Evaluation of anticoagulant therapy management in a teaching hospital in Tunisia: information and education for vitamin k antagonist newly treated patients need to be improved.

OBJECTIVE: The objective of this study was to assess the level of Vitamin K antagonist (VKA) therapy knowledge among VKA newly treated patients. METHODS: Questionnaire-based interviews were administered in a university hospital to VKA newly treated patients covering both cognitive (i.e. indication, route of administration, treatment monitoring and side effects) and know-how (i.e. safety precautions, what affects anticoagulant therapy and the management of overdose signs) aspects of therapy knowledge. KEY FINDINGS: A total of 55 patients were included. The mean overall score of patients' knowledge was 5.78 (SD = 3.425) out of 20. The mean scores of cognitive and practical knowledge were 3.8 (2.26) and 1.98 (1.78) out of 10, respectively. Factors associated with an insufficient level of VKA therapy knowledge included low level of education, lack of access to therapy information and continuous access to this information. CONCLUSIONS: Knowledge about VKA therapy among newly treated patients is insufficient. Patient's medication knowledge should be improved to ensure better adherence.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry.

BACKGROUND: The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI). METHODS: Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%). RESULTS: Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866). CONCLUSIONS: Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

Edinburgh questionnaire in the screening for peripheral artery disease in type 2 diabetic patients.

AIM: to analyze Edinburgh questionnaire (EQ) screening performance for peripheral artery disease (PAD) in type 2 diabetic patients. METHODS: Cross sectional study including 150 type 2 diabetic patients without PAD history. All patients responded to EQ and had peripheral pulse checkup and measurement of the ankle/brachial index (ABI). PAD was considered to be present when the ABI was ≤ 0.9 Results: Participants mean age was 57.46 ± 8.04 years and sex-ratio (men/women) was 1.3. EQ has revealed intermittent claudication in 18 patients (12%). On examination, 42 patients (28%) had at least one weakened or abolished pulse in upper limbs. ABI has revealed the presence of PAD in 16% of patients. The EQ sensibility specificity, positive and negative predictivevalueswere 29, 91,39 and 87%, respectively. Among patients with false negative results (n=17), nine had peripheral neuropathy. CONCLUSION: In diabetic patients, EQ had a very low sensibility for the PAD screening. In fact, the important false negative rate, due to the coexisting of peripheral neuropathy, had limited the use of this questionnaire.

Response to clopidogrel and of the cytochrome CYP2C19 gene polymorphism.

INTRODUCTION: Clopidogrel (clopi) is a prodrug widely prescribed in the management of coronary artery disease and requires the intervention of hepatic cytochrome P450 2C19 (CYP2C19) for its activation. However, there is interindividual variability in response to clopi despite the use of recommended doses. Thus, the studies have highlighted the effect of the CYP2C19 gene polymorphism or Cyp2C19 gene on the response to clopi and particularly Cyp2C19 * 2 which may be associated with an increased risk of major cardiovascular events or MACE. OBJECTIVE: To evaluate the effect of Cyp2C19 * 2 polymorphism on MACE occurrence and hemorrhagic complications in patients treated with clopi. METHODS: We carried out a descriptive longitudinal study including 71 patients placed under clopi for a minimum duration of one month. Genotyping of the Cyp2C19 allele was performed by conventional polymerase chain reaction (PCR). After a follow-up period of 495 ± 183 days, we performed a statistical analysis to evaluate the association between the Cyp2C19 * 2 polymorphism and the occurrence of MACE or hemorrhagic complications. RESULTS: Among our patients, 51% had an angioplasty, 42% medical treatment and 7% a coronary artery bypass surgery. In our study population, 52% were heterozygous (HTZ), 28% homozygous (HMZ) healthy * 1 / * 1 and 20% HMZ had the loss of function allele * 2 / * 2. The allelic frequency of Cyp2C19 * 2 was 46%. Follow-up mean duration was of 495 ± 183 days. During this period, the prevalence of MACE was 11% and that of hemorrhagic complications was 13%. In our study, we did not observe a significant association between the occurrence of MACE or hemorrhagic complications with the genotype carrying the Cyp2C19 * 2 allele. CONCLUSION: Among patients treated with clopi, wearing a Cyp2C19 * 2 function loss allele didn't seem to be associated with a significantly higher risk of MACE, nor a significantly lower risk of hemorragic complications. This suggests the necessity of larger studies.

Design and Rationale of the National Tunisian Registry of Atrial Fibrillation: Protocol for a Prospective, Multicenter Trial.

BACKGROUND: Atrial fibrillation (AF) is an important health problem in Tunisia. A significant change in the epidemiological pattern of heart disease has been seen in the last 3 decades; however, no large prospective multicenter trial reflecting national data has been published so far. Robust data on the contemporary epidemiological profile and management of AF patients in Tunisia are limited. OBJECTIVE: The aim of this study is to analyze, follow, and evaluate patients with AF in a large multicenter nationwide trial. METHODS: A total of 1800 consecutive patients with AF by electrocardiogram, reflecting all populations of all geographical regions of Tunisia, will be included in the study, with the objective of describing the epidemiological pattern of AF. Patients will be officially enrolled in the National Tunisian Registry of Atrial Fibrillation (NATURE-AF) only if an electrocardiogram diagnosis (12-lead, 24-hour Holter, or other electrocardiographic documentation) confirming AF is made. The qualifying episode of AF should have occurred within the last year, and patients do not need to be in AF at the time of enrollment. Patients will be followed for 1 year. Incidence of stroke or transient ischemic attack, thromboembolic events, and cardiovascular death will be recorded as the primary end point, and hemorrhagic accidents, measurement of international normalized ratio, and time in therapeutic range will be recorded as secondary end points. RESULTS: Results will be available at the end of the study; the demographic profile and general risk profile of Tunisian AF patients, frequency of anticoagulation, frequency of effective treatment, and risks of thromboembolism and bleeding will be evaluated according to the current guidelines. Major adverse events will be determined. NATURE-AF will be the largest registry for North African AF patients. CONCLUSIONS: This study would add data and provide a valuable opportunity for real-world clinical epidemiology in North African AF patients with insights into the uptake of contemporary AF management in this developing region. TRIAL REGISTRATION: ClinicalTrials.gov NCT03085576; https://clinicaltrials.gov/ct2/show/NCT03085576 (Archived by WebCite at http://www.webcitation.org/6zN2DN2QX). REGISTERED REPORT IDENTIFIER: RR1-10.2196/8523.

[Diurnal, weekly and seasonal variation of sudden cardiac death in northern Tunisia]. / Mort subite d'origine cardiaque au nord de la Tunisie : variation circadienne, hebdomadaire et saisonnière.

BACKGROUND: Several studies have reported a circadian variation in the occurrence of sudden cardiac death. AIM: To analyze the circadian, weekly and seasonal variations of sudden cardiac death occurring in northern Tunisia. METHODS: We prospectively collected epidemiological and autopsic data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between October 2010 and September 2012. RESULTS: The study population included 392 men and 108 women with a mean age of 52.3±15.8 years. Physical inactivity and smoking were the most common risk factors, they accounted for 76.4% and 57.9% respectively. Family history of sudden death was identified in 9.8% of victims. The vast majority of deaths occurred in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the most frequent causes of death (269 cases). Sudden cardiac death was homogeneously distributed over the day. A maximum of events occurred on Sundays (17.8%) and a minimum on Mondays (11.4%), we also recorded an excess cardiac mortality in winter with a peak in December and a nadir in September (13% vs. 4.4% P=0.0001). CONCLUSIONS: In northern Tunisia, under Mediterranean climate, a winter excess cardiac mortality was found. Sudden cardiac death was homogeneously distributed over the day, however, an excess of mortality was recorded over the weekend with a nadir on Monday.

[Prevalence of non-conventional cardiovascular risk factors in Tunisian diabetics]. / Prévalence des facteurs de risque cardiovasculaire non conventionnels chez les sujets diabétiques tunisiens.

BACKGROUND: The cardiovascular risk appears very early in the history of diabetes mellitus and is related not only to hyperglycemia but mainly to the other risk factors associated to diabetes mellitus. OBJECTIVE: To evaluate the prevalence of non-conventional cardiovascular risk factors in a Tunisian diabetic population. PATIENTS AND METHODS: The prospective study enrolled 120 type 2 diabetic patients recently diagnosed and 60 healthy people, sex and age matched. All have benefited from blood sampling in order to analyze biological parameters routinely undertaken in diabetes. Non-conventional cardiovascular risk factors were also determined such as: microalbuminuria of 24 hours, high sensitivity C-reactive protein (hs CRP), homocysteinemia, vitamin B12, folate and insulinemia. The participants have also benefited from abdominal echography to search nonalcoholic hepatic steatosis. RESULTS: Diabetics were aged 51.4 ± 8.9 years in comparison with healthy people (50.1 ± 6.39 years). A positive microalbuminuria was observed in 27.5% of diabetics versus 6.9% in healthy people (OR=5.1; P=0.001). The two third of diabetics had metabolic syndrome versus 25% of healthy people (OR=6.0; P<0.001) and insulinoresistance evaluated by HOMA-IR, was 3.4 ± 0.2 in diabetics versus 2 ± 0.1 in healthy people; P<0.001. HsCRP level was significantly higher in diabetics in comparison with healthy people (3.7 ± 0.2mg/L versus 1.9 ± 0.3mg/L; P<0.001) and hyperhomocysteinemia was more frequently found in diabetics. Also, we noted that 69.6% of patients had hepatic steatosis versus only 24.6% of healthy people (OR=7.1; P<0.001). CONCLUSION: The non-conventional cardiovascular risk factors were more frequently found in early diagnosed type 2 diabetic patients than in healthy people. These non-conventional factors could be helpful in stratification of the cardiovascular risk level and also in the screening of ischemic heart diseases.

Sudden death due to pulmonary embolism in north Tunisia: 37 cases study.

AIM: To determine frequency of pulmonary embolism as the cause of sudden death and to study clinical, epidemiological characteristics and risk factors. METHODS: Prospective study of cases of sudden death secondary to pulmonary embolism, whose autopsy was performed in the forensic department of Tunis, between October 2009 and of September, 2011. RESULTS: During study period, 37 cases of pulmonary embolism were recorded. They represented 6.8 % of all cases of sudden cardiovascular deaths. Victims were male in most cases (65 %). Victims were aged between 21 and 87 years with an average age of about 52 years. Pathological histories were noted in 9 cases: three cases of recent surgery, four cases of pelvic trauma, a case of ovarian tumor and a case of which the PE arose in post-partum. Concerning other risk factors of pulmonary embolism, confinement to bed was noted in 24 cases (64.8 %), obesity in 12 cases (32.4 %), an arterial high blood pressure in 4 cases. Histories of psychiatric pathology were noted in 5 cases (13.5 %). Symptomatology preceding death was dominated by sudden death (35 %) followed by dyspnoea (30 %) and thoracic pains (16 %). In 8 cases , victims consulted emergencies within 48 hours preceding death, for a varied symptomatology without diagnosis of pulmonary embolism is suspected. At autopsy, in 30 cases embolism was massive. In 29 % of the cases, a deep venous thrombosis was revealing in particular at the primitive iliac veins. CONCLUSION: Pulmonary embolism is an affection that still kills a lot. It can benefit from prevention and from an effective treatment. This testifies the major importance of clinical diagnosis of pulmonary embolism as well as the technical means for the diagnosis.

[Relation entre la température ambiante, l'humidité et la mort subite cardiaque au nord de la Tunisie]. / Relationship between ambient temperature, humidity and sudden cardiac death in northern Tunisia.

BACKGROUND: Several studies have suggested a relationship between weather parameters and the occurrence of sudden cardiac death. AIM: The aim of this work was to study the impact of changes in temperature and humidity level on the occurrence of sudden cardiac death in the north of Tunisia. METHODS: it's an autopsic study that included all victims of sudden cardiac death occurring in northern Tunisia between October 2010 and September 2012. The minimum, maximum and average of daily temperatures and humidity during the study period were recorded and compared with the monthly variation in the occurrence of sudden death. RESULTS: The study population included 392 men and 108 women with a mean age of 52.2 + / - 15.8 years.The highest rate of sudden death (37%) was observed at ambient temperatures below 15 degrees and only 4.2% of deaths occurred at temperatures above 30 degrees ambient temperatures (p <0.001). Among the population aged over 60 years, the highest mortality rate (47.3%) were recorded at temperatures below 15 degrees, while 35.5% of young patients under 40 years died during periods with temperatures between 20 and 30 degrees and 56.8% of deaths occurred in the humidity levels between 60 and 78% . CONCLUSION: In the north of Tunisia where the climate is temperate, a temperature drop below 15 degrees was significantly associated with a sudden cardiac death. This excess winter cardiac mortality was more pronounced in the elderly.

[Weekly variation of sudden cardiac death in northen Tunisia]. / La variation hebdomadaire de la survenue de mort subite cardiaque au nord de la Tunisie.

BACKGROUND: The sudden cardiac death remains a major public health problem. Several studies have reported weekly variation of this dramatic event. AIM: The aim of this work is to determine the day-of-week variability in sudden cardiac death in northen Tunisia. METHODS: We prospectively collected clinical, socio demographic and autopsic data of victims of sudden cardiac death occurring in the northern Tunisia between october 1 st ,2010 and september 30,2012. RESULTS: The study population included 392 men and 108 women with a mean age of 52.27 + / - 15.8 years. Three quarters of the victims was sedentary, 57.9% were smoker and a family history of sudden death was identified in 9.8% of cases. The vast majority of deaths had occurred either in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the leading cause of death with 267 cases (53.4%); however a negative autopsy was found in 13.9% of victims. The highest sudden death occurrence was on Sundays (17.8%) and the lowest on Mondays (11.4% p: 0.01).The same weekly variation was noted among both men and women , and also in victims > 60 years, a minimum of events occurred on Mondays (11.6%) and a maximum on Sundays (21.9%). In addition, we found the same peak of mortality on Sunday (18.8%) in young adults and the nadir on Monday (10.3%). CONCLUSIONS: The present study demonstrates marked variation in the occurrence of sudden cardiac death in the northern Tunisia with peak on Sundays and nadir on Mondays. No age or gender- related differences were found in weekly variation of sudden death.

[Echocardiographic factors determining immediate result of percutaneous mitral balloon commissurotomy]. / Paramètres échocardiographiques prédictifs du résultat immédiat de la commissurotomie mitrale percutanée.

AIM: Define echocardiographic predictors of the result after percutaneous mitral balloon commissurotomy (PMC). METHODS: PMC by the Inoue balloon was attempted in 247 patients (77% female) with severe mitral valve stenosis. The mean age was 35 years. All the patients had undergone echocardiographic examination before PMC to assess mitral anatomy, commissural calcification, and to determine the Wilkins score. RESULTS: The mean value of Wilkins score was 7,98 +/- 1,61 (range 5-13) and the mean mitral valve area (MVA) before PMC was 1 +/- 0,19 cm2 (range 0,5- 1,4 cm2). 29 patients (11,7%) had one-commissural calcification and 2 patients (0,8%) had bi-commissural calcifications. After PMC, the mean MVA increased to 1,79 +/- 0,34 cm2 (p <0,001) resulting in a success rate of 83%. Severe mitral regurgitation (> or =grade 3) occurred in five patients (2%). Wilkins score was an independent predictor of the immediate result of PMC but, if > 8, this score had a weak predictive value. Commissural morphology was another independent predictor of the immediate result of PMC. CONCLUSION: Echocardiography is now the cornerstone for the assessment of mitral anatomy before PMC and should integrate Wilkins score and commissural morphology for the selection of patients to PMC.

[In-hospital prognosis of right ventricular myocardial infarction]. / Pronostic a la phase hospitalière de l'infarctus du ventricule droit.

AIM: To identify prognostic risk factors for in-hospital outcome of right ventricular myocardial infarction (RVI). METHODS: A retrospective study of 20 patients admitted with acute myocardial infarction with a RVI defined by ST segment elevation > or = 1 mm in V3R and V4R leads. RESULTS: The mean age was 62 years. RVI was associated with an inferior myocardial infarction in 18 patients. Half of the patients had hemodynamic complication on admission (cardiogenic shock in 4 cases, right ventricular failure in 6 cases) and third degree atrio-ventricular block was present in 5 patients. Sixteen patients (80%) received thrombolysis and 3 went to an emergency angioplasty. The in-hospital mortality was 25% caused by a cardiogenic shock in 4 patients and a ventricular fibrillation in 1 patient. Statistic analysis showed that cardiogenic shock on admission, the absence of thrombolytic therapy and the low ejection fraction of the left ventricle were associated with a high in-hospital mortality (p = 0.004, p = 0.03, p = 0.03 respectively). CONCLUSION: In-hospital outcome of RVI is characterized by hemodynamic complications leading to a high incidence of mortality. Thus RVI must be diagnosed quickly and maximal therapeutic efforts must be done to procure the opening of the occluded coronary artery.

Coronary bypass in an adult with Kawasaki disease.

We present the case of a 30-year-old female patient with few coronary risk factors for atherosclerosis but with 3-vessel coronary artery disease possibly secondary to Kawasaki disease. Coronary angiography showed total occlusion of the left anterior descending artery and a right coronary artery aneurysm. Quadruple coronary artery bypass was performed. The postoperative course was uneventful.