[show abstract][hide abstract] ABSTRACT: Ann Saudi Med 2013 July-August www.annsaudimed.net 339 C oronary artery disease (CAD) is well recog-nized as a most common cause of death in both women and men in large parts of the industrial-ized world. 1 Over the past decade, the existence of sex/ gender differences in terms of presentation of symp-toms, validity of diagnostic tests, in-hospital medica-tion, drug side effects, clinical outcomes, complications, and management of acute coronary syndrome (ACS) are frequently reported in the published reports. 2-5
[show abstract][hide abstract] ABSTRACT: Background
Data comparing acute coronary syndrome (ACS) patients from the Middle East with those from the Indian subcontinent is scarce. The aim of this study was to compare clinical characteristics and outcomes between Middle East Arabs and those from the Indian subcontinent presenting with ACS.
Methods and Results
This was a prospective, multinational, observational study of ACS patients admitted to 65 hospitals in 6 Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE–II (Registry of Acute Coronary Events). Analyses were performed using univariate and multivariate statistics. The Middle Eastern Arab group was significantly older (60 versus 49 years; p < 0.001), hypertensive (51% versus 36%; p < 0.001), diabetic (42% versus 34%; p < 0.001), with prior myocardial infarction (MI) (22% versus 13%; p < 0.001) and higher GRACE risk score (27% versus 8%; p < 0.001). Indian subcontinent patients were more likely to be smokers (55% versus 29%; p < 0.001) presenting predominantly with ST-elevation MI (57% versus 39%; p < 0.001). The Middle Eastern cohort suffered more congestive heart failure (15% versus 9%; p < 0.001), re-current ischemia (18% versus 9%; p < 0.001), re-infarction (2.6% versus 1.2%; p = 0.001), cardiogenic shock (7.0% versus 3.0%; p < 0.001) and received less evidence-based treatment. On multivariate analysis, Middle Eastern Arabs had higher 1-year mortality compared to those from the Indian subcontinent (adjusted odds ratio, 1.81; 95% CI: 1.19–2.74; p = 0.005).
Middle East Arabs were associated with higher rates of coronary risk factors, more complicated in-hospital course and a higher long-term mortality when compared to patients from the Indian subcontinent.
Journal of the Saudi Heart Association 04/2013; 25(2):137–138.
[show abstract][hide abstract] ABSTRACT: We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their manage-ment on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.
[show abstract][hide abstract] ABSTRACT: The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS).
Data were analyzed from 7922 consecutive patients admitted to hospitals throughout six Middle-Eastern countries with the final diagnosis of ACS, as part of Gulf RACE II (Registry of Acute Coronary Events II). Anemia at admission was defined according to the World Health Organization definition (<13 g/dL in men and <12 g/dL in women). Analyses were conducted using univariate and multivariate statistical techniques.
The median age of the cohort was 56 (48-65) years, with the majority being male (79%). Anemia at admission was present in 2241 patients (28%). Patients with anemia were more likely to have in-hospital complications including heart failure, recurrent ischemia, re-infarction, cardiogenic shock, stroke, and major bleed. Even after adjustment, anemia was still associated with mortality at in-hospital (odds ratio [OR]=1.71, 95% confidence interval [CI], 1.34-2.17; P<0.001), at one-month (OR=1.34, 95% CI, 1.06-1.71; P=0.016), and at one-year (OR=1.22, 95% CI, 1.01-1.49; P=0.049) post-admission with ACS.
Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year. Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.
Clinical Medicine & Research 05/2012; 10(2):65-71.
[show abstract][hide abstract] ABSTRACT: To evaluate the impact of evidence-based cardiac medications (EBMs) on 1-month and 1-year mortality among discharged acute coronary syndrome (ACS) patients in the Middle East.
Data were analyzed from 7,567 consecutive ACS patients admitted to 66 hospitals in 6 Middle Eastern countries enrolled in the Gulf RACE II in October 2008 to June 2009. Individual EBMs or concurrent use of the EBM combination consists of an anti-platelet therapy, angiotensin-converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker (ARB)), β-blocker, and a statin at discharge, were evaluated. Analyses were performed using univariate and multivariate statistical techniques.
The mean age of the cohort was 56 +/- 12 years with 79% being males. 65% of the patients received the concurrent EBM combination at discharge. Aspirin, clopidogrel, statins, b-blockers and ACEIs/ARBs use was 96%, 71%, 95%, 82% and 81%, respectively. 70% of the patients were prescribed both aspirin and clopidogrel concurrently at discharge. Adjusting for demographic, clinical, revascularization, and country characteristics, the multivariable logistic regression models demonstrated no differences in mortality at both 1-month (3.0 vs. 3.6%; p = 0.828) and 1-year (3.5 vs. 3.5%; p = 0.976) between the concurrent EBM combination users and non-users.
The majority of the ACS patients in the Middle East were prescribed the guideline recommended EBM combination at discharge. However, potential still remains for further optimization of management. Further studies are required to examine the long term effect of concurrent use of the EBM combination on mortality in the region.
International journal of clinical pharmacology and therapeutics 04/2012; 50(6):418-25. · 1.20 Impact Factor
[show abstract][hide abstract] ABSTRACT: Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy.
This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics.
Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use.
Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.
[show abstract][hide abstract] ABSTRACT: We assessed the use and determinants of cardiac catheterization during index admissions, among patients with acute coronary syndrome (ACS) in the Middle East. Data were analyzed from 8150 consecutive ACS patients enrolled prospectively. The overall rate of cardiac catheterization was 20%. Major predictors of cardiac catheterization were university hospitals, hospitals with catheterization facilities, physician type, and Gulf citizenship. High-risk patients were catheterized less compared to low-risk patients; odds ratio (OR) 0.44, 95% confidence interval (CI): 0.33-0.60, P < .001 and OR 0.68, 95% CI: 0.48-0.98, P = .037 for patients with non-ST-elevation ACS and ST-elevation myocardial infarction, respectively. The use of cardiac catheterization in patients with ACS from Middle East is low. It is related more to hospital characteristics than to baseline risks. There is a need to explore ways to increase overall rate of in-hospital cardiac catheterization in the region and direct it to patients who would benefit most.
[show abstract][hide abstract] ABSTRACT: Background: Patients with acute coronary syndrome (ACS) are frequently presented with ischemic chest pain; however a considerable population had atypical presentation. We studied the clinical characteristics and outcomes of patients with atypical presentation across ACS (STEMI, NSTEMI, and unstable angina).
Methods and results: Data were collected from a prospective, multicenter, multinational study over 6 months. Patients with ACS were stratified according to the predominant symptom into; Typical (with ischemic chest pain) and Atypical (without ischemic chest pain) presentation. Patients’ characteristics and in-hospital management and outcomes were compared. We recruited 8,162 patients (76% males) presented with STEMI (39%) and NSTEACS (61%). On admission, 79% patients had typical and 21% patients had atypical presentation. Atypical group’ patients were 6 years older (55 vs 61 ys, p<.001) and had more risk factors for ACS. Age, heart rate (HR), diabetes mellitus (DM), renal failure and Killip class>1 were significant predictors of atypical presentation. This group was significantly less likely to receive evidence-based therapy and experienced significantly worse in-hospital outcomes i.e. heart failure (33.9% vs 11.6%), cardiogenic shock (9.5% vs 4.0%), hospital stay (5.5±0.05 vs 6.0 ±0.13 days, p<0.001) and higher mortality rate (overall ACS 6.9% vs 2.7%, STEMI 18.6% vs 4.5%, NSTEMI 4.2% vs 1.9% and unstable angina 2.4% vs 0.7%.p=0.00). After adjustment for confounders (age, sex, HR, DM, and SBP), atypical presentation was associated with 2-fold increase in mortality (OR 1.9, CI: 1.29 –2.75). Mortality rates were significantly higher in GRACE risk categories in patients with atypical presentation.
Conclusion: Patients with ACS who presented without typical chest pain were frequently underestimated and undertreated. Regardless of the type of ACS, atypical presentation had worse outcomes and needs more attention.
[show abstract][hide abstract] ABSTRACT: To identify the characteristics, treatments and hospital outcomes for patients diagnosed with acute coronary syndromes (ACS) in the Gulf area.
Prospective, multinational, multicentre, observational survey of consecutive ACS patients who were admitted to 65 hospitals during May 2006.
A total of 1484 ACS patients were recruited. The mean age was 55 years, and 76% were men. The final discharge diagnosis was ST-segment elevation myocardial infarction (STEMI) in 37%, non-ST-segment elevation myocardial infarction (NSTEMI) in 32%, left bundle branch block myocardial infarction (LBBB MI) in 2%, and unstable angina in 29%. Among patients with STEMI and LBBB MI, the reperfusion rate was 65%, with use of primary percutaneous coronary intervention in 7% and thrombolytic therapy in 93%. When thrombolytic therapy was used, the median door to needle time was 45 minutes, with 37% receiving it within 30 minutes of hospital presentation. During the first day of hospitalization, aspirin was administered to 94%, clopidogrel to 51%, and beta blockers to 65%. Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers and statins were used in 62% and 82%, respectively. Coronary angiography during hospitalization was performed in 21%. In-hospital mortality was 3%.
We were able to determine the characteristics, treatments and in-hospital outcomes of patients hospitalized with ACS in our region. There is room for improvement in using medications, reducing needle to door time and utilizing more cardiac catheterization services.
Saudi medical journal 03/2008; 29(2):251-5. · 0.62 Impact Factor
[show abstract][hide abstract] ABSTRACT: Gender associations with acute coronary syndrome (ACS), remain inconsis.tent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored.
A prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis.
Patients enrolled from December 2005 until December 2007 included those pre.sented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed.
Of 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given b-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treat.ments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7-5.5; P=.14).
These data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.
Annals of Saudi medicine 33(4):339-46. · 1.10 Impact Factor