Sonia Marrakchi

Arrhythmia and thyroid dysfunction

ContextArrhythmia is a major cause of morbidity and mortality in Europe and in the United States. The aim of this review article was to assess the results of the prospective studies that evaluated the risk of arrhythmia in patients with overt and subclinical thyroid disease and discuss the management of this arrhythmia.Evidence acquisitionA literature search was carried out for reports published with the following terms: thyroid, hypothyroidism, hyperthyroidism, subclinical hyperthyroidism, subclinical hypothyroidism, levothyroxine, triiodothyronine, antithyroid drugs, radioiodine, deiodinase, atrial flutter, supraventricular arrhythmia, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation, torsade de pointes, amiodarone and atrial fibrillation. The investigation was restricted to reports published in English.Evidence analysisThe outcome of this analysis suggests that patients with untreated overt clinical or subclinical thyroid dysfunction are at increased risk of arrhythmia. Hyperthyroidism increased atrial arrhythmia; however, hypothyroidism increased ventricular arrhythmia.ConclusionThe early recognition and effective treatment of thyroid dysfunction in patients with arrhythmia is mandatory because the long-term prognosis of arrhythmia may be improved with the appropriate treatment of thyroid dysfunction.ZusammenfassungKontextArrhythmien sind ein wesentlicher Grund für Morbidität und Moralität in Europa wie in den USA. Ziel dieser Review-Arbeit war daher das Assessment von Ergebnissen prospektiver Studien zur Evaluation des Arrhythmierisikos für Patienten mit manifester und subklinischer Schilddrüsenerkrankungen. Ferner wird das Management dieser thyreoidassoziierter Arryhthmien diskutiert.Erfassung der EvidenzGesucht wurde mit folgenden Begriffen: Schilddrüse, Hypothyreose, Hyperthyreose, subklinische Hyperthyreose, subklinische Hypothyreose, Levothyroxin, Trijodthyronin, Thyreostatika, Radiojod, Dejodinasen, Vorhofflattern, supraventrikuläre Arrhythmie, ventrikuläre Arrhythmie, ventrikuläre Tachykardie, Ventrikelflimmern, Torsade de pointes, Amiodaron und Vorhofflimmern. Die Suche war beschränkt auf englischsprachige Publikationen.EvidenzanalyseDie Ergebnisse der Analyse weisen darauf hin, dass Patienten mit unbehandelter (sub-)klinischer Schilddrüsendysfunktion ein erhöhtes Arrhythmierisiko haben. Eine Hyperthyreose verstärkte ein Vorhofflimmern, eine Hypothyreose dagegen eine ventrikuläre Arrhythmie.FazitUnbedingt erforderlich sind das zeitnahe Erkennen und die effektive Behandlung einer Schilddrüsenfunktionsstörung, denn die langfristige Prognose einer Arrhythmie lässt sich durch entsprechende Behandlung der Schilddrüsendysfunktion verbessern.

Cardiac resynchronization therapy allows the optimization of medical treatment in heart failure patients

AIM Cardiac resynchronization therapy (CRT) is recommended for selected patients with advanced heart failure (HF) despite optimal medical treatment. However, the doses of pharmaceuticals in this population are often limited by adverse effects. We compared the drug regimens of 21 patients before and 6 months after they underwent the implantation CRT systems. METHODS We studied 17 men and four women (mean age=63.4 ± 11 years) presenting in New York Heart Association HF classes III-IV, and with a left ventricular ejection fraction (LVEF) ≤ 35% and cardiac dyssynchrony, who underwent implantation of CRT systems. RESULTS At baseline, 52% of patients were treated with β-adrenergic blockers (β-B), though in optimal doses in only 19%. The introduction of (β-B) was complicated by cardiogenic shock in three patients. At baseline, all patients were treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), of whom 76% received optimal doses. After 6 months of CRT, β-B were administered to 76% of patients, in optimaklon ACE or ARB but 75% of them were receiving maximal doses. After 6 months of CRT, β blockers have been introduced in 72% of patients and maximal doses have been achieved in 60% of them. Maximal doses of ACE or ARB were reached in 95% of the study population. We noticed that systolic blood pressure was higher after implantation. There was also a significant improvement in functional status and left ventricular ejection fraction compared to baseline. CONCLUSION CRT is an efficacious adjunctive device therapy to standard medical therapy for patients with heart failure and cardiac dyssynchrony. Its benefits are in addition to those afforded by standard pharmacological therapy. Achieving maximal doses of medical treatment and the possibility of introducing β blockers after CRT prove that CRT and pharmacological treatment are complementary strategies and should not be considered as competitive.

Does Ramadan fasting affect the intensity of acenocoumarol‐induced anticoagulant effect?

Each year, during the holy month of Ramadan, millions of healthy adult Muslims refrain from eating and drinking from dawn to dusk. Although fasting is not obligatory for the sick, many patients with stable diseases and taking oral medications are motivated to observe Ramadan fasting, including those treated with vitamin-K antagonists (VKAs) the main oral anticoagulants used to prevent and treat many thrombotic disorders. It is well known that the dose–response to VKA can be affected by various factors, such as diet (Cust odio das Dôres et al, 2007) and drug interactions (Ansell et al, 2008). During Ramadan, not only are eating patterns altered but also the amount and types of food. The daily medication schedule is also changed because of fasting. Thus, the relationship between dose and response to VKA may be affected during Ramadan. However, data on the effects of Ramadan fasting on VKA-anticoagulant activity are scarce. This study evaluated the effects of Ramadan fasting on International Normalized Ratio (INR) stability in patients treated with long-term acenocoumarol. A total of 67 patients (29 females, 38 males, mean age 60 11 4 years) were included in this prospective, open, single-centre study. Exclusion criteria were an INR <1 7 or >4 5 before Ramadan. To study the effect of fasting on INR stability, the INR of patients was assessed at three time-points: an initial visit at 3 d before Ramadan began (INR1), a second visit on the 15th day of Ramadan (INR2), and a third visit just before the end of Ramadan (INR3). INR3 was assessed only in those patients with an INR2 < 4 5. Asymptomatic AVK overdose was defined as INR >4 5. The INR values were determined by measuring the prothrombin time using a fully automated STA-R coagulation analyser (Diagnostica Stago, Asnier, France). All statistical analyses were performed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). INRs values were compared with the non-parametric Wilcoxon test. A P-value of <0 05 was considered statistically significant. The INR increased acutely during the first 2 weeks of Ramadan for the majority of patients. Indeed, the mean INR2 value was significantly higher than that of INR1 (4 1 1 7 vs. 2 9 0 8; P < 0 0001, respectively) (Fig 1) and a mean variation of +46 5% (range: 35% to +256 4%) was observed between INR1 and INR2. Furthermore, 25 (37 3%) patients had an INR2 > 4 5. These patients were excluded from the second part of the study. A significant increase in the INR was also observed during the last 2 weeks of Ramadan (Fig 1). Indeed, the mean INR3 value recorded at the end of Ramadan was significantly higher than that of INR2 (3 4 0 88 vs. 2 9 0 6; P < 0 0001, respectively). However, only five (11 9%) patients reached an INR3 > 4 5. Baseline INR value and acenocoumarol daily dosage were significantly higher in patients with an INR >4 5 (n = 30) compared to those with an INR ≤4 5 (n = 37) (Table I). Multivariate analyses identified two independent predictors factors were associated with a high INR (INR>4 5) during Ramadan: baseline INR > 3 [odds ratio (OR) = 10 6; 95% confidence interval (CI) 2 49–27 02; P < 0 001] and acenocoumarol dosage ≥4 mg/d (OR = 4 15; 95% CI 1 14–15 09; P = 0 003). Five bleeding episodes were recorded (7 4%) during the whole study period. According to the Bleeding Academic Research Consortium (Mehran et al, 2011), one was classified as type 3c (intracranial haemorrhage) and four were classified as type 1 (two cases of bleeding gums, one of small bruising and one nosebleed). All of the bleeding events occurred in patients with an INR > 7. This pilot study showed that Ramadan fasting significantly affects the INR stability of patients treated for long-term with acenocoumarol. Indeed, about half (44 8%) of our patients reached a VKA overdose (INR >4 5) and bleeding complications occurred in 7 4% of the patients during the study period.

256: Ramadan fasting and high sensitive CRP in patients with stable coronary artery disease: a pilot study

Introduction Ramadan fasting is one of the five pillars observed by Muslim adults worldwide. Data on incidence of acute coronary syndrome during fasting Ramadan are scarce and conflicting. Inflammation plays a major role in atherothrombosis, and measurement of cardiac biomarkers such as High sensitive C-reactive protein (hs-CRP) may provide a strong independent predictor of future cardiac events. Aim of this study was to evaluate the effect of fasting during Ramadan on hs-CRP in patients with stable coronary artery disease (CAD). Patients and Methods it was a prospective pilot study among 27 patients with stable CAD (within the last 6 months) who were observed before and at the end of Ramadan fasting. Patients were recruited from outpatients department. Twenty one were males and 6 were females with a mean age of 59±8.2 years (52-75 y). Fifteen patients had hypertension, 10 were smokers and 7 were diabetics. Blood was analyzed at the first visit was a week before the onset of Ramadan and the second visit at the third week of Ramadan. The assay of hs-CRP was done with the collected sera by Demeditec Diagnostics Systems Laboratories (Germany). Results Six patients were excluded for the second visit due to various reasons (break voluntary of fasting in two cases, 4 patients with concurrent inflammatory disorders e.g. rheumatoid disease in 2 cases and intercurrent infections in two others). A total of 21 subjects were screened during this period. There was a significant reduction in hs-CRP during Ramadan compared before this period: 6.6±8.7 vs 3.8±5.5 (p Conclusion The practice of fasting during the month of Ramadan by the people with stable CAD might be cardio-protective as it resulted in the lowering of hs-CRP.

ANÉVRYSME AORTIQUE D'ORIGINE SYPHILITIQUE : À propos d'un cas

: The incidence of tertiary syphilis has declined in recent years owing to the early recognition of the disease and use of antibiotics. As a result, syphilitic aortic aneurysms are rarely encountered nowadays. We report the case of a 65 years old man, who was admitted to our hospital in June 2004 for dyspnea, cough and chest discomfort. On physical examination, blood pressure was 130/80 mmHg with no significant laterality, pulse rate was 70 per minute and there was a decrease of breath sounds over the right lung. Laboratory findings revealed a slight elevation of the erythrocyte sedimentation rate. Serological studies for syphilis showed a positive venereal disease laboratory test (VDRL) at 1/32 and a positive Treponema pallidum hemagglutination test (TPHA) at 1/2560. The chest radiography showed a right para cardiac opacity measuring 16 x 12 cm. Fiber optic bronchoscopy showed an extrinsic compression of the right upper lobar bronchus. Gadolinium-enhanced magnetic resonance angiography and 16 multidetector-row spiral computed aortography showed a huge partially thrombosed saccular aneurysm of the ascending aorta measuring 132 mm in diameter. The circulating lumen measured 53 mm in its largest diameter. This aneurysm involved the innominate artery. There was no other arterial involvement. The patient was given a three week course of intravenous penicillin followed by a successful surgical procedure in September 2004 with ascending aortic replacement and innominate artery reimplantation. This case illustrates well a formerly common, but now extremely rare disease.

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

Multimodality Imaging in Hypertrophic Cardiomyopathy Associated With Anomalous Hypertrophied Papillary Muscles: A Case Report

Introduction: Multimodality imaging can help rule in/out the diagnosis of hypertrophic cardiomyopathy (HCM) in patients with significant left ventricular (LV) hypertrophy. Case Presentation: We describe a 73-year-old woman referred to us for consultation because of a giant negative T wave on her electrocardiography. Echocardiography revealed diffuse severe hypertrophy associated with hypertrophied anterolateral papillary muscles with a bifid head and with extensive wall insertion into the apicolateral segment. Three-dimensional echocardiography and cardiac magnetic resonance confirmed these data. Importantly, automated function imaging determined the global longitudinal strain at -10.2%. Conclusions: According to our multimodality imaging approach, hypertrophic cardiomyopathy was the most probable diagnosis.

0419: Comparison of clinical and angiographic features of acute coronary syndromes with and without obstructive sleep syndrome detected by the Berlin questionnaire

Introduction obstructive sleep apnea sundromeObstructive sleep apnea syndrome (OSA) is a common and often underdiagnosed disease. It is involved in the progression of atherosclerosis and could be considered as a factor of cardiovascular risk. Objective The aim of this study was to compare the clinical and angiographic characteristics of patients admitted for acute coronary syndrome with high risk and low risk of OSA detected by the Berlin questionnaire Materials and methods 150 patients with an average age 61.6 years with a sex ratio of 3.65 were admitted for acute coronary syndrome over a period of 3 months. Patients already paired with OSA were excluded. All patients responded to the questionnaire Berlin. 50.6% were considered at high risk for OSA and 49.4% were considered low risk of OSA. The evaluation of the distribution of coronary lesions was studied by the modified score Friesinger. Results cf Table Abstract 0419 – Table: results High risk OSA N= 76 Low risk OSA N =74 p Age 63±11 60±11 0,5 Male 34,2% 44,3% 0,048 Female 15,2% 6,3% Hypertension 36.7% 24,1% 0,015 Diabetes 62,9% 37,1% 0,042 Tobacco 26,6% 37,6% 0,085 Dyslipidemia 22,8% 3,8% 0,001 ACS ST + 19% 24,1% 0,41 ACSST – 28,2% 25,6% 0,65 One vessel 26,5% 20,6% NS Multivessel 26,5% 26,4% NS Coronary Score 7,6±4,4 8,47±5,5 0,09 Conclusion The presence of cardiovascular risk factors including hypertension, diabetes and dyslipidemia was significantly associated with a high probability of OSA according to the Berlin questionnaire. However, the distribution of coronary lesions was similar and independent of the probability of OSA.

201: Are QT intervals correlated to apnea-hypopnea index in obstructive sleep apnea?

Introduction Several studies proved that obstructive sleep apnea (OSA) is associated with cardio-vascular diseases such as cardiac arrhythmia. QT duration and dispersion reflect the heterogeinity of ventricular repolarization and are considered as precursors of ventricular arrhythmia Aim The aim of this study is to assess the relation between the severity of OSA parameters as apnea hypopnea index and QT intervals. Methods Forty patients (18 men and 22 women) who were diagnosed with OSA by overnight polysomnography were included in this prospective study. The mean age was 56±10 years old. They were all in sinus rhythm. Before initiating continuous positive airway pressure therapy, we calculated on a 12 lead ECG : QT duration (QTend) corrected to Bazett formula and QT dispersion (QT end max -QT end min). Results Twenty four patients had severe OSA (AHI >30), 4 had moderate OSA (AHI between 15 and 30) and 12 had a mild OSA (AHI between 5 and 15). There was a significant positive correlation between QT dispersion and AHI (r=0.48, p=0.001) Conclusion The severity of OSA seems to be correlated with ventricular repolarization heterogeinity These results suggest that the higher is the AHI the higher is the risk of ventricular arrhythmia occurence. Further studies are needed to validate these results.

203: Correlation between P wave variables and apnea-hypopnea index in obstructive sleep apnea

Introduction Obstructive sleep apnea (OSA) is associated with several cardio-vascular abnormalities as atrial fibrillation (AF). AF occurrence in OSA increases the risk of stroke which worsens the prognosis of these patients. P wave dispersion (Pd) and maximal P wave duration (P max) are simple electrocardiographic parameters which reflect atrial conduction abnormalities and have been reported to be predictors of atrial fibrillation Aim the aim of this study is to determine the correlation between apnea-hypopnea index (AHI) and P wave dispersion and maximal P wave duration. Methods Forty patients (18 men and 22 women) who were diagnosed with OSA by overnight polysomnography were included in this prospective study. The mean age was 56±10 years old. They were all in sinus rhythm. Before initiating continuous positive airway pressure therapy, we evaluated on a 12 lead ECG P wave duration and P wave dispersion (P max - P min). Results Twenty four patients had severe OSA (AHI >30), 4 had moderate OSA (AHI between 15 and 30) and 12 had a mild OSA (AHI between 5 and 15). Mean P max duration was 119±21 ms. P wave dispersion was 93±6 ms. There was a significant positive correlation between P max and AHI (r= 0.45, p=0.001) and between P wave dispersion and AHI (r=0.42, p=0.001) Conclusion The severity of OSA seems to be correlated with the importance of atrial conduction abnormalities. These results suggest the higher is the AHI the higher is the risk of AF occurrence in OSA. Further studies are needed to validate these results.