Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates

The Saudi Association for Pulmonary Hypertension [previously called Saudi Advisory Group for Pulmonary Hypertension] has published the first Saudi Guidelines on Diagnosis and Treatment of Pulmonary Arterial Hypertension back in 2008. [1] That guideline was very detailed and extensive and reviewed most aspects of pulmonary hypertension [PH]. One of the disadvantages of such detailed guidelines is the difficulty that some of the readers who just want to get a quick guidance or looking for a specific piece of information might face. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and helpful to clinicians dealing with PH patients to select the best management strategies for the typical patient suffering from a specific condition. This Guideline was designed to provide recommendations for problems frequently encountered by practicing clinicians involved in management of PH. This publication targets mainly adult and pediatric PH-treating physicians, but can also be used by other physicians interested in PH

Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: pulmonary hypertension due to left heart disease

Pulmonary hypertension [PH] due to left heart disease is the most common cause of pulmonary hypertension in the western world. It is classified as WHO PH group II. Different pathophysiologic abnormalities may take place in this condition, including pulmonary venous congestion and vascular remodeling. Despite the high prevalence of WHO group 2 PH, the major focus of research on PH over the past decade has been on WHO group 1 pulmonary arterial hypertension [PAH]. Few investigators have focused on WHO group 2 PH; consequently, the pathophysiology of this condition remains poorly understood, and no specific therapy is available. Clinical and translational studies in this area are much needed and have the potential to positively affect large numbers of patients. In this review, we provide a detailed discussion upon the pathophysiology of the disease, the recent updates in classification, and the diagnostic and therapeutic algorithms

Asymptomatic metastatic osteosarcoma to the right ventricle: case report and review of the literature

Metastatic cardiac tumors are far more common than primary tumors, and benign primary cardiac tumors are common than malignant tumors. We report a 22-year-old Saudi woman with right femur osteosarcoma who was found to have a large right ventricular mass by transthoracic and transesophageal echocardiography. Diagnosis was highly suggestive by cardiac magnetic resonance imaging [MRI] and fluorodeoxyglucose positron emission tomography/computed tomography [FDG PET/CT] scan. We performed a review of the literature for metastatic osteosarcoma of the right ventricle

Age and its relationship to acute coronary syndromes in the Saudi project for assessment of coronary events [SPACE] registry: the SPACE age study

To characterize risk profile of acute coronary syndrome [ACS] patients in different age groups and compare management provided to in-hospital outcome. Prospective multi-hospital registry. Seventeen secondary and tertiary care hospitals in Saudi Arabia. Five thousand and fifty-five patients with ACS. They were divided into four groups: /= 70 years. Main outcome measures: prevalence, utilization and mortality. Ninety-four percent of patients <40 years compared to 68% of patients >70 years were men. Diabetes was present in 70% of patients aged 56-70 years. Smoking was present in 66% of those <40 years compared to 7% of patients >70 years. Fifty-three percent of the patients >70 years and 25% of those <40 years had history of ischemic heart disease. Sixty percent of patients <40 years presented with ST elevation myocardial infarction [STEMI] while non-ST elevation myocardial infarction was the presentation in 49% of patients >70 years. Thirty-four percent of patients >70 years compared to 10% of patients <40 years presented >12 h from symptom onset with STEMI. Fifty-four percent of patients >70 compared to 64-71% of those <70 years had coronary angiography. Twenty-four percent of patients >70 compared to 34-40% of those <70 years had percutaneous coronary intervention. Reperfusion shortfall for STEMI was 16-18% in patients >56 years compared to 11% in patients <40 years. Mortality was 7% in patients >70 years compared to 1.6-3% in patients <70 years. For all comparisons [p < 0.001]. Young and old ACS patients have unique risk factors and present differently. Older patients have higher in-hospital mortality as they are treated less aggressively. There is an urgent need for a national prevention

Novel approach for the management of sub-massive pulmonary embolism

Right ventricular [RV] dysfunction has been identified as a poor prognostic indicator in sub-massive pulmonary embolism [SPE]. We hypothesized that using selective vasodilator agent is beneficial in improving RV function in patients with this condition. We used inhaled prostacyclin analogue [Iloprost, Ventavis[registered]] in five patients with SPE. Helical computerized tomography angiogram was confirmatory for pulmonary embolism and echocardiography was used to evaluate the RV status. All patients received inhaled Iloprost, 2.5 to 5 microg every 4 hours for 3 weeks. Patients were prospectively followed for 3 months. They were assessed at baseline before starting Iloprost treatment and at 3 days, 3 weeks, and 3 months after treatment. All patients showed significant improvement in their functional class, Borg dyspnea score, NT pro-BNP level, and echocardiographic parameters. In SPE, directing therapy toward decreasing pulmonary vascular resistance improves the associated pulmonary hemodynamic compromise and improves RV function

Incidence of ventricular arrhythmia and associated patient outcomes in hospitalized acute coronary syndrome patients in Saudi Arabia: findings from the registry of the Saudi Project for Assessment of Acute Coronary Syndrome [SPACE]

Mortality in acute coronary syndrome [ACS] patients with ventricular arrhythmia [VA] has been shown to be higher than those without VA. However, there is a paucity of data on VA among ACS patients in the Middle Eastern countries. Prospective study of patients admitted in 17 government hospitals with ACS between December 2005 and December 2007. Patients were categorized as having VA if they experienced either ventricular fibrillation [VF] or sustained ventricular tachycardia [VT] or both. Of 5055 patients with ACS enrolled in the SPACE registry, 168 [3.3%] were diagnosed with VA and 151 [98.8%] occurred in-hospital. The vast majority [74.4%] occurred in patients with ST-segment elevation myocardial infarction. In addition, males were twice as likely to develop VA than females [OR 1.7; 95% CI 1.1- 3]. Killip class >I [OR 2.0; 95% CI 1.3-3.1]; and systolic blood pressure <90 mm Hg [OR 6.4; 95% CI 3.5-11.8] were positively associated with VA. Those admitted with hyperlipidemia [OR 0.49; 95% CI 0.3-0.7] had a lower risk of developing VA. Adverse in-hospital outcomes including re-myocardial infarction, cardiogenic shock, congestive heart failure, major bleeding, and stroke were higher for patients with VA [P?.01 for all variables] and signified a poor prognosis. The in-hospital mortality rate was significantly higher in VA patients compared with non-VA patients [27% vs 2.2%; P=.001]. In-hospital VA in Saudi patients with ACS was associated with remarkably high rates of adverse events and increased in-hospital mortality. Using a well-developed registry data with a large number of patients, our study documented for the first time the prevalence and risk factors of VA in unselected population of ACS

Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: Results of the Saudi project for assessment of coronary events [SPACE] registry

The Saudi Project for Assessment of Coronary Events [SPACE] registry is the first in Saudi Arabia to study the clinical features, management, and in-hospital outcomes of acute coronary syndrome [ACS] patients. We conducted a prospective registry study in 17 hospitals in Saudi Arabia between December 2005 and December 2007. ACS patients included those with ST-elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction and unstable angina; both were reported collectively as NSTEACS [non-ST elevation acute coronary syndrome]. 5055 patients were enrolled with mean age +/- SD of 58 +/- 12.9 years; 77.4% men, 82.4% Saudi nationals; 41.5% had STEMI, and 5.1% arrived at the hospital by ambulance. History of diabetes mellitus was present in 58.1%, hypertension in 55.3%, hyperlipidemia in 41.1%, and 32.8% were current smokers; all these were more common in NSTEACS patients, except for smoking [all P < 0.0001]. In-hospital medications were: aspirin [97.7%], clopidogrel [83.7%], beta-blockers [81.6%], angiotensin converting enzyme inhibitors/angiotensin receptor blockers [75.1%], and statins [93.3%]. Median time from symptom onset to hospital arrival for STEMI patients was 150 min [IQR: 223], 17.5% had primary percutaneous coronary intervention [PCI], 69.1% had thrombolytic therapy, and 14.8% received it at less than 30 min of hospital arrival. In-hospital outcomes included recurrent myocardial infarction [1.5%], recurrent ischemia [12.6%], cardiogenic shock [4.3%], stroke [0.9%], major bleeding [1.3%]. In-hospital mortality was 3.0%. ACS patients in Saudi Arabia present at a younger age, have much higher prevalence of diabetes mellitus, less access to ambulance use, delayed treatment by thrombolytic therapy, and less primary PCI compared with patients in the developed countries. This is the first national ACS registry in our country and it demonstrated knowledge-care gaps that require further improvements