Patient journey for hypertension and dyslipidemia in Saudi Arabia: highlighting the evidence gaps.

BACKGROUND: In recent years, Saudi Arabia has witnessed staggering rates of hypertension and dyslipidemia-related cardiovascular (CV) deaths, overburdening the healthcare ecosystem of the country. Appropriate public health interventions can be devised through quantitative mapping of evidence. Identification of potential data gaps can prioritize future research needs and develop a 'best-fit' framework for patient-centric management of hypertension and dyslipidemia. METHODS: This review quantified data gaps in the prevalence and key epidemiological touchpoints of the patient journey including awareness, screening, diagnosis, treatment, adherence, and control in patients with hypertension and dyslipidemia in Saudi Arabia. Studies published in English between January 2010 and December 2021 were identified through a structured search on MEDLINE, Embase, BIOSIS, and PubMed databases. An unstructured search on public and government websites, including Saudi Ministry of Health, without date limits was carried out to fill data gaps. After exclusion of studies based on predefined criteria, a total of 14 studies on hypertension and 12 studies and one anecdotal evidence for dyslipidemia were included in the final analyses. RESULTS: The prevalence of hypertension was reported to be 14.0%-41.8% while that for dyslipidemia was 12.5%-62.0%. The screening rate for hypertension was 100.0% as revealed by the nationwide surveys. Among hypertensive patients, only 27.6%-61.1% patients were aware of their condition, 42.2% patients underwent diagnosis, 27.9%-78.9% patients received antihypertensive treatment, 22.5% patients adhered to treatment medication, while blood pressure (BP) control was achieved in 27.0%-45.0% patients. Likewise, among patients with dyslipidemia, 10.5%-47.3% patients were aware of their condition, 34.6% patients were screened, and 17.8% underwent diagnosis. Although high treatment rates ranging from 40.0%-94.0% were reported, medication adherence recorded was 45.0%-77.4% among the treated patients. The overall low control rates ranged from 28.0%-41.5%. CONCLUSIONS: The study findings highlight evidence gaps along key touchpoints of patient journey. Reinforcing the efforts for high-quality evidence-based research at a national level may pave a path for better resource utilization and provide guidance to practice and amend health policies for patients, healthcare practitioners (HCPs), and healthcare policy makers for better patient outcomes in Saudi Arabia.

Digital Health Tools for Managing Noncommunicable Diseases During and After the COVID-19 Pandemic: Perspectives of Patients and Caregivers.

BACKGROUND: A reduction in the number of face-to-face medical examinations conducted for patients with noncommunicable diseases (NCDs) during the first wave of the COVID-19 pandemic has led to health care professionals quickly adopting different strategies to communicate with and monitor their patients. Such strategies include the increased use of digital health tools. However, patient preferences, privacy concerns, a lack of regulations, overregulation, and insufficient evidence on the efficacy of digital health tools may have hampered the potential positive benefits of using such tools to manage NCDs. OBJECTIVE: This viewpoint aims to discuss the views of an advisory board of patient and caregiver association members. Specifically, we aim to present this advisory board's view on the role of digital health tools in managing patients with NCDs during and after the COVID-19 pandemic, and to identify future directions based on patients' perspectives. METHODS: As an initiative under the NCD Partnership (PARTners in Ncds Engage foR building Strategies to improve Healthy ageing In Patients) model of Upjohn, a web-based advisory board of patient and caregiver advocates was held on July 28, 2020, to bring together key stakeholders from public and private sectors. RESULTS: The following key themes emerged: (1) technology developers should understand that the goals of patients may differ from those of health care professionals and other stakeholders; (2) patients, health care professionals, caregivers, and other end users need to be involved in the development of digital health tools at the earliest phase possible, to guarantee usability, efficacy, and adoption; (3) digital health tools must be better tailored to people with complex conditions, such as multimorbidity, older age, and cognitive or sensory impairment; and (4) some patients do not want or are unable to use digital health care tools, so adequate alternatives should always be available. CONCLUSIONS: There was consensus that public-private partnership models, such as the Upjohn NCD Partnership, can be effective models that foster innovation by integrating multiple perspectives (eg, patients' perspectives) into the design, development, and implementation of digital and nondigital health tools, with the main overall objective of improving the life of patients with NCDs.

What should be the Optimal Carotid Stent Opening Rate Without Post-Dilation?

BACKGROUND: There is not a widely accepted optimal rate of stent opening in patients underwent carotid artery stenting. In this study we evaluated the effect of carotid stent opening rate (CSOR) without performing post-dilation on in-hospital and long-term outcomes. METHODS: A total of 825 patient patients underwent carotid artery stenting without post-dilation enrolled to the study. The patients divided into two groups according to their final CSOR (50% ≤ Post-stent deployment (SD) <80% and 80% ≤ Post-SD ≤ 100%). In-hospital and 3-year outcomes were compared between the groups. RESULTS: During hospitalization, the rate of ipsilateral stroke, major stroke and transient ischemic attacks were similar between the groups (respectively; 6.2% vs. 4.1, P = 0.190; 1.5% vs. 1.8, P = 0.811; 1.5% vs. 1.9%, P = 0.683). The 3-year Kaplan-Meier overall survival rates for the first and second groups were 87.6% and 84.4%, respectively (log rank test P = 0.426). The 3-year Kaplan-Meier overall cumulative ipsilateral stroke rates for the first and second groups were 88.0% and 88.6%, respectively (log rank test P = 0.409) CONCLUSION: Our study demonstrated that a CSOR higher than 50% without performing a post-dilation might be an effective therapeutic approach since there was not a significant difference regarding outcomes between the patients with a 50% ≤ Post-SD <80% and 80% ≤ Post-SD ≤ 100%. The need for post-stent balloon dilation might have been eliminated due to subsequent stent self-expansion.

Evaluation of Tp-e Interval, Tp-e/QT Ratio, and Tp-e/QTc Ratio in Patients with Asymptomatic Arrhythmogenic Right Ventricular Cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate repolarization dispersion measured from the 12-lead surface electrocardiogram (including Tp-e interval, Tp-e/QT, and Tp-e/QTc ratio) in asymptomatic ARVD patients METHODS: We selected 27 patients with asymptomatic ARVD and 27 age- and gender-match young, healthy volunteers. RESULTS: Tp-e interval, Tp-e/QT and Tp-e/QTc ratio were also significantly higher in ARVD group compared to the control group (all P < 0.001). There were negative correlation between S global and Tp-e, Tp-e/QT, Tp-e/QTc ration (r = -0.57, P = 0.02; r = -0.85, P = 0.02; r = -0.63, P < 0.01; respectively). There were also negative correlation between Sm global and Tp-e, Tp-e/QT, Tp-e/QTc ration (r = -0.61, P < 0.01; r = -0.67, P < 0.01; r = -0.68, P < 0.01; respectively). Moreover, Em global were negative correlation between Tp-e, Tp-e/QT, and Tp-e/QTc (r = - 0.64, P < 0.001, r = - 0.75, P < 0.01; r = -0,69, P < 0.01; respectively) CONCLUSION: In conclusion, we have presented strong evidence suggesting that Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were increased in asymptomatic ARVD patients.

Peripheral self-expandable stent catheter fracture: Retrieval of two different components with two different modalities.

A 58-year-old man whose right superficial femoral artery had been stented 2 weeks previously presented at the emergency service complaining of right leg pain of 2 days' duration. Angiography revealed a radiopaque foreign body distal to the stent. It was removed with a snare. Due to sudden disappearance of the popliteal artery pulse seventy-two hours after the procedure, an urgent control angiogram was performed, which showed a large thrombus occluding the superficial femoral artery. Surgery revealed a second larger radiolucent foreign body causing the thrombus. This was recognized as the distal tip and shaft of the peripheral self-expandable stent catheter used in the initial procedure. This report discusses preventive measures to be taken against this complication.

Plasma factor XI and XII activity in patients with slow coronary flow.

The exact pathophysiology of slow coronary flow (SCF) phenomenon, characterized by delayed opacification of coronary arteries during coronary angiography, is still unknown, although endothelial dysfunction, inflammation, vasomotor disorders and atherosclerosis are shown. The present study was conducted to investigate whether there is a coagulation pathway abnormality in patients with SCF measuring plasma factor XI and XII activity. The study included 55 patients with angiographically proven SCF (group I) and 40 individuals with normal coronary flow (NCF, group II). Baseline demographic properties were similar in both groups. Echocardiographic parameters were also similar in patients with SCF and NCF. Factor XI activity was significantly higher in group I when compared with group II. Factor XII activity was also significantly higher in group I when compared with group II (108.9 ±â€Š19 vs. 98.8 ±â€Š20, P = 0.018 and 131.2 ±â€Š17 vs. 119.1 ±â€Š16, P = 0.001, respectively). We conclude that SCF phenomenon appears to be associated with enhanced procoagulant state, which may support the role of inflammation and atherosclerosis in the pathogenesis of this phenomenon.

Two-dimensional strain and strain rate imaging of the left atrium and left ventricle in adult patients with atrial septal defects before and after the later stage of percutaneous device closure.

AIM: Atrial septal defect (ASD) causes chronic volume overload of the right heart. The potential adverse effects of this long-standing volume overload to left atrium (LA) and left ventricle (LV) and their response to ASD closure has been poorly studied. METHODS: We studied 20 ASD patients before the procedure, at the 24-hour and 1 month following the percutaneous closure. Twenty age-matched controls served as the control group. The analysis for atrial deformation was performed on the lateral wall, mid segment of the LA from apical four-chamber view. Peak longitudinal strain (S) and strain rate (SR) during LA reservoir, passive emptying, atrial contraction phases and LV global longitudinal systolic S and SR were measured. RESULTS: Peak S and SR at LA reservoir, conduit and late contraction phases in ASD patients were similar to controls. All of these parameters increased immediately after the closure of the defect. Similarly, SLV and SRLV in ASD patients were not significantly different from the controls and significantly increased after the closure. But LA S, SR and LV S, SR results decreased in 1 month after the closure. SLV in ASD patients was significantly correlated with echocardiographic findings and the invasively measured defect size. CONCLUSION: LA and LV S and SR are not significantly affected in ASD patients. However, correction of the long-standing volume overload by percutaneous closure causes an early increase in LA and LV longitudinal deformation that correlates with the magnitude of the atrial septal defect. But this increase decreased in 1 month after closure.

The relationship between gamma-glutamyltransferase and coronary collateral circulation in patients with chronic total occlusion.

OBJECTIVE: The aim of this study was to evaluate the relation between blood gamma-glutamyltransferase (GGT) levels and coronary collateral circulation in patients with chronic total occlusion (CTO). METHODS: Two hundred twenty-two patients with chronic stable coronary artery disease (CAD) and CTO were included in this cross-sectional, observational study. Coronary collaterals were graded from 0 to 3 according to the Rentrop method. Patients with grade 0-1 collateral development were regarded as poor collateral group (n=66) while patients with grade 2-3 collateral development were regarded as good collateral group (n=156). Statistical analysis was performed using independent samples t, Mann-Whitney U and Chi-square tests, logistic regression and receiver operator curve analysis. RESULTS: The poor coronary collateral group had significantly higher levels of serum GGT compared to the good collateral group (p<0.001). Multiple logistic regression analysis showed that GGT levels were independent predictors of poor collateral circulation (OR-0.946, 95% CI=0.918-0.9719, p<0.001). The result of ROC curve analysis for GGT was as following: area under the ROC curve (AUC)=0.732, 95% CI: 0.622-0.841, p<0.001. CONCLUSION: Higher GGT levels are associated with poor coronary collateral circulation in patients with CTO. GGT may be used to predict the grade of coronary collateral circulation in CTO patients with chronic stable CAD.

Decreased plasma adiponectin is associated with impaired left ventricular longitudinal systolic function in hypertensive patients: a two-dimensional speckle tracking study.

The influence of plasma adiponectin levels on myocardial contractile function has not been fully examined. We aimed to investigate the relationship between three-directional systolic function and plasma adiponectin levels in asymptomatic hypertensive patients using two- dimensional speckle-tracking echocardiography. The study population consisted of 78 patients with hypertension and 40 healthy controls. Longitudinal strain was significantly reduced in all patients, including those without LV hypertrophy (p=0.009). In multiple-regression analysis, plasma adiponectin levels (ß=-0.273, p=0.008) and LV mass index (ß=0.458, p<0.001) independently correlated with LV longitudinal strain. Decreased plasma adiponectin concentrations were associated with the progression of LV hypertrophy with impaired LV longitudinal systolic function.

Huge aortic pseudoaneurysm arising from the aorta-saphenous vein graft anastomosis after coronary artery bypass grafting.

Pseudoaneurysm of the aortic root is a rare condition and potentially fatal if not treated. It may occur in different etiologies. In this case, we aim to show an aortic pseudoaneurysm arising from the aorta-saphenous vein graft anastomosis.

The effect of cilostazol on right heart function and pulmonary pressure.

INTRODUCTION: Cilostazol is a PDE3 inhibitor and used to treat peripheral arterial disease. There are few reports on the influence of cilostazol on heart. AIMS: The aim of this study was to assess this effect on right ventricular function and pulmonary artery pressure. METHODS: Forty patients with normal left and right ventricular ejection fraction and mild or moderate pulmonary artery hypertension were enrolled in the study. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), tissue Doppler imaging (TDI), and two-dimensional speckle-tracking echocardiography (2D-STE) before and after oral administration of cilostazol. Also pulmonary artery pressure assessed before and after administration of cilostazol. RESULTS: After cilostazol administration, there were significant increases in the TAPSE (1.9 ± 0.3 cm vs. 2.2 ± 0.3 cm, P < 0.001). Peak longitudinal strain (-18.7 ± 4.5% vs. -21.3  ± 3.7%, P = 0.001), isovolumetric acceleration (IVA) (176.6 ± 62.7 cm/sec(2) vs. 200.6 ± 61.9 cm/sec(2) , P = 0.025), right ventricular FAC increased significantly (37.6 ± 8.0% vs. 41.5 ± 8.9%, P < 0.001). Pulmonary artery pressure decreased significantly (39.9 ± 7.9 vs. 36.6 ± 5.5 mmHg, P = 0.001) after cilostazol administration. CONCLUSION: Our study demonstrated that cilostazol improved right ventricular systolic function and reduced pulmonary artery pressure.

Evaluation of autonomic functions by heart rate variability after stenting in patients with carotid artery stenosis.

OBJECTIVE: Although carotid stenting is an effective treatment for severe carotid stenosis, it has been associated with alterations in autonomic functions during or shortly after the procedure. Heart rate variability (HRV) is an established tool for the asessment of autonumic functions. In this study, our aim was to investigate the relation between the alterations in autonomic functions and HRV by Holter monitoring parameters. METHODS: Patients (19 male, 8 female) that are suitable for carotid artery stenting, without a history of hypertension, diabetes mellitus, severe coronary artery or valvular heart disease, were enrolled to our study. Short-term HRV analysis recordings were obtained at the beginning, and after the procedure. The square root of the mean squared differences of successive NN intervals (RMSSD), total frequency, low frequency (LF), high frequency (HF), normalized units LF (LFnu), normalized units HF (HFnu), LF/HF ratios were analyzed. Results were statistically analysed by using Wilcoxon test. RESULTS: Total frequency did not show any significant changes after the procedure (1101 ± 829, 981 ± 855). While RMSSD and HFnu values significantly increased respectively (23 ± 12/33 ± 22, and 22 ± 10/35 ± 10, p < 0.05) after the procedure, HF values increased nonsignificantly after the procedure (82 ± 92/92 ± 108). LF, LFnu, and LF/HF values were significantly decreased after the procedure. (228 ± 166/112 ± 100, 70 ± 15/55 ± 18, 4 ± 2.5/2.1 ± 2, respectively, p < 0.05) CONCLUSIONS: While RMSSD and HF are used as markers of vagal activity, LF is a marker of sympathetic modulation and LF/HF ratio shows sympathovagal balance. In our study, we showed that carotid artery stenting is associated with increase in parasympathetic activation, and this finding is demonstrated by HRV parameters.

The comparison in reduction of QT dispersion after primary percutaneous coronary intervention according to existence of thrombectomy in ST-segment elevation myocardial infarction.

BACKGROUND: Primary percutaneous coronary intervention (PPCI) is the standard treatment in patients with ST-segment elevation myocardial infarction (STEMI). Thrombectomy devices are used to remove thrombus or to prevent embolization of thrombus and plaque during PPCI. QT dispersion (the difference between maximal and minimal QT interval calculated on a standard 12-lead electrocardiogram) represents the regional nonuniformity of ventricular repolarization. It may reflect early coronary reperfusion in reducing electrophysiological instability by decreasing QT dispersion in the recovery phase after acute STEMI. HYPOTHESIS: Our aim was to show whether an additional effect of thrombectomy on reducing QT dispersion will be seen in patients undergoing PPCI for STEMI. METHODS: The study population included 80 consecutive patients who were admitted to the hospital within 12 hours after the onset of acute STEMI and angiographic evidence of intraluminal thrombus in the infarct-related artery. Patients with atrial fibrillation or flutter, intraventricular conduction abnormalities, pre-excitation, cardiogenic shock, cardiomyopathy, ventricular hypertrophy, and severe valvular heart disease were excluded from the study. RESULTS: There were no significant differences between groups regarding gender, age, cardiovascular risk factors, and time from symptom onset to treatment, except for smoking, which was much higher in the PPCI plus thrombectomy group. Infarct-related artery distribution (left anterior descending artery [LAD] to non-LAD), and neither the rate of balloon predilatation nor stent implantation were different between groups. Successful coronary patency was achieved in each case. QT interval measurements were similar between groups at admission. However, at 24 hours, QT and QTc dispersions were less in the PPCI plus thrombectomy group (41 ± 9 vs 33 ± 7 ms, P < 0.05 and 45 ± 8 vs 35 ± 7 ms, P = 0.03, respectively), but not in the other QT interval measurements. When patients were divided into 2 groups according to infarct-related artery (LAD and non-LAD groups), QT interval measurement parameters did not show any significant differences. CONCLUSIONS: Thrombectomy additional to PPCI helps more effective reperfusion at the microvascular level and provides additional prognostic information.

P-wave dispersion by 12-lead electrocardiography in carotid artery stenting.

OBJECTIVE: Although carotid artery stenting (CAS) is an effective treatment for severe carotid stenosis, it has been associated with alterations in autonomic functions during or shortly after the procedure. And, autonomic functions influence P-wave durations. In this study, our aim was to investigate P-wave durations on 12-lead surface electrocardiography after CAS. METHODS: Patients (19 male, 8 female) who are suitable for CAS, without a history of hypertension, diabetes mellitus, severe coronary artery or valvular heart disease, were enrolled in our study. 12-lead surface electrocardiography recordings were obtained at the beginning, immediately after and at the 24 h of the procedure. P-wave maximum, minimum and dispersion durations were analyzed by double-blinded observers. Results were statistically analysed using Friedman and Wilcoxon tests. RESULTS: The P maximum and P dispersion values were significantly increased immediately after the procedure and continued with high levels at 24-h recordings, respectively (128 ± 10/19 ± 7, 143 ± 14/37 ± 11, and 137 ± 11/30 ± 7 ms, p value <0.05). The P minimum value was significantly decreased immediately after the procedure (109 ± 11/105 ± 10 ms, p value <0.05). At 24-h recordings, a nonsignificant increase occured in P minimum values (106 ± 8 ms). CONCLUSIONS: P maximum and dispersion durations were significantly increased after the CAS and continued with high levels at 24-h recordings, which may be associated with the alterations in autonomic functions via augmented parasympathetic activity by vagally mediated stimulus. Overall, these findings suggest that decline in cardiovascular activity is prolonged at least 24 h after CAS.

Comparison of left atrial mechanical function in nondipper versus dipper hypertensive patients: a speckle tracking study.

AIM: Nondippers are known to carry a high risk of cardiovascular morbidity and mortality. The aim of this study was to investigate the effects of dipper and nondipper status of hypertension on longitudinal systolic and diastolic functions of left atrial (LA) myocardial tissue by means of two-dimensional speckle-tracking echocardiography in treated hypertensive patients. METHODS: A total of 78 outpatients treated with antihypertensive drugs for at least 1 year were included in the study. The patients were classified as nondippers if their daytime ambulatory systolic and diastolic blood pressure did not decrease by at least 10% during the night. Global longitudinal LA strain/strain rate data were obtained by two-dimensional speckle imaging with automated software and compared between the groups. RESULTS: LA volume index, left ventricular (LV) wall thickness and mass index as well as filling pressure (E/E') were significantly higher in nondippers (all P < 0.001), whereas systolic tissue velocity (S') was significantly lower in nondippers. They also had decreased values of mean peak LA strain (dippers = 27.6 ± 5.5% vs. nondippers = 21.5 ± 4.5%, P < 0.001), strain rate during reservoir (dippers = 1.27 ± 0.4/sec vs. nondippers = 0.98 ± 0.3/sec, P = 0.001), and conduit period (dippers = 1.41 ± 0.4/sec vs. nondippers = 1.06 ± 0.3/sec, P < 0.001). Moreover, we found that LA mechanical dysfunction was closely associated with LV mass, filling pressure, and regional LV contractility. CONCLUSION: Nondipping in treated hypertensive patients was associated with an adverse cardiac remodeling and impaired LA mechanical function. Further studies are warranted to demonstrate the long-term prognostic significance of these findings.

Time course of right ventricular remodeling after percutaneous atrial septal defect closure: assessment of regional deformation properties with two-dimensional strain and strain rate imaging.

BACKGROUND: Quantitative assessment of the right ventricular (RV) function in atrial septal defect (ASD) patients before and after closure remains difficult. The aim of this study was to assess the regional RV function in ASD patients, to evaluate the extent and time course of RV remodeling following ASD closure, and to investigate whether any regional difference exists in RV remodeling. METHODS: Twenty patients with ASD and 20 age-matched controls were included. All underwent standard echocardiography and two-dimensional strain (S) and strain rate (SR) imaging by speckle tracking before, and 24 hours and 1 month after the defect closure. RESULTS: Right ventricular S was higher in ASD patients except apical lateral segment S, which was lower when compared with controls. There was no difference in RV SR between ASD patients and controls. RV septal S and SR, and lateral SR decreased in 24 hours after the procedure and remained the same at 1 month. RV lateral basal and mid S decreased and apical S increased in 24 hours after the closure. All 3 segments showed some more increase at 1 month. RV apical S showed strong correlations with systolic pulmonary artery pressure and global RV systolic function indices. CONCLUSIONS: Chronic volume overload in ASD patients causes alterations in RV deformation. Percutaneous closure results in rapid remodeling and normalization of RV deformation. The major geometrical and deformational changes are completed in 24 hours. Lateral wall S seems to reflect the RV deformational changes due to volume loading and unloading better than SR in ASD patients.