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3.  Delay of Fibrinolysis in ST- Elevation Myocardial Infarction: Results of an Investigation Conducted in a Single Center in Sousse Tunisia 
The aim of our study was to assess the delay of fibrinolysis in ST elevation myocardial infarction (STEMI) in our region and to identify characteristics associated with prolonged delay.
Patients and Methods:
We analyzed clinical characteristics of a prospective cohort of unselected patients admitted for (STEMI). The study was conducted over three years 2007-2009 and 250 patients were included in a single center without capability of percutaneous coronary intervention.
The mean age of our patients was 58±13, 7 years. Ninety percent of our patients consult directly the emergency department and 61, (5%) of them were admitted within first 6 hours of onset of symptoms. Median time to reperfusion was 46 min. Predictor of this long delay to initiate fibrinolysis were inter-department decision OR 6; 95% CI 3,48-10,34, diabetes OR 2,25; 95% CI 1,28-3,96 age >58,4 years OR 1,97; 95% CI 1,19-3,25 and transfer from regional hospital to our center OR 1,78; 95% 1,03-3.07.
These results suggest that improvement in organization health care system can shorten delay to fibrinolysis in a center without percutaneous coronary intervention capability.
PMCID: PMC4268612  PMID: 25538818
Delay of fibrinolysis; ST-elevation myocardial infarction; reperfusion
4.  Assessment of Heart Rate Turbulence in Hypertensive Patients: Rationale, Perspectives, and Insight Into Autonomic Nervous System Dysfunction 
Heart rhythm turbulence is classically impaired in patients with previous myocardial infarction and congestive heart failure and is poorly investigated in patients with essential hypertension.
To evaluate heart rhythm turbulence parameters (turbulence onset, (TO); turbulence slope, (TS) in a series of hypertensive patients while gaining insight into autonomic nervous system dysfunction.
Setting and Design:
University hospital, cross-sectional monocentric study.
Materials and Methods:
Heart rhythm turbulence was assessed in 50 hypertensive (case group) and 40 normotensive patients (control group).
TO and TS were found independently correlated with hypertension. The mean TO was found at -1.64% ± 2.85% in the normotensive patients compared to 1.21% ± 1.95% in the hypertensive patients; the mean TS was found at 4.29 ± 3.18 ms/RR in the normotensive patients compared to 2.27 ± 0.93 ms/RR in the hypertensive patients. Hypertension has a predictive value on heart rhythm turbulence impairment (OR 4.99, 95% CI 1.28-19.41, P = 0.02). Insights into the role of autonomic nervous system dysfunction for the management of hypertensive patients and prevention of malignant ventricular arrhythmia are presented and discussed with regard to heart rhythm turbulence.
Essential hypertension is correlated with blunted heart rhythm turbulence parameters.
PMCID: PMC4268613  PMID: 25538819
Autonomic; hypertension; nervous; rate; turbulence
5.  Cardioprotective Effects of Ghrelin in Heart Failure: From Gut to Heart 
Chronic heart failure (CHF) is a major cause of morbidity and mortality. Cardioprotective effects of ghrelin, especially in its acylated form have been demonstrated in heart failure (HF) models and exploratory human clinical studies. Hence, it has been proposed for the treatment of HF. However, the underlying mechanism of its protective effects against HF remains unclear. Future researches are needed to evaluate the efficacy of Ghrelin as a new biomarker and prognostic tool and for exploring its therapeutic potential in patients suffering from CHF.
PMCID: PMC4268614  PMID: 25538820
Cardioprotective effects; ghrelin; gut
6.  First Degree Heart Block with Multi-focal Atrial Ectopics in an Adolescent Girl Due to Hypomagnesemia 
Nutritional deficiencies are common in adolescent children and include deficiencies of both micro- and macronutrients. Magnesium is an important mineral that is essential for maintenance of numerous electrophysiological and biochemical processes in the body. We report an adolescent girl who developed an episode of syncope with first degree heart block on electrocardiography and run of multifocal atrial ectopics on 24 h holter monitoring. Serum magnesium was found to be low with decreased urinary magnesium excretion. There were no other electrolyte abnormalities. Structural heart disease was ruled out by a normal echocardiogram. The rhythm changes were attributable to nutritional hypomagnesemia and were promptly reversed on correcting the hypomagnesemia.
PMCID: PMC4268615  PMID: 25538821
First degree heart block; hypomagnesemia; multifocal atrial ectopics
7.  Spontaneous Coronary Artery Dissection and Acute Myocardial Infarction after Cesarean Section in a Postpartum Woman with Untreated Dyslipidemia 
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI). We are presenting a case of a young woman with a history of untreated dyslipidemia presented with AMI secondary to left anterior descending coronary artery dissection during postpartum period. Physicians should be aware of this rare etiology of AMI which occurs during pregnancy and postpartum, since early diagnosis and treatment play a key role in saving both the mother and the baby. It is important to screen for other possible causes such as collagen vascular diseases, blunt injury to the chest, or cocaine abuse.
PMCID: PMC4268616  PMID: 25538822
Acute myocardial infarction; coronary artery dissection; postpartum; pregnancy; women
8.  Diffuse Pulmonary Hemorrhage After Fibrinolytic Therapy for Acute Myocardial Infarction in a Cocaine Abuser Patient 
We report a 45-year-old man with antroseptal myocardial infarction who developed bilateral basal alveolar infiltrates after initiating the fibrinolytic therapy. Although thrombolytic therapy with streptokinase is generally used in the course of acute myocardial infarction and has diminished morbidity and mortality, pulmonary hemorrhage is an uncommon, but a potentially life-threatening complication that should be regarded as one of the differential diagnoses of pulmonary infiltrates or dropping hemoglobin with no apparent bleeding site.
PMCID: PMC4268617  PMID: 25538823
Alveolar infiltrates; fibrinolytic therapy; myocardial infarction; pulmonary hemorrhage; streptokinase
9.  Assessment of Carotid Body Tumor and Its Association with Tetralogy of Fallot: Effect of the Chronic Hypoxia 
This is a rare combined presentation of Tetralogy of Fallot and carotid body tumor (CBT). Hypotheses and further discussion provides data for the development of CBT as a response to chronic hypoxemia. This present study demonstrates and discusses such an occurrence.
PMCID: PMC4268618  PMID: 25538824
Carotid body; carotid tumor; hypoxia; Tetralogy of Fallot
10.  Giant Pulmonary Artery Aneurysm in a Patient with Rheumatic Mitral Stenosis 
Pulmonary artery (PA) aneurysm is a rare condition, frequently associated with pulmonary hypertension. However, the evolution and treatment of this pathology is still not clear. We report a case of a 45-year-old female patient with giant PA aneurysm associated with rheumatic mitral stenosis and severe pulmonary arterial hypertension. The patient had undergone balloon mitral valvotomy around 7 years back; aneurysm was first identified 3 years back during routine follow-up. The PA aneurysm size, however, had remained almost unchanged with associated severe pulmonary regurgitation. Surgical correction was advised but denied by the patient. To our knowledge, this is the first case report of such a large PA aneurysm in association with rheumatic heart disease. Although medical therapy for pulmonary hypertension was started, surgical correction of the aneurysm was advised in order to prevent the future complications.
PMCID: PMC4268619  PMID: 25538825
Pulmonary artery aneurysm; pulmonary hypertension; rheumatic heart disease
11.  Xanthomas and hypercholoesterolemia 
PMCID: PMC4268620  PMID: 25538826
13.  The Medieval Origins of the Concept of Hypertension 
Despite the well-known history of hypertension research in the modern era, like many other cardiovascular concepts, main points in the medieval concept of this disease and its early management methods remain obscure. This article attempts to make a brief review on the medieval origin of the concept of this disease from the Hidayat of Al-Akhawayni (?-983 AD). This article has reviewed the chapter of “Fi al-Imtela” (About the Fullness) from the Hidβyat al-Muta’allimin fi al-Tibb (The Students' Handbook of Medicine) of Al-Akhawayni.
The definition, symptoms and treatments presented for the Imtela are compared with the current knowledge on hypertension. Akhawayni believed that Imtela could result from the excessive amount of blood within the blood vessels. It can manifest with symptoms including the presence of a pulsus magnus, sleepiness, weakness, dyspnea, facial blushing, engorgement of the vessels, thick urine, vascular rupture, and hemorrhagic stroke. He also suggested some ways to manage al-Imtela'. These include recommendations of changes in lifestyle (staying away from anger and sexual intercourse) and dietary program for patients (avoiding the consumption of wine, meat, and pastries, reducing the volume of food in a meal, maintaining a low-energy diet and the dietary usage of spinach and vinegar). Al-Akhawayni's description of “Imtela,” despite of its numerous differences with current knowledge of hypertension, can be considered as medieval origin of the concept of hypertension.
PMCID: PMC4268622  PMID: 25538828
Al-Akhawayni; hypertension; Islamic golden age; medieval history; Traditional Persian Medicine
14.  The Efficacy of Hydration with Normal Saline Versus Hydration with Sodium Bicarbonate in the Prevention of Contrast-induced Nephropathy 
Contrast-induced acute kidney injury [contrast-induced nephropathy (CIN)] is one of the major causes of hospital-acquired acute renal failure. Volume supplementation is the most effective strategy to prevent acute renal failure caused by contrast; but the effects of sodium bicarbonate regimens are unknown in CIN prevention. The aim of this survey is to compare the efficacy of hydration with normal saline versus hydration with sodium bicarbonate in the prevention of the CIN in patients undergoing coronary angiography.
Materials and Methods:
In a clinical trial, 350 patients undergoing coronary interventions were randomized into two groups: One group received normal saline and another group received sodium bicarbonate before and after infusion of the contrast. Patients in both the groups had received N-acetylcysteine. CIN was defined as relative increase in serum creatinine equal to or more than 25% of baseline or increase to 0.5 mg/dl in 48 h after the injection of the contrast.
CIN was seen in 46 patients (13.1%) after coronary interventions. Incidence of CIN in patients receiving normal saline (19.4%) was more than in patients receiving sodium bicarbonate (6.9%) (P = 0.001). Hemodialysis was needed only in one patient who received saline normal. Relative risk to induce CIN in both groups was as 2.8 and was in the range of 1.50-5.25 with confidence interval of 95% and P = 0.001. Thus, the probability of CIN was significantly more in the usage of normal saline.
This survey showed that hydration with sodium bicarbonate is superior to hydration with normal saline and has better protection effects.
PMCID: PMC4124663  PMID: 25104980
Contrast; nephropathy; sodium bicarbonate
15.  Oxytocin Ameliorates the Immediate Myocardial Injury in Heart Transplant Through Down Regulation of the Neutrophil Dependent Myocardial Apoptosis 
Cardiac oxytocin (OT) is structurally identical to that found in the hypothalamus, which thereby indicates that cardiac OT is derived from the same gene and is an active form of OT. The abundance of OT and OT receptors in atrial myocytes shows that, directly and/or via the release of the cardiac hormone atrial natriuretic peptide, OT can regulate the force of cardiac contractions. Previous studies have demonstrated the role of OT in the myocardial inflammatory response. The mechanism by which OT elicits protective myocardial effects in the immediate post-transplantation period is not yet clear, and the role of the early phase inflammatory elements in this mechanism has not yet been studied. As a result, in this study, we have investigated the anti-inflammatory effects of OT on myocardial protection in the immediate post-transplantation period.
Adult male Albino rats were grouped into: Sham, Control, and OT-treated groups. The control and treated groups sustained cervical heterotopic heart transplant. Myocardial injury was assessed by measuring: Plasma cardiac troponin I, myocardial proinflammatory cytokines, and histopathological assessment for score of injury, and degree of apoptosis. Myocardial myeloperoxidase, neutrophil infiltration, and neutrophil chemotactant agents, reactive oxygen species, and reactive nitrogen species formation all were measured in the myocardium after 3 hour of reperfusion to assess the neutrophil-dependant myocardial injury and the mechanism involved.
Oxytocin down-regulates the neutrophil chemotactant agents the KC/CXCL1 and MIP-2/CXCL2 which recruit less neutrophil into myocardium, this decrement in myocardial PMN infiltration is associated with less reactive oxygen species and reactive nitrogen species formation in the myocardium after 3 hours of global ischemia reperfusion. These oxytocin-induced down-regulation inflammatory and oxidative processes will end in less myocardial injury through impedance in the post-myocardial ischemia/reperfusion apoptotic process.
Oxytocin ameliorates myocardial injury in heart transplant through down-regulation the myocardial inflammatory response, reactive oxygen species, and neutrophil-dependant myocardial apoptosis.
PMCID: PMC4124664  PMID: 25104981
Heart transplant; neutrophil-dependant myocardial apoptosis; oxytocin
16.  Negative Pressure Pulmonary Edema Following Septoplasty Surgery Triggering Acute Subendocardial Myocardial Infarction 
Negative pressure pulmonary edema (NPPE) is defined as fluid transudation into the pulmonary interstitium which occurs as a result of elevated negative intrathoracic pressure caused by the upper respiratory tract obstruction and strong inspiratory effort. NPPE is usually seen during emergence from general anesthesia in the early post-operative period especially after upper respiratory tract surgery. We present a case of a 37-year-old male patient who underwent septoplasty operation and developed NPPE which could not diagnosed and progressed to acute subendocardial myocardial infarction.
PMCID: PMC4124665  PMID: 25104982
Acute subendocardial myocardial infarction; negative pressure pulmonary edema; septopolasty; upper respiratory tract obstruction
17.  Electrocution Induced Symptomatic Bradycardia Necessitating Pacemaker Implantation 
Electrical or electrocution injury is a common accidental occurrence and mostly workplace related. Fatal arrhythmias, skin injury and sudden death may ensue. However, it is rare for electrocution to result in permanent low rate sinus bradycardia, incompatible with an active lifestyle. The probable mechanisms for this pathological sinus bradycardia are sinus node dysfunction and autonomic dysfunction with vagal predominance. We describe a young patient who suffered a non fatal electrocution with resultant low rate sinus bradycardia and its successful treatment with a dual chamber rate responsive pacemaker.
PMCID: PMC4124666  PMID: 25104983
Autonomic resetting; electrical injury; electrocution; pacemaker; poor chronotropic response; sinus bradycardia; vagal tone predominance
18.  A Giant Left Main Trunk and Left Circumflex Artery-to-Right Ventricle Fistula 
Coronary artery fistula including the left trunk and left circumflex is uncommon. We present a 24-year-old male patient with a giant left main trunk and left circumflex artery to right ventricle fistula, which is diagnosed by transthoracic echocardiography and coronary computed tomography angiography. In this paper, the case report is to provide a better understanding of clinical characteristics for this disease.
PMCID: PMC4124667  PMID: 25104984
Angiography; computed tomography; coronary artery; Fistula
19.  Carcinoma of Unknown Primary Presenting as Large Right Atrial and Ventricular Mass Secondary to Disseminated Tumor Thrombosis 
We report a 65-year-old male patient who presented with right heart failure and a large mobile right atrial and ventricular mass on echocardiography. His computed tomography demonstrated bilateral supraclavicular/mediastinal lymphadenopathy, right atrial and ventricular mass with right pulmonary artery segmental embolism, and multiple liver hypodense lesions. His tumor markers were negative. However, fine-needle aspiration cytology of supraclavicular lymph node revealed metastatic carcinoma suggestive of squamous cell carcinoma. He was suspected to have carcinoma of unknown primary origin. This case illustrates a rare presentation of carcinoma of unknown primary origin with disseminated tumor thrombosis primarily manifesting in heart and other sites.
PMCID: PMC4124668  PMID: 25104985
Carcinoma of unknown primary; cardiac metastasis; right atrium; tumor thrombosis
20.  A Case of Anomalous Origin of Circumflex Artery from Right Sinus of Valsalva Recognized by Three-dimensional Transesophageal Echocardiography and Coronary Computed Tomography Angiography 
Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly. It is thought to be of no clinical relevance unless cardiac surgery is performed. We report a 53-year-old patient with aberrant circumflex coronary artery origin from the right aortic sinus of Valsalva which was first suspected from transthoracic 2D and transesophageal 3D echocardiographic views and confirmed by coronary CT angiography. The patient did not receive further diagnostic or therapeutic options. Therefore, we recommended medical therapy with optimal treatment of his cardiovascular risk factors together with regular clinical follow up.
PMCID: PMC4124669  PMID: 25104986
Coronary artery anomaly; coronary computed tomography angiography; transesophageal echocardiography
23.  Short Term Efficacy and Safety of Low Dose Tolvaptan in Patients with Acute Decompensated Heart Failure with Hyponatremia: A Prospective Observational Pilot Study from a Single Center in South India 
In acute decompensated heart failure (ADHF), diuretic use, the mainstay therapy for congestion, is associated with electrolyte abnormalities and worsening renal function. Vasopressin mediates fluid retention in heart failure. In contrast to diuretics, the vasopressin antagonist tolvaptan may increase net volume loss in heart failure without adversely affecting electrolytes and renal function. Hyponatremia (serum sodium concentration, <135 mEq/L) is a predictor of death among patients with heart failure.
We prospectively observed the short term efficacy and safety of low dose (15 mg) tolvaptan in admitted patients with hyponatremia and ADHF in Indian population.
A total of 40 patients with ADHF along with hyponatremia (<125 mEq/L) on standard therapy were treated with 15 mg of tolvaptan at a single oral dose for 7 days.
Serum sodium concentrations increased significantly after treatment with tolvaptan from baseline (P < 0.02). There was a significant improvement in symptoms and New York Heart Association (NYHA) class after starting tolvaptan (P ≤ 0.05). Total diuretic dose and mean body weight was reduced non-significantly at 7th day from the baseline. Side-effects associated with tolvaptan included increased thirst, dry mouth and increased urination. Few patients had worsening renal function. However, several patients developed hypernatremia.
In this small observational study, tolvaptan initiation in patients with ADHF with hyponatremia in addition to standard therapy may hold promise in improvement in NYHA class and serum sodium. At the same time, we observed that serious adverse events such as renal function deterioration and hypernatremia developed after tolvaptan treatment, which needs to be addressed in future by randomized study with larger sample size.
PMCID: PMC4062982  PMID: 24949180
Acute decompensated heart failure; hyponatremia; tolvaptan; vasopressin antagonist
24.  Expanding Giant Right Coronary Artery Aneurysm: An Acute Need for New Management Strategies 
Angiography use has become increasingly common worldwide. Coronary artery aneurysm may be an incidental finding during angiography. Occasionally it might be symptomatic or may become symptomatic over the course of time. Rupture of aneurysm may lead to disastrous complications. Here we present a case in which aneurysm was asymptomatic but surgical intervention was done because of rapid increase in the size of aneurysm. This is to drive home the point that timely surgical intervention is instrumental in preventing complications associated with possible rupture of the aneurysm.
PMCID: PMC4062983  PMID: 24949182
Angiography; coronary artery bypass grafting; coronary artery aneurysm
25.  Recurrent Myocardial Infarction in a Case of Congenital Afibrinogenemia 
Afibrinogenemia is a rare autosomal recessive bleeding disorder with an estimated prevalence of 1:1,000,000. Usual presentation of this disorder is spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures. Paradoxically, few patients with afibrinogenemia may also suffer from severe thromboembolic complications. The management of these patients is particularly challenging because they are not only at risk of thrombosis but also of bleeding. We are presenting a case of 33-year-old male patient of congenital afibrinogenemia who had two episodes myocardial infarction in a span of two years. The patient was managed conservatively with antiplatelet therapy and thrombolytic therapy was not given due to high risk for bleeding.
PMCID: PMC4062984
Afibrinogenemia; antiplatelet therapy; myocardial infarction

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