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Background Ultrasonographic B-lines have recently emerged as a bedside imaging tool for the differential diagnosis of acute dyspnea in the Emergency Department (ED). However, despite its simplicity, LUS has not fully penetrated emergency department. This study aimed to assess the accuracy and reproducibility of ultrasonographic B-lines performed by emergency medicine (EM) residents for the diagnosis of congestive heart failure (CHF) in patients admitted to ED for acute dyspnea. Patients and methods This is a cross-sectional prospective study conducted between January 2016 and October 2017 including patients aged over 18 years admitted to ED for acute dyspnea. At admission, two consecutive bedside LUS study were performed by a pair of EM residents who received a 2-h course for recognition of sonographic B-lines to determine independently B-lines score and B-profile pattern. All participating sonographers were blinded to patients’ clinical data. B-lines score ≥ 15 or a B-profile pattern was considered as suggestive of CHF. The final leading diagnosis was assessed by two expert sonographers, who were blinded to the residents’ interpretations, based on clinical findings, chest X-ray, brain natriuretic peptide, cardiac and lung ultrasound testing. Accuracy and agreement of B-lines score and B-profile pattern were calculated. Results We included 700 patients with a mean age of 68 ± 12.6 years and a sex ratio (M/F) of 1.43. The diagnosis of CHF was recorded in 371 patients (53%). The diagnostic performance of B-lines score at a cut-off 15 and B-profile pattern was, respectively, 88% and 82.5% for sensitivity, 75% and 84% for specificity, 80% and 85% for positive predictive value, 84% and 81% for negative predictive value. The area under receiver operating characteristic curve was 0.86 [0.83–0.89] and 0.83 [0.80–0.86], respectively, for B-lines score and B-profile pattern. There was an excellent agreement between residents for the diagnosis of CHF using both scores (kappa = 0.81 and 0.85, respectively, for ordinal scale B-lines score and B-profile pattern). Conclusion Lung ultrasound B-lines assessment has a good accuracy and an excellent reproducibility in the diagnosis of CHF in the hand of EM residents following a short training program. Trial registration Name of the registry: clinicaltrials.gov; Trial registration number: NCT03717779; Date of registration: October 24, 2018 ‘Retrospectively registered’; URL of trial registry record: clinicaltrials.gov

Aim of study Cardiac output (CO) responses to acute changes in body position and Valsalva maneuver (VM) were proposed to assess cardiac contractile reserve. We investigated the value of sitting position (SP), leg raising (LR), and VM for identifying heart failure (HF) in patients with undifferentiated dyspnea. Materials and methods It is a prospective study including patients over 18 years old admitted to the emergency department (ED) for dyspnea. Bioimpedance CO was measured at baseline, under SP, LR, and VM. HF diagnosis was based on clinical assessment, serum levels of brain natriuretic peptide (BNP) and echocardiography findings. Study population was divided into patients with heart failure (HF group) and patients without HF (HF- group). Diagnostic performance of CO change under the three maneuvers was calculated by sensitivity, specificity, likelihood ratio and receiver operating characteristic (ROC) curve. Results 290 patients were enrolled in the study. The final diagnosis was dyspnea due to congestive heart failure in 147 patients (50.7%). CO change with VM was the most accurate exam in identifying congestive heart failure as the cause of dyspnea with a sensitivity, specificity, positive and negative likelihood ratios of 79%, 60%, 1.97, and 0.36 respectively. Area under ROC curve was 0.62(95% CI, 0.55–0.69), 0.63(95% CI, 0.56–0.69), and 0.70(95% CI, 0.64–0.76) respectively for SP, LR, and VM. In a multivariate analysis, CO change with VM, but not with SP or LR, carried independent diagnostic value (p Conclusion the diagnosis of HF can be aided with use of analyzing the effect of VM on non-invasively measured CO among patients admitted to the ED with undifferentiated dyspnea. Diagnostic yield of SP and LR was poor.

AIM OF THE STUDY The diagnosis of heart failure in the emergency department (ED) is challenging. The aim of this study was to evaluate systolic time intervals (STIs) using phonoelectrocardiography for the diagnosis of heart failure (HF) in ED patients with undifferentiated dyspnea. METHODS A total of 855 patients with dyspnea and suspected HF were prospectively enrolled. They underwent echocardiographic measurements of left ventricular ejection fraction (LVEF), B-type natriuretic peptide (BNP) testing and computerised phonoelectrocardiography to assess STIs including electromechanical activation time (EMAT), left ventricular ejection time (LVET) and EMAT/LVET ratio. Diagnosis accuracy of STIs was calculated including sensitivity, specificity, likelihood ratio and receiver operating characteristic (ROC) curve. RESULTS Patients with HF (n = 530) had significantly higher EMAT and lower LVET compared with non-HF patients. ROC curve c-statistic was 0.74, 0.72 and 0.78 for EMAT, LVET and EMAT/LVET respectively. Sensitivity and specificity of EMAT/LVET at a cut-off = 40% were 72% and 88% respectively. EMAT/LVET had the highest correlation with LVEF (r = 0.48). In patients with intermediate BNP (n = 107), positive likelihood ratio increased from 1.8 with BNP alone to 3.6 with BNP combined to EMAT/LVET. Patients without HF had STIs values not significantly different from those with preserved LVEF (≥45%). CONCLUSIONS Given their immediate availability, phonoelectrocardiography STIs' parameters and particularly EMAT/LVET ratio could have an important role in the diagnosis approach of HF in patients with undifferentiated dyspnea in the ED.

Resume Introduction Malgre les progres realises dans le domaine de l’antibioprophylaxie, l’endocardite infectieuse reste une pathologie frequente. L’insuffisance cardiaque en est sa principale complication. Objectif de l’etude Etudier les differentes caracteristiques des patients atteints d’endocardite infectieuse compliquee d’insuffisance cardiaque et determiner son impact sur la mortalite. Patients et methodes A partir du registre des endocardites infectieuses incluant 241 patients repondant aux criteres de la DUKE universite modifies, nous nous sommes interesses aux patients ayant une insuffisance cardiaque a l’admission, a savoir une dyspnee superieure ou egale a stade II de NYHA. Au total, 85 patients ont ete inclus dans ce groupe insuffisance cardiaque (35,2 % du registre). Resultats L’endocardite infectieuse etait presente dans 77,6 % des cas sur valve native. Sur le plan bacteriologique, les hemocultures etaient positives dans seulement 43,5 % des cas. Parallelement a l’antibiotherapie, 65,8 % des patients ont necessite le recours a la chirurgie dont l’indication etait essentiellement l’instabilite hemodynamique. La mortalite totale dans notre registre etait de 19,5 %, beaucoup plus elevee dans le groupe atteint d’insuffisance cardiaque (28,2 % vs 14,7 % ; p = 0,006). En analyse multivariee, les facteurs predictifs de mortalite du groupe d’endocardite infectieuse compliquee d’insuffisance cardiaque etaient la presence d’une anemie (OR = 5,2 ; IC 95 % : [1,6–24] ; p = 0,02), l’infection par le staphylocoque (OR = 5,7 ; IC 95 % : [0,8–29,8] ; p = 0,03) et l’absence de recours a une chirurgie precoce (OR = 3,1 ; IC 95 % : [1,1–14,7] ; p = 0,01). Conclusion L’insuffisance cardiaque est la complication la plus frequente de l’endocardite infectieuse et sa premiere cause de deces.

Background Prognostic assessment is important for the management of patients with acute pulmonary embolism (PE). The Pulmonary Embolism Severity Index (PESI) score has been previously validated in studies, but its widespread use in clinical practice and validity are uncertain. Purpose We sought to validate the PESI as a predictor of short- and intermediate-term mortality. Methods Consecutive patients admitted at our institution with a confirmed PE between January 2009 and December 2015 were screened. Information on clinical presentation, diagnostic work-up, treatment and mortality during a 30-day and 1-year follow-up was collected. To facilitate analyses, raw PESI score was dichotomized into low risk (I-II) vs. high-risk (III-V) groups. Results The cohort included 178 subjects (mean age, 58.6 ± 18.2 years; 47% male). Among these patients, 58.8% were at low risk. No significant difference in baseline characteristics between the 2 groups was found. One-year follow-up was available in 96.1% of patients. There was a significant difference in 30-day mortality between the two groups in favour of the low risk group (7.2% vs. 25.4%, P Conclusions Our data indicate that the PESI score is a reproducible scoring tool in real life to risk stratify patients with acute PE, can be used to predict the prognosis of patients with PE and helps in definitive the optimal management.

Introduction Cardiogenic shock (CC) is a devastating complication of the ST elevation acute myocardial infarction (STEMI). Its mortality remains high despite the huge progress in critical care and coronary revascularization. Purpose We aim in this study to evaluate in-hospital mortality and its predicting factors in cardiogenic shock complicating a STEMI. Materials and methods It is a retrospective, mono-centric study including 267 patients from the MIRAMI registry who presented a CC-STEMI between 1995 and 2016. Results In-hospital mortality rate from all causes was 49.1% with a slight non-significant raise tendency over the study years (P = 0.299). The major cause was primary left ventricle dysfunction (61%) and death occurred within the first 24 hours in almost half of cases (49.2%). In uni-variate analysis, in-hospital mortality was more often in autumn (P = 0.033), among females (P = 0.001) and in elderly (P = 0.019). The major clinical mortality predicting factors were: hypertension (P 60 min (P = 0.034), a delay from symptoms onset to hospitalization > 6 hours (P = 0.034), anterior territory of the STEMI (P = 0.006) and Q wave on ECG (P = 0.043). Biological predicting factors were: anemia (P = 0.001), renal dysfunction (P Conclusion In hospital mortality in CS-STEMI remains high even in literature so that the treatment strategy should be based on an urgent and multi-disciplinary approach.

Coronary artery stent infection with mycotic aneurysm is a rare life-threatening complication following coronary angioplasty, usually requiring surgical intervention. Reaching and confirming the diagnosis remains the most challenging aspect of this complication. We describe an unusual case of bare metal stent infection and coronary artery aneurysm in the setting of tricuspid valve infective endocarditis, resulting in ST elevation myocardial infarction, with a favorable outcome after primary angioplasty and antibiotic therapy. In the current era of growth of coronary stent implantation, it’s important for clinicians to consider and to prevent such potentially fatal events. The diagnosis process remains difficult and requires the association of multiple clinical, biological and imaging parameters. Although treatment modalities tend to favor surgery, we showed that coronary angioplasty could be a successful alternative solution.

Hamdi Boubaker,1,2 Mohamed Habib Grissa,1,2 Kaouther Beltaief,1,2 Zohra Dridi,3 Mohamed Fadhel Najjar,4 Wahid Bouida,1,2 Riadh Boukef,5 Soudani Marghli,6 Semir Nouira1,2 1Department of Emergency, Fattouma Bourguiba University Hospital, 2Research Laboratory (LR12SP18), University of Monastir, 3Department of Cardiology, 4Department of Biochemistry, Fattouma Bourguiba University Hospital, Monastir, 5Department of Emergency, Sahloul University Hospital, Sousse, 6Department of Emergency, Tahar Sfar University Hospital, Mahdia, Tunisia Background: The goal of this study was to determine the value of systolic time intervals and their change during Valsalva maneuver (VM) in the diagnosis of left ventricular dysfunction (LVD) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Methods: We included 166 patients admitted to the emergency department for AECOPD. Measurement of systolic time intervals included electromechanical activation time (EMAT), left ventricular ejection time (LVET), and EMAT/LVET ratio. These were performed at baseline and during the first strain phase of the VM using a computerized phonoelectrocardiographic method. The diagnosis of LVD was determined on the basis of clinical examination, echocardiography, and brain natriuretic peptide. The values of systolic time intervals were compared between patients with and without LVD; their diagnostic performance was assessed using the area under receiver operating characteristic (ROC) curve.Results: Patients with LVD (n=95) had a significantly higher EMAT and lower LVET and EMAT/LVET ratio compared to patients without LVD (n=71); the area under ROC curve was 0.79, 0.88, and 0.90, respectively, for EMAT, LVET, and EMAT/LVET ratio. All baseline systolic time intervals changed significantly during VM in patients without LVD but they did not change in patients with LVD. The area under ROC curve increased to 0.84 and 0.93,­respectively, for EMAT and EMAT/LVET ratio but did not change for LVET.Conclusion: Simple and noninvasive measurements of systolic time intervals combined with VM could be helpful to detect or rule out LVD in patients admitted to the emergency room for COPD excacerbation. The EMAT/LVET ratio seems to have the best diagnostic value. Keywords: chronic obstructive pulmonary disease, exacerbation, systolic time intervals, Valsalva maneuver&nbsp

Background ST elevation myocardial infarction (STEMI) remains one of the most frequent emergencies, requiring an as early as possible reperfusion that may result, in some cases, from physiological fibrinolysis. Objective We aimed to analyze the clinical characteristics of patients presenting with clinical markers of spontaneous reperfusion (SR) during acute myocardial infarction, and to evaluate its effect on hospital prognosis. Methods We retrospectively reviewed data for 1785 patients admitted for STEMI. The patients were divided into SR group (spontaneous relief of chest pain less than 5 on a scale from 0 to 10, and ST segment elevation resolution of more than 50% from baseline) and non-SR group (the remaining population). The clinical and prognostic features of the patients were analyzed. Results The incidence of SR in our population was 10.4% of patients (N = 187). SR patients were younger (57.6 vs. 61.1 years; P = 0.002) and had a higher prevalence of current smoking (77.9% vs. 65.9%; P = 0.003) and less myocardial damage as indicated by lower peak creatine kinase (1158 vs. 2022 UI/l; P In hospital mortality (3.2% vs. 10%; P = 0.013), heart failure (8.4% vs. 19.7%; P = 0.001), atrial fibrillation (0.6% vs. 7.3%; P = 0.002) and acute pericarditis (0% vs. 4%; P = 0.011) were significantly lower for SR patients. Multivariate analysis found smoking as the only predictor factor of SR (OR = 1.82, 95% CI [1.2–2.7]; P = 0.003). Conclusion Our data shows that SR decreased infarction size, improved heart function and reduced mortality. The subgroup of STEMI with SR carries a more favorable prognosis.

Background A number of factors may offset the cardioprotective effects of glucose‐insulin‐potassium (GIK) on outcome of patients with acute coronary syndrome, such as hyperglycemia induced by this cocktail infusion. We performed a study to evaluate the effect of intensive insulin therapy in association with GIK on 1‐year outcome in patients hospitalized for acute coronary syndrome. Methods and Results In a randomized prospective controlled trial we included 772 patients with non–ST‐segment elevation acute coronary syndrome. Patients were randomized into 3 groups: GIKI 2 group, who received GIK with intensive insulin therapy for 24 hours; GIK group, who received GIK with nonintensive insulin therapy; and control group, who received usual care. The primary outcome criteria were the rates of major cardiovascular events combining death, reinfarction, and stroke rate at 1 year. In addition, we measured platelet function assay‐100 and plasminogen activator inhibitor‐1 at admission and 24 hours later. Based on an intention‐to‐treat analysis, major cardiovascular events at 1 year was 12.8% in the GIKI 2 group, 15.5% in the GIK group, and 20.5% in the placebo group; the difference was significant between the GIK 2 and control groups ( P =0.01). Platelet function assay‐100 at 24 hours decreased significantly from baseline in the control group but not in the GIKI 2 group. Plasminogen activator inhibitor‐1 decreased significantly in the GIKI 2 group but significantly increased in the control group. Minor hypoglycemic events were more frequent in the GIKI 2 group compared with other groups. Conclusions GIKI 2 led to improvement of 1‐year outcome rates in patients with non–ST‐segment elevation acute coronary syndrome. This beneficial effect was associated with a decrease in platelet reactivity and an increase on fibrinolysis tests. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00965406.

The Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry in Acute Coronary Events (GRACE) scores were largely evaluated and validated in stratifying risk of cardiovascular events in patients with chest pain and acute coronary syndrome. Our objective was to compare these 2 scores in predicting outcome in emergency department (ED) patients with undifferentiated chest pain.This was a prospective cohort study including patients presenting to 4 EDs with chest pain with nondiagnostic or normal ECG. For all included patients (n = 3125), TIMI and GRACE scores were calculated. Follow-up was conducted at 30-day and 1-year post-ED index admission to identify major adverse events. Main outcome included all cause mortality, acute coronary syndrome, and coronary non-ED planned revascularization. Prognostic performance of the scores was assessed by the receiver operating characteristic (ROC) curves.We reported 285 (9.1%) major adverse events at 30 days and 436 (13.9%) at 1 year. In patients with low TIMI (≤2) and GRACE (109) scores, a significant proportion had major adverse events at 30 days (5% and 7.5%, respectively) and 1 year (7.9% and 12.9%, respectively). Area under ROC curve at 30 days was 0.66 (95% confidence interval [CI], 0.62-0.71) vs 0.57 (95% CI, 0.53-0.62), respectively, for TIMI and GRACE scores. At 1 year, the area under ROC was 0.67 (95% CI, 0.62-0.71) and 0.65 (95% CI, 0.60-0.70), respectively, for TIMI and GRACE scores.The TIMI and GRACE scores are not valid in short- and long-term risk stratification in our chest pain patients.

Background: Although drug-eluting stents (DES) for percutaneous coronary intervention have dramatically reduced the incidence of in-stent restenosis, their deployment for large-size coronary lesions is still controversial because of problems such as prolonged dual antiplatelet therapy, late in-stent thrombosis and costs. Aim: This study sought to evaluate the safety and effectiveness of drug-eluting stents (DES) compared to baremetal stents (BMS) for patients with large coronary vessels ≥ 3.5 mm. Methods: This is a retrospective case-control comparative study conducted in the cardiology A department of the university hospital Fattouma Bourguiba in Monastir. A total of 77 consecutive patients (80 lesions) who underwent, between October 2003 and March 2014, successfully DES implantation were compared to 73 consecutive patients (84 lesions) who were treated with BMS in large coronary vessels ≥ 3.5 mm. Results: The average age in our population was 59.7 ± 11.3 years with a male majority without any significant difference between the two groups. The DES group contained significantly more patients with diabetes (67.5% vs. 38.1%; p

Background Prognostic assessment is important for the management of patients with acute pulmonary embolism (PE). The Pulmonary Embolism Severity Index (PESI) score has been previously validated in studies, but its widespread use in clinical practice and validity is uncertain. Purpose We sought to validate the PESI as a predictor of short- and intermediate-term mortality. Methods Consecutive patients admitted at our institution with a confirmed PE between January 2008 and December 2017 were screened. Information on clinical presentation, diagnostic work-up, treatment and mortality during a 30 day and 1-year follow-up was collected. To facilitate analyses, raw PESI score was dichotomized into low risk (I–II) vs. high risk (III–V) groups. Results The cohort included 224 subjects (mean age, 58.6 ± 18.2 years; 47% male). Among these patients, 61.3% were at low risk. No significant difference in baseline characteristics between the 2 groups was found. One-year follow-up was available in 97.4% of patients. There was a significant difference in 30-day mortality between the two groups in favour of the low risk group (6.3% vs 24.1%, P In multivariate analysis, the PESI (class III–IV versus I–II, OR 6.2, 95% CI 2.6–11.2) was an independent predictors of an adverse outcome (death, cardiogenic shock and need for mechanical ventilation). The discriminatory power of the PESI score to predict long-term mortality, expressed as the area under the ROC curve, was 0.81 (95%CI, 0.62–0.88) at 1 year. Conclusions Our data indicate that the PESI score is a reproducible scoring tool in real life to risk stratify patients with acute PE, can be used to predict the prognosis of patients with PE and helps in definitive the optimal management.

Introduction Coronary chronic total occlusion (CTO) angioplasties are considered the most complex of angioplasties requiring experienced operators as well as many specific materials and techniques. Purpose This study aims to identify the predictors of success or failure of CTO angioplasty and to evaluate the short- and medium-term results of this procedure. Material and methods This study is a single-centric retrospective comparative study including patients who underwent CTO angioplasty in the cardiology “A” department at Fattouma-Bourguiba Hospital during the period between January and 2008 and December 2015. Results Our study included 200 patients with attempt of CTO angioplasty. The mean age was 63 ± 8.63 years and the mean number of cardio-vascular risk factors was 2.67. Acute coronary syndrome was the main indication (57.5%) for coronarography. A multi-truncal coronary status was reported in 53.5% of the cases. The mean J-CTO score was 1.42 ± 1.3 and 44% of lesions were estimated difficult to very difficult. The anterograde approach has been the most used technique. The angiographic success of ATL has been reported in 106 patients (53%). DES were implanted in 69.9% of cases. The leading cause of angioplasty failure was the impossibility to cross the lesion by the wire. The procedural complications occurred in 11.5% of cases. The independent predictors of ATL failure were: dyslipidaemia, a bending > 45 degrees (P Conclusion The results of our study showed a clinical benefit of CTO angioplasty in case of success and demonstrated once more many failure predicting angiographic factors.

Background Patients with renal insufficiency experience worse prognosis after STEMI. The current guidelines do not clearly draw specific strategies for patients with renal dysfunction (RD). Aim The aim of this study is to compare primary PCI (PPCI) and thrombolysis results as well as in-hospital mortality after successful reperfusion between the RD patients (RD+) and patients with normal renal function (RD−). Methods We retrospectively reviewed data for 1785 patients admitted for STEMI between January 2007 and October 2017. Two groups were identified: PPCI (624 patients) and thrombolysis (679 patients). Hundred and twenty-two patients had RD defined by creatinine levels at admission > 130 umol/L, they were equally treated by PPCI and thrombolysis. Results In the PPCI group, despite a similar pre-procedural TIMI flow (P = 0.54), TIMI III restoring was significantly lower in the RD+ group (74.1% vs. 93.2%, p = 0.01). Suboptimal result was also higher in the RD+ group (15.6% vs. 3.2%, P Conclusion RD reduces either PPCI or thrombolysis success, with no proven microvascular damage after PPCI. In-hospital prognosis, however, is worse in the RD group only after successful PPCI, but not after successful streptokinase thrombolysis.

BackgroundPatients with renal insufficiency experience worse prognosis after STEMI.Aim of the study to compare primary PCI (PPCI) and thrombolysis results as well as in-hospital mortality after successful reperfusion between patients with or without renal dysfunction (RD).MethodsFrom January 1995 to October 2014, 1588 patients admitted for STEMI were enrolled in our registry. Two reperfusion groups were identified: PPCI (315 patients) and thrombolysis (379 patients). We compared the group of RD patients (RD+) and normal renal function patients (RD). Our main endpoints were: (1) The success of reperfusion and (2) the in-hospital mortality.ResultsNinety patients (13%) had RD, 50% of which underwent PPCI, and 50% received thrombolytics. In the PPCI group, although TIMI flow was similar before angioplasty (p=0.82), TIMI III flow restoration was significantly lower in the RD+group (78.6% vs 91.8%, p=0.013).Suboptimal result was also higher in the RD+group (13.6% vs 2.7%, p

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.

Platelet glycoprotein IIb/IIIa is a membrane receptor which plays a key role in coronary artery disease and thrombotic events. However, there is a considerable controversy regarding the clinical impact of glycoprotein IIIa platelet antigen 1 (PlA1)/platelet antigen 2 (PlA2) polymorphism as a risk factor for myocardial infarction. To evaluate the association between glycoprotein IIIa PlA1/PlA2 polymorphism and 1-year cardiovascular events occurrence in aspirin-treated patients with stable coronary artery disease. We prospectively included 188 postacute coronary syndrome patients (183 men) aged 59 ± 10 years and receiving aspirin (250 mg/day). The clinical outcome at 1 year was the composite end point of nonfatal myocardial infarction, stroke, recurrent unstable angina or cardiac death. Genotyping for PlA1/PlA2 polymorphism was conducted using PCR and restriction fragment length polymorphism analysis. The genotype distribution of glycoprotein IIIa PlA1/PlA2 polymorphism was PlA1/PlA1, 55.3%; PlA1/PlA2, 39.3% and PlA2/PlA2, 4%. Incidence of composite end point in homozygous PlA1/PlA1 carriers was significantly higher than in PlA2/PlA2 and PlA1/PlA2 patients [14.4 vs. 3.6% odds ratio 4.5 (1.2-16.6, 95% confidence interval); P = 0.012]. Multivariate analysis identified three strong predictive factors of cardiac death: age more than 65 years [odds ratio = 6.8, (1.4-34, 95% confidence interval); P = 0.018], ventricular ejection fraction less than 50% [odds ratio = 8.6, (1.7-42.6, 95% confidence interval); P = 0.008] and homozygous PlA1/PlA1 genotype [odds ratio = 8.8, (1.0-78.6, 95% confidence interval); P = 0.014]. Our results demonstrated that glycoprotein IIIa PlA1/PlA1 genotype carriers have a significantly increased risks of acute vascular ischemic events associated with a poor prognosis at 1 year. These postacute coronary syndrome patients might require an optimized secondary antithrombotic prophylaxis strategy.

Resume Plusieurs travaux ont montre une mortalite paradoxalement plus faible chez les fumeurs ayant beneficie d’une thrombolyse a la phase aigue de l’infarctus du myocarde (IDM) comparativement aux non-fumeurs. Ce « paradoxe des fumeurs » a ete par ailleurs peu etudie en cas d’angioplastie primaire. But du travail Etudier l’impact du tabagisme sur la mortalite a 30 jours des patients admis pour un IDM selon la strategie de reperfusion. Patients et methodes Etude realisee a partir du registre des IDM avec sus-decalage ST incluant 688 patients ayant beneficie, soit d’une thrombolyse hospitaliere ou prehospitaliere (n = 397) ou d’une angioplastie primaire (n = 291). Parmi ces patients, 482 (70,1 %) etaient des fumeurs actifs. Resultats Dans le groupe thrombolyse, la prevalence de l’hypertension arterielle, du diabete et des IDM anterieurs etait significativement plus faible chez les patients tabagiques. Dans le groupe angioplastie primaire, le diabete et l’hypertension arterielle etaient moins frequents. La mortalite a j30 des patients tabagiques etait significativement plus faible chez les fumeurs en cas de thrombolyse comparativement aux non-fumeurs (5,3 vs 13 % ; p = 0,008). En analyse multivariee, l’etat de choc (p

Various genetic polymorphisms have been proposed to explain the persistent platelet hyperactivity (HPR) under aspirin treatment. PlA polymorphism of platelet GPIIIa receptor has been largely studied. However, its influence on platelet sensitivity to aspirin remains controversial.The aim of this prospective study is to investigate whether this PlA polymorphism is associated with a greater prevalence of HPR in stable coronary artery disease patients Material and Methods: 188 stable coronary artery disease patients were included. Platelet aspirin inhibitory effect was determined with PFA-100 using Collagen/Epinephrine closure time (CEPI-CT). A CEPI-CT160sec was defining the HPR status. GPIIIa PlA polymorphism was established using polymerase chain reaction and classical restriction fragments length polymorphism.The observed frequencies of different genotypes were not different from those predicted by the Hardy-Weinberg equilibrium: PlA1/lA1 (55.3%), PlA1/PlA2 (39.4%) and PlA2/PlA2 (5.3%). HPR patients with inadequate aspirin inhibition were significantly more often homozygous PlA1/A1 (65.4% vs. 47.7%, p=0.015). After multivariate analysis, PlA1/A1 genotype was the only independent risk factor for persistent HPR (OR: 2.07; 95% CI [1.14 to 3.76; p=0.016).In CAD patients receiving daily low dose of aspirin, there is a significant and independent association between the expression of GPIIIa PlA1 allele and the occurrence of persistent HPR detected with PFA-100.

Aims Ramadan fasting (RF) may affect aspirin resistance. We conducted this study in patients with cardiovascular risk (CVR) factors to assess the effect of RF on aspirin resistance and explore whether type 2 diabetes mellitus (DM) would influence this effect. Methods A total of 177 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking aspirin. Physical exam and standard biological tests including glycaemia and serum lipids data were performed before Ramadan (Pre-R), at the last week of Ramadan (R) and four weeks after the end of Ramadan (Post-R). In the same visits caloric intake was calculated and platelet reactivity to aspirin was assessed using Verify Now point-of-care assay. Results In the overall population, there was no significant change in absolute aspirin reaction unit (ARU) values and in metabolic parameters. In DM patients (n = 127), ARU change from Pre-R values was+19.7 (p = 0.01) and +14.4 (p = 0.02) respectively at R and Post-R. During Ramadan, glycaemia, triglycerides, and cholesterol levels increased significantly and returned to Pre-R values thereafter. These changes were not observed in non-DM patients. Conclusions During RF aspirin resistance increased only in DM patients. This effect persisted one month after Ramadan. Simultaneous alteration of glycemic control and increase of serum lipids levels could potentially be a favorable factor. Study registration The protocol was registered at clinicaltrials.gov under: NCT02720133.

Background Balloon mitral commissurotomy (BMC) has become widely accepted as the treatment of choice for mitral stenosis in patients with favorable anatomy, but few tools are available to predict its long-term outcome. Purpose We sought to determine a simple score to predict late outcome of BMC in patients with mitral stenosis. Methods Late results of BMC were assessed in 1035 consecutive patients at our institution. A good immediate result was defined as valve area ≥ 1.5 cm2 without mitral regurgitation > 2/4. BMC procedure was performed using the double balloon or the Inoue balloon techniques. Ore to predict late outcome of BMC in patients with mitral stenosis. Results Mean age of our population was 35.6 ± 12 years. A successful procedure was observed in 92.4% of cases. At a mean follow-up of 20 years, the rate of survival with freedom from mitral surgery, or repeat percutaneous mitral commissurotomy and with New York Heart Association class I or II was of 47.6 ± 2.4%. By multivariate analysis using Cox regression model, three predictors of poor late functional results were identified: prior commissurotomy (P = 0.014), Wilkins score > 8 (P Table 1 ). Conclusion Twenty-year outcome of balloon mitral commissurotomy in a relatively young population is very encouraging and can be predicted by a simple score.

Introduction Hyperglycemia (HG) has been shown to be a powerful predictor of worse outcome after ST segment-elevation myocardial infarction (STEMI). Aim Investigate the relationship between acute HG and angiographic and clinical outcome after primary or rescue angioplasty for STEMI. Methods We retrospectively included 489 patients who underwent revascularization for STEMI. We compared hospital outcomes of patients with HG (HG+) with those without HG (HG−) and outcomes of diabetic with non-diabetic patients in the HG+ group. Plasma glucose was measured at hospital admission. HG was defined as plasma glucose > 11 mmol/L (198 mg/dL). Results Among the overall population, 184 (37.6%) patients had HG. Procedural success was significantly lower in the HG+ group (86% vs. 92%, P = 0.05) with lower rates of ST segment resolution at 24 hours (47.3% vs. 61.4%, P = 0.006). Hospital outcomes were worse in the HG+ group with a higher mortality (20% vs. 10.4%, P = 0.008). Predictive factors for intrahospital mortality in the overall cohort were: procedural failure (OR: 4.76; 95% CI [1.65–13.7]; P = 0.004), heart failure at admission (OR: 9.75; 95% CI [4.14–22.87]; P Conclusion In patients with STEMI, HG is an important predictor of worse outcomes with an increased mortality risk even beyond 11 mmol/L. In non-diabetic patients, both elevated glucose and HbA1c levels were associated with adverse outcomes.

Study objective The distinction between hemorrhagic and ischemic stroke has critical implications for management. For that purpose, clinical scores have been proposed to be used in areas with limited health care resources where brain computed tomographic (CT) scan is not readily available. We conducted this study to evaluate the predictive value of the Allen and Siriraj scores in the differential diagnosis of stroke subtypes. Methods We prospectively collected data for 4 years on the clinical characteristics of patients with stroke in a multicenter study. For all patients, we calculated the Allen and the Siriraj scores and we assessed their accuracy in predicting stroke subtypes with receiver operating characteristics (ROC) curves. Results We assessed 1,023 patients. Of these, 82.7% (n=846) had ischemic stroke. The area under the ROC curve was higher for Siriraj score compared with the Allen score (0.780 versus 0.702; P =.04). Using the original cutoff points, Siriraj score has a sensitivity for the diagnosis of hemorrhage of 60% and a specificity of 95%; the corresponding values for the Allen score are 55% and 70%, respectively. The negative predictive value was higher for Siriraj score compared to the Allen score (90% versus 80%). The diagnosis of stroke subtype was best predicted at Siriraj score less than –4. Conclusion Siriraj score is a valid and useful tool for predicting stroke subtype in a clinical setting in which financial constraints make systematic brain CT scan unfeasible.

Introduction Despite progress in the field of antibiotic prophylaxis, infective endocarditis (IE) remains a common and serious disease. Heart failure (HF) represents the most common cause of death in this pathology. Objective We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by HF and to evaluate the impact of early surgery on 1 year outcome. Patients and methods It is about a single-center observational study that included 241 patients admitted for definite left-sided native valve IE according to the Duke criteria. We are interested in the subgroup of 85 patients with heart failure. Results The average age of our patients was 42±18 years. When compared with patients without CHF (n = 156), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in HF patients. Aortic valve IE, elderly patients were more frequent in HF patients. Congestive HF was independently predictive of in-hospital mortality [OR=3.1, IC 95% (1.9-8.2); p = 0.007]. Early surgery was performed in 51% of HF patients with a peri-operative mortality of 19%. In the HF group, anemia [OR=4, IC 95% (0.9-17); p = 0.05), uncontrolled infection [OR=4, IC 95% (0.9-16.2);p= 0.05), and major neurological events (OR=9, IC 95% (1.4-21.6); p= 0.019) were multivariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR=0.41 (0.17-0.73); p = 0.02]. Conclusion Native valve IE complicated by HF is more frequent in aortic IE and is associated with severe regurgitation. Congestive HF is an independent predictor of in-hospital and 1 year mortality. In HF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

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.

AIMS To evaluate the safety, efficacy and long-term actuarial results of balloon mitral commissurotomy in young patients with severe rheumatic mitral stenosis. METHODS AND RESULTS Event-free survival and freedom from restenosis were analyzed in 110 patients 20 years old or younger (group 1) and compared with those of 554 adults (group 2). Young patients were less frequently in atrial fibrillation (6% vs 35%, P

BACKGROUND Patients with renal insufficiency experience worse prognosis after STEMI. The current guidelines do not clearly draw specific strategies for patients with renal dysfunction (RD). AIM The aim of this study is to compare primary PCI (PPCI) and thrombolysis results as well as in-hospital mortality after successful reperfusion between the RD patients (RD+) and patients with normal renal function (RD-). METHODS We retrospectively reviewed data for 1,388 patients admitted for STEMI between January 1995 and October 2011. Two groups were identified: PPCI (315 patients) and thrombolysis (379 patients). Ninety patients (13%) had RD defined by creatinine levels at admission > 130 micromol/l, they were equally treated by PPCI and thrombolysis. RESULTS In the PPCI group, despite a similar pre-procedural TIMI flow (P = 0.82),TIMI III restoring was significantly lower in the RD+ group (78.6% vs. 91.8%, P = 0.013). Suboptimal result was also higher in the RD+ group (13.6% vs. 2.7%, P < 0.001), but ST regression after TIMI III achievement was similar in the 2 groups (P = 0.43), probably reflecting no microvascular damage. In the thrombolysis group, successful reperfusion was also significantly lower when RD exists (58% vs. 74%, P = 0.03). After successful reperfusion, RD+ patients experienced higher in-hospital mortality in the PPCI group (29% vs. 4.3%; P < 0.001), whereas mortality was similar in the thrombolysis group (3% vs. 0%, P = 0.42). CONCLUSION RD reduces either PPCI or thrombolysis success, with no proven microvascular damage after PPCI. In-hospital prognosis, however, is worse in the RD group only after successful PPCI, but not after successful streptokinase thrombolysis.

BackroundAmiodarone is a widely used antiarrhythmic drug in Tunisia and worldwide. However, its side effects are quite frequent hampering its use despite its efficacy.ObjectiveThe purpose of our study was to determin the prevalence of amiodarone side effects and to analyse its predictors in our population.ResultsFrom May 1st 2010 to April 30th 2012, 200 consecutive patients (mean age: 61.9±12.9 years) were included. Mean duration of amiodarone therapy was 51.9±48.4 months with a mean dose of 288.1±274.2g. Atrial fibrillation (81.5%) was the most common indication. Amiodarone side effects occurred in 144 patients (72%). Refering to multivariate analysis, independent predictors were:–Advanced age (p=0.02), treatment duration (p 6 months (p=0.008) for corneal deposits.–Age >70 years (p=0.001) and cumulative dose (p70 years (p=0.002) and treatment duration (p300g (p=0.012) and heart failure (p= 0.05) for bradycardia.–Cumulative dose >100g (p= 0.012) for QT prolongation–Treatment duration (p 18 months (p=0.009) and concomittent CCB use (p

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

ObjectiveBenefits of statins in the long term follow-up of ST elevation myocardial infarction (STEMI) have been established, but the short term benefits of early statins prescription remain unproven, especially according to the reperfusion result.Aim of the studyTo assess the benefit of early statins prescription in in-hospital outcome of STEMI patients.MethodsBetween January 1995 and November 2011, 1388 patients admitted for STEMI have been included in the MIRAMI (MonastIR Acute Myocardial Infarction) registry. During this period, statins were introduced in early management of STEMI patients. This enabled us subdivide patients, after excluding those with missing treatment data, into 2 groups: early prescribed statins group (n=561) versus no statins prescribed group (n=804). We compared in-hospital outcome between these two groups and among the subgroups of successful or failure reperfusion therapy.ResultsIn the early statins prescription group, there was a significant reduction of in-hospital mortality (12.1% vs 5.3%, p

Background Despite significant progress made in diagnostic and therapeutic modalities, infective endocarditis (IE) remains a serious affection associated with considerable mortality and morbidity. Aim To describe the epidemiological and clinical aspects of native valve infective endocarditis (IE) in a Tunisian high-volume tertiary care center and to identify the predictors of outcome. Methods and results Demographic, clinical, laboratory, and echocardiographic characteristics were examined in 176 patients who fulfilled the modified Duke criteria for native valve IE between January 1993 and December 2008. Logistic regression analysis was used to identify prognostic factors for death. Mean age was 36.1±7.5 years. Diagnosis was definite in 85% of cases. Median time to diagnosis was 19 days. Rheumatic heart disease (RHD) was the predominant (47%) underlying heart condition. Mitral valve location was the most frequent seat of IE (37.7%). One or more vegetations were detected in more than 86.8% of cases. The median size of vegetation was >15 mm in 26% of cases. In 84 cases (48.5%), cultures remained negative. Serology was positive in 16 cases, and in 4 cases leaflet culture identified the agent. Causative microorganisms were mainly Staphylococci (n=42 (24.2%), including 8 coagulase-negative Staphylococcus), and Streptococci (n=32). Overall mortality was 18.6%. On multivariate analysis, congestive heart failure (hazard ratio = 5.62, 95% CI 1.32 to 12.54, p=0.008) and large vegetations (>15 mm; hazard ratio = 4.28, 95% CI 1.91 to 11.69, p=0.004) and neurological complications (hazard ratio = 3.27, 95% CI 1.84 to 9.11, p=0.002) were predictive of in-hospital mortality. Conclusion IE remains a serious disease affecting a young population in Tunisia, with RHD as still the most common underlying heart disease, and it is associated with a high mortality.

Objectifs Etudier le degre d'association de signe de Frank avec les manifestations cliniques et infra -cliniques de l'atherosclerose, en particulier la maladie coronaire. Methodes Il s'agit d’une etude transversale ayant inclus 40 patients de sexe masculin porteurs de signe de Frank, admis pour des cardiopathies diverses, et qui s'est basee sur le recueil des donnees demographiques, et biologiques. Resultats L'âge moyen etait de 63,7 ± 11,6 (46 ans-85 ans). Pour les facteurs de risque cardiovasculaire le tabac etait de loin le plus present dans 95 % des cas, suivie par la dyslipidemie dans 42,5 % des cas, suivie par l'HTA dans 37,5 % des cas, et par le diabete dans 32,5 % des cas. L'hemoglobine glyquee moyenne etait de 6,55 ± 1,56 %, le taux de TG 4,32 ± 0,81, de CT 7,24 ± 2,35, HDL-C 3,61 ± 1,89 et le LDL – C 5,57 ± 2,6. Un evenement cerebro-vasculaire avere a ete note chez 3 patientes (7,5 %), quant a la maladie cardiovasculaire, en particulier la maladie coronarienne, elle etait presente dans 85 %. Conclusion Notre etude a permis de confirmer l'existence d'une association entre le signe de Frank et les manifestations cliniques et infracliniques de l'atherosclerose.

Background Unresponsiveness to clopidogrel or aspirin has been reported in patients with acute coronary syndrome (ACS). Recent findings have suggested that high postclopidogrel treatment platelet reactivity (HPR) may increase the risk of recurrent thrombotic events, especially after coronary angioplasty (PCI). Objectives We sought to investigate the effect of clopidogrel resistance assessed by the Impact-R device (Cone and platelet analyzer measuring whole blood platelet adhesion under flow conditions) on the incidence of major cardiovascular events (MACE) among tunisian ACS patients in dual antiplatelet therapy. Methods Prospective study included 131 ACS patients almost of them who underwent PCI with stent implantation (76.3%). The mean age was 59.4 years ± 11.2 years. 77.9% were males, 37.4% patients had history of hypertension, and 54.3% patients were diabetic. Patients were receiving a loading dose of 300 or 600 mg followed by a maintenance dose of 75 mg, they were also receiving a maintenance dose of aspirin ranging from 125 mg to 250 mg. ADP-induced platelet aggregation were assessed at 48 hours using the Impact R (Diamed ® ). The degree of platelet adherence was evaluated as a percent of surface coverage (SC) and residual HPR was defined as a SC ≤2.8%. The clinical primary endpoint was the occurrence of MACE including cardiac death, MI and unstable angina. Results Clopidogrel resistance was detected in 21 pts (16%). After a mean follow-up 13.8 ± 6.1 months, 29 MACE were reported (22.1%) including 14 cardiac death (10.7%). According to ADP-induced platelet aggregation profile a significant a higher incidence of MACE in patients with HPR was noted (47.6% vs 17.3%, OR = 4.3; p = 0.002). A multivariate COX analysis showed that left ventricular dysfunction (HR = 6.1; 95% CI[2.6–14.4], clopidogrel resistance (HR = 3.04; 95% IC[1.3–6.4] and 2 or 3-vessel disease (HR = 2.6; 95% CI[1.3–6.4]) were independent predictors factors of MACE. Conclusions Our prospective study, reinforce the importance of being able to detect clopidogrel resistance by platelet function test among patients with ACS.

IntroductionHigh glycaemia at admission in STEMI patients is common and associated with an increased risk of in-hospital and post-discharge death.AimTo evaluate the impact of admission glycaemia in the short prognosis of diabetic and non-diabetic patients admitted for STEMI and to identify independent predictors of post-ACS mortality.Population and methodsThis study included 567 patients admitted to a single coronary care unit for STEMI, between January 2004 and June 2012. Our population was divided in three groups according to the tertiles of glycaemia at admission (T111mmol/l). Rates of success after revascularisation, intrahospital mortality, and ventricular arrhythmias were collectedResultsHyperglycaemia at admission was associated to worse cardiovascular risk profile, more severe coronary disease (more 3 vessel disease), incomplete revascularization, higher creatinine levels and more life threatening ventricular arrhythmias (VT/VF). In the predefined tertiles, in-hospital mortality was 4%, 5.2% and 14% (p11mmol/l (224 patients), outcomes were similar between the diabetic and non diabetic patients with death rates respectively 13.8% and 13.9% (p:0.988) In a multivariate analysis, predictive factors of intrahospital mortality were ventricular arrhythmias (OR:70.74, CI [14.298–349.99]; p 130μmol/l (OR: 5.99; CI[1.37-26.18], p:0.017)ConclusionsThese data suggest that, in an STEMI population, glycemia at admission is a short prognostic marker, accurately predicting both death and survival post STEMI.

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

Background Numerous recent studies showed that about 4 to 30% of patients treated with conventional doses of clopidogrel do not display adequate antiplatelet response and then the concept of clopidogrel resistance has arisen. Recently, a number of observations have indicated that patients with diabetes mellitus (DM) exhibit persistent platelet activation and low response after antiplatelet therapy. Objective The purpose of this study was to establish the prevalence and the predictive factors of the resistance to clopidogrel in a coronary artery disease population, using ex vivo measure of platelet aggregation: the cone and platelet analyzer. Methods The population of this prospective study was comprised of 105 patients with acute coronary syndrome. Mean age was 57.8 ± 10.8 years, 81.9% were males, 36,5% patients had history of hypertension, 54,3% patients were diabetic. Patients were given a loading dose of 300-600 mg followed by a maintenance dose of 75 mg on top of a maintenance dose of aspirin ranging from 125 mg to 250 mg. Platelet aggregation was assessed using the Impact R (Diamed®). The degree of platelet adherence was evaluated as a percentage of surface coverage (SC). Residual platelet reactivity was defined as a SC ≤ 2.8%. Results The mean surface coverage was of 7.78 + 4.29%. We found that 17.1% of our population was clopidogrel resistant. By univariate analysis female sex and diabetes were associated with an increased incidence of clopidogrel resistance, nevertheless, by multivariate analysis, diabetes was the only independent predictive factor, (OR=3.5, IC 952[1.1-11.4]; P=0.0039). The prevalence of clopidogrel resistance was higher in diabetic patients compared to non diabetics (24.6% vs 8.3%; p=0.02) respectively. This prevalence was greater in diabetic patients treated by insulin (30%). Concomitant medication did not influence the incidence of clopidogrel resistance in particular the use of Omeprazol and Atorvastatin. Conclusions Diabetic patients do not respond well to the available antiplatelet regimen when compared with similar patients without DM. The clinical implications of these findings are unknown but are potentially important.

BackgroundRenal artery stenosis (RAS) is a strong independent predictor of mortality in patients (pts) with coronary artery disease (CAD).Aim of studyTo develop and validate a score predicting RAS in patients with CAD.MethodsThree hundred consecutive pts (50 females) with significant CAD underwent abdominal aortography following coronary angiography to screen for significant RAS defined as luminal narrowing of > 50%. Univariate and multivariate analyses were performed comparing pts with and without RAS. Significant factors associated with RAS were included in constructing a score that predicts RAS.The score was internally validated in pts randomly selected from the entire study group (validation group; n=103), using ROC curves and the Hosmer-Lemeshow goodness-of-fit test.ResultsTwenty-seven pts (9%) had a significant RAS. Univariate predictors of significant RAS were: age > 65 years (OR=4.5, p < 0.0001), hypertension (OR=3.6, p=0.001), and female gender (OR=3.6, p=0.015). We found a tendency of more prevalent renal insufficiency (37.1% vs. 21.5%; p=0.05) and the presence of 2 or more significant CAD lesions (70.4% vs. 50.9%; p=0.05) in pts with RAS.Multivariate analysis showed that age > 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 ranged from 0 to 7: 2 points for age > 65 years and hypertension 1 point for female gender, renal insufficiency, and > 3-vessel disease). Internal validation showed a good performance (ROC curve = 0.79 and Chi2 Lemeshow = 3.45). For a score < 2, the negative predictive value is 98%. Applying this criteria, 48.3% of our population would not require systematic abdominal angiography.ConclusionThe 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.

The aim of this pilot study was to compare the effect of two different regimens of aspirin dosage on platelet of coronary artery disease (CAD) diabetic patients. Twenty-five CAD diabetic patients were included. Initially, all patients received aspirin 100 mg/day for 10 days. At day 10, aspirin antiplatelet effect was determined by measuring the collagen/epinephrine closure time (CT) 2 h after the last aspirin dosage and the next morning at 8 a.m.. The aspirin regimen was modified to 100 mg twice daily for patients showing a non-optimal platelet-inhibitory effect (CT < 298 s at 8 a.m.). Persistent high platelet reactivity (HPR) was defined by a CT < 160 s. During the 100 mg/day aspirin regimen, the prevalence of HPR at 8 a.m. was 48%, and only 7 patients (28%) had showed an optimal platelet-inhibitory effect. Bridging to the twice-daily regimen, the HPR was significantly reduced (p = 0.025), and the optimal platelet-inhibitory effect was reached for 3 other patients. Our results showed that 100 mg aspirin twice-daily dosing rather than a once-daily dose significantly improves the aspirin effect on platelet of CAD diabetic patients. However, large prospective studies were needed to confirm whether this strategy will be clinically relevant and safe.

The aim of this study was to assess the association between “aspirin non responsiveness” in patients with coronary artery diseases (CAD) and the risk of major adverse cardiovascular events (MACE). 204 patients with CAD receiving aspirin (250 mg/d) were included. Both Collagen/Epinephrine Closure Time (CEPI-CT) and urinary Thromboxane B2 (uTxB2) concentration was used to determine the patients aspirin responsiveness. The clinical primary endpoint was the occurrence of MACE including: cardiovascular death, MI, stroke or transient ischemic attack. The secondary endpoint was the occurrence of Recurrent Acute Vascular Event (RAVE: MI, stroke or transient ischemic attack). After 1-year follow-up, no responders diagnosed by CEPI-CT had a trend for higher risk of MACE (13% vs 7.4%; P = 0.22) and significant higher risk of RAVE (OR = 2.1; 95%CI: 1.7–2.4; P = 0.01) when compared to good responders. Multivariate analysis showed that CEPI-CT

Background Percutaneous transvenous mitral balloon valvotomy (PTMV) optimal results are usually achieved when echocardiographic Wilkins score (WS) is ≤8. WS from 9 to 11 represent a gray zone in which only some patients have good results. Aim The aim of this study was to determine the early and long term results of this procedure in patients with WS 8 or less and at the gray WS zone. Methods Retrospective review of clinical records of patients with rheumatic MS submitted to PTMV from January 1990 to December 2010. Follow-up was obtained by clinical records when available. Procedure was considered unsuccessful when post-procedure MV area (MVA) was Results We analyzed data for 378 patients with a WS ≤11, 80.5% were women. Mean age at the time of repair was 33 years [10 to 76 years] and the mean follow up time was 74 months. Before the procedure, 33.9% had a WS in the gray zone. They were older (36 years vs. 31 years, p PTMV was safe in the two groups with same rates of success but a lower mitral surface gain in the gray zone group (0.88cm2 vs. 1.05cm2, p During follow up, patients in the gray zone had significantly lower event free survival (freedom from death, systemic embolism and restenosis) (58.6% vs. 69.2%, p Conclusion PTMV was a safe procedure in both WS groups. Optimal results patients with a WS≤8 zone. Patients with a WS 9-11 experienced worse outcomes during follow up.

IntroductionThe optimal timing of coronary intervention in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) is a matter of debate.PurposeWe proposed through this work to study the optimal time to coronary angiography in patients admitted for acute coronary syndrome without ST-segment elevation in the Tunisian context and its prognostic impact on inhospital mortality.Materials and methodsIt is about an observational study from MIRACOS registry that included 407 patients admitted for NSTE-ACS. We were interested to find general characteristics, the time to coronary angiography, mortality and in-hospital complications.ResultsA total of 407 patients were included in our study. Nearly half of our patients (49.5%) were considered at high cardiovascular risk. The average to coronary angiography was 5.09 days. Patients who underwent early coronary angiography were significantly younger (p=0.01), had a lower incidence of diabetes (p=0.01), left heart failure (p=0.0001) and electrical changes suggestive of ischemia (p=0.009). Patients who have undergone an invasive strategy had significantly lower levels of creatinine (p

Background: Mitral stenosis is the most common valvular heart lesion found in pregnancy. When severe, it leads to significant risk of mortality for both mother and fetus, since the hemodynamic adaptations to pregnancy are badly tolerated. Many pregnant women with mitral stenosis present in a critically ill condition. The role of Balloon Mitral Valvotomy (BMV) in such patients is ill-defined. Purpose: We sought to evaluate the feasibility, efficacy and safety of emergent BMV in pregnant patients with refractory pulmonary edema and to determine maternal and fetal outcome. Methods: Of 88 patients undergoing BMV during pregnancy from January 1990 to December 2011 in Cardiology A Department of Monastir Hospital, 28 women were in New York Heart Association functional class IV and underwent emergent BMV. During the procedure, radiation exposure was minimized by means of total abdominal and pelvic shielding. Results: The mothers's mean age at the time of BMV was 28.86±5.7 (range 19–43) years, and the gestation period was 30±5.1 (range 20 –39) weeks. Ten patients were primiparas. Mitral valve (MV) was assessed using the Wilkins score which averaged 7.4±1.8 (range 4 to 14). Fluoroscopy time was 7.8±1.9 minutes. The BMV procedure was successful in 25 (89.3%) patients with a dramatic improvement in patient symptoms. The mitral valve area increased from 0.8±0.2 cm2 to 2.2±0.42 cm2 (p < 0.0001). The mitral valve pressure gradient decreased from 22.2±9.3 to 5.7±4 mm Hg (p < 0.0001). The left atrial pressure decreased from 29.4±9.3 to 15.4±7.3 mm Hg (p < 0.0001). The pulmonary artery pressure decreased from 58.8±21.1 to 37.2±14.3 mm Hg (p < 0.0001). One patient developed severe mitral regurgitation and required urgent mitral valve replacement. There was no maternal mortality or significant foetal morbidity. Pregnancy was uneventful in all patients, all babies were born at full term by spontaneous vaginal delivery in 24 cases (85.7%) and by cesarian section for obstetrical reasons in 4 (14.3%), with no obvious malformations (4 of them were twin babies). None of the babies needed intensive care monitoring. The average Apgar scores at 1 min were 8.6±1. The mean birth weight was 3.1 Kilograms ranged from 1.9 to 3.8 kg. Conclusion: During pregnancy, emergent BMV is safe and feasible in patients with symptomatic mitral stenosis and severe pulmonary edema. There is marked symptomatic relief, along with excellent maternal and fetal outcomes.