epidemiology of acute coronary syndrome in Oman. Results from the Oman-RACE study

This study aimed to evaluate the epidemiology and coronary risk factors of acute coronary syndrome [ACS] in Oman. Data were collected through a prospective, multinational, multicentre survey of consecutive patients, hospitalised over a 5-month period in 2007 with a diagnosis of ACS, in Yemen and five Arabian Gulf countries [Oman, Bahrain, Kuwait, Qatar, United Arab Emirates]. Here we present data of Omani patients aged >/= 20 years who received a provisional diagnosis of ACS and were consequently admitted to 14 different hospitals. There where 1,340 confirmed ACS episodes in 748 men and 592 women [median age 61 years]. The overall crude incidence rate of ACS was 338.9 per 100,000 person-years [P-Y]. The age-standardised rate [ASR] of ACS was 779 and 674 per 100,000 P-Y for men and women, respectively. The ASR male-to-female rate ratio was highest in the ST-elevation myocardial infarction [STEMI] group [2.26, 95% confidence interval [[CI], 1.63 to 3.15] followed by the non-STEMI [NSTEMI] group [1.68, 95% CI 1.28 to 2.21] and unstable angina [0.79, 95% CI 0.66 to 0.99]. Unstable angina accounted for 55%, STEMI for 26% and NSTEMI for 19% of ACS cases. Among the coronary risk factors, there was a high prevalence of hypertension [68%], diabetes mellitus [DM] [36%], hyperlipidaemia [63%], and overweight/obesity [65%], with a relatively low rate of current tobacco use [11%]. Our study confirms a high incidence of ACS in Omanis and supports the notion that the cardiovascular disease epidemic is also sweeping developing countries

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

Predictive value of a 4-hour accelerated diagnostic protocol in patients with suspected ischemic chest pain presenting to an emergency department

Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department [ED] includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED's. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol [ADP] using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman. One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T [<0.010 microg/l] were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome [ACS] patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events [MACE] [Group I: negative ADP]. High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE [Group II: positive ADP]. One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients [8.4%] and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% [95% CI: 0.28-0.76], specificity of 93% [0.85-0.97], a negative predictive value of 91% [0.83-0.96], a positive predictive value of 60% [0.32-0.82], negative likelihood ratio of 0.5 [0.30-0.83] and a positive likelihood ratio of 8.2 [3.3-20] in predicting MACE. A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE among low probability ACS patients discharged from ED. However, 30-day MACE in ADP negative patients was relatively high in contrast to guideline recommendations. Hence, there is a need to establish ED chest pain unit and adopt new protocols especially adding a point-of-care exercise treadmill test in the ED

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

Relationship between admitting nonfasting blood glucose and in-hospital mortality stratified by diabetes mellitus among acute coronary syndrome patients in Oman

Hyperglycemia in patients admitted for acute coronary syndrome [ACS] is associated with increased in-hospital mortality. We evaluated the relationship between admitting [nonfasting] blood glucose and in-hospital mortality in patients with and without diabetes mellitus [DM] presenting with ACS in Oman. Data were analyzed from 1551 consecutive patients admitted to 15 hospitals throughout Oman, with the final diagnosis of ACS during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf Registry of Acute [>7-<9 mmol/l], moderate hyperglycemia [>/= 9-<11 - mmol/l], and severe hyperglycemia [7-<9 mmol/l], moderate hyperglycemia [>/= 9-<11 - mmol/l], and severe hyperglycemia [>/= 11 mmol/l]. of all, 38% [n=584] and 62% [n=967] of the patients were documented with and without a history of DM, respectively. Nondiabetic patients with severe hyperglycemia were associated with significantly higher in-hospital mortality compared with those with euglycemia [13.1 vs 1.52%; P<0.001], mild hyperglycemia [13.1 vs 3.62%; P = 0.003], and even moderate hyperglycemia [13.1 vs 4.17%; P = 0.034]. Even after multivariate adjustment, severe hyperglycemia was still associated with higher in-hospital mortality when compared with both euglycemia [odds ratio [OR], 6.3; p<0.001] and mild hyperglycemia [OR, 3.43; P = 0.011]. No significant relationship was noted between admitting blood glucose and in-hospital mortality among diabetic ACS patients even after multivariable adjustment [all P values >0.05]. Admission hyperglycemia is common in ACS patients from Oman and is associated with higher in-hospital mortality among those patients with previously unreported DM

Gender-related differences in the presentation, management, and outcomes among patients with acute coronary syndrome from Oman

To assess gender-related differences in the presentation, management, and in-hospital outcomes among acute coronary syndrome [ACS] patients from Oman. Data were analyzed from 1579 consecutive ACS patients from Oman during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf RACE [Registry of Acute Coronary Events]. Analyses were conducted using univariate and multivariate statistical techniques. In this study, 608 [39%] patients were women with mean age 62 +/- 12 vs. 57 +/- 13 years [p < 0.001]. More women were seen in the older age groups [age <55 years: 25% vs. 43%, 55-74 years: 60% vs. 49% and >75 years: 15% vs. 8%; p < 0.001]. Women had higher frequencies of diabetes, hypertension, hyperlipidemia, obesity, angina, and aspirin use, but less history of smoking. Women were significantly less likely to have ischemic chest pain, ST-elevation myocardial infarction [STEMI], non-STEMI and were more likely to have dyspnea, unstable angina, ST depression and left bundle branch block. Both groups received ACS medications and cardiac catheterization equally; however, women received anticoagulants [88% vs. 79%; p < 0.001], angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin II receptor blockers [ARBs] [70% vs. 65%; p = 0.050] more and clopidogrel less [20% vs. 29%; p < 0.001]. Women experienced more recurrent ischemia and heart failure but with similar in-hospital mortality [4.6% vs. 4.3%] even after adjusting for age [p = 0.500]. Women admitted with ACS were older than men, had more risk factors, presented differently with no difference in hospital mortality. This is similar to Gulf RACE study except for mortality. Women received anticoagulants/ACEIs /ARBs more but were under-treated with clopidogrel

Acute coronary syndrome in Oman results from the gulf registry of acute coronary events

Acute coronary syndrome [ACS] is the most common cause of cardiovascular mortality and morbidity in Western countries. International guidelines for diagnosis and treatment have been developed based on randomised clinical trials. However, data from international registries report a lack of association between guideline recommendations and actual clinical practice. Similarly, the Gulf Heart Association initiated a registry called Gulf Registry of Acute Coronary Events [Gulf RACE]. This registry was developed to determine the characteristics and management of ACS in the Gulf countries including Oman. Here, we report on the results of the various Gulf RACE registry studies from Oman and compare our results with the main Gulf RACE data as well as other international registries

Coronary perforation and covered stents: an update and review

Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventionat cardiology. Coronary perforations are classified as type I [extraluminal crater], II [myocardial or pericardial blushing], and III [contrast streaming or cavity spilling]. Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardiat drainage. However, type III perforations can be managed with covered stents without need for surgical intervention

Acute coronary syndrome in young adults from Oman: results from the gulf registry of acute coronary events

To assess the prevalence, risk factors, presenting features, and in-hospital outcomes of acute coronary syndrome [ACS] patients 40 years of age. A total of 121 [7.6%] patients were

Tricuspid valve endocarditis in an intravenous drug abuser masquerading as pulmonary tuberculosis

Intravenous drug abuse contributes to considerable illness burden in developed and developing countries. Tricuspid valve endocarditis [TVE] is rare in Middle East countries, though many reports of it in intravenous drug abusers are found in other countries. We describe a case of TVE mimicking pulmonary tuberculosis in a 33-year-old man with a history of intravenous heroin use

Immediate and six-month clinical outcome of percutaneous coronary intervention in a tertiary hospital in the Sultanate of Oman

To evaluate the clinical characteristics, angiographic profile, in-hospital and six-month clinical outcome of patients who underwent percutaneous coronary intervention in a tertiary hospital in the Sultanate of Oman. Two hundred and five consecutive patients with both acute coronary syndrome and stable coronary artery disease, who underwent percutaneous coronary intervention between January 2007 and June 2007, were retrospectively analyzed. Follow-up information was obtained from outpatient visits of these patients at six-months. The primary end point in this study was the occurrence of major adverse cardiovascular events [MACE], defined as cardiac death, any myocardial infarction [MI], cerebrovascular accident [CVA] and target vessel revascularization [TVR] with either repeat percutaneous coronary intervention [PCI] or coronary artery bypass surgery [CABG]. Secondary end points included angiographic success rate, procedural success rate, angina status, and the rate of clinical and angiographic restenosis. The angiographic and procedural success rate was 98% and 95% respectively. Fifty-one percent of patients surveyed had single vessel disease, 34% had double vessel disease and triple vessel disease was seen in 15% of patients. Type A lesion was found in 16%, Type B in 55% and Type C in 29% of patients. The majority of patients had single vessel stenting [83%]. The mean +/- SD number of stents per patient was 1.6 +/- 0.9. There were four in-hospital deaths [2%] and six patients [2.9%] had non-ST elevation myocardial infarction before hospital discharge. Out of 205 patients, 53 patients were lost to follow-up. Among the 148 patients followed up, 105 patients [71%] were asymptomatic at follow-up, 36 [24%] patients had stable angina and 7 [5%] had a late myocardial infarction including three patients with stent thrombosis [2%]. Among the 43 patients with angina or late infarction, 28 patients underwent coronary angiogram. Angiographic in-stent restenosis was seen in 14 patients. Of them, 8 patients underwent CABG and 6 patients repeat PCI. Fourteen patients had patent stents. The remaining fifteen patients were on optimal medications including two patients with stent thrombosis as they refused coronary angiogram. Overall, 132 of 148 patients [105 asymptomatic/14 patents tents/13 with angina] [89%] were free from major adverse cardiac events. Considering anginal status and repeat angiograms, composite clinical [15 patients] and angiographic [14 patients] six-month restenosis rate in percutaneous coronary intervention patients [29/148] was 19.5%. Results of percutaneous coronary intervention in our setup is excellent with good immediate results, low complication rate, good six-month clinical outcome and is comparable to international standards