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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.

Left ventricular hypertrophy is the most prevalent cardiac abnormality in hemodialysis patients. The diagnosis of this abnormality is possible by electrocardiogram and/or echocardiography. Our study aimed to assess the prevalence of left ventricular hypertrophy in hemodialysis patients and the accuracy of different electrocardiographic criteria.This was a cross-sectional retrospective study including 60 hemodialysis patients between 2017 and 2018. A left ventricular mass index higher than 115g/mThis was a cohort of 60 patients composed of 27 men and 33 women with a mean age 52.6±15,8years. Hypertension was the most common cardiovascular risk factor (82 %). The prevalence of left ventricular hypertrophy at echography was 65 %. Prevalence of left ventricular hypertrophy at electrocardiographic varied across the different criteria ranging from 5 % (R wave in DI) to 32 % (Perugia score). The highest left ventricular hypertrophy prevalence at electrocardiographic was found with the five following criteria: Perugia score (32 %), Peguero-Lo Presti index (28 %), Sokolow-Lyon index, Cornell index, Framingham-adjusted Cornell voltage (17 %). Sensitivity was ranged from 5 % (R in DI, Gubner-Ungerleider index, and product) to 41 % (Perugia score). The specificity of most criteria was ≥90 % except for the Perugia score (85 %). The sensitivity, specificity, postitive and negative productive values and left ventricular hypertrophy prevalence using the five most accurate criteria combined were respectively 48, 90, 70.28, 77.85 and 33 %. Hypertension, duration of HD, arteriovenous fistula, interdialytic weight gain, systolic blood pressure, hemoglobin9g/dL and hyperparathyroidism were significantly associated with left ventricular hypertrophy.The prevalence of left ventricular hypertrophy detected by echocardiography was high. All electrocardiographic criteria had a low sensibility and a high specificity in the diagnostic of echocardiographic left ventricular hypertrophy. To improve the accuracy of electrocardiographic criteria, it is necessary to combine several electrocardiographic criteria and not often focused on a single classic electrocardiographic index.

The aim of this study was to evaluate the variation of homocysteine (Hcy) levels in patients with rheumatoid arthritis (RA) and to analyze the relationship to inflammatory parameters, cardiovascular risk, and methotrexate (MTX).This cross-sectional study assessed disease activity and treatment in RA patients. The European League Against Rheumatism (EULAR) 2015 HeartSCORE was performed for cardiovascular (CV) risk estimation and levels of plasma Hcy, serum folate concentrations, vitamin B12, and erythrocyte sedimentation rate (ESR) were measured.A total of 103 participants with mean age 53 ± 10 years and mean disease duration 10.55 ± 7.34 years were included. Patients were treated with MTX in 69.9% of cases and corticosteroid in 80.5% of cases. Of all patients, 13% had a cardiovascular inheritance, 25% were hypertensive, and 18% had diabetes. The EULAR 2015 HeartSCORE was high and very high (≥5%) in 35% of cases. Mean Hcy level was 12.54 ± 4.2 µmol/L [6.89-32.92] and hyperhomocysteinemia was noted in 20.4% of patients. Analytic study demonstrated that hyperhomocysteinemia was associated with male gender (p = 0.01), MTX use (p = 0.01), smoking (p = 0.008), renal failure (p = 0.04), and high disease activity (p = 0.05), but there was no association with the HeartSCORE (p = 0.23). Hcy level was negatively correlated with folate (p = 0.009) and vitamin B12 level (p = 0.02) and positively with age (p = 0.01), C‑reactive protein (CRP; p = 0.05), and Simplified Disease Activity Index (SDAI; p = 0.03). In multivariate logistic regression analysis, current MTX use, levels of vitamin B12 and creatine, and Clinical Disease Activity Index (CDAI) appeared to be independent factors associated with hyperhomocysteinemia.MTX use, CDAI, and the levels of vitamin B12 and creatine are independent factors associated with hyperhomocysteinemia.HINTERGRUND: Ziel der vorliegenden Studie war es, Unterschiede in den Werten für Homocystein (Hcy) bei Patienten mit rheumatoider Arthritis (RA) und den Zusammenhang mit Entzündungsparametern, Herz-Kreislauf-Risiko und Methotrexat (MTX) zu untersuchen.In dieser Querschnittstudie wurden Krankheitsaktivität und Therapie von RA-Patienten analysiert. Zur Abschätzung des kardiovaskulären Risikos wurde The European League Against Rheumatism (EULAR) 2015 HeartSCORE eingesetzt und die Werte für Plasma-Hcy, Folsäurekonzentration im Serum, Vitamin B12 und Blutsenkungsgeschwindigkeit (BSG) bestimmt.Es wurden 103 Teilnehmer mit einem mittleren Alter von 53 ± 10 Jahren und einer mittleren Krankheitsdauer von 10,55 ± 7,34 Jahren in die Studie einbezogen. In 69,9% der Fälle wurden die Patienten mit MTX und in 80,5% mit Kortikosteroiden behandelt. Bei 13% der Patienten bestanden familiär kardiovaskuläre Erkrankungen, bei 25% Hypertonie und bei 18% Diabetes mellitus. In 35% der Fälle war der EULAR 2015 HeartSCORE hoch oder sehr hoch (5%). Im Mittel betrug der Hcy-Wert 12,54 ± 4,2 µmol/l [6,89–32,92], und eine Hyperhomocysteinämie lag bei 20,4% der Patienten vor. Die Auswertung ergab, dass eine Hyperhomocysteinämie mit männlichem Geschlecht (p = 0,01), MTX-Therapie (p = 0,01), Rauchen (p = 0,008), Niereninsuffizienz (p = 0,04) und hoher Krankheitsaktivität (p = 0,05) assoziiert war, aber es gab keinen Zusammenhang mit dem HeartSCORE (p = 0,23). Der Hcy-Wert war negativ mit den Werten für Folsäure (p = 0,009) und Vitamin B12 (p = 0,02) korreliert und positiv mit dem Alter (p = 0,01), C‑reaktivem Protein (CRP; p = 0,05) und dem Simplified Disease Activity Index (SDAI; p = 0,03). In der multivariaten logistischen Regressionsanalyse schienen eine derzeitige MTX-Therapie, Werte für Vitamin B12 und Kreatin sowie der Clinical Disease Activity Index (CDAI) unabhängige Faktoren zu sein, die mit Hyperhomocysteinämie assoziiert waren.MTX-Therapie, CDAI und die Werte für Vitamin B12 und Kreatin sind unabhängige, mit Hyperhomocysteinämie assoziierte Faktoren.

The article starts with a report on the history of medical simulation with some examples, and then it explores the evolution of mannequins and the methods using simulation in medicine, from the beginning to their present use.

Galectin-3 is a new biomarker assumed to reflect fibrogenesis and inflammation. We aimed to investigate the relation of Gal-3 with the severity of coronary artery disease in patients with ST elevation myocardial infarction.The prospective study enrolled 62 patients with ST elevation myocardial infarction who underwent coronary angiography. The burden of atherosclerosis was assessed by the number of involved vessels, the number of coronary lesions with a stenosis diameter more than 50% and the Gensini score. Gal-3 levels were measured on admission on miniVIDAS (BioMérieux).The mean age of the patients was 56±11 years old; 93.5% were males. Diabetes, hypertension and hyperlipidemia were respectively 29%, 35.5% and 24.2%. Among patients, 80.6% were active smokers. Mean level of Gal-3was 17±11 ng/ml and didn't differ significantly from the number of involved coronary vessels (p=0.82) and the Gensini score (p=0.4). There was a positive correlation between the number of coronary lesions with a stenosis diameter greater than 50% and Gal-3 (p=0.04).In patient with ST elevation myocardial infarction we found a positive correlation between the number of coronary stenosis and Gal-3 level.

BACKGROUND Coronary diseases remain the first cause of death in the world; the management of this condition has improved, thanks to new technical tools and multicentric registries. Recently in Tunisia, the number of intervention procedures has markedly increased, giving the explosion of cardiovascular risk factors among Tunisian people. OBJECTIVE The aim of the study was to investigate the in-hospital and one-year clinical outcome of patients treated with percutaneous coronary intervention (PCI) in Tunisia. METHODS We will conduct a prospective, multicentric, observational study including patients > 18 year-old who underwent a PCI between 31January and 30 June 2020. The primary end point are the occurrence of a major adverse cardiovascular event , defined as cardiovascular death, myocardial infarction, cerebrovascular accident, and target vessel revascularization with either repeat PCI or coronary artery bypass surgery (CABG). Secondary end-points consist in procedural success rate, stent thrombosis, and the rate of redo-PCI/CABG for in-stent restenosis. RESULTS Results will be available at the end of the study as well as the demographic profile and general risk profile of Tunisian patients undergoing PCI. The complexity level of procedures, as left main, bifurcation, chronic occlusion PCI will be analyzed and immediate as well as long term results will be determined. NATURE-PCI will be the first national multicentric registry of angioplasty in Africa. CONCLUSIONS This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of contemporary coronary artery disease in this developing region. CLINICALTRIAL clinicaltrials.gov

Background The effects of Ramadan fasting (RF) on cardiometabolic risk factors in patients with stable ischemic heart disease are not well known. Aim The aim of this study was to evaluate the impact of RF on lipid profile and cardiovascular risk factors in patients with a stable coronary heart disease. Methods A prospective observational study carried out in the Cardiology department of Charles Nicolle Hospital (Tunisia). Eighty-four patients with a stable ischemic heart disease who intended to fast were enrolled during May 2020. Detailed clinical and biochemical assessments were performed before and after the holy month. Parameters of glycemic control, lipid profile, ultrasensitive C-reactive protein concentration (us-CRP) and homocysteine were performed before- and after- Ramadan (BR and AR, respectively). Results Eighty-four patients including 79 males and 5 females, with a mean age of 57 ± 7 years completed the study. Levels of cholesterol, triglycerides, low-density lipoprotein-cholesterol and apoprotein A were significantly improved AR fasting in comparison with their BR values. There was a significant decrease in blood fasting glucose, insulin level, Homeostasis model assessment of insulin resistance index and in us-CRP level. Conclusion In patients with stable ischemic heart disease, RF may be accompanied by an improvement of lipid profile and glycemic parameters without increase in coronary events.

Simulation is a growing pedagogical method in training health professionals. The use of high-fidelity simulators may be associated with significant stress.to measure self-assessed intensity of stress before and after a planned simulation training session of a third degree atrio-ventricular block among medical students.A sample of 30 students participating in a high-fidelity simulation training course (10 playing the role of team leader and 20 in the role of medical intern) was studied. Stress was evaluated by self-assessment using a numerical scale before and after the session. The peri-traumatic distress inventory was used to measure the level of distress experienced by the participants.The median stress score was 3, 5±2, 4 before and 6, 2±2, 4 after the simulation session (p0.001). Stress intensity increased significantly after the session in students playing the role of the team leader than those playing the role of medical intern (8, 4±0, 8 versus 5, 2±2, 3 p0.001).The average score for peri-traumatic distress inventory was also significantly higher in the team leaders (18, 8±10, 4 Vs 9, 2±3, 7 p=0,022).Simulation-induced stress, as measured by self-assessment, increased significantly after the session and was influenced by the role to be played during the scenario. Stress should be taken into account before debriefing.

Background The rheumatoid arthritis is responsible of an increased risk of cardiovascular (CV) morbidity and mortality. Objectives The aim of the study is to determine, in established RA patients, the presence of silent myocardial ischemia using a stress test and its association with the disease activity and the CV risk factors and scores. Methods It is a transversal and prospective study in a rheumatologic center in Charles Nicolle hospital in Tunisia. 103 RA patients, asymptomatic for CV disease were submitted to a stress test. Demographic data, cardiovascular risk factors and the disease characteristics were assessed for all patients and risk factors of silent myocardial ischemia in RA patients were identified. The comparison of qualitative variables was performed with the Chi square test and the comparison of qualitative variable and quantitative ones was performed with the Student’s test. The significance level was set at 0.05. Results There were 103 patients (sex-ratio=0.3) with a mean age of 53±10 years. The evaluation of the disease activity showed that the mean DAS28 CRP, CDAI and SDAI were 3.9±1.38, 17.17±11.4 and 33.39±26, respectively. A screening for CV risk factors revealed: 13% of patients had a cardiovascular inheritance, 25% of patients were either smokers or hypertensives, 18% had diabetes, 70% were obese or overweighted and 14 patients had dyslipidemia. The ischemic ratio (CT/HDL) revealed that 42% of patients had a moderate to high myocardial ischemic risk. HeartSCORE was high in 35% of cases. A silent myocardial ischemia in the stress test was found in 11 patients (10.6%) and was associated with male sex (p=0.03), advanced age (p=0.04), erosive character (p=0.05), the advanced age of the rheumatoid arthritis diagnosis (p=0.01) and the ischemic ratio (p=0.06). No relationship was found with the majority of traditional CV factors nor with disease activity variables. Conclusion Our results corroborated the hypothesis that the stress test could reveal subclinical CV dysfunction, supported the utility of the Heartscore as a screening tool, and put in perspective the potential usefulness of complementary approaches in CV risk assessment in RA patients. Disclosure of Interests None declared

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

Resume Introduction Le risque cardiovasculaire apparait tres tot dans l’histoire du diabete, il est lie a l’hyperglycemie mais surtout aux autres facteurs de risque frequemment associes. Objectif Evaluation de la prevalence des facteurs et des marqueurs de risque cardiovasculaire non conventionnels dans une population de diabetiques tunisiens. Methodes Nous avons inclus dans une etude prospective des patients diabetiques de type 2 recemment diagnostiques et des temoins non diabetiques apparies selon l’âge et le sexe. Parallelement au bilan biologique classique, une analyse des facteurs de risque cardiovasculaires non traditionnels a ete realisee : microalbuminurie des 24 heures, C reactive proteine ultrasensible (CRPus), homocysteine, vitamine B12, folates et insulinemie. Tous les participants ont beneficie de plus d’une echographie abdominale a la recherche d’une steatose hepatique. Resultats L’âge moyen des 120 patients diabetiques (51,4 ± 8,9 ans) etait comparable a celui des 60 temoins (50,1 ± 6,39 ans). Une microalbuminurie etait retrouvee chez 27,5 % des diabetiques et 6,9 % des temoins (OR = 5,1 ; p = 0,001). Les deux tiers des diabetiques avaient un syndrome metabolique contre un quart des temoins (OR = 6,0 ; p Conclusion Les facteurs de risque cardiovasculaire non traditionnels etaient plus frequemment observes chez les sujets ayant un diabete de type 2 de decouverte recente que dans la population temoin. Ces facteurs non conventionnels peuvent etre utiles pour la stratification du niveau du risque et pour guider la strategie de depistage des cardiopathies ischemiques.

Several studies have suggested a relationship between weather parameters and the occurrence of sudden cardiac death.The aim of this work was to study the impact of changes in temperature and humidity level on the occurrence of sudden cardiac death in the north of Tunisia.it's an autopsic study that included all victims of sudden cardiac death occurring in northern Tunisia between October 2010 and September 2012. The minimum, maximum and average of daily temperatures and humidity during the study period were recorded and compared with the monthly variation in the occurrence of sudden death.The study population included 392 men and 108 women with a mean age of 52.2 + / - 15.8 years.The highest rate of sudden death (37%) was observed at ambient temperatures below 15 degrees and only 4.2% of deaths occurred at temperatures above 30 degrees ambient temperatures (p0.001). Among the population aged over 60 years, the highest mortality rate (47.3%) were recorded at temperatures below 15 degrees, while 35.5% of young patients under 40 years died during periods with temperatures between 20 and 30 degrees and 56.8% of deaths occurred in the humidity levels between 60 and 78% .In the north of Tunisia where the climate is temperate, a temperature drop below 15 degrees was significantly associated with a sudden cardiac death. This excess winter cardiac mortality was more pronounced in the elderly.

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

The sudden cardiac death remains a major public health problem. Several studies have reported weekly variation of this dramatic event.The aim of this work is to determine the day-of-week variability in sudden cardiac death in northen Tunisia.We prospectively collected clinical, socio demographic and autopsic data of victims of sudden cardiac death occurring in the northern Tunisia between october 1 st ,2010 and september 30,2012.The study population included 392 men and 108 women with a mean age of 52.27 + / - 15.8 years. Three quarters of the victims was sedentary, 57.9% were smoker and a family history of sudden death was identified in 9.8% of cases. The vast majority of deaths had occurred either in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the leading cause of death with 267 cases (53.4%); however a negative autopsy was found in 13.9% of victims. The highest sudden death occurrence was on Sundays (17.8%) and the lowest on Mondays (11.4% p: 0.01).The same weekly variation was noted among both men and women , and also in victims60 years, a minimum of events occurred on Mondays (11.6%) and a maximum on Sundays (21.9%). In addition, we found the same peak of mortality on Sunday (18.8%) in young adults and the nadir on Monday (10.3%).The present study demonstrates marked variation in the occurrence of sudden cardiac death in the northern Tunisia with peak on Sundays and nadir on Mondays. No age or gender- related differences were found in weekly variation of sudden death.

Although coronarography is still the gold standard to evaluate coronary lesions, it remains a bidimensional representation of a tridimensional complex structure, which can represent a source of error in measurements.to perform a correlation and concordance study between quantitative coronary angiography (QCA) and intravascular ultrasound measurements for intermediate and ambiguous lesions.We analysed 40 patients' coronary arteries from March 2009 to November 2011 by both QCA and intravascular ultrasound to perform then a correlation and concordance study.the correlation study confirmed the limits of the angiogram in providing accurate measurements. The correlation coefficient was yet high in reference diameters (r=0,78, p0,001) and minimal lumen diameters (r=0,58, p0,001), but was middling for stenosis percentages (r=0,23, p=0,03). This coefficient was also high for lesions lengths (r=0,51, p=0,01). BlandAltaman diagrams showed however wide limits of agreement, reflecting possibility of large measurements error and confirming the absence of concordance between the two techniques.Coronarography though being the most widespread mean of evaluating coronary lesions lacks to provide accurate measurements, which can influence patient's management, especially in case of intermediate lesions.

Background : In Tunisia, diabetes mellitus and hemoglobinopathies are major public health problems. Glycated hemoglobin (HbA1c) is recommended for long-term monitoring of diabetes mellitus, but the presence of hemoglobin variants may interfere with HbA1c measurement. The aim was to determine the prevalence of hemoglobin variants in Tunisian diabetics and optimize the monitoring of diabetics using HbA1c. Methods : The study enrolled 9,792 Tunisian diabetic patients. HbA1c was measured by cation-exchange high-pressure liquid chromatography (HPLC). All the chromatograms were analyzed for the presence of Hb variants. Results : We identified 228 cases (2.33%) of Hb variants with D-10 HPLC (Bio-Rad): 191 with HbA/S trait, 27 with HbA/C trait, and 10 hemoglobin variants with the mention ‘Variant-Window’ on the chromatograms and subsequently identified as HbA/S on Variant I HPLC (Bio-Rad). Thus, the prevalence of HbS was 2.05%. We did not find any homozygous variant. All HbA1c results were reported to the treating physician. Conclusions : To evaluate glycated hemoglobin in populations with a high prevalence of hemoglobinopathies, we should use the HPLC method, which is easy, economical, and reliable. Based on an algorithm, hemoglobin variants visualized on HPLC should be reported to the physician to improve the management of patients. Keywords: hemoglobinopathies; HbA1c; HPLC; diabetes mellitus; prevalence; Tunisia (Published: 27 October 2014) Citation: Libyan J Med 2014, 9 : 25768 - http://dx.doi.org/10.3402/ljm.v9.25768

Coronarography presents some limits in assessing intermediate stenosis. Intravascular ultrasound provides tridimensional measurements of the artery, with more reliable data guiding revascularization decision.to evaluate the impact of intravascular ultrasound measurements on revascularization decision of intermediate and ambiguous coronary lesions.We prospectively analysed 40 patients' coronary arteries from March 2009 to November 2011 by both quantitative coronary angiography (QCA) then intravascular ultrasound, and compared our decision before and after intravascular ultrasound.in the final revascularization decision after intravascular ultrasound, medical treatment rate raised from 22% to 25%, percutaneous coronary intervention dropped from 55% to 50%, and coronary artery bypass graft slightly raised from 23% to 25%. Therapeutic decision changed after intravascular ultrasound in 47% of patients (p=0,01), which reflects an important impact of this technique in management of intermediate coronary lesions.Intravascular ultrasound provided more accurate measurements which permitted a better detection of ischemia and influenced notably our therapeutic strategies.

Prognosis of acute coronary syndrome (ACS) in elderly patients is bleak. Also older people tend to receive less invasive treatment than younger patients.To analyze the impact of coronary revascularization on the mid-term outcome of septuagenarian patients admitted with ACS.We retrospectively studied 250 patients 70 years or older hospitalised for ACS between january 2006 to september 2010.This population was more likely to be male with mean age 74 years and 93 % of ACS were inaugural events (60% NSTEMI, 40% STEMI). Coronary angiograms showed complex coronary lesions with a high incidence of multivessel disease, bifurcation lesions, and calcified stenosis. Seventy-six patients were treated medically and 174 underwent percutaneous or surgical revascularization. At six-month clinical follow-up, major adverse cardiac events (MACE) were significantly higher in medically treated than revascularized patients (62% Vs 31.7%, P0.001). Patients with invasive strategy have significantly higher event free survival rate comparing to those assigned to medical management (64% Vs 49.7%, p: 0.01).Our study confirmed the superiority of invasive strategy compared to medical treatment in septuagenarian patients with acute coronary syndromes. Advanced age should not exclude patients from invasive strategy with complete revascularization.

Although the prognosis of acute coronary syndrome (ACS) in elderly patients is bleak , elderly population is less well treated both in medical and interventional terms. aims: to analyse angiographic findings in septuagenarian patients admitted with ACS and its impact on the therapeutic strategy.We retrospectively analysed 250 patients 70 years or older hospitalised for ACS who underwent a coronary angiography between january 2006 to September 2010.This population was more likely to be male with mean age 74 years and 93 % of ACS were inaugural events (60% N STEM, 40% STEMI).Coronary angiograms showed complex, diffuse coronary lesions with a high incidence of multivessel coronary artery disease , bifurcation lesions , and calcified stenosis.Angiographic findings after ACS in elderly were characterised by multivessel disease and complex lesions .Surgical or percutaneous coronary revascularizaion was possible in the majority of these patients.

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

The presence, extent and location of calcium in coronary artery lesions are important determinants of the success of per cutaneous coronary intervention (PCI). Although coronarography remains the gold standard for coronary disease detection, Intravascular ultrasound ( IVUS) is proposed as a superior technique for identifying patients with coronary artery calcification .To define sensibility and specificity of coronary angiography in detecting calcifications considering the IVUS as gold standard.Target lesion calcification was assessed in 40 patients (35 men; mean age 57.4 ± 10 years) by angiography and intravascular ultrasound.Ultrasound detected calcium in 51 of 85 target lesion (60%),whereas angiography showed calcifications in only 16 lesion (19% p0.001 compared with IVUS). Coronary angiography detected 8% of 0-45° arc calcium category, 7% of 45-90° calcium category, 58% of 90-180° calcium category, and 80% of more than 180° calcium category. The overall sensitivity of angiography in identifying calcium was 31% and increased with an increasing arc of lesionassociated calcium. The overall specificity of the angiographic detection of target lesion calcium was 100%.Intra coronary ultrasound analysis shows that target lesion calcification is much more widespread in coronary artery disease than what angiography reveals. The sensitivity of angiography was poor, with although a very high specificity.

The cardiovascular risk appears very early in the history of diabetes mellitus and is related not only to hyperglycemia but mainly to the other risk factors associated to diabetes mellitus.To evaluate the prevalence of non-conventional cardiovascular risk factors in a Tunisian diabetic population.The prospective study enrolled 120 type 2 diabetic patients recently diagnosed and 60 healthy people, sex and age matched. All have benefited from blood sampling in order to analyze biological parameters routinely undertaken in diabetes. Non-conventional cardiovascular risk factors were also determined such as: microalbuminuria of 24 hours, high sensitivity C-reactive protein (hs CRP), homocysteinemia, vitamin B12, folate and insulinemia. The participants have also benefited from abdominal echography to search nonalcoholic hepatic steatosis.Diabetics were aged 51.4 ± 8.9 years in comparison with healthy people (50.1 ± 6.39 years). A positive microalbuminuria was observed in 27.5% of diabetics versus 6.9% in healthy people (OR=5.1; P=0.001). The two third of diabetics had metabolic syndrome versus 25% of healthy people (OR=6.0; P0.001) and insulinoresistance evaluated by HOMA-IR, was 3.4 ± 0.2 in diabetics versus 2 ± 0.1 in healthy people; P0.001. HsCRP level was significantly higher in diabetics in comparison with healthy people (3.7 ± 0.2mg/L versus 1.9 ± 0.3mg/L; P0.001) and hyperhomocysteinemia was more frequently found in diabetics. Also, we noted that 69.6% of patients had hepatic steatosis versus only 24.6% of healthy people (OR=7.1; P0.001).The non-conventional cardiovascular risk factors were more frequently found in early diagnosed type 2 diabetic patients than in healthy people. These non-conventional factors could be helpful in stratification of the cardiovascular risk level and also in the screening of ischemic heart diseases.

Introduction Arterial hypertension (AH) is a potent factor of cardiovascular death in chronic dialysis patients (CDP). Development of ambulatory blood pressure monitoring (ABPM) allowed a better analysis of inter dialysis blood pressure (BP) profile. We studied the relationship between ABPM findings and clinical and biological data in CDP, to determinate its clinical application. Methods Retrospective study of 24 hours ABPM (after dialysis) in 28 CDP divided into 3 groups according to pre dialyses BP profile: G1: CDP with controlled AH (n=8) G2: CDP with un-controlled AH (n=12) G3: CDP without AH (n=8) Results ABPM findings are correlated to clinical BP measurements before and after dialysis. Mean systolic ABP is lower than pre dialysis clinical BP. 82% of CDP loose the BP circadian cycle. 64,3% of CDP and 83,3% of patients with AH had echocardiographic left ventricular (LV) hypertrophy. LV mass is correlated to BP load, the anemia's severity, the loss of the BP circadian cycle and the use of acetate in dialysis bath. Conclusion ABPM in CDP has various clinical applications: • diagnosis of AH • Evaluation of AH treatment • Evaluation of cardiovascular death risk

Atrial fibrillation (AF) is a frequent complication after coronary artery bypass grafting (CABG) which increase morbidity and hospitalization length.To identify the predictors of atrial fibrillation and its repercussion on hospital and mid-term outcomes in patients undergoing (CABG).We undertook a retrospective review of the data of 224 patients undergoing CABG. The mean age of the patients was 60.8 years. Atrial fibrillation was diagnosed from serial postoperative electrocardiogram.Twenty two patients developed postoperative atrial fibrillation. Multivariate analysis showed that only: age, left circumflex stenosis, sternal wound infection and low cardiac output were predictors of AF following CABG. Hospital mortality was similar in the two groups (5% Vs 9.6 % P=0.7).In our study, the incidence of post-CABG atrial fibrillation was 9.8%. Multivariate predictors were age, left circumflex lesion, sternal wound infection and low cardiac output. Hospital mortality and mid-term outcome were similar in the two groups.

The outcome of coronary artery bypass grafting (CABG) in diabetic patients has traditionally been worse than in nondiabetic patients. Recent studies have suggested an improvement in outcome in diabetic patients undergoing CABG. However, the direct impact of diabetes on mortality and morbidities following CABG remains unclear.To evaluate the early and mid term outcomes of diabetic patients compared to non-diabetics following CABG.We retrospectively analyzed the data of 228 CABG patients from January 2005 to December 2010: one hundred and twenty-six diabetics and 102 non-diabetic.Diabetic patients were more likely to be female(27% Vs 12.7% P=0.009) were less smoker (55.6% Vs 80.4% P0.0001) with higher rate of three vessel disease(67.5% Vs 42.2% P=0.005) compared to non-diabetics.Hospital mortality was significantly higher among diabetic patients (16% Vs 4.1% P=0.005).Length of care unit stay was more important (2.3 days Vs 2.1 days P=0.048) , but with a similar rate of sternal wound infection even after bilateral internal thoracic artery grafting. After 28 months mean follow- up, mid-term survival of diabetics was significantly decreased compared to no-diabetics (91% Vs 99% p0.001) .However, Event-free survival was similar in the two groups (76% Vs 80% p=0.82).These results suggest that diabetes is associated with poorer early and mid-term outcomes following (CABG).

The issue of superiority of single internal thoracic artery grafting versus bilateral internal thoracic artery grafting remains unresolved.The aim of this study was to compare the early results and midterm outcome of single and bilateral internal thoracic artery grafting for multivessel coronary artery bypass grafting.Between January 2005 and March 2010, 196 patients underwent primary coronary artery bypass grafting with at least one internal thoracic artery grafts. Early results and Outcomes of patients undergoing single internal thoracic artery (SIMA) plus saphenous vein grafting (n=145) and bilateral internal thoracic artery (BIMA) plus saphenous vein grafting (n=51) were obtained at a mean followup of 29 months.Patients with bilateral internal thoracic artery grafting were younger, had less hypertension, higher left main disease and better Euroscore than patients undergoing single internal thoracic artery grafting. In-hospital mortality was similar for the two groups: 6.9 % for patients undergoing SIMA versus 5.9 % for those undergoing BIMA (p=0.8). Sternal wound infection was also similar (2.8% versus 3.9% p=0.68). Mid-term mortality was (4% VS 4.8% p=0.71) and event free survival probability at 28 months was 75% for the single-graft group compared with 85.7% for the bilateral-graft group (P =0.46).Our study found similar early and mid-term clinical outcomes for patients undergoing SIMA plus saphenous vein grafting and those undergoing BIMA plus saphenous vein grafting for multivessel coronary artery bypass grafting.

Echinococcosis is a human infection caused by the larvalstage of Echinococcocus granulosus. The most commonsites of infection are the liver and the lungs. Cardiac in-volvement is very rare (0.5-3%) even in regions in whichhydatic disease is endemic (the south Mediterranean coun-tries and Africa). We report a case of a 28-year-old man,who died suddenly. According to his family he was an ap-parently healthy man without medical history; he was founddead in the bathroom. The post-mortem examination re-vealed a large cyst (6×8 cm) in the left ventricle of the heartwith an intact wall (Picture 1) and a small daughter cystprotruding in the pericardial cavity (Picture 2, panel A). Thecytologic examination of the cyst fluid demonstrated thepresence of the characteristic scolices and hooklets and con-firmed the diagnosis of cardiac hydatid cyst. Causes of car-diac sudden death involve different mechanisms (1) includ-ing ventricular arrhythmia, cardiac outflow obstruction orconduction tract disturbance, pulmonary and cerebral embo-lism, cardiac tamponade, and myocardial ischemia.

Purpose Despite significant enhancements in resuscitation methodology, survival after sudden cardiac arrest remains low. Improved knowledge of warning signs and symptoms may help to detect victims for sudden death. Aim to study the warning symptoms prior to sudden cardiac death. Methods We prospectively collected epidemiological and autopsy data from victims of sudden cardiac death in northern Tunisia (3.6 million people) between October 2012 and September 2013. We included victims ?20 years old requiring a forensic autopsy. Data (risk factors, symptoms) were collected by assessment of the accounts of family members/relatives, witnesses, as well as medical records during this time period. The heart was weighed and then investigated by macroscopic examination looking for scars of myocardial infarction. The three main coronary arteries were macroscopically examined by transverse slices at 2-3-mm intervals along their lengths. Results Of the 542 sudden deaths within the study period, 372 males and 91 females were medico-legally autopsied. Mean age of victims was 50.9±15 years. Physical inactivity and smoking were the most common risk factors, accounting for 74.7% and 61.5%, respectively. A family history of sudden death was identified in 10.8% of victims. Most deaths occurred in a public place (39.3%) or at home (36.9%). Of the total deaths, 298 (64.4%) occurred while the individuals were relaxing, 52 (11.2%) while sleeping, 92 (19.9%) while dealing with an activity, and 21 (4.5%) under emotional stress. Syncope was the most frequent symptom occurring in 36.1%, chest pain in 18.6%, dyspnea in 8.6% and 10.1% had dizziness or fainting. The autopsic study showed that 231 deaths (49.9%) were due to coronary artery diseases. Eight percent of victims have consulted a doctor within the last 48 hours and 21% up to 1 month. Conclusions Warning symptoms prior to sudden cardiac death may occur longer before the death. Recognizing these precocious signs could have implications for prevention of this public health problem.

Introduction Heart failure is a common problem in elderly people. In the elderly population, heart failure with preserved ejection fraction (HFPEF) has been increasingly recognized. The aim of this study was to compare clinical features and clinical outcomes between HFPEF and HFREF in patients older than 65 years. Methods We enrolled 30 patients over 65 years old, who were admitted for heart failure between April 2009 and February 2010. We retrospectively analysed the clinical features including laboratory data and echocardiography parameters. Results In 19 patients (63%) left ventricular ejection fraction was preserved. Acute pulmonary edema (74% vs 27%) is the most frequent presentation in patients with HFPEF. Those patients have thicker left ventricular wall (68% vs 27%). The ischemic heart diseases as background disease is more frequent in HFREF (46% vs 5, 2%). There was no difference in short-term outcomes between HFPEF and HFREF. Conclusion Our study has shown that more than the half of the CHF patients over 65 years of age had HFPEF. Left ventricular hypertrophy was one of the risk factors for HFPEF, and the short-term outcomes of HFPEF in this population were not different from that of HFREF.