncontrolled hypertension defined by a systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Results Three hundred twenty-one investigators participated in the study. We enrolled 25,890 patients with a female predominance (Sex ratio, 1.21) and an average age of 64.4 ± 12.2 years. Most individuals were treated in the public sector (74%), 39.4% of patients were diabetic, 25.8% were obese, 44.6% were overweight and 14% were smokers. Hypertension was controlled in 51.7% of cases if we consider 140/90 as a BP target, and only in 18.6% if we consider 130/80 as a target. The independent predictors of uncontrolled blood pressure were male sex (OR = 1.09, 95%CI [1.02–1.16]), age > 65 year-old (OR = 1.07, 95% CI[1.01–1.13], diabetes (OR = 1.18, 95% CI [1.11–1.25], Smoking (OR = 1.15, 95% CI [1.05–1.25]), Obesity (OR = 1.14, 95% CI[1.07–1.21]), management in public sector (OR = 1.25, 95% CI [1.16–1.34]), and Heart rate > 80 bpm (OR = 1.59, 95% CI [1.48–1.71]). Contrarily, high educational level (OR = 0.9, 95% CI [0.84–0.97], absence of history of coronary disease (OR = 0.86, 95% CI [0.8–0.93]), salt restriction (OR = 0.48, 95% CI [0.45–0.51]), drug compliance (OR = 0.57, 95% CI[0.52–0.61]), and regular physical activity (OR = 0.77, 95% CI[0.71–0.84]) are strong predictors of blood pressure control. Conclusion NaTuRe HTN showed that blood pressure control was reached in more than half of the Tunisian people. The control remains low in patients with high cardiovascular profiles and in those treated in the public sector. A national health program based on therapeutic education, regular control and continuous support to the public institutions is needed to decrease the burden of hypertension incidence rate.

Introduction There are no clear data about the incidence and the prophylactic strategies of arterial and venous thromboembolic events (TE) in COVID-19 ambulatory patients. Thus, we conducted this study to analyze thromboembolic complications in this setting and to assess thromboprophylaxis management and outcomes in the real life. Patients and methods This is an observational study including Covid-19 ambulatory patients. We assessed incidence of venous and arterial TE events as well as thromboprophylaxis outcomes and hemorrhagic complications. We defined high risk thrombo-embolic factor according to the Belgian guidelines which are the only guidelines that described thromboprophylaxis in COVID-19 ambulatory patients. Results We included 2089 patients with a mean age of 43±16 years. The incidence of 30 days venous and arterial TE complications in our cohort was 1%. Venous thromboembolic complications occurred in 0.8% and arterial thromboembolic complications occurred in 0.3%.We noted at least one high-risk TE factor in 18.5% of patients but thromboprophylaxis was prescribed in 22.5% of the cases, LMWH in 18.1%, and Rivaroxaban in 3.7%. Hemorrhagic events occurred in eight patients (0.3%): five patients showed minor hemorrhagic events and three patients showed major ones (0.14%). Conclusions Our study showed that the incidence of thromboembolic complications is very low in COVID-19 ambulatory patients. Paradoxically, there is an over prescription of thrombo-prophylaxis in this population.

Background Cardiotoxicity following breast cancer radiotherapy (RT) represents one of the most redoubtable toxicities. The Global longitudinal strain measurement (GLS) based on 2D speckle tracking imaging (STI) allows detection of left ventricular (LV) dysfunction at a subclinical stage. The aim of this prospective study was to detect patients at risk of cardiotoxicity using echocardiographic parameters and to determine the association between segmental RT doses and early cardiac toxicity. Material and methods The STI was performed prior to RT and at 3, 6 and 12 months after. The association between subclinical LV dysfunction, defined as a reduction of GLS more than 10% from the initial value, radiation doses to different LV segments and non-radiation factors were performed based on multivariate analyses. Results From June 2017 to August 2018, a total of 103 female patients were included. Sixty patients had left sided RT. Seven patients (7.8%) developed a GSL impairment. The segmental alterations predominated in the anteroseptal and apical LV segments. The mean Dmean in altered segments was significantly higher than in non-altered segments (6.7 ± 8.8Gy-7.8 ± 8.9Gy vs 4.9 ± 7.9–5.4 ± 8.2Gy; p 55 years and obesity were important confounding factors that should be considered during radiotherapy planning. Conclusion The results of our study show that radiation dose is correlated with the subclinical LV segments' alteration. Global heart delineation seems to be insufficient during the breast radiotherapy planning. Segmental delineation of the LV may be an interesting alternative to limit segmental doses and to reduce the risk of subclinical alterations. A mean dose of 5Gy could be proposed in exposed heart segment.

Summary Heart failure remains a health challenge in Africa, associated with significant rates of hospitalization, morbidity and mortality. The current review aims to summarize the most recent data on the epidemiology, aetiology, risk factors and management of heart failure, comparing countries in North Africa and sub-Saharan Africa. There is a paucity of data on heart failure epidemiology, aetiology and management, and on the sociodemographic characteristics of African patients with heart failure. Heart failure prevalence has been evaluated among all medical admissions or admissions to cardiac units or emergency departments in a few hospital-based studies conducted in countries in North Africa and sub-Saharan Africa. Common causes of heart failure in Africa include ischaemic heart disease, hypertensive heart disease, dilated cardiomyopathy and valvular heart disease. The aetiology of heart failure differs between countries in North Africa and sub-Saharan Africa. Diagnosing heart failure proves challenging in Africa because of a lack of basic tools and the necessary human resources. The principal drugs used frequently for heart failure therapy are lacking in sub-Saharan Africa. The clinical profile of heart failure in sub-Saharan Africa differs from that in North African countries; this is related to aetiological factors, socioeconomic status and availability of diagnostic tools. There is an evident need to establish a large multicentre registry to evaluate the heart failure burden in almost all African countries, and to highlight the major cardiovascular risk factors and co-morbidities. The present review highlights the importance of this syndrome in Africa, and calls for improvements in its early diagnosis, treatment and, possibly, prevention.

Background Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries. Objective The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia. Methods We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis. Results In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022. Conclusions This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region. Trial Registration Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761 International Registered Report Identifier (IRRID) RR1-10.2196/24595

Background: The severe valve disease especially stenosis is a contraindication to conception according to World Health Organization. This situation is still encountered in countries with a high rheumatic fever prevalence. The objective of this study is to determine the predictors of maternal cardiac, obstetric and neonatal complications.Methods: This is an observational study of all pregnant women with severe valvulopathy, delivered between 2010 and 2017.Results: We included 60 pregnancies in 54 women. Cardiac complications occurred in 37 patients (61%). In multivariate analysis, the predictors of these complications were parity (OR = 2.41, p = 0.023), revelation of valvulopathy by pregnancy (OR = 6.34, p = 0.025), severe mitral stenosis (OR= 6.84, p= 0.035) and systolic pulmonary arterial pressure (OR = 1.08, p= 0.01). Obstetrical complications were noted in 19 women (31.8%). The predictors of these complications were primiparity (OR = 5.22, p = 0.032), multiple valve disease (OR = 5.26, p = 0.028), systolic pulmonary arterial pressure (OR = 1.04, p = 0.04) and treatment with vitamin K antagonist (OR = 8.71, p = 0.04). Neonatal complications were noted in 39% of new-borns. The predictors of these complications were the occurrence of obstetric complications (OR = 15.48, p = 0.001) and the revelation of valvulopathy by pregnancy (OR = 6.95, p = 0.017).Conclusions: The revelation of valve disease by pregnancy is a predictor not only of cardiac complication but also of neonatal complications, thus valve disease screening during pre-conceptional counselling is so crucial.

The distal radial approach (DRA) is suggested to have benefits over the conventional radial approach (CRA) in terms of local complications and comfort of both patient and operator. Therefore, we aimed to compare the feasibility and safety of DRA and CRA in a real life population. We conducted a prospective, observational multicentric trial, including all patients undergoing coronary procedures in September 2019. Patients with impalpable proximal or distal radial pulse were excluded. Thus, the choice of the approach is left to the operator discretion. The primary endpoints were cannulation failure and procedure failure. The secondary endpoints were time of puncture, local complications and radial occlusion assessed by Doppler performed one day after the procedure. We enrolled 177 patients divided into two groups: CRA (n = 95) and DRA (n = 82). Percutaneous intervention was achieved in 37% in CRA group and 34% in DRA group (p = 0.7). Cannulation time was not significantly different between the two sets (p = 0.16). Cannulation failure was significantly higher in DRA group (4.8% vs 2%, p

Background Hypertension is a major concern of public health policy in Tunisia. However hypertension is both highly prevalent (almost 35% of the Tunisian population) and insufficiently treated and controlled, which is partly due to unawareness. Historically, barbershops previously have been used for blood pressure screening and to improve hypertension controlled rate Objective This study aimed to screen hypertension in barbershops. Study design SALOON-HTN is a cross-sectional, descriptive, non-interventional, multicenter survey aiming to screen hypertension by measuring blood pressure in barbershops, located in Metline Township (limited contact with the healthcare system). Twenty-seven barbershops hairdressers were trained by a medical staff to measure the blood pressure by an ambulatory device. All subjects willing to participate in the survey were asked to measure their blood pressure after at least 5 minutes rest. Three measures were performed by the Hairdressers, with an interval of 1 minute between each measure. The mean of the last two measures was considered. If the mean blood pressure level exceeded 135 and/or 85 mmHg the subject was referred to physician. Patients Adults aged more than 18 years were included. Results A total of 1 536 patients were included in the study. The mean age was 40.7±15 years; 57% were men. Among them, 54.2% had never measured their blood pressure; 439 (28.5%) participants had hypertension, only 136 (8.9%) of those with hypertension were aware of their condition, 95 participants (69.9% of those who were aware of their condition) were receiving treatment, and hypertension was controlled in 43.2% participants of those being treated. Overall control was worst in our study (8.9%). Conclusion Saloon-htn confirmed the poor control and unawareness of hypertension. There is an obvious need for programs to increase access to primary care physicians. Funding Acknowledgement Type of funding source: None

Background: The severe valve disease especially stenosis is a contraindication to conception according to WHO. This situation is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine the predictors of maternal cardiac, obstetric and neonatal complications. Methods: This is an observationnal study of all pregnant women with severe valvulopathy, delivered between 2010 and 2017. Results: We included 60 pregnancies in 54 women. Cardiac complications occurred in 37 patients (61%). In multivariate analysis, the predictors for these complications were parity (OR = 2.41, p = 0.023), revelation of valvulopathy by pregnancy (OR = 6.34, p = 0.025), severe mitral stenosis (OR = 6.84, p = 0.035) and systolic pulmonary arterial pressure (OR = 1.08, p = 0.01). Obstetrical complications were noted in 19 women (31.8%). The predictive factors for these complications were primiparity (OR = 5.22, p = 0.032), multiple valve disease (OR = 5.26, p = 0.028), systolic pulmonary arterial pressure (OR = 1.04, p = 0.04) and treatment with vitamin K antagonist (OR = 8.71, p = 0.04). Neonatal complications were noted in 39% of new-borns. The predictive factors for these complications were the occurrence of obstetric complications (OR = 15.48, p = 0.001) and the revelation of valvulopathy by pregnancy (OR = 6.95, p = 0.017). Conclusions: The revelation of valve disease by pregnancy is predictor of not only cardiac complication but also neonatal complications, thus valve disease screening during pre-conceptional counselling is crucial.

BACKGROUND Coronary diseases remain the first cause of death in the world; the management of this condition has improved, thanks to new technical tools and multicentric registries. Recently in Tunisia, the number of intervention procedures has markedly increased, giving the explosion of cardiovascular risk factors among Tunisian people. OBJECTIVE The aim of the study was to investigate the in-hospital and one-year clinical outcome of patients treated with percutaneous coronary intervention (PCI) in Tunisia. METHODS We will conduct a prospective, multicentric, observational study including patients > 18 year-old who underwent a PCI between 31January and 30 June 2020. The primary end point are the occurrence of a major adverse cardiovascular event , defined as cardiovascular death, myocardial infarction, cerebrovascular accident, and target vessel revascularization with either repeat PCI or coronary artery bypass surgery (CABG). Secondary end-points consist in procedural success rate, stent thrombosis, and the rate of redo-PCI/CABG for in-stent restenosis. RESULTS Results will be available at the end of the study as well as the demographic profile and general risk profile of Tunisian patients undergoing PCI. The complexity level of procedures, as left main, bifurcation, chronic occlusion PCI will be analyzed and immediate as well as long term results will be determined. NATURE-PCI will be the first national multicentric registry of angioplasty in Africa. CONCLUSIONS This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of contemporary coronary artery disease in this developing region. CLINICALTRIAL clinicaltrials.gov

Introduction reduced exercise capacity, coronary artery abnormalities and reversible myocardial ischemia have been demonstrated after arterial switch operation (ASO) and coronary reimplantation. Despite this, indices of systolic function, assessed by standard and Doppler echocardiography, are within the normal range. The aim of this study was to highlight the long-term changes in myocardial function following coronary reimplantation using Doppler and speckle-tracking imaging (STI) echocardiography. Methods this observational case control study included 36 patients and 20 gender and age-matched healthy controls. A group study was performed using patients who were followed for at least 6 months after the operation and who visited the pediatric cardiology outpatient between October 2015 and May 2016. Systolic and diastolic parameters, left ventricle (LV) and right ventricle (RV) myocardial performance were assessed in each group. Results the LV global peak strain parameters revealed a significant decrease in the longitudinal and circumferential strain components. The LV global longitudinal strain (GLS) values were lower in both groups of operated patients than controls (-19.9 ± 2.2% (group 1) versus -20.9 ± 1.6% (group 2) versus -22.9 ± 2.3% (group 3), p

BACKGROUND The present study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions. It will allow us to have an overview of the Tunisian hypertensive patient in order to optimize treatment and to know the degree of adherence of practitioners to international recommendations in the care of the hypertension in Tunisia. OBJECTIVE he present study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions. METHODS National, observational, cross-sectional, and multicenter study that will include patients older than 18 years with hypertension for duration of 4 weeks, following up in public and private centers and after signing a consent form. The study will exclude patients undergoing dialysis. The parameters that will be evaluated include demographic and anthropometric data, lifestyle habits, BP levels, lipid profile, treatment and adherence to treatment. The data are collected via the DACIMA Clinical Suite® web interface. RESULTS At the end of the study, we will find the demographic and anthropometric characteristics of the patients, their past medical history, clinical features and their paraclinical exploratory characteristics (biology, EKG and / or holter blood pressure, transthoracic echocardiography (TTE),). We will provide a description of the therapeutic environment and of adverse events occurring during medical treatment and recommendations. CONCLUSIONS We will provide a description of the therapeutic environment and of adverse events occurring during medical treatment and recommendations. CLINICALTRIAL ClinicalTrials.gov Identifier: NCT04013503.

The present study aimed to examine the putative preventive effect of the ethanolic extract Date Palm Pollen (DPP, Phoenix dactylifera L., family Arecaceae) on isoproterenol-induced myocardial infarction (MI) in rats. Twenty four rats were randomly divided into four groups including control. They were treated with DPP extract (400mg/kg) and clopidogrel (0.2mg/kg) for 7days followed by myocardial injury induction using subcutaneous isoproterenol (100mg/kg) with an interval of 24h for two days (6th and 7th day). Administration of isoproterenol exhibited indicative changes in the ECG pattern evidenced by significant elevation of ST-segment and cardiac injury markers viz.; troponin-T, creatine phosphokinase (CPK), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) by 315%, 71%, 64% and 170%, respectively as compared to control. Additionally, the angiotensin-converting enzyme (ACE) activity in plasma was increased by 33% associated to histological myocardial necrosis. However, pre-co-treatment with DPP extract improved the cardiac biomarkers injury, normalized cardiac function indices and prevented the ventricular remodeling process through inhibition of ACE activity by 34% and the inhibition of the generation of radical oxygen species. Extensive characterization of this DPP extract using LC-HRMS revealed numerous flavonoids and phenols compounds which could be endowed with cardiopreventive actions. Overall, these results proved that DPP extract has preventive effects on cardiac remodeling process.

Summary Background Valvular heart diseases occur frequently in Tunisia, but no precise statistics are available. Aim To analyse the characteristics of patients with abnormal valvular structure and function, and to identify the aetiological spectrum, treatment and outcomes of valvular heart disease in a single cardiovascular centre in Tunisia. Methods This retrospective study included patients with abnormal valvular structure and function, who were screened by transthoracic echocardiography at a single cardiology department between January 2010 and December 2013. Data on baseline characteristics, potential aetiology, treatment strategies and discharge outcomes were collected from medical records. Results There were 959 patients with a significant valvular heart disease (mean age 53 ± 17 years; female/male ratio 0.57). Valvular heart disease was native in 77% of patients. Mitral stenosis was the most frequent lesion (44.1%), followed by multiple valve disease (22.3%). Rheumatic origin (66.6%) was the most frequent aetiology, followed by degenerative (17.2%) or ischaemic (8.1%) causes, endocarditis (1.4%) and congenital (0.9%) causes. Native valve disease was severe in 589 patients (61.4%). Percutaneous mitral balloon valvuloplasty was performed in 36.9% of patients with mitral stenosis. Among patients with severe valvular heart disease, surgical treatment was indicated for 446 (75.7%) patients. Only 161 (36.1%) patients were finally operated. Postoperative mortality was 13.6% for all valvular heart diseases. Conclusion This retrospective study has shown that the main cause of valvular heart disease in Tunisia is rheumatic fever. Mitral stenosis and multiple valve disease are the most frequent valvular heart diseases in Tunisia. Percutaneous mitral balloon valvuloplasty and prosthetic valve replacement are the preferred treatment methods for valvular heart disease.

Introduction L’obesite est un fleau social. L’hypertension arterielle masquee (HTAM) est une entite de description relativement recente qui pose un probleme de diagnostic. Elle confere au patient qui en souffre un risque augmente d’evenements cardiovasculaires. Le but de ce travail est de determiner la prevalence de l’HTAM dans une population de patients obeses, etudier les caracteristiques cliniques et paracliniques chez ces patients, et identifier les facteurs associes cliniques et paracliniques a l’HTAM dans cette population. Patients et methodes Notre etude est prospective incluant des patients obeses normotendus en mesure clinique suivis au service d’endocrinologie pour exploration d’obesite. Tous ces patients ont beneficie d’une mesure ambulatoire de la pression arterielle (MAPA) pour depister une HTAM. La population a ete divisee en 2 groupes : groupe d’HTAM (G1) et groupe des normotendus (G2). Resultats Nous avons recrute 50 patients dont l’âge moyen etait de 46,52 ± 10,4 ans avec des extremes allant de 22 a 64 ans. Une nette predominance feminine etait objectivee avec un sex-ratio (H/F) egal a 0,19. L’IMC moyen etait de 36,03 ± 5,2 kg/m2. Une repartition androide des graisses etait objectivee chez tous nos patients. Le diabete et la dyslipidemie etaient les facteurs les plus fortement retrouves (38 % et 40 % respectivement). Seulement 18 % des patients avaient un syndrome d’apnees du sommeil (SAS). Cinq de nos patients etaient tabagiques actifs. Le recueil des chiffres tensionnels en consultation avait montre une PAS moyenne de 120, 8 ± 8,8 mmHg et une PAD moyenne de 75 ± 7,3 mmHg. L’etude des parametres echocardiographiques a retrouve que l’oreillette gauche (OG) etait dilatee chez 16 patients (32 %). Le ventricule gauche (VG) etait hypertrophie chez 32 patients (64 %). L’etude des parametres biologiques chez les patients diabetiques avait montre une glycemie a jeun moyenne a l’admission de 7,59 ± 3,6 mmol/L avec une HBA1C moyenne de 9,03 ± 1,3 %. Pour les patients non diabetiques, une hyperglycemie moderee a jeun a ete retrouvee. Un diabete de primo-decouverte a ete diagnostique chez 2 patients. Un syndrome metabolique etait retrouve chez 62 % des patients. Dans notre etude, la prevalence d’HTAM chez les adultes obeses etait de 36 % survenait chez des sujets majoritairement non dippers (38 %). La PA normale haute etait plus frequente dans le groupe d’HTAM. Dans notre etude, le diabete, le SAS, le tabagisme, le syndrome metabolique, une pression arterielle normale haute, les perturbations du bilan lipidique, une glycemie a jeun elevee, une hyperuricemie, une dilatation de l’OG, une masse VG elevee et une alteration des deformations myocardiques de l’OG et du VG etaient des facteurs associes a une HTAM chez les adultes obeses. Conclusion Il parait primordial de realiser un depistage ambulatoire chez les patients obeses a risque qui presenteraient des facteurs associes a l’HTAM. La morbi-mortalite induite et le risque cardiovasculaire seraient non negligeables et le justifie pleinement.

Introduction Le Lupus erythemateux systemique (LES) est affection non specifique d’organe. L’atteinte cardiaque est grevee d’une lourde mortalite. Elle survient a n’importe quel moment de l’evolution de la maladie et peut etre asymptomatique. L’echocardiographie est un examen non invasif, disponible, reproductible et incontournable dans la prise en charge des patients presentant un LES. C’est une excellente technique pour detecter l’atteinte cardiaque, stratifier le pronostic, orienter et evaluer les differentes strategies therapeutiques. L’objectif de notre travail etait de determiner la frequence et de decrire les differentes anomalies echocardiographiques chez une population lupique. Patients et methodes Nous avons realise une etude transversale descriptive portant sur des patients ayant un LES vus a la consultation ou hospitalises au service de Medecine interne CHU Hedi Chaker Sfax (Tunisie) sur une periode de 1 mois. Les patients ont beneficie d’une echocardiographie transthoracique avec une etude de la fonction systolique et diastolique ventriculaire gauche, la fonction systolique ventriculaire droite, les pressions pulmonaires, les valves cardiaques et les deformations myocardiques en utilisant les moyens echocardiographiques conventionnels et les nouvelles techniques (speckle tracking). Resultats Vingt patients ont ete inclus dans l’etude avec une predominance feminine (90 %). L’âge moyen etait de 36 ans (extremes : 24–57 ans). Les manifestations echocardiographiques etaient frequentes, touchant 75 % des patients mais variables. Tous les patients avaient une fraction d’ejection normale par la methode de Teichlotz. Elle etait alteree chez 5 patients (25 %) par la methode de Simpson. Le strain longitudinal global etait altere chez plus que la moitie des patients (55 %). Une dysfonction diastolique de type 1 d’Appleton a ete observee chez 20 % des patients, et une oreillette gauche dilatee chez 10 %. Quatre patients (20 %) avaient une valvulopathie significative dont 3 avec indication operatoire. L’epanchement pericardique etait retrouve chez 15 % des malades et etait de faible abondance dans tous les cas. Une hypertension arterielle pulmonaire etait retrouvee chez 15 % des patients. Discussion Notre etude s’est focalisee sur les atteintes echocardiographiques du lupus, mais d’autres manifestations cardiovasculaires peuvent passer inapercues a l’echographie a savoir les troubles du rythme, les troubles de conduction ou une insuffisance coronaire. Ce travail a montre l’utilite de l’echocardiographie dans la detection des anomalies cardiaques infracliniques au cours du LES ainsi que l’interet des nouvelles techniques de deformations myocardiques (speckle tracking) par rapport aux moyens conventionnels. Conclusion Les anomalies echocardiographiques observees chez les patients lupiques doivent inciter a inclure cet examen de maniere systematique dans le bilan des patients lupiques et a renouveler dans la surveillance.

Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. It is rare to see heart block as the first-and-only presentation of infectious myocarditis. We report the case of a young healthy patient who presented with syncope secondary to a complete heart block. It was caused by acute presumed viral myocarditis. The diagnosis was confirmed with cardiac magnetic resonance imaging. With close monitoring, the EKG abnormalities resolved over the following 5 days. In this case report, we present the importance of several imaging tools to diagnose a rare and reversible cause of conduction disturbances. In at-risk individuals, clinicians should rule out a treatable cause of heart block before proceeding with permanent pacemaker implantation due to enormous clinical and cost implications involved.

Cardiovascular diseases (CVD) are a major cause of morbidity and mortality, driven by the epidemiological transition world-wide.We aimed to describe the epidemiological profile of CVD hospitalizations, to assess their chronological trends and to estimate their future projected trends.We retrospectively collected data from the regional morbidity registry of the University Hospital of Sfax, Tunisia, between 2003 and 2016. We included patients with ischemic heart disease (IHD), heart failure (HF) and rhythm and conduction disorder (RCD).The mean age-standardized hospital incidence rate (ASHIR) was 94.8, 20.6 and 14/100000 inhabitants/year for IHD, HF and RCD, respectively. Trends analysis of CVD showed a significant increase in the ASHIR of IHD from 54.3/100000 inhabitants in 2003 to 123/100000 inhabitants in 2016, with an Annual Percentage Change (APC) of 3.59% (95%CI:0.4-6.7%;p0.001). An upward trend was observed for HF, with ASHIR rising from 8.6/100000 inhabitants in 2003 to 22.6/100000 inhabitants in 2016, with an APC of 8.29% (95%CI:4.1-12;p0.001). For RCD, no significant change in ASHIR was found. Projections showed that the estimated ASHIR would attend 131 and 36.5/100000 inhabitants for IHD and HF, respectively, while RCD would decline to 19.6/100000 inhabitant in 2026.IHD and HF were rising at an alarming rate and were expected to continue up to the next 10 years. Therefore, there is an urgent need to emphasize on primordial, primary, and secondary prevention in order to reduce the massive burden of CVD.

Introduction Cardiotoxicity following breast cancer radiotherapy (RT) is one of the major side effects. The Global longitudinal strain measurement (GLS) based on 2D speckle tracking imaging (STI) allows detection of left ventricular (LV) dysfunction at a subclinical stage. The aim of the study is to detect patients at risk of cardiotoxicity using STI and to determine the correlation between segmental RT doses and sub-clinical cardiotoxicity. Method All patients received 3D conformal RT. The STI was performed prior to RT and then 3, 6 and 12 months after. A LV GLS impairment was defined as a reduction of more than 10% from the initial value. A qualitative evaluation of the Bull's eye alteration of different segments was also performed. Independent-sample T test was used to compare mean doses of RT according to the alteration of the different segments. Results From June 2017 to August 2018, a total of 103 female patients were included. Sixty patients had left sided RT and 95 patients received chemotherapy prior to RT. Seven patients (7.8%) presented a LV GLS impairment. During the follow-up, the LV strain alterations predominated in the anteroseptal and apical LV segments. The mean radiation doses in LV segments with altered strain values was significantly higher than in non-altered segments (6.7-8.2 Gy vs. 4.9-5.4 Gy; P Conclusion The Results of our study show that radiation dose is correlated with the subclinical LV segments’ alteration. STI with global and segmental strain analysis is an important tool to detect early sub-clinical cardio-toxicity.

Myocardial infarction is very rare in children. It can have different etiologies such as thromboembolism caused by nephrotic syndrome (NS).We report the case of a 15 year old boy with NS, diagnosed at the age of 7 year, admitted for prolonged chest pain. The final diagnosis was ST-elevation myocardial infarction with thromboembolism in the left anterior descending artery due to hypercoagulability of NS.This association is very uncommon and the management of both conditions presents a challenge. Resumo: O enfarte do miocárdio (EM) é raro nas crianças. Pode ter etiologias diferentes, tais como o tromboembolismo causado por síndrome nefrótico (SN).Apresentamos o caso de um rapaz de 15 anos com SN, diagnosticado desde os sete anos e admitido por dor torácica prolongada. O diagnóstico final foi de enfarte do miocárdio com elevação do segmento ST com tromboembolismo na descendente anterior esquerda (DAE) devido a hipercoagulabilidade do SN.Essa associação é muito incomum e o tratamento de ambas as situações representa um desafio.