Reperfusion therapy in renal dysfunction patients presenting with STEMI: Which is better in the Tunisian context?

BackgroundPatients with renal insufficiency experience worse prognosis after STEMI. Current guidelines do not clearly draw specific strategies for renal dysfunction (RD) patients, and most clinical trials exclude them from the study population.Aim of the studyTo compare primary PCI (PPCI) and thrombolysis (using Strepokinase) results as well as in-hospital mortality after successful reperfusion between patients with or without RD.MethodsFrom January 1995 to October 2011, 1388 patients admitted for STEMI were enrolled in the MIRAMI (MonastIR’s Acute Myocardial Infarction) registry. Two reperfusion groups were identified: PPCI (315 patients) and thrombolysis (379 patients). Patients who underwent rescue PCI were excluded. Due to lacking clearance data, we used a serum creatinine level >130μmol/l to define RD patients. We compared in each reperfusion group: (1) The success of revascularization (TIMI III flow restoring with <20% residual stenosis after PPCI, pain relief with ST regression >50% 60min after thrombolysis) and (2) the in-hospital mortality rate after reperfusion success between the RD patients (RD+) and normal renal function patients (RD−).ResultsNinety patients (13%) had RD, 50% of which underwent PPCI, and 50% received thrombolytics. Among RD+ and RD- groups, baseline characteristics were similar between the two reperfusion groups.In the PPCI group, although TIMI flow was similar before angioplasty (p=0.82), TIMI III restoring was significantly lower in the RD+ group (78.6% vs 91.8%, p=0.013). Suboptimal result was also higher in the RD+ group (13.6% vs 2.7%, p<0.001), but ST regression after TIMI III achievement was similar in the 2 groups (p=0.43) reflecting probably no microvascular damage.In the thrombolysis group, successful reperfusion was also significantly lower when RD exists (58% vs 74%, p=0.03).After successful reperfusion, in-hospital mortality is higher among RD+ patients in the PPCI group (33.3% vs 4.3%, p<0.001), whereas it is similar after successful thrombolysis (2.6% vs 0%, p=0.42).ConclusionRD reduces either PPCI or thrombolysis success, with no proven microvascular damage after PPCI. In-hospital prognosis is however worse in RD group only after successful PPCI, but not after successful Streptokinase thrombolysis

057 A simple prediction score for significant renal artery stenosis in patients with coronary artery disease

BackgroundRenal artery stenosis (RAS) is a strong independent predictor of mortality in patients (pts) with coronary artery disease (CAD).Aim of studyTo develop and validate a score predicting RAS in patients with CAD.MethodsThree hundred consecutive pts (50 females) with significant CAD underwent abdominal aortography following coronary angiography to screen for significant RAS defined as luminal narrowing of > 50%. Univariate and multivariate analyses were performed comparing pts with and without RAS. Significant factors associated with RAS were included in constructing a score that predicts RAS.The score was internally validated in pts randomly selected from the entire study group (validation group; n=103), using ROC curves and the Hosmer-Lemeshow goodness-of-fit test.ResultsTwenty-seven pts (9%) had a significant RAS. Univariate predictors of significant RAS were: age > 65 years (OR=4.5, p < 0.0001), hypertension (OR=3.6, p=0.001), and female gender (OR=3.6, p=0.015). We found a tendency of more prevalent renal insufficiency (37.1% vs. 21.5%; p=0.05) and the presence of 2 or more significant CAD lesions (70.4% vs. 50.9%; p=0.05) in pts with RAS.Multivariate analysis showed that age > 65 years (OR=4.1%, 95% CI=1.6-10.3, p=0.003) and hypertension (OR=3.1, 95% CI=1.2-7.7, p=0.015) were independent predictors of RAS. The ranged from 0 to 7: 2 points for age > 65 years and hypertension 1 point for female gender, renal insufficiency, and > 3-vessel disease). Internal validation showed a good performance (ROC curve = 0.79 and Chi2 Lemeshow = 3.45). For a score < 2, the negative predictive value is 98%. Applying this criteria, 48.3% of our population would not require systematic abdominal angiography.ConclusionThe performance of our predictive score was good, and significant reduction in the need to perform systematic abdominal aortography could be expected with the use of this score

Atrial fibrillation management strategies in routine clinical practice: insights from the International RealiseAF Survey

Atrial fibrillation (AF) can be managed with rhythm- or rate-control strategies. There are few data from routine clinical practice on the frequency with which each strategy is used and their correlates in terms of patients' clinical characteristics, AF control, and symptom burden.RealiseAF was an international, cross-sectional, observational survey of 11,198 patients with AF. The aim of this analysis was to describe patient profiles and symptoms according to the AF management strategy used. A multivariate logistic regression identified factors associated with AF management strategy at the end of the visit.Among 10,497 eligible patients, 53.7% used a rate-control strategy, compared with 34.5% who used a rhythm-control strategy. In 11.8% of patients, no clear strategy was stated. The proportion of patients with AF-related symptoms (EHRA Class > = II) was 78.1% (n = 4396/5630) for those using a rate-control strategy vs. 67.8% for those using a rhythm-control strategy (p = II.In the RealiseAF routine clinical practice survey, rate control was more commonly used than rhythm control, and a change in strategy was uncommon, even in symptomatic patients. In almost 12% of patients, no clear strategy was stated. Physician awareness regarding optimal management strategies for AF may be improved

Maladie De Forestier Revelee Par Une Dysphagie A Propos De Deux Cas

La maladie de Forestier ou hyperostose ankylosante vertébrale engainante est un désordre musculo-squelettique non inflammatoire responsable d\'une ossification ligamentaire essentiellement du ligament longitudinal antérieur. Elle touche de préférence l\'homme de plus de 50 ans. La dysphagie est un symptôme rarement observé dans l\'évolution de la maladie de Forestier. Nous rapportons deux cas révélés par une dysphagie isolée. Il s\'agit de deux hommes âgés de 50 et 56 ans. Le diagnostic était radiologique. La radiographie standard du rachis a objectivé des ostéophytes du rachis cervical. Le transit oesogastroduodénal a montré une compression modérée de l\'oesophage cervical. Le traitement était médical reposant sur les anti inflammatoires non stéroïdiens et les antalgiques. Le traitement chirurgical est indiqué dans les cas de dysphagie sévère. Keywords: maladie de Forestier, hyperostose vertébrale, dysphagie. Journal Tunisien d\'ORL et de chirurgie cervico-faciale Vol. 18 2007: pp. 55-5

Effect of Systemic Hypertension With Versus Without Left Ventricular Hypertrophy on the Progression of Atrial Fibrillation (from the Euro Heart Survey).

Hypertension is a risk factor for both progression of atrial fibrillation (AF) and development of AF-related complications, that is major adverse cardiac and cerebrovascular events (MACCE). It is unknown whether left ventricular hypertrophy (LVH) as a consequence of hypertension is also a risk factor for both these end points. We aimed to assess this in low-risk AF patients, also assessing gender-related differences. We included 799 patients from the Euro Heart Survey with nonvalvular AF and a baseline echocardiogram. Patients with and without hypertension were included. End points after 1 year were occurrence of AF progression, that is paroxysmal AF becoming persistent and/or permanent AF, and MACCE. Echocardiographic LVH was present in 33% of 379 hypertensive patients. AF progression after 1 year occurred in 10.2% of 373 patients with rhythm follow-up. In hypertensive patients with LVH, AF progression occurred more frequently as compared with hypertensive patients without LVH (23.3% vs 8.8%, p = 0.011). In hypertensive AF patients, LVH was the most important multivariably adjusted determinant of AF progression on multivariable logistic regression (odds ratio 4.84, 95% confidence interval 1.70 to 13.78, p = 0.003). This effect was only seen in male patients (27.5% vs 5.8%, p = 0.002), while in female hypertensive patients, no differences were found in AF progression rates regarding the presence or absence of LVH (15.2% vs 15.0%, p = 0.999). No differences were seen in MACCE for hypertensive patients with and without LVH. In conclusion, in men with hypertension, LVH is associated with AF progression. This association seems to be absent in hypertensive women

Progression From Paroxysmal to Persistent Atrial Fibrillation. Clinical Correlates and Prognosis

Objectives: We investigated clinical correlates of atrial fibrillation (AF) progression and evaluated the prognosis of patients demonstrating AF progression in a large population. Background: Progression of paroxysmal AF to more sustained forms is frequently seen. However, not all patients will progress to persistent AF. Methods: We included 1,219 patients with paroxysmal AF who participated in the Euro Heart Survey on AF and had a known rhythm status at follow-up. Patients who experienced AF progression after 1 year of follow-up were identified. Results: Progression of AF occurred in 178 (15%) patients. Multivariate analysis showed that heart failure, age, previous transient ischemic attack or stroke, chronic obstructive pulmonary disease, and hypertension were the only independent predictors of AF progression. Using the regression coefficient as a benchmark, we calculated the HATCH score. Nearly 50% of the patients with a HATCH score &gt;5 progressed to persistent AF compared with only 6% of the patients with a HATCH score of 0. During follow-up, patients with AF progression were more often admitted to the hospital and had more major adverse cardiovascular events. Conclusions: A substantial number of patients progress to sustained AF within 1 year. The clinical outcome of these patients regarding hospital admissions and major adverse cardiovascular events was worse compared with patients demonstrating no AF progression. Factors known to cause atrial structural remodeling (age and underlying heart disease) were independent predictors of AF progression. The HATCH score may help to identify patients who are likely to progress to sustained forms of AF in the near future. \ua9 2010 American College of Cardiology Foundation

Finite-difference time-domain method for design and analysis of microcavity - Coupled submicron-width waveguides

In this paper the finite-difference time-domain (FDTD) method is reviewed and then used to model and predict the geometric parameters used for the design of the device. The waveguide consists of a periodic array of air gap etched into a silicon (Si) strip on a silicon dioxide (SiO2) layer. The width and the depth of the grooves of the air gap (n = 1) as well as the length of the silicon layer (n = 3.4) are investigated. Using FDTD, the optical parameters are characterized. The effect of the air gap on the field profile distribution of the whole structure is calculated and performed in the range 0.09687 μm –1.55 μm. The field profile, and the response of the microcavity against frequency are calculated from sinusoidal sources. The spectral behavior of the structure is performed and its validity is verified by calculation of the reflectance spectra