Design and Rationale of the National Tunisian Registry of Heart Failure (NATURE-HF): Protocol for a Multicenter Registry Study

BACKGROUND

The frequency of heart failure (HF) in Tunisia is on the rise and has now become a public health concern. This is mainly due to an aging Tunisian population (Tunisia has one of the oldest populations in Africa as well as the highest life expectancy in the continent) and an increase in coronary artery disease and hypertension. However, no extensive data are available on demographic characteristics, prognosis, and quality of care of patients with HF in Tunisia (nor in North Africa).

OBJECTIVE

The aim of this study was to analyze, follow, and evaluate patients with HF in a large nation-wide multicenter trial.

METHODS

A total of 1700 patients with HF diagnosed by the investigator will be included in the National Tunisian Registry of Heart Failure study (NATURE-HF). Patients must visit the cardiology clinic 1, 3, and 12 months after study inclusion. This follow-up is provided by the investigator. All data are collected via the DACIMA Clinical Suite web interface.

RESULTS

At the end of the study, we will note the occurrence of cardiovascular death (sudden death, coronary artery disease, refractory HF, stroke), death from any cause (cardiovascular and noncardiovascular), and the occurrence of a rehospitalization episode for an HF relapse during the follow-up period. Based on these data, we will evaluate the demographic characteristics of the study patients, the characteristics of pathological antecedents, and symptomatic and clinical features of HF. In addition, we will report the paraclinical examination findings such as the laboratory standard parameters and brain natriuretic peptides, electrocardiogram or 24-hour Holter monitoring, echocardiography, and coronarography. We will also provide a description of the therapeutic environment and therapeutic changes that occur during the 1-year follow-up of patients, adverse events following medical treatment and intervention during the 3- and 12-month follow-up, the evaluation of left ventricular ejection fraction during the 3- and 12-month follow-up, the overall rate of rehospitalization over the 1-year follow-up for an HF relapse, and the rate of rehospitalization during the first 3 months after inclusion into the study.

CONCLUSIONS

The NATURE-HF study will fill a significant gap in the dynamic landscape of HF care and research. It will provide unique and necessary data on the management and outcomes of patients with HF. This study will yield the largest contemporary longitudinal cohort of patients with HF in Tunisia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03262675; https://clinicaltrials.gov/ct2/show/NCT03262675.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12262.

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.

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.

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]

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]

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.

[Long-term outcome of surgically treated teratology of Fallot]

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.

[Home treatment of venous thrombosis. "For and against"]

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.