Habib Haouala

Lack of association between factor V Leiden and prothrombin G20210A polymorphisms in Tunisian subjects with a history of myocardial infarction

BACKGROUND Myocardial infarction is a multifactorial disease. It is provoked by occlusions in the coronary arteries resulting from exposure to multiple risk factors. OBJECTIVE To study the risk of myocardial infarction associated with the gene polymorphisms of factor V Leiden and factor II (G20210A). MATERIALS AND METHODS Cases consisted of 100 myocardial infarction patients who were hospitalized in the Principal Military Hospital of Tunis and 200 control subjects with no history of myocardial infarction. RESULTS The prevalence of the factor V Leiden was higher in myocardial infarction patients (9%) than in control subjects (6%) with an OR=1.55 (95% CI=0.58-4.12), whereas the prevalence of prothrombin G20210A mutation was 3% and 2.5% in the patient and control groups, respectively [OR=1.21 (95% CI=0.22-5.94)]. CONCLUSION Our results indicate that neither factor V Leiden nor the prothrombin G20210A contributed to the risk factors for myocardial infarction.

The Effect of ACE I/D Polymorphisms Alone and With Concomitant Risk Factors on Coronary Artery Disease:

Background: Coronary artery disease (CAD), also known as atherosclerotic heart disease, is a leading cause of mortality and morbidity throughout the world. The role of insertion/deletion (I/D) polymorphisms of the angiotensin-converting enzyme (ACE) gene in the etiology of CAD remains to be more completely clarified. The aim of this study was to determine the role of the ACE I/D polymorphism in patients with CAD and to study the association together with traditional risk factors in assessing the risk of CAD. Methods: Our study population included 145 Tunisian patients with symptomatic CAD and a control group of 300 people matched for age and sex. All participants in the study were genotyped for the ACE I/D polymorphisms obtained by polymerase chain reaction amplification on genomic DNA. Results: Our analysis showed that the ACE D allele frequency (P < 10−3; odds ratio [OR] = 5.2; 95% confidence interval [CI] = 3.6-7.6) and DD genotype (P < 10−3; OR = 6.8; 95% CI = 4.4-10) are significantly more prevalent among patients with CAD than in controls and may be predisposing to CAD. We further found that the risk of CAD is greatly potentiated by several concomitant risk factors (smoking, diabetes, hypertension, dyslipidemia, and a family history of CAD). Conclusion: The ACE D allele may be predictive in individuals who may be at risk of developing CAD. Further investigations of these polymorphisms and their possible synergisms with traditional risk factors for CAD could help to ascertain better predictability for CAD susceptibility.

Spontaneous multivessel coronary artery dissection associated with cannabis use

Cannabis is the most widely used illicit drug in the world. It is generally considered to be a drug with low toxicity. Nevertheless, there are several case reports of myocardial infarction following cannabis use in otherwise low-risk individuals. We report the first case of a cannabis user presenting with acute coronary syndrome related to multivessel coronary artery dissection.

Samter–Beer triad presenting as Kounis type I variant of syndrome

Kounis syndrome (KS) was first described in 1991 by Kounis and Zavras. It has been established as an acute coronary syndrome triggered by allergic or hypersensitivity reactions resulting in mast cell and platelet activation. Various causes have been found to trigger KS including drugs, various conditions (bronchial asthma, urticarial, food allergy), environmental exposure and stent implantation. Clinical manifestations of Kounis syndrome include the spectrum of acute coronary syndromes, including coronary spasm, acute myocardial infarction (MI), or stent thrombosis. KS is an infrequently diagnosis among patients with MI. Herein, we report a case of Kounis syndrome in the setting of Samter-Beer triad of asthma, nasal polyps, and aspirin allergy.

Multimodality imaging assessment of a caseous calcification of the mitral valve annulus

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

Design and Rationale of the National Tunisian Registry of Atrial Fibrillation: Protocol for a Prospective, Multicenter Trial

Background Atrial fibrillation (AF) is an important health problem in Tunisia. A significant change in the epidemiological pattern of heart disease has been seen in the last 3 decades; however, no large prospective multicenter trial reflecting national data has been published so far. Robust data on the contemporary epidemiological profile and management of AF patients in Tunisia are limited. Objective The aim of this study is to analyze, follow, and evaluate patients with AF in a large multicenter nationwide trial. Methods A total of 1800 consecutive patients with AF by electrocardiogram, reflecting all populations of all geographical regions of Tunisia, will be included in the study, with the objective of describing the epidemiological pattern of AF. Patients will be officially enrolled in the National Tunisian Registry of Atrial Fibrillation (NATURE-AF) only if an electrocardiogram diagnosis (12-lead, 24-hour Holter, or other electrocardiographic documentation) confirming AF is made. The qualifying episode of AF should have occurred within the last year, and patients do not need to be in AF at the time of enrollment. Patients will be followed for 1 year. Incidence of stroke or transient ischemic attack, thromboembolic events, and cardiovascular death will be recorded as the primary end point, and hemorrhagic accidents, measurement of international normalized ratio, and time in therapeutic range will be recorded as secondary end points. Results Results will be available at the end of the study; the demographic profile and general risk profile of Tunisian AF patients, frequency of anticoagulation, frequency of effective treatment, and risks of thromboembolism and bleeding will be evaluated according to the current guidelines. Major adverse events will be determined. NATURE-AF will be the largest registry for North African AF patients. Conclusions This study would add data and provide a valuable opportunity for real-world clinical epidemiology in North African AF patients with insights into the uptake of contemporary AF management in this developing region. Trial Registration ClinicalTrials.gov NCT03085576; https://clinicaltrials.gov/ct2/show/NCT03085576 (Archived by WebCite at http://www.webcitation.org/6zN2DN2QX) Registered Report Identifier RR1-10.2196/8523

Association of FV G1691A Polymorphism but not A4070G With Coronary Artery Disease

Coronary artery disease (CAD) is one of the chief causes of death in the world. Several hypotheses have been promoted as for the origin of the disease, among which are genetic predispositions and/or environmental factors. The aim of this study was to determine the effect of factor V (FV) gene polymorphisms (Leiden, G1691A [FVL] and HR2 A4070G) and to analyze their association with traditional risk factors in assessing the risk of CAD. Our study population included 200 Tunisian patients with symptomatic CAD and a control group of 300 participants matched for age and sex. All participants were genotyped for the FVL and HR2 polymorphisms. Multivariate logistic regression was applied to analyze independent factors associated with the risk of CAD. Our analysis showed that the FVL A allele frequency (P < 10–3, odds ratio [OR] = 2.81, 95% confidence interval [CI] = 1.6-4.9) and GA genotype (P < 10–3, OR = 4.03, 95% CI = 2.1-7.6) are significantly more prevalent among patients with CAD compared to those controls and may be predisposing to CAD. We further found that the FVL mutation is an independent risk factor whose effect is not modified by other factors (smoking, diabetes, hypertension, dyslipidemia, and a family history of CAD) in increasing the risk of the disease. However, analysis of FV HR2 variation does not show any statistically significant association with CAD. The FVL polymorphism may be an independent risk factor for CAD. However, further investigations on these polymorphisms and their possible synergisms with traditional risk factors for CAD could help to ascertain better predictability for CAD susceptibility.

0185: Prevalence of conventional risk factors in 44154 Tunisians patients with coronary heart disease

Introduction The prevalence of the major conventional cardiovascular risk factors (cigarette smoking, diabetes mellitus, hypertension, and dyslipidemia) among coronary heart disease (CHD) patients in Tunisia has not been studies extensively. The aim of this study was to evaluate the frequency of cardiovascular risk factors and their association in patients hospitalised for coronary heart disease at Rabta, charles Nicolle, Habib Thameur, Military Hospitals (Tunis), Fattouma Bourguiba hospital (Monastir), Farhat Hached, and Sahloul hospitals (Sousse); Mohamed Tahar Maamouri Hospital (Nabeul); Menzel Bourguiba Hospital and Ibn El Jazzar Hospital (Kairouan) over the period 1994-1998 and during 2004. Methods The clinical features of 44154 patients (25635 men (58.1%) and 18519 women (41.1%) on hospital admission were analyzed. Results 40.8% of the patients were hospitalized for coronary deficiency, 16.5% for valvular cardiopathy, 4.8% for cardiomiopthy, 16.9% for arrhythmia and conduction disturbance, 3.6% for essential hypertension, 2.5% for stroke and 14.9% for various pathologies. The prevalence of hypertension, diabetes, smoking, obesity and dyslipidemia was 29.9%, 30.3%, 66.9%, 11.9%, and 30.2% respectively in the men and 43.5%, 30.2%, 3.5%, 14.6%, and 27.1% respectively in women. Conclusion With this risk factor profile Tunisia has to implement a national strategy of primary prevention and heart health promotion in addition to the efforts recently made in secondary prevention of some chronic disease such as hypertension, diabetes, and smoking.

0337 : Predictors of early mortality in acute myocardial infarction complicated by cardiogenic shock

Introduction The most serious complication during myocardial infarction (MI) is cardiogenic shock. Its the result of myocardial and/or mechanical failure complication. The aim of our study was to investigate the epidemiological and clinical characteristics of a serie of patients hospitalized for MI complicated by cardiogenic shock as well as the predictive factors of early mortality. Methods It was a single-center retrospective study of 70 patients hospitalized in the service of cardiology of the military hospital for myocardial infarction complicated by cardiogenic shock, between 2005 and 2012. Results The mean age was 63±10 years, 80% were men. Cardiovascular risk factors were as follows: 89% were smokers, 62% presented diabetes mellitus, 50% had hypertension, 40% had dyslipidemia and 10% had a family history of coronary artery disease. 24% of patients had renal insuffisancy. 39% were admitted before the 6th hour from beginning of chest pain, 12% were admitted between the 6th and the 12th hour and 45% were admitted beyond the 12th hour. On admission 41% were in left ventricular failure, and 59% in shock. The majority of myocardial infarction (45%) were anteriors. Angiography had identified a single truncal achieved in 28% of cases, bi- vessel in 44% of cases and tri- truncal in 28% of cases. The trans-coronary angiolpasty (TCA) was primary in 27% of cases and of rescue in 73% of cases. Revascularization was complete in 37% of cases. The mean LVEF was 49±14.4%. The average of hospital stay was 7±8 days. Hospital mortality was 47%, occurring on average in the sixth day of hospitalization (6±9 days). We found that renal failure, late onset of shock, hyperglycemia, leukocytosis, use of vasopressors, and the anterior territory of MI were significantly predictive of hospital mortality. Conclusion Despite advances in the treatment of myocardial infarction, particularly reperfusion techniques, and medical care in intensive care units, cardiogenic shock mortality in acute phase of myocardial infarction remains high. Renal failure, late onset of shock, hyperglycemia and the anterior territory of MI were the major predictive of hospital mortality. A multidisciplinary approach including medical actors and pre-hospital centers specialized in the treatment of this condition is actually necessary. The author hereby declares no conflict of interest

0495: Clinical impact of second-generation everolimus eluting stent compared with first-generation sirolimus-eluting stent in diabetes mellitus patients

Purpose This study sought to study the second-generation everolimuseluting stent (EES) as compared with first-generation sirolimus-eluting (SES) in diabetes mellitus (DM) patients. Methods All DM patients treated with EES or SES from January 2010, to December 2011 were included. The EES was compared with SES for the primary composite endpoint of clinically driven detected restenosis, definite stent thrombosis (ST), and all-cause mortality. Results In 226 percutaneous coronary intervention-treated DM patients, 353 stents were implanted (EES 118, SES 235). The EES was associated with significantly lower restenosis rates compared with SES (SES vs. EES: 16.7% vs. 2.8%, p=0,001, OR: 2.96; 95% CI: 1.57 to 5.57). Lower incidence of ST (SES vs. EES: 2,1% vs 0,8%, p=0,38) and mortality (SES vs. EES: 1,7 % vs 0%, p=0,15) was noted but did not reach statistical significance. Conclusions In all-comer DM patients the use of EES was associated with improved outcomes compared with SES mainly driven by lower rates of clinically driven detected restenosis.