Metabolic effects of Ramadan fasting in patients at high risk of cardiovascular diseases.

BACKGROUND AND AIM: The effects of Ramadan fasting on health are a little controversial. The present study is aimed at evaluating the metabolic effects on a group of 517 patients with ≥2 cardiovascular risk factors over a period running from 2012 to 2014. METHODS: Each patient was assessed at three visits: before, during, and after Ramadan. Demographical, clinical and biological tests were performed at each visit. RESULTS: Metabolically, we noted a significant and discrete rise in blood glucose level (+1.2 mmol/L), triglycerides (+0.3 mmol/L), cholesterol (+0.12 mmol/L) and creatinine (+3 µmol/L) during Ramadan. These disturbances decreased significantly after Ramadan. The same variations were observed among diabetics (n=323). However, there was a significant decrease in HbA1c after Ramadan (9.0% vs 7.6%, p<0.001). Our findings also revealed there was no significant correlation between variations of metabolic parameters and dietary intake. No acute metabolic incidents were reported during the study period. CONCLUSION: The current study showed that Ramadan is responsible for a transient but well tolerated disturbance of metabolic parameters followed by a significant post-Ramadan improvement. These changes did not seem to be directly related to dietary intake.

Effects of Ramadan fasting on platelet reactivity in diabetic patients treated with clopidogrel.

BACKGROUND: The effects of Ramadan fasting (RF) on clopidogrel antiplatelet inhibition were not previously investigated. The present study evaluated the influence of RF on platelet reactivity in patients with high cardiovascular risk (CVR) in particular those with type 2 diabetes mellitus (DM). METHODS: A total of 98 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking clopidogrel at a maintenance dose of 75 mg. Clinical findings and serum lipids data were recorded before Ramadan (Pre-R), at the last week of Ramadan (R) and 4 weeks after the end of Ramadan (Post-R). During each patient visit, nutrients intakes were calculated and platelet reactivity assessment using Verify Now P2Y12 assay was performed. RESULTS: In DM patients, the absolute PRU changes from baseline were +27 (p = 0.01) and +16 (p = 0.02) respectively at R and Post-R. In addition, there was a significant increase of glycemia and triglycerides levels with a significant decrease of high-density lipoprotein. In non DM patients there was no significant change in absolute PRU values and metabolic parameters. Clopidogrel resistance rate using 2 cut-off PRU values (235 and 208) did not change significantly in DM and non DM patients. CONCLUSIONS: RF significantly decreased platelet sensitivity to clopidogrel in DM patients during and after Ramadan. This effect is possibly related to an increase of glycemia and serum lipids levels induced by fasting. TRIAL REGISTRATION: Clinical Trials.gov NCT02720133. Registered 24 July 2014.Retrospectively registered.

["Smoker's paradox" and reperfusion's strategy in acute myocardial infarction]. / "Paradoxe des fumeurs" et stratégie de reperfusion à la phase aiguë de l'infarctus du myocarde.

UNLABELLED: Previous studies have shown that smokers with acute myocardial infarction (AMI) treated by thrombolysis have lower mortality rates than nonsmokers, a phenomenon often termed "smoker's paradox". This "smoker's paradox" has been rarely studied in case of primary angioplasty. AIM OF THE STUDY: To evaluate the impact of smoking status on the early mortality of patients admitted with AMI with regard to the strategy of reperfusion (intravenous thrombolysis versus primary angioplasty). PATIENTS AND METHODS: Study undertaken from the Monsatir registry of ST elevation MI including 688 patients having had either a hospital or a prehospital thrombolysis (n=397) or a primary angioplasty (n=291). Among those patients, 482 (70.1%) were active smokers. RESULTS: In the thrombolysis group, the prevalence of hypertension, diabetes and anterior location of MI was significantly less among smokers. In the group primary angioplasty, only diabetes and hypertension were less frequent. The immediate mortality was significantly less among smokers in case of thrombolysis comparatively to non-smokers (5.3 vs 13%; p=0.008). By multivariate analysis, cardiogenic shock (p<0.0001), anterior MI (p=0.03) and active smoking (p=0.03) were independent predictive factors of mortality in case of thrombolysis. A trend toward a lower mortality among smokers was observed in the primary angioplasty group (10 vs 17.6%; p=0.07). CONCLUSION: "The smoker's paradox" seems to be observed mainly among patients having had thrombolysis.

Long term outcome of balloon mitral commissurotomy during pregnancy: a prospective physical and mental evaluation of babies.

AIM: The immediate and long-term results of balloon mitral commissurotomy (BMC) during pregnancy were evaluated in patients and in their babies looking for radiation side effects. METHODS AND RESULTS: Sixty one patients (mean age: 28.5+/-5.0 years) had BMC at a mean age of gestation of 26.8+/-5.5 weeks. The procedure was successful in all patients except in one who had a severe mitral regurgitation and subsequent mitral valve replacement (MVR). All patients delivered at term vaginally in 58 (95.1%) cases. There was only one death in a patient who delivered at home. At a mean follow-up of 66.8+/-36.0 months, 4 patients had MVR, the remaining were in NYHA class I/II. Restenosis was found in 4 (7.2%) patients. The 63 babies (two gemellar pregnancies) had a normal weight of birth except of one case of hypotrophy. At a mean follow-up of 64.5+/-32.5 months, two babies died, 1 had hypotrophy, 2 had microcephaly, 8 had an IQ < 70 but none had a severe mental retardation (IQ <34). None of these events were radiation related. CONCLUSION: BMC is the procedure of choice in pregnant patients with mitral stenosis. No late radiation side effects were observed in children but longer follow-up is required.

[Coronary angioplasty in the acute phase of a myocardial infarction on a myocardial bridge]. / Angioplastie coronaire à la phase aiguë d'un infarctus du myocarde sur pont myocardique.

A myocardial bridge is usually asymptomatic but can cause myocardial ischemia, myocardial infarction or sudden death. Two occurrences of coronary angioplasty in the acute phase of an anterior myocardial infarction on a myocardial bridge are reported. The first case was first treated only with a balloon, and then with a stent 12 h later after a relapse of angina pectoris and the recurrence of a severe compression. The second case immediately benefited from a stent. A systematic control at six months has shown the absence of restenosis in the first case and an asymptomatic occlusion of the stent in the second case. Its deocclusion has revealed a myocardial bridge downstream of the stent. Myocardial stunning might have caused a decreased systolic compression by the bridge in the first case, and an underestimation of its actual length in the second case. Its regression is held responsible for these two relapses. A long active stent installed at high pressure could be used to treat myocardial bridges during myocardial infarctions.

Balloon mitral commissurotomy in juvenile rheumatic mitral stenosis: a ten-year clinical and echocardiographic actuarial results.

AIMS: To evaluate the safety, efficacy and long-term actuarial results of balloon mitral commissurotomy in young patients with severe rheumatic mitral stenosis. METHODS AND RESULTS: Event-free survival and freedom from restenosis were analyzed in 110 patients 20 years old or younger (group 1) and compared with those of 554 adults (group 2). Young patients were less frequently in atrial fibrillation (6% vs 35%, P<0.001) and had less mitral valve deformities (echo score 5.9+/-2.1 vs 7.5+/-3.0, P<0.0001). Mitral valve area index by 2D-echo was of 0.66+/-0.1cm(2)/m(2)in group 1 and 0.67+/-0.1cm(2)/m(2)in group 2 (P=ns) and was larger in group 1 (1.5 vs 1.3 cm(2)/m(2)) after the procedure (P<0.0001). There were more complications in group 2 (8.4% vs 0%, P=0.01). Procedural success was obtained in 110 (100%) patients of group 1 vs 501 (92%) patients of group 2 (P<0.0001). At follow-up mitral valve area index was 1.34 cm(2)/m(2)in group 1 and 1.16 cm(2)/m(2)in group 2 (P<0.0001). At 10 years, freedom from restenosis was 61% in group 1 vs 71% in group 2 (P=0.35) and event-free survival was 74% and 69% respectively (P=0.15 CONCLUSION: Balloon mitral commissurotomy is safe and effective in young with rheumatic mitral stenosis and provides better immediate results than in adults. However long-term outcome was similar between the 2 groups: 2/3 of patients were alive and free from clinical events at 10 years.

[Prognosis of infectious endocarditis]. / Pronostic de l'endocardite infectieuse.

OBJECTIVE: To study clinical course and prognostic factors of infective endocarditis. PATIENT AND METHODS: Infective endocarditis was identified in 126 consecutive patients (criteria of DURACK). Of these, 73 were male, mean age was 29.9 + 15 years, 98 (77.7%) had past history of cardiac disease. The evolution has been marked by 38 deaths (30%) in spite of the recourse to surgery (69 patients). The mean follow-up period was 52 months, the event-free survival was 61% at 5 years. RESULTS: By univariate analysis the predictors of bad prognosis: Large vegetations > 10 mm, delay of apyrexia > 10 days presence of a neurological accident and the absence of surgical treatment. Multivariate analysis: Vegetation > 10 mm (OR 1.97, 1-4.1, p = 0.05), presence of a neurological accident (OR:2.76, 1.32-5.76, p = 0.007) and the absence of surgical treatment (OR: 5.03, 2-11.4, p < 0.001). CONCLUSION: Infective endocarditis remains a serious affection, identification of patients with poor prognosis should lead to early surgical referral: this attitude provides good immediate and long-term results.

Predictors of long-term event-free survival and of freedom from restenosis after percutaneous balloon mitral commissurotomy.

BACKGROUND: Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities. METHODS: Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 +/- 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) >/=1.5 cm(2) after BMC and <1.5 cm(2) at follow-up. RESULTS: The actuarial survival rates were 98%, 98%, and 97% at 5, 7, and 10 years, respectively. The 5-, 7-, and 10-year event-free survival rates were 85%, 81%, and 72%. Multivariate predictors of a higher 10-year event-free survival rate were lower echocardiographic score (79% for a score /=12, P <.001) and cardiac sinus rhythm (P =.04) before BMC, lower mean left atrial pressure (P <.001), lower mitral valve gradient (P <.001), and less than or equal to grade 2 mitral regurgitation (P =.036) after BMC. Restenosis occurred in 16% of patients. The restenosis-free rates were 88%, 80%, and 66% at 5, 7, and 10 years, respectively. A higher freedom from restenosis at 10 years was associated with a lower score (77% for a score /=12, P =.03) and a larger MVA before BMC (P =.03), a larger MVA (P <.001), and a lower mitral valve gradient (P =.04) after BMC. CONCLUSIONS: BMC produces excellent 10-year results in patients with pliable mitral stenosis and good results in patients with semipliable or calcified mitral stenosis. BMC is the procedure of choice in patients with pliable valves and it is a reasonable treatment option in young patients with unfavorable mitral valve anatomy.

[Right ventricular dilatation and intraventricular septal motion after surgical closure of atrial septal defect]. / Dilatation ventriculaire droite et cinétique du septum interventriculaire après fermeture chirurgicale de la communication interauriculaire.

The persistence of right ventricular dilatation and paradoxical interventricular septal motion are two echocardiographic abnormalities rarely reported after surgical closure of atrial septal defects. The aim of this study was to identify the predictive factors of these abnormalities in the long-term and to study their functional consequences. One hundred and two patients aged 18 +/- 14 years (range 1-62 years) underwent closure of atrial septal defects. Thirty-five patients were under 10 years of age, 33 were 10 to 20 years of age and 34 were over 20. Fifty-six patients were female. The rhythm was sinus in the great majority of cases (97%). Three patients, all over 40 years of age, were in atrial fibrillation. Before surgery, right ventricular dilatation was observed in 95 patients (91.2%), paradoxical septal wall motion in 93 patients (91.2%), the ratio of pulmonary/systemic output was 2.7 +/- 0.6 (range 1.7 to 7.4) and over 2 in 90% of patients: pulmonary systolic pressure was 32.3 +/- 12 mmHg and over 40 mmHg in 18 patients (17.6%). Ninety-four patients were followed up regularly with a mean follow-up time of 5.5 +/- 3.6 years (1-14 years). The right ventricle remained dilated in 37 patients (39.4%) after surgery: the right ventricular dimension decreased from 36 +/- 1 to 27.8 +/- 6.2 mm (p = 0.001). The ratio of end diastolic right ventricular/left ventricular dimension also decreased from 1.07 +/- 0.31 to 0.56 +/- 0.12 (p = 0.0001). Multivariate analysis identified two predictive factors of persistent right ventricular dilatation: age > 40 years (p = 0.009) and a pulmonary/systemic flow ratio > 3 (p = 0.03). Interventricular septal wall motion remained paradoxical in 21 patients (22%). Multivariate analysis identified two predictive factors of persistent paradoxical septal motion: age > 40 years (p = 0.02) and systolic pulmonary pressures > 40 mmHg (p = 0.03). These abnormalities remained asymptomatic in all but two patients with persistent long-term hypertension and a residual atrial septal defect. The persistence of right ventricular dilatation and paradoxical septal motion was quite common, with older age at surgery, systolic pulmonary artery pressure > 40 mmHg and a ratio of pulmonary/systemic blood flow > 3, being predisposing factors. These abnormalities were clinically asymptomatic when isolated.