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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.

About 40% of the mechanism of ischaemic stroke in young adults remains unclear. A paradoxical embolism associated with persistence of a patent foramen ovale and/or the presence of an atrial septal anevrysm are significantly more frequent in patients examined for ischaemic stroke of unknown cause than in control subjects.was to evaluate the contribution of trans-oesophageal echocardiography to the diagnosis of abnormalities of the interatrial septum and to identify the role played by this condition in unexplained ischemic stroke.In 30 consecutive patients, trans-oesophageal echocardiography recording were made during a saline contrast study.Abnormalities of the interatrial septum was diagnosed in 23.3% cases. The proportion of patent foramen ovale was 10% (3 patients); atrial septal anevrysm was detected in 6.6%(2 patients). The prevalence of patent foramen ovale associated with atrial septal anevrysm was 6.6% (2 patients).Transesophageal echocardiography with contrast appears to be an effective exam in diagnosis of abnomalities of the interatrial septum and our study was suggestive of their embolic nature.

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

Hypertensive crisis is defined as a severe elevation in blood pressure (BP) without target organ injury. There are few data about the efficacy and safety of comparative oral antihypertensive drugs.To compare the efficacy and safety of oral captopril (25 mg) and nicardipine (20 mg) in hypertensive crisis.This prospective, randomized study included 50 patients attended at the emergency department with a hypertensive crisis (arterial blood pressure of at least 180/110 mmHg without target organ damage confirmed after 15 min of rest. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate (HR) were assessed at several intervals during 4 h after the drug administration. Therapeutic success was defined by a SBPor =160 and DBPor =90 mmHg two hours after drug administration. The initial clinical characteristics as age, sex, initial systolic and diastolic BP and HR were no different in the two groups.BP levels started to significantly decrease within 15 minutes. At 2 hours, SBP and DBP dropped were similar in captopril group and nicardipine group,respectively to 162/94 vs 161/89 mmHg; p=ns. The therapeutic success at the second hour has been obtained in 68% of cases in the two groups. Age70 years was a predictor's factor of therapeutic failure in the captopril group. Heart rate significantly dropped after 30 min in the captopril group (82.3 +/- 11.8 vs 77.6 +/- 12.7 c/min; p=0.037). This effect was maintained over four hours. There were no side effects in this study.Oral captopril or nicardipine are efficacy and safe in the treatment of hypertensive crisis.

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.

Controversy persists as to whether atrial fibrillation (AF) has a direct negative effect on the outcome of percutaneous balloon mitral commissurotomy (PBMC). The study aim was to assess the effect of AF on immediate and 10-year clinical and echocardiographic actuarial results of patients with rheumatic mitral stenosis undergoing PBMC.A total of 195 consecutive patients with AF (group 1) was analyzed and compared with 195 patients in sinus rhythm (group 2), matched for the severity of mitral valve morphological changes.Group 1 patients were older (43.8 + 12 versus 30.5 +/- 12.7 years; p0.001), and a greater proportion had grade 1 mitral regurgitation (25.1 versus 9.7%; p0.0001). The procedural success was 89.8% in group 1 and 92.3% in group 2 (p = NS), but group 1 patients had a smaller mitral valve area (2.1 +/- 0.4 versus 2.3 +/- 0.4 cm2; p0.0001). Patients in AF had a lower 10-year survival (91.4 versus 99.4%; p = 0.018), a lower 10-year event-free-survival (60.3 versus 70%; p = 0.02), and a lower 10-year freedom from restenosis (40 versus 66%; p = 0.048). AF was an independent predictor of overall mortality (OR = 10.79; p0.033) and of combined events (death, redo PBMC or mitral valve surgery; OR = 1.95; p0.012), and was a univariate predictor of restenosis (p = 0.048).Patients with AF have good immediate results, but poorer long-term outcome after PBMC. AF a marker of worse prognosis in patients with mitral stenosis as it is in the general population.

Amyloidosis is a rare disease characterized by an extracellular accumulation of a protein polysaccharid complex (Amyloid). Cardiac involvement is considered as a major prognostic factor.We report the case of two women, hospitalized for heart failure. The diagnosis of cardiac amyloidosis was suggested by echocardiography: Left ventricular concentric hypertrophy and typical amyeloid infiltration with hyperechoic, shiny and granite-like aspect of the interventricular septum. The histological confirmation was obtained by gastric biopsy in the first case and biopsy of the salivary glands in the second revealing an amyloidosis AL. This cardiac amyloidosis was secondary to multiple myeloma: monoclonal Gammopathy with immunoglobulin Lambda in the first and Kappa in the second, and the presence of a plasmocyte infiltration in the sternal puncture.Amyloidosis is a rare pathology, the cardiac involvement is frequent in the type AL and can occur with or without clinical manifestations. Echocardiography should be systematic in patients with confirmed amyloidosis.

The aim of this study was to determine the concordance of emergency physicians' and cardiologists' interpretations of emergency department (ED) electrocardiograms (ECG) and to evaluate the impact of ECG misinterpretation on patient management. From December 1993 to April 1994 one hundred ninety five ECG interpretations (3.3% of all consultants) were registered prospectively using a programmed-response data sheet. A second blinded interpretation by a cardiologist was performed and compared with the emergency physicians' interpretations. The overall concordance between emergency physicians' and cardiologist ECG interpretations was observed in 149 (76%) cases (kappa = 0.41). The concordance rate was lower in abnormal ECGs (kappa = 0.19).In our study, the quality of ECG interpretation by ED physicians is satisfactory and the rare misinterpretations have minimal clinical impact.

The goal of this study was to compare the clinical presentation and angiographic morphology of patients having an unstable angina pectoris. A total of 321 patients were consecutively studied and underwent cardiac catheterization, mean age 59 + 6 years. According to Braunwald classification, class III was predominant (58%) On coronary angiography, 148 patients had single vessel disease, double-vessel in 92 and triple-vessel in 64. Morphology of coronary artery lesions was classified according to Ambrose's classification, 100 patients had simple lesions (type I or IIA), 204 patients had complex lesions (type IIB, III, intracoronary thrombus or total occlusion). Thoracic rest pain (class III) or postinfarction angina (class C), were associated with the presence of complex lesions. This subgroup of high risk patients would benefit from either Glycoprotein IIb/IIIa blockers with an early revascularisation strategy.

Right heart emboli-in-transit have been echocardiographically documented in up to 4 to 23% of patient with acute pulmonary embolism. The most appropriate therapeutic approach still remains an unresolved problem because there are no prospective and randomized trials to definitively answer this question. Thrombolysis seems to be the more attractive alternative. We report a case of 44 years old man presented with a right atrial thrombus complicated by severe pulmonary embolism treated successfully by low molecular weight heparin.

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.

Background Hyperglycemia has been shown to be a powerful predictor of worse outcome after ST segment-elevation myocardial infarction (STEMI). The aim of this study was to investigate the relation between acute hyperglycemia and angiographic and clinical outcome after primary or rescue angioplasty for STEMI. Methods We prospectively included 383 patients who underwent revascularization for STEMI: 332 primary angioplasty and 51 rescue angioplasty, Plasma glucose was measured at hospital admission. Acute hyperglycemia (HG) was defined as plasma glucose of 11 mmol/L, regardless of the diabetic status. Results Among the 383 patients with STEMI included in the study, 158 (41.2%) patients had acute hyperglycemia. There was no difference among the two groups with regard to clinical characteristics, cardiovascular risk factors and hemodynamic parameters. Angioplasty success, TIMI 3 flow and ST segment resolution were significantly lower in acute HG group. On multivariate regression, HG wasn’t found to be an independant predictor of angioplasty success (p=0.08; OR=0.9; 95%IC [0.92–1]) or of ST resolution, however diabetes was independently associated with ST segment resolution after achieving TIMI 3 flow (OR= 3.2; 95% CI [1.02 – 8.1]; p=0.014). Acute hyperglycemia (OR: 3.8; p=0.005) was found to be an independent predictor of in-hospital mortality in multivariate analysis. Among the HG patients, mortality predictors were: glycemia level (OR=1.13; 95%CI [1.03–1.23]; p=0.005), Killip class (OR: 2.14; 95% CI [1.36 – 3.35]; p=0.001), blood hemoglobin level (OR: 0.69; 95%CI [0.53 – 0.9]; p=0.007), and angioplasty success (OR: 0.25; 95%CI [0.08–0.82]; p=0.022). Conclusion Acute hyperglycemia in patients with STEMI is an important predictor of mortality with an increasing mortality risk even beyond 11 mmol/L but diabetes is a better predictor of ST resolution after TIMI 3 restoring. This suggests the usefulness of assessment of glycemic metabolism in the setting of reperfusion for acute myocardial infarction and the beneficial effect of strict glycemic control.

The proportion of pts receiving a reperfusion therapy was fluctuating but relatively stable during the last 16 years ranging from 45.2% in 1995 to 58.2% in 2010 with a peak of 74.2% in 2001. From 1995 to 2000, reperfusion was almost exclusively performed by thrombolysis whereas a dramatic increase of the use of PAMI was observed between 2000 and 2005 followed by a decrease in favor of the use of thrombolysis during the following 5 years probably due to an increase of the use of prehospital thrombolysis that ranged from14.3% in 2001 to 84% in 2009 among the thrombolysed pts.

Background Primary angioplasty for acute myocardial infarction (PAMI) proved superior to thrombolysis in many major trials. However, PAMI is available in only limited number of centers particularly in developing countries. On the other hand, it was clearly shown that thrombolysis when given early is associated with a comparable outcome to PAMI. It is however not known if this can apply to streptokinase (SK) that is the most widely used lytic agent in developing countries. Objective The aim of this study was to assess the in-hospital outcome of patients given early thrombolysis using SK. Methods From the Monastir AMI registry including 1148 patients, 403 received SK therapy. This population was divided into three groups based on the delay between the onset of symptoms and treatment: Group I: 0 – 3 hours (n= 208), Group II: 3 – 6 hours (n= 145) and Group III more than 6 hours (n = 50). Mean age was 60.3 +/− 12 years, 349 (86.6%) were male. Baseline characteristics were similar between the three groups. Results Clinical reperfusion defined as sedation of chest pain and ST elevation regression for more than 50% from baseline was observed in 75.1% of Group I, 58.8% of Group 2 and in 46.8% of Group 3 pts. (p Conclusion Early thrombolysis (less than 3 hours from chest pain onset) using streptokinase is associated with a very high percentage of clinical reperfusion (75%), a lower rate of heart failure and mortality. These results have important clinical implications particularly in developing countries. Group I Group II Group III p Heart failure 31 (14.9%) 37 (25.5%) 18 (36%) 0.001 Ventricular fibrillation 8 (3.8%) 10 (6.9%) 2 (4%) 0.407 Ventricular tachycardia 6 (2.9%) 10 (6.9%) 4 (8%) 0.133 Pericarditis 10 (4.8%) 7 (4.8%) 4 (8%) 0.636 Death 14 (6.7%) 9 (6.2%) 7 (14%) 0.166

BackgroundAtrial fibrillation (AF) is a common finding in patients with severe mitral stenosis requiring Balloon Mitral Valvotomy (BMV). Its immediate and long term prognosis remains controversial.ObjectivesWe sought to evaluate the effect of AF on the immediate and long-term (23 years) outcome of patients undergoing BMV.MethodsThe immediate procedural and the long-term clinical outcome after BMV of 139 patients with AF were collected and compared with those of 381 patients in normal sinus rhythm (NSR).ResultsPatients with AF were older (43.3 vs. 29.7 years; p < 0.001), had frequently a history of systemic embolism (9.4% vs. 1.6%, p> 0.001) and of mitral commissurotomy (28.1% vs. 19.4%, p=0.035). Patients with AF had more frequently a Wilkins score > 8 (51.4% vs. 30.9%, p

BackgroundAlthough drug-eluting stents (DES) have been shown to dramatically reduce restenosis and improve the rate of event-free survival, the benefit of DES appears to be limited to restenosis. In this retrospective, single-center study we aimed to compare the long-term outcomes of DES versus bare-metal stent (BMS) in large coronary arteries (diameter≥3.5mm).MethodsA total of 164 consecutive patients (mean age 60 years) required percutaneous coronary intervention with stents≥3.5mm in diameter, 84 were BMS and 80 DES. The primary endpoint was major adverse cardiac events (MACE) defined as angiographically defined in-stent restenosis (ISR), stent thrombosis and death from any cause.ResultsA mean clinical follow up of 28 months was obtained. The DES group had higher rates of diabetes (63% vs 37%, p=0.001), previous CAD (74% vs 25%, p=0.001) and previous PCI (69% vs 31%, p=

IntroductionRight ventricular (RV) infarction is a serious and life threatening condition which mainly complicates an inferior wall myocardial infarction (MI). In the literature, data for predictive factors of mortality in this setting remains scarce.Aim to study predictive factors of intrahospital mortality in patients with RV infarction.Methods and resultsData was collected from a monocenter registry including all patients with AMI admitted in our department between January 1995 and March 2013. 1483 patients were enrolled in our registry. RV infarction was diagnosed in 160 (10.7%) patients, always complicating an inferior wall MI. 37 (23.1%) patients presented with right sided heart failure while the remaining patients presented with isolated features of RV involvement on the ECG with ST elevation in the right leads. Intrahospital death occurred in 20 patients (12.5%) and was significantly higher in patients with RV heart failure (p=0.02). Among all deaths included in our registry, RV infarction was responsible for 14.5%. The reperfusion strategy was Thrombolysis in 48 patients (30%), angioplasty in 62 patients (38.8%), a combined approach in 10 cases (6.3%) and conservative treatment in 40 cases (25%). There was no difference in mortality among all strategies (p: 0.556). In patients who had angioplasty, post procedural TIMI flow 0 or 1 was associated with a higher mortality (p130umol/l (OR: 8.22; 95% CI [1.33-50.9]; p: 0.023), triple vessel disease (OR: 7.09; 95% CI [1.738-28.93]; p: 0.006) and left ventricular failure with KILLIP>1 (p: 0.004).ConclusionOur data support the fact that several factors may predict intra-hospital mortality after RV myocardial infarction among which renal impairment, the extent of coronary artery disease and left ventricular heart failure are most the powerful predictors.

Background Although congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. Objective We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome. Methods and results Two hundred and twenty consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. When compared with patients without CHF (n=144), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in CHF patients (n=76, 34.5%). Aortic valve IE, elderly patients were more frequent in CHF patients. Congestive heart failure was independently predictive of in-hospital [OR 3.8 (1.7-9.0); P=0.0013] and 1 year mortality [HR 1.8 (1.1-3.0); P=0.007]. Early surgery was performed in 63% of CHF patients with a peri-operative mortality of 15%. In the CHF group, comorbidity index, anemia, uncontrolled infection, and major neurological events were multivariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR 0.45 (0.22-0.93); P=0.03]. Conclusion Native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. Congestive heart failure is an independent predictor of in-hospital and 1 year mortality. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.