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.

Epidemiologic features and management of hypertension in Tunisia, the results from the Hypertension National Registry (NaTuRe HTN).

BACKGROUND: Hypertension is the leading cause of morbi-mortality in our country. Thus, we conducted this national survey on hypertension to analyze the profile of the Tunisian hypertensive patient and to assess the level of blood pressure control. METHODS: Nature HTN is an observational multicentric survey, including hypertensive individuals and consulting their doctors during the period of the study. Blood pressure measurements were conducted during consultation, using a standardized auscultatory or oscillometric sphygmomanometer after at least 15 min of rest. The diagnosis of new hypertension is based on the 2018 ESC/ESH criteria. The primary endpoint of our study was uncontrolled hypertension defined by a systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. RESULTS: Three hundred twenty-one investigators participated in the study. We enrolled 25,890 patients with a female predominance (Sex ratio, 1.21) and an average age of 64.4 ± 12.2 years. Most individuals were treated in the public sector (74%), 39.4% of patients were diabetic, 25.8% were obese, 44.6% were overweight and 14% were smokers. Hypertension was controlled in 51.7% of cases if we consider 140/90 as a BP target, and only in 18.6% if we consider 130/80 as a target. The independent predictors of uncontrolled blood pressure were male sex (OR = 1.09, 95%CI [1.02-1.16]), age > 65 year-old (OR = 1.07, 95% CI[1.01-1.13], diabetes (OR = 1.18, 95% CI [1.11-1.25], Smoking (OR = 1.15, 95% CI [1.05-1.25]), Obesity (OR = 1.14, 95% CI[1.07-1.21]), management in public sector (OR = 1.25, 95% CI [1.16-1.34]), and Heart rate > 80 bpm (OR = 1.59, 95% CI [1.48-1.71]). Contrarily, high educational level (OR = 0.9, 95% CI [0.84-0.97], absence of history of coronary disease (OR = 0.86, 95% CI [0.8-0.93]), salt restriction (OR = 0.48, 95% CI [0.45-0.51]), drug compliance (OR = 0.57, 95% CI[0.52-0.61]), and regular physical activity (OR = 0.77, 95% CI[0.71-0.84]) are strong predictors of blood pressure control. CONCLUSION: NaTuRe HTN showed that blood pressure control was reached in more than half of the Tunisian people. The control remains low in patients with high cardiovascular profiles and in those treated in the public sector. A national health program based on therapeutic education, regular control and continuous support to the public institutions is needed to decrease the burden of hypertension incidence rate.

[Diagnostic accuracy, limits and practical implications of Multidetector Computed Tomography Coronarography. About 105 cases]. / Performances, limites et implications pratiques du coroscanner. A propos de 105 cas.

BACKGROUND: Non-invasive examination of coronary artery disease is an attractive and rapidly evolving possibility. In certain clinical situations ,multi-detector computed tomography coronarography (MDCT) is currently considered as a promising technique alternative to conventional coronary angiography (CCA). PURPOSE: We suggest from our personal study and from a review of the literature, to analyze diagnostic accuracy of MDCT , its limits and to deduct, its practical implications and its indications. METHODS: 105 patients underwent 64-slice MDCT . Coronary angiography was performed every time when the MDCT was pathologic. In two cases the MDCT was realized in complement of inconclusive coronary angiography .Study of coronary arteries was based on "per -segment" and "per- patients" analyse Results : The mean age was 63,3 years., sex ratio was 0 ,7. Hypertension was noted in 63% of cases 29 ,9 % of patients had mellitus diabetes.The initial clinical presentation was unusual chest pain in 46 patients, exercise chest pain in 40 cases. the MDCT was done for the detection of silent ischemia In 5 cases, for screening of CAD in patients with dilated cardiomyopathy in 5 cases , before cardiac surgery in 3 case and before non cardiac surgery in 2 cases. MDCT was normal in 30 patients ( 28% ) so coronary angiography was avoided in 60% of patients with unusual chest pain, and in 50% of patients with dilated cardiomyopathy and in also in 50% of patients selected for cardiac or non cardiac surgery. In per-segment study the sensitivity, specificity, positive and negative predictive value of the MDCT in detecting coronary stenosis were respectively 89 %,98% , 91% and 97% versus, 98%,89%,94%, 95% the per-patient evaluation .The MDCT was inclusive in10 patients because .of calcifications in 8 cases and because uncontrolled unchecked heart rate in 40 cases Conclusion : our results for negative predictive value of MDCT are similar to reports from the literature. This suggests that in this clinical setting , MDCT may replace coronary in patients with low probability of coronary artery diseases, its is also useful for assessment of cardiomyopathy and before cardiac or non cardiac surgery.

[Epidomiological characteristics of infective endocarditis: a study of 135 cases]. / Caractéristiques épidémiologiques de l'endocardite infectieuse: etude de 135 cas].

BACKGROUND: Infective endocarditis (IE) is a serious pathology which is in a continuum evolution in the setting of diagnosis and therapeutic fields AIM: To describe clinical, echocardiographic, microbiological, therapeutic and outcome characteristics of infective endocarditis in a Tunisian population. METHODS: The records of 135 patients admitted to adult cardiology department of la Rabta hospital between January 1981 and December 2011 were collected. The diagnosis of certain IE was retained according to modified Duke Criteria. RESULTS: The mean age of patients was 38.5 ± 16 years, with a male predominance (sex ratio: 1.4). IE affected native valves in 77% of cases, prosthetic valve in 15.5% of cases, congenital heart disease in 2% and pacemaker in 1.48% of patients. The portal of entry was identified in 43.7% of the patients, the oral origin was predominant. Blood cultures were positive in only 34% of patients. Causative microorganism was staphylococcus in 43.6%, streptococcus in 43.6% and negative bacill gram in 17.4% of patients. Echocardiography showed vegetation in 98% of patients, cardiac abscess in 23.7% of patients and valve mutilation in 17.7% of cases. Prosthesis dehiscence was present in 4.5% of cases. Complications were primarily hemodynamic (57%) followed by embolic events (34%). Surgery occurred in 57.7% of patients, it was early in 69% of cases. The indication was mainly hemodynamic and mixed in 70%of patients. Hospital mortality was 28% with predictor's factors: left heart (p=0.02), prosthesis (p <0.05), staphylococcus (p<0.005), heart failure (p<0.05) and neurological complications (p=0.04). CONCLUSION: According to our study, infective endocarditis has always touched a young population in Tunisia, rheumatic valve disease is still the predominant underlying heart disease and both streptococcus and staphylococcus are most frequently isolated. Mortality remains high despite considerable progress in terms of diagnosis and therapy.

[Determinants factors of hospital morbidity and mortality after reintervention of valve replacement]. / Facteurs déterminants dans la morbi-mortalité hospitaliére des réinterventions d un remplacement valvulaire.

BACKGROUND: Valve surgery involves valvular substitutes that expose to different types of complications that can lead to re subsequent interventions. AIM: was to identify the predictors factors of in-hospital morbidity and mortality of re interventions after valve replacement. METHODS: Retrospective study of 73 consecutive patients who underwent a re valve replacement between 1985 and 2010 in the Cardiovascular Surgical department of La Rabta hospital. RESULTS: The average age at further surgery was 44 years ( 15-80 years) and sex ratio of 0.87 . The average time between interventions was 10 years (3 days -33 years). Different etiologies were found prosthesis thrombosis (36.9% ). The overall hospital mortality was 36.9 % , 11 intraoperative deaths and 16 immediate postoperative deaths. CONCLUSION: The iterative intervention of valve replacement surgery is increasingly mastered by the surgical team. According to this study , the prognosis depends mainly on the patient preoperatively state, the cause of further surgery and its mode of occurrence.

[Is BNP assay useful for the diagnosis of acute dyspnea in emergencies departments?]. / Est-ce que le dosage du brain natriuretic peptide est utile dans le diagnostic de la dyspnée aiguë aux urgences?

BACKGROUND: It would be interesting to the emergency doctor to have at his disposal a helpful diagnostic tool like brain natriuretic peptide (BNP). Such assay is simple, available and reliable. AIMS: To report our experience on the role of BNP in the etiological diagnosis of acute dyspnea (AD) in emergency room (ER) and to assess the cost-effectiveness ratio of such diagnosis strategy. METHODS: A prospective study conducted in the ER of Rabta university teaching hospital of Tunis, from March 1st to June 20th 2010, involving 30 consecutive patients presenting to the emergency for AD. All patients underwent echocardiography in their acute phase and benefited from the dosage of BNP during the first 4 hours. The echocardiography parameters were collected by a single operator who was unaware of the results of the BNP dosage. RESULTS: The mean age of patients was 72.8years with a sex ratio of 1.5. AD was of orthopnea type in 9 cases and stage III NYHA dyspnea in the other patients. Clinical and radiological signs of left heart failure were noted in 30% of cases. Ultrasound data have objectified systolic dysfunction in 4 cases, diastolic in 3 cases and systolic plus diastolic in 10 cases. The BNP levels were below 100 pg/ml in 10 cases with pulmonary origin of the AD. A BNP level between 100 and 400 pg/ml was noted in 3 cases. In our study, the clinical probability of AHF prior to performing the test was estimated at 53% and estimated at 100% after the BNP assay. The BNP assay has reduced the length of stay in the emergency department 4 to 5 days and saved nearly 50% of the cost of care per patient. CONCLUSION: The BNP assay, has allowed us to confirm the AHF all cases. Given the prognostic value and economic benefit of this test we recommend its use in ER of our country.

Cardiac injury in traumatic subarachnoid hemorrhagea: prospective study in 35 patients.

BACKGROUND: Various electrocardiographic abnormalities have been noted since 1954 in patients with head trauma complicated by subarachnoid hemorrhage (SAH). However, very few studies have interested to these ECG modifications in the case of post traumatic SAH (t-SAH) AIM: To assess the incidence of ECG abnormalities during the first five days after admission and the predictive value of these cardiac complications on the mortality in t-SAH. METHODS: This prospective study included 35 patients out of 125 with traumatic SAH diagnosed in the emergency unit in Rabta's hospital (2001-2009). Patients with cardio vascular history, thoracic trauma, non neurological coma and vascular-related neurological coma were excluded. An electrocardiogram monitoring was performed. A brain CT scan was performed in admission, 48 h after and case of neurological aggravation. Serum cardiac troponin IC levels were determined on hospital admission and then on the third and fifth days of hospitalization. The statistical analysis was based on the non-parametric variance test of Kruskal-Wallis to compare the means; on the chi 2 and Fisher tests to compare percentage, with a significant result at 0.05 percentile and on the Odds ratio nonparametric factors for death. Association between 2 quantitative variables have been analyzed by Pearson coefficient of correlation. RESULTS: Mean age of the 35 patients was 39 ± 17 years. Sex ratio was 4 in favor of men. The prevalence of electrocardiographic changes was of 57% (20 patients). Serum Troponin I level showed a peak on the 3rd day then it decreased. The majority of electrical abnormalities occurred during the third after admission and are associated to a markedly increased Troponin I plasma level and to the highest rate of mortality. Statistical analysis showed a significant correlation between T wave changes and the increase of serum Tn IC level (p= 0; 0002). The relative risk of mortality was higher than 7.2 times in cases with increase serum TnIc level. CONCLUSION: We demonstrated that ECG changes were common in patients with t SAH and the major predictive factors of mortality were the increase of serum TnIC and T wave changes.

[Mitral stenosis a rare antology of diffuse pulmonary ossification]. / Le rétrécissement mitral cause rare d'ossification pulmonaire diffuse.

BACKGROUND: Diffuse pulmonary ossification is a rare entity with unknown pathogenesis. It presents with the formation of mature bone within the pulmonary parenchyma. Pulmonary ossification can be idiopathic or associated with diffuse and chronic lung disease, system disorders or heart disease essentially mitral stenosis. AIM: We report a case of a 49 year-old woman with long standing mitral stenosis. CASE: The patient had undergone a valve replacement with a mechanical prosthesis. She complains from dyspnea on exertion and dry cough. Frontal chest radiograph shows bibasilar confluent calcific areas of increased opacity. Computed tomography scans confirmed the presence of ossified acinar clusters. Other aetiologies of diffuse pulmonary ossification were eliminated by different complementary exams. CONCLUSION: Diffuse pulmonary ossification is slowly progressive. Patients are generally asymptomatic or complain from mild symptoms. Most cases are of diffuse pulmonary ossification are diagnosed during autopsy. Establishing a prognosis is difficult as few living cases are diagnosed.