Coronary artery disease and diabetes mellitus

Objectives: diabetes mellitus [DM] and coronary artery disease [CAD] are closely related. DM is a risk factor for CAD, but it is also equivalent to established CAD. The prevalence of DM and CAD is growing primarily due to the rising prevalence of obesity. The rapidly changing life style, especially in developing countries, plays major role in the occurrence of these diseases

Methods: we performed a literature review to summarize and explore the relationship between CAD and DM with a special focus on Arab countries in terms of risk factors and prevalence. We suggest future directions to prevent escalation in the incidence of DM and CAD in Arab countries

Conclusion: an important part of any preventive program for CAD should include clear prevention strategies for DM and other associated metabolic risk factors, such as obesity. Preventive measures, such as physical exercise in high-risk groups, at the population level should be encouraged

Recent advances in the management of hypertension

Hypertension is a worldwide prevalent disease that leads to considerable morbidity and mortality. While its underlying basis of genetics and pathology as well as its complications are universally agreed upon, management of hypertension remains to be controversial. In this article, we will present clear evidence of the recent advances in the management of hypertension that include newer therapeutic agents replacing old strategies. Moreover, a suggested approach that is evidence based is provided to help in establishing agreement in line of therapy

Brugada syndrome: are we doing enough to prevent sudden death?

Brugada syndrome [BS] is an inherited arrythmogenic disease characterized by typical ECG changes in the form of an SR pattern in VI to V2, and ST segment elevation in VI to V3 and prolongation of the QT interval in right precordial leads. This syndrome carries an increased risk of sudden death due to arrhythmias. This disease was first described in 1992 by Joseph Brugada et al and was named Brugada syndrome by Yan and Antzelvitch in 1996. By 2003 more than 600 patients had been reported by Brugada et al and hundreds by others. A genetic aspect to BS is now recognized and been linked to the alpha subunit of the cardiac sodium channel gene SCN5A. Over five dozen mutations in SCN5A have been identified. Accentuation of the right ventricular notch under pathophysiological conditions leads to exaggeration of the J-wave or J-point elevation and a saddle-shaped configuration of the repolarisation waves. Diagnosis is essentially by electrocardiogram, either by spontaneous changes or by provocation by sodium channel blockers drugs, e.g., procainamide, flecainide. The role of electrophysiological studies in induction of arrhythmia in asymptomatic individuals by electron beam computed tomography and signal-averaged electrocardiogram is not settled. Unfortunately, an effective drug is not available at present, but quinidine has a place in treatment. New promising drugs are emerging like cilostazol and tedisamil. At present, implantation of an ICD is the only effective means of preventing sudden death

Hypertension in Saudi Arabia

To determine the prevalence of hypertension among Saudis of both gender, between the ages of 30-70 years in rural as well as urban communities. This work is part of a major national study on Coronary Artery Disease in Saudis Study [CADISS]. This is a community-based study conducted by examining subjects in the age group of 30-70 years of selected households during a 5-year period between 1995 and 2000 in Saudi Arabia. Data were obtained from history using a validated questionnaire, and examination including measurement of blood pressure. The data were analyzed to provide prevalence of hypertension. Logistic regression was used to develop a risk assessment model for prevalence of hypertension. The total number of subjects included in the study was 17,230. The prevalence of hypertension was 26.1% in crude terms. For males, the prevalence of hypertension was 28.6%, while for females; the prevalence was significantly lower at 23.9% [p<0.001]. The urban population showed significantly higher prevalence of hypertension of 27.9%, compared to rural population's prevalence of 22.4% [p<0.001]. The prevalence of CAD among hypertensive patients was 8.2%, and 4.5% among normotensive subjects [p<0.001]. Increasing weight showed significant increase in prevalence of hypertension in a linear relationship. Hypertension is increasing in prevalence in KSA affecting more than one fourth of the adult Saudi population. We recommend aggressive management of hypertension as well as screening of adults for hypertension early to prevent its damaging consequences if left untreated. Public health awareness of simple measures, such as low salt diet, exercise, and avoiding obesity, to maintain normal arterial blood pressure need to be implemented by health care providers

Metabolic syndrome in Saudi Arabia

Metabolic syndrome [MS] is a well-established risk factor for the development of coronary artery disease [CAD]. We designed this study to obtain the prevalence of MS and each of its components in Saudi Arabia. This study is part of Coronary Artery Disease in Saudi Study [CADISS]. We conducted this community-based national epidemiological health survey by examining Saudi subjects in the age group of 30-70 years of selected households over a 5-year period between 1995 and 2000 in Saudi Arabia. We interviewed all subjects, examined and took measurements of their blood pressure, weight, height, waist circumference, as well as fasting samples of plasma glucose, triglycerides, and high-density lipoprotein [HDL] cholesterol. We obtained the prevalence of MS based on the presence of at least 3 of the following: abdominal obesity [waist circumference >102 cm [40 inch] in male and >88 cm [35 inch] in female], triglycerides >=150 mg/dl [1.69 mmol/L], HDL cholesterol <40 mg/dl [1.03 mmol/L] in male and <50 mg/dl [1.29 mmol/L] in female, blood pressure >=130/85 mm Hg, fasting glucose >=110 mg/dl [6.1 mmol/L] as defined by the Adult Treatment Panel [ATP] III in 2001. We included 17,293 subjects in this survey during the study period. The overall age-adjusted prevalence of MS in Saudi Arabia obtained from this study is 39.3%. Age adjusted prevalence in males is 37.2% and crude prevalence is 40.9% [95% confidence interval [CI] 39.8-42], while females have a higher prevalence of 42% and crude prevalence of 41.9% [95% CI 40.9-42.9]. Saudi subjects from urban areas have significantly higher prevalence of 44.1% [95% CI 43.2-45] compared to those living in rural areas of 35.6% [95% CI 34.3-36.7] [p<0.0001]. Low HDL affects 81.8% of females and 74.8% of males with MS leading all other factors, and it continued to be consistent in all different age groups. Metabolic syndrome is a risk factor for CAD, as the prevalence of CAD was higher among patients with MS [6.7%] compared to subjects without MS [4.6%] [p<0.0001]. The prevalence of MS is high in Saudi Arabia. Low HDL cholesterol plays a major role in the contribution to the MS in Saudi Arabia. Therefore, we recommend routine assessment for the components of MS in patients with CAD, furthermore, we encourage aggressive management of the MS for primary prevention of CAD, particularly, measures to increase HDL cholesterol

Diabetes mellitus in Saudi Arabia

Diabetes mellitus [DM] is a major public health problem worldwide, and it is a known risk factor for coronary artery disease [CAD]. New recommendations for the diagnosis of diabetes have changed the epidemiology of DM. Therefore, we designed this study with the objective to determine the prevalence of DM among Saudis of both sexes, between the ages of 30-70-years in rural as well as urban communities. This work is part of a major national project: Coronary Artery Disease in Saudis study [CADISS] that is designed to look at CAD and its risk factors in Saudi population. This study is a community-based national epidemiological health survey, conducted by examining Saudi subjects in the age group of 30-70-years of selected households over a 5-year period between 1995 and 2000. Data were obtained from history, fasting plasma glucose levels, and body mass index. The data were analyzed to classify individuals as diabetic, impaired fasting glucose and normal, using 1997 American Diabetes Association [ADA] criteria, which was adopted by the World Health Organization [WHO] in 1998, to provide prevalence of DM in the Kingdom of Saudi Arabia [KSA]. A total of 17232 Saudi subjects were selected in the study, and 16917 participated [98.2% response rate]. Four thousand and four subjects [23.7%], out of 16917 were diagnosed to have DM. Thus, the overall prevalence of DM obtained from this study is 23.7% in KSA. The prevalence in males and females were 26.2% and 21.5% [p<0.00001]. The calculated age-adjusted prevalence for Saudi population for the year 2000 is 21.9%. Diabetes mellitus was more prevalent among Saudis living in urban areas of 25.5% compared to rural Saudis of 19.5% [p<0.00001]. Despite the readily available access to healthcare facilities in KSA, a large number of diabetics 1116 [27.9%] were unaware of having DM. The overall prevalence of DM in adults in KSA is 23.7%. A national prevention program at community level targeting high risk groups should be implemented sooner to prevent DM. We further recommend a longitudinal study to demonstrate the importance of modifying risk factors for the development of DM and reducing its prevalence in KSA

Asymptomatic giant pulmonary artery aneurysm in an elderly male patient

Pulmonary artery aneurysm is rarely seen in clinical practice. It has been reported to develop in patients due to several underlying etiologies. However, the natural history is not yet defined, and management remains controversial. We report a case of giant main pulmonary artery aneurysm 6.06 cm in diameter in an asymptomatic 75-year-old male who has an incidental abnormal chest x-ray for preoperative evaluation as management of benign prostatic hypertrophy. The patient was managed conservatively. He was discharged home in good general condition to be followed up by echocardiography every 6 months. We conclude that pulmonary artery aneurysm can reach a massive size with no apparent symptoms. The treatment can therefore be conservative as no clear guidelines to support interventional management, particularly in the absence of pulmonary hypertension

Coronary artery disease in Suadi Arabia

Coronary artery disease [CAD] is a major public health problem worldwide. To our knowledge, there is no national data available from community based studies on prevalence of CAD in the Kingdom of Saudi Arabia [KSA]. Therefore, we designed this study with the objective to determine the prevalence of CAD among Saudis of both sexes, between the ages of 30-70-years in rural as well as urban communities. Further, to determine the prevalence and clinical pattern of the major modifiable risk factors for CAD among the same population. This work is part of a major national study on CAD in Saudis Study [CADISS]. This is a community based study conducted by examining subjects in the age group of 30-70-years of selected households during 5-year period between 1995 and 2000 in KSA. Data were obtained from history using a validated questionnaire, and electrocardiography. The data were analyzed to provide prevalence of CAD and risk assessment model. Nine hundred and forty-four subjects, out of 17232 were diagnosed to have CAD. Thus, the overall prevalence of CAD obtained from this study is 5.5% in KSA. The prevalence in males and females were 6.6% and 4.4% [P<0.0001]. Urban Saudis have a higher prevalence of 6.2% compared to rural Saudis of 4% [P<0.0001]. The following variables are found to be statistically significant risk factors in KSA: age, male gender, body mass index [BMI], hypertension, current smoking, fasting blood glucose, fasting cholesterol and triglycerides. The overall prevalence of CAD in KSA is 5.5%. A national prevention program at community level as well as high risk groups should be implemented sooner to prevent the expected epidemic of CAD that we are seeing, beginning. Measures are needed to change lifestyle and to address the management of the metabolic syndrome, to reduce modifiable risk factors for CAD. A longitudinal study is needed to demonstrate the importance of reducing modifiable risk factors for CAD in KSA

Peripartum cardiomyopathy searching for better underst and ing

Congestive heart failure is an uncommon complication of pregnancy with potentially life-threatening consequences. Peripartum cardiomyopathy [PPCM] is a disease of unknown cause in which severe left ventricular dysfunction occurs during late pregnancy or the early puerperium. In the past, the diagnosis of this entity was made on clinical grounds; however, modern echocardiographic techniques have allowed more accurate diagnoses by excluding cases of diseases that mimic the clinical symptoms and signs of heart failure. Risk factors for peripartum cardiomyopathy include advanced maternal age, multiparity, African descent, twinning, and long-term tocolysis. An extensive search for the causes of peripartum cardiomyopathy has been unrevealing. Treatment does not differ from treatment of idiopathic cardiomyopathy. The prognosis of peripartum cardiomyopathy is related to the recovery of ventricular function. Caution is advised in recommending subsequent pregnancy especially if left ventricular dysfunction is persistent. In this review, we will discuss different aspects of PPCM as the initial patient contact, obstetricians and family practitioners must recognize this malady early and rapidly institute the proper medical therapy directed towards the congestive state

Lack of associatin of coronary artery disease with H.pylori infection

It has been suggested from previous studies that there is an associated increased risk of coronary artery disease [CAD] in patients with Helicobacter pylori [H.pylori]. However, others dispute this. We therefore evaluated this hypothesis in a group of patients with confirmed H.pylori infection. A total of 158 patients with dyspeptic symptoms were evaluated by esophago-gastro-duodenoscopy [EGD] in King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia from May through to June 1997. Endoscopic biopsies and histology as well as culture and serology for H.pylori were obtained. In patients with confirmed H.pylori a further analysis was performed looking at associated [CAD] or known risk factors for CAD. Among the 158 patients who underwent EGD, 143 patients [90.5%] were found to have H.pylori either by culture, histology or serology, or both in a percentage of [31.5%] [77.6%] and [60.8%]. There was no evidence of CAD in this group of patients based on history, electrocardiogram [ECG], echocardiography, ECG stress test, dypiridamole thallium scan or coronary angiography. Other known risk factors for CAD were cigarette smoking [12.6%], diabetes mellitus [10.5%], hypertension [1.4%] and hyperlipidemia [2.8%]. Helicobacter pylori infection does not increase the risk of CAD, and should not be considered as an independent risk factor for CAD. Further, prospective large trial is needed to confirm our finding

Arterial hypertension in Saudi Arabia

Across-sectional population-based survey employing a cluster sampling method and household visits by trained health teams investigated hypertension prevalence in the Kingdom among 13, 700 individuals of both sexes in all age groups. The World Health Organization [WHO] definition of hypertension of 160/95 mmHg was used; it was found that 9.1% and 8.7% of the total sample investigated were systolic and diastolic hypertensive, respectively. However, 12.4% and 7.9% of children younger than 18 years were systolic and diastolic hypertensive. Among adults aged 18 years and above, 5.3% were systolic and 7.3% were diastolic hypertensive; 87.5% of systolic and 79.4% of diastolic hypertensive were aged 40 years and over. Females had statistically significant elevated systolic hypertension compared with males [P< 0.01]. However, if blood pressure 140/90 mmHg is used as a criterion for hypertension definition, the prevalence among the latter age groups would be 20.4% for systolic and 25.9% for diastolic hypertension. The prevalence of Isolated Systolic Hypertension [ISH], Isolated Diastolic Hypertension [IDH] and Systolic Hypertension [SDH] among adults above 18 years was 1.8%, 3.8% and 3.5% respectively. ISH was higher among females compared with males [2% vs 1.4%], while IDH was higher among males than females [4.4% vs 3.4%]. There is a need for tracking childhood hypertension, which could provide long-term analysis for risk adult hypertension

community-based epidemiological study of hypertension in Riyadh region

During 1988 [1408 H] nutritionists and medical investigators collected data on blood pressure and food items through a community-based study in the Riyadh region. The total number of the randomly chosen population amounted to 2667 individuals of both sexes in all ages. Of the total sample investigated, it was found that 1.76% had systolic blood pressure of more than 160 mm Hg; 2.75% had diastolic blood pressure of more than 90 mm Hg; and 0.87% had diastolic blood pressure of more than 100 mm Hg. A total of 59.1% of individuals with a systolic blood pressure of more than 160mm Hg were 55 years and above; and 51.14% of those individuals with systolic hypertension were females. For diastolic blood pressure of more than 90 mm Hg, 82.19% were more than 55 years old, and 47.95% were females. Some local Saudi foods were subjected to analytical procedures, through which it was possible to locate foods high in animal fat and/or sodium as unfavorable components for diets of hypertensive [e.g., sambousah with meat, mandy meat, shakshuka omlet]. Measurements of vitamins and minerals, such as ascorbic acid, potassium, and calcium, in favorable foods [e.g., qorsan and gerish] were also conducted. Analytical tables which show relevant constitutes of local Saudi food can be of help in the dietary management of hypertension and adoption of a therapeutic lifestyle

Fever of unknown origin: experience in Riyadh, Saudi Arabia

Fever of unknown origin constitutes a continual challenge to clinicians all over the world. The pattern of etiological factors varies from one geographic area to another. Over a 4-year period, 62 patients were diagnosed as having this syndrome in the University Hospitals, Riyadh, kingdom of Saudi Arabia. Of these, infection and neoplasms accounted for 71% of the cases. Tuberculosis, brucellosis, and lymphoma were the most common diagnoses. Infection by Schistosoma mansion and Salmonella typhi caused prolonged obscure fever in one patient. Our approach to diagnosis is discussed and compared with the experience in the literature. The application of noninvasive diagnostic methods such as ultrasonography, radioisotope scanning and improved microbiological techniques should further reduce the incidence of fever of unknown origin in the Kingdom. However of its epidemiological pattern in this area will assist practicing physicians in the judicious use of available diagnostic facilities

Clinical associations of left bundle branch block in a University Hospital in Saudi Arabia: a retrospective study of 75 cases

Medical records of 75 patients with known left bundle branch block were analysed for their clinical associations including various cardiac and non-cardiac diseases, ECG analysis; of mean frontal plane QRS axis, and echocardiographic analysis of left ventricular size and function and left atrial size. Hypertension and coronary atherosclerotic heart disease were the commonest clinical diseases found occurring in 39 of 75 patients [52%.]. Cardiomyopathy was noted in nine [12%]. Fifteen [20%] had no identifiable disease. Left axis; deviation was present in 35% and the majority of these [96%] had associated cardiac disorder. Of the 1 5 patients without an identifiable cardiac disease, 14 [93%] had a normal QRS axis. About 50% of the patients had echocardiographic evidence of left ventricular dysfunction