Sonia Hamdi

Platelet glycoprotein IIIa (platelet antigen 1/platelet antigen 2) polymorphism and 1-year outcome in patients with stable coronary artery disease.

Platelet glycoprotein IIb/IIIa is a membrane receptor which plays a key role in coronary artery disease and thrombotic events. However, there is a considerable controversy regarding the clinical impact of glycoprotein IIIa platelet antigen 1 (PlA1)/platelet antigen 2 (PlA2) polymorphism as a risk factor for myocardial infarction. To evaluate the association between glycoprotein IIIa PlA1/PlA2 polymorphism and 1-year cardiovascular events occurrence in aspirin-treated patients with stable coronary artery disease. We prospectively included 188 postacute coronary syndrome patients (183 men) aged 59 ± 10 years and receiving aspirin (250 mg/day). The clinical outcome at 1 year was the composite end point of nonfatal myocardial infarction, stroke, recurrent unstable angina or cardiac death. Genotyping for PlA1/PlA2 polymorphism was conducted using PCR and restriction fragment length polymorphism analysis. The genotype distribution of glycoprotein IIIa PlA1/PlA2 polymorphism was PlA1/PlA1, 55.3%; PlA1/PlA2, 39.3% and PlA2/PlA2, 4%. Incidence of composite end point in homozygous PlA1/PlA1 carriers was significantly higher than in PlA2/PlA2 and PlA1/PlA2 patients [14.4 vs. 3.6% odds ratio 4.5 (1.2–16.6, 95% confidence interval); P = 0.012]. Multivariate analysis identified three strong predictive factors of cardiac death: age more than 65 years [odds ratio = 6.8, (1.4–34, 95% confidence interval); P = 0.018], ventricular ejection fraction less than 50% [odds ratio = 8.6, (1.7–42.6, 95% confidence interval); P = 0.008] and homozygous PlA1/PlA1 genotype [odds ratio = 8.8, (1.0–78.6, 95% confidence interval); P = 0.014]. Our results demonstrated that glycoprotein IIIa PlA1/PlA1 genotype carriers have a significantly increased risks of acute vascular ischemic events associated with a poor prognosis at 1 year. These postacute coronary syndrome patients might require an optimized secondary antithrombotic prophylaxis strategy.

Permanent cardiac pacing in a patient with persistent left superior vena cava and concomitant agenesis of the right-sided superior vena cava

Persistent left superior vena cava (PLSVC) can be incidentally detected during pacemaker implantation from the left pectoral side. Optimal site pacing is technically difficult, and lead stability of the right ventricle (RV) can lead to such a situation. We describe a case of successful single‐chamber pacemaker implantation in a 76‐year‐old woman with a PLSVC and concomitant agenesis of the right‐sided superior vena cava, after failed attempts with the conventional procedure. The pacemaker had been working well after 12 months of follow‐up.

Risk profile and in-hospital prognosis in elderly patients presenting for acute ST-elevation myocardial infarction in the Tunisian context

Objectives Little is known about the risk profile and in-hospital prognosis of elderly patients presenting for ST-elevation myocardial infarction (STEMI) in Tunisia. We sought to determine in-hospital prognosis of elderly patients with STEMI in a Tunisian center. Methods The study was carried out on a retrospective registry enrolling 1403 patients presenting with STEMI in a Tunisian center between January 1998 and January 2013. Patients ≥75 years old were considered elderly. Risk factors and in-hospital prognosis were compared between elderly and younger patients, and then predictive factors of in-hospital death were determined in elderly patients. Results Out of the overall population, 211 (15%) were part of the elderly group. Compared to younger patients, elderly patients were more likely to have arterial hypertension but less likely to be smokers and obese. Thrombolysis was significantly less utilized in the elderly group (22.3% vs. 36.6% in the younger group, p < 0.001), whereas the use primary percutaneous coronary intervention was comparable between the two sub-groups (24.2% vs. 28.8%, p = 0.17). The incidence of in-hospital complications was higher in the elderly group, and so was the in-hospital mortality rate (14.2% vs. 8.1%, p = 0.005). Heart failure on-admission, renal failure on-admission, and inotropic agents use were independently associated to in-hospital death in the elderly group. Conclusions In the Tunisian context, elderly patients presenting with STEMI have higher prevalence of risk factors and a worse in-hospital course in comparison to younger patients. Clinical presentation on-admission has a strong impact on in-hospital prognosis.

Wide QRS in a 2-month infant associated with recurrent ventricular tachycardia: A case of Brugada-like syndrome

We report the case of a 2-month old infant who experienced recurrent sustained ventricular tachycardia (VT) in a structurally normal heart. Resting electrocardiogram (ECG) showed wide QRS with a complete right bundle branch bloc (RBBB) morphology. There was no family history of syncope or sudden death, but the ECGs of the father and the brother showed incomplete RBBB with negative T waves on V1 lead. This case seems to fit well with the newly defined entity of Brugada-like syndrome with a highly suspected genetic underlying disposition.

Prevalence and prognostic significance of anemia in patients presenting for ST-elevation myocardial infarction in a Tunisian center

Background Anemia on admission is a powerful predictor of major cardiovascular events in patients presenting for acute coronary syndromes. We sought to determine the prevalence and prognostic impact of anemia in patients presenting for ST-elevation myocardial infarction (STEMI). Methods We analyzed data from a Tunisian retrospective single center STEMI registry. Patients were enrolled between January 1998 and October 2014. Anemic and nonanemic patients were compared for clinical and prognostic features and according to four prespecified hemoglobin level subgroups. In patients with severe anemia, factors associated with in-hospital death were studied. Results A total of 1498 patients were enrolled. Mean age was 60.47 ± 12.7 years and prevalence of anemia was 36.6%. Anemic patients were more likely to be elderly, hypertensive, and diabetic in comparison to nonanemic patients. In-hospital mortality was significantly higher in anemic patients (14.9% vs. 5%, p < 0.001). Lower hemoglobin levels were significantly associated with a higher prevalence of heart failure on admission, cardiogenic shock, and in-hospital mortality (p < 0.001 for all). In univariate analysis, factors associated with in-hospital death in patients with severe anemia were hypertension (p = 0.044), heart failure on admission (p < 0.001), renal failure on admission (p < 0.001), and primary percutaneous coronary intervention (pPCI) use (p = 0.016). The absence of pPCI use was independently associated with in-hospital death in multivariate analysis (odds ratio = 2.22, 95% confidence interval: 1.07–4.76, p = 0.033). Conclusion According to this study, anemic patients presenting for STEMI have a higher in-hospital mortality rate. The absence of pPCI use was independently associated with in-hospital death.

0105: Prognostic value of anemia in patients hospitalized for acute heart failure

Purpose The purpose of our study is to investigate the presence of anemia among patients admitted for acute heart failure and to evaluate its short and medium term prognostic value. Methods This is a retrospective study of 234 patients admitted in the cardiology department of Fattouma Bourguiba Monastir hospital between January 2010 and March 2011. Anemia was defined according to the criteria of the World Health Organization (WHO): Haemoglobin Results The mean hemoglobin (Hb) was 12.1±2.26g / dl. The prevalence of anemia in our population is 55.6% (N=130 cases). A significantly higher frequency of anemia is found among subjects older than 75 years (71.18% vs 50.28%, P=0.005), patients with impaired renal function (72.46% vs 48.48%, p=0.001) and among those who had shown signs of right heart failure (72.18% vs. 48.48%, p=0.001) whereas no statistically significant difference was found among hypertensive diabetics or those with impaired LVEF. 17 of our patients died during hospitalization. 10 Among these patients had anemia. The relative increase in hospital mortality in anemic patients was not significant. Nevertheless, the rate of rehospitalization during follow-up of 6 months and the rate of mortality at 6 months were significantly higher in patients who had anemia; Respectively 14.28% vs 3.68%, p=0.001 and 7.83% vs 3.68% p=0.019. Conclusion Anemia is frequent in patients admitted for acute heart failure and seems to be related to an increase in readmission and mortality at 6 months in our study.

P-193: Impact of renal failure on in-hospital prognosis in patients with hypertension presenting with acute myocardial infarction: insights from a tunisian registry

BACKGOUND Patients with hypertension (HTN) presenting with acute myocardial infarction (AMI) are at high risk of major cardiac events in the hospital course. On the other hand, renal failure on admission (RF) is common in this population. We aimed to study the impact of renal failure on admission on in-hospital mortality in patients with HTN presenting with AMI. METHODS We reviewed data from a retrospective registry including 1498 patients presenting to our center for AMI from January 1998 to November 2014. Patients were managed either by primary percutaneous coronary intervention (pPCI), prehospital thrombolysis or conservative medical treatment. In-hospital prognosis was studied according to hypertensive status of patients and the impact of RF on mortality. RESULTS Out of the overall study population, 451 (30.1%) have hypertension and 288 (19.2%) have RF (plasma creatinin rate on admission more than 120μmol/L). Patients with HTN were older (65.9 vs. 58.1 years, p<0.001), and more likely to be female (50.2% vs. 24.4%, p<0.001) when compared with patients without HTN. Patients with HTN were also more likely to have diabetes mellitus (DM) (43.8% vs. 22.5%, p<0.001), hyperlipidemia (45.2% vs. 28.3%, p<0.001), prior history of coronary artery disease (35.8% vs. 30.3%, p=0.003) but less likely to be cigarette smokers (20.6% vs. 49.2%, p<0.001). In hypertensive patients, 101 (27.4%) were managed by pPCI and 150 (29.4%) were managed by prehospital thrombolysis. Plasma creatinin rate on admission was significantly higher in hypertensive patients (120±73μmol/ L vs. 99±37μmol/L in non-hypertensives, p<0.001) with more frequently RF (46.9% vs. 25.8% in non-HTN patients, p<0.001). In-hospital mortality rate was significantly higher in hypertensive patients (42.6% vs. 28.9%, p=0.001). In univariate analysis, factors associated with in-hospital death in HTN patients were age (70.3 vs. 65.2 years in non-HTN patients, p<0.001), female gender (p=0.04), history of DM (p=0.06), acute heart failure on admission (AHF) (p<0.0001) and RF (p<0.001). CONCLUSIONS In our study, in HTN patients presenting with AMI, renal failure on admission was common and associated with higher mortality rate.

045: Is there a protective effect of statins in contrast-induced nephropathy after coronary angiography?

Background Contrast-induced nephropathy (CIN) is a frequent complication after coronary angiography. In the exclusion of saline hydration, the effectiveness of other means of prevention remains unclear, and almost poor. Because of its pleotropic effects, statins have been used in CIN prevention, but data remains controversial. Objective To evaluate the benefit of statins in the prevention of CIN after coronary angiography. Methods We used the database of a randomized controlled trial conducted in our department during the period March to November 2010 to study the effectiveness of ascorbic acid in the prevention of CIN. Patients undergoing coronary angiography were randomly assigned to a saline hydration prevention protocol or a saline hydration associated to ascorbic acid protocol. The primary endpoint was the occurrence of CIN defined as a creatinin arise of more than 25% the baseline level during the following 48 to 72 hours. The relationship between statin intake at baseline and CIN incidence was retrospectively evaluated using a Chi-square test. Results Among the 202 patients included, 126 (62.3%) were treated with statins. There was no significant difference between the two groups concerning the baseline characteristics, particularly in ascorbic acid treatment (p=0.94). CIN incidence dropped from 20.8% in the patients not taking statins to 11.7% in those treated with statins. This resulted in a tendency (p=0.08) but difference wasn’t statistically significant, probably due to the small sample of the population. Conclusion In our study, treatment with statins led to a trend to reduce CIN incidence. The small sample of the population couldn’t allow stronger conclusion. Statins seem to be promising but larger trials are needed.

086: Acute heart failure: Characteristics and predictors of six months mortality

Aim Heart failure is known to be a major cause of morbidity and mortality in developed countries. The number of Tunisians suffering from acute heart failure (AHF) is increasing, but only little is known about the prognosis and possible risk factors for a fatal outcome in our population. The aim of our study is to describe patients with AHF with regard to clinical presentation and mortality at 6 months. Method and results We conducted a retrospective study including 234 patients from a Tunisian center hospitalized with AHF. Our study populations average age was 65±13.8, 56% were male. Hypertension was noted in 60.3% of the cases, diabetes in 51.7% and 69.7% of the patients had new-onset heart failure. Ischemic etiology was noted in 48.7% of cases followed by hypertensive, dilated cardiomyopathy and valvular cardiopathy observed respectively in 21.4%, 14.5%, and 11.1% of cases. Left ventricular ejection fraction (LVEF) was reported in 97% of our population. 46.6% of these had preserved systolic function (LVEF > 45%) and 17.2% had a LVEF At six months 25 patients (11.2%) died. We identified several clinical and biochemical prognostic risk factors in univariate analysis. Independent predictors of 6 months mortality were QRS width ≥130 ms (adjusted HR, 6.15; 95% CI, 1.25-30.15;p=0.025), hyperglycemia at admission (adjusted HR, 1.32; 95% CI, 1.12-1.56;p=0.001), high serum level of glycated hemoglobin (adjusted HR, 0.49; 95% CI, 0.39-0.67; p Conclusion We present the characteristics and prognosis of our population of AHF patients. Six months mortality is relatively high, and independent clinical risk factors include wide QRS, hyperglycemia at admission, poorly controlled diabetes, worsening of renal function during hospitalization and the non-use beta-blockers at discharge.

042: Real life dual antiplatelet therapy after NSTE-ACS in a Tunisian population: is there a need for 12 months of treatment?

Aim Even if the recommended duration for dual antiplatelet therapy (DAT) after non ST elevation acute coronary syndromes (NSTE-ACS) is 12 months, evidence concerning the benefit of clopidogrel adjunction especially beyond 3 months remains poor. The aim of the study was to assess the effective clopidogrel intake and the incidence of a composite endpoint including all causes death and non fatal myocardial infarction in a Tunisian population after NSTE-ACS. Methods We included patients admitted for NSTE-ACS in our department between January 2010 and August 2011 for whom long term evaluation was possible. In-hospital deaths were excluded (including post operative deaths). By telephone follow up, we evaluated the effective DAT duration and the occurrence of all causes death and non-fatal myocardial infarction. Results One hundred thirty patients were included. Mean (SD) follow up was 261 (99) days. DAT was effectively observed during 94(103 days (extremes ranging from 0 to 360 days). Angioplasty was performed in 51.5%, coronary artery bypass graft in 8.4% and medical therapy was considered in 40.1%. In 35 (26.9%) patients, aspirin was the only antiplatelet therapy taken after discharge although DAT was prescribed; 46.9% of the patients took the DAT for more than 3 months, and 23.1% for more than 6 months. The composite endpoint occurred in 6 (4.6%) patients: 2 deaths (both of cardiac causes) and 4 myocardial infarctions. Three of them were under DAT, and the 3 others remained event free during 7, 240 and 270 days after clopidogrel withdrawal. These findings suggest that DAT does not protect against death or myocardial infarction. The rebound phenomenon after clopidogrel withdrawal isn’t patent in our population. Conclusion In the Tunisian context, DAT observance is poor after NSTE-ACS. Death and non fatal myocardial infarction don’t seem to be reduced by DAT and the rebound phenomenon after clopidogrel withdrawal isn’t patent. This may be in part attributed to the small sample of population and the predominantly low risk (as assessed by TIMI risk score), but larger studies are needed to strengthen the evidence for DAT after NSTE-ACS.