Impact of specific training and competition on myocardial structure and function in different age ranges of male handball players.

Handball activity involves cardiac changes and demands a mixture of both eccentric and concentric remodeling within the heart. This study seeks to explore heart performance and cardiac remodeling likely to define cardiac parameters which influence specific performance in male handball players across different age ranges. Forty three players, with a regular training and competitive background in handball separated into three groups aged on average 11.78 ± 0.41 for youth players aka "schools", "elite juniors" 15.99 ± 0.81 and "elite adults" 24.46 ± 2.63 years, underwent echocardiography and ECG examinations. Incremental ergocycle and specific field (SFT) tests have also been conducted. With age and regular training and competition, myocardial remodeling in different age ranges exhibit significant differences in dilatation's parameters between "schools" and "juniors" players, such as the end-diastolic diameter (LVEDD) and the end-systolic diameter of the left ventricle (LVESD), the root of aorta (Ao) and left atrial (LA), while significant increase is observed between "juniors" and "adults" players in the interventricular septum (IVS), the posterior wall thicknesses (PWT) and LV mass index. ECG changes are also noted but NS differences were observed in studied parameters. For incremental maximal test, players demonstrate a significant increase in duration and total work between "schools" and "juniors" and, in total work only, between "juniors" and "seniors". The SFT shows improvement in performance which ranged between 26.17 ± 1.83 sec to 31.23 ± 2.34 sec respectively from "seniors" to "schools". The cross-sectional approach used to compare groups with prior hypothesis that there would be differences in exercise performance and cardiac parameters depending on duration of prior handball practice, leads to point out the early cardiac remodeling within the heart as adaptive change. Prevalence of cardiac chamber dilation with less hypertrophy remodeling was found from "schools" to "juniors" while a prevalence of cardiac hypertrophy with less pronounced chamber dilation remodeling was noted later.

[Aspects of myocardic parameters of Tunisian handball players: an echocardiographic study]. / Particularités des paramètres myocardiques chez les joueurs Tunisiens de handball : etude échocardiographique

BACKGROUND: Given that handball is a mixed sports activity requiring 3 energy systems, namely aerobic, anaerobic alactic and lactic, it supposes then a cavity dilatation for the efforts involving endurance and a parietal hypertrophy for the efforts involving anaerobic work. AIM: To obtain, using the echocardiographic method, myocardic measurements from 3 groups of Tunisian handball players of different ages, in order to define the myocardic predispositions of the young players and to define the morphodynamic adaptation of the heart of the adult players so that the impact of the specialty on the operation and the morphology of the heart can be better explained. METHODS: Two-dimensional and time motion (T.M.) echocardiography (using a TOSHIBA SSH 104 A) was conducted to examine the following parameters: diastolic and systolic diameters of the left ventricle, the root of the aorta, the left atrium and the right ventricle, as well as the mean velocity of the shortening of circumferential fibers, the ejection time of left ventricle, and the dimensions of the inter-ventricular septum and the posterior wall as well as the E/A ratio. The echocardiograms were performed by medical technicians and reviewed by physicians. Thirty six handball players were involved in this study. Height and weight of all players were measured before the medical test. RESULTS: The Obtained results enable us to advance that the loads of drive and competition in handball requested the increase in the parameters of dilatation in the young players of 11-12 years to 15-16 years, whereas parameterize them of hypertrophy improved thereafter. What justifies the idea, which says that in the young players work must be based primarily on the improvement of aerobic quality requesting the dilatation of the myocardium, thereafter one can consider anaerobic work. CONCLUSION: The practice of handball at an early age may induce both cavity dilatation and parietal hypertrophy. The long-term consequences and significance of this marked remodeling of the athlete's heart is not known.

Association of the long QT syndrome With goiter and deafness.

We report on the long QT syndrome occurring in conjunction with nontoxic multinodular goiter and sensorineural deafness in several siblings of a large family. Autosomal and X-linked recessive and dominant modes of inheritance are possible for the different phenotypes. The affected family members had various phenotype combinations, suggesting variable expressivity and incomplete penetrance.

Physician assessment of stroke risk in hypertensive patients in the Middle East and Africa: results of the action survey.

OBJECTIVES: In the absence of reliable, contemporary national data, the ACTION survey was designed to: a) provide preliminary data on stroke risk in the MEA (Middle East and Africa); b) describe the contribution of specific cardiovascular risk factors; 3) assess blood pressure (BP) control. DESIGN AND PATIENTS: This was a multi-center observational study in nine countries in the MEA region. From 2003 to 2005, 562 physicians from a variety of specialties recorded observations of cardiovascular risk factors in 4,747 hypertensive patients, aged 54-80 years. The 10-year absolute stroke risk was calculated using a scoring system based on the Framingham Heart Study observations, and comparisons made with an age-matched cohort. RESULTS: The mean 10-year stroke risk was estimated at 22.7% and was significantly higher for men (25.4%) than for women (19.5%) (P < .001) and for diabetics (28.2%) than for non-diabetics (19.4%) (P < .001). Compared with an age-matched Framingham cohort, the estimated stroke risk in our population was almost double, and was significantly higher for females (212%) than for males (192%) (P < .001). Hypertension, diabetes, left ventricular hypertrophy, and smoking were major contributing risk factors, as were physical inactivity and elevated cholesterol. Blood pressure was controlled in only 18% of the population and in 12% of diabetics. CONCLUSION: Physicians of all specialties were willing to participate in stroke risk assessment. The risk of stroke in hypertensive patients in the MEA region is high, and is higher than would be predicted using Framingham data, particularly for females. Hypertension appears to be poorly controlled in more than 80% of hypertensive patients in the MEA region.

[Echocardiographic factors determining immediate result of percutaneous mitral balloon commissurotomy]. / Paramètres échocardiographiques prédictifs du résultat immédiat de la commissurotomie mitrale percutanée.

AIM: Define echocardiographic predictors of the result after percutaneous mitral balloon commissurotomy (PMC). METHODS: PMC by the Inoue balloon was attempted in 247 patients (77% female) with severe mitral valve stenosis. The mean age was 35 years. All the patients had undergone echocardiographic examination before PMC to assess mitral anatomy, commissural calcification, and to determine the Wilkins score. RESULTS: The mean value of Wilkins score was 7,98 +/- 1,61 (range 5-13) and the mean mitral valve area (MVA) before PMC was 1 +/- 0,19 cm2 (range 0,5- 1,4 cm2). 29 patients (11,7%) had one-commissural calcification and 2 patients (0,8%) had bi-commissural calcifications. After PMC, the mean MVA increased to 1,79 +/- 0,34 cm2 (p <0,001) resulting in a success rate of 83%. Severe mitral regurgitation (> or =grade 3) occurred in five patients (2%). Wilkins score was an independent predictor of the immediate result of PMC but, if > 8, this score had a weak predictive value. Commissural morphology was another independent predictor of the immediate result of PMC. CONCLUSION: Echocardiography is now the cornerstone for the assessment of mitral anatomy before PMC and should integrate Wilkins score and commissural morphology for the selection of patients to PMC.

[In-hospital prognosis of right ventricular myocardial infarction]. / Pronostic a la phase hospitalière de l'infarctus du ventricule droit.

AIM: To identify prognostic risk factors for in-hospital outcome of right ventricular myocardial infarction (RVI). METHODS: A retrospective study of 20 patients admitted with acute myocardial infarction with a RVI defined by ST segment elevation > or = 1 mm in V3R and V4R leads. RESULTS: The mean age was 62 years. RVI was associated with an inferior myocardial infarction in 18 patients. Half of the patients had hemodynamic complication on admission (cardiogenic shock in 4 cases, right ventricular failure in 6 cases) and third degree atrio-ventricular block was present in 5 patients. Sixteen patients (80%) received thrombolysis and 3 went to an emergency angioplasty. The in-hospital mortality was 25% caused by a cardiogenic shock in 4 patients and a ventricular fibrillation in 1 patient. Statistic analysis showed that cardiogenic shock on admission, the absence of thrombolytic therapy and the low ejection fraction of the left ventricle were associated with a high in-hospital mortality (p = 0.004, p = 0.03, p = 0.03 respectively). CONCLUSION: In-hospital outcome of RVI is characterized by hemodynamic complications leading to a high incidence of mortality. Thus RVI must be diagnosed quickly and maximal therapeutic efforts must be done to procure the opening of the occluded coronary artery.

[Epidemiological transition and health impact of cardiovascular disease in Tunisia]. / La transition epidémiologique ses determinants et son impact sur les systemes de sante a travers l'analyse de la tendance des maladies cardiovasculaires en Tunisie.

OBJECTIVE: We aim at analysing the increase of CVDs in the Tunisian hospitals in order to assess the burden of NCDs in the transitional context. METHODS: Data are recorded through the Tunisian National Morbidity and Mortality Survey (TNMMS). In order to assess the CVDs (CHDs vs RHDs) trend, two representative samples of Cardiology Departements patients were compared one is selected from the TNMMS and the second from the hospitalisations recorded in 1992. Causes, stay duration, status at the end of the hospitalisation, transfer to another hospital and patients socio-demographic characteristics are recorded and compared for the two periods. All the diagnosis are coded referring to the DMC 10. To analyze the determinant of the epidemiological transition, we have elaborated the CVD causal pattern and we have documented all their determinants. RESULTS: CHD rate has dramatically increased, while RHD has decreased especially on men. In 1992, 39.2% of men and 11.8% of women were admitted for CHD. In 2002, these rate are respectivly 58.8% and 38.2% while RHD rates were, in 1992, 11.8% on men and 25.3% on women vs 4.4% and 11.7% respectively. CONCLUSION: This study has confirmed that so far controlling transmitted diseases seems to be successful, Tunisian people are about to face a new problems as hypertension, obesity, diabetes and tobacco smoking. The new challenge with the burden of diseases requires the implementation of a national strategy relevant to the epidemiological, social and economical transition. Population needs and cost effectiveness of interventions assessment is crucial to set the national priorities.

[Delays in acute myocardial infarction treatment: results of a multicenter study in the district of Tunis (Tunisia)]. / Delai de prise en charge et acces aux soins de l'infarctus du myocarde dans les structures hospitalieres. Résultats d'une étude multicentrique.

OBJECTIVE: 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 = 1.02, 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 revascularisation 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 = 1.08, p < 0.001) and delay (2.56 p < 0.001) and tobacco smoking (RR = 2.83, p < 0.0001). CONCLUSION: 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.

[The cost of acute myocardial infarction management: the Tunisian experience]. / Cout direct medical de la prise en charge de l'infarctus du myocarde en phase aigue.

OBJECTIVE: 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. RESULTS: 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. CONCLUSION: 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.

[Secondary prevention of cardiovascular diseases: knowledge and practices of patients]. / Prevention secondaire des maladies cardiovasculaires: connaissances et pratiques des malades.

UNLABELLED: 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%). RESULTS: 66.9% of men have quit 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 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. CONCLUSION: CVDs prevention and control is facing the crucial question on lifestyle change and enhancing patients responsibility in their own health promotion.

Coronary bypass in an adult with Kawasaki disease.

We present the case of a 30-year-old female patient with few coronary risk factors for atherosclerosis but with 3-vessel coronary artery disease possibly secondary to Kawasaki disease. Coronary angiography showed total occlusion of the left anterior descending artery and a right coronary artery aneurysm. Quadruple coronary artery bypass was performed. The postoperative course was uneventful.

[Right atrial myxoma in a patient with mood disturbances]. / Myxome geant de l'oreillette droite revelee par un trouble de l'humeur.

Cardiac myxomas represents 50% of the benign heart tumors. Right atrial myxomas are more rare than left localisations. Their major risks are in occurrence of pulmonary embolisms. The clinical features are non specific and the diagnosis is based on echocardiography. The treatment of choice for myxomas is surgical removal. We report a case of 32-year-old woman with an abnormality of the heart auscultation found when examined for humour disturbance. Echocardiography revealed a giant echogene, mass of the right atrium, prolapsing in the tricuspid orifice. Per-operative findings mentioned a mass with 10 cm of length. Anatomo-pathologic results conclude to atrial myxoma. The evolution after 8 months of surgical treatment was normalisation of heart auscultation and the improvement of the patient humour.

[Knowledge, treatment and control of hypertension. Results of a multicenter study of patients hospitalized for cardiac ischemia]. / Connaissance, traitement et controle de l'hypertension arterielle. Resultats d'une enquete multicentrique aupres de malades hospitalises pour cardiopathies ischemiques.

The study objective was to assess the prevalence, level of treatment, and control of hypertension in CHDs patients. We conducted a cross-sectional survey on 1109 patients hospitalised for a first episode of MI in the main hospitals of the District of Tunis during the period 1999-2000. Hypertension and control level are defined according to the JNC recommendations. HBP is defined as SBP > = 140 and or DBP > = 90 mm Hg and the use of blood pressure-lowering medication for the indication of hypertension. Hypertension is controlled by medication if SBP < 140 and DBP < 90 mm Hg. We conduct analysis by socio demographic variables, medical history and CHDs risk factors. 54.9% men and 72.1% women were hypertensive. The prevalence of hypertension increases with age in both genders. The logistic regression have shown that the age-adjusted odds ratios were statically significant for diabetes, obesity, high cholestrolemia and cigarettes smoking. Only 68.9% of the hypertensive were aware of having hypertension, women were more aware than men (84.6% versus 61.7%, p < 0.001). Awareness increase with age and education level. Among hypertensive, 94.4% were treated but only 41.3% were controlled. The study highlights the problem of the hypertension, and contributes to identify the iceberg of this CHDs risk factor. An effort must be done to involve the health personnel for educating patients, the population for changing their life style and manager for enhancing the availability of drugs. The question is how much will be the cost of HBP and CVDs control for a country which has a limited resources.

[Value of ambulatory blood pressure monitoring in blood pressure profile determination in type 2 diabetes]. / Apport de la MAPA dans l'étude du profil tensionnel du diabétique type 2.

Risk assessment in the type 2 diabetic patients must take into account the major risk factors, particularly arterial hypertension which is commonly associated, increasing the risk for macrovascular and microvascular complications. The aim of this study is to determine whether ambulatory blood pressure monitoring provides additional information to clinical (office) blood pressure measurement for the detection and control of hypertension in type 2 diabetic patients. Ambulatory blood pressure monitoring is more helpful than office blood pressure measurement for the evaluation of blood pressure levels. It is very valuable in type 2 diabetic patients for detecting autonomic dysfunction and elevated blood pressure load, which are associated with cardiovascular complications.