Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

DRESS characteristics according to the causative medication

BACKGROUND

To date, no study has identified a clear relationship between drug and a specific clinical presentation of DRESS.

OBJECTIVES

To investigate the particularities of DRESS and analyze the variation of DRESS pattern according to culprit drugs.

METHODS

We analyzed cases of DRESS notified to the Department of Clinical Pharmacology at the University Hospital of Monastir over a 15-year period. The statistical study was performed using the comparative and multivariate analysis.

RESULTS

DRESS was mostly induced by anticonvulsive agents (27%) followed by allopurinol (26.3%) and antibiotics (24%): For anticonvulsive agents, the occurrence of lymphadenopathy was higher, renal involvement was rare and mild, and positive skin tests were more frequent. The allopurinol group was associated with the patient's older age and a lower incidence of lymphadenopathy and kidney injury. For antibiotics, eosinophilia rate was lower, time to recovery was shorter, and RegiSCAR score was low. The multivariate analysis showed a link of allopurinol with severe renal impairment, antibiotics with short latency period and low RegiSCAR score, and anticonvulsants with high propensity of positive skin test.

CONCLUSION

We report the largest African and south Mediterranean cohort of DRESS and evaluated the usefulness of skin tests in identifying the culprit drug. The prominent finding was that latency period and renal involvement may independently differ according to culprit drugs.

Comparison of coronary vessel sizing using coronary angiography versus intravascular ultrasound in Egyptian patients

Background: Coronary artery disease (CAD) is a leading causeof death worldwide. Intravascular imaging is an important toolin the arsenal of each interventional cardiologist. While angiographyprovides a two-dimensional image of a three-dimensionalstructure, intravascular imaging enhances understanding by providingdetailed cross-sectional images. This study aimed to investigatethe discrepancies in coronary vessel sizing between quantitativecoronary angiography (QCA) and intravascular ultrasound.Methods: This cohort study was conducted on 69 patients whowere referred for elective coronary angiography. Patients weresubjected to history taking, examination, blood samples, electrocardiogram(E.C.G.), and echocardiography. Then, a comparisonof each vessel’s luminal diameter by QCA and IVUS was done.Results: The study included 69 patients; The mean age was 54.7± 9.7. There was a statistically significant difference between thestudied vessels regarding the discrepancy between luminal diametersmeasured by IVUS and QCA. IVUS luminal diameter waslarger than QCA luminal diameter (the median difference in measuresof QCA and IVUS in the left main artery, LAD, LCX, and RCAwere -0.8, -0.55, -0.4, and -0.5 respectively). Furthermore, thereis a statistically significant difference between the studied vesselsregarding the presence of a difference >0.75 mm between theluminal diameters measured by IVUS and QCA (Difference >0.75mm in the left main artery, LAD, left circumflex and RCA were55.8%, 21.7%, 30.8%, and 15.4% respectively). Conclusion: Coronarylesions were underestimated by QCA in comparison to IVUSregarding luminal diameter, especially the left main (LM).

SYNCHRONOUS OCCURRENCE OF THREE DIFFERENT THYROID TUMORS

Background

Thyroid nodules are common; however, the association of two or more different tumors in the thyroid gland is unusual. We present a first case with the association of three histological types of thryroid tumors. To the best of our knowledge, this association has not been reported in the literature before. We aim here to highlight the possible coexistence of many lesions in the thyroid gland and to discuss treatment options.

Case presentation

We report the case of a female patient who presented with a multinodular goiter. The final pathology after total thyroidectomy found the association of a multifocal papillary thyroid microcarcinoma arising within a Hurthle cells adenoma in a lobe and a noninvasive follicular thyroid neoplasm with papillary nuclear features in the other lobe. Due to the very low risk of recurrence, the patient was not treated with radioactive iodine.

Conclusions

Many controversies remain about the management of Hurthle cells tumors and many variants of papillary thyroid carcinoma. Although the management of our case did not change, more studies are necessary to analyze the evolution of patients with multiple thyroid neoplasms. When discussing therapeutic options, the advantages and disadvantages should be considered case by case based on disease staging.

Some novel growth functions and their application with reference to growth in ostrich

Four novel growth functions, namely, Pareto, extreme value distribution (EVD), Lomolino, and cumulative β-P distribution (CBP), are derived, and their ability to describe ostrich growth curves is evaluated. The functions were compared with standard growth equations, namely, the monomolecular, Michaelis-Menten (MM), Gompertz, Richards, and generalized MM (gMM). For this purpose, 2 separate comparisons were conducted. In the first, all the functions were fitted to 40 individual growth curves (5 males and 35 females) of ostriches using nonlinear regression. In the second, performance of the functions was assessed when data from 71 individuals were composited (570 data points). This comparison was undertaken using nonlinear mixed models and considering 3 approaches: 1) models with no random effect, 2) random effect incorporated as the intercept, and 3) random effect incorporated into the asymptotic weight parameter (Wf). The results from the first comparison showed that the functions generally gave acceptable values of R2 and residual variance. On the basis of the Akaike information criterion (AIC), CBP gave the best fit, whereas the Gompertz and Lomolino equations were the preferred functions on the basis of corrected AIC (AICc). Bias, accuracy factor, the Durbin-Watson statistic, and the number of runs of sign were used to analyze the residuals. CBP gave the best distribution of residuals but also produced more residual autocorrelation (significant Durbin-Watson statistic). The functions were applied to sample data for a more conventional farm species (2 breeds of cattle) to verify the results of the comparison of fit among functions and their applicability across species. In the second comparison, analysis of mixed models showed that incorporation of a random effect into Wf gave the best fit, resulting in smaller AIC and AIC values compared with those in the other 2 approaches. On the basis of AICc, best fit was achieved with CBP, followed by gMM, Lomolino, and Richards functions, respectively. The exponential, MM, Pareto, and EVD equations produced negative values for initial weight (W0) if left unconstrained. The Gompertz equation, in spite of having a fixed inflection point and therefore being less flexible, gave accurate estimates of both W0 and Wf and an acceptable goodness of fit favored by having fewer parameters than the other sigmoidal functions. Nevertheless, all the sigmoidal functions appeared appropriate in describing the growth trajectory of male and female ostriches to a reasonable level of accuracy.

Glucose-6-phosphate dehydrogenase deficiency in Tunisia: molecular data and phenotype-genotype association

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common human enzyme defect. In this study, we aimed to perform a molecular investigation of G6PD deficiency in Tunisia and to associate clinical manifestations and the degree of deficiency with the genotype. A total of 161 Tunisian subjects of both sexes were screened by spectrophotometric assay for enzyme activity. Out of these, 54 unrelated subjects were selected for screening of the most frequent mutations in Tunisia by PCR/RFLP, followed by size-based separation of double-stranded fragments under non-denaturing conditions on a denaturing high performance liquid chromatography system. Of the 56 altered chromosomes examined, 75 % had the GdA(-) mutation, 14.28 % showed the GdB(-) mutation and no mutations were identified in 10.72 % of cases. Hemizygous males with GdA(-) mutation were mostly of class III, while those with GdB(-) mutation were mainly of class II. The principal clinical manifestation encountered was favism. Acute hemolytic crises induced by drugs or infections and neonatal jaundice were also noted. Less severe clinical features such as low back pain were present in heterozygous females and in one homozygous female. Asymptomatic individuals were in majority heterozygote females and strangely one hemizygous male. The spectrum of mutations seems to be homogeneous and similar to that of Mediterranean countries; nevertheless 10.72 % of cases remain with undetermined mutation thus suggesting a potential heterogeneity of the deficiency at the molecular level. On the other hand, we note a better association of the molecular defects with the severity of the deficiency than with clinical manifestations.

Megavoltage cone beam computed tomography: Commissioning and evaluation of patient dose

The improvement in conformal radiotherapy techniques enables us to achieve steep dose gradients around the target which allows the delivery of higher doses to a tumor volume while maintaining the sparing of surrounding normal tissue. One of the reasons for this improvement was the implementation of intensity-modulated radio therapy (IMRT) by using linear accelerators fitted with multi-leaf collimator (MLC), Tomo therapy and Rapid arc. In this situation, verification of patient set-up and evaluation of internal organ motion just prior to radiation delivery become important. To this end, several volumetric image-guided techniques have been developed for patient localization, such as Siemens OPTIVUE/MVCB and MVision megavoltage cone beam CT (MV-CBCT) system. Quality assurance for MV-CBCT is important to insure that the performance of the Electronic portal image device (EPID) and MV-CBCT is suitable for the required treatment accuracy. In this work, the commissioning and clinical implementation of the OPTIVUE/MVCB system was presented. The geometry and gain calibration procedures for the system were described. The image quality characteristics of the OPTIVUE/MVCB system were measured and assessed qualitatively and quantitatively, including the image noise and uniformity, low-contrast resolution, and spatial resolution. The image reconstruction and registration software were evaluated. Dose at isocenter from CBCT and the EPID were evaluated using ionization chamber and thermo-luminescent dosimeters; then compared with that calculated by the treatment planning system (TPS- XiO 4.4). The results showed that there are no offsets greater than 1 mm in the flat panel alignment in the lateral and longitudinal direction over 18 months of the study. The image quality tests showed that the image noise and uniformity were within the acceptable range, and that a 2 cm large object with 1% electron density contrast can be detected with the OPTIVUE/MVCB system with 5 monitor units (MU) protocol. The registration software was accurate within 2 mm in the anterior-posterior, left-right, and superior-inferior directions. The additional dose to the patient from MV-CBCT study set with 5 MU at the isocenter of the treatment plan was 5 cGy. For Electronic portal image device (EPID) verification using two orthogonal images with 2 MU per image the additional dose to the patient was 3.8 cGy. These measured dose values were matched with that calculated by the TPS-XiO, where the calculated doses were 5.2 cGy and 3.9 cGy for MVCT and EPID respectively.

Comparison of dosimetric characteristics of Siemens virtual and physical wedges for ONCOR linear accelerator

Dosimetric properties of virtual wedge (VW) and physical wedge (PW) in 6- and 10-MV photon beams from a Siemens ONCOR linear accelerator, including wedge factors, depth doses, dose profiles, peripheral doses, are compared. While there is a great difference in absolute values of wedge factors, VW factors (VWFs) and PW factors (PWFs) have a similar trend as a function of field size. PWFs have stronger depth dependence than VWF due to beam hardening in PW fields. VW dose profiles in the wedge direction, in general, match very well with those of PW, except in the toe area of large wedge angles with large field sizes. Dose profiles in the nonwedge direction show a significant reduction in PW fields due to off-axis beam softening and oblique filtration. PW fields have significantly higher peripheral doses than open and VW fields. VW fields have similar surface doses as the open fields, while PW fields have lower surface doses. Surface doses for both VW and PW increase with field size and slightly with wedge angle. For VW fields with wedge angles 45° and less, the initial gap up to 3 cm is dosimetrically acceptable when compared to dose profiles of PW. VW fields in general use less monitor units than PW fields.

[Tracheotomy complications in resuscitation patients]

Many statistics on what concerned the tracheotomy complications are old, dating from 1960-1970, and discouraging to practise this kind of gesture. Moreover, it is unfeasible to objectively evaluate this technique from these huge sets where it is often difficult to separate the dramatic complications (massive haemorrhage, suffocating pneumothorax,...) and those more benign. The authors analyze through a retrospective study of 32 tracheotomised patients, the index of these complications in distinguishing those of the early stage and the late stage can occur even after decannulation. In the acute phase, haemorrhages 9.3 p 100) per inadequate haematosis, the pneumothorax (3.1 p 100) and the infection of the stoma (12.5 p 100) are the most frequent. The opening tracheotomy infection can support pulmonary infections (28.1 p 100) which cause serious problems at tracheotomised. After decannulation, the principal complication is the tracheobronchial stenosis (3.1 p 100). Its diagnosis is difficult and should be done by systematic endoscopic control of the trachea and radiological explorations at the time of the decannulation. The authors insist on the use of proper equipments, protocols of rigorous care and strict post-operative monitoring.

[Distribution of cardiovascular risk factors in coronary patients in Sahel, Tunisia]

We evaluated cardiovascular risk factors and their association in patients in Sahel, hospitalized for coronary disease over the period 1994-1998. The clinical features of 3455 patients (72.4% men, 1741 with myocardial infarction, 1714 with unstable angina) were analysed on hospital admission. The prevalence of smoking, dyslipidaemia, hypertension, diabetes and obesity was 77.4%, 39.4%, 28.5%, 42.5% and 25.1% respectively in men and 2.9%, 43.7%, 59.2%, 56.6% and 31.9% respectively in women. With this risk factor profile a national strategy of primary prevention and heart health promotion is needed in Tunisia.

[Hydatid cyst of the right atrium]

Cardiac hydatid cysts are rare; the right atrial location is even rarer and carries serious complications. We report three cases of cardiac hydatid cyst of the right atrium. The first patient died in the postoperative period due to right heart failure and massive tracheal bleeding. The course of the disease of the two other patients was uneventful. Echocardiography is the most informative technique for identifying and localising the cyst before surgery. Right atrium hydatid cyst should be treated by early surgical excision with a view to prevent the risk of pulmonary embolism.

[Impact of diabetes on mortality after myocardial infarction]

Myocardial infarction is a common cause of mortality in people with diabetes. The aim of this study was to determine early and mid-term mortality in diabetic patients with myocardial infarction and to determine if hyperglycemia was predictor of mortality. We conducted a retrospective study of 100 diabetic patients compared with 100 non diabetic patients who were hospitalised in our institution between 1999 and 2003 for myocardial infarction.

RESULTS

Hospital and one year mortality were highest among diabetic patients compared with non diabetic patients. Multivariate analysis showed that admission plasma glucose was a consistent predictor factor of in hospital mortality RR 1.2 (IC 1.02-1.47). Admission plasma glucose was significantly higher in nonsurvivors diabetic patients than in survivors (22.7 vs 16 mmol/l P = 0.04). The predictor factors of one year mortality was age, female sex and no beta blocker at discharge RR5.3 (1.9-14.3).

CONCLUSION

Diabetic patients with myocardial infarction have poor prognosis and hyperglycemia was associated with in hospital mortality.

[Prognosis of periprosthetic regurgitation after mitral valve replacement using the Saint Jude prosthesis]

Periprosthetic regurgitation (PPR) is a common complication of mitral valve replacement (MVR). The management of moderate and minor PPR remains controversial. The goal of this prospective study was to determine the incidence, predictors and outcome of PPR discovered using omniplan transoesophageal echocardiography (TEE) performed at the early postoperative period (14.7 days) of MVR with SJM prosthesis. Our study enrolled 56 patients, the mean age was 44.5 +/- 11.9 years. The incidence of PPR was 59% (33 patients). TEE showed one jet in nine patients (27%), two jets in 23 patients (70%) and three jets in one patient (3%). PPR is minor in 24 patients (63%) and moderate in nine patients (27%). No patient developed hemolytic anemia or congestive heart failure. In univariate analysis, diameter of prostheses > 27 mm, number of suture knots < 17 and diameter of prostheses/number of knot ratio > 1.7 independently predicted the presence of PPR. In multivariate analysis only a rapport diameter of protheses/number of suture knots > 1.7 mm is predictif of PPR (odd ratio = 9, P = 0.036). Ninety percent of PPR remained present at six weeks and only 29% were present after 12.5 months.

CONCLUSION

Mild and minor PPR were frequent during the early postoperative period after MVR. The clinical significance and natural history is benign and they do not require any specific treatment.

[Evaluation of the hemodynamic profile of mitral Saint Jude Medical prostheses in the early and late postoperative period]

This study was to estimate the Doppler haemodynamic profiles of 56 prosthetic mitral valves (St Jude prosthesis) in the premature post-operating period, to study the correlation of the prosthetic area calculated by Doppler method (continuity equation (CE) and pressure half times (PHT)) and the area of the effective orifice in the post-operating premature period, in 6 weeks and after 6 months. The values of peak gradient and mean gradient at six week and at 12.5 months were not significantly different from those obtained in the premature exam. The prosthetic area calculated by continuity equation (ACE) in the premature postoperative period was significantly different between the various size (p = 0.0001). The (ACE) measured at 6 weeks and late (12.5 months), was not significantly different from that calculated in the premature exam (respectively p = 0.79 and p = 0.8). The (PHT) was very variable even within the different size of the prosthesis, however values measured at six weeks and in the late exam was not different from that calculated in the premature exam. In absence of complications, it seems to us that we can satisfy with using as reference exam data obtained in the premature exam.

Hydatid cyst of the right atrium and rheumatic mitral disease: a fortuitous association

Ecchinococcal infestation of the heart accounts for only 0.5-2% of ecchinococcosis cases. A case is reported of right atrial hydatid cyst associated with rheumatic mitral valve disease in a 43-year-old woman. Physical examination and chest X-radiography revealed mitral disease. Transthoracic and transesophageal echocardiography demonstrated a single, large cystic mass of 4 x 4 cm located in the right atrium, and heavily calcified mitral rheumatic disease with commissural fusion. Confirmatory computed tomography and magnetic resonance imaging excluded other extracardiac locations. Radioisotopic lung perfusion scanning and angiographic scanning excluded pulmonary embolism. The patient underwent mitral valve replacement and the hydatid cyst was excised. An intraoperative examination and subsequent pathology confirmed a diagnosis of hydatid cyst.

[Delays in the management of AMI: Results of an investigation conducted in Sousse (Tunisia)]

The goal of our work was to assess the delays of admission for Acute Myocardial Infarction (AMI) in Sousse (Tunisia) and to identify predictors of these delays. Our prospective survey was led from January 1999 to December 2001; 232 patients with AMI were included. The onset of symptoms usually occurred in the patient's home (80.6%). The chest pain was atypical in 19.4% of cases; 91% of patients directly consulted the emergency departments, whereas the ambulatory emergency services were used in only in 2.2% of cases. Delays of hospitalization in coronary care units were on average too long (14 h 21 min +/- 19 h 16 min). This prolongation was essentially caused by a too long period between onset of symptoms and first patient call. In bivariate analysis, dyslipidemia, diabetes, absence of smoking and an atypical symptoms were associated with prolonged hospitalization delays. However in multivariate analysis, only diabetes and atypical symptoms were independent factors associated with a hospitalization delay of more than 12 h. In 23% of the patients, a prolonged pre-hospital time period prevented the use of thrombolysis.

CONCLUSION

Pre-hospital delays should be shortened by a multidisciplinary action that especially focuses on a better sanitary education of patients to risk.

[Familial hypertrophic cardiomyopathy associated with Wolff-Parkinson-White syndrome]

Familial hypertrophic cardiomyopathy (HCM) with Wolff-Parkinson-White (WPW) syndrome is extremely rare and associated with a high risk of ventricular tachyarrhythmia and sudden death. We report a familial form of hypertrophic cardiomyopathy associated with Wolff-Parkinson-White syndrome in two siblings 7 and 12-year-old. These patients showed progression to left ventricular dilatation. Early recognition and treatment of such forms can improve such evolution and the risk of sudden death.

[Myocardial infarction and abnormal origin of the circumflex coronary artery]

Abnormal origin of the circumflex coronary artery without any stenosis is generally considered benign and without any particular ischemic risk. We report a case of a 21 year old man who suffered a posterior lateral myocardial infarction with objective criteria: electrocardiographic, echocardiographic and isotopic. The patient received thrombolytic therapy at H2. Angiography showed an abnormal origin of the circumflex coronary artery which was free of any stenosis. Certain cases of the circumflex artery anomaly can, therefore, be complicated by myocardial infarction, and the benign nature of the anomaly needs to be re-examined.