Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF).

BACKGROUND: Contemporary registries on atrial fibrillation (AF) are scare in North African countries. HYPOTHESIS: In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal. METHODS: NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described. RESULTS: A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA2 DS2 VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died. CONCLUSIONS: NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.

Association between Small Dense Low-Density Lipoproteins and High-Density Phospolipid Content in Patients with Coronary Artery Disease with or without Diabetes.

OBJECTIVE: To evaluate the phospholipid profile in total plasma, non-high-density lipoprotein (HDL), and HDL fractions. We tried to correlate the phospholipid profile to low-density lipoprotein (LDL) size, as reflected by cholesterol content in each LDL subclass. METHODS: We measured small dense LDL-C levels after heparin-magnesium precipitation and measured high-density lipoprotein phospholipid (HDL-P) levels using a colorimetric enzymatic method. RESULTS: The correlation of the phospholipid profile to small dense LDL-C (sdLDL-C) in patients with coronary problems showed a negative association between small dense low-density lipoprotein (sdLDL) and HDL-P (r = -0.73; P = .02). Moreover, a strong positive correlation was detected between TG and the ratio HDL-P/HDL-C (r = 0.83; P <.001). CONCLUSIONS: HDL phospholipid has an antiatherogenic effect in coronary artery disease with or without diabetes. Further, large LDL modulation seems to be associated with diabetes rather than coronaropathy.

Evaluation of left ventricular function by 2D Strain in acute coronary syndrome.

BACKGROUND: The 2D Strain is a new echo-cardiographic technique allowing the study of the myocardial deformation based on a follow-up of the acoustic markers of the LV wall. The aim of our study was to validate the contribution of this technique in the detection of the ischemia and in the prediction of the culprit coronary axis and the number of vessels affected and also we analyzed the correlation of this parameter with the Left Ventricle Ejection Fraction (LVEF) and the Wall Motion Score Index (WMSI). METHODS: This is a prospective study included 173 consecutive patients admitted for acute coronary syndrome (ACS) during the period between January 2015 and October 2016.  All the patients had echocardiography with analysis of function by 2DStrain and a coronary angiography .The data have been listed on an SPSS database. CONCLUSION: The 2D Longitudinal Strain represents an excellent parameter which allows a reliable detection of an alteration in the systolic function of the LV in ischemic heart disease and it's very useful to predict the culprit coronary axis and the number of vessels affected.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry.

BACKGROUND: The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI). METHODS: Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%). RESULTS: Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866). CONCLUSIONS: Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

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.

-174G>C interleukin-6 gene polymorphism in Tunisian patients with coronary artery disease.

BACKGROUND AND OBJECTIVES: A state of low-grade inflammation accompanies the pathogenesis of atherosclerotic events. Interleukin-6 (IL-6) is a pleotropic pro-inflammatory cytokine that modulates the development of acute coronary syndromes (ACSs), partly by destabilizing coronary atherosclerotic plaques. We have examined the contribution of the -174G>C IL-6 promoter variant on the risk of coronary artery disease (CAD) among Tunisians. PATIENTS AND METHODS: Study subjects included 418 CAD patients and 406 age- and sex-matched controls. IL-6 genotyping was done by PCR-restriction fragment length polymorphism. RESULTS: The frequency of the -174C allele (mutant) was lower in Tunisians than in Europeans, and the distribution of -174 G>C genotypes was similar between CAD patients and control subjects. Moreover, compared to GG genotype carriers, -174C allele carriage did not increase the CAD relative risk (odds ratio and 95% confidence interval=1.09 and 0.80-1.49), which remained nonsignificant after adjusting for traditional risk factors for CAD (age, smoking, hypertension, diabetes and obesity). CONCLUSION: The -174G>C IL-6 promoter variant is not associated with an increased risk of CAD among Tunisians.

Functional interleukin-10 promoter variants in coronary artery disease patients in Tunisia.

OBJECTIVES: The contribution of interleukin (IL)-10 promoter variants -1082G/A, -819C/T, and -592C/A to the risk of coronary artery disease (CAD) was investigated in 291 CAD patients and 291 age- and gender-matched control subjects. METHODS AND RESULTS: IL-10 genotyping was performed using PCR-allele-specific amplification (PCR-ASA). Regression analysis was employed in assessing the contribution of the IL-10 variants to the overall CAD risk. A higher frequency of the -592A allele (p = 0.004), but not the -1082A (p = 0.828) or -819T (p = 0.952) alleles, was seen in CAD patients. A higher frequency of -592C/A (p = 0.011), and a lower frequency of -592C/C (p = 0.015) genotypes was noted in patients compared to healthy controls. Regression analysis demonstrated an association of -592C/A [OR (95% CI) = 1.82 (1.02-3.23)] and -592A/A [OR (95% CI) = 3.33 (1.27-9.09)] genotypes with 1-artery disease. Haplotype analysis revealed that none of the eight possible IL-10 haplotypes was associated with CAD or with the severity of CAD, and was confirmed by multivariate regression analysis, after adjusting for a number of confounders (smoking, systolic and diastolic blood pressure, hypertension, diabetes, glucose, cholesterol, and triglycerides). CONCLUSIONS: Our results suggest that the -592C/A, more so than the -1082G/A or the -819C/T IL-10 promoter variant alleles, may be considered to be a risk factor for CAD in Tunisians.

TNF-alpha -308G>A and IL-6 -174G>C polymorphisms in Tunisian patients with coronary artery disease.

OBJECTIVE: Our aim was to evaluate the contribution of tumor necrosis factor (TNF)-alpha -308G>A and interleukin (IL)-6 -174G>C gene promoter variants to the presence of coronary artery disease (CAD) in Tunisians. DESIGN AND METHODS: Study subjects comprised 418 angiographically proven CAD patients and 406 age-, gender-, and ethnic origin-matched controls. Genotyping was performed using polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis. RESULTS: There were no significant differences in the allelic distribution of TNF-alpha -308A (19.6% vs. 19.0%, P=0.73), and IL-6 -174C (15.6% vs. 14.3%, P=0.47) promoter polymorphisms between CAD patients and control subjects, respectively. In addition, single locus analysis revealed no differences in genotype frequencies between the two study groups, and the combined distribution of both genotypes did not differ significantly between controls and CAD patients (P>0.05). CONCLUSION: There is no allelic or genotypic association of TNF-alpha -308G>A and IL-6 -174G>C promoter polymorphisms with CAD in Tunisians, thereby confirming an ethnic-selective contribution of both gene variants to CAD presence.

Human platelet alloantigens HPA-1, HPA-2, and HPA-3 polymorphisms associated with extent of severe coronary artery disease.

The contribution of human platelet antigen (HPA)-1 (GPIIb/IIIa), HPA-2 (GPIb/IX), and HPA-3 (GPIIb/IIIa) polymorphisms to the risk of coronary artery disease (CAD) was investigated in 341 CAD patients and 316 matched control subjects. HPA genotyping was performed by PCR-SSP. Regression analysis was employed in assessing the contribution of these variants to CAD risk. The frequency of HPA-1b (P = .009) and HPA-3b (P = .004) alleles, and HPA-1a/1b (P = .045), HPA-1b/1b (P = .007), and HPA-3b/3b (P = .008) genotypes were higher in patients than control subjects. No significant association was demonstrated between the HPA variants and 1-, 2- and 3-vessel disease. HPA-1b/2a/3b (Pc = .021) and HPA-1b/2b/3a (Pc = .002) haplotypes were positively associated with CAD, thereby conferring a disease susceptibility nature to these haplotypes. Multivariate analysis confirmed the positive association of HPA-1b/2a/3b (aOR = 3.72; 95% CI = 1.49-9.28), and in addition identified HPA-1b/2a/3a (aOR = 2.49; 95% CI = 1.06-5.86) to be positively associated with CAD, after adjusting for a number of covariates. Our results demonstrate positive association of HPA variants and specific HPA-1/HPA-2/HPA-3 haplotypes with CAD in Tunisians.

Association of three polymorphisms selected from a genome-wide association study with coronary heart disease in the Tunisian population.

Despite extensive exploration of many genes, strong evidence of a molecular genetic association with coronary heart disease (CHD) or myocardial infarction (MI) remains to be obtained. Recently, significant interest has emerged in mapping genetic susceptibility for complex traits through whole-genome studies association generating promoting data that will determine the genetic contribution to common human diseases such as coronary heart disease. The aim of the present case-control study including 324 healthy controls and 296 patients with coronary heart disease from Tunisia, was to assess relation between three polymorphisms previously reported to be strongly associated with coronary heart disease in the Welcome Trust Case Control Consortium (WTCCC) and the German myocardial infarction family studies: locus 9p21.3 (rs 1333049), locus 6q25.1 (rs6922269) and 2q36.3 (rs2943634). By single locus analysis, no differences in genotype distribution and allelic frequency were found between the two groups of study. The risk allele (C) for rs2943634 was less frequent among Tunisian population than in controls from the WTCCC and German studies (57% vs 65%). The three SNPs previously reported to be associated with CHD were not replicated in our small sample.

-308G>A and -1031T>C tumor necrosis factor gene polymorphisms in Tunisian patients with coronary artery disease.

BACKGROUND: Recent research has shown that inflammation plays a key role in coronary artery disease (CAD) and other manifestations of atherosclerosis. Several lines of evidence support a key role for tumor necrosis factor-alpha (TNF-alpha), a potent immunomodulator and pro-inflammatory cytokine, in the development of atherosclerosis and in complications of CAD. METHODS: We investigated the possible association between CAD and the TNF gene promoter polymorphisms -308G>A and -1031T>C in a Tunisian population. We compared the distribution of these polymorphisms between 418 patients with CAD and 406 healthy controls using polymerase chain reaction restriction fragment length-polymorphism analysis. RESULTS: The frequency of the TNF-alpha -308A allele in the control group was similar to that observed in CAD patients [p=0.78; odds ratio (OR)=1.15; 95% confidence interval (CI)=0.86-1.55], but higher than those described in other Europeans, such as in the French, Finnish and Spanish. Concerning the TNF-alpha -1031T/C polymorphism, the same distribution was observed between patients with CAD and controls (p=0.12; OR=1.27; 95% CI=0.94-1.72). In addition, the genotype and allele frequencies of control individuals were comparable to those previously reported in healthy Tunisian controls and other ethnic groups. Haplotype analysis (TNF-alpha -308G>A and -1031T>C) demonstrated no significant association between TNF haplotypes and CAD. CONCLUSIONS: We conclude that TNF promoter gene polymorphisms at position -308G>A and -1031T>C do not play a major role in the pathogenesis of CAD in the Tunisian population.

[Doppler tissue imaging contribution in the study of diastolic dysfunction in hemodialysis patients]. / Place du Doppler tissulaire myocardique dans l'etude de la dysfonction diastolique ventriculaire gauche chez les malades hemodialyses.

BACKGROUND: Doppler echocardiography is currently the main tool permitting the diagnosis and the characterization of the stages of diastolic dysfunction. AIM: The purpose of this study is to precise the contribution of Doppler tissue imaging in the study of diastolic function and to identify the parameters having the most discriminating power of diastolic dysfunction in hemodialysis patients. METHODS: Conventional Doppler echocardiography study implies left ventricular diastolic function from: Doppler transmitral flow (E/A, isovolumic relaxation time (TRIV), deceleration of mitral E-wave time (TDE), duration of A wave), color M-mode flow propagation velocity (Vp); The study of pulmonary venous flow (S/D, Systolic fraction (FS) and duration of pulmonary venous A wave); The annulus Doppler Tissue Imaging (Ea/Aa, E and A waves durations, VTI of E and A); and finally combined indexes (ratio of peak E-wave velocity to Vp (E/Vp), difference in duration between pulmonary venous and mitral flow A wave (Ap-Am) and ratio of peak mitral and annulus E-wave velocities (E/Ea). RESULTS: Left ventricular diastolic dysfunction is found in 88% of the 50 haemodialysis patients: abnormal relaxation pattern 56%, pseudo-normal pattern 28% and restrictive pattern 4%. The parameter Vp discriminates normal patterns. The parameters TRIV, S/D and FS characterise abnormal relaxation. Ea/Aa ratio characterises pseudo-normal pattern and E/A ratio restrictive pattern. Discriminating analysis allows a correct classification of 100% of pseudo-normal pattern patients with 3 variables: Ea/Aa, FS and Vp or E/Vp. Doppler parameters which discriminating power is significant (p < 0.0001) are, in decreasing order: E/A, Ea/Aa, TRIV, Vp, FS, S/D, E/Vp and TDE. CONCLUSION: DTI contributes mainly in the characterization of stage II diastolic dysfunction patients and allows in association with pulmonary venous flow parameters (Ap-Am) and combined indexes (E/Vp et E/Ea) an accurate appreciation of left ventricular filling pressures.

[Doppler echocardiographic diagnosis of ventricular asynchrony. Present situation and future perspectives]. / Diagnostic de l'asynchronisme ventriculaire par l'echocardioographie Doppler- situation actuelle et perspectives d'avenir.

Heart failure is among the most common chronic diseases in the modem era. It is the major cause of morbi--mortality and hospitalization in patients aged more than 60 years. Dilatation of left ventricle frequently induces intracardiac conduction delays resulting. in asynchronous left ventricular motion. Showing as left bundle branch block in the surface EKG. Diagnosis of asynchrony based only on electrocardiogram criteria (wide QRS complex and left bundle branch block(LBBB)) proves to be non satisfactory considering the absence of parallelism between conduction unrests and cardiac dyssynchrony: 35% of LBBB are not associated with interventricular asynchrony and 20% without intraventricular asynchrony. So there is a necessity to define new criteria of asynchrony linked more directly to cardiac mechanical activity then EKG. Doppler Echocardiography brings more informative parameters concerning inter and intra ventricular asynchrony. Doppler tissue imaging can provide accurate information on electromechanical coupling and also assess interventricular and intraventricular dyssynchrony. It seems to be very promising for the prediction of the most satisfactory response to cardiac resynchronization therapy.

Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study.

BACKGROUND: Since the first description of infective endocarditis, the profile of the disease has evolved continuously with stable incidence. However, epidemiological features are different in developing countries compared with western countries. OBJECTIVE: To describe epidemiological, microbiological and outcome characteristics of infective endocarditis in Tunisia. PATIENTS AND METHODS: This was a descriptive multicenter retrospective study of inpatients treated for infective endocarditis from 1991 to 2000. Charts of patients with possible or definite infective endocarditis according to the Duke criteria were included in the study. RESULTS: Four hundred and forty episodes of infective endocarditis among 435 patients (242 males, 193 females; mean (SD) age=32.4 (16.8) years, range 1-78 years) were reviewed. The most common predisposing heart disease was rheumatic valvular disease (45.2%). Infective endocarditis occurred on prosthetic valves in 17.3% of cases. Causative microorganisms were identified in 50.2% of cases: streptococci (17.3%), enterococci (3.9%), staphylococci (17.9%), and other pathogens (11.1%). Blood cultures were negative in 53.6% and no microorganism was identified in 49.8%. Early valve surgery was performed in 51.2% of patients. The in-hospital mortality was 20.6%. CONCLUSION: Infective endocarditis is still frequently associated with rheumatic disease among young adults in Tunisia, with a high frequency of negative blood cultures and high in-hospital mortality, given that the population affected is relatively young.

[Long-term outcome of surgically treated teratology of Fallot]. / Evolution a long-terme de la tetralogie de Fallot operee.

Tetralogy of Fallot is the most common cyanotic congenital heart disease. The surgical treatment that is palliative or complete repair has allowed to transform the preview of this heart disorder. We suggests to study the long term outcome in patients undergoing surgical repair of tetralogy of Fallot, by emphasizing the quality of their lives, the complications, as well as the mortality. Ventricular arrhythmia and sudden cardiac death after repair of tetralogy of Fallot are devastating complications in adults survivors and their prediction remains difficult.

[Multicenter study of atrial fibrillation]. / La fibrillation auriculaire. Etude multicentrique.

1134 patients presented a first episode of atrial fibrillation (AF) between January 1985 and December 2000. Age average was 58.6 years (15-60). 656 (57.8%) were male and 478 (42.2%) were female. The first etiology of AF was rheumatic carditis (36.1%). AF was idiopathic in 27.7% of cases. Morbi-mortality was significantly higher in patients with AF versus those with sinus rhythm; five years survival was respectively 96% and 85%. Success rate was 70% with electrical cardioversion versus 40% with pharmacological cardioversion. Results of AF reduction was independent of left atrium diameter. Only long standing of AF predicted failure of AF reduction.

[Home treatment of venous thrombosis. "For and against"]. / Traitement à domicile des thromboses veineuses. "Le pour et le contre".

The ambulatory treatment of venous thromboses is made possible since the avenement of the low molecular weight heparins, which ensures an efficacy and a safety, comparable with the infractioned heparins, with less side effects and hemorrhagic complications. The simplicity of the therapeutic diagram with the low molecular weight heparin, the biological monitoring less astringent as well as the reduction of the cost of the treatment constitute solid arguments in favour of this therapeutic modality. The essential condition for such attitude remains the respect of the indications and of counter indications.