Acute heart failure presentations and outcomes during the fasting month of Ramadan: an observational report from seven Middle Eastern countries.

BACKGROUND: Fasting during the month of Ramadan is practiced by over 1.5 billion Muslims worldwide. It remains unclear, however, how this change in lifestyle affects heart failure, a condition that has reached epidemic dimensions. This study examined the effects of fasting in patients with acute heart failure (AHF) using data from a large multi-center heart failure registry. METHODS AND RESULTS: Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multi-center study of consecutive patients hospitalized with AHF during February-November 2012. The study included 4,157 patients, of which 306 (7.4%) were hospitalized with AHF in the fasting month of Ramadan, while 3,851 patients (92.6%) were hospitalized in other days. Clinical characteristics, precipitating factors, management, and outcome were compared among the two groups. Patients admitted during Ramadan had significantly lower prevalence of symptoms and signs of volume overload compared to patients hospitalized in other months. Atrial arrhythmias were significantly less frequent and cholesterol levels were significantly lower in Ramadan. Hospitalization in Ramadan was not independently associated with increased immediate or 1-year mortality. CONCLUSIONS: The current study represents the largest evaluation of the effects of fasting on AHF. It reports an improved volume status in fasting patients. There were also favorable effects on atrial arrhythmia and total cholesterol and no effects on immediate or long-term outcomes.

Coronary artery disease prevalence and outcome in patients hospitalized with acute heart failure: an observational report from seven Middle Eastern countries.

OBJECTIVES: The purpose of this study was to report prevalence, clinical characteristics, precipitating factors, management and outcome of patients with coronary artery disease (CAD) among patients hospitalized with heart failure (HF) in seven Middle Eastern countries and compare them to non-CAD patients. METHODS: Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicenter study of 5005 consecutive patients hospitalized with acute HF during February-November 2012 in 7 Middle Eastern countries. RESULTS: The prevalence of CAD among Acute Heart Failure (AHF) patients was 60.2% and varied significantly among the 7 countries (Qatar 65.7%, UAE 66.6%, Kuwait 68.0%, Oman 65.9%, Saudi Arabia 62.5%, Bahrain 52.7% and Yemen 49.1%) with lower values in the lower income countries. CAD patients were older and more likely to have diabetes, hypertension, dyslipidemia and chronic kidney disease. Moreover, CAD patients were more likely to have history of cerebrovascular and peripheral vascular disease when compared to non-CAD patients. In-hospital mortality rates were comparable although CAD patients had more frequent re-hospitalization and worse long-term outcome. However, CAD was not an independent predictor of poor outcome. CONCLUSION: The prevalence of CAD amongst patients with HF in the Middle East is variable and may be related to healthcare sources. Regional and national studies are needed for assessing further the impact of various etiologies of HF and for developing appropriate strategies to combat this global concern.

Rationale, Design, Methodology and Hospital Characteristics of the First Gulf Acute Heart Failure Registry (Gulf CARE).

BACKGROUND: 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). MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Absence of obesity paradox in Saudi patients admitted with acute coronary syndromes: insights from SPACE registry.

BACKGROUND AND OBJECTIVES: To describe the distribution of body mass index (BMI) and its relationship with clinical features, management, and in-hospital outcomes of patients admitted with acute coronary syndromes (ACS). DESIGN AND SETTINGS: The Saudi Project for Assessment of Coronary Events is a prospective registry. ACS patients admitted to 17 hospitals from December 2005-2007 were included in this study. METHODS: BMI was available for 3469 patients (68.6%) admitted with ACS and categorized into 4 groups: normal weight, overweight, obese, and morbidly obese. RESULTS: Of patients admitted with ACS, 72% were either overweight or obese. A high prevalence of diabetes (57%), hypertension (56.6%), dyslipidemia (42%), and smoking (32.4%) was reported. Increasing BMI was significantly associated with diabetes, hypertension, and hyperlipidemia. Overweight and obese patients were significantly younger than the normal-weight group (P=.006). However, normal-weight patients were more likely to be smokers and had 3-vessel coronary artery disease, worse left ventricular dysfunction, and ST elevation myocardial infarction. Glycoprotein IIb-IIIa antagonists were used significantly more in overweight, obese, and morbidly obese ACS patients than in normal-weight patients (P≤.001). Coronary angiography and percutaneous intervention were reported more in overweight and obese patients than in normal-weight patients (P≤.001). In-hospital outcomes were not significantly different among the BMI categories. CONCLUSION: High BMI is prevalent among Saudi patients with ACS. BMI was not an independent factor for in-hospital outcomes. In contrast with previous reports, high BMI was not associated with improved outcomes, indicating the absence of obesity paradox observed in other studies.

Quality of care in primary percutaneous coronary intervention for acute ST-segment -elevation myocardial infarction: Gulf RACE 2 experience.

BACKGROUND AND OBJECTIVES: Primary percutaneous coronary intervention (pPCI) has been recognized as an effective management strategy for acute ST-segment-elevation myocardial infarction (STEMI). However, there is no first-hand information regarding the quality of pPCI procedures in the Arabian Gulf countries. This study aims to explore the quality of pPCI practice. DESIGN AND SETTINGS: The Gulf Race II was designed as a prospective, multinational, multicentre registry of acute coronary events, focusing on the epidemiology, management practices, and outcomes of patients with acute coronary syndrome. The study recruited consecutive patients aged 18 years and above from 65 hospitals in 6 adjacent Middle Eastern countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen). PATIENTS AND METHODS: We used data from the Gulf Registry of Acute Coronary Events (Gulf RACE 2). We analyzed data on patients who received pPCI to assess the guidelines-supported performance measure of door-to-balloon (D2B).

Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia.

BACKGROUND AND OBJECTIVES: Gender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored. DESIGN AND SETTINGS: A prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis. PATIENTS AND METHODS: Patients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed. RESULTS: Of 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given b-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7-5.5; P=.14). CONCLUSION: These data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Weekend versus weekday, morning versus evening admission in relationship to mortality in acute coronary syndrome patients in 6 middle eastern countries: results from gulf race 2 registry.

We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their management on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.

Impact of evidence-based cardiac medication on short- and long-term mortality in 7,567 acute coronary syndrome patients in the Gulf RACE-II registry.

OBJECTIVE: To evaluate the impact of evidence-based cardiac medications (EBMs) on 1-month and 1-year mortality among discharged acute coronary syndrome (ACS) patients in the Middle East. METHODS: Data were analyzed from 7,567 consecutive ACS patients admitted to 66 hospitals in 6 Middle Eastern countries enrolled in the Gulf RACE II in October 2008 to June 2009. Individual EBMs or concurrent use of the EBM combination consists of an anti-platelet therapy, angiotensin-converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker (ARB)), ß-blocker, and a statin at discharge, were evaluated. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The mean age of the cohort was 56 +/- 12 years with 79% being males. 65% of the patients received the concurrent EBM combination at discharge. Aspirin, clopidogrel, statins, b-blockers and ACEIs/ARBs use was 96%, 71%, 95%, 82% and 81%, respectively. 70% of the patients were prescribed both aspirin and clopidogrel concurrently at discharge. Adjusting for demographic, clinical, revascularization, and country characteristics, the multivariable logistic regression models demonstrated no differences in mortality at both 1-month (3.0 vs. 3.6%; p = 0.828) and 1-year (3.5 vs. 3.5%; p = 0.976) between the concurrent EBM combination users and non-users. CONCLUSION: The majority of the ACS patients in the Middle East were prescribed the guideline recommended EBM combination at discharge. However, potential still remains for further optimization of management. Further studies are required to examine the long term effect of concurrent use of the EBM combination on mortality in the region.