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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.

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.

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.

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.

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.

Resume Objectifs Le choix de la technique chirurgicale pour le traitement des tumeurs osseuses primitives malignes necessite un bilan d’extension locoregional precis. La presence d’un envahissement articulaire (EA) est un element decisif a preciser d’une facon rigoureuse par l’imagerie pour eviter une resection incomplete potentiellement fatale ou au contraire une resection inutilement etendue. L’objectif de ce travail est d’etudier la valeur diagnostique de l’IRM dans le diagnostic preoperatoire de l’envahissement articulaire dans les tumeurs osseuses primitives du genou en se referant aux resultats de l’examen anatomo-pathologique des specimens chirurgicaux. Patients et methodes Etude retrospective d’une serie consecutive de 42 sarcomes osseux du genou operes entre le 1er janvier 2003 et le 31 mai 2014. Deux radiologues specialises en imagerie musculo-squelettique ont procede a une relecture systematique en insu des IRM preoperatoires de facon consensuelle. Une reevaluation systematique des specimens chirurgicaux a ete effectuee par un pathologiste specialiste en pathologie musculo-squelettique. Les resultats de l’IRM ont ete compares aux resultats anatomo-pathologiques globalement et signe par signe. Resultat Certains parametres avaient une bonne performance dans le diagnostic d’EA. Les signes IRM les plus sensibles etaient l’extension epiphysaire, l’atteinte des marges du cartilage articulaire (jonction os–cartilage) et l’atteinte du massif spinal. Les signes les plus specifiques etaient l’existence d’une masse intra-articulaire, l’extension a l’echancrure intercondylienne et l’axe longitudinal ≥ 120 mm. La valeur diagnostique de l’epanchement articulaire n’a pas pu etre precisee. Conclusion Il est important de realiser l’IRM selon une technique rigoureuse et reproductible explorant le genou dans les trois plans de l’espace. L’IRM doit repondre de facon simple et claire (articulation saine, douteuse ou envahie). L’interpretation de l’IRM doit tenir compte des voies d’extension tumorale. La tomodensitometrie pourrait aider au diagnostic dans les cas douteux, en affirmant ou en infirmant l’integrite des corticales osseuses. Niveau de preuve IV.

Aim of the work Tuberculosis is still one of the important health problems. Because of its insidious evolution, tuberculous (TB) tenosynovitis (TS) is usually misdiagnosed and undertreated. The aim of this study was to investigate clinical and therapeutic outcomes of TB TS. Patients and methods A retrospective study of 8 patients followed-up for TB TS was conducted. Clinical and therapeutic data were collected. Results The median age was 45 years (range 33–59 years), they were 5 females and 3 males with a median duration till diagnosis of 15 months. Fever, night sweats, and weight loss were reported by 3 patients. Physical examination showed swelling of the wrist and crepitation of the palmar side with affected fingers movements in 7 cases. A carpal tunnel syndrome was found in another case. The median erythrocyte sedimentation rate was 15 mm/1st hour and the C-reactive protein 5 mg/dl. Plain radiographies of the wrists were normal. Ultrasonography showed flexor TS in all cases. Since tuberculin skin tests were positive in all patients, TB TS was suspected. Surgical synovectomy was conducted and histological examination confirmed TB. In addition to surgical synovectomy, patients were treated with anti-TB drugs for 12 months. No relapse was noted for a mean follow-up duration of 2 years. Conclusions TB TS can be misdiagnosed because of its insidious evolution. Histological examination confirms the diagnosis. Surgical synovectomy could confirm the diagnosis rapidly by the histological examination and be part of the treatment. Medical treatment should be well-conducted and maintained to avoid relapse and future complications.

Aims Several evidences suggest the association between the evolution of coronary artery disease (CAD) and the development of coronary syndrome that is often associated with disrupted plaque and partial or complete thrombosis of the related artery. Because of the inflammatory nature of CAD, we investigated the human leukocyte antigen (HLA)-G, HLA-E, and HLA-F genetic polymorphisms within CAD patients and evaluated their potential association with this disease in Tunisian population. Methods Different polymorphisms in HLA-G (14-bp Insertion/Deletion, +3142C/G), HLA-E (HLA-E*01:01/01:03 A/G), HLA-F (HLA-F*01:02 T/C, 01:03 C/T, 01:04 A/C) genes were typed using different laboratory techniques in a cohort of 89 CAD patients and 84 controls. Results A significant association was reported between the HLA-G +3142 G allele (OR = 1.64, 95% CI = 1.05–2.56, p = 0.02) and increased risk of CAD. No association was found for the other studied polymorphisms. When we considered the haplotypes, we found TDELCA and TDELGG haplotypes associated to CAD with p = 0.008 and p = 0.030, respectively, suggesting the potential interaction between HLA-G and HLA-E genes. Conclusions Our findings indicated that the HLA-G +3142C/G polymorphism and TDELCA and TDELGG haplotypes can harbour a reliable diagnosis value for the risk of CAD development suggesting that HLA-G, -E and -F molecules might be involved in the pathogenesis of the disease. However, further studies are necessary to confirm our results.

Highlights • Coxiella burnetti should be evocated in patients with acute myocarditis in epidemic countries. • The prognosis of myocarditis is uncertain Treatment with corticoid could be useful in myocarditis to avoid the evolution to dilated cardiomyopathy. • Myocarditis in certainly under estimated in patients with Q fever., We report the case of a 19-year-old healthy adolescent, living in an urban area, admitted because of acute chest pain and extensive anterior ST elevation. Coronary arteries were normal on coronary angiography; troponins were very high, echocardiography revealed a preserved global systolic function but an alteration of the longitudinal strain in the inferolateral wall. Cardiac MRI confirmed the diagnosis of acute myocarditis. As part of the etiological workup, Coxiella burnetii serology showed an acute infection. The diagnosis of Coxiella burnetii myocarditis was retained and the patient was treated with doxycycline and corticosteroid therapy. The myocardial localization of this germ is unusual but can be serious, hence the interest of a Coxiella serology in endemic countries face to any acute myocarditis.

Introduction Chronic kidney disease (CKD) has been related to poor quality of anticoagulation and an increased risk of bleeding. This study aims to evaluate the association between impaired renal function (eGFR Methods This is an ancillary analysis of the prospective NATURE AF registry (NAtionalTUnisianREgistry of Atrial Fibrillation). Between March and June 2017, we prospectively registered information of 912 patients with a recently diagnosed AF and they were followed for one year. Patients with CKD were in turn categorized according to their eGFR level (Stage 3A: 59–45 mL/min, Stage 3B: 44–30 mL/min, Stage 4:29-15 mL/min and Stage 5: Results A total of 103 patients (11.4%) had eGFR Table 1 ). Conclusions Early stages of CKD seem to be associated with poorer anticoagulation control in patients with non-valvular AF taking VKA but without statistically significant difference. Larger studies with longer follow-up are necessary.

Background Around 25 million people around the world are suffering from heart failure (HF), and each year 2 million new cases of HF are diagnosed. Despite the therapeutic improvement in the treatment of HF, its incidence and prevalence is still increasing. Evidence from the literature showed that gender discrepancies in HF management may exist. The aim of our study was to compare the management of HF between the genders. Patients and methods NATURE HF is a prospective registry including 2040 patients diagnosed with HF from October 2017 to January 2019. Management of HF was compared between genders at one-year follow-up. Results 2040 patients were included: 70.9% male patients and 29.1% female patients. Women were older than men (mean age 65.69 ± 12 vs. 62.6 ± 12; P Conclusion Gender differences were detected in clinical presentation and management of HF. Female patients with HF were undertreated by Beta-blockers, Digoxin and Furosemid.

Background Patients with heart failure and renal impairment have poor outcomes and variable quality of care. Aims The present study aimed to evaluate whether chronic kidney disease (CKD) could have adverse effects on mortality, morbidity rates and optimal treatment prescription in patients with a diagnosis of heart failure. Methods This is an ancillary analysis of the prospective NATURE HF registry (NAtional TUnisian REgistry of Heart Failure). Between October 2017 and January 2018, we prospectively registered information of patients with heart failure and followed them for one year. Results We registered information of 2040 patients with heart failure. Prevalence of CKD (eGFR There were 19.9% patients in Stage 3a/b (cl 59–30 mL/min) and 3.6% in Stage 4/5 (cl CKD patients’ have more re-hospitalizations and mortality rates compared to those without CKD, respectively 12% vs. 5,8% (P = 0,001) and 16% vs. 12% (P = 0,003). The prescription of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was more important in CKD patients’ (72% vs. 67,5%, P There was no difference in ICD implantation rates between the two groups. Conclusions Patients with heart failure and chronic renal impairment had poor outcomes but received recommended therapy as patients without CKD. This study highlights the need for multidisciplinary approach and better evidence for treatment, to improve morbidity and mortality.

Introduction Trastuzumab chemotherapy has been associated with left ventricular (LV) dysfunction. We aimed to assess early changes in LV and right ventricular (RV) mechanics associated with trastuzumab treatment for breast cancer. As well as explore whether early changes in 2-dimensional (2D)-speckle tracking echocardiography (STE) could predict later chemotherapy-induced cardiotoxicity. Methods Thirty-one patients with breast cancer who received Trastuzumab treatment were included. Echocardiograms were available for analysis with 2D-STE at the following time points: pretreatment (T0), 4 months (T1), and 12 months (T2). All patients had a normal pretreatment LV ejection fraction (LVEF). Cardiotoxicity was defined as a decrease in LVEF of at least 10 percentage points from baseline on follow-up echocardiography. Results Cardiotoxicity developed in 6 of the 31 patients (19%). The mean (±SD) LVEF at T0 was 66% (± 6); at T1 60% (± 7); and at T2, 54% (± 6). Global longitudinal strain (GLS) at T1 was the strongest indicator of subsequent cardiotoxicity (area under the curve, 0.85; cutoff value, −14.7; sensitivity, 91%; specificity, 82%; P = 0.003). The average 2D LV GLS was −20.58% (± 2.2) with a statistically significant decrease at T1 and T2 (LVGLS −19.35 (± 2.1) and−18.55 (± 2.3), P Conclusion Trastuzumab treatment leads to early deterioration of LV GLS and circumferential strain. Right ventricular GLS and radial strain were also affected. Early changes in GLS are good predictors of subsequent development of trastuzumab-induced cardiotoxicity.

Introduction In developing countries, mitral stenosis (MS) is the most common valvular heart disease revealed by pregnancy. Since cardiac surgery is very risky in this case, percutaneous mitral balloon commissurotomy (PMC) is currently the treatment of choice. Purpose We aimed to evaluate the immediate, medium and long-term results of PMC in pregnant women with severe MS. Methods This was a retrospective study that included 20 pregnant women suffering from severe MS, hospitalized in the cardiology department of a tertiary care center, and treated by PMC during last two decades. Results Mean patients age was 31.5 ± 4.6 years. The PMC was performed on average 27.5 ± 1.8 weeks of pregnancy. Functional improvement was observed immediately after successful PMC. Mitral valve area increased from 1.01 ± 0.1 cm2 averaged to 1.89 ± 0.3 cm2 (P Conclusion It is clear that PMC is an effective technique in the management of MS during pregnancy. The ultimate goal is to improve the hemodynamic situation of the patient in order to pursue the pregnancy and to get better conditions for childbirth.

Introduction Right ventricular (RV) systolic dysfunction is an important predictor of poor outcomes in heart failure (HF) with reduced ejection fraction (EF), usually evaluated by conventional parameters. RV longitudinal strain (RVLS) is recently proposed to be more sensitive tool to evaluate RV function. The purpose of this study was to compare the prognostic value of strain and conventional parameters of RV function in HF with reduced EF. Method Echocardiography was performed in all patients discharged after decompensated HF with EF Results During a mean follow-up of 283 ± 67 days, major cardiac events rate were 28.7% after 3 months and 38.3% in 1year. RV dysfunction was associated with major cardiac events both in 3 months (P = 0.01) and in 1 year (P = 0.04). In patients with RV dysfunction, the survival rate decreased by 38,4% in 1year and by 60% when all parameters were impaired. The overall performance for the prediction of cardiac events was greatest for RVLS (area under the curve: 0.76; TAPSE: 0,68; FAC: 0.67). The cut-off value of RVLS was − 11,5% to predict cardiac events in 3 months (se = 65%, sP = 80) and in 1 year (se = 68%, sP = 75). In multivariate analyses, RVLS remained an independent predictor of major cardiac events in 3months (OR = 21,6; 95%CI:1,5-309; P = 0.02) and in 1 year (OR = 8,4; 95%CI: 1,3–52; P = 0,02). Conclusion In HF with reduced EF, RVLS is a stronger predictor of outcome than RV conventional parameters, providing a stronger prognostic stratification.

Background Maternal mortality in general has decreased in the past decade, but over the same period, cardiac maternal death has not declined. In emerging countries, rheumatic valve disease is the most common cardiac disease in pregnant women. We conducted this study in order to determine predictors of cardiac complication in such pregnant condition. Patients and methods It was a retrospective study including all pregnant women with at least one severe cardiac valve disease and who gave birth in our hospital between 2010 and 2017. Maternal cardiac event was defined as cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, endocarditis. Results We included 60 pregnancies in 54 women during the study period. The mean age was 32.55 ± 5.6 years, the mean gestity was 2.8 ± 1.6 (1–9), the valvular disease was discovered during pregnancy in 45%, a multiple valve disease was diagnosed in 47% of cases. The most frequent severe cardiac valve disease was mitral stenosis (65% of the cases). Cardiac complications occurred in 37 patients (61%). On Univariate analysis, the predictors of such complications was gestity (3.16 ± 1.8 versus 2.21 ± 1.16, P = 0.038), parity (2.45 ± 1.21 varsus 1.69 ± 0.87, P = 0.01), discovery of the valvylar disease during the pregnancy (P = 0.039), mitral stenosis (86.5% versus 47.8%, P = 0.001), atrial fibrillation (48.6% versus 21.7%, P = 0.37, and systolic pulmonary pressure (57.29 ± 15.8 versus 40.39 ± 9.7, P Conclusion Severe Mitral stenosis was the main cause of cardiac complication in pregnant cardiac woman. The percutaneous mitral dilatation could improve the maternal prognosis and should be attempted when anatomic data are in favor.

Introduction The aim of this study was to document clinical practice in Tunisia regarding the use of electronic cardiac devices in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). Methods This is an ancillary analysis of the prospective NATURE HF registry (National TUnisian REgistry of Heart Failure). Between October 2017 and January 2019, we prospectively registered information of patients with heart failure and they were followed for one year. We analyzed data of patients with a diagnosis of HF, LVEF Results A total of 2040 patients were included in the registry. Fifty-six of them received a CRT pacemaker (CRT-P; 40 patients) or CRT defibrillator (CRT-D; 16 patients). Mean age was 62 years and the most frequent causes of HF were ischemic. Overall mortality at one year was 16.1%. The hospitalization rate was 19.6%, significantly higher in patients with CRT-D than with CRT- P (12.5% vs. 37,5%, P = 0.03). The mortality rate was 16.1%, without any statistically significant difference in patients with CRT-P or CRT-D (12.5% vs. 25%, P = 0.25) ( Fig. 1 ). Conclusion The NATURE HF registry shows that the use of cardiac resynchronization therapy in HF with reduced LVEF in Tunisia is in accordance with international recommendations but with lower rates which could be explained by the low income of the population.

Background Atrial fibrillation (AF) and heart failure (HF) often coexist aggravating prognosis and constituting a major public health problem. The prevalence of AF especially in patients with chronic HF remains poorly understood in our country. Aim To assess the prevalence of AF in patients with HF recruited from the prospective NATURE-HF registry (NAtional TUnisian REgistry of Heart Failure).and to determine the clinical profile as well as the evolutionary modalities of this group. Materials and methods Between October and November 2017, we prospectively registered 2040 patients with a history of HF. Patients with AF were picked. Clinical features, etiological characteristics, management as well as outcome were recorded within one year of follow-up. Results Among 2040 patients with HF, 337 patients with a mean age of 65 ± 13 years old presented with AF (16.5%). The frequency of cardiovascular risk factors associated with AF was: hypertension, diabetes, dyslipidemia and tobacco in respectively 42.9%, 29.8%, 20.8% and 19.7% of patients. The causes of underlying heart disease of HF associated with AF were: coronary artery diseases (30.4%), heart valve diseases (30.1%), primitive heart disease (24.7%); rythmic cardiopathy (12.8%) and hypertensive (1.2%). Over a follow-up of 12 months, there was no significant difference in terms of hospitalisation between HF patients with or without associated AF (6.3% vs. 7.5%, P = 0.4). However, the presence of AF was associated with a worse prognosis in terms of mortality (17.9% in patients with AF compared to 12% in patients without AF, P = 0.004) despite comparable clinical features to baseline with patients without AF. Conclusion NATURE HF showed that AF frequently appears in patients with HF and it occurs at an average age lower than that found in the literature. Otherwise, the results of NATURE HF emphasize that AF seems to worsen the prognosis in patients followed for HF.

Introduction Cardiovascular diseases, acute coronary syndromes and heart failure account for the highest mortality rate worldwide. The major underlying mechanism driving the onset and maintenance of cardiovascular diseases is atherosclerosis. Atherosclerosis is a consequence of Oxidative stress. Purpose We aimed to analyze the influence of superoxide dismutase (SOD) and glutathion peroxidase (GPX) activities on angiographic severity and left ventricular dysfunction in the Acute Coronary Syndrome. Methods SOD and GPX activity levels were evaluated in 117 patients admitted for either ST segment elevated myocardial infarction (STEMI) or non-ST segment elevated myocardial infarction (NSTEMI). Results Lower SOD and GPX activity levels were seen in elderly and patients who presented with STEMI and high risk NSTEMI. There was no significant relation between antioxidant activity, angiographic coronary artery severity and the left ventricular systolic function at admission (SOD: 6.1 vs. 7.5 U/mg, P = 0.17; GPX: 1.27 vs. 1.31 μmol/mn/mg, P = 0.79). SOD and GPX activities levels were neither significant in relation to mortality nor to survival rates up to twelve months. Conclusion We found no relationship between reduced levels of SOD and GPX activity post-acute coronary syndrome, left ventricular dysfunction and mortality up to 12-months of follow-up in this study.

Background Instruments to assess symptom burden and quality of life among patients with atrial fibrillation (AF) have not been well evaluated in community practice or associated with patient outcomes. The purpose of this study is to evaluate AF symptoms and their association to patient outcome. Methods Between March and June 2017, we conducted a prospective, observational NATURE-AF registry (National Tunisian Registry of Atrial Fibrillation) with a 1-year follow-up period. In total, 912 patients with a recently diagnosed AF were included. Demographics, clinical and etiological characteristics as well as arrhythmia management strategies and one year outcome were recorded. The association between AF-related symptoms and outcomes was assessed using logistic regression. Results The mean age was 64.2 years ± 13.4; fifty two percent of patients were female. AF related to valvular heart disease was detected in 23.2% patients. Symptoms severity evaluated using the European Heart Rhythm Association (EHRA) classification system showed 57.9% symptomatic patients (EHRA = 2) and 38.4% patients had severe or disabling symptoms (EHRA 3–4). 96.9% of patients were on vitamin K antagonist and 13.8% of patients received antiplatelet therapy. During follow-up, we noted 0.9% symptomatic stroke, 0.7% systemic thromboembolism, 6.0% incident heart failure, 11.5% cause-specific hospitalization, 0.5% major bleeding, and 5.6% cases of death. Over 1- year of follow-up, AF symptoms were associated with a high risk of heart failure (OR = 4.2, P Conclusions NATURE AF registry showed most patients with AF were symptomatic. The major complication was heart failure. AF symptoms were associated with higher risk of heart failure, major bleeding, stroke but not death nor hospitalization.

Introduction Identifying patients who are likely to achieve and maintain a therapeutic international normalized ratio when prescribed a vitamin K antagonist (VKA) for stroke prevention in atrial fibrillation (AF) is challenging. The SAMe-TT2R2 score was developed on the basis of common clinical factors that can highlight patients who may be unable to achieve and maintain good anticoagulation control. Purpose Our objective was to validate this score in a nationwide cohort of non-valvular AF patients. Methods We studied a cohort of consecutive Tunisian patients with non-valvular AF who had oral anticoagulation. The baseline and 6-months SAMe-TT2R2 score was calculated. Results We included 915 patients, of whom 440 (48.1%) were male. Their median age was 65 years, median Cardiac failure or dysfunction, Hypertension, Age over 75 years [Doubled], Diabetes, Stroke [Doubled] - Vascular disease, Age between 65–74 and Sex category [Female] (CHA2DS2-VASc) score was 2 (0–9), and median Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score was 1 (0–5). The median SAME-TT2R2 score was 2 (0–8). At 12 months, the mean ± standard deviation time in therapeutic range was 48.9% ± 28.7% overall, and 110 patients (12.0%) had a time in therapeutic range value > 65%. Patients with a SAME-TT2R2 score 0 to 1 had a mean time in therapeutic range of 49.3% ± 30.4%, whereas patients with a SAME-TT2R2 score ≥ 2 had a mean time in therapeutic range of 48.7% ± 28.0% (P 0.871). The odds ratio for having a low time in therapeutic range value was 1 (95% confidence interval, 0.9–1.0; P 0.871) for those patients with a SAME-TT2R2 score ≥ 2. Conclusions In a “real-world” cohort of patients with atrial fibrillation and oral anticoagulation with VKA, there was no clinical value evidence of the SAME-TT2R2 score for the identification of patients who would have poor-quality anticoagulation.

Background Adequate prepregnancy prediction of maternal cardiovascular risk is important for counselling and management of pregnancy in women with sever heart valve disease (SHVD) Patients and methods In this retrospective study, we determined the outcomes of 60 pregnancies in 54 women with SHVD. The CARPREG (CARdiac disease in PREGnancy) risk scores were calculated for each pregnancy, as was the total number of cardiovascular (TPc) risk predictors (TPo) from these and other studies combined. Results Maternal cardiovascular events occurred during 37 pregnancies (61%). Cardiovascular event rates increased with higher risk scores. The predictors of cardiac events were severe mitral stenosis, revelation of the heart disease by pregnancy, systolic pulmonary arterial pressure and the parity. The area under the curve (AUC) of CARPREG risk score for maternal cardiovascular risk was 0.69 (P = 0.32). The threshold value of 2 was predictive of cardiac maternal complications, corresponding to a sensitivity of 60% and a specificity of 66%. Conclusion The CARPREG risk score is accurate to predict cardiac complications in our population of pregnant patients with severe valve heart disease.

Introduction Left ventricular (LV) systolic dysfunction is an important predictor of cardiovascular death and readmission, usually evaluated by LV ejection fraction (LVEF). Global longitudinal strain (GLS) obtained by 2D speckle tracking is recently proven to be more powerful than conventional EF in detecting changes in myocardial function. The purpose of this study was to compare the prognostic value of GLS and conventional LVEF in HF with reduced EF. Method In this study, echocardiography was performed in all patients discharged from our center after decompensated systolic HF between January and Jun 2017. The echocardiographic images were analysed to obtain conventional and strain parameters. Our patients have been followed for 1 year. The end point was all cardiac events (mortality, readmission). Results During a mean follow-up of 283 ± 67 days, 14 (17.7%) patients were died, and 22 patients (28.2%) were rehospitalized. Patients who died during follow-up had significantly lower LVEF (20% vs. 26%, P = 0.05) and mean GLS (− 6.85% vs. − 8.9%, P = 0.03). Mean GLS was also significantly low in rehospitalized patients (− 7.4% vs. − 9.2%, P = 0.017), but LVEF was approximately same (24.9% vs. 25.8 P = 0.520). After adjusting for age, gender, BMI, heart rate and conventional echocardiographic parameters, GLS remained an independent predictor of mortality and rehospitalisation (HR: 1.19 95% CI: 1.04–1.37, P = 0.032) and also had a higher Harrell's C statistics than LVEF (0.65 vs. 0.63). Conclusion In patients with severe systolic HF, GLS is an independent predictor for all cardiac events, and it's proved to be the most powerful when compared to conventional parameters as LVEF.

Aims Oxidative stress is associated with atherosclerosis and plaque lesions in experimental in vitro models. Few in vivo studies have examined the association between redox status and the prognosis of acute coronary syndromes. We aimed to investigate the relation between the oxidative stress and coronary artery disease (CAD) severity in patients presenting with acute coronary syndromes. Methods and Results We undertook a prospective, observational study of 117 patients who had been admitted because of an acute coronary syndrome. We recorded clinical and angiographic features and cardio-vascular events (cardio-vascular death, reinfarction, readmission with a new ischemic event, or need for coronary revascularization). Oxidative stress indices including glutathione peroxidase (GPX) and superoxide dismutase (SOD) activities were measured in serum(markers of systemic antioxidant status). The mean age of the patients (86% of whom were men) was 61.5 ± 11.7 years; 57.3% were admitted with non-ST-segment-elevation acute coronary syndrome. Left ventricular ejection fraction was normal (> 50%) in 53.4%. Both SOD and GPX were associated with the severity of coronary artery disease (CAD). SOD and GPX levels were significantly lower in patients with 3-vessels disease P = 0.001 and P = 0.017 respectively). SOD and GPX activities were correlated with the SYNTAX score (y = 1.3 ± 0,01, R2= 0.01). Mean duration of the follow-up period was 6.9 ± 2.05 months. In the 15.15% who experienced cardio-vascular events, SOD and GPX activities were lower, without statistical correlation (P = 0.56, P = 0.23). Conclusion Oxidative stress is an important contributor to CAD. A low level of activities of SOD and GPX is independently associated with the severity of coronary artery disease in patients presenting an acute coronary syndrome.

Here we discuss the efficacy of colistin-tigecycline combination in the treatment of multidrug-resistant (MDR) Klebsiella pneumoniae infective endocarditis (IE). We report a case of a 67-year-old head-injured patient who developed a carbapenem-resistant K. pneumoniae IE. The patient was treated with colistin-tigecycline combination, with a favourable outcome. In conclusion, colistin-tigecycline combination may be a possible combination in the therapy of IE caused by MDR Enterobacteriaceae.

The risk of cardiovascular disease in elderly is significantly higher than in young subjects; paradoxically some treatments that have proven their efficacy in reducing cardiovascular risk are often under prescribed in this age group. The benefits of statins in secondary cardiovascular prevention are well established in patients

Introduction Fumer est nocif pour le cœur et la circulation. La poursuite du tabac chez le coronarien est un element de mauvais pronostic. Le sevrage tabagique beneficie du meilleur rapport cout/efficacite en prevention primaire et secondaire. Il est imperatif d’evaluer le comportement du tabagique apres un syndrome coronarien aigu et identifier l’impact du sevrage sur l’evolution et le pronostic. Methodes Nous avons realise une etude analytique des dossiers des 250 patients hospitalises entre aout 2013 et juillet 2014 et suivis jusqu’au mars 2015 dans le service de cardiologie du CHU Hedi Chaker a Sfax pour sans sus decalage de ST (SCA ST-). Resultats Dans notre population, un tabagisme actif etait note dans 52 % des cas avec une forte dependance. Au total, 82 % des patients ont arretes le tabagisme immediatement apres le SCA ST. Mais, 55 % entre eux ont reussi surement un sevrage tabagique. La reprise du tabagisme etait maximale au cours du premier mois 62,8 % et minimale au bout de 5 a 6 mois 5,71 %. Dans notre serie, le statut tabac initial n’influence pas la survenue des evenements cardiovasculaires majeurs MACE. Par contre, on remarque une difference significative dans la survenue de MACE selon le sevrage tabagique apres le SCA ST- et que la poursuite de tabagisme apres SCA est impliquee dans la survenue des MACE. En representant les differents MACE selon le sevrage tabagique, on remarque une correlation significative pour tous les evenements. Le sevrage du tabagisme reduit le risque de re-hospitalisation mais aussi son delai qui est de jours 74 jours chez les patients sevres de tabac, et de 28 jours chez les patients non sevres avec une difference significative. Conclusion Nos resultats montrent que le fait de cesser de fumer apres un syndrome coronarien peut avoir des effets benefiques importants sur les evenements cliniques pendant le suivi a long terme malgre ce taux de sevrage est faible.

Resume Buts de l’etude Etudier les profils epidemiologiques, cliniques, therapeutiques et pronostiques de l’infarctus de myocarde (IDM) chez les insuffisants renaux chroniques. Montrer l’impact de l’insuffisance renale chronique (IRC) a court, moyen et long termes. Determiner les facteurs predictifs d’evenements cardiovasculaires et cerebraux majeurs (MACCE) hospitaliers et a moyen terme chez les insuffisants renaux chroniques. Patients et methodes Etude retrospective incluant 231 patients hospitalises entre janvier 2005 et decembre 2006 pour IDM avec sus-decalage persistant de ST. Notre population a ete repartie en deux groupes : groupe 1 : debit de filtration glomerulaire (DFG) superieur ou egal a 60 ml/min : 112 patients ; groupe 2 : DFG inferieur a 60 ml/min : 119 patients. Resultats Les insuffisants renaux avaient plus d’antecedents d’accidents vasculaires cerebraux et d’hypertension arterielle. Le recours aux therapies medicamenteuses et de reperfusion urgente etait moindre dans le groupe 2. En multivariee, l’IRC etait un facteur predictif de survenue de MACCE hospitaliers ( p = 0,016), a six mois ( p = 0,003), a un an ( p = 0,004) et a deux ans ( p = 0,015). Les facteurs predictifs de MACCE hospitaliers chez les insuffisants renaux etaient : le recours au tonicardiaques ( p = 0,001) et l’angioplastie (ATL) primaire ( p = 0,043). A un an apres l’IDM, seul le pontage aortocoronaire etait predictif de MACCE ( p = 0,03). Conclusion Un lien significatif a pu etre demontre entre l’IRC et la survenue de MACCE apres IDM. Nos resultats confirment la necessite de la prise en compte de la fonction renale lors de la prise en charge et l’evaluation du risque de l’IDM.

Supraventricular tachycardia in infants are variable. We try to summarize clinical, electrical and treatment particularities of supraventricular arrhythmia in infants. The majority of infants with supraventricular arrhythmia have a good clinical outcome and an excellent prognosis and may not require chronic antiarrhythmic therapy if they had precocious treatment.

A 45 day old new-born with arrhythmia-induced cardiomyopathy complicated by thrombus formation is presented. Drug treatment produced immediate symptomatic relief and subsequent reversion to normal cardiac function. The thrombus disappeared a few days later.

ObjectiveBrain natriuretic peptide (BNP) quantification is a useful cardiovascular diagnostic and prognostic test. In renal failure its use may have constraints, as it depends on renal clearance and concomitant volume overload.The aim of this study was to evaluate the clinical usefulness of BNP in hypertensive patients on maintenance hemodialysis (HD).Design and Methods we measured BNP levels in 30 patients immediately before and after HD. All patients had preserved left ventricular ejection fraction (LVEF≥50%) and underwent 48-hours ambulatory blood pressure measurement. Cardiac parameters were evaluated by echocardiography.ResultsThe left ventricular mass index (LVMi) and BNP levels decreased significantly after HD (p

Background The utility of Brain Natriuretic Peptide (BNP) and cystatin C for detecting left ventricular (LV) diastolic dysfunction after myocardial infarction (MI) in patients without heart failure symptoms still unclear. In this study, we investigated the relation between BNP, serum cystatin C levels and LV diastolic dysfunction after MI in patients without systolic dysfunction. Methods We studied 127 patients without renal dysfunctionafter first acute coronary syndrome (ACS). LV diastolic function was assessed with conventional Doppler, by means of mitral inflow and with tissue Doppler echocardiography by means of mitral annulus. The ratio of early diastolic transmitral E wave velocities to tissue Doppler mitral annulus early diastolic E’ wave velocities (E/E’), was used to detect LV filling pressures. Patients were divided in three groups according to E/E’ ratios 15 (group III). Plasma concentrations of BNP and serum cystatin C were measured at admission. Results The BNP and serum cystatin C levels were positively correlated significantly with E/E’ ratio (r=0.786, p 15 had highest BNP (321±75pg/mL) and cystatin C (1.1±0.2mg/L) levels. E/E’ 10 to 15 group had a mean BNP level of 151±28pg/mL and a mean cystatin C value of 0.78±0.1mg/L, and those with E/E’ 15. Conclusion The assessment of the blood concentration of BNP and cystatin C is of potential value for identification of those patients after myocardial infarction to detect early cardiovascular changes, especially LV diastolic dysfunction.

BackgroundThe utility of Brain Natriuretic Peptide (BNP) and cystatin C for detecting left ventricular (LV) diastolic dysfunction after myocardial infarction (MI) in patients without heart failure symptoms still unclear. In this study, we investigated the relation between BNP, serum cystatin C levels and LV diastolic dysfunction after MI in patients without systolic dysfunction.MethodsWe studied 127 patients without renal dysfunction after first acute coronary syndrome (ACS). LV diastolic function was assessed with conventional Doppler, by means of mitral inflow and with tissue Doppler echo-cardiography by means of mitral annulus. The ratio of early diastolic transmitral E wave velocities to tissue Doppler mitral annulus early diastolic E’ wave velocities (E/E’), was used to detect LV filling pressures. Patients were divided in three groups according to E/E’ ratios15 (group III). Plasma concentrations of BNP and serum cystatin C were measured at admission.ResultsThe BNP and serum cystatin C levels were positively correlated significantly with E/E’ ratio (r=0.786, P15 had highest BNP (321±75pg/mL) and cystatin C (1.1±0.2mg/L) levels. E/E’ 10 to 15 group had a mean BNP level of 151±28pg/mL and a mean cystatin C value of 0.78±0.1mg/L, and those with E/E’15.ConclusionThe assessment of the blood concentration of BNP and cystatin C is of potential value for identification of those patients after myocardial infarction to detect early cardiovascular changes, especially LV diastolic dys-function.