[Acute myocardial infarction in elderly patients]

Age is the most important determinant of outcome for patients with acute coronary syndromes [ACS] and ischemic heart disease is the leading cause of death among elderly patients. To determine the epidemiologic particularities, the clinical presentation, and the treatment of Acute Myocardial Infarction [AMI] in patients over 65 years. One hundred patients >65 years of age with myocardial infarction were hospitalized in intensive care of cardiologic unit of Military Hospital of Tunis between 2000 and 2008. Clinical characteristics, reperfusion therapy and outcomes of in-hospital period and for one year follow-up were seen for every patient. The mean age of our population was 77 years. Sex-ratio was 3/1.Our population was divided into tow groups; patients aged between 65 and 75 years [48 patients] and those aged more than 75 years [52 patients]. Only 44% of our patients had arrived at the hospital within the first 12 hours. STEMI was found in 65% of our patients. At admission, 40% had congestive heart failure [[3] Killip II], 10% were in cardiogenic shock. Urgent reperfusion therapy was given to 58% of our patients; 33% received a thrombolytic therapy and 25% were allocated to primary PCI. During in-hospital period, 40% have developed congestive heart failure, 20% have had a cardiogenic shock and 12% were died. All these events were more frequent in patients aged over 75 years and reperfusion therapy was associated with best outcome. In our study invasive treatment such as fibrinolysis and PCI was associated to better outcome in acute period and at 12 months of follow up in elderly patients treated for AMI

[Sirolimus eluting sent in the prevention of restenosis in small coronary arteries]

Angioplasty of coronary arteries with a small diameter [commonly defined as diameter inferior than 2.75 mm] is associated with a high rate of restenosis and revascularization. Since the use of Drug Eluting Stents [DES] and considering their good results on simple lesions compared to other techniques [balloon dilation and bare metal stents], many studies have also demonstrated the superiority of DES in reducing restenosis and revascularization of complex lesions in particular lesions on coronary arteries with small diameter. Assessement of this revascularization procedure. Our study is a prospective one carried on between june 2002 and august 2006, involving a cohort of 299 patients. Patients are divided into 2 groups: group I: 175 patients with 220 lesions on coronary arteries with small diameter treated by 233 sirolimus DES [Cypher] and group II: 124 patients treated by 136 angioplasty of coronary arteries with diameter superior than 2.75 mm using 179 DES. During hospitalisation, there was no significant difference in MACE between the 2 groups. Nevertheless: 2 patients among the first group had no angioplasty because of unsuccessful progression of the balloon through the lesion and the absence of atherectomy in our center. All patients having acute thrombosis during hospitalization and presenting with ST elevated acute coronary syndrom had successful urgent revascularization with TIMI 3 flow. The mid-term follow-up [12 months] concerned 157/174 patients in group land 113/123 patients in group II. We observed a higher mortality and non fatal myocardial infarction in group I without statistically significant difference. despite the complexity of the lesions on coronary arteries with small diameter and despite the association with several risk factors in particular diabetes, the use of DES reduces the MACE specially secondary revascularisations thus improving early and midterm prognosis

[Infective endocarditis on probe of pacemaker]

Infective endocarditis is an uncommon but potentially lethal complication of permanent cardiac pacing. Infection is mainly caused by local contamination during the implantation procedure. The most frequently detected causative microorganisms were staphylococci. The clinical presentation is often atypical causing prolonged diagnostic delay. Bacteriological data and visualisation of neostructures consistent with vegetations on transoesophageal echocardiography, strongly suggest pacemaker lead infection. Management is based on a combined approach using both prolonged antibiotic treatment and early complete device explantation. Percutaneous techniques are currently the method of choice for lead extraction but it is not without possible complications. Antibiotic prophylaxis in order to reduce infection risk related to pacemaker implantation is widely recommended

[Overview on the management of vasovagal syncope]

Prerequis: Vasovagal syncope [VVS] is the most common type of syncope. Despite its benignity, quality of life may be severely affected in a significant proportion of highly symptomatic patients

Aim was to review achral knowledgement concerning vasovagal syncope, to assess the utility of diagnostic investigation and report the updat therapeutic management

Methods: An electronic search of the relevant literature was carried out using medline. Key words used for the final search were "Vasovagal syncoe" "pathophysiology" "diagnosis" "tilt-table testing", "imlantableloop recorder", "treatment", "tilt training", isometric muscle tensing", "cardic pacing"

Results: A typical history of VVS is usually sufficient to make the diagnosis without any additional testing. Further testing is required when the diagnosis remains uncertain. Approaches to treatemtn are largely empirical and this is due to our lack of understanding of the pathopysiology. The management of VVS is often limited to reassuring and advising how to avoid predisposing factors with behaviour modification. For patients with recurrent episodes of syncope and premonitory symptoms, a conservative nondrug approach such a isometric muscle tensing should be considered. Tilt training can also be considered first-line therapy in motivated patients. Nevertheless, if patients still experience sudden reccurrent and unpredictable episodes of syncoep, a more aggressive treatment strategy is required with need of a prophylactic pharmacologic therapy. Various forms of medical treatment have been proposed but there are limited data from randomized controlled trials to support their effectiveness. The role of cardiac pacing is controversial and its indication should be restricted to patients over the age of 40 with severe recurrent syncope that is refractory to other therapies and in whom episodes include a substantial bradycardic component

Chronic heart failure: place of œchocardiographie-doppler in the evaluation of the risk of mortality

Chronic heart failure [CHF] is a major cause of morbidity and mortality. Despite recent improvements in the management of this condition, the overall prognosis remains poor. Echocardiography is the most useful test in the evaluation of systolic and diastolic function and has also a prognostic value. The aim of this study is to determine echocardiographic predictors of mortality in patients with CHF. We followed 100 patients with a diagnosis of CHF over an average period of 44 +/- 40.5 months. We compared echocardiographic parameters in survivors and non survivors. Four variables predicted death: LVEF <35% [p=0.001], TDE <150ms [p=0.001], E/A ratio >2 [p=0.05] and E/Ea ratio >10 [p=0.008]. Doppler echocardiography has a central role in the evaluation of patients with CHF. It provides valuable prognostic information by combination of several parameters

[Cor triatrium sinister sinister symptom free in adulthood]

Cor triatrium sinister is a rare congenital disease [0,1% of cases of congenital heart disease]. Cor triatrium is recognized by the finding of an abnormal fibromuscular membrane that subdivise the left atrium into posterosuperior and anteroinferor chambers. This anomaly creates an obstacle to the venous pulmonary flow. Depending on the severity of obstruction, cor triatrium may be symptomatic in childhood but it can be symtom free even in adulthood. Diagnosis of this abnormality has been easy supported by transthoracic and transoesophageal echocardiography. Treatment is easy to perform and consists in surgical definitive correction in symptomatic patients. We report a case of a 31-year-old man in whom a non obstructive cor triatrium was discovered while evaluation for an atrial fibrillation secondary to a hyperthyroidism. According to this rare case we try to evaluate the severity and the outcome of this disease relating the literature data