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Summary Background: Stroke is a major complication of nonvalvular atrial fibrillation (AF). Despite its proven efficacy in stroke prevention, oral anticoagulation (OAC) is associated to a significant increase in bleeding complications. New techniques such as percutaneous left atrial appendage (LAA) closure were developed. Aim: To evaluate immediate, mid- and long-term outcomes after percutaneous LAA closure in Tunisian patients presenting with nonvalvular AF. Methods and Results: Nineteen patients with nonvalvular AF were prospectively enrolled for percutaneous LAA closure between February 2013 and June 2014. The Watchman device was used in all LAA closure procedures. Clinical and echocardiographic follow-up were carried-out at 1, 6, 12 months and six years in all patients. Mean age was 68.4 ± 7.5 years. Thirteen patients were female, 16 had hypertension, 12 had diabetes mellitus and seven had a history of stroke or transient ischemic attack (TIA). Average CHA2DS2VASc (Congestive Heart Failure/Left Ventricular Dysfunction, Hypertension, Age≥75, Diabetes mellitus, Stroke/Transient Ischemic Attack/Thromboembolic event, Vascular disease,Age≥65, Sex category) score was 4.2 ± 1.5 and HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding tendency, Labile INR, Age≥65, Drugs) score was 3.5 ± 1. Ten patients had a history of severe bleeding. Procedural success was achieved in all patients. Pericardial effusion with tamponade was reported in one case. No post-procedural death was reported. Regular follow-up at 1, 6 and12 months then every year up to 6 years reported no stroke, no thromboembolic event, no Watchman device thrombosis and three cases of death caused by a respiratory problem and cancers. Conclusion According to this study, LAA closure with Watchman device was safe and effective in preventing stroke in patients with nonvalvular AF and contra indication to OAC.

Coronary artery disease is the leading cause of death in emerging countries. Contemporary data about clinical profile and prognosis in Tunisian patients presenting for non ST-elevation acute coronary syndrome (NSTE-ACS) are lacking.We sought to study the risk profile and 3-year mortality predictors in Tunisian patients presenting for NSTE-ACS in the contemporary setting.In this single center study, data about all consecutive patients presenting to our center for NSTE-ACS from April 2014 to July 2016 were extracted and outcomes exhaustively updated. 3-year mortality predictors were determined by multivariable survival analysis.A total of 340 patients were included, of which 204 (61.8%) were male. Mean age was 63.6 ± 10.3 years. Prevalence of diabetes mellitus, hypertension and smoking was 57.3%, 62.4%, and 45.3%, respectively. In-hospital, 6, 12 and 36-month mortality rate was 2.3%, 3.2%, 7.1% and 15.2%, respectively. In multivariable survival analysis, independent predictors of death were age75 (HR=5.45, 95% CI: 2.9-10.03, p0.001), ST-segment deviation (HR=1.86, 95% CI: 1.04-3.33, p=0.036), anemia (HR=2.56, 95% CI: 1.41-4.67, p=0.002), left ventricular ejection fraction (LVEF)40% (HR=3.5, 95% CI: 1.84-6.67, p0.001) and a Global Registry of Acute Coronary Events (GRACE) score ≥140 (HR=2.38, 95% CI: 1.02-5.57, p=0.044).In Tunisian patients presenting for NSTE-ACS, long-term mortality was high. Advanced age, ST-segment deviation, anemia, LVEF40% and a GRACE score ≥140 were independent long-term predictors of death.

Background.Cardiomyopathy mediated by iron disposition in cardiomyocytes is a dreadful cause of morbidity and mortality in patients with beta thalassemia major (BTM). Conventional transthoracic echocardiography (TTE) parameters are preserved at late stages of cardiomyopathy induced by iron overload. Therefore, cardiac imaging modalities based on myocardial deformation such as strain imaging are used for early detection of cardiac iron overload.Aim.To demonstrate the contribution of longitudinal strain (LS) in early detection of cardiac iron overload in children with BTM.Methods.Sixty children (30 children with BTM and 30 healthy controls) were enrolled in this study. Conventional TTE study was performed in both patient and control groups. LV regional longitudinal strain (RLS) were determined and compared between the two study groups.Results.Mean age was 10.4 ± 5years in BTM group compared to 10.2 ± 5 years in control group (p=0.876). Compared to control group, there was no significant difference in conventional TTE parameters except for indexed left atrium (LA) area and volume. LA was significantly larger in BTM children (27.59 ±13.1ml/m² vs. 18.23 ± 4.33 ml/m², p=0.001). RLS was lower in anterior, septal and inferior walls in basal and middle segments of LV in BTM group while there was no significant difference in RLS in apical segment between the two groups (-27.30 ± 5.1 vs. -28.83 ± 4.33, p=0.22).Conclusion.In asymptomatic BMT children with normal conventional TTE parameters, LS could be used for the detection of subclinical myocardial dysfunction.

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: Hyperglycemia on-admission is a powerful predictor of adverse events in patients presenting for ST-elevation myocardial infarction (STEMI). Aim: In this study, we sought to determine the prognostic value of hyperglycemia on-admission in Tunisian patients presenting with STEMI according to their diabetic status. Methods: Patients presenting to our center between January 1998 and September 2014 were enrolled. Hyperglycemia was defined as a glucose level ≥11 mmol/L. In-hospital prognosis was studied in diabetic and non-diabetic patients. The predictive value for mortality of glycemia level on-admission was assessed by mean of the area under receiver operating characteristic (ROC) curve calculation. Results: A total of 1289 patients were included. Mean age was 60.39 ± 12.8 years and 977 (77.3%) patients were male. Prevalence of diabetes mellitus was 70.2% and 15.2% in patients presenting with and without hyperglycemia, respectively (p

Background: Brugada syndrome (BrS) is a rare inherited cardiac arrhythmia associated with a high risk of sudden cardiac death (SCD) due to ventricular fibrillation (VF). BrS is characterized by coved-type ST-segment elevation in the right precordial leads (V1-V3). Mutations in SCN5A gene coding for the α-subunit of the NaV1.5 cardiac sodium channel are identified in 15–30% of BrS cases. Genetic testing of BrS patients generally involves sequencing of the protein-coding portions and flanking intronic regions of SCN5A. This excludes the 5′UTR and 3′UTR from the routine genetic testing. Methods: We here screened the coding sequence, the flanking intronic regions as well as the 5′ and 3′UTR regions of SCN5A gene and further five candidate genes (GPD1L, SCN1B, KCNE3, SCN4B, and MOG1) in a Tunisian family diagnosed with BrS. Results: A new SCN5A-Q1000K mutation was identified along with two common polymorphisms (H558R and D1819). Multiple genetic variants were identified on the SCN5A 3′UTR, one of which is predicted to create additional microRNA binding site for miR-1270. Additionally, we identified the hsa-miR-219a-rs107822. No relevant coding sequence variant was identified in the remaining studied candidate genes. Conclusions: The absence of genotype-phenotype concordance within all the identified genetic variants in this family gives extra evidences about the complexity of the disease and suggests that the occurrence and prognosis of BrS is most likely controlled by a combination of multiple genetic factors, rather than a single variant. Most SCN5A variants were localized in non-coding regions hypothesizing an impact on the miRNA-target complementarities. Keywords: SCN5A, Brugada syndrome, 3′UTR, microRNAs, Genotype-phenotype correlation

Brugada syndrome (BrS) is a rare inherited cardiac arrhythmia associated with a high risk of sudden cardiac death (SCD) due to ventricular fibrillation (VF). BrS is characterized by coved-type ST-segment elevation in the right precordial leads (V1-V3) in the absence of structural heart disease. This pattern is spontaneous, or is unmasked by intravenous administration of Class I antiarrhythmic drugs. The SCN5A-encoded α-subunit of the NaV1.5 cardiac sodium channel has been linked to BrS, and mutations in SCN5A are identified in 15–30% of BrS cases. Genetic testing of BrS patients generally involves sequencing of protein-coding portions and flanking intronic regions of SCN5A, according to recent international guidelines. This excludes the regulatory untranslated regions (5’UTR and 3’UTR) from the routine genetic testing of BrS patients. We here screened the coding sequence, the flanking intronic regions as well as the 5’ and 3’UTR regions of SCN5A gene and further five candidate genes (GPD1L, SCN1B, KCNE3, SCN4B, and MOG1) in a Tunisian family diagnosed with Brugada syndrome.A new Q1000K mutation was identified on the SCN5A gene along with two common polymorphisms (H558R and D1819). Furthermore, multiple genetic variants were identified on the SCN5A 3’UTR, one of which is predicted to create additional microRNA (miRNAs) binding site for miR-1270. Additionally, we identified the hsa-miR-219a rs107822. No relevant coding sequence variant was identified in the remaining studied candidate genes. Although Q1000K is localized in the conserved binding site of MOG1 which predicts a functional consequence, this new mutation along with the additional variants were differentially distributed among the family members without any clear genotype-phenotype concordance. This gives extra evidences about the complexity of the disease and suggests that the occurrence and prognosis of BrS is most likely controlled by a combination of multiple genetic factors and exposures, rather than a single polymorphism/mutation. Most SCN5A polymorphisms were localized in non-coding regions hypothesizing an impact on the miRNA-target complementarities. In this regard, over-expression of miR-1270 led to a significant decrease of luciferase activity suggesting a direct role regulating SCN5A. Therefore, genetic variants that disrupt its binding affinity to SCN5A 3’UTR and/or its expression might cause loss of normal repression control and be associated to BrS.

Prehospital thrombolysis (pHT) is recommended by the European Society of Cardiology (ESC) as a surrogate to primary percutaneous coronary intervention (pPCI) in acute ST-elevation myocardial infarction(STEMI) when transfer delays are long. We sought to study early outcomes in patients presenting for

Diabetic patients presenting for acute ST-elevation myocardial infarction (STEMI) are at high risk of adverse events during hospital course. On the other hand, renal failure on admission is common in this population. We sought to determine the early prognosis of diabetic patients presenting for

Acute coronary syndromes are a leading cause of death worldwide and in developing countries. In Tunisia, patients presenting for ST-elevation myocardial infarction (STEMI) have a particular risk profile. Thus, we sought to determine prognostic features and predictors of adverse outcomes in Tunisian

In the setting of ST-elevation myocardial infarction (STEMI), early reperfusion either by prehospital thrombolysis (pHT) or primary percutaneous coronary intervention (pPCI) is associated with better in-hospital and long-term outcomes. We sought to evaluate the impact on early outcomes of

In patients managed by primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI), the no-reflow phenomenon is assessed in different ways, according to studies. Nevertheless, it is well-established as a powerful predictor of poor prognosis. We sought to

Summary Background Infective endocarditis (IE) is a rare condition in the paediatric setting. No data on the epidemiology and prognosis of IE in children are available from North African countries. Aim To investigate the epidemiological profile and prognosis of IE in children in Tunisia. Methods All patients aged ≤ 18 years presenting with IE in three Tunisian tertiary care centres between January 1997 and September 2013 were included. Clinical features and 30-day and 6-month mortality rates were studied. Factors predictive of death at 6-month follow-up were determined. Results A total of 73 patients were included in the present study. The mean age was 12 ± 4.8 years; 35 (50.7%) patients were male. Rheumatic heart disease (RHD) was the underlying heart disease in 17 (23.3%) cases and IE occurred in a structurally normal heart in 36 (49.3%) cases. Staphylococcus species were isolated in 17 (23.3%) cases. Regarding IE localization, the mitral valve was involved in 28 (38.4%) cases and the aortic valve in 14 (19.2%) cases. Recourse to surgery was reported in 37 (50.7%) cases. Thirty-day and 6-month mortality rates were 13.6% and 19.2%, respectively. Heart failure on admission or during the hospital course, acute renal failure and neurological complications were significantly associated with death at 6-month follow-up in the univariate analysis and after adjustment for age and sex. Conclusions In the Tunisian context, IE in children is still characterized by the high prevalence of RHD as an underlying heart disease. Short- and long-term mortality rates remain high. Heart failure, acute renal failure and neurological complications are significantly associated with death at 6-month follow-up.

Anemia is regarded as a powerful predictor of in-hospital major events in patients presenting for acute coronary syndrome. We sought to determine clinical and prognostic correlates of anemia in patients presenting for acute ST-elevation myocardial infarction (STEMI) in our region. A total of 1498

Hyperglycemia on-admission has been identified as a powerful predictor of adverse outcomes in patients presenting with acute ST-elevation myocardial infarction (STEMI). Nevertheless, the prognostic value of hyperglycemia is still to be investigated in diabetic versus non-diabetic patients. In the

Renal artery stenosis (RAS) is a strong independent predictor of mortality in patients with coronary artery disease (CAD). The study aimed to determine the prevalence of RAS in patients with significant CAD in order to develop and validate a score predicting RAS. Three hundred consecutive patients (50 females) with significant CAD underwent abdominal aortography following coronary angiography to screen for significant RAS defined as luminal narrowing of 50% or more. Univariate and multivariate analyses were performed comparing patients with and without RAS. Significant factors associated with RAS were included in constructing a score that predicts RAS. The score was internally validated in patients randomly selected from the entire study group (validation group; n = 103), using ROC curves and the Hosmer–Lemeshow goodness-of-fit test. Twenty-seven patients (9%) had a significant RAS. Multivariate analysis showed that age over 65 years (OR = 4.1%, 95% CI = 1.6-10.3, p = 0.003) and hypertension (OR = 3.1, 95% CI = 1.2–7.7, p = 0.015) were independent predictors of RAS. The predictive score including these two variables and three others (female gender, renal and insufficiency, and more than 2- or 3-vessel disease) ranged from 0 to 7. Internal validation showed a good performance (ROC curve = 0.79 and χ2 Lemeshow = 3.45). For a score of less than 2, the negative predictive value is 98%. The rate of significant RAS in patients with significant CAD was 9%. The performance of our predictive score was good, and significant reduction in the need to perform systematic abdominal aortography could be expected with the use of this score.

Ischemic preconditioning (IP) is associated with lesser myocardial infarct size in animal studies. In humans, when occurring before ST-elevation myocardial infarction (STEMI), the prognostic significance of IP episodes is still controversial. In this study, we sought to determine prognostic features

Reverse cholesterol transport (RCT) is the pathway, by which the excess of cholesterol is removed from peripheral cells to the liver. An early step of RCT is the efflux of free cholesterol from cell membranes that is mediated by high-density lipoproteins (HDL). Phospholipid transfer protein (PLTP) transfers phospholipids between apolipoprotein-B-containing lipoproteins (i.e., chylomicrons and very low-density lipoproteins) and HDL. PLTP contributes to the HDL maturation and increases the ability of HDL to extract the cellular cholesterol. It is known that RCT is impaired in type 2 diabetic patients, especially when cardiovascular complication is associated with. In this study, we measured the serum capacity that promotes cellular cholesterol efflux and the plasma PLTP activity in type 2 diabetic patients with coronary artery disease (CAD) (n = 35), those without CAD (n = 24), and 35 healthy subjects as a sex- and age-matched control. In patients with CAD, plasma triglyceride level was higher compared to controls (p < 0.01) and HDL-cholesterol was lower (p < 0.01 vs control and the patients without CAD). In diabetic patients with or without CAD, PLTP activity was consistently increased, compared to controls, while cellular cholesterol efflux activity was decreased by 20% (p < 0.001) or 13.5% (p < 0.01), respectively. In conclusion, plasma PLTP activity was increased in type 2 diabetic patients with or without CAD, which could impair cellular cholesterol removal and might accelerate atherosclerosis in diabetic patients.

Objective Hypertension is another common condition in older subjects, representing the most common morbid condition after osteoarthritis (Psaty et al., 2001). Hypertension represents a major risk factor for cardiovascular disease, the major source of morbidity among the over 65 population (ISTAT, 2005). In such a context, the aims of the present study were to investigate whether hypertension was associated independently with physical disability. Design and Methods A cross-sectional survey was conducted, covering a sample of 598 subjects (202 male, 396 female, mean aged 72,3 years) aged 65 years and over. The study approved by ethics Committee and supported by OMS and FNUAP. Information was gathered by home-based personal interview using a structured questionnaire. We assessed their disability status, sociodemographic informations and health behaviours. Disability was recorded on three levels scale: (intense, moderate and no disability) Statistical analysis was performed with SPSS and the significance was accepted at the p > 0.05 level. Multiple logistic regression models were used to obtain the independent variables associated with hypertension. Results The prevalence of hypertension was 52% (n=311), more frequent for female population (55% vs 45% for male). The prevalence of disability was 34.6%, only 10% have intense disability. Those with hypertension had higher Body Mass Index, waist circumference and diabetes. Regarding disability, the individuals who presented the highest prevalence of hypertension were more dependent. Multiple logistic regression revealed that the following were significantly independent factors of hypertension: Disability (OR = 1.6).Diabetes mellitus (OR = 2.36]).and a higher BMI (OR = 2.36). Conclusions We conclude that hypertension is associated not only to cardiovascular factors (Diabetes obesity) but also with higher functional disability. Older subjects are exposed at significantly higher likelihood of physical disability. Public health strategies to prevention hypertension in elderly may protect them also against disability.

PurposeThe aims of this study is to characterize hyponatremic hospitalized patients with HF and to clarify the relations between hyponatremia and outcomes during hospitalization and at 6 months.MethodsThis is a retrospective study of 234 patients admitted in the cardiology department of Fattouma Bourguiba Monastir hospital between January 2010 and March 2011.Hyponatremia was defined as a blood value of sodium < 135mmol/l.ResultsThe mean serum sodium concentration is 138±5mmol / l. Hyponatremia (Na +

Cardiac biomarkers are used to distinguish acute dyspnea due to left-heart dysfunction from that of pulmonary origin. However, they have not been assessed in the specific setting of acute exacerbation of chronic obstructive pulmonary disease (AECOPD), where they might be released without left-heart impairment.To assess the accuracy of troponin T and of amino-terminal pro-brain natriuretic peptide (NT-proBNP) in the diagnosis of AECOPD associated with left ventricular (LV) dysfunction.Both biomarkers were measured in 148 consecutive patients on intensive care unit admission for AECOPD. A panel of physicians adjudicated blindly the cause of AECOPD to be unlikely, possibly associated, or definitely associated with LV dysfunction.The final diagnosis was AECOPD definitely associated with acute left-heart dysfunction in 31.1%, possibly associated with LV dysfunction in 13.5%, and probably not associated with LV dysfunction in 55.4%. Both NT-proBNP and troponin T levels were significantly different among the three groups. The area under the receiver operating characteristic curve was greater for NT-proBNP (0.95 vs. 0.67). A cutoff of 1,000 pg/ml was accurate to rule out left-heart involvement in AECOPD (sensitivity, 94%; negative predictive value, 94%; negative likelihood ratio, 0.08). A cutoff of 2,500 pg/ml had the best operating characteristics to rule in the diagnosis (positive likelihood ratio, 5.16). Left-heart involvement in AECOPD was the only variable independently associated with increased secretion of NT-proBNP (odds ratio, 74; 95% confidence interval, 15-375; p = 0.0001).NT-proBNP and troponin T are useful in excluding AECOPD associated with left ventricular dysfunction. NT-proBNP was the more accurate of the two.

Contrast induced nephropathy (CIN) is an increasing problem in cardiology invasive imaging, limited by the absence of treatment and few prevention methods. Anti oxidant benefits of ascorbic acid have been reported by small series but evidence remains poor. To evaluate the effect of ascorbic acid

Contrast-induced nephropathy (CIN) is a frequent complication after coronary angiography. In the exclusion of saline hydration, the effectiveness of other means of prevention remains unclear, and almost poor. Thanks to its pleotropic effects, statins have been used in CIN prevention, but data

AimHeart failure is known to be a major cause of morbidity and mortality in developed countries. The number of Tunisians suffering from acute heart failure (AHF) is increasing, but only little is known about the prognosis and possible risk factors for a fatal outcome in our population. The aim of our study is to describe patients with AHF with regard to clinical presentation and mortality at 6 months.Method and resultsWe conducted a retrospective study including 234 patients from a Tunisian center hospitalized with AHF.Our study population's average age was 65±13.8, 56% were male. Hypertension was noted in 60.3% of the cases, diabetes in 51.7% and 69.7% of the patients had new-onset heart failure. Ischemic etiology was noted in 48.7% of cases followed by hypertensive, dilated cardiomyopathy and valvular cardiopathy observed respectively in 21.4%, 14.5%, and 11.1% of cases. Left ventricular ejection fraction (LVEF) was reported in 97% of our population. 46.6% of these had preserved systolic function (LVEF > 45%) and 17.2% had a LVEF < 30%. At discharge, 41.5% of patients had beta-blockers and 86.8% either ACE-inhibitors or angiotensin receptor blockers in use.At six months 25 patients (11.2%) died. We identified several clinical and biochemical prognostic risk factors in univariate analysis. Independent predictors of 6 months mortality were QRS width ≥130 ms (adjusted HR, 6.15; 95% CI, 1.25-30.15;p=0.025), hyperglycemia at admission (adjusted HR, 1.32; 95% CI, 1.12-1.56;p=0.001), high serum level of glycated hemoglobin (adjusted HR, 0.49; 95% CI, 0.39-0.67; p

Cardiovascular disease (CVD) is the predominant cause for morbidity and mortality in diabetes mellitus (DM). Patients with diabetes mellitus have two to three times the incidence of atherosclerotic disease compared to the general population (Kannel & McGee, 1979). Several etiologic factors increase susceptibility to CVD in DM including insulin resistance, dyslipidemia, endothelial dysfunction, prothrombosis, and increased protein glycation (Baynes & Thorpe, 1999). Plasma homocysteine levels are elevated in patients with diabetes, particularly in patients with type 2 diabetes as well as in individuals in prediabetic states who exhibit insulin resistance. Homocysteine (Hcy) is a non-essential amino acid that is produced from demethylation of methionine. Hcy can be remethylated into methionine by means of vitamin B12-dependent methionine synthase and 5-methyltetrahydrofolate as a methyl donor. Hcy can be also catabolized into cysteine (the transsulfuration pathway) via cystathionine beta synthase and cystathioninase, both enzymes being vitamin B6dependent. A third way to remove Hcy is conversion to S-adenosylhomocysteine (SAH). The last reaction is mediated by SAH-hydrolase and favors the SAH formation in case of increased Hcy concentrations. S-Adenosyl methionine (SAM) is a universal methyl donor that is formed from methionine and converted into SAH after donating its methyl group. SAH is a potent inhibitor of most known methyltransferases (Kloor & Osswald, 2004). Among the main determinants of tHcy levels in non-diabetic subjects are age, sex, renal function, several diseases, drugs, coffee and chronic alcohol consumption, smoking and physical inactivity (Refsum et al., 2006). Genetic factors and nutritional deficiencies of folate

Background Food items might have a synergistic and antagonistic effect on health. The Mediterranean diet (MD) has long been associated with lower incidence of cardiovascular disease and cancer. Elevated blood homocysteine is a risk factor for cardiovascular disease. A 5-mmol/L increase is associated with an approximately 70% increase in relative risk of cardiovascular disease in adults. For patients with established risk factors, this risk is likely even greater. Thiolactonase; the antioxidant enzymatic component of HDL plays a crucial role in metabolizing homocysteine thiolactone and reducing homocysteine endothelial damages. Objective A total of 53 elderly coronary artery disease patient swere recruited and divided into diabetic patient (n = 27; age = 68.3 years) and non diabetics (n = 26; age = 68.7 years). We evaluated plasma homocysteine levels (tHcy); thiolactonase activity (HTase) and studied the effects of adherence to a Mediterranean diet on them. Material & methods Plasmatic tHcy was determined by capillaryGC-MS; HTLase activity was estimated by a kit immunoassay. Dietary intakes were evaluated by a validated food frequency questionnaire and transformed into a score traducing adherence to MD. Results Significantly higher median tHcy levels were found in diabetic patients as compared to the non diabetic ones (18.5 μmol/L vs. 5.8; p = 0.057) associated to lower HTase activities (266.8U/L vs. 327.4; p = 0.058). Moreover, in the diabetic patients tHcy levels were negatively associated with thiolactonase activities (r= −0.637; p 0.00). In this group, MD reduced diastolic blood pressure (r= −0.558; p = 0.014). In the non diabetic group, tHcy levels were negatively correlated with HTase activities (r = 0.759; p = 0.00) and diet score (r = −0.0706; p = 0.013) while HTase activities were positively correlated with diet score (r = 0.0759; p = 0.00). Conclusion Elevated homocysteine in diabetic patients may partly be explained by the diminished thiolactonase activities and could be considered as an additional risk factor for cardiovascular events. Adherence to MD could be the first efficient step to prevent these complications.

ObjectiveThe purpose was to review the long term outcomes of patients with VSD considered not to require surgical closure during childhood.BackgroundAlthough patients with small VSD have generally been considered not to require surgery, more recent data suggest that a significant percentage of these patients develop serious Problems during adult life.MethodsThe patient population consisted of 320 consecutive patients with small VSD followed on 11 years, from 1995 until 2006.ResultsThe mean age at the first visit was 6± 3,7 years. Spontaneous VSD closure was observed in 66 patients (20,6%). No patients died.Defect locations were as follows: perimembranous 192 (59%), trabecular 105 (33%), outlet infracristal 5 (2%), inlet 18 (6%).The small VSD (< 3 mm), a trabecular location and an early age of dignosis had greater chances to the spontaneous closure.Left ventricular (LV) size by Echocardiography was normal in 292 (91%) patients, enlarged in 26 patients (8%). In our population 8 patients had aortic regurgitation « LAUBRY-PEZZI » syndrome, 7 of them have perimembranous location of VSD and outlet infracristal location in the last case.3 of them had severe aortic regurgitation and 2 of them had surgical closure and valve repair. 2 patients (0,6%) had an episode of endocarditis.None had systolic LV dysfunction, and pulmonary artery pressure (PAP) was normal in all patients.ConclusionOutcome in well-selected patients with a small VSD is good. Surgical closure does not appear to be required during childhood as long as left-to-right shunt is

It is now well accepted that an elevated blood glucose level is associated with increased mortality in patients presenting with acute myocardial infarction (AMI). However, the underlying mechanisms of these deleterious effects of hyperglycemia are not well understood. Impaired microvascular function, or the no-reflow phenomenon may be one of these factors. Objectives We investigated the association between hyperglycemia and the no-reflow phenomenon in patients with AMI. Results A total of 250 patients presenting with AMI were evaluated. The no-reflow phenomenon was found in 29 (11.6%) patients, their glucose level on hospital admission was significantly higher than patients who did not exhibit this phenomenon (16.5 ± 9.3 vs. 12. 2 ± 7.1 mmol/l; p = 0.008). There was no difference in patients characteristics except for diabetes (51.7% vs. 29.7% ;p=0.017). Maximum level of creatine kinase (CK) were significantly higher in patients with no-reflow (4320 ± 1981 vs. 2980.3 ±1955 IU, p= 0.01). Patients with no-reflow presented more frequently with heart failure (44.8% vs. 14.1%;p In multivariate analysis the blood glucose level was an independent prognostic factor for no-reflow (OR: 1.8; 95% CI: 1.2-4, p Conclusions Hyperglycemia might be associated with impaired microvascular function after AMI, resulting in a larger infarct size and worse functional recovery.

Objectives Determine the frequency of various cardiovascular anomalies and atypical aspects in tunisian sporting student athletes and study sex, body area, sport's disciplines and sport's seniority influences on the clinical, electrocardiographic and echocardiographic parameters. Material and methods Population of 400 sporting students with an average age of 16 years and sex ratio of 2. They were mainly 168 athletes (42%) and 156 combat sportsmen (39%). Results The clinical examination revealed a functional systolic breath in 22 case, a mitral insufficiency systolic breath in 1 case. The resting ECG showed an incompleted “BBD” in 25 students, a first degree “BAV” in 1 case, a sinusal bradycardia in 4 cases, a sinusal tachycardia in 3 cases, a short PR in 5 cases and left ventricular hypertrophy by Sokolow index in 4 cases. Effort ECG was within the normal limits in all sportsmen. Echocardiography was normal in 398 cases. The mean left ventricular end-diastolic diameter (“DTD”) was 47 mm and the mean left ventricular end-systolic diameter (“DTS”) was 28 mm. The average of interventricular septum diastolic diameter (« SIV ») was 9 mm. The mean posterior wall thickness (“PP”) was 8mm. Two cases of valvular heart disease were found having justified a final sport inability. The anthropometric parameters and the sex appear to influence some electrocardiographic and echocardiographic parameters more than the sporting specialities. Conclusion This study suggests the interest of a clinical, electrocardiographic and echocardiographic exploration, within the medical standard assessment to sporting section integration.

Failure of myocardial perfusion after coronary angioplasty for acute myocardial infarction (AMI) is associated with a poor prognosis. Grade 3 ischemia (G3I) was shown to be associated with failure of myocardial perfusion. Aim Evaluate the prognosis impact of G3i, recorded on the admission electrocardiogram, after percutaneous coronary intervention (PCI) for AMI. Methods One hundred eight patients had PCI in the setting of AMI. G3I was defined as: Absence of S wave below the TP-PR isoelectric line in > 2 leads. Patients meeting the ST-elevation criteria but not the G3I criteria were classified as grade 2 ischemia (G2I). Myocardial perfusion was evaluated on ST-segment resolution and angiographyally on the flow of infarct-related artery graded according to the TIMI scale. Occurrence of no-reflow, no ST-segment resolution and hospital mortality were evaluated. Results Patients were divided in 2 groups: G3I (51 patients) and G2I. (57 patients). Clinical and angiographic characteristics were similar, absence of ST-segment resolution; the no-reflow phenomena and hospital mortality were more common in the G3I group respectively: 47% vs 20% (p= 0.002), 27% vs 10% (p = 0,024) and 21,.6% Vs 8.8% (p = 0.062). IG3, female gender, diabetes and delay to consultation > 2 hours were associated with the occurrence of no-reflow, persistence of ST- segment elevation and hospital death. In multivariate analysis, IG3 was an independent factor of no-reflow and absence of ST- segment resolution: OR 3.45 (CI 95% [1.15 to10.31]) p=0.027 and OR 3.47 (CI 95% [1.37 to9.01]) p=0.011, respectively. Female gender, no-reflow and persistence of ST-segment elevation were the only independent predictive factors of hospital mortality, respectively : OR 10,59 (CI 95% [1,68 to66,8]) p=0,012 ; OR 7,39 (CI 95% [1,52 to35,8]) p=0,013 ; OR 50 (CI 95% [4,69 to532]) p=0,001 but not the grade 3 ischemia. Conclusion Grade 3 ischemia on the admission electrocardiogram of acute myocardial infarction is a strong independent predictors of failure of tissular reperfusion.

Subsequent studies have shown that metabolic syndrome (MetS) defined using the Adult Treatment Panel III (ATP-III) imparts an increased risk of type 2 diabetes mellitus as well as clinical and subclinical coronary artery disease (CAD) in older populations. Because the prevalence of MetS is increasing alarmingly among adolescents and young adults, it is important to quantify its relation with clinical CAD occurring early in life. Aim We sought to examine the association between MetS and early-onset CAD. Methods Between January 2006 and January 2008 we performed a case-control study with 40 early-onset CAD subjects (acute myocardial infarction, angina with ≥ 50% stenosis, or coronary revascularization) in men under age 46 years or women under age 56 years and 60 control subjects matched for gender and age. Results The population was composed by 44 men, median age was 41 years. Different components of Mets were compared for both cases (40 subjects) and control (60 subjects). Blood systolic and diastolic pressure were respectively 129 ± 24 mmHg vs 124 ± 23 mmHg and 76.1 ± 11.4 vs 74.4 ± 12.8 mmHg (p=0.5). Waist circumference was lower in controls with 92 ± 15 cm vs 100.6 ± 12 cm for the cases (p=0.05). HDL cholesterol tend to be higher in controls with 1.19 ± 0.4 mmol/l vs 1.06 ± 0.8 mmol/l (p=0.4). Triglyceride and fasting glycemia were significantly higher in cases with respectively 2.3 ± 1.5 vs 1.34 ± 0.8 mmol/l, and 9.7± 6 vs 6.5 ± 3.4 mmol/l (p ≤ 0.05). Mets was consequently higher in cases, actually 66.7% of the cases had Mets vs 25.7% in controls. (p Conclusions Presence of MetS was higher in young patients with CAD, a better physical activity and dietary patterns are necessary to prevent this syndrome as it's related to high coronary risk.

Aim To analyze apolipoprotein gene polymorphisms in the Tunisian population and to check the relation of these polymorphisms and homocysteine, lipid and apolipoprotein levels to the coronary artery disease (CAD). Methods In healthy blood donors and in patients with CAD complicated by myocardial infarction (MI) four apolipoprotein gene polymorphisms [APO (a) PNR, APO E, APO CI and APO CII] were determined and plasma levels of total homocysteine, total cholesterol (TC), triglycerides (TG), HDL-cholesterol (HLD-C) and apolipoproteins (apo A-I, Apo B, Apo E) were measured. Results Analysis of the four apolipoprotein gene polymorphisms shows a relative genetic homogeneity between Tunisian population and those on the other side of Mediterranean basin. Compared to controls, CAD patients have significantly higher main concentrations of TC, TG, LDL-C, apo B and homocysteine, and significantly lower ones of HDL-C, apo A-I and apo E. The four apolipoprotein gene polymorphisms have not showed any significant differences between patients and controls. However, the APO E4 allele appears to be associated to the severity of CAD and to high levels of atherogenic parameters and low level of apo E, which has very likely an anti-atherogenic role. Conclusion Although APO (a) PNR, APO CI and APO CII genes are analyzed in only few populations, they show a frequency distribution, which is not at variance with that of APO E gene and other widely studied genetic markers. In the Tunisian population the APO E 4 appears to be only indirectly involved in the severity of CAD. In the routine practice, in addition of classic parameters, it will be useful to measure the concentration of apo E and that of Homocysteine and if possible to determine the APO E gene polymorphism.

Introduction and objectives Percutaneous closure of patent ductus arteriosus (PDA) is a well-established technique. We evaluated the usefulness of the Amplatzer duct occluder (ADO) for the percutaneous closure of large patent ductus arteriosus in 16 children less than 2 years of age. Methods The patient's mean age was 15, 5 months (from 6 to 24 months) and their mean weight was 8, 6 (4–13, 5) kg. In addition, 2 patients were under 5 Kg. mean symptoms were recurrent pulmonary infections (7 patients), dyspnea (5 patients) and 2 of them had patent cardiac failure. All completed follow-up (3 months – 6 years). Results The mean PDA diameter was 4.4, 8(2–6) mm. dilated left ventricular was noticed in all cases and pulmonary hypertension within 7 cases. The device was implanted successfully in all the patients. Sizes of the device were 10/8 in one case, 8/6 in 9 cases, 6/4 in 6 cases. Aortography showed initial total occlusion in 65.8% of patients. At 3-month follow-up, total occlusion was observed in 100% of patients. No deaths or significant complications were associated with the procedure during the study period. One patient develop hemopericardium with tamponade witch treated successfully by pericardiocentesis. Conclusions In children under 2 years of age, percutaneous closure of large patent ductus arteriosus using an Amplatzer occluder was a safe and effective procedure.