Challenges in Clinical Research in Low and Middle Income Countries: Early Career Cardiologists' Perspective.

Despite a growing burden of cardiovascular diseases (CVDs) in Low and Middle Income Countries (LMICs), there remain significant barriers to researchers living in these countries regarding the initiation, progression and completion of research. These obstacles are multifactorial, ranging from a lack of general incentives, national and institutional initiatives and capacity, limited opportunities for funding, and lack of mentorship and support for the presentation and publication of research. In this perspective piece, we highlight some of the challenges we have observed from our experience as early career cardiologists in LMICs and present some potential solutions to address these issues.

Impact of Earthquake on Cardiovascular Health: What Should Cardiovascular Healthcare Providers Anticipate After the Devastating Earthquakes in Turkey and Syria?

Natural disasters like earthquakes have direct and indirect association with major adverse cardiac events. They can impact cardiovascular health by multiple mechanisms not to mention their impact on cardiovascular care and services. Besides the humanitarian tragedy that calls attention globally, we as part of cardiovascular community are concerned with the short and long outcomes of those who survived the recent Turkey and Syria earthquake tragedy. Therefore, in this review, we aimed to draw attention of cardiovascular healthcare providers to the anticipated cardiovascular issues that may arise in survivors on short- and long-term postearthquakes to ensure proper screening and earlier management of this population. With the anticipated increase in natural disasters in future considering climate changes, geological factors, and human activities, the cardiovascular healthcare providers as part of medical community should be aware of the high rate of cardiovascular disease burden that can occur among survivors of earthquakes and other natural disasters, so, they should act accordingly in terms of preparedness measures, adequate response planning starting from services re-allocation to personnel training and enhancing access to medical and cardiac care in both acute and chronic contexts, not to mention screening and risk-stratifying the patients to optimize their management.

Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq.

BACKGROUND: Risk stratification is the cornerstone in managing patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS) and can attenuate the unjustified variability in treatment and guide the intervention decision notwithstanding its impact on better healthcare resources use. This study sought to disclose real adherence to guidelines in risk stratification of NSTE-ACS patients and in adopting intervention decision in practice. METHODS: Multicentre prospective study recruited NSTE-ACS patients. Baseline characteristics were collected, TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores were calculated, management strategy as well as timing to intervention were recorded. RESULTS: n. = 150, 72% of them were males, mean age was (59 ± 12.32) years. TIMI score was calculated in 5.3% of patients with none of them had GRACE score calculated. Invasive strategy was adopted in 85.24 and 82.7% of low GRACE and TIMI risk categories respectively, while invasive approach used in 42.85 and 40% of high GRACE and TIMI risk categories respectively. The immediate intervention in less than 2 hours was more to be used in low-risk categories while the high-risk and very high-risk patients whom were managed invasively were catheterized within >72 h; or more frequently to be non-catheterized at all. Sixty percent of those with acute heart failure, 80.76% of those with ongoing chest pain, 85% of those with dynamic ST changes same as 80% of those with cardiogenic shock were treated conservatively. Using multivariable analysis older age, ongoing chest pain and cardiogenic shock predicted conservative approach. CONCLUSIONS: There is striking underuse of risk scores in practice that can contribute to treatment-risk paradox in managing NSTE-ACS in form of depriving those with higher risk from invasive strategy despite being the most beneficiaries. The paradox did not only involve the very high-risk patients but also the very high-risk criteria like ongoing chest pain and cardiogenic shock predicted conservative approach, this highlights that the entire approach to patients with NSTE-ACS should be reconsidered, regardless of the use of risk scores in clinical practice. Audit programs activation in middle eastern countries can inform policymakers to put a limit to the treatment-risk paradox for better cardiovascular care and outcomes.

Non-ST elevation acute coronary syndromes; clinical landscape, management strategy and in-hospital outcomes: an age perspective.

BACKGROUND: As the elderly represent a substantial proportion of medical care beneficiaries, and there is limited data about age disparity in emerging countries, this study sought to investigate the impact of age on the management in patients with non-ST elevation acute coronary syndromes (NSTE-ACS). RESULTS: Two hundred patients with NSTE-ACS enrolled prospectively, patients' data, pharmacotherapy, management strategy as well timing to catheterization were documented. Patients grouped into ≥ 65 years versus < 65 years; 32.5% were ≥ 65-year-old. The older group presented as high GRACE risk (Global Registry of Acute Coronary Events) (67.7% versus 15.6%). Elderly patients were less likely to be referred for catheterization compared with younger counterparts (55.4% versus 76.3%, p = 0.003). Within low risk class patients, none of the elderly versus 9.33% of younger patients were catheterized within 2 h; in the same line, none of the elderly versus 16% of younger patients were catheterized within 24 h. Alternatively, at high risk class, 6.81% of the elderly and none of the younger patients were catheterized within 2 h. On the univariate analysis of variables to predict invasive strategy, presence of history of prior IHD, diabetes, absent in-hospital acute heart failure or atrial fibrillation/flutter, higher haemoglobin and lower creatinine levels predicted the use of invasive strategy, while on multivariate analysis, acute heart failure (95% CI - 0.38 to - 0.41, p = 0.01), lower haemoglobin (95% CI 0.002-0.07, p = 0.03), and atrial fibrillation/flutter (95% CI - 0.48 to - 0.02, p = 0.03) predicted conservative strategy. The elderly were more likely to have acute heart failure (32.3% versus 14.8%, p = 0.004), same as stroke (3.1% versus none, p = 0.04). CONCLUSIONS: Less-invasive strategy used in the elderly with NSTE-ACS compared with younger counterparts, yet age was not a predictor of catheterization underuse on multivariate analysis. It is crucial to bridge the age gap in the healthcare system in setting of ACS management by grasping the attention of decision makers and emphasizing on the adherence of healthcare providers to the guidelines to improve cardiovascular care and outcomes.

Impact of COVID-19 on global diversity in scientific contributions in American cardiology meetings: Geographical and economic perspectives.

Objective: To determine the global diversity in geographical and economic class of countries contributed to group of American cardiology meetings in 2019 and 2020 (prior to and during COVID-19 pandemic). Methods: Cross sectional recording of contributing authors' countries for abstracts of three American College of Cardiology Congress (ACC), Heart Failure Society of America meeting (HFSA) and Transcatheter Cardiovascular Therapeutics (TCT) meeting. Analysis of these contributions according to continent and World Bank Class of the contributing countries was done. Results: total 10,609 contributions from 95 countries were analysed. After excluding US, Asia had the highest contribution to ACC meetings in 2019 (45.44%) and 2020 (42.63%), p = 0.0002, while Europe had the highest contributions to both HFSA (58.78% in 2019 and 47.42% in 2020), p = 0.07 and TCT (63.25% in 2019 and 55.86% in 2020), p = 0.0002. Middle income countries (MIC) contributions increased from 14.96%, 10.02%, 6.06% in 2019 (pre COVID19) to 19.29%, 19.34%, 17.52% in 2020 (COVID19 era) in ACC, HFSA and TCT respectively. Conclusion: Researchers from low- and middle-income countries are under-represented in high impact American cardiology meetings with higher contributions in COVID-19 era. It is pivotal to enhance collaboration with them to reflect the real solidarity for which we are calling during and beyond the pandemic.

Women in cardiology: critical status and a call to move forward.

BACKGROUND: Healthcare workforce should mirror the population in representing patients' diversity; however, in certain medical specialties like cardiology, there is a significant under-representation of females in fellowship programs. There is limited data discussing this issue in the Middle East, and up to our knowledge, no prior literature has cast a light on this subject in Iraq. MAIN TEXT: Women represent not a minority but rather a negligible proportion of cardiologists in the Middle East, in general, and in Iraq, in particular, as over two decades, recruiting females in cardiology training never progressed. Women are facing many challenges that explain this gender gap, mainly work-life balance and risk of exposure to radiation in addition to society's perceptions in the Middle East that underestimate women in interventional specialties. CONCLUSIONS: Serious efforts and forward steps should be taken by decision makers in cardiology fellowship programs and national cardiology societies to bridge this gender gap in order to improve cardiovascular care for both genders regardless of social barriers and traditional customs and to offer more access of care to those female patients who wish to be treated by female doctors based on their personal convictions.