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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

Clopidogrel non-responsiveness is multifactorial; several genetic and non-genetic factors may contribute to impaired platelet inhibition. The goal of this study is to determine the effect of the cytochrome P450 CYP2C19*2 polymorphism on the platelet response to clopidogrel in patients with and without diabetes mellitus (DM). We conducted an observational study in patients with coronary artery disease and consequent exposure to clopidogrel therapy (75 mg/day for at least 7 consecutive days). We have analyzed two groups of patients: group I (DM patients) and group II (non-diabetes mellitus patients). Platelet reactivity was assessed by the VerifyNow P2Y12 assay and high on clopidogrel platelet reactivity (HPR) was defined as P2Y12 reaction units (PRU) ≥ 208. Genotyping for CYP2C19*2 polymorphism was performed by PCR-RFLP. We have included 150 subjects (76 DM and 74 non-diabetes mellitus patients). The carriage of CYP2C19*2 allele, in DM patients, was significantly associated to HPR (odds ratio (OR) 4.437, 95% confidence interval (CI) 1.134 to 17.359; p = 0.032). Furthermore, 8.4% of the variability in percent inhibition by clopidogrel could be attributed to CYP2C19*2 carrier status. However, in non-diabetes mellitus patients, there was no significant difference in platelet response to clopidogrel according to the presence or absence of CYP2C19*2 allele carriage (OR 1.260, 95% CI 0.288 to 5.522; p = 0.759). Our study suggests that the carriage of CYP2C19*2 polymorphism, in DM patients, might be a potential predictor of persisting HPR in these high-risk individuals. Clinical Trials.gov NCT03373552 (Registered 13 December 2017)

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

Brugada syndrome is an inherited arrhythmia characterized by a particular ECG pattern typically distinguished by a coved-type ST segment elevation in the right precordial leads, conferring a high risk of sudden cardiac death in young adults and less frequently in infants and children. The ST segment elevation in the Brugada syndrome can be very dynamic and modified by several factors such as fever, diet, and raised plasma insulin concentration, autonomic activity, alcohol and cocaine toxicity, and medication. Approximately 20%–25% of BrS patients are genetically diagnosed with pathogenic variations in SCN5A gene encoding for the cardiac sodium channel. However, known BrS-susceptibility genes can only explain 30%–35% of clinically diagnosed cases, indicating that 65%–70% of BrS patients remain genetically unsolved. The incomplete penetrance of BrS mutations and the dynamic ECG manifestations confer difficulties in establishing a clear genotype-phenotype correlation. Brugada syndrome patients are particularly recommended to follow a lifestyle where the ECG triggering factors should be avoided in order to minimize the risk of Brugada-associated arrhythmia and sudden death.

Matrix metalloproteinases (MMPs) play an important role in early atherosclerosis, extracellular matrix remodeling, plaque rupture and myocardial infarction. MMP gene polymorphisms contribute to the risk of developing cardiovascular diseases. In this study, we investigated, for the first time, the association between MMP-1-16071G/2G, MMP-12 -82A/G and MMP-12 1082A/G genotypes and haplotypes and the risk of ischemic stroke (IS) among patients with type 2 diabetes mellitus (T2DM). To examine whether these genetic polymorphisms are associated with susceptibility to IS, 196 patients with IS and 192 controls were examined by PCR-based RFLP. When the analyses were adjusted for multiple risk factors, no interaction between T2DM and MMP-1-1607 1G/2G polymorphism on the risk of ischemic stroke was found (p=0.074). However, MMP-12 polymorphisms genotypes were associated with the higher risk of IS in diabetic patients compared with total patients. The -82G-1082G haplotype of MMP-12 polymorphisms was associated with higher risk of ischemic stroke in diabetic patients [AOR=2.33; 95% CI (1.25-3.62), P=0.032]. These findings showed that there was an important joint effect of the MMP-12 polymorphisms and T2DM on the risk of IS and therefore it can be considered as a potential marker of cerebrovascular disorders in diabetic patients.

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

Serum cystatin C concentration was recently reported as a marker of cardiovascular disease (CVD). In the present study, we evaluated the association between the increase of serum cystatin C levels and the risk of CVD in type 2 diabetes. 42 patients with type 2 diabetes were included in the present study; 27 of them have CVD. The control group consisted of 30 healthy adults. Cystatin C, creatinine, microalbuminuria and CRP were measured on Cobas 6000(TM). Cystatine C level was significantly higher in patients with CVD. A significant difference in serum cystatin C was found in patients with and without CVD among albuminuria. No difference in serum cystatin C levels was found according to number of affected vessels. A cystatin C level above 1.10 mg/L was associated with increase of risk of CVD with significant difference (OR = 42.52; IC 95% 1.455 to 1242.827 and p = 0.029). Our results suggested that the increase of serum cystatin C concentrations is a potential marker for CVD in diabetes.

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

Introduction Excess of total homocysteine (tHcy) and decrease of thiolactonase activities (HTase) have been proposed as risk factors for coronary artery diseases (CAD). Objectives We evaluated the relationship of tHcy and HTase with paraoxonase 1 (PON1) gene polymorphism according to CAD severity. Design and methods 118 healthy volunteers and 91 CAD patients were compared. Results Serum levels of tHcy and oxidized LDL (ox-LDL) increased significantly by 26% and 48% in CAD patients and were associated with significantly lower levels of HDL cholesterol (p = 0.02) and 42% of decrease in HTase activities (p

Background The relationship between apolipoprotein E (ApoE) polymorphism, fasting lipid parameters, and coronary artery disease (CAD) is controversial. Methods We studied this relationship, for the first time, in Tunisian type 2 diabetic patients. The studied population comprised 157 type 2 diabetic patients (145 of them were not on any lipid-lowering drugs). Fasting lipids were measured by enzymatic methods and ApoE genotypes were determined by polymerase chain reaction–restriction fragment length polymorphism. Results Our results showed that the alleles E2, E3, and E4 were found in 4%, 88%, and 8% of patients, respectively. In the total type 2 diabetic population, no association was found between ApoE polymorphism, lipid parameters, and CAD. However, the E4 allele was associated with elevated low-density lipoprotein cholesterol concentration and with CAD in type 2 diabetic men. Conclusion The effect of ApoE polymorphism on CAD is gender-dependent in the Tunisian type 2 diabetic population. ApoE 4 allele may enhance atherogenesis indirectly by a strong effect on low-density lipoprotein cholesterol.

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.

Background Aspirin (ASA) failure to inhibit in vitro platelet function had been termed ASA resistance. The prevalence of this phenomenon as measured with different platelet function tests varies widely among studies. Objectives In this study, we propose to determine the prevalence of ASA non-responsiveness in stable coronary artery patients using three different tests. Patients and methods One hundred ninety-one patients with a stable coronary artery disease and receiving secondary ASA prophylaxis (250 mg/day) were tested. For each patient the ASA-induced platelet inhibition was determined using three different tests: Ivy Bleeding time (BT), collagen/epinephrine closure time (CEPI-CT; PFA-100™, Dade-Behring) and urinary 11-dehydrothromboxane B2 (uTxB2) excretion level. The agreement between these tests was evaluated by kappa statistics test. Results The prevalence of biological ASA resistance was 15.7% (n = 30), 20.4% (n = 39) and 24.6% (n = 47) by BT, PFA-100™ and UTxB2, respectively. Only fourteen patients (7.3%) were non-responders for two tests: 6 (3.1%) BT/ PFA-100™; 1 (0.5%) BT/UTxB2; 7 (3.7%) PFA-100™/UTxB2). A poor agreement was found between these three methods and only 3 patients were resistant with all the tests (1.6%). Conclusion The lack of agreement supposed that different types of aspirin resistance exist. Thus, combination of two tests or more could be a primary solution for a better identification of ASA resistant patients. This hypothesis must be confirmed by a large-scale randomized study with clinically well-defined endpoints.

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.

We present a retrospective analysis of clinical symptoms and echocardiographic features in 14 patients having cardiac hydatic cysts and screened during the 18 last years, with surgical correlations in 13. The heart was the sole location of the cyst in six patients. The revealing symptoms were precordial pain (six patients), dyspnea (two patients). A systolic murmur of false pulmonic stenosis was present in three patients. In 13 patients, two-dimensional echocardiographic images of hydatic cysts were those of masses of liquid content with a well-contrasted capsule, which was single in eight patients and multiple in five, one of which had a honeycomb appearance. The mass was solid and calcified in one patient. The outlines of the cysts were particularly sharp on transesophageal echocardiograms (six patients). The cyst size ranged from 1.8 to 11 cm in diameter. Cysts were located in the intramyocardium in 10 patients (left ventricle in four patients, interventricular septum in four patients, right ventricle in two patients), the pericardium in three and the mediatinum in one. There were a Doppler pulmonary valve gradient in three patients. Computed tomography (eight patients) and coronary arteriography (seven patients) have no additional diagnosis value than echocardiography. Nuclear magnetic resonance imaging (three patients) was helpful in determining extracardiac extension of the cysts. Transthoracic and transesophageal two-dimensional echocardiography have a central role in diagnosing cardiac hydatic cysts.

Brugada syndrome (BrS) is an autosomal-dominant genetic cardiac disorder caused in 18–30 % of the cases by SCN5A gene mutations and manifested by an atypical right bundle block pattern with ST segment elevation and T wave inversion in the right precordial leads. The syndrome is usually detected after puberty. The identification of BrS in pediatric patients is thus a rare occurrence, and most of the reported cases are unmasked after febrile episodes. Usually, having a family history of sudden death represents the first reason to perform an ECG in febrile children. However, this practice makes the sporadic cases of cardiac disease and specially the asymptomatic ones excluded from this diagnosis. Here, we report a sporadic case of a 2-month-old male patient presented with vaccination-related fever and ventricular tachycardia associated with short breathing, palpitation and cold sweating. ECG changes were consistent with type 1 BrS. SCN5A gene analysis of the proband and his family revealed a set of mutations and polymorphisms differentially distributed among family members, however, without any clear genotype–phenotype correlation. Based on our findings, we think that genetic testing should be pursued as a routine practice in symptomatic and asymptomatic pediatric cases of BrS, with or without family history of sudden cardiac death. Similarly, our study suggests that pediatrician should be encouraged to perform an ECG profiling in suspicious febrile children and quickly manage fever since it is the most important factor unmasking BrS in children.

Background Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities. Methods Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 ± 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) ≥1.5 cm2 after BMC and

The association of E670G (rs505151) polymorphism in PCSK9 gene with an increased risk of coronary artery disease (CAD) and ischemic stroke (IS) was reported in previous studies. We investigated the effect of the E670G (rs505151) on the risk of CAD and IS in a Tunisian cohort. Genotyping of the PCSK9 E670G was performed using polymerase chain reaction (PCR)-based restriction fragment length polymorphism (RFLP) and then confirmed by direct sequencing. The frequency of the 670G allele was significantly higher in the CAD than in the no-CAD subgroup (0.132 vs. 0.068, p = 0.030). As expected, the incidence of E670G was significantly important in IS subgroup than control group (0.122 vs. 0.073, p = 0.032). Furthermore in CAD patients, the 670G carriers showed significantly increased plasma total cholesterol and LDL-cholesterol levels compared to E670 carriers (6.78 [6.47–7.00] vs. 4.92 [4.02–5.46] mmol/l, p

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

OBJECTIVES In this study, we investigated the association between matrix metalloproteinase-1 (MMP-1) G-1607GG, MMP-12 A-82G and MMP-12 A1082G genotypes and haplotypes and the prognosis of coronary artery disease (CAD). METHODS A total of 129 Tunisian patients with CAD were followed prospectively for a median of 2.5 years. Genotypes were determined by a PCR-based restriction fragment length polymorphism. Two endpoints were considered: restenosis and incidence of clinical vascular events (restenosis, myocardial infarction, stroke, cardiac death). RESULTS Genotypes of MMP-1 G-1607GG, MMP-12 A-82G and MMP-12 A1082G were not associated with the incidence of restenosis or clinical events. Analysis of haplotypes consisting of alleles of MMP-1 G-1607GG and MMP-12 A1082G showed that the rate of clinical events was significantly higher in patients carrying the GG-A haplotype than those with other haplotypes (0.637 vs. 0.424, respectively, odds ratio=1.45; 95% confidence interval=1.04-2.04; P

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.

BACKGROUND Behcet's disease (BD) is a multisystemic immuno-inflammatory disorder. Inflammatory processes may cause lipid peroxidation, alteration of lipid profile and increase the risk of atherosclerosis. The aim of this study was to evaluate the association between thiolactonase (HTLase) activity and plasma homocysteine levels (tHcy) in a BD population and to investigate their association with methylenetetrahydrofolate reductase (MTHFR) 677C-->T genotype. METHOD A total of 35 BD patients were compared to 39 healthy volunteers. RESULTS Significantly higher tHcy levels associated with lower HTLase activities were found in BD patients as compared to healthy controls (p

Several matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been implicated in the development and outcome of coronary artery disease (CAD). We investigated whether MMP-12 and TIMP-1 levels were associated with risk, severity, and outcome of CAD. Plasma MMP-12 and TIMP-1 levels are measured in 50 and 44 patients with CAD, respectively, by enzyme-linked immunosorbent assay. Of all patients, 16 were taking statins. Patients who were not on statins were classified into 3 groups according to number of >50% stenotic vessels. Compared with 29 volunteers without CAD, patients without statins (n = 34) had higher MMP-12 concentrations (1.71 vs 1.08 ng/ml, p = 0.021). MMP-12 levels were significantly lower in patients with than in those without statin treatment (0.99 vs 1.71 ng/ml, p = 0.008). There was no association between MMP-12 levels and number of >50% stenotic vessels. MMP-12 concentrations were not associated with outcome of CAD. However, plasma TIMP-1 levels were associated with restenosis independently of number of stenotic vessels and age (p = 0.035) but not with risk or severity of CAD. In conclusion, plasma MMP-12 concentration was associated with the presence of CAD. Statin therapy decreases plasma MMP-12 levels in patients with CAD. Increased TIMP-1 levels may prevent restenosis after angioplasty.

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.

Short-term and mid-term results of percutaneous balloon pulmonary valvuloplasty (BPV) are well known. However, data documenting long-term effectiveness of BPV are scarce.The long-term results of 62 patients were assessed by catheterization and Doppler echocardiography 1 to 10 years (mean 6.4 +/- 3.4) after BPV. Mean age of the patients was 13.5 +/- 10.5 years (range 9 months to 44 years). Twenty patients were 16 years of age or older. Right ventricular peak systolic pressure was systemic or suprasystemic in 72% of patients. A double-balloon technique was used in 29 patients. The balloon-to-pulmonary valve diameter ratio was 1.4 +/- 0.38 (range 1 to 1.8). Total systolic transpulmonary pressure gradient in excess of 50 mm Hg in all patients before BPV decreased from 98 +/- 40 to 32 +/- 23 immediately after BPV and to 19 +/- 9 mm Hg at follow-up (P.001). Infundibular gradient increased from 8 +/- 10 to 14 +/- 24 mm Hg after BPV and fell to 1 +/- 4 mm Hg at follow-up (P.01). In 16 patients it was/=20 mm Hg and virtually disappeared spontaneously in all at follow-up. The valvar gradient fell from 93 +/- 39 to 19 +/- 11 (P.001) and was 18 +/- 9 mm Hg at follow-up. It remained unchanged in 3 patients (range 36 to 45 mm Hg). In 3 (4.8%) other patients, a new gradient35 mm Hg developed that was/=50 mm Hg in all 3. Among 5 patients having dysplastic valves, 3 had a gradient35 mm Hg. There were no predictors of a gradient35 mm Hg at long-term follow-up by univariate or multivariate Cox proportional hazards analysis. Mild to moderate pulmonary regurgitation was present in 39% of patients. On electrocardiography, right ventricular hypertrophy decreased significantly in 90% of patients.BPV as a treatment of typical pulmonic valve stenosis produces excellent long-term results. Restenosis is rare (4.8%) and occurs more frequently in patients with dysplastic valves. There is a constant spontaneous regression of associated infundibular obstruction.

Background Radiocontrast nephropathy is associated with increased morbidity and mortality, particularly in patients with percutaneous coronary interventions. A number of agents that improve renal circulation have been clinically tested for prevention of radiocontrast nephropathy, but none of them has succeeded. Protection of renal tubular cells against oxidative stress is another approach to avoid radiocontrast nephropathy. Prophylactic effects of antioxidants such as N-acetylcysteine have been reported by several investigators, although the effectiveness of these compounds is still a matter of debate. Ascorbic acid, an antioxidant agent, a safe and not expensive medication, could be used to prevent radiocontrast nephropathy. Methods We conducted a randomized, double-blind, placebo-controlled trial of ascorbic acid in 202 patients who underwent coronary angiography and/or intervention. The patients were randomly assigned to receive either oral Vitamin C (3 g at least 2 hours before the procedure and 2 g in the night and the morning after the procedure) or placebo, in adjunct to hydration. Serum creatinine was measured prior to and 48h after coronary angiography. The primary end-point was the occurrence of CIN, defined as an increase in serum creatinine ≥0.5 mg/dL (44.2 μmol/L) or ≥25% above baseline at 48h after exposure to contrast medium. Results Complete data on the outcomes were available on 202 patients, 107 of whom had received Vitamine C. There were no significant differences between the Vitamin C and placebo groups in baseline characteristics, amount of hydration, or type and volume of contrast used. CIN occurred in 11 out of 107 (10.3%) patients in the Vitamin C group and 20 out of 95 (21.1%) patients in the placebo group (P=0.032). Conclusion There was detectable benefit for the prophylactic administration of oral Vitamin C over an aggressive hydration protocol in patients Undergoing Coronary Angiography or Intervention.

Background 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. Because of its pleotropic effects, statins have been used in CIN prevention, but data remains controversial. Objective To evaluate the benefit of statins in the prevention of CIN after coronary angiography. Methods We used the database of a randomized controlled trial conducted in our department during the period March to November 2010 to study the effectiveness of ascorbic acid in the prevention of CIN. Patients undergoing coronary angiography were randomly assigned to a saline hydration prevention protocol or a saline hydration associated to ascorbic acid protocol. The primary endpoint was the occurrence of CIN defined as a creatinin arise of more than 25% the baseline level during the following 48 to 72 hours. The relationship between statin intake at baseline and CIN incidence was retrospectively evaluated using a Chi-square test. Results Among the 202 patients included, 126 (62.3%) were treated with statins. There was no significant difference between the two groups concerning the baseline characteristics, particularly in ascorbic acid treatment (p=0.94). CIN incidence dropped from 20.8% in the patients not taking statins to 11.7% in those treated with statins. This resulted in a tendency (p=0.08) but difference wasn’t statistically significant, probably due to the small sample of the population. Conclusion In our study, treatment with statins led to a trend to reduce CIN incidence. The small sample of the population couldn’t allow stronger conclusion. Statins seem to be promising but larger trials are needed.

Although radial approach has been shown to be feasible for coronary angiography, angioplasty, and even stent placement, there have been no prospective evaluations of ease and safety of left radial approach for coronary angiogram. We examined procedural duration and success as well as complications in 415 consecutive patients. Radial artery occlusion was assessed immediately post-procedure and at 2 month follow-up using echo-Doppler measurements. Procedure failure rate was 9%, mean time for sheath insertion was 4.7 ± 4.7 min, and mean procedure duration was 19.1 ± 8.2 min. No major complications occurred. Asymptomatic radial artery occlusion was noted in 71% of the first 49 patients, decreased to 24% in the next 119 receiving 2,000–3,000 units of heparin, and to 4.3% in the last 210 receiving 5000 (p < 0.05). Comparison with the femoral approach in the same laboratory suggested that the radial approach took longer, but provided similarly high-quality results without great difficulty in coronary cannulation. Hence, the left radial approach for coronary angiography (with heparin administration) allows immediate ambulation and may be especially useful for outpatients and when the femoral approach is not possible. © 1996 Wiley-Liss, Inc.