Analyzing recent coronary heart disease mortality trends in Tunisia between 1997 and 2009

Effectiveness of a 3-year community-based intervention for blood pressure reduction among adults: a repeated cross-sectional study with a comparison area

Raised blood pressure is the leading risk factor for cardiovascular diseases. We aimed to demonstrate the effectiveness of a 3-year community-based healthy lifestyle promotion intervention at a neighbourhood level for blood pressure reduction among adults in the context of a political transition. We conducted repeated cross-sectional surveys including 1880 (940 from each area) participants at baseline and 1977 (1001 in the intervention area; 976 comparison area) participants at follow-up. Data collection was conducted through home visits. Multiple linear regression models were used to identify the intervention effect and factors associated with blood pressure change in each area. The prevalence of hypertension was 4.4% lower (35.8% vs. 31.4%) in the intervention area after 3 years (p = 0.044). The mean systolic and diastolic blood pressures changed significantly in the intervention area, from 132.4 ± 19.2 mmHg at baseline to 130.6 ± 17.7 mmHg at follow-up (p = 0.035) and from 78.7 ± 11.8 mmHg to 76.9 ± 11.1 mmHg (p < 10-3), respectively. In the control group, the mean systolic blood pressure increased from 129.4 ± 17.8 mmHg to 130.4 ± 17.9 mmHg (p = 0.38). A significant protective effect of the intervention on systolic (β = -0.4; 95% CI: -0.76; -0.06) and diastolic blood pressures (β = -0.22; 95% CI: -0.38; -0.07) was found in the intervention area. In the control area, the effect was not significant for systolic blood pressure. Lifestyle intervention at the neighbourhood level, in the context of a sociopolitical transition, was found to be effective for reducing blood pressure in Sousse, Tunisia. This approach could be scaled up and applied in other similar settings. Future research also needs to focus on designing, implementing, and evaluating multisectoral action plans and legislative measures.

Dietary fat quality, plasma atherogenic lipoproteins, and atherosclerotic cardiovascular disease: An overview of the rationale for dietary recommendations for fat intake

The scientific evidence supporting the current dietary recommendations for fat quality keeps accumulating; however, a paradoxical distrust has taken root among many researchers, clinicians, and in parts of the general public. One explanation for this distrust may relate to an incomplete overview of the totality of the evidence for the link between fat quality as a dietary exposure, and health outcomes such as atherosclerotic cardiovascular disease (ASCVD). Therefore, the main aim of the present narrative review was to provide a comprehensive overview of the rationale for dietary recommendations for fat intake, limiting our discussion to ASCVD as outcome. Herein, we provide a core framework - a causal model - that can help us understand the evidence that has accumulated to date, and that can help us understand new evidence that may become available in the future. The causal model for fat quality and ASCVD is comprised of three key research questions (RQs), each of which determine which scientific methods are most appropriate to use, and thereby which lines of evidence that should feed into the causal model. First, we discuss the link between low-density lipoprotein (LDL) particles and ASCVD (RQ1); we draw especially on evidence from genetic studies, randomized controlled trials (RCTs), epidemiology, and mechanistic studies. Second, we explain the link between dietary fat quality and LDL particles (RQ2); we draw especially on metabolic ward studies, controlled trials (randomized and non-randomized), and mechanistic studies. Third, we explain the link between dietary fat quality, LDL particles, and ASCVD (RQ3); we draw especially on RCTs in animals and humans, epidemiology, population-based changes, and experiments of nature. Additionally, the distrust over dietary recommendations for fat quality may partly relate to an unclear understanding of the scientific method, especially as applied in nutrition research, including the process of developing dietary guidelines. We therefore also aimed to clarify this process. We discuss how we assess causality in nutrition research, and how we progress from scientific evidence to providing dietary recommendations.

Hypoadiponectinemia-induced upregulation of microRNA449b downregulating Nrf-1 aggravates cardiac ischemia-reperfusion injury in diabetic mice

Diabetes enhances myocardial ischemic/reperfusion (MI/R) injury via an incompletely understood mechanism. Adiponectin (APN) is a cardioprotective adipokine suppressed by diabetes. However, how hypoadiponectinemia exacerbates cardiac injury remains incompletely understood. Dysregulation of miRNAs plays a significant role in disease development. However, whether hypoadiponectinemia alters cardiac miRNA profile, contributing to diabetic heart injury, remains unclear. Methods and Results: Wild-type (WT) and APN knockout (APN-KO) mice were subjected to MI/R. A cardiac microRNA profile was determined. Among 23 miRNAs increased in APN-KO mice following MI/R, miR-449b was most significantly upregulated (3.98-fold over WT mice). Administrating miR-449b mimic increased apoptosis, enlarged infarct size, and impaired cardiac function in WT mice. In contrast, anti-miR-449b decreased apoptosis, reduced infarct size, and improved cardiac function in APN-KO mice. Bioinformatic analysis predicted 73 miR-449b targeting genes, and GO analysis revealed oxidative stress as the top pathway regulated by these genes. Venn analysis followed by luciferase assay identified Nrf-1 and Ucp3 as the two most important miR-449b targets. In vivo administration of anti-miR-449b in APN-KO mice attenuated MI/R-stimulated superoxide overproduction. In vitro experiments demonstrated that high glucose/high lipid and simulated ischemia/reperfusion upregulated miR-449b and inhibited Nrf-1 and Ucp3 expression. These pathological effects were attenuated by anti-miR-449b or Nrf-1 overexpression. In a final attempt to validate our finding in a clinically relevant model, high-fat diet (HFD)-induced diabetic mice were subjected to MI/R and treated with anti-miR-449b or APN. Diabetes significantly increased miR-449b expression and downregulated Nrf-1 and Ucp3 expression. Administration of anti-miR-449b or APN preserved cardiac Nrf-1 expression, reduced cardiac oxidative stress, decreased apoptosis and infarct size, and improved cardiac function. Conclusion: We demonstrated for the first time that hypoadiponectinemia upregulates miR-449b and suppresses Nrf-1/Ucp3 expression, promoting oxidative stress and exacerbating MI/R injury in this population. Dysregulated APN/miR-449b/oxidative stress pathway is a potential therapeutic target against diabetic MI/R injury.

Sex, Racial, and Ethnic Disparities in Acute Coronary Syndrome: Novel Risk Factors and Recommendations for Earlier Diagnosis to Improve Outcomes

In this review, sex, racial, and ethnic differences in acute coronary syndromes on a global scale are summarized. The relationship between disparities in presentation and management of acute coronary syndromes and effect on worse clinical outcomes in acute coronary syndromes are discussed. The effect of demographic, geographic, racial, and ethnic factors on acute coronary syndrome care disparities are reviewed. Differences in risk factors including systemic inflammatory disorders and pregnancy-related factors and the pathophysiology underlying them are discussed. Finally, breast arterial calcification and coronary calcium scoring are discussed as methods to detect subclinical atherosclerosis and start early treatment in an attempt to prevent clinical disease.

Cardiac rupture during acute myocardial infarction : Autopsy study (2004-2020)

INTRODUCTION

Cardiac rupture is a rare but critical complication of myocardial infarction with an incidence of 1 to 3% of cases. We aimed in this autopsy study to analyze the anatomical, epidemiological, cardiac, and coronary profiles of cardiac rupture in the Monastir region.

METHODS

We conducted a descriptive study with retrospective data collection of all cases of myocardial infarction complicated by a cardiac rupture over seventeen years (2004-2020).

RESULTS

Thirty-one cases were included in this study. The mean age of the cases was 67 years with a male predominance. Sixteen cases (57%) had cardiovascular risk factors. The most common symptomatology reported before death was acute chest pain in 57% of cases. Fourteen cases (45%) corresponded to the definition of sudden cardiac death. At autopsy, the heart had a mean weight of 452.78 grams. A large hemopericardium was associated in 90% of cases. Myocardial rupture involved the posterior wall of the left ventricle in 50% of cases. The myocardial rupture occurred at a site of acute myocardial infarction in 86% of cases and on a myocardial scar in 14% of cases. The coronary study showed double or triple vessel atherosclerotic coronary artery disease in 57% of cases with fresh thrombi at the infarct-related coronary in 11% of cases.

CONCLUSIONS

Our analysis found that cardiac rupture mostly involved elderly subjects with underlying cardiovascular risk factors. Our findings sustain that age is a determining prognostic factor after acute coronary syndrome with the need for further education and awareness-raising efforts to speed up access to care for these patients.

A potential oral microbiome signature associated with coronary artery disease in Tunisia

The coronary artery disease is a chronic inflammatory disease involving genetic as well as environmental factors. Recent evidence suggests that the oral microbiome has a significant role in triggering atherosclerosis. The present study assessed the oral microbiome composition variation between coronary patients and healthy subjects in order to identify a potential pathogenic signature associated with coronary artery disease (CAD). We performed metagenomic profiling of salivary microbiomes by 16S rRNA next-generation sequencing. Oral microbiota profiling was performed for 30 individuals including 20 patients with CAD and 10 healthy individuals without carotid plaques or previous stroke or myocardial infarction.We found that oral microbial communities in patients and healthy controls are represented by similar global core oral microbiome. The predominant taxa belonged to Firmicutes (genus Streptococcus, Veillonella, Granulicatella, Selenomonas), Proteobacteria (genus Neisseria, Haemophilus), Actinobacteria (genus Rothia), Bacteroidetes (genus Prevotella, Porphyromonas) and Fusobacteria (genus Fusobacterium, Leptotrichia). More than 60% relative abundance of each sample for both CAD patients and controls is represented by three major genera including Streptococcus (24.97% and 26.33%), Veillonella (21.43% and 19.91%) and Neisseria (14.23% and 15.33%).  Using penalized regression analysis, the bacterial genus Eikenella was involved as the major discriminant genus for both status and Syntax score of CAD. We also reported a significant negative correlation between Syntax score and Eikenella abundance in coronary patients' group (Spearman rho =-0.68, p= 0.00094). In conclusion, the abundance of Eikenella in oral coronary patient samples compared to controls could be a prominent pathological indicator for the development of CAD.

Drug-Eluting-Balloon Angioplasty in Tunisian population versus Everolimus-platinum-chrome-stent for de-novo coronary lesion

RESEARCH PROBLEM

Drug-eluting balloon (DEB) angioplasty is a well-established treatment modality for in-stent restenosis, however its safety and efficacy in de-novo lesion especially in large vessel remains undetermined. Theoretically, DEB sight to eliminate stent thrombosis and reduce restenosis rates by leaving no metal behind.

AIM

To compare the results of angioplasty of de novo lesions by DEB (SEQUENT PLEASE) versus DES (Promus Premier and Promus Elite) in a Tunisian population. THE ENDPOINTS will be primarily the Late Lumen Loss at 12 months and secondarily the Major Cardiovascular Event rate (MACE) at 12 months.

INVESTIGATIVE PROCESS

This is a randomized controlled non-inferiority trial including 290 patients with chronic coronary disease or non-ST elevation myocardial infarction with de novo lesions. After coronarography, angiographic parameters concerning lesion location and quantitative analysis will be collected. Patients will be treated with DEB or DES according to their allocation group. Before removal of the guide, post-procedural angiographic parameters will be evaluated. Follow-up will be performed for 12 months and an angiographic examination will be performed either as an emergency or at 12 months. The significance level will be 5%. A univariate analysis will be performed to search for predictive factors of MACE.

RESEARCH PLAN

Ethical considerations will be undertaken and respected. The study will run for 15 months starting August 25, 2021 Trial registration: NCT05516446.

Management of diabetics. Comparative study of two contrasting health structures

BACKGROUND

The proportion of total Tunisian with Diabetes reached 15.5% in 2016. The objective of this study was to analyze diabetic's management in contrasted health care settings.

METHODS

Mixed methodology (quantitative and qualitative) with explanatory design was used in contrasted health care structures (a primary health center (PHC) and the National Institute of Nutrition and Food Technologies (INNTA)). Interviews with health providers and patients were than condcuted in both centers to explain quantitative findings.

RESULTS

Quality of care assessement was performed among 100 patients in the PHC and 96 in the hospital. Glycemic control was reached in less than 30 % of the cases in both centers. Although clinical evaluation was better in the PHC, conducting ECGs, measuring of HbA1c  and  LDL-Ch were far from being optimal. The qualitative study did supply some hypotheses explaining these gaps: treatments shortage and lack of laboratory assessments specifically pointed in PHC settings, potentially lower its attractiveness, thus compounding overcrowding and stressful working conditions in hospitals. These last points as well as poor communication and overloaded clinics in hospital were major sources of providers and patient dissatisfaction.

CONCLUSION

This study made it clear that primary health care is a cornerstone in diabetes management. However, it is crucial to strengthen primary health care centers by operational technical support (laboratory equipements and quality information system) as well building capacities of health professionals in information, education and communication.

Explaining the increment in coronary heart disease mortality in Mexico between 2000 and 2012

BACKGROUND

Mexico is still in the growing phase of the epidemic of coronary heart disease (CHD), with mortality increasing by 48% since 1980. However, no studies have analyzed the drivers of these trends. We aimed to model CHD deaths between 2000 and 2012 in Mexico and to quantify the proportion of the mortality change attributable to advances in medical treatments and to changes in population-wide cardiovascular risk factors.

METHODS

We performed a retrospective analysis using the previously validated IMPACT model to explain observed changes in CHD mortality in Mexican adults. The model integrates nationwide data at two-time points (2000 and 2012) to quantify the effects on CHD mortality attributable to changes in risk factors and therapeutic trends.

RESULTS

From 2000 to 2012, CHD mortality rates increased by 33.8% in men and by 22.8% in women. The IMPACT model explained 71% of the CHD mortality increase. Most of the mortality increases could be attributed to increases in population risk factors, such as diabetes (43%), physical inactivity (28%) and total cholesterol (24%). Improvements in medical and surgical treatments together prevented or postponed 40.3% of deaths; 10% was attributable to improvements in secondary prevention treatments following MI, while 5.3% to community heart failure treatments.

CONCLUSIONS

CHD mortality in Mexico is increasing due to adverse trends in major risk factors and suboptimal use of CHD treatments. Population-level interventions to reduce CHD risk factors are urgently needed, along with increased access and equitable distribution of therapies.

Estimation of cardiovascular risk in a rural population of Lucknow district using WHO/ISH risk prediction charts

Context:

Cardiovascular diseases (CVDs) are the number one cause of death globally, with low- and middle-income countries being affected disproportionately. By 2020, it is projected that there will be 25 million deaths from CVD worldwide, 19 million of which would be from middle- and low-income countries.

Aims:

The aim of this study was to estimate the 10-year risk of cardiovascular events among adults aged ≥40 years in a rural population of Lucknow district using the World Health Organization (WHO)/International Society of Hypertension (ISH) risk prediction charts for SEAR-D region.

Settings and Design:

This was a community based cross-sectional study, conducted from September 2017 to August 2018, in the rural areas of Lucknow district.

Methods and Material:

This study was conducted on 397 subjects aged ≥40 years. The two sets of the WHO/ISH risk prediction charts, with and without cholesterol, for WHO SEAR-D region were used in the study.

Statistical analysis used:

SPSS, version 23 was used for data analysis.

Results:

Using the risk assessment tools, with and without cholesterol, 78.5 and 76.8%, respectively, of the study population were in the 10-year cardiovascular risk category of <10% risk, while 11.2 and 10.4%, respectively, were in the category of ≥20% risk. Risk categories were found to be concordant in 86.3% of the population.

Conclusions:

The WHO/ISH risk prediction charts can be used at low-cost resource setting as a tool to predict CVD risk among asymptomatic individuals, thus, helping in early detection and prevention of CVDs in resource-scarce settings.

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.

Premature mortality attributable to smoking among Tunisian men in 2009

INTRODUCTION

Tobacco smoking is a significant public health threat in the world, a risk factor for many diseases, and has been increasing in prevalence in many developing countries. In this study, we aimed to estimate the burden of premature deaths attributable to smoking among Tunisian men aged 35–69 years in 2009.

METHODS

The number of deaths attributable to smoking was estimated using the population attributable risk fraction method. Smoking prevalence was obtained from a nationally representative survey. Causes of death were obtained from the registry of the National Public Health Institute. Relative risks were taken from the American Cancer Society Prevention Study (CPS-II).

RESULTS

Total estimated premature deaths attributable to smoking among men in Tunisia were 2601 (95% CI: 2268–2877), accounting for 25% (95% CI: 23.3–26.6) of total male adult mortality. Cancer, cardiovascular and respiratory diseases were the major causes of premature deaths attributable to smoking with 1272 (95% CI: 1188–1329), 966 (95% CI: 779–1133) and 364 (300–415) deaths, respectively.

CONCLUSIONS

Tobacco smoking is highly relevant and is related to substantial premature mortality in Tunisia, around double that estimated for the region as a whole. This also has not decreased over the past 20 years. Urgent actions are needed to reduce this pandemic.

[Non-communicable diseases in Southern Tunisia: morbidity, mortality profile and chronological trends]

OBJECTIVES

Non-communicable diseases (NCDs) represent a major public health problem worldwide. Giving their impact on the morbidity and mortality burden, understanding their chronological trends over time is a priority for epidemiological surveillance. We aimed to determine the epidemiological specificities of NCDs and to study their chronological trends over the period&#160;2010-2015.

METHODS

We retrospectively collected data of hospitalized&#160;patients from the regional registry of morbidity and mortality in the Southern University Hospital of Tunisia during the period 2010-2015.

RESULTS

We included 18,081 patients with NCDs aged ≥ 25 years. The distribution of NCDs was characterized by the predominance of cardiovascular disease (CVD) (10,346 cases, 57.2%). Chronological trends analysis of NCDs showed that NCDs remained globally stable between 2010 and 2015. The same result applied to the group of cancers, chronic respiratory diseases and diabetes mellitus. However, CVD increased significantly between 2010 and 2015 (ρ = 0.84; p = 0.036). The proportion of CVD increased significantly among men (ρ = 0.87; p = 0.019) and elderly (ρ = 0.88; p = 0.019). The hospital mortality rate of NCDs increased significantly (ρ = 0.85; p = 0.031), notably for CVDs (ρ = 0.94; p = 0.005).

CONCLUSION

Chronological trends analysis revealed a significant rise in the morbidity and mortality burden of CVDs during the period 2010-2015. It is imperative, therefore, to strengthen health care for these&#160;patients and to introduce the concept of integrated NCDs prevention as an essential component of the health system.

Adverse risk factor trends limit gains in coronary heart disease mortality in Barbados: 1990-2012

Background

Although most countries face increasing population levels of obesity and diabetes their effect on coronary heart disease (CHD) mortality has not been often studied in small island developing states (SIDs) where obesity rates are among the highest in the world. We estimated the relative contributions of treatments and cardiovascular risk factors to the decline in CHD mortality from 1990 to 2012 in the Caribbean island, Barbados.

Methods

We used the IMPACT CHD mortality model to estimate the effect of increased coverage of effective medical/surgical treatments and changes in major CHD risk factors on mortality trends in 2012 compared with 1990. We calculated deaths prevented or postponed (DPPs) for each model risk factor and treatment group. We obtained data from WHO Mortality database, population denominators from the Barbados Statistical Service stratified by 10-year age group (ages 25–34 up to 85 plus), population-based risk factor surveys, Global Burden of Disease and Barbados’ national myocardial infarction registry. Monte Carlo probabilistic sensitivity analysis was performed.

Results

In 1990 the age-standardized CHD mortality rate was 109.5 per 100,000 falling to 55.3 in 2012. Implementation of effective treatment accounted for 56% DPPs (95% (Uncertainty Interval (UI) 46%, 68%), mostly due to the introduction of treatments immediately after acute myocardial infarction (AMI) (14%) and unstable angina (14%). Overall, risk factors contributed 19% DPPs (95% UI 6% to 34%) mostly attributed to decline in cholesterol (18% DPPs, 95% UI 12%, 26%). Adverse trends in diabetes: 14% additional deaths(ADs) 95% UI 8% to 21% ADs) and BMI (2% ADs 95%UI 0 to 5% ADs) limited potential for risk factor gains.

Conclusions

Given the significant negative impact of obesity/diabetes on mortality in this analysis, research that explores factors affecting implementation of evidenced-based preventive strategies is needed. The fact that most of the decline in CHD mortality in Barbados was due to treatment provides an example for SIDs about the advantages of universal access to care and treatment.

Implications of the growing burden of diabetes for premature cardiovascular disease mortality and the attainment of the Sustainable Development Goal target 3.4

Non-communicable diseases (NCDs) are a major cause of deaths globally, and cardiovascular disease (CVD) is the leading cause of these deaths. 42% of NCD deaths are premature (occurring before the age of 70 years). As part of the United Nations 3rd Sustainable Development Goal (SDG) on health and wellbeing, target 3.4 is to reduce premature mortality from NCDs by one third between 2015 and 2030. This target adds to the World Health Organization (WHO) target of reducing premature deaths from NCDs by 25% between 2010 and 2025. As diabetes is a major risk factor for CVD, it is important to account for the trends in diabetes when considering premature CVD mortality. We aimed to describe the global trends in diabetes prevalence and mortality, critically review the literature on the estimated attainability of the WHO and SDG targets, and determine if and how these studies accounted for trends in diabetes. Worldwide, the prevalence of diabetes is rising, with an estimated 9.0% global prevalence in adults aged 20-69 by 2030, and low- and middle-income countries (LMICs) having the largest increase of the burden in absolute numbers and age-standardized prevalence. There is a lack of data from most LMICs on the excess CVD mortality associated with diabetes and therefore no consensus on the global risk of CVD mortality in people with diabetes. Where data do exist, there are discrepancies between studies on the direction of mortality trends from diabetes over time. We reviewed 12 studies that estimated the attainability of the WHO or SDG targets for premature NCD mortality. Seven of these considered the potential impacts of achieving the 2025 WHO risk factor targets. Six studies modelled the impact of current trends in risk factors, including diabetes, continuing toward the target dates. Four studies compared this 'business as usual' model with the attainment of the risk factor targets for the world as whole and individual regions, 2 studies for NCD mortality overall, and 2 specifically for CVD mortality. On the impact of diabetes with regards to attainment of the WHO or SDG targets for premature CVD mortality, the overall results were inconclusive. Some concluded that none of the countries or regions considered would meet the targets, and others predicted that in some areas, the targets would be met. Examining the potential impact of trends in diabetes on future CVD mortality rates in LMICs is limited by a relative lack of high quality studies, including on the age specific excess mortality associated with diabetes. Filling these data gaps will enable better estimates of the potential impacts on future CVD mortality of the rapidly increasing prevalence of diabetes in LMICs and help to better inform health policy and the attainment of SDG target 3.4.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry

Background

The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI).

Methods

Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%).

Results

Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866).

Conclusions

Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

Comparing Strategies to Prevent Stroke and Ischemic Heart Disease in the Tunisian Population: Markov Modeling Approach Using a Comprehensive Sensitivity Analysis Algorithm

Background

Mathematical models offer the potential to analyze and compare the effectiveness of very different interventions to prevent future cardiovascular disease. We developed a comprehensive Markov model to assess the impact of three interventions to reduce ischemic heart diseases (IHD) and stroke deaths: (i) improved medical treatments in acute phase, (ii) secondary prevention by increasing the uptake of statins, (iii) primary prevention using health promotion to reduce dietary salt consumption.

Methods

We developed and validated a Markov model for the Tunisian population aged 35–94 years old over a 20-year time horizon. We compared the impact of specific treatments for stroke, lifestyle, and primary prevention on both IHD and stroke deaths. We then undertook extensive sensitivity analyses using both a probabilistic multivariate approach and simple linear regression (metamodeling).

Results

The model forecast a dramatic mortality rise, with 111,134 IHD and stroke deaths (95% CI 106567 to 115048) predicted in 2025 in Tunisia. The salt reduction offered the potentially most powerful preventive intervention that might reduce IHD and stroke deaths by 27% (−30240 [−30580 to −29900]) compared with 1% for medical strategies and 3% for secondary prevention. The metamodeling highlighted that the initial development of a minor stroke substantially increased the subsequent probability of a fatal stroke or IHD death.

Conclusions

The primary prevention of cardiovascular disease via a reduction in dietary salt consumption appeared much more effective than secondary or tertiary prevention approaches. Our simple but comprehensive model offers a potentially attractive methodological approach that might now be extended and replicated in other contexts and populations.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Decline in Cardiovascular Mortality: Possible Causes and Implications

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

Assessment of cardiovascular risk in Tunisia: applying the Framingham risk score to national survey data

OBJECTIVE

This paper aims to assess the socioeconomic determinants of a high 10 year cardiovascular risk in Tunisia.

SETTING

We used a national population based cross sectional survey conducted in 2005 in Tunisia comprising 7780 subjects. We applied the non-laboratory version of the Framingham equation to estimate the 10 year cardiovascular risk.

PARTICIPANTS

8007 participants, aged 35-74 years, were included in the sample but effective exclusion of individuals with cardiovascular diseases and cancer resulted in 7780 subjects (3326 men and 4454 women) included in the analysis.

RESULTS

Mean age was 48.7 years. Women accounted for 50.5% of participants. According to the Framingham equation, 18.1% (17.25-18.9%) of the study population had a high risk (≥20% within 10 years). The gender difference was striking and statistically significant: 27.2% (25.7-28.7%) of men had a high risk, threefold higher than women (9.7%; 8.8-10.5%). A higher 10 year global cardiovascular risk was associated with social disadvantage in men and women; thus illiterate and divorced individuals, and adults without a professional activity had a significantly higher risk of developing a cardiovascular event in 10 years. Illiterate men were at higher risk than those with secondary and higher education (OR=7.01; 5.49 to 9.14). The risk in illiterate women was more elevated (OR=13.57; 7.58 to 24.31). Those living in an urban area had a higher risk (OR=1.45 (1.19 to 1.76) in men and OR=1.71 (1.35 to 2.18) in women).

CONCLUSIONS

The 10 year global cardiovascular risk in the Tunisian population is already substantially high, affecting almost a third of men and 1 in 10 women, and concentrated in those more socially disadvantaged.

Improving cardiovascular protection: focus on a cardiovascular polypill

Lack of adherence may explain, at least in part, the poor cardiovascular risk factors control observed in patients with ischemic heart disease, increasing the risk of developing new events. Polypill improves medication adherence, which may actually reduce blood pressure and LDL cholesterol compared with the drugs given separately. The fixed combination of acetylsalicylic acid 100 mg + ramipril 2.5, 5, or 10 mg + either simvastatin 40 mg or atorvastatin 20 mg is the unique cardiovascular polypill that has been registered in 22 countries worldwide. The polypill-containing simvastatin has been specifically tested in a clinical trial including only patients with ischemic heart disease. The FOCUS study showed that patients treated with the polypill showed a higher adherence compared with those receiving separate medications.

A Community-based Cross-sectional Study of Cardiovascular Risk in a Rural Community of Puducherry

Background:

The World Health Organization (WHO) / International Society of Hypertension (ISH) risk prediction chart can predict the risk of cardiovascular events in any population.

Aim:

To assess the prevalence of cardiovascular risk factors and to estimate the cardiovascular risk using the WHO/ISH risk charts.

Materials and Methods:

A cross-sectional study was done from November 2011 to January 2012 in a rural area of Puducherry. Method of sampling was a single stage cluster random sampling, and subjects were enrolled depending on their suitability with the inclusion and exclusion criteria. The data collection tool was a piloted and semi-structured questionnaire, while WHO/ISH cardiovascular risk prediction charts for the South-East Asian region was used to predict the cardiovascular risk. Institutional Ethics committee permission was obtained before the start of the study. Statistical analysis was done using SPSS version 16 and appropriate statistical tests were applied.

Results:

The mean age in years was 54.2 (±11.1) years with 46.7% of the participants being male. On application of the WHO/ISH risk prediction charts, almost 17% of the study subjects had moderate or high risk for a cardiovascular event. Additionally, high salt diet, alcohol use and low HDL levels, were identified as the major CVD risk factors.

Conclusion:

To conclude, stratification of people on the basis of risk prediction chart is a major step to have a clear idea about the magnitude of the problem. The findings of the current study revealed that there is a high burden of CVD risk in the rural Puducherry.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments

BACKGROUND

Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey.

METHODS

Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model.

RESULTS

Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder.

DISCUSSION

CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

Acute coronary syndrome among patients with chest pain: Prevalence, incidence and risk factors

BACKGROUND

Urbanization and adoption of new diet and lifestyles had increased the cardiovascular risk factor (CVRF) rate and therefore, acute coronary syndrome (ACS) in developing countries such as Tunisia. We aimed at determining ACS prevalence among a sample of Tunisian patients with chest pain, at establishing the standardized incidence rate (SIR) of ACS, and at quantifying the relationship between ASC and CVRF in this population.

METHODS

We studied 3158 patients admitted to a chest pain unit for non-traumatic chest pain collected in Emergency Data from January 2012 to December 2014. For all patients, the data were collected using a standardized form. We performed univariate rather than multivariate logistic regression analyses to identify age and gender-related CVRF in ACS. Linear interpolation was used for curve estimation.

RESULTS

707 (22.3%) chest pain patients were classified as ACS. The age-SIR per 10(-5)personyear (PY) was 85.7; it was 112.6 in men and 45.3 in women. Eighty one percent of patient with ACS cumulated 2 CVRF and more. The highest odds ratio were 2.00 (95% CI 1.64-2.44) for diabetes and 1.81 (95% CI 1.50-2.18) for active smoking. ACS in elderly patients was significantly associated with active smoking (OR: 2.36), diabetes (OR: 1.72) and personal ACS history (OR: 1.71). We found a significant and very high linear relation between the number of CVRF and ACS odds ratio (R(2)=0.958).

CONCLUSION

Our results showed that the incidence of ACS in a Tunisian population is not very different from what is observed in developed countries; with a close relation with CVRF especially diabetes and smoking.

[Management of patients treated for acute ST-elevation myocardial infarction in Tunisia: Preliminary results of FAST-MI Tunisia Registry from Tunisian Society of Cardiology and Cardiovascular Surgery]

FAST-MI Tunisian registry was initiated by the Tunisian Society of Cardiology and Cardio-vascular Surgery to assess characteristics, management, and hospital outcomes in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We prospectively collected data from 203 consecutive patients (mean age 60.3 years, 79.8 % male) with STEMI who were treated in 15 public hospitals (representing 68.2 % of Tunisian public centres treating STEMI patients) during a 3-month period at the end of 2014. The most common risk factor was tobacco (64.9 %), hypertension (38.6 %), diabetes (36.9 %) and dyslipidemia (24.6 %).

RESULTS

Among these patients, 66 % received reperfusion therapy, 35 % with primary percutaneous coronary interventions (PAMI), 31 % with thrombolysis (28.6 % of them by pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 and 358 min for PAMI, respectively. The in-hospital mortality was 7.0 %. Patients enrolled in interventional centers (n=156) were more likely to receive any reperfusion therapy (19.8 % vs 44.6 %; p<0.001) than at the regional system of care with less thrombolysis (26.9 % vs 44.6 %; p=0.008) and more PAMI (52.8 % vs 8.5 %; p<0.0001). Also the in-hospital mortality was lower (6.4 % vs 9.3 %) but not significant.

CONCLUSIONS

Preliminary results from FAST-MI in Tunisia show that the pharmaco- invasive strategy should be promoted in non-interventional centers.

Heavier smoking may lead to a relative increase in waist circumference: evidence for a causal relationship from a Mendelian randomisation meta-analysis. The CARTA consortium

OBJECTIVES

To investigate, using a Mendelian randomisation approach, whether heavier smoking is associated with a range of regional adiposity phenotypes, in particular those related to abdominal adiposity.

DESIGN

Mendelian randomisation meta-analyses using a genetic variant (rs16969968/rs1051730 in the CHRNA5-CHRNA3-CHRNB4 gene region) as a proxy for smoking heaviness, of the associations of smoking heaviness with a range of adiposity phenotypes.

PARTICIPANTS

148,731 current, former and never-smokers of European ancestry aged ≥ 16 years from 29 studies in the consortium for Causal Analysis Research in Tobacco and Alcohol (CARTA).

PRIMARY OUTCOME MEASURES

Waist and hip circumferences, and waist-hip ratio.

RESULTS

The data included up to 66,809 never-smokers, 43,009 former smokers and 38,913 current daily cigarette smokers. Among current smokers, for each extra minor allele, the geometric mean was lower for waist circumference by -0.40% (95% CI -0.57% to -0.22%), with effects on hip circumference, waist-hip ratio and body mass index (BMI) being -0.31% (95% CI -0.42% to -0.19), -0.08% (-0.19% to 0.03%) and -0.74% (-0.96% to -0.51%), respectively. In contrast, among never-smokers, these effects were higher by 0.23% (0.09% to 0.36%), 0.17% (0.08% to 0.26%), 0.07% (-0.01% to 0.15%) and 0.35% (0.18% to 0.52%), respectively. When adjusting the three central adiposity measures for BMI, the effects among current smokers changed direction and were higher by 0.14% (0.05% to 0.22%) for waist circumference, 0.02% (-0.05% to 0.08%) for hip circumference and 0.10% (0.02% to 0.19%) for waist-hip ratio, for each extra minor allele.

CONCLUSIONS

For a given BMI, a gene variant associated with increased cigarette consumption was associated with increased waist circumference. Smoking in an effort to control weight may lead to accumulation of central adiposity.

Estimation of the cardiovascular risk using World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction charts in a rural population of South India

BACKGROUND

World Health Organization/International Society of Hypertension (WHO/ISH) charts have been employed to predict the risk of cardiovascular outcome in heterogeneous settings. The aim of this research is to assess the prevalence of Cardiovascular Disease (CVD) risk factors and to estimate the cardiovascular risk among adults aged >40 years, utilizing the risk charts alone, and by the addition of other parameters.

METHODS

A cross-sectional study was performed in two of the villages availing health services of a medical college. Overall 570 subjects completed the assessment. The desired information was obtained using a pre-tested questionnaire and participants were also subjected to anthropometric measurements and laboratory investigations. The WHO/ISH risk prediction charts for the South-East Asian region was used to assess the cardiovascular risk among the study participants.

RESULTS

The study covered 570 adults aged above 40 years. The mean age of the subjects was 54.2 (±11.1) years and 53.3% subjects were women. Seventeen percent of the participants had moderate to high risk for the occurrence of cardiovascular events by using WHO/ISH risk prediction charts. In addition, CVD risk factors like smoking, alcohol, low High-Density Lipoprotein (HDL) cholesterol were found in 32%, 53%, 56.3%, and 61.5% study participants, respectively.

CONCLUSION

Categorizing people as low (<10%)/moderate (10%-20%)/high (>20%) risk is one of the crucial steps to mitigate the magnitude of cardiovascular fatal/non-fatal outcome. This cross-sectional study indicates that there is a high burden of CVD risk in the rural Pondicherry as assessed by WHO/ISH risk prediction charts. Use of WHO/ISH charts is easy and inexpensive screening tool in predicting the cardiovascular event.

A victory for statins or a defeat for diet policies? Cholesterol falls in Poland in the past decade: A modeling study

AIM

The present study is aimed to examine whether recent changes in population total cholesterol (TC) levels in Poland might be attributed to increased use statins.

METHODS

Two independent, nationally representative cross-sectional studies were conducted in adults aged 18-79 years in 2002 (n=2993, mean age 46.2 years) and 2011 (n=2413, mean age 45.8 years), including measurements of TC in venous blood samples. The mean change of TC between 2002 and 2011 was assessed. Then the expected therapeutic reduction in TC level in 2011 attributable to statins only was calculated based on already published statin effectiveness data. Uncertainty was quantified using probabilistic sensitivity analysis.

RESULTS

Statin uptake in Poland rose to 11.2% in 2011 (95% Confidence Intervals (CI): 10% to 12.5%) and approximately 32% (95% CI: 28.4 to 36.0%) in subjects aged 60-79 years. Mean TC in Poland in 2002 was 5.35 mmol/l, and fell by 0.21 mmol/l (95% CI: 0.14 to 0.28) by 2011. This fall would have been only 0.03 mmol/l (95% CI: -0.04 to 0.10) for the total adult population and 0.06 mmol/l (95% CI: -0.09 to 0.22) in people aged 60-79 years if statins had not been used. Statin use thus apparently explained approximately 85% (95% CI: 49% to 120%) of the observed decrease.

CONCLUSION

Between 2002 and 2011, statin medications apparently explained a large part of the observed fall in population cholesterol level, suggesting very little changes in population TC attributed to dietary changes.

Are polymorphisms of the immunoregulatory factor CD40LG implicated in acute transfusion reactions?

The CD40 ligand (CD40L/CD154), a member of TNF superfamily, is notably expressed on activated CD4+ T-cells and stimulated platelets. CD40L is linked to a variety of pathologies and to acute transfusion reactions (ATR). Mutations in this gene (CD40LG) lead to X-linked hyper-IgM syndrome. Some CD40LG polymorphisms are associated with variable protein expression. The rationale behind this study is that CD40L protein has been observed to be involved in ATR. We wondered whether genetic polymorphisms are implicated. We investigated genetic diversity in the CD40LG using DHPLC and capillary electrophoresis for screening and genotyping (n = 485 French and Tunisian blood donors). We identified significant difference in the CD40LG linkage pattern between the two populations. Variant minor alleles were significantly over-represented in Tunisian donors (P<0.0001 to 0.0270). We found higher heterogeneity in the Tunisian, including three novel low frequency variants. As there was not a particular pattern of CD40LG in single apheresis donors whose platelet components induced an ATR, we discuss how this information may be useful for future disease association studies on CD40LG.

Health system challenges of NCDs in Tunisia

OBJECTIVES

The objective of this study was to present a qualitative 'situation analysis' of the healthcare system in Tunisia, as it applies to management of cardiovascular disease (CVD) and diabetes. A primary concern was the institutional capacity to manage non-communicable diseases (NCDs).

METHODS

Research took place during 2010 (analysis of official documents, semi-structured interviews with key informants, and case studies in four clinics). Walt and Gilson's framework (1994) for policy analysis was used: content, actors, context, and process.

RESULTS

Problems of integration and coordination have compounded funding pressures. Despite its importance in Tunisian healthcare, primary health is ill-equipped to manage NCDs. With limited funds, and no referral or health information system, staff morale in the public sector was low. Private healthcare has been the main development filling the void.

CONCLUSION

This study highlights major gaps in the implementation of a comprehensive approach to NCDs, which is an urgent task across the region. In strategic planning, research on the health system is vital; but the capacity within Ministries of Health to use research has first to be built, with a commitment to grounding policy change in evidence.

Living with diabetes and hypertension in Tunisia: popular perspectives on biomedical treatment

OBJECTIVES

The growing prevalence of non-communicable diseases across the Middle East and North Africa poses major challenges for underfunded health services. This article presents data on the perspectives of ordinary Tunisians who are coping with two of these diseases--diabetes and hypertension--and who are obtaining treatment through Tunisian public health clinics. Little has been written to date on patient experiences of biomedical treatment in Maghreb countries.

METHODS

Based on qualitative methods and semi-structured interviews with 24 patients attending two clinics, one urban and one rural.

RESULTS

We examine popular aetiological beliefs, ideas about biomedical treatment and its implications, and comparative views on the benefits and drawbacks of treatment in both public and private clinics.

CONCLUSIONS

We highlight two main themes. One was nostalgia for a recent past when 'pure' and 'natural' food, 'proper' meals and less stressful lives meant less chronic illness, with demanding and costly treatment. The other concerned communication in the clinic, and the recurrent dismay patients felt at what they saw as the cursory attention and guidance they received from clinic staff in public facilities.

Global perspective on acute coronary syndrome: a burden on the young and poor

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

Coronary heart disease: pandemic in a true sense

Cardiovascular diseases are caused because of abnormalities in the heart and blood vessels. Recent trends reveal that the incidence of coronary heart disease (CHD) has gradually decreased in many developed countries, but the situation remains quite challenging in developing nations that account for more than 60% of the global burden. Multiple socio-demographic, personal, physician related and healthcare delivery system related factors have been identified which act in variable combinations to either influence the incidence of CHD or affect the short/long-term outcome of the disease. Of all CHD cases who succumb within 28 days of onset of symptoms, almost 67% fail to reach even a hospital. This clearly signifies the importance of primary prevention and early recognition of the warning signs in averting cause-specific mortality. The main priority is to develop cost-effective equitable health care innovations in CHD prevention and to monitor the trend of CHD so that evidence-based interventions can be formulated. To conclude, inculcating health-promoting behaviors in school children and the general population by means of community-based health screening and education interventions could avert many more deaths attributed to CHDs.