[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

[Cardiac conduction disorders in atheletes: diagnosis and management]

The sino-atrial or atrio-ventricular conduction disturbances are commonly seen in athletes. They are due to predominant effect of the parasympathetic tone. To describe the physiological cardiac adaptation to physical exercises and to specify the limits of this activity in front of persons with conduction abnormalities. Review of literature and lecture of recommendations. Conduction disturbances in athletes disappear during physical activities. Their frequency is variously reported in literature. These disorders should be well considered particularly when they are priors to sport practice and need definitive implantable devices. Such decision must be taken after a detailed evaluation of the nature of the physical activity wished and the conduction disturbance type. The decision to allow competition should be take after a careful evaluation of the conduction disorder and the type of sport

[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

[Successful use of levosimendan in a patient with cardiogenic shock complicating acute myocardial infarction]

Levosimendan is a new inodilator that improves cardiac contractility by sensitizing troponin C to calcium. This drug has proved to be effective in treating advanced congestive heart failure but has not been evaluated in cardiogenic shock. We present the case of a 54-year-old male patient treated successfully with levosimendan for cardiogenic shock following acute myocardial infarction. Treatment with dobulamine, revascularisation and intra-aortic balloon conterpulsation had first failed to improve his hemodynamic variables. Levosimendan induced a steady decline of increased pulmonary capillary wedge pressure, followed by an increase in cardiac index and mixed venous oxygen saturation. Left ventricular ejection fraction improved from 25% to 47%. Infusion of levosimendan can be used in cardiogenic shock without side effects and to improve hemodynamics and left ventricular function

[Which place for VDD mode single electrode pacemaker?]

VDD mode single electrode pacemaker is a technique of cardiac stimulation which preserves auriculo-ventricular synchronism using a single electrode. Its importance has decreased because of the numerous satisfactions previous by the DDD mode. We describe our experience with this mode and we discuss the advantages, limits and indications of this mode of cardiac stimulation

[Homocysteinaemia and degenerative complications in non insulin dependent diabetes mellitus]

Type 2 diabetes mellitus [non insulin-dependent diabetes mellitus: NIDDM] is known to be associated with degenerative complications. Although, the pathophysiology of such complications is well known, the role of homocysteine [Hey] is still discussed.The aim of the present study was to evaluate the relationship between the homocysteine levels and the NIDDM related complications in a group of NIDDM patients. Our study population consisted of 41 NIDDM patients including 13 subjects [G1] without complications [group controls], 17 patients [G2] with microangiopathy and 11 patients [G3] with coronary deficiency. Plasmatic homocysteine, glycemia, glycated haemoglobin [HbAIC] and lipid parameters were assessed in all patients. Our results showed that mean levels of plasmatic homocysteine were within the normal range [10.4 +/- 3.3 micro mol/l, 9.9 +/- 5.5 micro mol/l and 14.8 +/- 10.4 micro mol/l in G1, G2 and G3 respectively]. Nevertheless, moderate hyperhomocysteinaemia was found in 36% in the coronary group [G3], 17.3% in patients with microangiopathy [G2] and 7.7% in controls.These preliminary results showed that cardiovascular complications in NIDDM patients may be related to high levels of homocysteine

Prevalence des cardiopathies ischemiques: Resultats d'un depistage en population

A cross - sectional population survey was carried out in the Ariana region in 2000-01. The aim of this study is to report the prevalence of CHD as indicated by ECG Minnesota coding. Method: A randomly selected sample included 1837 adults 40-70 years. Data on socio-economic status, demographic, medical history, health behavior, clinical and biological investigations were recorded. Risk factors [hypertension, dyslipedemia, obesity, diabetes] are defined according to WHO criteria's. Standard supine 12 lead ECGs were recorded. All ECGs are red and classified according to the Minnesota codes criteria on CHD probable, CHD possible and on Major abnormalities and minor abnormalities. CHD prevalence was higher on women. Major abnormalities are more common on women [20,6% vs 13%], while minor abnormalities prevalence was higher on men [15,5% vs 7,5%] [p<0,0001]. The prevalence increased with age in both genders. This study tested how feasible is the population approach on CVDs surveillance. It highlighted the burden of cardiovascular diseases and support that women are at risk as men are. The value of ECG findings must be integrated in the cardiovascular diseases surveillance to identify high risk population

Delai de prise en charge et acces aux soins de l'infarctus du myocarde dans les structures hospitalieres

We aimed to assess the acute myocardial infarction management in Tunis public hospitals during one year [from March 2000 to February 2001]. Method: A standard questionnaire was designed to record prospective data on 740 patients with a follow up during 28 days. Multivariate analysis was performed using the logistic regression model with all-factors as well as age, gender, CHD risk factors as predictors of the delay and fatality. 54% of patients were admitted during the first 6 hours after the onset of symptoms. In multivariate analysis, the delay of consultation is significantly correlated with gender [OR=2.3, p<0.001], age [OR=l.02, p<0.01] and health insurance [OR=1.5, p<0.01]. 90% of patients consulted in emergency wards. The emergency ambulance transported 19.6% of patients. 48% of patients underwent early revascularization of thrombolysis, 51% on men vs 31% on women [p <0.01]. The fatality rate was higher on women 14% vs 6.4% on men [p<0.01] at 5 days and 27.2% vs 13.6% at 28 days. In multivariate analysis, the principal fatality predictive factor was age [RR=l.08, p < 0,001] and delay [2.56 p <0.001] and tobacco smoking [RR=2,83, p <0.0001]. this study highlighted the problem of acute myocardial infarction management in public hospitals in Tunisia and it constitutes a baseline to assess different interventions focusing on cardiovascular diseases control and surveillance

Cout direct medical de la prise en charge de l'infarctus du myocarde en phase algue

to assess the medical direct cost of acute myocardial infarction. Method: data are recorded through a prospective study in 7 wards of cardiology of the District of Tunis during one year: from November 2001 to October 2002. cost of hospital stay, biologic analyses, drugs, functional investigations and possible non surgical cardiologic intervention [IC] was calculated. 632 AMI cases are recorded, the death rate is 7.8%. The average of hospital stay was 13.3 days. 49.1% of patients benefited from thrombolytic therapy, 55.5% benefited from a coronary angiography and 16.1% of an act of IC. The mean of direct cost [CGM] was 2171 Tunisian Dinars and the median was 1731 DT, of whom room costs 31.7%, 22.5% acts of IC, 7.2% drugs, 26.2% functional investigations and 12.4% biological analyses. The mean cost of IC was 3030 +/- 401 DT. The methodology of our study remains original in our country and can be used to assess the other aspects of AMI as other diseases cost management

Prevention secondaire des maladies cardiovasculaires: Connaissances et pratiques des malades

The aim of our study is to assess the degree of awareness and practices of patients with cardiovascular disease. Method: During October 2002- February 2003, we conducted a CAP study [Knowledge, attitudes, behaviors] at some outpatient clinic visit of Tunis District. Using a standardized questionnaire, investigators have collected demographic and personal data, informations about risk factor levels, knowledge and attitudinal characteristics related to risk factors for patients who satisfied the inclusion criteria. 443 patients have been interviewed [68.4% are men]; 40% have more than 65 years old. Half of patients have never been schooled. Most of them have low socioeconomic level [38.8%] or middle one [56.0%]. 66.9% of men have quitted tobacco smoking and 19.5% still smoking 41.3% of patients have some difficulties to change their lifestyle, The difference is statically significant by educational and occupational levels. Almost 60% of them used to practice daily a moderate physical activity, which was more frequent among men then women [p<0.01]. During the last year, majority of patients has had checked their blood pressure [98%], glycaemia [94%] and cholesterolemia [94%]. However, about 57% to 67% of patients knew if they have hypertension, diabetes or hypercholesterolemia. Most of patients are aware that healthy lifestyle can be important in preventing heart attacks and stroke and that control of blood pressure, cholesterolemia and glycaemia reduce recurrence of these attacks once they happened. CVDs prevention and control is facing the crucial question on lifestyle change and enhancing patients responsibility in their own health promotion

torsade de pointes a couplage court: Notre experience et revue de la litterature.

We present three cases of short-coupled variant of torsade de pointes with review of the literature. These women presented with syncope or presyncope due to torsade de pointes initiated by a short-coupled premature ventricular beat and without evidence of prolonged QT. There were no electrolyte disturbances in all cases, no apparent structural heart disease in two cases and a mild interventricular septum hypertrophy in the other case. One patient took spiramycin and metro nidazole and another was taking pheniramin and lincomycin without any evidence of cause to effect relationship. One patient responded to verapamil but died suddendly after 44 months of follow-up. The two others. Received implantable cardioverter-defibrillators and verapamil per os. They still alive 46 and 54 months later. Short-coupled variant of torsade de pointes have a high incidence of sudden death, so it is very important for physicians to identify and treat it promptly, long-term verapamil treatement is effective but still insufficient and patients should be considered for implantable cardioverter-defibrillator therapy