Cholesterol embolization syndrome following thrombolytic therapy

Cholesterol embolization syndrome [CES] is a rare and serious complication of thrombolytic therapy. Awareness of this complication would lead to earlier diagnosis and better management. We report a case of a 70-year-old man who presented with acute myocardial infarction and was thrombolysed with tenecteplase. His hospital stay was complicated by acute renal failure, blue toe syndrome and livedo reticularis. Skin biopsy revealed cholesterol crystals. He eventually became dialysis dependent

Prospective observational studies of the management and outcomes in patients with atrial fibrillation: a systematic review

Atrial fibrillation [AF] is a major global public health problem. Observational studies are necessary to understand patient characteristics, management, and outcomes of this common arrhythmia. Accordingly, our objective was to describe the current status of published prospective observational studies of AF. MEDLINE and EMBASE [to June 2012] and reference lists of eligible studies were searched for English-language prospective observational registries of AF [n >/= 100 and follow-up >/= 6 months]. Two reviewers independently extracted data. Disagreements were resolved by consensus. Eight prospective studies enrolled a total of 17,924 patients with AF [total 41,306 patient-years of exposure; follow-up 11 months to 9.9 years]. The majority of subjects were enrolled in Europe [74%] or North America [21%], and 0.3% had rheumatic AF. The most consistently reported comorbidities were diabetes mellitus [range 5-18%], hypertension [39-68%], heart failure [5-58%], and prior stroke [4-17%]. Three studies did not report all the variables necessary to calculate the currently recommended stroke risk assessment score, and no study reported all the variables required to calculate a recently validated bleeding risk score. The most consistently reported management features were oral anticoagulation [32-64%] and aspirin [28-61%] use. Calcium channel blockers were less frequently used than other rate controlling agents, and digoxin was most common in the single study from Africa [63%]. Total mortality was reported in all studies, while data on stroke/systemic embolism, hospitalizations, and major hemorrhage rates were not always reported. Current literature on real-world management of AF is relatively limited with inadequate data to allow detailed comparisons among reports. Data on rheumatic AF and from Africa and the developing world in general are sparse.

Regional variability in hospital mortality in patients hospitalized with st-segment elevation myocardial infarction: findings from the gulf registry of acute coronary events

To study the short-term mortality from ST-segment elevation myocardial infarction [STEMI] in the Arabian Gulf region of the Middle East, and to examine whether these geographically and culturally related countries had similar or different outcomes. The Gulf Registry of Acute Coronary Events recruited consecutive acute coronary syndrome patients from six Middle Eastern countries over a 5-month period. Of 6,706 patients recruited, 2,626 [39%] had STEMI, and a total of 165 patients died in hospital, with a crude mortality rate of 6.3%. However, mortality rates varied geographically between 10% in Yemen, 9.6% in Oman and 3.3% in the other countries. The unadjusted odds ratio of mortality for Yemen was 3.2 [95% CI: 2.2-4.7], and 3.1 [95% CI: 1.9-4.8] for Oman, compared to other Gulf countries. Even after adjusting for age and gender, the mortality remained significantly higher, almost double, in Oman and Yemen compared to other countries. This could be understood in the light of significant differences in a number of practice pattern variables such as reperfusion therapy, timely presentation and use of evidence-based medications. We found significant variability in STEMI mortality among Gulf Arab countries and identified areas requiring further efforts to reduce excess mortality in the region

Influence of diabetes on the outcome of acute coronary syndrome in Kuwait

To describe the baseline characteristics and management of patients with and without diabetes mellitus [DM] hospitalized with acute myocardial infarction [AMI] and to assess the influence of DM on hospital outcomes and hospital mortality. We analyzed data from a 6-month observational study [Kuwait Acute Coronary Syndrome Registry] of unselected patients admitted with a diagnosis of AMI over a period of 6 months, from December 2003 through May 2004. Of 1,295 patients enrolled, 609 [47%] were diabetics and 686 [53%] were non-diabetics. Diabetics were more likely to have a past history of coronary artery disease, hypertension and left ventricular systolic dysfunction than non-diabetics. There was less use of beta-blockers and aspirin in diabetics as compared to non-diabetics [62 vs. 71% and 95.5 vs. 97.9%, p<0.03, for beta-blockers and aspirin, respectively]. Left ventricular failure and cardiogenic shock occurred more often in diabetics compared to non-diabetics [16 vs. 7% and 5 vs. 3%, p<0.001, for left ventricular failure and shock, respectively]. The mortality rate was 6% for diabetics and 2% for non-diabetics [p<0.001]. DM is a major health problem among the adult population in Kuwait and almost half the AMI population suffer from diabetes. Diabetic patients had higher rates of complications, especially left ventricular failure and cardiogenic

Determinants of in-hospital cardiac catheterization in acute coronary syndrome patients in Kuwait

Clinical trials and practice guidelines have established the efficacy of early invasive strategy for high risk acute coronary syndrome [ACS] patients. This analysis was undertaken to detect the predictors of in-hospital cardiac catheterization [prior to hospital discharge] in patients with ACS in Kuwait and to assess if this use of early catheterization was according to published guidelines. We analyzed data from a prospective registry of 2054 consecutive patients admitted to all 7 general hospitals in Kuwait with the diagnosis of ACS over a period of 6 months in 2004. Citizens were more likely to receive in-hospital catheterization than expatriates [52.1% vs 38.6%; odds ratio 1.7; 95% confidence interval [CI], 1.4 to 2.2; p<0.001]. Patients with recurrent ischemia were more likely to undergo in-hospital catheterization than patients without recurrent ischemia [55.9% vs 12.2%; odds ratio 11.2; 95% CI, 8.6 to 14.5; p<0.001]. two coronary artery disease risk factors [hyperlipidemia and positive history] were associated with high rate of in-hospital cardiac catheterization [respectively, odds ratio 1.3; 95% CI, 1.2 to 2; p<0.001 and odds ratio 1.5; 95% CI, 1.3 to 2.3; p<0.001]. Although high risk patients benefit the most from an early invasive strategy after ACS, this strategy was persrvered for those with recurrent ischemia and citizens. Other risk factors were not determinants of in-hospital cardiac catheterization. Thus, there is substantial opportunity to improve the use of this effective therapy in high risk patients

Should we screen asymptomatic diabetics for coronary artery disease?

Diabetes is a major worldwide healthcare problem and cardiovascular diseases are the most common causes of mortality and morbidity in the type 2 diabetic population with Coronary artery disease [CAD] accounting for 65% to 80% of deaths in diabetic patients. It has been suggested that screening asymptomatic diabetics could identify early coronary artery disease which may improve their outcomes. In this review, we summarize the data regarding screening asymptomatic diabetics and provide recommendations based on the evidence

use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the gulf registry of acute coronary events [GULF RACE]

The use of certain medications in acute myocardial infarction [AMI] is known to lower morbidity and mortality. We aimed to evaluate, through the use of performance measures, the implementation of specific guidelines-recommended pharmacotherapy in the management of AMI in patients living in the Arabian Peninsula. The Gulf Registry of Acute Coronary Events [Gulf RACE] enrolled ACS patients from 6 countries in the Arabian Peninsula. We examined the use of 7 performance measures that relate to the management of ST-segment elevation myocardial infarction [STEMI] and non-ST-segment elevation myocardial infarction [NSTEMI]. 5833 AMI patients were enrolled in Gulf RACE. In the first 24 hours of hospital arrival, 5713 [98%] patients were administered aspirin. The prescription rate at discharge was 5376 [97%] for aspirin, 4354 [78%] for beta-blockers, 5639 [84%] for statins and 3145 [57%] for clopidogrel. Left ventricular systolic function [LVSF] was evaluated in 3861 [66%] patients. Of those who had ejection fraction < 40% [921 patients], 725 [85%] received angiotensin converting enzyme inhibitor [ACEI] or angiotensin receptor blocker [ARB] at discharge. There was good adherence to guidelines-recommended medications in patients admitted to hospital with a diagnosis of AMI. The implementation of more performance measures need to be evaluated in order to assess the full picture of AMI management in this part of the world

Early stroke in patients with acute myocardial infarction: incidence, risk factors and clinical outcomes

Limited data is available about stroke developing after acute myocardial infarction [AMI]. We investigated the incidence, risk factors and in-hospital outcome of stroke after AMI in clinical practice with and without use of thrombolysis. We analyzed data from a prospective registry of consecutive patients admitted to the coronary care unit [CCU] at Mubarak Al Kabeer Hospital in Kuwait. Of 2481 patients admitted with AMI between 1999 and 2003, 29 [1.2%] developed stroke during their hospital stay. Age older than 60 years [OR 5.5; 95% Cl 2.4 to 12.5; P< 0.001] and systolic blood pressure higher than 160 mmHg [OR 3.2; 95% Cl 1.lto 9.5; P< 0.04], were identified as independent predictors for stroke among patients with AMI. Patients who received thrombolytic therapy were not at an increased risk for developing stroke [OR 0.7; 95% Cl 0.2 to 2.0]. Patients developing stroke were 12 times more likely to die during hospitalization compared with patients who did not develop stroke [OR 12.6; 95% Cl 5.4 to 26.7; P< 0.001]. Stroke is an infrequent but serious complication of AMI. Older age and high systolic blood pressure at admission are independent predictors of stroke

Kuwait acute coronary syndromes registry: baseline characteristics, management practices and in-hospital outcomes of patients hospitalized with acute coronary syndromes in Kuwait

To identify the characteristics of patients with acute coronary syndromes [ACS], their hospital management and in-hospital outcomes, through a prospective registry system in Kuwait. A registry involving all 7 general hospitals in Kuwait was set up. Consecutive patients diagnosed as having ACS over a period of 6 months were enrolled. Of 2,129 patients enrolled, 718 [34%] had ST segment elevation myocardial infarction [STEMI], 576 [27%] non-ST segment elevation myocardial infarction [NSTEMI] and 835 [39%] unstable angina [UA]. Thrombolytic therapy was used in 556 [77%] patients with STEMI. The median time from diagnostic electrocardiogram to administration of thrombolytic therapy was 38 min. Almost all patients with ACS [2,050, 96%] received aspirin during hospitalization. Only a minority received clopidogrel, 18 [3%] STEMI, 36 [6%] NSTEMI and 96 [12%] UA patients. The use of glycoprotein llb/llla antagonists was minimal [38 patients, 2%]. beta-blockers were used in 1,473 [69%] patients, while 982 [46%] received angiotensin-converting enzyme inhibitors. Coronary angiography during hospitalization was performed in 119 [17%], 120 [21%] and 126 [15%] patients with STEMI, NSTEMI and UA, respectively. In-hospital mortality occurred in 31 [4%] myocardial infarction patients and 4 [0.5%] UA patients [p < 0.0001]. This registry has enabled us to determine the incidence and characteristics of ACS patients in Kuwait. It has also enabled us to identify some barriers that we need to overcome for the full implementation of published guidelines for the management of patients with ACS

Impact of fasting in Ramadan in patients with cardiac disease

To investigate whether Ramadan fasting has any effect on patients with heart disease. We prospectively studied 465 outpatients with heart disease who were fasting during the month of Ramadan from October 24 to November 24, 2003. These studied subjects were from various medical centers in the Gulf region; State of Qatar, Kuwait, United Arab Emirates, and Bahrain. We performed detailed clinical assessments one month before Ramadan, during Ramadan and one month after Ramadan and analyzed predictors of outcome. Overall, the mean age was 55.9 +/- 11.3 years [age range 32-72]. Of the 465 patients treated, 363 [78.1%] were males and 102 [21.9%] females. Among them, 119 [25.6%] patients had congestive heart failure, 288 [62%] patients with angina, 22 [4.7%] patients with atrial fibrillation and 11 [2.4%] patients with prosthetic metallic valves. Three hundred and seventy [79%] had prior myocardial infarction [MI], 195 [17.2%] had prior coronary artery bypass surgery [CABG], and 177 [38%] had prior percutaneous coronary interventions [PCI]. At the time of follow-up, we found that 91.2% could fast and only 6.7% felt worse while fasting in Ramadan. Of the studied subjects, 82.8% were compliant with cardiac medications and 68.8% were compliant with dietary instructions. We hospitalized 19 patients during Ramadan for cardiac reasons [unstable angina, worsening heart failure, MI, uncontrolled hypertension, subtherapeutic anticoagulation or arrhythmias]. The effects of fasting during Ramadan on stable patients with cardiac disease are minimal. Most patients with stable cardiac disease can fast

Pharmacotherapy of systolic heart failure

Systolic heart failure is defined as heart failure due to left ventricular systolic dysfunction. It represents a major admission diagnosis, and carries a high rate of mortality and morbidity. Ischemic heart disease and systemic hypertension are the two most common causes of systolic heart failure. Moreover, lack of compliance with diet and/or drug therapy represents the most common cause of heart failure decompositions and hospital readmissions. The pharmacotherapy of systolic heart failure aims toward reduction of both mortality and morbidity. This includes angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, spironolactone, digitalis, and others. Moreover, a new modality of adjunctive therapy was recently introduced for severe heart failure i.e. cardiac resynchronization therapy

Reperfusion therapy for ST-segment elevation myocardial infarction: a review of the available treatment options in Kuwait

Acute myocardial infarction is currently classified into two broad categories of ST-segment elevation [STEMI] and non-ST-segment elevation [NSTEMI] myocardial infarction, based on electrocardiographic features at the time of presentation. This classification serves as an important factor determining the type of treatment a patient receives. Reperfusion therapy is currently the standard treatment for STEMI. There are two forms of reperfusion therapy, pharmacologic and mechanical. There is strong evidence that, when carried out in a timely fashion and in appropriate circumstances, mechanical reperfusion provides lower mortality and morbidity events compared to pharmacologic reperfusion. In this article we will review the pros and cons of each of the two reperfusion therapies and comment on the treatment options available to physicians in Kuwait