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.

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.

Evaluation of students' motivation during the gamification of electrocardiogram interpretation learning.

INTRODUCTION: The quality of the training of medical students is one of the guarantors of the proper functioning of our health system. Gamification is an innovative educational pedagogical method that stimulates the pleasure of learning and encourages learner motivation. AIM: To evaluate the subjective and external motivations and academic self-efficacy of DCEM1 students by playing with TD sessions designed to learn the systematic interpretation of rhythm disorders on surface ECGs using playing cards. METHODS: It was a descriptive, cross-sectional study. Three successive groups of 25 students each took part in this study which took place at the Faculty of Medicine of Tunis. Each group was subdivided into 5 subgroups. During the TD session, the same 18 playing cards are distributed to each subgroup, and various wide and thin QRS tachycardia ECG plots are projected successively. Each subgroup should collect playing cards related to the methodical interpretation of each ECG trace and establish the final diagnosis of rhythm disorder. At the end of the pedagogical training, an anonymous self-assessment questionnaire to measure the types of motivation and academic self-efficacy was submitted to the students. RESULTS: Seventy-five students participated in our study. They were mostly female (sex ratio = 4). Gamification learning using playing cards has generated learners' intrinsic motivation (5.89 ± 0.97), allowing them to feel more confident in themselves, capable of acquiring new skills. Regarding extrinsic motivation, having good results on the exam was not their main concern (4.34 ± 1.23). This learning method has created a feeling of self-efficacy among our learners (5,004 ± 0,98). Indeed, they proved to be able to assimilate the fundamental notions of the course (5.86 ± 1.26), to understand the most complex material of the course (5 ± 1.55) and to acquire the competences targeted by this course (5.41 ± 0.5 ). Finally, all learners were satisfied with the method of gamification learning using playing cards. They recommended that this method be generalized throughout all ECG sessions. CONCLUSION: Gamification learning seems to be an effective and appropriate approach to teaching in the medical field since it allows to associate the notion of pleasure and the act of learning and stimulating motivation and self-efficacy learners.

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.

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.

Atrial septal defect closure in adults: A ten-year experience.

INTRODUCTION: Atrial septal defects (ASD) constitute the most frequent congenital heart disease in adults and ostium secundum (OS) the most common type. Benefit of its closure in adulthood has long been controversial. AIM: To evaluate outcomes of OS-ASD closure in adults. METHODS: Retrospective cohort study, over a ten-year period from 2008 to 2018. All adults (≥20 years old) who benefited from OS-ASD closure were included. Study endpoints were closure success rate, functional status evolution and incidence of new arrhythmias at 12 months. RESULTS: Fifty patients were recruited. Dyspnea (≥ NYHA II) was noted in 58% and arrhythmia in 18% of patients. Feasibility of a percutaneous closure was 50%. Closure success rate was 100%. Surgery was associated with high postoperative morbidity with longer hospitalization stay (20 vs. 4 days, p <0.001). At 12 months, an improvement in functional status was observed in 79%. Incidence of new arrhythmias was 5%. A significant decrease in right cavities dilation as well as pulmonary arterial pressure has been reported. CONCLUSIONS: Immediate results of OS-ASD closure in adults are satisfactory. Percutaneous closure is associated with reduced hospital morbidity. At 12 months, a significant improvement in functional status was observed however the possible occurrence of new arrhythmias imposes a close follow-up.

[Contrast-induced nephropathy after cardiac catheterization: a prospective study of 180 patients]. / Néphropathie induite par les produits de contraste iodés après cathétérisme cardiaque : Une étude prospective de 180 patients.

BACKGROUND: Contrast-induced nephropathy (CIN) is associated with an increased cardiovascular morbi-mortality. Little is known about the incidence and risk factors of CIN after cardiac catheterization in Tunisian patients. AIM: To determine the incidence of CIN and its predictors after coronary angiography as well as its prognostic and therapeutic repercussions in a Tunisian patients' cohort. METHODS: In this prospective single center study, 180 consecutive patients who underwent cardiac catheterization were enrolled; all patients were followed-up for 3 months. RESULTS: The incidence of CIN defined as an absolute increase in serum creatinine ³ 5 mg/l (44µmol/l) and/or a relative increase in serum creatinine ³ 25%, was 17.2%. In multivariate logistic regression, independent predictors of CIN were: diabetes mellitus (Odds Ratio (OR)=2.26 ; 95% confidence interval (95%CI) : 1.29- 3.98, p=0.005), creatinine clearance < 80ml/mn (OR=2.87 ; 95%CI : 1.59-5.19, p<0.001), left ventricular ejection fraction (LVEF) < 45% (OR=2.03 ; 95%CI : 1.22-3.39, p=0.007) and use of a volume of contrast media > 90ml (1.72 ; 95%CI : 0.99-2.99, p=0.05). Perprocedural hypotension was the strongest independent predictor of CIN in our study (OR=3.99; 95% CI: 1.65-9.66, p=0.002). CIN was totally regressive within one month in 27 patients (86.7%) while 3 patients (10%) had a residual renal dysfunction at the end of the follow-up period (3 months). CONCLUSION: More than one angiocoronarography on 6 resulted in CIN in our population. CIN affects cardiovascular prognosis even if renal function normalization is usually obtained within one month after the investigation. Besides identifying risk factors of CIN in order to apply preventive measures in risky patients, we stress the necessity of insuring a good hemodynamic status while achieving the procedure.

Acute myocardial infarction in a patient with hypofibrinogenemia: a case report.

INTRODUCTION: Congenital fibrinogen deficiency is a rare coagulation disorder usually responsible for hemorrhagic diathesis. However, it can be associated with thrombosis and there have been limited reports of arterial thrombotic complications in these patients. CASE PRESENTATION: A 42-year-old Tunisian man with congenital hypofibrinogenemia and no cardiovascular risk factors presented with new onset prolonged angina pectoris. An electrocardiogram showed features of inferior acute myocardial infarction. His troponin levels had reached 17 ng/L. Laboratory findings confirmed hypofibrinogenemia and ruled out thrombophilia. Echocardiography was not useful in providing diagnostic elements but did show preserved left ventricular function. Coronary angiography was not performed and our patient did not receive any anticoagulant treatment due to the major risk of bleeding. Magnetic resonance imaging confirmed myocardial necrosis. Our patient was managed with aspirin, a beta-blocker, an angiotensin-converting enzyme inhibitor and statin medication. The treatment was well tolerated and no ischemic recurrence was detected. CONCLUSION: Although coronary thrombosis is a rare event in patients with fibrinogen deficiency, this condition is of major interest in view of the difficulties observed in managing these patients.

[Introduction to myocardial doppler imaging]. / Introduction au Doppler tissulaire myocardique: principes physiques et applications cliniques.

Introduced in 1989, the myocardial doppler tissue imaging has now many clinical applications. Doppler tissue imaging explores the proper systolic and diastolic regional function of myocardial fibers. We can measure myocardial velocities by recording signals of low velocitiy and high magnitude, the strain and the strain rate are then derived from velocities. Specific software is therefore necessary. There are many ways of recording and representing myocardial doppler tissue parameters. Diagnostic and prognostic value of myocardial doppler tissue imaging is now proved and this method has many applications in ischemic cardiopathy and in cardiomyopathies. The development of powerful software is promising for the applications of the strain in the future.

[Stress echocardiography and mitral stenosis: what interest?]. / Echocardiographie de stress et retrecissement mitral: quel interet?

The stress echocardiography is used extensively as a diagnostic and prognostic tool and the assessment of ischemic cardiopathies. Its use in valvulopathies is more limited, but is increasing with time. The discrepancies between the functional symptoms and hemodynamics at rest is frequently met in patients with mitral stenosis. By assessing changes of pressures, gradients and surface stress echocardiography helps to identify the real hemodynamic conditions permitting to recommend a more aggressive approach in certain situations.

[Doppler echocardiography and arhythmogenic right ventricular dysplasia]. / Echocardiographie-Doppler et dysplasie arythmogène du ventricule droit.

The aim of this study is to evaluate new echocardiographic modes in diagnosis of arrhythmogenic right ventricular dysplasia (ARVD). Our study is prospective, including ten patients with ARVD and a control group of ten healthy subjects. Transthoracic echocardiography included evaluation of classical criteria's, cross sectional measurements of the right ventricular. M mode and pulsed tissue Doppler techniques were used for quantitative measurement of tricuspid annular motion at the lateral and septal positions. Assessed by M mode, the total amplitude of the tricuspid annular motion was decreased in the lateral and septal positions in the patients compared with the controls. The tissue Doppler velocity pattern showed decreased early diastolic peak annular (Ea) velocity and an accompanying decrease in early (Ea) to late diastolic(Aa) velocity ratio in all positions; the systolic annular velocity was decreased only in the lateral position. Tricuspid annular measurement are valuable, easy to obtain and allow quantitative assessment of right ventricular function. ARVC patients showed an abnormal velocity pattern that may be an early but non specific sign of disease.