National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study.

BACKGROUND: In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics. OBJECTIVE: The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention. METHODS: The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite). RESULTS: The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation. CONCLUSIONS: This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/47525.

Management of patients with cardiovascular diseases during Ramadan.

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

Design and Rationale of the National Observational Multicentric Tunisian Registry of Hypertension: Protocol for Evaluating Hypertensive Patient Care in Clinical Practice.

BACKGROUND: This study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions. OBJECTIVE: This study will provide us an overview of hypertension (HTN) management in Tunisia and the degree of adherence of practitioners to international recommendations. METHODS: This is a national observational cross-sectional multicenter study that will include patients older than 18 years with HTN for a duration of 4 weeks, managed in the public sector from primary and secondary care centers as well as patients managed in the private sector. Every participating patient signed a consent form. The study will exclude patients undergoing dialysis. The parameters that will be evaluated are demographic and anthropometric data, lifestyle habits, blood pressure levels, lipid profiles, treatment, and adherence to treatment. The data are collected via the web interface in the Dacima Clinical Suite. RESULTS: The study began on April 15, 2019 and ended on May 15, 2019. During this period, we included 25,890 patients with HTN. Data collection involved 321 investigators from 24 Tunisian districts. The investigators were doctors working in the private and public sectors. CONCLUSIONS: Observational studies are extremely useful in improving the management of HTN in developing countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT04013503; https://clinicaltrials.gov/ct2/show/NCT04013503. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21878.

New-onset atrial fibrillation after acute coronary syndrome: prevalence and predictive factors.

INTRODUCTION: New-onset AF atrial fibrillation (NOAF) frequently complicates acute coronary syndromes (ACS) leading to adverse outcomes in the short and long term. The prevalence of NOAF in patients hospitalized for ACS is variably reported and ranges between 2 and 37%. Several predictor factors have been implicated in the literature but remain a subject of controversy. AIM: To determine the prevalence of NOAF in a population of patients admitted for ACS and to identify its predictive factors. METHODS: We carried out a prospective, descriptive and comparative observational study in hospitalized patients with ACS who did not have a previous diagnosis of AF. RESULTS: In our study, we included 404 patients hospitalized for ACS. The prevalence of NOAF was 10%. In the multivariate analytical study, we retained as independent predictors of NOAF: age greater than 62 years (p = 0.04; adjusted OR = 4.83; CI95%: 1.07-21.77), chronic renal failure (p = 0.043; adjusted OR = 6.61; CI95%: 1.06-35.80), history of stroke (p = 0.002; adjusted OR = 44.51; CI95%: 3.97- 498.10) and finally uricemia greater than or equal to 62 mg / l (p = 0.04; adjusted OR = 4.4; CI95%: 1.06-18.15). CONCLUSIONS: The prevalence of NOAF in patients with ACS was 10%. Its systematic screening in these patients appears to be a relevant approach because of the strong association between these two pathologies.

Design and Rationale of the National Tunisian Registry of Heart Failure (NATURE-HF): Protocol for a Multicenter Registry Study.

BACKGROUND: The frequency of heart failure (HF) in Tunisia is on the rise and has now become a public health concern. This is mainly due to an aging Tunisian population (Tunisia has one of the oldest populations in Africa as well as the highest life expectancy in the continent) and an increase in coronary artery disease and hypertension. However, no extensive data are available on demographic characteristics, prognosis, and quality of care of patients with HF in Tunisia (nor in North Africa). OBJECTIVE: The aim of this study was to analyze, follow, and evaluate patients with HF in a large nation-wide multicenter trial. METHODS: A total of 1700 patients with HF diagnosed by the investigator will be included in the National Tunisian Registry of Heart Failure study (NATURE-HF). Patients must visit the cardiology clinic 1, 3, and 12 months after study inclusion. This follow-up is provided by the investigator. All data are collected via the DACIMA Clinical Suite web interface. RESULTS: At the end of the study, we will note the occurrence of cardiovascular death (sudden death, coronary artery disease, refractory HF, stroke), death from any cause (cardiovascular and noncardiovascular), and the occurrence of a rehospitalization episode for an HF relapse during the follow-up period. Based on these data, we will evaluate the demographic characteristics of the study patients, the characteristics of pathological antecedents, and symptomatic and clinical features of HF. In addition, we will report the paraclinical examination findings such as the laboratory standard parameters and brain natriuretic peptides, electrocardiogram or 24-hour Holter monitoring, echocardiography, and coronarography. We will also provide a description of the therapeutic environment and therapeutic changes that occur during the 1-year follow-up of patients, adverse events following medical treatment and intervention during the 3- and 12-month follow-up, the evaluation of left ventricular ejection fraction during the 3- and 12-month follow-up, the overall rate of rehospitalization over the 1-year follow-up for an HF relapse, and the rate of rehospitalization during the first 3 months after inclusion into the study. CONCLUSIONS: The NATURE-HF study will fill a significant gap in the dynamic landscape of HF care and research. It will provide unique and necessary data on the management and outcomes of patients with HF. This study will yield the largest contemporary longitudinal cohort of patients with HF in Tunisia. TRIAL REGISTRATION: ClinicalTrials.gov NCT03262675; https://clinicaltrials.gov/ct2/show/NCT03262675. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12262.

Epidemiology of heart failure and long-term follow-up outcomes in a north-African population: Results from the NAtional TUnisian REgistry of Heart Failure (NATURE-HF).

The NATURE-HF registry was aimed to describe clinical epidemiology and 1-year outcomes of outpatients and inpatients with heart failure (HF). This is a prospective, multicenter, observational survey conducted in Tunisian Cardiology centers. A total of 2040 patients were included in the study. Of these, 1632 (80%) were outpatients with chronic HF (CHF). The mean hospital stay was 8.7 ± 8.2 days. The mortality rate during the initial hospitalization event for AHF was 7.4%. The all-cause 1-year mortality rate was 22.8% among AHF patients and 10.6% among CHF patients. Among CHF patients, the older age, diabetes, anemia, reduced EF, ischemic etiology, residual congestion and the absence of ACEI/ ARBs treatment were independent predictors of 1-year cumulative rates of rehospitalization and mortality. The female sex and the functional status were independent predictors of 1-year all-cause mortality and rehospitalization in AHF patients. This study confirmed that acute HF is still associated with a poor prognosis, while the mid-term outcomes in patients with chronic HF seems to be improved. Some differences across countries may be due to different clinical characteristics and differences in healthcare systems.

Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF).

BACKGROUND: Contemporary registries on atrial fibrillation (AF) are scare in North African countries. HYPOTHESIS: In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal. METHODS: NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described. RESULTS: A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA2 DS2 VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died. CONCLUSIONS: NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.

Silent stroke in patients with atrial fibrillation: Prevalence and predictive factors.

BACKGROUND: Silent strokes are damagesof brain not accompanied by symptoms suggestive of stroke. Currentepidemiological trends suggesttheirindependent association with atrial fibrillation (AF). However, this association is not yetwelldefined. AIM: To assess the prevalence of silent stroke in AF and determine itspredictivefactors. METHODS: We carried out a cross-sectional study enrolling 37 patients followed for non-valvular AF in the cardiologydepartment. All participants had a clinicalevaluation and brain MRI. RESULTS: The mean age was 66 ± 7 yearswith asex ratio (M / F) of 0.76. The mostcommon class of AF was the persistent form (70%). Oral anticoagulant therapywasprescribedin 32 patients (94.1%). Silent strokewerereported in 9 patients (24.3%). Age ≥72 years and CHA2DS2VASc score ≥ 4 weresignificantlyassociatedwith silent strokes in the univariate study withsensitivities of 77.8% and 62.5% respectively and specificities of 78.6% and 92.3% respectively. In the multivariate study, only CHA2DS2VASc score ≥ 4 wasconsidered to be an independentpredictor of silent stroke in AF (p = 0.004; adjusted OR = 20; CI95%: 2.6-152.6). CONCLUSIONS: Our resultsregarding the association between silent strokesand AF confirmedpreviousevidence. Screening for theselesions in AF patients at high thromboembolicriskappears to be a relevant approachgiventheirpoorprognosis.

Tunisian Consensus document on magnetic resonance imaging in patients with intracardiac devices.

INTRODUCTION: Patients with ferromagnetic cardiac devices, particularly cardiac implantable electronic devices (CIED) such as pacemakers or implantable cardioverter defibrillators, are often inappropriately deprived of magnetic resonance imaging (MRI) for safety reasons. This consensus document is written by a multidisciplinary working group involving rhythmologists, interventional cardiologists, echocardiographists and radiologists. Its objective is to establish good practice recommendations to optimize the management of patients with cardiac devices requiring MRI examination, while ensuring their safety and facilitating their access to MRI.

Diagnostic accuracy of strain imaging in predicting myocardial viability after an ST-elevation myocardial infarction.

In the acute phase of ST-elevation myocardial infarction (STEMI) viability imaging techniques are not validated and/or not available.This study aimed to evaluate the ability of strain parameters assessed in the acute phase of STEMI, to predict myocardial viability after revascularization.Thirty-one STEMI patients whose culprit coronary artery was recanalized and in whom baseline echocardiogram showed an akinesia in the infarcted area, were prospectively included. Bidimensional left ventricular global longitudinal strain (GLS), and territorial longitudinal strain (TLS) in the territory of the infarct related artery were obtained within 24 hours from admission. Delayed enhancement (DE) cardiac magnetic resonance imaging (CMR) was used as a reference test to assess post-revascularization myocardial viability. DE-CMR was performed 3 months after percutaneous coronary intervention. According to myocardial viability, patients were divided into 2 groups; CMR viable myocardium patients with more than half of infarcted segments having a DE <50% (group V) and CMR nonviable myocardium patients with half or more of the infarcted segments having a DE >50% (group NV).GLS and TLS were lower in group V compared to group NV (respectively: -14.4% ±â€Š2.9% vs -10.9% ±â€Š2.4%, P = .002 and -11.0 ±â€Š4.1 vs -3.2 ±â€Š3.1, P = .001). GLS was correlated with DE-CMR (r = 0.54, P = .002) and a cut off value of -13.9% for GLS predicted viability with 86% sensitivity (Se) and 78% specificity (Sp). TLS showed the strongest correlation with DE-CMR (r = 0.69, P < .001). A cut off value of -9.4% for TLS yielded a Se of 78% and a Sp of 95% to predict myocardial viability.GLS and TLS measured in the acute phase of STEMI predicted myocardial viability assessed by 3 months DE-CMR. They are prognostic indicators and they can be used to guide the priority and usefulness of percutaneous coronary intervention in these patients.

Diagnostic and prognostic value of 2D-Strain in Non-ST Elevation Myocardial Infarction.

BACKGROUND: Strain has shown a promising diagnostic and prognostic value in acute coronary syndromes. With, however, less data in non-ST elevation myocardial infarction (NSEMI). AIM: to evaluate in NSTEMI patients, the ability of strain to predict the severity of the disease, by assessing correlations to established prognostic parameters, and to predict culprit and occluded coronary arteries (CA). Secondary, to determine factors associated to strain changes during follow-up. METHODS: The study was prospective, NSTEMI patients with significant coronary lesion and without significant non-ischaemic disease were included. Angiographic and echocardiographic investigation including global (GLS) and territorial (TLS) longitudinal strain were performed within 24h from admission. Syntax I score was calculated. Severe coronary artery disease (CAD) was defined by left main of three-vessel disease. RESULTS: Seventy NSTEMI patients aged 60.2±10.1 years were enrolled; 61% were smokers, 54% diabetics and 46% hypertensive. 34% had a severe CAD, 7% had an acute coronary occlusion (ACO) and 14% a chronic coronary total occlusion (CTO). GLS >-15.3% predicted a left ventricular ejection fraction (LVEF) <50% with 80% Sensitivity (Se) and 78% Specificity (Sp). GLS was associated to CAD complexity and severity. GLS > -14.1% detected severe CAD with 83% Se and 80%Sp. TLS determined the culprit artery in 74% of cases and TLS > -9.2% predicted ACO with 85% Se and 85% Sp. TLS was also associated to CTO. At a 10 months median follow-up [3-12months], GLS significantly improved, baseline LVEF, GLS, wall motion score index and revascularization were the predictors of this improvement. CONCLUSION: In NSTEMI patients, GLS detected severe CAD and poor myocardial function. TLS predicted the culprit vessel and its occlusion. GLS improvement at midterm was predicted by baseline systolic LV function parameters and myocardial revascularization.

Simulation training for continuing professional development of nurses in cardiology and cardiovascular surgery.

BACKGROUND:   Nurses play a key role in cardiac arrest management, especially those assigned to cardiac intensive care units, where they are often actively involved in cardiopulmonary resuscitation. AIM: To evaluate the effect of simulation training in in continuing professional development of nurses in this setting. METHODS: A comparative study using paired samples (where the candidate was his own control with repeated measures before and after intervention), was conducted among nurses working in the cardiology and cardiovascular surgery division of our institution. The primary endpoint was the change in skills judged on the basis of competency score of 20 assessed before and after simulation training. RESULTS: 32 nurses participated in the training session. Despite a median job seniority of 8.5 years [4.0 - 12.5], only 44% of nurses had already participated in a simulation session. Although most of the candidates (84%) had previously performed chest compressions, only 34% had delivered an electrical defibrillation during their exercise. We showed a significant increase in overall scores from 8.0 [5.0 - 9.8] to 17.5 [17.0 - 19.0] after the simulation training session (p<0.0001). All the criteria judged in the evaluation grid (basic life support, manual electrical defibrillation) were significantly improved and the most positive effect was observed in the manual defibrillation where the prior experience of the participants was limited. CONCLUSIONS: Simulation learning had a major positive impact on the development of nurses' skills in terms of cardiopulmonary resuscitation.

Left ventricular non compaction and septal defects.

We report the case of a 23-year-old woman with a not yet described (to the best of our knowledge) association of left ventricle non-compaction with both atrial and ventricular defects. Family genetic survey concluded to, a probably sporadic, E101K gene mutation.

Prevalence and predictors of Sleep Apnea in Atrial Fibrillation patients.

BACKGROUND: Obstructive Sleep Apnea Syndrome (OSAS) is a common but often under diagnosed condition that constitutes a real public health problem. The prevalence of OSAS in atrial fibrillation (AF) patients ranges from 32 to 85% according to recent studies. AIM: To determine the prevalence and severity of OSAS in a population followed for non-valvular AF (NVAF), and to identify OSAS's predictive factors in this population. METHODS: A cross-sectional study was conducted, including successive patients followed for NVAF. Patients with a known history of OSAS were not included. All patients had a clinical screening for symptoms suggestive of OSAS and underwent an ambulatory sleep study. RESULTS: We included 100 patients in this study. OSAS was detected in 90% of NVAF patients. The average apnea-hypopnea index (AHI) was 21.6 ± 13.6 e/h. OSAS was mild in 32%, moderate in 27% and severe in 31% of cases. Clinical characteristics were comparable between patients with and without OSAS. The multivariate analytical study concluded that independent predictive factors of OSAS in AF patients were an age greater than 61 years (p=0.029), AF duration more than 2 years (p=0.04) and snoring (p=0.01). CONCLUSIONS: OSAS was diagnosed in 90% of NVAF patients. Thus, a systematic screening for OSAS in AF patients may be a relevant approach given its high prevalence in this population and its therapeutic implications. Snoring, age greater than 61 years, and AF duration more than 2 years were independently associated with OSAS in our study.

Unprotected left main percutaneous coronary intervention: prognostic value of SYNTAX score II.

BACKGROUND: Unprotected left main (LM) coronary artery disease (CAD) represents a challenging lesion with a major prognostic impact. AIM: Evaluate the clinical outcome and major adverse cardiac events (MACE) predictors of unprotected LM percutaneous coronary intervention (PCI) in an "all-comers" population. METHODS: We performed a prospective observational study of patients with unprotected LM stenosis treated by PCI. MACE were defined as the composite endpoint of all-cause death, myocardial infarction and target lesion revascularization. RESULTS: From January 2012 to December 2017, 150 consecutive patients who underwent unprotected LM PCI were included. The mean age was 64±12 years and 75.3% were males. Diabetes was noted in 50.7%. Emergent revascularization was performed in 20.7% of cases, including 3.3% patients with cardiogenic shock. Distal LM was involved in 76.7% of cases. A majority of patients (94.0%) had low or intermediate SYNTAX Score I (≤32). The median SYNTAX score II was 31.1. Drug-eluting stents were used in 78.7% and bare metal stents in 21.3% of patients, mainly in emergent setting where the former were unavailable. In distal LM PCI, provisional approach was mostly used (81.7%). The median follow-up was 13.4 months. MACE occurred in 23.3% with an estimate of 37.9% at 5 years. Significant predictors of MACE were cardiogenic shock, bare metal stents use, previous PCI, and SYNTAX score II ≥30. CONCLUSION: Unprotected LM PCI presents encouraging short and long term outcomes. SYNTAX score II might represent a predictor for long-term outcome in this particular lesion subset.

Outcome predictors of cardiogenic shock complicating ST-segment elevation myocardial infarction.

BACKGROUND: Cardiogenic shock complicating ST elevation myocardial infarction is burdened by a high mortality. There is only limited evidence for the management except for early revascularization and the relative ineffectiveness of intra-aortic balloon pump. AIM: Our objectives were to evaluate outcome and predictors of early all-cause 30-day mortality in the setting of cardiogenic shock complicating ST elevation myocardial infarction. METHODS: From January 2009 to August 2018, all patients who presented within the first 48 hours of ST elevation myocardial infarction complicated by cardiogenic shock and receiving invasive management were prospectively included. RESULTS: The study cohort comprised 122 consecutive patients. The mean age was 65±12 years and 74.5% of patients were males. Left ventricular failure was the most common etiology of cardiogenic shock (72.1%) and mechanical complications occurred in 8.2% of cases. Percutaneous coronary interventions were proposed for all patients and performed in a primary setting in 72.1%. A high prevalence of no reflow was noted (15.6%). Multivessel coronary artery disease was noted in 64.8% and multivessel percutaneous coronary interventions at the index procedure were performed in 22.1% of cases. Intra-aortic balloon pump was used in 17.2% of patients. The 30-day mortality was 58.2%. The only predictor of early mortality was the immediate multivessel percutaneous coronary intervention (OR=4.1, 95%CI 1.1-14.5; p=0.031). CONCLUSION: Despite invasive management strategies, 30-day mortality of cardiogenic shock complicating ST elevation myocardial infarction remained as high as 58.2%. Immediate multivessel percutaneous coronary intervention was the only predictor of early mortality.

Feasibility and safety of Same-Day Discharge after transradial percutaneous coronary intervention: a Tunisian monocentric study.

BACKGROUND: The continuing increase in care, needs and costs in cardiology with the advances in percutaneous coronary intervention (PCI) techniques represent the ideal scenario for considering same-day discharge (SDD) PCI program. AIM: The primary endpoints were to examine feasibility and safety of SDD-PCI. METHODS: We conducted a comparative observational study of a prospective cohort (April 2017 to September 2017) where patients benefited from SDD-PCI with a retrospective cohort (October 2016 to March 2017) where patients were conventionally managed. We established pre-procedural eligibility criteria and per and post-procedural exclusion criteria to estimate feasibility of SDD-PCI. Safety was assessed at 24 hours and 30 days comparatively in both groups. RESULTS: In the one-year study period, 709 PCI were performed. The eligibility for SDD-PCI was 17.2% (122 patients) and feasibility was 14.7% (104 patients). Ultimately, 50 out of 370 patients in the prospective cohort (SDD-group) and 54 out of 339 patients in the retrospective cohort (control-group) had or could have benefited from SDD-PCI. The transradial access was the most used (98.1%). 59.7% of treated lesions were B2 or C type, 53.8% interested the left anterior descending artery and 29.8% were bifurcations. In both groups, no complications were observed at 24 hours. At 30 days, one single non-fatal myocardial infarction related to subacute stent thrombosis occurred in the SDD-group and was attributed to antiplatelet therapy interruption. CONCLUSION: SDD-PCI is feasible and safe on the condition of strict stratification criteria of patients before judging their discharge the same day after PCI.

Oral anticoagulation therapy using acenocoumarol during the month of ramadan: a comparative study between fasting and non-fasting patients.

BACKGROUND AND OBJECTIVES: The effect of Ramadan fasting on anticoagulation by vitamin K antagonists has been previously investigated in small scale studies with controversial results. From this perspective, this study aimed to compare the fluctuations of anticoagulation in fasting and nonfasting patients taking Acenocoumarol and to identify the factors associated with such fluctuations. METHODS: The study, conducted between May and August 2018, was a comparative one. Three study periods were defined: before Ramadan (BR), Ramadan and after Ramadan (AR). Enrolment involved ambulatory patients aged over eighteen, without medical contraindications to fasting (for the fasting group) and whom international normalized ratio (INR) was within the therapeutic target range during the last three months BR. Anticoagulation monitoring consisted in five consecutive INR assays; INR0 (during the 14 days BR), INR1 (between the 1st and the 14th day of Ramadan), INR2 (between the 15th and the 28th day of Ramadan), INR3 (28 days after INR2) and INR4 (28 days after INR3). INR stability was assessed by calculating four percentages of time in therapeutic range (TTR); TTR0 (between INR0 and INR1), TTR1 (between INR0 and INR2), TTR2 (between INR2 and INR3) and TTR3 (between INR3 and INR4). The null hypothesis was the occurrence of an anticoagulation imbalance (evaluated by TTR) in fasting patients in comparison with non-fasting ones. RESULTS: One hundred and twenty-two patients (84 fasting patients), aged 60 ± 19 years, were included. In fasting patients, the average differences of INR1, 2, 3 and 4 compared with INR0 were statistically non-significant and accounted for +0.46, +0.34, +0.28 and +0.30 respectively. Among the three TTRs, only TTR2 significantly decreased in comparison with TTR0 in fasting group (50.3 ± 37.4 vs. 63.6 ± 39.3%, p=0.004). TTR1, 2 and 3 were comparable between fasting and non-fasting patients. CONCLUSIONS: The fluctuations of anticoagulation balance, assessed by TTR, were comparable between fasting and non-fasting patients taking Acenocoumarol.

Factors associated to adequate time in therapeutic range with oral vitamin K antagonists in Tunisia.

INTRODUCTION:   The quality of chronic anticoagulation and predictor factors of poor anticoagulant control in patients under acenocoumarol were unknown in North Africa. METHODS: It is an observational study, carried out between November 2015 and November 30, 2016. The international normalized ratio (INR) values were prospectively obtained, and TTR was calculated using the Rosendaal method. RESULTS: Overall, 215 patients were included in this study, with a mean age of 63±0,8 years. The prevalence of poor anticoagulation control was 78.1%; 95% CI [72.2-83.2] (168 patients with TTR less than 65%). The median TTR with the Rosendaal method was 44.4%. After multivariate adjustment, variables significantly associated with adequate anticoagulation level were: history of ischemic stroke (Adjusted OR equal to 4.3, 95% CI: 1.4-12.9), associated prescription of antiplatelet therapy (Adjusted OR equal to 3.5, 95% CI: 1.1-11.2), daily prescribed dose of coumarins less than 6 mg (Adjusted OR equal to 6.4, 95% CI: 1.1- 36) and lower risk of bleeding assessed as HAS-BLED score (Adjusted OR: 0.5, 95% CI: 0.3-0.8). CONCLUSION: The quality of anticoagulation management with VKA among outpatients who received acenocoumarol was suboptimal. Strategies should be undertaken by clinicians and patients to improve the quality of anticoagulation, to address challenges to adverse cardiovascular outcomes in individuals treated with chronic anticoagulation.

Atrial flutter ablation by femoral approach in a woman with azygos continuation of an interrupted inferior vena cava and dual chamber pacemaker.

This report describes a case of isthmus-dependent atrial flutter ablation by the femoral approach in a 54-year-old woman with a previously unknown absence of the inferior vena cava (IVC) and dual chamber pacemaker. Despite looping of the catheters, ablation and termination of atrial flutter were performed successfully without function alteration of the pacemaker leads.  This is the first report of an inferior-to-superior approach for ablation of atrial flutter in the absence of the perihepatic IVC with the presence of chronic indwelling leads in the area targeted for radiofrequency.