In-hospital and one-year clinical outcome of percutaneous coronary intervention in a tertiary hospital in Oman: Oman PCI registry

Objectives: The aim of the study was to investigate the in-hospital and one-year clinical outcome of patients treated with percutaneous coronary intervention [PCI] in a tertiary hospital in Oman

Methods: We conducted a retrospective, single-center, observational study looking at patients > 18 years old who underwent a PCI from 1 January to 31 December 2013. The primary end point was the occurrence of a major adverse cardiovascular event [MACE], defined as death, any myocardial infarction [MI], cerebrovascular accident [CVA], and target vessel revascularization [TVR] with either repeat PCI or coronary artery bypass surgery [CABG]. Secondary end-points included procedural success rate, angina status, stent thrombosis, and the rate of redo-PCI/CABG for in-stent restenosis

Results: A total of 1 045 consecutive patients were analyzed. The mean age of the cohort was 58.2 +/- 11.2 years. Hyperlipidemia [66.8%], hypertension [55.1%], and diabetes mellitus [45.9%] were the predominant risk factors. Stable angina, ST-elevation MI, non-ST-elevation MI, and post-acute coronary syndrome [ACS] were common indications [approximately 20.0% each]. The angiographic and procedural success rate was 95.0%. Forty-six percent of patients had single-vessel disease, 34.4% had double vessel disease, and triple vessel disease was seen in 19.1% of patients. Ninety-eight percent had balloon angioplasty with stenting, and only 1.9% of patients had balloon angioplasty without stenting. The majority of patients had single-vessel stenting [81.3%]. A drug-eluting stent was used in 88.4% of patients, and a bare-metal stent in 11.6%. Inhospital MACE was 3.6%. There were 19 in-hospital deaths [1.8%], and four patients [0.4%] had CVA/MI. Out of 1 026 patients discharged, 100 patients were lost to followup. Among the 926 patients followed-up, 673 patients [72.7%] were asymptomatic. Oneyear MACE was 17.0%, including 5.0% death and 6.0% MI. Repeat revascularization was performed in 53 patients [5.7%] for documented in-stent restenosis. Definite stent thrombosis was documented in 10 [1.1%] patients. At discharge, the majority of patients were on post-ACS evidence-based medications, aspirin [100%], clopidogrel [99.6%], statin [97.6%], beta-blocker [88.7%], and angiotensin-converting-enzyme inhibitors [83.9%]

Conclusions: Omani patients treated with PCI were much younger than Western patients with a high prevalence of risk factors. Successful PCI was achieved in a large percentage of patients with a low incidence of in-hospital complications and mortality. At one-year follow-up, the majority patients had a good clinical outcome

In-hospital outcome of patients with cardiogenic shock complicating acute myocardial infarction: results from Royal hospital percutaneous coronary intervention registry, Oman

Objectives: Cardiogenic shock [CS] is still the leading cause of in-hospital mortality in patients presenting with acute myocardial infarction [AMI]. The aim of this study was to determine the in-hospital mortality and clinical outcome in AMI patients presenting with CS in a tertiary hospital in Oman

Methods: This retrospective observational study included patients admitted to the cardiology department between January 2013 and December 2014. A purposive sampling technique was used, and 63 AMI patients with CS admitted to [36.5%] or transferred from a regional hospital [63.5%] were selected for the study

Results: Of 63 patients, 73% [n = 46] were Omani and 27% [n = 17] were expatriates: 79% were male and 21% were female. The mean age of patients was 60 +/- 12 years. The highest incidence of CS [30%] was observed in the 51-60 year age group. Diabetes mellitus [43%] and hypertension [40%] were the predominant risk factors. Ninety-two percent of patients had ST-elevation MI, 58.7% patients were thrombolysed, and 8% had non-ST-elevation MI. Three-quarters [75%] of CS patients had severe left ventricular systolic dysfunction [defined as ejection fraction <30%]. Coronary angiogram showed single vessel disease in 17%, double vessel disease in 40%, and triple vessel disease in 32% and left main disease in 11%. The majority of the patients [93.6%] underwent percutaneous coronary intervention [PCI], among them 23 [36.5%] underwent primary PCI. In-hospital mortality was 52.4% in this study

Conclusions: CS in AMI patients presenting to a tertiary hospital in Oman have high in-hospital mortality despite the majority undergoing PCI. Even though the in-hospital mortality is comparable to other studies and registries, there is an urgent need to determine the causes and find any remedies to provide better care for such patients, specifically concentrating on the early transfer of patients from regional hospitals for early PCI

Epidemiology of diabetes mellitus in Oman results from two decades of research

This study aimed to describe the epidemiology of diabetes mellitus over the past two decades in Oman, particularly in terms of its prevalence and incidence. In addition, the study sought to estimate the future incidence of diabetes in Oman. Three national and three regional surveys conducted between 1991 and 2010 were analysed to obtain the age-adjusted prevalence and undiagnosed proportion of type 2 diabetes mellitus [T2DM] among Omani subjects aged >/=20 years. Diabetes mellitus registers and published studies were used to determine incidence rates of both type 1 diabetes mellitus [T1DM] and T2DM in Oman. Linear regression was used to determine trends and projections for diabetes in 2050. The age-adjusted prevalence of T2DM in Oman varied from 10.4% to 21.1%, while the highest prevalence of impaired fasting glucose was found in males [35.1%]. In comparison to men, higher incidence rates of T2DM were found in women [2.7 cases compared to 2.3 cases per 1,000 person-years, respectively]. No significant trends were observed for the prevalence or incidence of T2DM in both genders. Undiagnosed T2DM was more common in men [range: 33-68%] than women [range: 27-53%]. The results of this study show that by 2050, there will be an estimated 350,000 people with T2DM living in Oman [a 174% increase compared to estimates for 2015]. Health authorities need to prioritise diabetes prevention and control in order to prevent or delay long-term complications and avert a potential epidemic of diabetes in Oman

Carcinoma of unknown primary presenting as large right atrial and ventricular mass secondary to disseminated tumor thrombosis

We report a 65-year-old male patient who presented with right heart failure and a large mobile right atrial and ventricular mass on echocardiography. His computed tomography demonstrated bilateral supraclavicular/mediastinal lymphadenopathy, right atrial and ventricular mass with right pulmonary artery segmental embolism, and multiple liver hypodense lesions. His tumor markers were negative. However, fine-needle aspiration cytology of supraclavicular lymph node revealed metastatic carcinoma suggestive of squamous cell carcinoma. He was suspected to have carcinoma of unknown primary origin. This case illustrates a rare presentation of carcinoma of unknown primary origin with disseminated tumor thrombosis primarily manifesting in heart and other sites

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

Clinical pathways for non-ST elevation acute coronary syndrome in Oman: an Oman heart association protocol for hospital quality improvement initiative

In 2012, Oman Heart Association [OHA] published its own guidelines for the management of patients with unstable angina/ non-ST-elevation myocardial infarction, the aim was not to be comprehensive but rather simplified and practical in order to reduce the gap between the long comprehensive guidelines and our actual practice. However, we still feel that the busy registrars and residents need simpler and direct clinical pathways or protocol to be used in the emergency departments, coronary care units and in the wards. Clinical pathways are now one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes in acute care

Mechanical prosthetic valves and pregnancy a therapeutic dilemma of anticoagulation

Choosing the best anticoagulant therapy for a pregnant patient with a mechanical prosthetic valve is controversial and the published international guidelines contain no clear-cut consensus on the best approach. This is due to the fact that there is presently no anticoagulant which can reliably decrease thromboembolic events while avoiding damage to the fetus. Current treatments include either continuing oral warfarin or substituting warfarin for subcutaneous unfractionated heparin or low-molecular-weight heparin [LMWH] in the first trimester [6-12 weeks] or at any point throughout the pregnancy. However, LMWH, while widely-prescribed, requires close monitoring of the blood anti-factor Xa levels. Unfortunately, facilities for such monitoring are not universally available, such as within hospitals in developing countries. This review evaluates the leading international guidelines concerning anticoagulant therapy in pregnant patients with mechanical prosthetic valves as well as proposing a simplified guideline which may be more relevant to hospitals in this region

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

Multi-factorial causes of torsade de pointes in a hospitalised surgical patient

A 55-year-old chronic alcoholic male known to be positive for human immunodeficiency virus [HIV] was admitted to a surgical ward following perianal abscess drainage. He was noted to have sinus bradycardia, ventricular premature complexes, and mild hypotension. His laboratory investigations revealed mild hypokalaemia. He was intermittently agitated and alcohol withdrawal syndrome [AWS] was diagnosed. Postoperatively, he received intravenous piperacillin/tazobactam and metronidazole infusions along with a small dose of dopamine. Analysis of a 24-hour Holter monitor [ECG] showed a prolonged QT interval with two episodes of self-terminating torsade de pointes. His AWS was treated, hypokalaemia was corrected, and dopamine, along with antibiotics, was withdrawn. There was no recurrence of arrhythmias. This case highlights the importance of avoiding QT-prolonging drugs in hospitalised patients, since hospitalised patients often have multiple risk factors for a proarrhythmic response

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

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

Mobile right atrial thrombus with pulmonary thromboembolism in a patient with advanced hepatocellular carcinoma and disseminated tumor thrombosis

We report a 61-year-old male patient who presented with one month history of exertional dyspnea, persistent dry cough, abdominal pain with distension, poor appetite, and weight loss. This case illustrates a rare presentation of hepatocellular carcinoma with mobile right atrial thrombus and pulmonary embolism along with disseminated tumor thrombosis at multiple sites. Furthermore, this case reiterates that an early detection and diagnosis may have increasing importance in the advent of new therapies for treating advanced hepatocellular carcinoma

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

Ischemic stroke secondary to aortic dissection following rifle butt recoil chest injury: a case report

Ischemic stroke secondary to aortic dissection is not uncommon. We present a patient with left hemiplegia secondary to Stanford type A aortic dissection extending to the supra-aortic vessels, which was precipitated by rifle butt recoil chest injury. The diagnosis of aortic dissection was delayed due to various factors. Finally, the patient underwent successful Bentall procedure with complete resolution of symptoms. This case emphasizes the need for caution in the use of firearms for recreation and to take precautions in preventing such incidents. In addition, this case illustrates the need for prompt cardiovascular physical examination in patients presenting with stroke

Pacemaker lead thrombo-endocarditis in an intravenous drug abuser

We report a 30-year-old male intravenous drug abuser presenting with persistent pacemaker lead thrombosis with superimposed pacemaker lead endocarditis. He underwent urgent surgery, but expired due to refractory sepsis. This case confirms that patients with pacemakers are at risk of developing pacemaker lead thrombosis. In addition, they are at high risk of developing pacemaker lead endocarditis if additional risk factors for endocarditis are present. We believe this case report is unusual on account of pacemaker lead thrombosis as well as endocarditis occurring in a patient with history of intravenous drug abuse. Whether pacemaker patients with multiple leads need to be on long-term antiplatelet or anticoagulation therapy necessitates further studies