Disparities in health care delivery and hospital outcomes between non-Saudis and Saudi nationals presenting with acute coronary syndromes in Saudi Arabia.

BACKGROUND: Saudi Arabia has a non-Saudi workers population. We investigated the differences and similarities of expatriate non-Saudi patients (NS) and Saudi nationals (SN) presenting with acute coronary syndromes (ACS) with respect to therapies and clinical outcomes. METHODS: The study evaluated 2031 of the 5055 ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) from 2005 to 2007. Propensity score matching and logistic regression analysis were performed to account for major imbalances in age and sex in the two groups. RESULTS: The mean patient age was 56.2±9.8, and 83.5% of the study cohort were male. SN were more likely to have risk factors of atherosclerosis. ST-elevation MI (STEMI) was the most common ACS presentation in NS, while non-ST ACS was more common in SN. The median symptom-to-door time was significantly greater in NS patients (Median 175 min (197) vs. 130 min (167), p=0.027). The only difference in pharmacological therapies between the two groups was that NS were more likely to receive fibrinolytic therapy. NS were less likely than SN to undergo percutaneous coronary interventions (PCI; 32.6% vs. 42.8%, p=0.0001) or primary PCI (7.8% vs. 22.8%, p<0.001). Hospital mortality, cardiogenic shock, and heart failure were significantly higher in NS compared to SN. After adjusting for baseline variables and therapies, the odds ratios for hospital mortality and cardiogenic shock in NS were 2.9 (95% CI 1.5-6.2, p=0.004) and 2.8 (95% CI 1.5-4.9, p<0.001), respectively. CONCLUSION: Our findings indicate disparities in hospital care between NS and SN ACS patients. NS patients had worse hospital outcomes, which may reflect unequal health coverage and access-to-care issues.

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.

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.

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.

The prognostic impact of in-hospital worsening of renal function in patients with acute coronary syndrome.

BACKGROUND: Renal impairment is strongly linked to adverse cardiovascular (CV) events. Baseline renal dysfunction is a strong predictor of CV mortality and morbidity in patients admitted with acute coronary syndrome (ACS). However, the prognostic importance of worsening renal function (WRF) in these patients is not well characterized. METHODS: ACS patients enrolled in the SPACE (Saudi Project for Assessment of Coronary Events) registry who had baseline and pre-discharge serum creatinine data available were eligible for this study. WRF was defined as a 25% reduction from admission estimated glomerular filtration rate (eGFR) within 7 days of hospitalization. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared. RESULTS: Of the 3583 ACS patients, WRF occurred in 225 patients (6.3%), who were older, had more cardiovascular risk factors, were more likely to be female, have past vascular disease, and presented with more non-ST-segment elevation myocardial infarction than patients without WRF (39.5% vs. 32.8%; p=0.042). WRF was associated with an increased risk of in-hospital death, heart failure, cardiogenic shock, and stroke. After adjusting for potential confounders, WRF was an independent predictor of in-hospital death (adjusted odd ratio 28.02, 95% CI 13.2-60.28, p<0.0001). WRF was more predictive of mortality than baseline eGFR. CONCLUSION: These results indicate that WRF is a powerful predictor for in-hospital mortality and CV complications in ACS patients.

Incidence of ventricular arrhythmia and associated patient outcomes in hospitalized acute coronary syndrome patients in Saudi Arabia: findings from the registry of the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE).

BACKGROUND AND OBJECTIVES: Mortality in acute coronary syndrome (ACS) patients with ventricular arrhythmia (VA) has been shown to be higher than those without VA. However, there is a paucity of data on VA among ACS patients in the Middle Eastern countries. DESIGN AND SETTING: Prospective study of patients admitted in 17 government hospitals with ACS between December 2005 and December 2007. PATIENTS AND METHODS: Patients were categorized as having VA if they experienced either ventricular fibrillation (VF) or sustained ventricular tachycardia (VT) or both. RESULTS: Of 5055 patients with ACS enrolled in the SPACE registry, 168 (3.3%) were diagnosed with VA and 151 (98.8%) occurred in-hospital. The vast majority (74.4%) occurred in patients with ST-segment elevation myocardial infarction. In addition, males were twice as likely to develop VA than females (OR 1.7; 95% CI 1.13). Killip class >I (OR 2.0; 95% CI 1.3-3.1); and systolic blood pressure <90 mm Hg (OR 6.4; 95% CI 3.5-11.8) were positively associated with VA. Those admitted with hyperlipidemia (OR 0.49; 95% CI 0.3-0.7) had a lower risk of developing VA. Adverse in-hospital outcomes including re-myocardial infarction, cardiogenic shock, congestive heart failure, major bleeding, and stroke were higher for patients with VA (P≤.01 for all variables) and signified a poor prognosis. The in-hospital mortality rate was significantly higher in VA patients compared with non-VA patients (27% vs 2.2%; P=.001). CONCLUSIONS: In-hospital VA in Saudi patients with ACS was associated with remarkably high rates of adverse events and increased in-hospital mortality. Using a well-developed registry data with a large number of patients, our study documented for the first time the prevalence and risk factors of VA in unselected population of ACS.

Are acute coronary syndrome patients admitted during off-duty hours treated differently? An analysis of the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study.

BACKGROUND AND OBJECTIVES: It is often suggested that acute coronary syndrome (ACS) patients admitted during off-duty hours (OH) have a worse clinical outcome than those admitted during regular working hours (RH). Our objective was to compare the management and hospital outcomes of ACS patients admitted during OH with those admitted during RH. DESIGN AND SETTING: Prospective observational study of ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome study from December 2005 to December 2007. PATIENTS AND METHODS: ACS patients with available date and admission times were included. RH were defined as weekdays, 8 AM-5 PM, and OH was defined as weekdays 5 PM-8 AM, weekends, during Eid (a period of several days marking the end of two major Islamic holidays), and national days. RESULTS: Of the 2825 patients qualifying for this analysis, 1016 (36%) were admitted during RH and 1809 (64%) during OH. OH patients were more likely to present with heart failure and ST elevation myocardial infarction (STEMI) and to receive fibrinolytic therapy, but were less likely to undergo primary percutaneous coronary interventions (PCI). The median door to balloon time was significantly longer (P<.01) in OH patients (122 min) than in RH patients. No differences were observed in hospital outcomes including mortality between the two groups, except for higher heart failure rates in OH patients (11.1% vs 7.2%, P<.001). CONCLUSIONS: STEMI patients admitted during OH were disadvantaged with respect to use and speed of delivery of primary PCI but not fibrinolytic therapy. Hospitals providing primary PCI during OH should aim to deliver it in a timely manner throughout the day.

Glomerular filtration rate estimated by the CKD-EPI formula is a powerful predictor of in-hospital adverse clinical outcomes after an acute coronary syndrome.

The prognostic value of admission estimated glomerular filtration rate (eGFR) calculated by the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula for cardiovascular adverse outcomes in acute coronary syndrome (ACS) was explored. Baseline eGFR was classified as no renal dysfunction (>90 mL/min per 1.73 m(2)), borderline (90-60.1 mL/min per 1.73 m(2)), moderate (60-30.1 mL/min per 1.73 m(2)), or severe (≤30 mL/min per 1.73 m(2)) renal dysfunction. Of the 5034 patients, 3415 (67.8%) had eGFR <90. Compared to patients with an eGFR ≥60 mL/min per 1.73 m(2), patients with <60 mL/min per 1.73 m(2) were less likely to be treated with ß-blockers, angiotensin-converting enzyme inhibitors, or statins, or to undergo percutaneous coronary interventions. Lower eGFR showed a stepwise association with significantly worse adverse in-hospital outcomes. The adjusted odds ratio of in-hospital death with an eGFR <30 mL/min per 1.73 m(2) was 3.1 (95% confidence interval 1.1-8.4, P = .0324), compared with an eGFR >90 mL/min per 1.73 m(2). Estimated glomerular filtration rate calculated by the new CKD-EPI is an independent predictor of major adverse cardiac outcomes in patients with ACS.

Impact of diabetes on hospital adverse cardiovascular outcomes in acute coronary syndrome patients: Data from the Saudi project of acute coronary events.

BACKGROUND: Diabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi Arabia. METHODS: ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patients. RESULTS: Of the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2 ± 11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hypertension, hyperlipidemia) prevalences and were more likely to present with non-ST-elevation myocardial infarction (40.2% vs. 31.4%, p < 0.001), heart failure (25.4% vs. 13.9%, p < 0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardiogenic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI, 1.02-3.30, p = 0.042). CONCLUSIONS: A substantial proportion of Saudi patients presenting with ACS have DM and a significantly worse prognosis. These data highlight the importance of cardiovascular preventative interventions in the general population.

In-hospital adverse clinical outcomes of ST elevation myocardial infarction patients with renal dysfunction. Insights from the Saudi Project for Assessment of Coronary Events.

OBJECTIVE: To explore the prognostic value of baseline estimated glomerular filtration rate (eGFR) in Saudi patients presenting with ST elevation myocardial infarction (STEMI), and its impact on hospital therapies. METHODS: The STEMI patients with a baseline serum Creatinine enrolled in the SPACE (Saudi Project for Assessment of Coronary Events) registry were analyzed. This study was performed in several regions in Saudi Arabia between December 2005 to December 2007. Based on eGFR levels, patients were classified into: more than 90.1 ml/min (normal renal function), 90-60.1 (borderline/mildly impaired renal function), 60-30 (moderate renal dysfunction), and less than 30 ml/min/1.73 m2 (severe renal dysfunction). RESULTS: Two thousand and fifty-eight patients qualified for this study. Of these, 1058 patients had renal dysfunction. Patients with renal dysfunction were older, and had a higher prevalence of risk factors for atherosclerosis. Patients with moderate or severe renal dysfunction were less likely to be treated with beta blockers, angiotensin converting enzymes inhibitors, statins, or reperfusion therapies. Significantly worse outcomes were seen with lower eGFR in a stepwise fashion. The adjusted odds ratio of in-hospital death in patients with eGFR less than 30 ml/min was 5.3 (95% CI, 1.15-25.51, p=0.0383). CONCLUSION: A low baseline eGFR in STEMI patients is an independent predictor of all major adverse cardiovascular outcomes, and a marker for less aggressive in-hospital therapy.

Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: Results of the Saudi project for assessment of coronary events (SPACE) registry.

OBJECTIVES: The Saudi Project for Assessment of Coronary Events (SPACE) registry is the first in Saudi Arabia to study the clinical features, management, and in-hospital outcomes of acute coronary syndrome (ACS) patients. METHODS: We conducted a prospective registry study in 17 hospitals in Saudi Arabia between December 2005 and December 2007. ACS patients included those with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction and unstable angina; both were reported collectively as NSTEACS (non-ST elevation acute coronary syndrome). RESULTS: 5055 patients were enrolled with mean age ± SD of 58 ± 12.9 years; 77.4% men, 82.4% Saudi nationals; 41.5% had STEMI, and 5.1% arrived at the hospital by ambulance. History of diabetes mellitus was present in 58.1%, hypertension in 55.3%, hyperlipidemia in 41.1%, and 32.8% were current smokers; all these were more common in NSTEACS patients, except for smoking (all P < 0.0001). In-hospital medications were: aspirin (97.7%), clopidogrel (83.7%), beta-blockers (81.6%), angiotensin converting enzyme inhibitors/angiotensin receptor blockers (75.1%), and statins (93.3%). Median time from symptom onset to hospital arrival for STEMI patients was 150 min (IQR: 223), 17.5% had primary percutaneous coronary intervention (PCI), 69.1% had thrombolytic therapy, and 14.8% received it at less than 30 min of hospital arrival. In-hospital outcomes included recurrent myocardial infarction (1.5%), recurrent ischemia (12.6%), cardiogenic shock (4.3%), stroke (0.9%), major bleeding (1.3%). In-hospital mortality was 3.0%. CONCLUSION: ACS patients in Saudi Arabia present at a younger age, have much higher prevalence of diabetes mellitus, less access to ambulance use, delayed treatment by thrombolytic therapy, and less primary PCI compared with patients in the developed countries. This is the first national ACS registry in our country and it demonstrated knowledge-care gaps that require further improvements.

The Saudi Project for Assessment of Coronary Events (SPACE) registry: design and results of a phase I pilot study.

OBJECTIVE: The delay between the availability of clinical evidence and its application to the care of patients with acute coronary syndrome (ACS) in the Kingdom of Saudi Arabia remains undefined. The Saudi Project for Assessment of Coronary Events (SPACE) registry provides a comprehensive view of the current diagnostic and treatment strategies for patients with ACS; thus, the registry may be used to identify opportunities to improve the care of these patients. METHODS: Eight hospitals in different regions of Saudi Arabia were involved in the pilot phase of the registry, from December 2005 to July 2006. The study patients included individuals with ST segment elevation myocardial infarction (STEMI), non-STEMI and unstable angina. RESULTS: A total of 435 patients (77% men and 80% Saudis) with a mean age of 57.1 years were enrolled. Medical history included previously diagnosed ischemic heart disease (32%), percutaneous coronary intervention (12%), diabetes mellitus (53%), hypertension (48%), current smoking (39%), hyperlipidemia (31%) and family history of premature coronary artery disease (11%). The median door-to-needle time for fibrinolytic therapy received by patients with STEMIs was 90 min. Inhospital medications included acetylsalicylic acid (98%), clopidogrel (73%), angiotensin- converting enzyme inhibitors (74%), beta-blockers (73%), statins (88%), unfractionated heparin (80%), low-molecular weight heparin (22%) and glycoprotein IIb/IIIa inhibitors (9%). The inhospital mortality rate was 5%. CONCLUSION: The first nationwide registry of patients with ACS in the Kingdom of Saudi Arabia is presented. In contrast to registries from developed countries, our cohort is characterized by a younger age at presentation and a much higher prevalence of diabetes mellitus. Most patients with STEMIs did not receive fibrinolytic therapy within the time recommended in the American College of Cardiology/American Heart Association guidelines. The results of the present pilot study show potential targets for improvement in care.