Clinical Presentations and Outcomes in Patients Presenting With Acute Cardiac Events and Right Bundle Branch Block.

We conducted a retrospective analysis of 50 974 patients admitted with acute cardiac events with and without right bundle branch block (RBBB) over 23 years. Compared to non-RBBB, patients with RBBB (n = 386; 0.8%) were 3 years older (P = .001), more likely to present with breathlessness rather than chest pain (P = .001), and had more diabetes mellitus (P = .001). Patients with RBBB had significantly higher cardiac enzymes (P = .001); however, there were no significant differences in the presentation with ST-segment elevation myocardial infarction (24.6% vs 22.2%), non-ST-segment elevation myocardial infarction (23.7% vs 22.4%), and unstable angina (51.7% vs 55.4%). Patients with RBBB were more likely to have congestive heart failure (CHF; 9.6% vs 3.2%, P = .001), cardiogenic shock (10.6% vs 1.7%, P = .001), and ventricular tachyarrhythmias (7.3% vs 2.2%, P = .001). Left ventricular ejection fraction and hospital length of stay were comparable between the groups. All-cause mortality was 5 times greater in patients with RBBB (21% vs 4.2%, P = .001). Right bundle branch block was independent predictor of mortality (adjusted odd ratio 5.14; 95% confidence interval: 3.90-6.70). Subanalysis comparing normal QRS, RBBB, and left BBB showed that RBBB was associated with the worst outcomes except for CHF. Although RBBB presents in only about 1% of patients with cardiac disease, it was found to be an independent predictor of hospital mortality.

Left Bundle Branch Block in Acute Cardiac Events: Insights From a 23-Year Registry.

Between 1991 and 2013, we evaluated the demographics, presentations, and final diagnosis of patients hospitalized with acute cardiac events and left bundle branch block (LBBB). Of 50 992 patients, 768 (1.5%) had LBBB. Compared with non-LBBB patients, patients with LBBB were mostly older, female, diabetic, and had hypertension and chronic kidney failure (CKF; P < .001 for all). Dyspnea (P < .001) and dizziness (P = .037) were more frequent in patients with LBBB. The most frequent cause of admission with LBBB was congestive heart failure (CHF; 54.2%), followed by ST-elevation myocardial infarction (STEMI; 13.3%), valvular heart disease (9.4%), unstable angina (8.3%) and Non-STEMI (7.7%). On multivariate analysis, CKF (odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.09-3.70) and LBBB (OR: 2.96, 95% CI: 2.01-4.42) were predictors of in-hospital mortality in the entire study population. Further analysis of patients with LBBB showed that CKF (OR: 2.93, 95% CI: 1.40-6.12) was the only predictor of in-hospital mortality. Regardless the presenting symptoms, CHF was the final diagnosis in most cases with LBBB.

The influence of female gender on cardiac arrest outcomes: a systematic review of the literature.

BACKGROUND: Sudden cardiac arrest is an important cause of cardiovascular mortality. The impact of gender on the outcome of cardiac arrest is not clear and data about that is limited. OBJECTIVE: Understanding the influence of gender on cardiac arrest through a systematic review of the published literature. METHODS: A search of all published studies in English between January 1970 and May 2013 was performed using the electronic databases PubMed and MEDLINE, using the key words 'cardiac arrest', 'outcome', and 'gender'. RESULTS: Eleven studies were included in this review, all of which were observational studies conducted using national-based database registries of cardiac arrest. A total of 548,440 patients were enrolled in these studies with 220,646 (40.3%) of them being female patients. In general, there was a lower percentage of women in the reported studies compared to men. Women were older in age and more likely to have non-shockable rhythms as the initial rhythm. Women also had a lower rate of witnessed arrest, a lower rate of bystander resuscitation, a higher rate of survival until hospital admission and a lower rate of in-hospital survival compared to men. Women also had a more favorable one month survival and neurological outcome. CONCLUSION: In the reported literature female gender seems to offer survival and outcome advantages following out-of-hospital cardiac arrest over male gender. This is in contrast to most other aspects of heart disease in which women tend to have a worse prognosis.

Association of risk factors with acute myocardial infarction in Middle Eastern countries: the INTERHEART Middle East study.

BACKGROUND AND OBJECTIVES: Mortality from cardiovascular disease in the Middle East (ME) is projected to increase substantially by 2020. There are no large studies on the impact of risk factors for acute myocardial infarction (AMI) in the region. This is a report on the association of nine risk factors with AMI in the ME. METHODS AND RESULTS: As part of the INTERHEART (IH) study, we enrolled 1364 cases of first AMI and 1525 matching controls from eight ME countries. The age at first AMI was 51.2 ± 10.3 years, which is the youngest, and with the largest proportion of patients <40 years in the entire IH population. The overall population attributable risk (PAR) of the nine risk factors to AMI was higher in the ME (97.5%) than worldwide (90.4%). Elevated apolipoprotein (Apo)B/ApoA1 had the strongest association with AMI, with odds ratio (OR) of 3.43 and PAR of 57.1%, followed by smoking (OR 3.63 and PAR 45.6%). ApoB/ApoA1 had greater association than the conventional low-density lipoprotein (LDL)/high-density lipoprotein (HDL) cholesterol ratio. Both diabetes (OR 3.42, PAR 16.4%) and hypertension (OR 1.89, PAR 10.7%) had greater association with AMI in women than men. Abdominal obesity (OR 2.12, PAR 26.1%) and depression (OR 1.97, PAR 45.3%), but not conventional BMI, were significantly associated with AMI (p < 0.0001). CONCLUSION: This is the largest prospective population study of risk factors associated with AMI in the ME. AMI occurs at younger age in the ME than all other regions. The PAR for the nine risk factors was higher in the ME (97.5%) than the rest of the world. These findings should guide serious prevention strategies.

NIAMI: Towards the optimization of results in primary PCI.

The NAIMI trial has recently been published. It assessed one of the most contemporary and challenging issues in the management of acute myocardial infarction (AMI), namely prevention of reperfusion injury (RPI) after primary PCI for ST-elevation myocardial infarction (STEMI). It investigated the effect of the intravenous administration of Na nitrite given immediately prior to primary PCI for STEMI in 229 patients (118 in the treatment group, and 111 in placebo). The myocardial infarction (MI) size did not differ between the two groups as observed by cardiac MRI (CMR) with gadolinium enhancement at 6-8 days or plasma Troponin-I and creatine kinase (CK), or by left ventricular (LV) volume and ejection fraction (EF) as measured by echocardiography at 6-8 days and again at 6 months. They concluded that IV nitrites did not reduce the infarct size. There was, however, a trend towards benefit in diabetic patients in the post-hoc analysis. The small number of these subjects has probably lead to inconclusive outcome in this subset.

Sudden cardiac death in athletes: where do we stand.

We aimed to review the literature to explore the magnitude of sudden cardiac death (SCD) in young athletes. Although SCD in athletes is not a common event, it represents a tragedy of the apparently fit young population. SCD varies according to countries, age groups, and sex. In addition, it varies in the underlying causes and the screening tool. Therefore, we are in need for further research efforts. Guidelines, public and physician awareness, and education regarding the warning signs are integral part in the strategy to reduce SCD tragedy. However, all these requirements raise concern for cost-effectiveness in some countries for proper implementation.

Atrial fibrillation in Middle Eastern Arab and South Asian patients hospitalized with acute myocardial infarction: experience from a 20-year registry in qatar (1991-2010).

BACKGROUND: Recent evidence suggests that there are ethnic variations in atrial fibrillation (AF) susceptibility and incidence following acute myocardial infarction (AMI). OBJECTIVES: The aim of this study was to evaluate the incidence and predictors of AF in the setting of AMI in Middle Eastern Arab and South Asian patients and its impact on in-hospital morbidity and mortality. METHODS: A retrospective analysis of a prospective registry of all patients hospitalized with AMI in the state of Qatar from 1991 through 2010 was made. Clinical characteristics and outcomes of AMI patients with and without AF were compared. Sub-analysis according to ethnicity was also performed. RESULTS: During the 20-year period; a total of 12,881 patients were hospitalized with AMI. Of these 5028 were Arabs and 5985 were South Asians. A total of 227 had AF during hospitalization with an overall incidence of 1.8% (156 Arabs; incidence 3.1% and 48 South Asians; incidence 0.8%). The mean age of AF patients was 65 years (Arabs 69, South Asians 54). Patients with AF were significantly older and had more cardiovascular co-morbidities than patients without AF, and were more likely to have non-ST elevation AMI on presentation. Patients with AF had significantly higher in-hospital mortality rate (20.3% versus 7.1%; P=0.001) and stroke rates (1.8% versus 0.3%; P=0.001) when compared to patients without AF. Age was the only independent predictor of AF development in patients with AMI in our study. CONCLUSIONS: Our study reports variability in the prevalence of AF among AMI patients according to ethnicity using a 20-year registry from a Middle Eastern country. Advancing age was the major independent predictor of AF in our AMI patients. Further prospective studies are required evaluating optimal therapeutic approaches for these high-risk patients in order to reduce the high mortality observed.

The prevalence of metabolic syndrome components, individually and in combination, in male patients admitted with acute coronary syndrome, without previous diagnosis of diabetes mellitus.

BACKGROUND: Mortality from cardiovascular disease in the Middle East is projected to increase substantially in the coming decades. The prevalence of metabolic syndrome (MS) in acute coronary syndrome (ACS) continues to raise interest, but data from the Middle East is limited, especially in non-diabetic patients. This study was conducted to ascertain the prevalence of MS and frequency of its components, individually and in combination, in a male population presenting with ACS, but without a previous diagnosis of diabetes mellitus (DM). METHODS: This is a prospective study of 467 consecutive male patients hospitalized for ACS. They were categorized according to the specific criteria stated in the latest joint statement for the global definition of MS. RESULTS: The mean age was (49.7±10.7 years). Of the 467 patients, 324 (69.4%) fulfilled the criteria for MS. ST-Elevation Myocardial Infarction (STEMI) was identified in 178 patients (54.9%), and non-ST elevation ACS (NSTE-ACS) in 146 patients (45.1%). These proportions were not significantly different from those without MS (STEMI 51.7% vs. NSTE-ACS 48.3%, respectively). However, patients with MS were older (50.6±10 vs. 47.9±11 years; p=0.012), and more than half of those with MS were above 50 years. The most common abnormal metabolic components were reduced high-density lipoprotein cholesterol (HDL-c; 94.1%), elevated fasting blood glucose (FBG; 89.8%), and elevated triglycerides (81.8%), followed by increased waist circumference (61.7%) and raised blood pressure (40.4%). The majority of patients with MS had three or more metabolic components (326 patients, 69.4%), and 102 (21.8%) had two components, but only 37 (8.4%) had a single component. CONCLUSIONS: In ACS patients, without previous history of DM, MS is highly prevalent. Reduced HDL, elevated FBG and triglycerides were the most frequent metabolic components. The majority had multiple components. These findings raise alarm and show that drug therapy alone may not be fully effective, unless the underlying risk factors causing MS, such as weight and exercise, are also tackled.

Primary coronary angioplasty for ST-Elevation Myocardial Infarction in Qatar: First nationwide program.

In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as 'high volume', both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.

Acute myocardial infarction in a professional diver after jellyfish sting.

To our knowledge, acute myocardial infarction after jellyfish envenomation has not been reported previously. We describe a previously healthy 45-year-old male diver who had an acute inferior myocardial infarction with right ventricular involvement after a jellyfish sting on his left forearm while diving in the Gulf Sea. The patient had a normal controlled ascent after the incident. He had no risk factors for coronary artery disease, and cardiac catheterization revealed normal coronary arteries. Acute myocardial infarction should be considered in patients who experience chest pain or have hemodynamic compromise after jellyfish envenomation.