Rationale, design, methodology and hospital characteristics of the first gulf acute heart failure registry [gulf care]

There is paucity of data on heart failure [HF] in the Gulf Middle East. The present paper describes the rationale, design, methodology and hospital characteristics of the first Gulf acute heart failure registry [Gulf CARE]. Gulf CARE is a prospective, multicenter, multinational registry of patients >18 year of age admitted with diagnosis of acute HF [AHF]. The data collected included demographics, clinical characteristics, etiology, precipitating factors, management and outcomes of patients admitted with AHF. In addition, data about hospital readmission rates, procedures and mortality at 3 months and 1-year follow-up were recorded. Hospital characteristics and care provider details were collected. Data were entered in a dedicated website using an electronic case record form. A total of 5005 consecutive patients were enrolled from February 14, 2012 to November 13, 2012. Forty-seven hospitals in 7 Gulf States [Oman, Saudi Arabia, Yemen, Kuwait, United Gulf Emirates, Qatar and Bahrain] participated in the project. The majority of hospitals were community hospitals [46%; 22/47] followed by non-University teaching [32%; 15/47 and University hospitals [17%]. Most of the hospitals had intensive or coronary care unit facilities [93%; 44/47] with 59% [28/47] having catheterization laboratory facilities. However, only 29% [14/47] had a dedicated HF clinic facility. Most patients [71%] were cared for by a cardiologist. Gulf CARE is the first prospective registry of AHF in the Middle East, intending to provide a unique insight into the demographics, etiology, management and outcomes of AHF in the Middle East. HF management in the Middle East is predominantly provided by cardiologists. The data obtained from this registry will help the local clinicians to identify the deficiencies in HF management as well as provide a platform to implement evidence based preventive and treatment strategies to reduce the burden of HF in this region

Stent fracture: how frequently is it recognized?

In spite of there being several case reports, coronary stent fracture is not a well-recognized entity and incidence rates are likely to be underestimated. In this article, we review different aspects of stent fracture, including incidence, classification, predictors, outcome, diagnosis, and management

Adenosine-induced coronary artery spasm: a case report

To describe an uncommon complication of intravenous adenosine administration. A 41-year-old female patient presented with palpitations due to supraventricular tachycardia. The patient was treated with intravenous adenosine with resolution of the tachycardia. Subsequently, the patient developed chest pain and ST segment elevation in the inferior leads that resolved with sublingual nitroglycerin. This report showed a case of coronary spasm secondary to the administration of adenosine. We therefore recommend that discretion be exercised when giving adenosine, especially to patients with an underlying tendency for vasospastic reactions

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.

Baseline characteristics, management practices, and long-term outcomes of middle eastern patients in the second gulf registry of acute coronary events [Gulf RACE-2]

Limited data are available on patients with acute coronary syndromes [ACS] and their long-term outcomes in the Arabian Gulf countries. We evaluated the clinical features, management, in-hospital, and long-term outcomes of in such a population. A 9-month prospective, multicenter study conducted in 65 hospitals from 6 countries that also included 30 day and 1-year mortality follow-up. ACS patients included those with ST-elevation myocardial infarction [STEMI] and non-ST-elevation acute coronary syndrome [NSTEACS], including non-STEMI and unstable angina. The registry collected the data prospectively. Between October 2008 and June 2009, 7930 patients were enrolled. The mean age [standard deviation], 56 [17] years; 78.8% men; 71.2% Gulf citizens; 50.1% with central obesity; and 45.6% with STEMI. A history of diabetes mellitus was present in 39.5%, hypertension in 47.2%, and hyperlipidemia in 32.7%, and 35.7% were current smokers. The median time from symptom onset to hospital arrival for STEMI patients was 178 minutes [interquartile range, 210 minutes]; 22.3% had primary percutaneous coronary intervention [PCI] and 65.7% thrombolytic therapy, with 34% receiving therapy within 30 minutes of arrival. Evidence-based medication rates upon hospital discharge were 68% to 95%. The in-hospital PCI was done in 21% and the coronary artery bypass graft surgery in 2.9%. The in-hospital mortality was 4.6%, at 30 days the mortality was 7.2%, and at 1 year after hospital discharge the mortality was 9.4%; 1-year mortality was higher in STEMI [11.5%] than in NSTEACS patients [7.7%; P<.001].Compared to developed countries, ACS patients in Arabian Gulf countries present at a relatively young age and have higher rates of metabolic syndrome features. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates are high, but coronary revascularization procedures are low. Long-term mortality rates increased severalfold compared with in-hospital mortality

Clinical profile and mortality of st-segment elevation myocardial infarction patients receiving thrombolytic therapy in the middle east

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

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

Major bleeding in acute coronary syndrome

Acute coronary syndrome forms the vast majority of cases faced in daily cardiology clinical practice. It is usually managed by antiplatelates, antithrombotics and anticoagulants, all of which increase the risk of bleeding with associated increment in morbidity and mortality. Data gained from many studies and registries all over the world try to explore the magnitude of such problem as well as predictors and management. The definition of major bleeding in acute coronary syndrome is a dilemma by itself, as different definitions have led to inconsistency in its reported prevalence and magnitude of sequelae. Predicting the occurrence of major bleeding may help in saving lives, improving outcomes and cost-savings by preventing it. In this review, we try to explore these issues based on data extracted from large numbers of trials, studies and registries

Epidemiology of idiopathic cardiomyopathy in Qatar during 1996-2003

To report the rates of cardiomyopathies in the population below 50 years of age in Qatar. We conducted a retrospective review of clinical data on patients with Cardiomyopathy who were hospitalized in Hamad General Hospital, Doha. Data were collected from medical records during the 1996-2002 period and prospectively from the patients who were hospitalized during the year 2003. All Cardiomyopathy patients below 50 years of age who were citizens or permanent residents in Qatar were included in this study. During the study period, a total of 132 cases were recorded with idiopathic cardiomyopathies. Among these, 67.4% were males and 32.6% females; Qatari 31.8%, non-Qatari 68.2%. The consanguinity rate was high among Qatari patients. In the first 7-year study period, 1996-2002, the incidence rate of all types of cardiomyopathies was 2.5/100,000 population per year [95% Cl: 1.4-3.5]. It increased to 5.2/100,000 population during the year 2003 [95% Cl: 3.6-6.7]. Dilated Cardiomyopathy was most prevalent [75.8%] in all age groups, and the incidence increased remarkably with age. Lower prevalence of hypertrophic Cardiomyopathy [13.6%] and left ventricle noncompaction Cardiomyopathy [6.1%] was found. In children below 15 years of age, the incidence rate for all types of cardiomyopathies was 2.7/100,000 population. The overall mortality rate was 5.3%. Most cases of car-diomyopathy were identified at an early age: below 15 years and above 35 years of age. Introducing preventive and early diagnosis programs may have an impact on reducing the mortality and morbidity from idiopathic Cardiomyopathy

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

Clinical and histologic studies of a Qatari family with myofibrillar myopathy

The current study reports the first family with confirmed myofibrillar myopathy MFM in the Middle East and the third family worldwide. This study highlights the importance of considering MFM in young patients presenting with idiopathic cardiomyopathy, arrhythmia or atrioventricular block in the Gulf states. This is the first report that presented 2 different types of cardiomyopathy and 2 different indications of permanent pacemaker placement in the same generation of a family with MFM. This report studies a Qatari family consisting of one brother and 3 sisters. The brother had restrictive cardiomyopathy at the age of 16 years. One sister underwent heart transplantation for severe hypertrophic cardiomyopathy at the age of 15 years, the other sister had permanent pacemaker for complete heart block at the age of 21 years. This report is focused mainly on the clinical presentation and investigations carried out for the brother including echocardiogram, cardiac catheterization, cardiac and skeletal muscle biopsy, and electromyography and electrophysiology studies. The study findings support the diagnosis of MFM