A Case-based Implementation of Heart Failure Therapies, a Consensus Pathway by the Saudi Heart Failure Working Group.

The implementation of guideline-directed medical therapy (GDMT) in heart failure (HF) has many challenges in real-world clinical practice. The consensus document is written considering the variability of the clinical presentation of HF patients. HF medical therapies need frequent dose adjustment during hospital admission or when patients develop electrolyte imbalance, acute kidney injury, and other acute illnesses. The paper describes clinical scenarios and graphs that will aid the managing physicians in decision-making for HF therapy optimization.

Clinical features, socioeconomic status, management, short and long-term outcomes of patients with acute myocardial infarction: Phase I results of PEACE MENA registry.

BACKGROUND: The Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa (PEACE MENA) is a prospective registry program in Arabian countries that involves in patients with acute myocardial infarction (AMI) or acute heart failure (AHF). METHODS: This prospective, multi-center, multi-country study is the first report of the baseline characteristics and outcomes of inpatients with AMI who were enrolled during the first 14-month recruitment phase. We report the clinical characteristics, socioeconomic, educational levels, and management, in-hospital, one month and one-year outcomes. RESULTS: Between April 2019 and June 2020, 1377 patients with AMI were enrolled (79.1% males) from 16 Arabian countries. The mean age (± SD) was 58 ± 12 years. Almost half of the population had a net income < $500/month, and 40% had limited education. Nearly half of the cohort had a history of diabetes mellitus, hypertension, or hypercholesterolemia; 53% had STEMI, and almost half (49.7%) underwent a primary percutaneous intervention (PCI) (lowest 4.5% and highest 100%). Thrombolytics were used by 36.2%. (Lowest 6.45% and highest (90.9%). No reperfusion occurred in 13.8% of patients (lowest was 0% and highest 72.7%).Primary PCI was performed less frequently in the lower income group vs. high income group (26.3% vs. 54.7%; P<0.001). Recurrent ischemia occurred more frequently in the low-income group (10.9% vs. 7%; P = 0.018). Re-admission occurred in 9% at 1 month and 30% at 1 year, whereas 1-month mortality was 0.7% and 1-year mortality 4.7%. CONCLUSION: In the MENA region, patients with AMI present at a young age and have a high burden of cardiac risk factors. Most of the patients in the registry have a low income and low educational status. There is heterogeneity among key performance indicators of AMI management among various Arabian countries.

The Gulf Achievement of Cholesterol Targets in Out-Patients Study (GULF ACTION): Design, Rationale, and Preliminary Results.

AIM: To assess the current dyslipidemia management in the Arabian Gulf region by describing the demographics, study design, and preliminary results of out-patients who achieved low-density lipoprotein cholesterol (LDL-C) goals at the time of the survey. BACKGROUND: The Arabian Gulf population is at high risk for atherosclerotic cardiovascular disease at younger ages. There is no up-to-date study regarding dyslipidemia management in this region, especially given the recent guideline-recommended LDL-C targets. OBJECTIVE: Up-to-date comprehensive assessment of the current dyslipidemia management in the Arabian Gulf region, particularly in view of the recent evidence of the additive beneficial effects of ezetimibe and proprotein convertase subtilisin/kexin-9 (PCSK-9) inhibitors on LDL-C levels and cardiovascular outcomes. METHODS: The Gulf Achievement of Cholesterol Targets in Out-Patients (GULF ACTION) is an ongoing national observational longitudinal registry of 3000 patients. In this study, adults ≥18 years on lipidlowering drugs for over three months from out-patients of five Gulf countries were enrolled between January 2020 and May 2022 with planned six-month and one-year follow-ups. RESULTS: Of the 1015 patients enrolled, 71% were male, aged 57.9±12 years. In addition, 68% had atherosclerotic cardiovascular disease (ASCVD), 25% of these patients achieved the LDL-C target, and 26% of the cohort were treated using combined lipid-lowering drugs, including statins. CONCLUSION: The preliminary results of this cohort revealed that only one-fourth of ASCVD patients achieved LDL-C targets. Therefore, GULF ACTION shall improve our understanding of current dyslipidemia management and "guideline gaps" in the Arabian Gulf region.

Clinical Features, Socioeconomic Status, Management, and Outcomes of Acute Heart Failure: PEACE MENA Registry Phase I Results.

INTRODUCTION: PEACE MENA (Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa) is a prospective registry in Arab countries for in-patients with acute myocardial infarction (AMI) or acute heart failure (AHF). Here, we report the baseline characteristics and outcomes of in-patients with AHF who were enrolled during the first 14 months of the recruitment phase. METHODS: A prospective, multi-centre, multi-country study including patients hospitalized with AHF was conducted. Clinical characteristics, echocardiogram, BNP (B-type natriuretic peptide), socioeconomic status, management, 1-month, and 1-year outcomes are reported. RESULTS: Between April 2019 and June 2020, a total of 1258 adults with AHF from 16 Arab countries were recruited. Their mean age was 63.3 (±15) years, 56.8% were men, 65% had monthly income ≤US$ 500, and 56% had limited education. Furthermore, 55% had diabetes mellitus, 67% had hypertension; 55% had HFrEF (heart failure with reduced ejection fraction), and 19% had HFpEF (heart failure with preserved ejection fraction). At 1 year, 3.6% had a heart failure-related device (0-22%) and 7.3% used an angiotensin receptor neprilysin inhibitor (0-43%). Mortality was 4.4% per 1 month and 11.77% per 1-year post-discharge. Compared with higher-income patients, lower-income patients had a higher 1-year total heart failure hospitalization rate (45.6 vs 29.9%, p=0.001), and the 1-year mortality difference was not statistically significant (13.2 vs 8.8%, p=0.059). CONCLUSION: Most of the patients with AHF in Arab countries had a high burden of cardiac risk factors, low income, and low education status with great heterogeneity in key performance indicators of AHF management among Arab countries.

A retrospective study of real-world effectiveness and safety of rivaroxaban in patients with non-valvular atrial fibrillation and venous thromboembolism in Saudi Arabia.

Background: Real-world evidence on factor Xa inhibitor (rivaroxaban) prescribing patterns, safety, and efficacy in patients with non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) is rare. Herein, we sought to examine the above outcomes in the largest academic center in the Kingdom of Saudi Arabia (KSA). Methods: This is a retrospective observational study designed to examine the prescribing pattern, safety and real-world effectiveness of the factor Xa inhibitor rivaroxaban in patients with NVAF and VTE. Data on rivaroxaban prescriptions were collected and analyzed. Bleeding outcomes were defined as per the International Society on Thrombosis and Hemostasis (ISTH) definition. Results: A total of 2,316 patients taking rivaroxaban recruited through several departments of King Saud University Medical City (KSUMC). The mean age was 61 years (±17.8) with 55% above the age of 60 and 58% were females. Deep vein thrombosis and pulmonary embolism (VTE) was the most prevalent reason for prescribing rivaroxaban, followed by NVAF. A total daily dosage of 15 mg was given to 23% of the patients. The incidence rate of recurrent thrombosis and recurrent stroke was 0.2%. Furthermore, rivaroxaban had a 0.04 percent incidence rate of myocardial infarction. Half of the patients with recurrent thrombosis and stroke were taking 15 mg per day. The incidence rate of major bleeding was 1.1%. More over half of the patients who experienced significant bleeding were taking rivaroxaban at a dosage of 20 mg per day. According to the HAS-BLED Score (>2 score), 48 percent of patients who experienced significant bleeding had a high risk of bleeding. Non-major bleeding occurred in 0.6% of cases. Similarly, 40% of patients with non-major bleeding were taking rivaroxaban at a dosage of 20 mg per day. According to the HAS-BLED Score, just 6.6% of these individuals had a high risk of bleeding. 93.4% of the patients, on the other hand, were at intermediate risk. Conclusion: The prescription of rivaroxaban in this real-life cohort study differs from the prescribing label and the outcomes of a phase 3 randomised clinical trial. However, for individuals with VTE and NVAF, the 20 mg dose looked to be more efficacious than the pivotal trial outcomes. Furthermore, among patients with VTE and NVAF, rivaroxaban was linked to a decreased incidence of safety events such as recurrent thrombosis, recurrent stroke, MI, major bleeding, and non-major haemorrhage in a real-world environment.

Using tissue mitral valves in younger patients: A word of caution.

BACKGROUND: The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral valve replacement (MVR) using tissue versus mechanical valves. METHODS: This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151). RESULTS: There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow-up was 84 months (Q1: Q3: 38-139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49). CONCLUSIONS: Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups.

The Safety and Efficacy of Low-Molecular-Weight Heparin in Pregnant Women With Rheumatic Heart Disease and Valves Replacement.

BACKGROUND: In patients with rheumatic heart disease (RHD) and prosthetic valve replacement, the risk of thromboembolic complications is the highest during and immediately after pregnancy. Therapeutic anticoagulation during this period is crucial to minimize the risk of thromboembolic complications. The use of low-molecular-weight heparin (LMWH) remains an off-label indication. The type of anticoagulants used, dosing regimens, target anti-Xa levels, and frequency of anti-Xa monitoring are highly variable in the pregnant population and have been derived from pilots, observational studies, and empirical evidence. Herein, in a real-world setting, we sought to examine the efficacy and safety of variable anticoagulation options with a focus on LMWH in the management of RHD-related valvular disease in pregnant women. METHODS: This study is a retrospective study conducted at a large university-affiliated tertiary care center (King Saud University Medical City) between January 2011 and February 2020. All pregnant women with RHD who had heart valve replacements were reviewed. Patient data were extracted for demographic information, baseline characteristics, anticoagulation type, and primary outcomes. Primary endpoints were thromboembolic events, hemorrhagic complications, and fetal outcomes. RESULTS: A total of 744 pregnancies in 149 women were identified. The mean age ± SD of the women was 43.8 ± 12 years. A total of 86 women (58%) were on the LMWH regimen, 35 women (23%) were on LMWH and warfarin regimen, and 28 women (19%) were on unfractionated heparin (UFH) and warfarin regimen. Overall, thromboembolic events developed in five (0.7%) pregnancies. Of those, two were in the LMWH group, two were in the LMWH and warfarin group, and one was in the UFH and warfarin group. In addition, significant hemorrhagic complications occurred in five pregnancies. Of these, two occurred in the LMWH group, two in the LMWH and warfarin group, and one in the UFH and warfarin group. No adverse maternal and fetal outcomes were noted. CONCLUSION: This study presents the largest retrospective study of variable anticoagulation options in pregnant women with RHD and prosthetic valve replacement. LMWH is both safe and effective in preventing major thromboembolic complications compared to other forms of anticoagulation used during pregnancy.

Hemostatic profile detailing in apparent VWD cases: A cross sectional study.

The von willebrand disease (vWD) accounts to be one of the most common hereditary bleeding ailment that amounts its incidence to almost 1.5% of normal population. It is mostly associated with a defect in primary hemostasis as well as secondary defect in coagulation factor VIII as diagnosis of vwd happened to be challenging with earlier diagnostic criteria's. Testing Vwd in menorrhagia patients was not at ease. A cross-sectional study was conducted in female patients who have visited obstetrics and gynecology clinic at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia. The inclusion criteria consist of adult female patients between 16 and 45 years old with menorrhagia. A sample of 45 patients were screened and selected for the above-mentioned study. The SPSS Statistical analysis package was performed to analyze the data's. The fisher's exact test was conducted to compare the demographic variables. The independent samples t-test was conducted to compare the means of subjects. The P value of ≤0.05 considered as statistically significant. The cases manifested with a history of bleeding during periods stretching from 7 to 90 days. The vWD was reported in 6.6 % (n = 3) women out of the total 45 patients. The vWF: Ac mean ± SD (51.4 ± 6.3) and vWF: Ag Mean ± SD (93 ± 67) were significantly lesser in vWD patients with that of non-vWD (98.7 ± 22.6) vs (116 ± 42.4) (p = 0.027) (p = 0.032) respectively. WBC, ESR, MCV, MCH, Hemoglobin, PLT count, INR, PT, APTT and FVIII showed no significant difference among the groups (p > 0.05).

Circadian Rhythm and ST-Segment Elevation Myocardial Infarction: Insights From the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps).

Circadian rhythms have been identified in multiple physiological processes that may affect cardiovascular diseases, yet little is known about the impact of circadian rhythm on acute ST-segment elevation myocardial infarction (STEMI) onset and outcomes in the Middle East. The relationship between time of symptom onset during the 24-hour circadian cycle and prehospital delays and in-hospital death was assessed in 2909 patients with STEMI presenting in 6 Arabian Gulf countries. A sinusoidal smoothing function was used to show the average circadian trends. There was a significant association between time of symptom onset and the circadian cycle. The STEMIs were more frequent during the late morning and early afternoon hours ( P < .001). Patients with pain onset from 0.00 to 5:59 had median prehospital delays of 150 minutes versus 90 minutes from 6:00 to 11:59 and 12:00 to 17:59, respectively ( P < .001). Although there was no significant difference in mortality between the 4 groups ( P = .230), there was a significant association between time of symptom onset as sinusoidal function and in-hospital mortality ( P = .032). Patients with STEMI in the Middle East have significant circadian patterns in symptoms onset, prehospital delay, and timeliness of reperfusion. A circadian rhythm of in-hospital mortality was found over the 24-hour clock of symptom onset time.

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.

Clinical Presentation, Predictors, and Outcomes Among Mineralocorticoid Receptor Antagonist (MRA)-Eligible Acute Heart Failure Patients in the Heart Function Assessment Registry Trial in Saudi Arabia (HEARTS).

Mineralocorticoid receptor antagonist (MRA) therapy is indicated after myocardial infarction in patients with acute heart failure (AHF) with an ejection fraction ≤40% and lacking contraindications. We analyzed clinical presentations, predictors, and outcomes of MRA-eligible patients within a prospective registry of patients with AHF from 18 hospitals in Saudi Arabia, from 2009 to 2010. For this subgroup, mortality rates were followed until 2013, and the clinical characteristics, management, predictors, and outcomes were compared between MRA-treated and non-MRA-treated patients. Of 2609 patients with AHF, 387 (14.8%) were MRA eligible, of which 146 (37.7%) were prescribed MRAs. Compared with non-MRA-treated patients, those prescribed MRAs more commonly exhibited non-ST-segment elevation myocardial infarction, acute on chronic heart failure, past history of ischemic heart disease, and severe left ventricular systolic dysfunction; were more commonly administered oral furosemide and digoxin; and had higher in-hospital recurrent congestive HF rates. Mortality did not significantly differ ( P > .05) between groups. In Saudi Arabia, 37.7% of eligible patients received MRA treatment, which is higher than that in developed countries. The lack of long-term survival benefit raises concerns about systematic problems, for example, proper follow-up and management after hospital discharge, warranting further investigation.

Atrial Fibrillation in Patients Hospitalized With Heart Failure: Patient Characteristics and Outcomes From the HEARTS Registry.

Effect of atrial fibrillation (AF) on short- and long-term outcomes in heart failure (HF) is controversial. Accordingly, we examined this relationship in a national multicenter project using data from the Hearts Function Assessment Registry Trial in Saudi Arabia that studied the clinical features and outcomes of patients admitted with de novo and acute on chronic HF. Out of 2593 patients with HF, 449 (17.8%) had AF at presentation. Patients with AF were more likely to be males and older (mean age 65.2 ± 15.0 vs 60.5 ± 14.8 years) to have a history of ventricular tachycardia/ventricular fibrillation (3.1% vs 1.9%) or cerebrovascular accident (15.0% vs 8.5%). However, they were less likely to have diabetes (66.0% vs 55.9%) or coronary artery disease (55.6% vs 42.3%). The 1-, 2-, and 3-year crude mortality rates were significantly higher in patients with AF (23.2% vs 18.3%, 27.4% vs 22.3%, and 27.8% vs 23.2%, respectively). However, there was no significant difference in mortality after adjusting for covariates. Thus, in patients admitted with HF, AF upon presentation was not associated with increased mortality.

Clinical characteristics, management and outcomes of patients with chronic heart failure: Results from the heart function assessment registry trial in Saudi Arabia (HEARTS-chronic).

BACKGROUND: Several registries have described patients hospitalized with heart failure (HF), but only few looked at outpatients in the ambulatory setting mostly without long-term follow-up. We sought to determine the clinical characteristics, management, and 1-year outcomes of patients with chronic HF in Saudi Arabia. METHODS: Part of a prospective multicenter nationwide registry; HEart function Assessment Registry Trial in Saudi Arabia (HEARTS) and included chronic HF patients referred to four HFCs between September 2009 and December 2011. RESULTS: We enrolled 685 patients with mean age 55.66±15.97years, 70.1% were men and 96.1% were Saudis. The main etiologies of HF were CAD (38.8%), dilated cardiomyopathy (36.5%), and hypertension (10.5%). Severe left ventricular dysfunction was present in 70.6% and median NT-proBNP was 2934.37pg/ml. The prescription rates of evidence based therapies (EBTs) before admission to HFC, at discharge from 1st clinic visit, and at 1-year follow up were 90%, 91% and 94% for beta-blockers, 79%, 80%, and 86% for ACEi/ARBs and 44%, 45%, and 42% for aldosterone antagonists; respectively. ICD was inserted in 21.9% and CRT in 6.6% at enrollment and increased to 29.1% and 8.8% after one year respectively. The all-cause mortality rate at 1year was 9% and 93.7% of which was cardiac-related. The all-cause one-year hospitalization rate was 39% and the total emergency room visit rate was 50%. CONCLUSIONS: Chronic HF patients in Saudi Arabia are younger, commonly have severe LV systolic dysfunction and have relatively high annual mortality and re-hospitalization rates.

Repeated Monitoring With Transthoracic Echocardiography and Lung Ultrasound After Cardiac Surgery: Feasibility and Impact on Diagnosis.

OBJECTIVES: Cardiorespiratory complications are common after cardiac surgery and current monitors used to diagnose these are invasive and have limitations. Transthoracic echocardiography and lung ultrasound are noninvasive and frequently improve diagnosis in critically ill patients but have not been reported for routine postoperative monitoring after coronary, valve, and aortic surgery. The aim was to determine whether both repeated postoperative transthoracic echocardiography and lung ultrasound revealed or excluded clinically important cardiac and respiratory disorders compared to conventional monitoring and chest x-ray. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: Ninety-one patients aged older than 18 undergoing cardiac surgery INTERVENTIONS: Postoperative clinical patient assessment for significant cardiac and respiratory disorders by the treating physician was recorded at 3 time points (day after surgery, after extubation and removal of chest drains and at discharge) using conventional monitoring and chest x-ray. After each assessment, transthoracic echocardiography and lung ultrasound were performed, and differences in diagnosis from conventional assessment were recorded. MEASUREMENTS AND MAIN RESULTS: Transthoracic echocardiography was interpretable in at least 1 echocardiographic window in 99% of examinations. Transthoracic echocardiography and/or lung ultrasound changed the diagnosis of important cardiac and/or respiratory disorders in 61 patients (67%). New cardiac findings included cardiac dysfunction (38 patients), pericardial effusion (5), mitral regurgitation (2), and hypovolemia (1). New respiratory findings included pleural effusion (30), pneumothorax (4), alveolar interstitial syndrome (3) and consolidation (1). CONCLUSIONS: Routine repeated monitoring with cardiac and lung ultrasound after cardiac surgery is feasible and frequently alters diagnosis of clinically important cardiac and respiratory pathology.

A large Right atrial mass in a patient with hepatocellular carcinoma: Case report and literature review.

BACKGROUND: Hepatocellular carcinoma (HCC) is a common malignancy and the most frequent sites of metastasis include lungs, bone, lymphatic, and brain, however, Intra-cardiac involvement rarely develops in patients with HCC and it has poor prognosis. The clinical course may be complicated by many fatal cardiovascular complications. Absence of cardiac symptoms, however, is an unusual condition. CASE REPORT: We reported a rare case of hepatocellular carcinoma with large invasion into the right atrium and no cardiac symptoms. CONCLUSION: Cardiac metastases occur in 10% of all cancer patients. Heart involvement should be suspected in all patients.

Clinical features, management, and short- and long-term outcomes of patients with acute decompensated heart failure: phase I results of the HEARTS database.

AIMS: The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS) is a national multicentre project, studying clinical features, management, short- and long-term outcomes, and mortality predictors in patients admitted with acute decompensated heart failure (ADHF). METHODS AND RESULTS: Our prospective registry enrolled 2610 ADHF patients admitted to 18 hospitals in Saudi Arabia between October 2009 and December 2010, and followed mortality rates until January 2013. The patients included 66% men and 85.5% Saudis, with a median age (interquartile range) of 61.4 (15) years; 64% had acute on chronic heart failure (HF), 64.1% diabetes mellitus, 70.6% hypertension, and 55.7% CAD. Exacerbating factors for hospital admission included acute coronary syndromes (37.8%), infections (20.6%), non-compliance with low-salt diet (25.2%), and non-compliance with HF medications (20%). An LVEF<40% was found in 73%. In-hospital use of evidence-based medications was high. All-cause cumulative mortality rates at 30 days, 6 months, 1 year, 2 years, and 3 years were 8.3, 13.7, 19.5, 23.5, and 24.3%, respectively. Important independent predictors of mortality were history of stroke, acute on chronic HF, systolic blood pressure<90 mmHg upon presentation, estimated glomerular filtration rate<60 mL/min, and haemoglobin<10 g/dL. CONCLUSION: Patients with ADHF in Saudi Arabia presented at a younger age and had higher rates of CAD risk factors compared with those in developed countries. Most patients had reduced LV systolic function, mostly due to ischaemic aetiology, and had poor long-term prognosis. These findings indicate a need for nationwide primary prevention and HF disease management programmes.

Primary pulmonary hypertension during pregnancy: A case report.

We describe a case of a 25-year-old pregnant woman who presented with severe primary pulmonary hypertension (PPH). Her echocardiogram showed severe right ventricular hypertrophy with dilatation and Moderate right ventricular systolic dysfunction. Right ventricle systolic pressure (RVSP) was estimated to be 125 mmHg. She had an elective caesarean section under general anaesthesia at 32 weeks of gestation. Pulmonary artery pressures measured by a pulmonary artery catheter before anaesthesia were 102 mmHg and pulmonary vascular resistance was 429. Intraoperative nitric oxide was used to reduce pulmonary artery systolic pressure (PASP). After the delivery of a healthy infant, PASP was controlled with nebulized iloprost and silandifil. Five days later she was transferred from intensive care unit after she was started on silandifil 50 mg three times daily and a small dose of warfarin.

Prevalence and prognosis of congestive heart failure in Saudi patients admitted with acute coronary syndrome (from SPACE registry).

OBJECTIVES: The aim of this study was to assess the prevalence, clinical features, and in-hospital outcomes of heart failure in patients with acute coronary syndrome (ACS). MATERIALS AND METHODS: The Saudi Project for Assessment of Coronary Events recruited patients admitted with ACS from 17 hospitals in Saudi Arabia from 2005 to 2007. The outcomes of ACS patients with congestive heart failure (CHF) compared with those without CHF were analyzed. RESULTS: A total of 4523 patients with ACS were identified, of whom 905 (20%) had CHF. Compared with no CHF, patients with CHF were older (62±13.1 vs. 57±12.9 years; P=0.001), less likely to be men (70 vs. 79%; P=0.001), likely to present with non-ST-segment elevation myocardial infarction (48 vs. 36%; P=0.001), likely to have diabetes (71 vs. 54%; P=0.001), hypertension (64 vs. 54%; P=0.001) and previous history of coronary artery disease (53 vs. 43%; P=0.001), and likely to have significant left ventricular systolic dysfunction (left ventricular ejection fraction <35%) (56 vs. 30%; P=0.001). Patients with CHF were less likely to receive in-hospital ß-blockers (74 vs. 86%; P=0.001) and a percutaneous coronary intervention (19 vs. 50%; P=0.001). Adjusted in-hospital mortality and cardiogenic shock were higher in the CHF group (odds ratio 4.43, 95% confidence interval 2.52-7.78; and odds ratio 3.51, 95% confidence interval 2.23-5.52), respectively. CONCLUSION: ACS patients with CHF in the Saudi Project for Assessment of Coronary Events were older, more likely to have more cardiac risk factors, and less likely to be treated with optimum medical treatment on admission. These findings were associated with higher incidence of their in-hospital adverse outcomes. More aggressive treatment is warranted to improve prognosis.

Bentall procedure for an adult patient with supravalvular aortic stenosis and coronary aneurysms.

We describe the surgical management of a 35-year-old male with multiple coronary aneurysms and a diffuse form of supravalvular aortic stenosis who presented with acute myocardial infarction and left ventricular dysfunction. The patient underwent a Bentall procedure with left internal mammary artery to left anterior descending artery bypass grafting with the use of cardiopulmonary bypass utilizing the right axillary artery for arterial cannulation.

Design and preliminary results of the heart function assessment registry trial in Saudi Arabia (HEARTS) in patients with acute and chronic heart failure.

AIMS: The heart function assessment registry trial in Saudi Arabia (HEARTS) is the first multicentre national quality improvement initiative in the Arab population to study the clinical features, management, and outcomes of inpatients admitted with acute heart failure (AHF) and outpatients with high-risk chronic heart failure (HCHF). METHODS AND RESULTS: We conducted a prospective pilot phase for the registry that included consecutive patients with AHF and HCHF in five tertiary care hospitals in Saudi Arabia between October 2009 and December 2010. The study enrolled 1090 patients, 722 (66.2%) of whom were admitted with AHF and 368 (33.8%) had HCHF. The mean age ± SD of AHF patients was 60.6 ± 15.3 years; 65.2% were men, 55.3% were de novo heart failure, 60.7% had diabetes mellitus, 72.5% had moderate or severe left ventricular (LV) systolic dysfunction, and 51.5% had coronary artery disease as the main aetiology. More than 80% of AHF and HCHF patients were treated with beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Patients with HCHF had a similar clinical profile, but only one-third had implantable cardioverter defibrillators. In-hospital mortality was 5.3% for AHF patients and 7.5% at 30 days after hospital discharge. CONCLUSION: Heart failure patients in Saudi Arabia present at a relatively younger age, have a much higher rate of diabetes mellitus, and predominantly have LV systolic dysfunction, which is mainly ischaemic in origin, compared with patients in developed countries. The preliminary results of the study show potential targets for improvement in care.