Contrast media-induced nephropathy in Tunisia: prospective case-control study with cardio-nephrological monitoring.

Introduction: vascular opacification using iodinated contrast media (ICM) is often the primary diagnostic and therapeutic approach. However, the risk of post-injection nephrotoxicity of ICM is significantly higher in patients with underlying nephropathy. This study aimed to determine the incidence of Contrast Media Induced Nephropathy (CMIN) and identify predictive factors for its occurrence in patients from a cardiology department. Methods: our prospective study involved 158 patients who underwent coronary angiography or angioplasty at the cardiology department between December 2017 and May 2018. Two types of ICM were used in our study: Iopromide and Iohexol. All patients received either physiological serum (9‰) or bicarbonate serum (14‰) intravenously for hydration. We defined impaired renal function as an increase in creatinine ranging from 10 to 26 µmol/L, while CMIN was defined as an increase in serum creatinine exceeding 26.5 µmol/L. We investigated the factors associated with CMIN using logistic regression analysis. Results: the mean age of our patients was 60 ± 11 years (range: 29-82), with a predominance of men 63.9% (n=101). The most common cardiovascular risk factors were tobacco (36.1%, n = 57), diabetes (48.1%, n =76), hypertension (55%, n = 87). Pre-procedural creatinine averaged 81.1 ± 47.3 µmol / L with extremes ranging from 39 to 600 µmol / L. The median Mehran risk score was 3.2 (range: 0- 15). The interventional cardiology act consisted of coronary angiography in 86.2% (n=136) of cases, coronary angioplasty in 2.5% (n=4) of cases. We used iohexol and iopromide in 57.6% (n=91) and 42.4% (n=67) of cases, respectively. The overall incidence of CMIN was 9.5% (n=9). The multivariable regression analysis identified 4 risk factors independently linked to the occurrence of CMIN which were Pre-existing renal failure (OR: 6.05, 95%CI [1.23-29.62], p = 0.026), anemia (OR: 0.043, CI [1.03-8.96], p = 0.043), the toxic dose of PC (OR: 4.7, CI [1.28-17.7], p=0.02), and at a Mehran score = 11 (OR: 3.7, CI [0.88-15.6], p=0.036). Conclusion: the most effective approach for CMIN is prevention, which focuses on addressing modifiable risk factors to minimize the risk especially in patients with pre-existing renal failure.

[Immediate, medium- and long-term outcomes of percutaneous coronary intervention with very long drug eluting stent : An observational multicentric study]. / Les résultats immédiats, à moyen et à long terme de l'angioplastie coronaire par stent actif très long : à propos d'une étude multicentrique observationnelle.

INTRODUCTION: Very long coronary lesions account for 20% of coronary stenoses in the real world. There are few data on the effectiveness of angioplasty of these lesions with very long active stents (DES) in the literature. We conducted this study to assess the long-term outcomes of angioplasty with DES length ≥ 40 mm in a population with multiple cardiovascular risk factors. PATIENTS AND METHODS: This is a retrospective, multicenter, descriptive, and prognostic study, conducted between January 2015 and January 2020, in four Tunisian centers, including all patients who underwent angioplasty with a DES of length ≥ 40 mm with a follow-up of at least one year. The primary outcome was a combined criteria (major cardiovascular and Cerebral events: MACCE) (stroke, acute coronary syndrome, revascularization of the target lesion: TLR, cardiovascular death: CVD). RESULTS: We included 480 procedures. More than half of the patients had at least three risk factors. The prevalence of high blood pressure, diabetes and smoking were 61.1%, 56.6% and 60.4%, respectively. The treated lesions were complex: 23.54% calcified lesions, 8.75% chronic occlusions, 25% bifurcation lesions and 12.08% ostial lesions. The average length of the stents was 47.72 mm. We noted 17 cases of per-procedural complications (3.55%). The median follow-up was 35 months (extremes 1-60 months). The rate of stent thrombosis was 0.83%. The incidence of MACCE, TLR and CVD were respectively 16.25%, 8.12% and 5.2%. In multivariate analysis, diabetes (HR = 1.7, 95% CI [1.01-2.9]), dyslipidemia (HR = 2.08, 95% CI [1.3-3.3]), familial coronary artery disease (HR = 1.9, 95% CI [1.01-3.6]), left ventricle dysfunction (HR = 2.07, 95% CI [1.1-3.6]) and bifurcation lesions (HR = 1.9, 95% CI [1.2-3.14]) were the independent predictors of MACCE, while statin intake (HR = 0.38, 95% CI [0.19-0.78]) was a protective factor. CONCLUSION: Angioplasty with very long DES is associated with low levels of MACCE, TLR, stent thrombosis and CVD in our population. Therefore, it could be an interesting alternative to cardiac surgery. Randomized comparative studies of the two treatment options are needed.

Endovascular therapy for steno-occlusive subclavian artery disease early and long-term outcomes in a multicentric Tunisian study.

AIM: To evaluate the outcomes of endovascular therapy in patients with subclavian steno-occlusive disease over the short and long term in a Tunisian population. MATERIALS AND METHODS: Patients who underwent endovascular treatment of subclavian artery (SCA) steno-occlusive disease between 2013 and 2019 in three Tunisian centers were evaluated retrospectively. After treatment, patients were follow-up was scheduled at 1, 3, 6, 12 months postoperatively and annually afterwards by Doppler ultrasound and clinical findings. Primary outcomes included technical, clinical procedural success rates and limb salvage rate. Secondary outcomes included the occurrence of periprocedural complications and primary patency rates. RESULTS: 56 patients (33 males, 58.9%) were evaluated. Patients' mean age was 61.5 + years. Technical success rate was 94.6 %, being 100% in case of stenosis and 78.5% in case of occlusion. The technical success rate was 94.6%. The clinical success rate was 100% and the upper limb salvage rate was 100%. Minor amputations were performed on 5 patients. Perioperative mortality and morbidity rates were 0% and 8.9% respectively. Mean follow-up was 26.7±16.4 months (range 12-86 months). Two in-stent restenosis occurred (at 12 and 15 months) and one case of thrombosis at the 16th month. The primary patency rates were 88.7%+4.3% at the end of the first year and 78.7%+6.1% at 3 years. CONCLUSION: Endovascular treatment can be considered as a safe and effective treatment of SCA steno-occlusive disease, with low perioperative complication rates and a good patency rates over long term. KEY WORDS: Subclavian artery stenosis, Subclavian artery occlusion, endovascular, subclavian revascularization.

Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Behcet's Disease.

BACKGROUND: Behçet's disease (BD) is a multisystemic vasculiti where cardiac involvement is not common. Previous studies have shown that the incidence of ventricular arrhythmia and sudden cardiac death (SCD) is higher in patients with BD than in the healthy population. Among various possible explanations, autonomic nervous system (ANS) dysfunction has been suggested. Few studies have evaluated ANS function in patients with BD, and the results obtained are controversial. OBJECTIVE: We aimed to assess cardiac autonomic function by heart rate variability (HRV) in patients with BD; to evaluate circadian changes in HRV; and to study the relationship between HRV parameters and disease parameters. METHODS: Thirty-six patients with Behçet's disease (median age 42 years, 28 men) and 36 age- and sex-matched healthy volunteers were included. HRV analyses were performed in the time and frequency domains for the entire 24-hour period and for the daytime and nighttime periods. BD activity was studied with Behcet's disease current activity form (BDCAF). RESULTS: Patients with BD had significantly lower values of SDNN compared to controls. PNN50, RMSSD, and HF components mean values were significantly reduced in patients than in controls implying parasympathetic impairment. LF was comparable between the two groups, whereas LF/HF ratio was significantly higher in BD group. The circadian rhythm of HRV was preserved in patient group. There was no significant correlation of CRP or disease duration with HRV indices in Behçet's subjects. BDCAF score was found to be negatively correlated with LF/HF. CONCLUSION: Patients with BD, despite no cardiovascular involvement, have reduced parasympathetic activity compared with controls. However, circadian rhythms of autonomic function were preserved. As known, there is strong evidence for the role of the ANS in the pathogenesis of ventricular arrhythmias. Thus, being a practical tool, HRV can be an interesting approach for the rhythmic follow-up of BD patients.

Alveolar Hemorrhage Following Thrombolytic Therapy for Acute Myocardial Infarction: Two Case Reports and Literature Review.

Alveolar hemorrhage (AH) is a heterogeneous clinical syndrome with a high mortality rate, characterized by extensive bleeding into the alveolar spaces. AH secondary to systemic thrombolysis treatment in the setting of acute myocardial infarction is an uncommon complication, but potentially fatal and can lead to acute respiratory failure. This entity is rarely reported in the literature. We report two cases of acute AH after intravenous thrombolysis for acute myocardial infarction, which could contribute to the literature on the subject, and discuss the risk factors as well as the clinical and radiological findings supporting the diagnosis. We overview also the rare previous published case reports in this context, and we contrast our findings with those reported in the literature.

Both mediastinal and pericardial hydatidosis revealed by ST elevation acute coronary syndrome.

Hydatidosis remains an endemic disease in some regions of the world, such as Tunisia. The liver and the lungs are the most common sites in adults. Mediastinal and pericardial hydatid cysts are very rare even in endemic areas and true incidence has not been described in the literature. We report the case of a 74-year-old woman with clinical, biological and electrocardiographic features of acute myocardial infraction. Two-dimensional echocardiography and detailed imaging revealed a mediastinal and pericardial hydatid cyst. The particularity of the clinical presentation, the complementary investigations as well as the management and follow-up of the patient are discussed. This case is of great interest since the rarity of concomitant hydatid cyst in two uncommon localizations: mediastinum and pericardium, and the unusual incidental discovery during a myocardial infarction.

Serious Game Design with medical students as a Learning Activity for Developing the 4Cs Skills: Communication, Collaboration, Creativity and Critical Thinking: A qualitative research.

INTRODUCTION: The impact of technology in education has led to various changes in the way that different stakeholders, like students and teachers work and interact with each other. The use of the serious game design in educational contexts has been related to the development of the 21st century skills such as communication, collaboration, creativity and critical thinking. AIM: To analyze a serious game design process by third -year medical students, from the perspective of the 21st century competencies engaged in the game design process. Those outlined key competencies are communication, collaboration, creativity and critical thinking. METHODS: This is a qualitative, descriptive, and inductive study that follows a phenomenological approach. Twelve volunteer third-year medical students participated in an activity of designing of serious games. This study, carried out during summer internship in the cardiology department of Habib Thameur Hospital. The course of the designing of serious games with students spread over 4 weeks with 10 hours face-to-face and 10 hours of remote work. RESULTS: The participants in our study were twelves third-year medical students. Of these 12 students, 10 were female. The duration of each interview depends on each participant's ability. The analysis of the data, based on the phenomenological method of Giorgi brought out four central themes: theme 1: Critical thinking skills and problems solving skills, theme 2: Communication, theme 3: Creativity, theme 4: Collaboration. The overall essence of the phenomenon is these third medical students who experienced the serious game design outlined key competencies. CONCLUSION: Using serious game development-based learning as a learning method to impart multidimensional skills and knowledge suggests a promising approach for developing clinical reasoning, creativity, communication, and collaboration in students.

Effects of Ramadan fasting on blood pressure in hypertensive patients.

INTRODUCTION: During Ramadan, repeated cycles of fasting might contribute to changes in blood pressure among hypertensive patients. Studies on the effects of fasting on the blood pressure of hypertensive patients are scarce and have provided inconclusive results. AIM: To examine the effect of fasting on ambulatory blood pressure and heart rate in treated hypertensive subjects. METHODS: The study prospectively recruited 60 hypertensive patients between April and June 2019, followed up at the cardiology department of Habib Thameur Hospital of Tunis. A 24-hour pressure monitoring was carried out during two periods: prior to Ramadan and during the last ten days of Ramadan. We compared the average values of 24 hour, awake and asleep systolic and diastolic blood pressure and 24 hour, awake and asleep heart rate. RESULTS: We studied 40 women and 20 men; mean age was 58.4 years. 33% of the patients were diabetics, 42% dyslipidemics, 15% had coronaropathy. 45% of the patients were on monotherapy, 37% on dual therapy and 18% on a triple antihypertensive therapy. During Ramadan, 74% of the patients were taking the treatment once daily, 3% twice daily, and 23% three times per day. Average 24hour ambulatory blood pressure in the whole group was 129±17/74±10 mmHg before Ramadan and 128±17/73±9 mmHg during Ramadan (p>0.05). Daytime and nighttime mean values of systolic and diastolic blood pressure as well as mean values of heart rate were not different between both periods regardless of age, gender, medical history and lifestyle. CONCLUSIONS: In this study, there were no significant changes in systolic and diastolic blood pressures as well as heart rate during the 2 periods.

Assessing medical student satisfaction and interest with serious game.

INTRODUCTION: Serious games are interactive and entertaining digital software with an educational purpose, and they are increasingly being used in undergraduate medical education. Effective serious games attempt to form positive mood in order to encourage players to continue the play, leading to increased interest in gameplay and satisfaction as well as better academic performances. AIM: To determine  the medical students' satisfaction, situational and individual interest during a serious game. METHODS: This was a prospective study performed during a 2-year period (2018-2019 and 2019-2020). A total of 108 third-year medical students participated in this study. Students were asked to play a serious game on a computer for 20 minutes. A set of questionnaires containing evaluation grids to measure the satisfaction and interest was given to students. The effectiveness of the game was assessed using pre and post-tests. RESULTS: Following the exclusion criteria of students due to missing data, complete data were available for 97 students. Satisfaction and interest experienced by the students were high. The median of the game performance of students was 418, 04 points. There was a positive relationship between ease of use and game performance. There was a negative correlation between the three scales of interest and game performance. There was a significant difference between the mean scores of pre-tests and post-tests (p<0.01). CONCLUSION: The results of this study suggest the potentials of serious game on medical student's satisfaction, interest and learning achievement.

Prognostic value of atrial strain in non-ischemic dilated cardiomyopathy.

INTRODUCTION: Left atrial function in non-ischemic dilated cardiomyopathy (DCM) has long been underestimated when studying the ultrasound parameters of DCM. Currently, several ultrasound parameters of left atrial function have been proposed as markers to detect patients at risk. AIM: To evaluate the left atriumfunctionwith 2D speckle tracking echocardiography and itsprognostic value in the dilatedcardiomyopathy. METHODS: The study prospectively recruited 40 patients with dilated cardiomyopathy, between January and June 2014, followed up at the cardiology department of Habib Thameur Hospital of Tunis. An echocardiogram was performed for all patients at the beginning of the study. After a 6-month follow-up, the primary endpoint was the occurrence of a major cardiovascular event. The patients were divided into a first group without cardiovascular events (group 1) and a second group with a cardiovascular event (group 2). RESULTS: During the follow-up, 25 patients presented a major cardiovascular event (8 ventricular arrhythmias and 17 hospitalizations for acute decompensated heart failure). There were no significant differences between the two groups regarding cardiovascular risk factors, symptoms and blood testing values.In addition, regarding results obtained from speckle tracking echocardiography, atrial peak-systolic longitudinal strain (PALS) and time to peak atrial longitudinal strain (TPALS) values were observed to be significantly lower in group 2 ( 34.6% in group 1 vs 28.4% in group 2, p=0.000; and 344.6ms in group 1 vs 349.8 ms in group 2, p=0.016 respectively). CONCLUSION: The analysis of the LA speckle tracking in the dilatedcardiomyopathymay help cardiologistto identify patients at high cardiovascular risk and thus improve their management and follow-up.

The value of simulation in learning clinical reasoning.

BACKGROUND: Simulation allows learning in action, reflection and feedback. All these factors suggest the positive contribution of the simulation to the development of clinical reasoning. The main assessment tool for standardized testing of this skill is the script matching test. AIM: To assess the impact of teaching through high-fidelity clinical simulation on the clinical reasoning of third-year medical students, while assessing their teaching practices, satisfaction and confidence in the learning they received during this session. METHODS: We conducted an evaluative bicentric prospective study that included third-year medical students completing their cardiology internship during the first semester of the academic year 2019-2020 in the cardiology departments of Habib Thameur Hospital and Charles Nicolle Hospital, respectively. RESULTS: The study included 48 students. The students who participated in this study liked the teaching practices used in the simulation-assisted lessons. Their interest in these practices is validated by the average of 37,2±5,53 obtained for active learning, 8,04±1,85 for collaboration, 8,5±1,51 for diversity of styles and 8,02±1,72 for high expectations. In our study, the results showed that students were satisfied with the learning they had made during the simulation session. The average for the measurement of satisfaction by the 48 externals was 22,37±2,54. The results of our study indicated that students were confident that their learning would allow them to solve problems similar to those presented in the simulation in a real clinical setting. This is supported by the 31,48±4,63 average student confidence in their learning. Our study showed a progression of the students' clinical reasoning with simulation using a Script Concordance Test. The mark obtained by the students after the simulation session is significantly higher than the one obtained by the students before the simulation session with p=0.008. CONCLUSION: Simulation is an innovative pedagogical strategy and a contribution to optimizing the clinical reasoning process and improving the quality of care.

Prognostic value of ST2 in myocardial infarction.

INTRODUCTION: Soluble Suppression of Tumorigenicity 2 (ST2) is a biomarker of myocardial fibrosis increasingly recognized as a predictor of morbidity and mortality in heart failure. Its role in the prognosis after a myocardial infarction has not been validated to date. AIM: To evaluate the prognostic value of ST2 for in-hospital morbidity and mortality after myocardial infarction. METHODS: We conducted a longitudinal prospective study including 74 patients admitted for an acute uncomplicated cardiac myocardial infarction at Habib Thameur hospital between April and October 2016. ST2 blood samples were drawn until 72 hours post admission .The primary endpoint was the occurrence of a major cardiovascular event during hospitalization. RESULTS: Patients' mean age was 61.28 ± 13 years-old with a sex ratio of 1.8. The reason for admission was acute coronary syndrome with persistent ST segment elevation in 54% of cases and non-ST segment elevation acute myocardial infarction in 46% of cases. The ST2 assay was positive in 78% of cases with a mean value of 122.43 ± 95.72 ng/ ml. Left ventricular dysfunction was observed in 47% of cases. Fifteen per cent of the patients had a 3 vessel-disease, 24% a 2 vessel-disease and 34% a 1 vessel-disease. Twenty-six percent had at least one major cardiovascular event. In-hospital mortality was 10%. In multivariate analysis, ST2 was an independent factor associated with the occurrence of major cardiovascular events (RR = 2, p = 0.04). The cutoff value of ST2 of 35 ng/ml had a sensitivity of 95%, a specificity of 30% (AUC = 0.672, CI 0.546-0.798, p = 0.024), a negative predictive value of 100% and a positive value of 33%. A significant correlation was found between ST2 and troponin, blood glucose on admission, CRP and left ventricular ejection fraction (respectively: r = 0.398, p <0.0001, r = 0.281, p = 0.015, r = 0.245, p = 0.039, r = -0.401, p <0.0001). CONCLUSION: The measurement of ST2 after a myocardial infarction constitutes a new prognostic indicator of in-hospital morbidity and mortality.

Impairment of left and right ventricular longitudinal strain in asymptomatic children with type 1 diabetes.

AIM: The relationship between type 1 diabetes (T1DM) and cardiac function in children is not well established. The purpose of this study was to investigate whether children and adolescents with T1DM present early asymptomatic abnormalities of left ventricular (LV) and right ventricular (RV) function. In addition, we evaluated the relationship of any such abnormalities with glycemic control and diabetes duration. METHODS: This was a prospective study. Standard echocardiography, tissue Doppler imaging, and two-dimensional strain analysis were performed prospectively in 52 children with T1DM. The results were compared with those from 52 healthy children matched for age and sex. RESULTS: There were no significant differences between the two groups in LV ejection fraction or RV systolic function. There was a difference between the two study groups in transtricuspid flow: the E-wave and A-wave velocities were significantly higher in the diabetic group. Left ventricular global longitudinal strain (LV GLS) was significantly lower in children with T1DM (-20.01 ± 1.86% vs. -22.99 ± 0.98%, respectively; P < .001), as was RV free-wall longitudinal strain (RV FWLS) (-29.13 ± 1.85% vs. -30.22 ± 1.53%, respectively; P = .002). LV GLS was correlated with diabetes duration (r = 0.444, P < .001) and glycated hemoglobin (HbA1c) (r = 0.683, P < .001); however, no correlation was found between RV FWLS and HbA1c or diabetes duration. CONCLUSIONS: Our findings suggest that LV GLS and RV FWLS are impaired in children with T1DM and that the decrease in LV GLS is correlated with diabetes duration and HbA1c levels.

A large cardiac hydatid cyst in the interventricular septum: A case report.

Isolated cardiac location is an uncommon presentation of echinococcosis (0.5-2%), and involvement of the interventricular septum is even rarer. It may lead to various complications because of rupture and embolization. We report the case of a 26 - year- old man who was diagnosed to have a large inter-ventricular hydatid cyst complicated by both cerebral and coronary embolism. Presentation, management and follow-up of the patient is discussed. This case is of particular interest because of the rarity of septal localization of a hydatid cyst, and the conflict between the severity of the complications that occurred and the absence of correlated symptoms.

Script concordance test as a sanctionnal evaluation in cardiology.

INTRODUCTION: Sanctioning evaluation in cardiology is carried out using multiple choice questions, short-answer questions, clinical cases and editorial questions. However, these methods do not assess clinical reasoning in a context of uncertainty in contrast with script concordance tests (SCT). AIM: To compare the scores obtained by the students in the 3rd year of medicine with the SCT versus the sanctioning test of cardiology and to study the correlation between these two evaluation methods. METHODS: This is a prospective study including 31 3rd year students who completed their cardiology clerckship in the Cardiology Department of the HabibThameur Hospital during the first half of 2016. We compared the scores obtained in the 13 SCT test (39 items) with those of the cardiology normative test. RESULTS: Students 'mean score at SCT was significantly lower than that of experts (66.6 ± 10.2 vs 86 ± 6.7%, p <0.0001). The mean score obtained by students at the SCT was significantly higher than that of the cardiology sanctioning test (p <0.001). Cronbach alpha coefficient was 0.71. There was no correlation between the two tests (r = 0.329; p= 0.07). CONCLUSION: The evaluation of our students by the SCT showed mean score statistically higher than the questions of a classic test, without correlation between them. This should encourage us to incorporate SCT into our assessment methods to promote clinical reasoning.

Factors associated with poor medication compliance in hypertensive patients.

INTRODUCTION: Hypertension is a major cause of cardiovascular morbidity and mortality. Despite therapeutic advances, only one-third of patients achieve blood pressure targets. Poor compliance is one of the main causes. AIM: To study the factors associated with poor compliance in hypertensive patients. METHODS: We conducted a descriptive prospective study including 200 hypertensive patients treated and followed out between March and April 2017. The Girerd medication adherence questionnaire was submitted to patients during an semi-directed interview. RESULTS: Patients meanagewas of 63.28 ± 9.62 years-old and sex ratio of 0.92. The predominant risk factor was dyslipidemia in 45% of cases, followed by smoking 36.5% and diabetes 25.5%. A previous history of acute coronary syndrome was found in 33.5% of cases and atrial fibrillation in 13%. Fifteen percent of our patients consumed alcohol regularly and 9.5% practiced regular physical activity. Fifty-five percent of our patients were on low sodium diet. The prevalence of poor medication adherence was 20.5%. In multivariate analysis, independent factors related to poor medication adherence were: the number of treating specialist physicians greater than 1 (OR = 3.444, p = 0.008) and the absence of information received on hypertension (OR = 4.345; p= 0.003). CONCLUSION: The improvement of medication adherence for our patients must be based on information on hypertension and its risks and the harmonization of care between treating physicians.

Early outcomes of cardiac surgery in elderly patients.

BACKGROUND: Due to the increase in average life expectancy and the higher incidence of cardiovascular disease, more elderly patients present for cardiac surgery nowadays. At the same time, age has been considered a predictor of morbidity and mortality. AIM: To evaluate the short-term outcomes of cardiac surgery in elderly patients. METHODS: We conducted a descriptive retrospective study including elderly patients who underwent cardiac surgery from January 2012 to 31st of December 2016. All patients were hospitalized before and after cardiac surgery in the cardiology department of Habib Thameur Hospital. RESULTS: Our study included 55 patients. Average age was 72±6 years old and sex-ratio was two. Eighty-five percent presented with angina, 18% with dyspnea and one patient with an aortic prosthetic valve endocarditis. Mean left ventricular function was 54 ±9 %. Mean EuroSCORE II was 1.91±1.18. Twenty-six per-cent had an urgent surgery. Mean extracorporeal circulation time was of 77±26 min and mean extubation time was 8±6 h. Eighty-four per cent had a coronary artery bybass grafting and 16% a valve replacement. Four per cent had a redux and 4% a combined surgery. Stay in surgical department varied between 3 and 10 days with average of 4.6±1.2 days. Early mortality rate was of 2% and 98% had complications. Ninety-eight complications occurred after surgery: 35 reintervention for mediastinal bleeding or tamponade, 28 bleedings requiring transfusions, eight heart rhythm disorders, an atrioventricular conduction block requiring ventricular, five atrial fibrillation, two ventricular tachycardias, a ventricular fibrillation, eight low cardiac outpout, seven prolonged mechanical ventilation and eight pneumonias. In univariate analysis, recent myocardial infarction and chronic kidney disease were predictive of early complications. CONCLUSION: Our data shows cardiac surgery is feasible in elderly patients with acceptable risk in terms of mortality and an increased morbidity due to their frailty. Careful patient selection is needed for the success of cardiac surgery in elderly patients.

Evaluation of patients' knowledge on their vitamin K antagonist treatment.

INTRODUCTION: Vitamin K antagonists (VKA) are currently the most prescribed oral anticoagulant treatment in Tunisia. Despite the standardization of biological monitoring and the better definition of therapeutic objectives, their side effects are a frequent reason for hospitalization. AIM: To evaluate patients' knowledge about their VKA treatment. METHODS: We realized a cross-sectional descriptive study in the Cardiology Department of HabibThameur Hospital from September to October 2016. A questionnaire consisting of 14 items was used in a semi-directed interview in order to assess patients' knowledge on their VKA treatment. RESULTS: Our study included one hundred patients. Mean age was 61 ± 12 years and sex ratio of 1.8. Forty-eight per cent were illiterate. The median duration of AVK intake was 5 years. Atrial fibrillation (AF) was the most frequent indication (57%). Eighty percent of patients had more than five correct answers on the eight items of knowledge: VKA's name (96%), tablet description (93%), dose (99%), time (94%), VKA's effect (70%), INR (56%), treatment's risk (49%) and the target INR (20%). Twenty-two percent had more than four correct answers on the 6 items of know-how: what to do in case of haemorrhage (70%), what to do in case of oblivion (45%), interactions precautions to be observed with food (13%), activities advised against (49%) and medical procedures advised against (27%). In multivariate analysis, only prior VKA information was significantly associated with a better knowledge of VKA (p = 0.027). CONCLUSION: Our patients' knowledge on their VKA treatment was insufficient to ensure the safety and efficacy of treatment. The creation of a therapeutic education program on is therefore necessary to reduce the iatrogenic risk of this treatment.

The effects of fasting on heart rate variability in hypertensive patients.

Heart rate variability (HRV) is an independent indicator of increased mortality in patients with myocardial infarction and congestive heart failure. The effects of fasting on the HRV are not known in hypertensive patients. Therefore, studying the effects of Ramadan fasting on hypertensive patients' HRV seems reasonable to address. We conducted a prospective study including 20 hypertensive patients with sinus rhythm. HRV was determined twice by ambulatory 24-hour Holter recordings at fasting during and after Ramadan. Subjects mean age was 55 ± 11.8 years. Sex-ratio was 1.5. When two groups compared, statistically significant differences were found in terms of SDNN (113 ± 71 vs 140 ± 38, p = 0.001), SDANN (109.7 ± 45 vs 134.8 ± 48.3, p = 0.008), T power (2368.7 ± 121.3 vs 3660.5 ± 170.9, p = 0.03) and LF (552.2 ± 31.3 vs 903.7 ± 48.9, p < 0.0001) values. HRV parameters were found to be decreased in Ramadan. Thus, Ramadan fasting enhances the activity of the sympathetic system in hypertensive patients.

Effect of ramadan fasting on acenocoumarol-induced antocoagulant effect.

Eating patterns, food intake and type of alimentation vary greatly during the month of ramadan. Furthermore, fasting, which practiced during the month of ramadan, can have an impact on drug's metabolism. These two factors, fasting and eating habits changes during the month of ramadan, may impact acenocoumarol anticoagulant effect, translated by variations of INR values. The aim of our study was to see ramadan fasting effects on INR variations in patients treated by acenocoumarol. A prospective monocentric study was conducted during the ramadan month on fasting outpatients that were treated by acenocoumarol. Baseline INR values (e.i. most recent available value before the month of ramadan) were compared to INR values obtained during the month of ramadan. All patients were monitored for signs of secondary haemorrhagic complications linked to treatment by anti-vitamin K (AVK). Thirty patients were included in the study with a sex ratio 1. Patients mean age was 65 years. Around two thirds of the patients were treated by AVK for atrial fibrillation. The majority of patients (94%) have been treated by AVK for more than a year. Mean INR was significantly higher during the month of ramadan than baseline (3.51 vs 2.52; p< 0.0001). There were also more overdoses during the month of ramadan than baseline (9 vs. 0; p=0.014). The increased INR values highlights the need of a close monitoring of INR values during the month of ramadan, particularly in patients with a high haemorrhagic risk.