Adherence to Medications in Patients with Ischaemic Heart Disease in Oman.

Objectives: This study aimed to evaluate the level of adherence to medication among patients with ischaemic heart disease (IHD) in Oman and assess the related factors. Methods: This cross-sectional questionnaire-based study among patients with IHD attending the outpatient clinic at Sultan Qaboos University Hospital, Muscat, Oman, was performed between January and December 2021. Results: A total of 105 patients (mean age = 49.9 ± 11.1 years, 78.1% male) were recruited. Most of the patients (80%) reported taking the medications by themselves; 77 (73.3%) patients said that over the preceding 2 weeks, they had missed at least 3 doses of their medication. The reasons for missing the medications included forgetting (100%), having to take too many tablets (57%), feeling that the tablets are not effective (48%) and having to take the tablets too often each day (23%). The factors responsible for patients failing to take medications could not be identified. Conclusion: Medication adherence was low among patients with IHD in Oman, with high pill burden being the most common reason for non-adherence. Physicians must bear this in mind when reviewing patients.

Evidence-based medicine or statistically manipulated medicine? Are we slaves to the P-value?

First popularized almost a century ago in epidemiologic research by Ronald Fisher and Jerzy Neyman, the P-value has become perhaps the most misunderstood and even misused statistical value or descriptor. Indeed, modern clinical research has now come to be centered around and guided by an arbitrary P-value of <0.05 as a magical threshold for significance, so much so that experimental design, reporting of experimental findings, and interpretation and adoption of such findings have become largely dependent on this "significant" P-value. This has given rise to multiple biases in the overall body of biomedical literature that threatens the very validity of clinical research. Ultimately, a drive toward reporting a "significant" P-value (by various statistical manipulations) risks creating a falsely positive body of science, leading to (i) wasted resources in pursuing fruitless research and (ii) futile or even harmful policies/therapeutic recommendations. This article reviews the history of the P-value, the conceptual basis of P-value in the context of hypothesis testing and challenges in critically appraising clinical evidence vis-à-vis the P-value. This review is aimed at raising awareness of the pitfalls of this rigid observation of the threshold of statistical significance when evaluating clinical trials and to generate discussion regarding whether the scientific body needs a rethink about how we decide clinical significance.

Yield of Cardiac Investigations in Patients Presenting with Acute Ischaemic Stroke: A single tertiary centre experience.

Objectives: Strokes are a major cause of morbidity and mortality. This study aimed to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischaemic strokes. Methods: This retrospective study involved patients who presented with a stroke to the Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019. Results: A total of 183 patients (mean age = 66.2 ± 13.5 years), the majority of which were male (n = 109, 59.6%), were included. The common risk factors included hypertension (74.9%), diabetes (61.7%) and hyperlipidaemia (54.6%). The middle cerebral artery was the most common artery affected, in 44 patients (24.0%). On admission, 14 (7.6%) patients were in atrial fibrillation (AF), while the rest were in sinus rhythm. The 24-hour electrocardiogram (ECG) Holter monitoring revealed no abnormalities in 135 patients. AF was observed in 15 (8.1%) patients (inclusive of the 14 who had AF on resting ECG). Furthermore, 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia, and nine (4.9%) had non-sustained ventricular tachycardia. Frequent supraventricular ectopics (>30/hour) was noted on 30 patients (16.3%), while five (2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients; however, 10 out of 132 (7.5%) patients presented a positive bubble echo. Enlarged left atria were found in 24 (13.1%) patients. Conclusion: The overall diagnostic yield of the abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with cryptogenic stroke, as suggested by newer guidelines, is recommended.

Cardioprotective and Antianginal Efficacy of Nicorandil: A Comprehensive Review.

ABSTRACT: Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.

Knowledge, Attitudes and Practices Regarding Traditional and Complimentary Medicine in Oman.

Objectives: This study aimed to assess the knowledge, attitudes and practices regarding traditional medicine (TM) in Oman and examine the factors that necessitate its use. Methods: This cross-sectional, questionnaire-based study was conducted among the general population from November 2019 and March 2020. All Omani nationals above the age of 18 were eligible to be enrolled. The questionnaire consisted of questions on the knowledge, attitudes and use regarding traditional medicine in Oman. Results: A total of 598 responses to the questionnaire were received (response rate: 85.4%), of which 552 were deemed complete. Most responses were received from males (62.5%) and the sample had a mean age of 33.6 ± 7.7 years. A majority of the respondents (90%) were aware of the different types of TM in Oman; a high percentage (81.5%) felt that it was effective. Most (67.8%) had tried at least one method of TM use. Individuals who were older had tried TM compared to those who had not (34.5 ± 7.8 years versus 31.8 ± 7.2 years; P <0.001); in addition, more males than females (72.2% versus 27.8%; P <0.001) and those with full-time employment than those without had tried TM (84.2% versus 14.2%; P <0.001). Herbal medications (65.8%) and traditional massage (60.4%) were the most common forms of TM practice. Among females, herbal medications (69.2%) and massage (63.5%) are most often used; among males, cupping (65.2%) followed by herbal medications (64.4%) and massage (59.3%) were used more often. Notably, back pain (74.3%) was the most common condition for which TM was reportedly used, with only a small percentage (8.3%) reporting any concomitant side-effects. Conclusion: There is widespread use of TM among Oman's urban population. An improved understanding of their benefits will facilitate their incorporation into modern health care services.

Angiographic Predictors of Viability During Intervention for a ST Elevation Myocardial Infarction.

Objectives: This study aimed to identify angiographic features that would predict myocardial viability after coronary intervention for ST elevation myocardial infarction (STEMI). Methods: This retrospective study included patients who attended Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 with a STEMI. Results: A total of 72 patients (61 male; mean age = 54.9 ± 12.7 years) were included in the study; 11 patients had evidence of non-viability on echocardiography. There were 13 patients with viable myocardium and 3 with non-viable myocardium who had a myocardial blush grade (MBG) of 2 or lower. Similarly, 10 patients with viability and 1 with non-viable myocardium had thrombolysis in myocardial infarction (TIMI) flow of 2 or lower in the infarct related artery (IRA). However, none of these were statistically significant. The TIMI flow in the IRA at the end of the procedure correlated with the MBG. Conclusion: There were no clear angiographic features during primary angioplasty that could predict myocardial viability.

Estimation of Salt Intake and its Relation to Knowledge and Attitude Regarding the Dangers of High Salt Intake among an Urban Omani Population: A pilot study.

Objectives: High salt consumption is a major risk factor for hypertension. Studies have shown dietary salt intake to be high in many parts of the world. This study aimed to assess the daily salt consumption of the Omani urban population and their knowledge and attitudes regarding dietary salt. Methods: This cross-sectional questionnaire-based study was conducted in Muscat between September and December 2017. Participants were recruited from malls, university students and staff, hospital staff and their relatives and relatives of patients. A previously validated questionnaires were used to assess the participants' salt intake and their knowledge and attitudes regarding salt intake. Results: A total of 345 participants were included in this study (response rate: 69%), of which 300 responses (mean age: 27.88 ± 7.9 years, 54.3% male) were included for analysis. Overall, 94.3% of the participants agreed that lowering salt in diet is important, and nearly half the participants said that they were taking measures to reduce salt intake. However, the median salt intake was high at 10.5 g/day (interquartile range: 7.3-15.1 g/day), with 90% of the respondents consuming more than the maximum recommended amount of salt per day. Salt intake was significantly higher in women and the older age group (>40 years). There did not appear to be any correlation between awareness of the dangers of salt intake and the amount consumed. Conclusion: The salt intake in the sampled population in Oman was high and did not depend on knowledge. Strategies should be designed to reduce salt intake among the urban population, including health education to increase knowledge about the complications of high salt intake.

Delays in Presentation by Patients with ST Elevation Myocardial Infarction: A single centre experience from Oman.

Objectives: To assess the causes of delay for presentation with ST elevation myocardial infarction (STEMI). Methods: Patients who presented with STEMI to the Emergency Department at the Sultan Qaboos University Hospital, Muscat, Oman between January 2017 and December 2019 and were admitted for primary angioplasty were included in this study. Results: A total of 101 patients were included with a mean age of 54.8 + 10.8 years and the majority were male patients (n = 80; 79.2%). The median (interquartile range) pain-to-door time was 60 min (30-120 min). There were 66 (65.4%) patients who arrived within 90 minutes. All except one arrived by privately arranged transport. Feeling that the pain was not important (61.0%) or not cardiac (22.8%) were the main reasons for delay. Being diabetic was the only patient factor that predicted delay. Conclusion: A high proportion of patients presenting to our institution with a STEMI arrived within recommended times. However more public education is required to improve awareness about the importance of early evaluation of chest pain.

Temperature, cardiovascular mortality, and the role of hypertension and renin-angiotensin-aldosterone axis in seasonal adversity: a narrative review.

Environmental temperature is now well known to have a U-shaped relationship with cardiovascular (CV) and all-cause mortality. Both heat and cold above and below an optimum temperature, respectively, are associated with adverse outcomes. However, cold in general and moderate cold specifically is predominantly responsible for much of temperature-attributable adversity. Importantly, hypertension-the most important CV risk factor-has seasonal variation such that BP is significantly higher in winter. Besides worsening BP control in established hypertensives, cold-induced BP increase also contributes to long-term BP variability among normotensive and pre-hypertensive patients, also a known CV risk factor. Disappointingly, despite the now well-stablished impact of temperature on BP and on CV mortality separately, direct linkage between seasonal BP change and CV outcomes remains preliminary. Proving or disproving this link is of immense clinical and public health importance because if seasonal BP variation contributes to seasonal adversity, this should be a modifiable risk. Mechanistically, existing evidence strongly suggests a central role of the sympathetic nervous system (SNS), and secondarily, the renin-angiotensin-aldosterone axis (RAAS) in mediating cold-induced BP increase. Though numerous other inflammatory, metabolic, and vascular perturbations likely also contribute, these may also well be secondary to cold-induced SNS/RAAS activation. This review aims to summarize the current evidence linking temperature, BP and CV outcomes. We also examine underlying mechanisms especially in regard to the SNS/RAAS axis, and highlight possible mitigation measures for clinicians.

Spotlight on hypertension in the Middle-East.

The Middle-East is a diverse region with many countries of differing socio-economic status. While some countries are facing war and famine, others have a booming economy. This is reflected in the health care in these countries. Hypertension is a problem of all these countries. In this spotlight, we wish to draw attention to the barriers faced by the different countries in the region in their fight to bring blood pressure under control.

Characteristics and Outcomes of Critically Ill Patients with Raised Cardiac Troponins Admitted in the Intensive Care Unit: A single centre experience from Oman.

Objectives: Critically ill patients have raised troponins. This study aimed to assess the incidence of myocardial injury in the intensive care unit (ICU) at a tertiary care hospital and assess the management and prognosis. Methods: This retrospective study included adult patients who were admitted to the ICU of Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 and had undergone a high-sensitive cardiac troponin (hs-cTn) assay. Patients admitted with a primary diagnosis of myocardial infarction were excluded. Results: A total of 264 patients had their hs-cTn measured during the study period. Of these, 128 (64.3 ± 17.1 years; 58.6% male) had elevated levels, giving an incidence rate of approximately 48.5%. Those with raised troponin were older and had more co-morbidities. These patients were also more critically ill with lower blood pressure, higher heart rates and increased hypotensive episodes. Of these, 47 were treated for acute coronary syndrome, 32 underwent coronary angiography and only three required stenting. Patients with raised troponin had a poor outcome with only 45 (35.2%) surviving to discharge compared to 101 (74.3%) with normal troponin. Patients with raised troponin had shorter hospital stays than those with normal troponin (16 versus 19 days; P = 0.017). Conclusion: A high proportion of critically ill patients showed evidence of myocardial injury without significant coronary artery disease, which is associated with a poor prognosis. Further prospective studies are required to ascertain the best course of treatment for these patients.

Prevalence of high blood pressure and cardiovascular risk factors from a community screening programme in the Middle-East; a 3-year analysis of data from the May Measurement Month programme (2017-2019) in Oman.

The May Measurement Month (MMM) programme is a global cross-sectional blood pressure (BP) screening programme. Here we present the combined data for the years 2017-2019 from Oman. BP was measured at various screening sites, according to standard protocol and hypertension was diagnosed if the BP was ≥140/90 mmHg or if the individual was already on antihypertensive medication. A total of 15,679 individuals (mean age 41.1 ± 12.6 years range 18-89 years; 71% male) were screened over the 3-year period. 7702 individuals (mean age 41.8 ± 13.9 years; 71.5% male) had three BP readings. The mean of the last two BP readings was 127.3 ± 17.1 mmHg. 1573 readings were in the hypertensive range (1004 newly diagnosed hypertension). A further 749 individuals were on antihypertensive medications with normal BP readings giving a proportion of 30.1% of the entire cohort being hypertensive. BP was high in 43% of patients on antihypertensive medications, 28.1% of those with previous myocardial infarction, 33.9% of those with previous stroke and 37.6% of the diabetic patients. BP strongly correlated with body mass index (BMI) and age (both p < 0.001), with a large proportion (68.5%) of individuals having high BMI(>25 kg/m2). Arab and South Asian ethnicity was associated with higher BMI and BP (both p < 0.001).Community screening programmes help identify previously undiagnosed hypertension and hypertensives with high BP. They also help to identify those at high cardiovascular risk. More emphasis should be given to monitoring those in high cardiovascular risk categories and high-risk ethnic groups.

Abnormal diastolic function and Global longitudinal strain in patients with Thalassemia Major on long term chelation therapy.

Cardiac complications are the major cause of mortality in patients with Thalassemia major (TM). Cardiac T2* MRI is currently the gold standard for assessing myocardial iron concentration. The aim of our study was to assess whether any echocardiographic parameter would correlate with these findings in patients well established on chelation therapy. This was a prospective study on patients with TM who are regularly followed in our clinic. Patients had a cardiac MRI and echocardiogram within 2 months of each other. Echo parameters included global longitudinal strain and diastolic function. We also compared these findings with those from a cohort of thalassemia intermedia (TI) and normal controls. A total of 84 patients (mean age 26.3 ± 6.1 years, 42.8% male) with TM were enrolled. All had normal left ventricular ejection fraction and only 8 patients had MRI T2* < 10. As compared to 17 patients with TI and 53 controls, these patients had significantly higher E/E' and lower pulmonary vein s/dd ratio suggesting early diastolic dysfunction. 28 patients fulfilled criteria for diastolic dysfunction even in the presence of normal MRI T2*. Global longitudinal strain (GLS) was significantly lower in the TM group as compared to the TI and controls. We found no correlation between any of the echo findings and the MRI T2*in TM patients. In patients with thalassemia and MRI T2* > 20 ms features of diastolic dysfunction persist even in the presence of normal LV function and normal GLS. This suggests that diastolic function remains abnormal even when myocardial iron concentrations are normal and follow up therefore is essential.

Comparison between two protocols for deflation of the TR band following coronary procedures via the radial route.

AIM: Coronary interventions are increasingly being performed via the radial rather than femoral route because of the lower complication rate. Compression devices such as the TR band are used to achieve hemostasis after the procedure. At present, there are no clear protocols for the deflation of the band. In this study we compared two protocols (early deflation with increased intervals vs. late deflation with smaller intervals) in terms of total time to band removal and complications, and patient and staff satisfaction. METHODS: All patients who underwent a transradial coronary procedure and had a TR band fitted were enrolled into the study. The TR band was applied using the patent hemostasis method (2 ml air pushed in after the radial pulse appears on pulse oximetry after full occlusion with 16 ml air). Patients were randomly assigned to either protocol. Protocol 1 involved removal of 2 ml of air starting 1 hour after the sheath removal and then removal of 2 ml every 30 minutes until the band came off. Protocol 2 involved removal of 4 ml of air 2 hours after the sheath removal and then further 4 ml of air every 15 minutes until the band came off. Patient and staff satisfaction was measured with a visual analogue scale. RESULTS: A total of 174 patients were recruited (mean age, 60 ± 11 years; 127 male, 47 female). The baseline characteristics including total heparin dose and type of procedure, in the two arms were the same. Protocol 2 (n = 84) was associated with a significantly lower time to TR band removal as compared to protocol 1 (n = 90; 201 ± 43 min vs. 274 ± 54 min; p < 0.001). There was no difference in complications such as bleeding or hematoma formation between the two groups. Patient satisfaction was the same between the two groups. However, the staff preferred protocol 1 (p = 0.01). CONCLUSION: A protocol of delayed initiation of TR band deflation followed by quick deflations is associated with a lower time to band removal with no increase in bleeding complications or patient satisfaction. However, the staff preferred longer intervals between deflations.

Awareness of the Dangers of High Salt Intake among the Urban Omani Population.

OBJECTIVES: This study aimed to assess the knowledge, attitudes and practices of the general public in Oman regarding the dangers of high salt intake. METHODS: This cross-sectional questionnaire-based survey was conducted among the urban population in Oman. Individuals aged ≥18 were invited to join the study. RESULTS: A total of 1,214 respondents (mean age 34 ± 10 years) answered the questionnaire. The majority were male (65.8%), employed (69.4%) and some were hypertensive (14.3%). Most (90.9%) were aware that excess salt can cause diseases such as hypertension and that it is either somewhat important (51.2%) or very important (42.9%) to reduce salt in the diet. However, only 42.2% said that they actively try to reduce salt in their diet. CONCLUSION: Although most people in urban areas of Oman appear to be aware of the dangers of high salt intake, only a few are actively trying to reduce it. More educational activities are required to improve awareness.