Prevalence of Cardiovascular Risk Factors and 10-Years Risk for Coronary Heart Disease in the United Arab Emirates.

BACKGROUND: In the United Arab Emirates (UAE), cardiovascular diseases (CVDs) are the leading cause of mortality, and the incidence of premature coronary heart diseases (CHDs) is about 10-15 years earlier than that in people of western countries. AIM: The current cross-sectional study aims to describe the prevalence of CVD risk factors and estimate the 10-years risk for CHDs in the population of Abu Dhabi, UAE. OBJECTIVE: The main objective was to report the 10-years risk for CHD in a sample of the UAE population. METHODS: We have analyzed the dataset from the Abu Dhabi Screening Program for Cardiovascular Risk Markers (AD-SALAMA), a population-based cross-sectional survey conducted between 2009 and 2015 (a sample of 1002, 20 to 79 years old without CVDs or diabetes). RESULTS: 18.0% of our sample have had hypertension (HTN), 26.3% were current smokers, 33% have had total cholesterol ≥200 mg/dL, 55.0% have had non-high-density lipoprotein (non-HDL) levels ≥130 mg/dL, 33.1% have had low-density lipoprotein cholesterol (LDL-C) levels ≥130 mg/dL, calculated by ß-quantification as 112.3 ± 47.1 mg/dL. 66.8% were overweight or obese, and 46.2% had a sedentary lifestyle. Nearly 85% of our sample has had one or more major cardiovascular risk factors. The estimated 10-year risk of cardiovascular disease according to different risk assessment tools was as follows: 7.1% according to the national cholesterol education program Framingham risk score (FRAM-ATP), 2.9% according to Pooled Cohort Risk Assessment Equation (PCRAE) , 1.4% according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), and 1.1% according to Reynolds Risk Score. Despite the fact that our sample population have had exhibited major risk factors, the above-mentioned international scoring systems underestimate the 10-year risk of cardiovascular diseases, given the high prevalence at younger ages. CONCLUSION: The proportion of modifiable risk factors has been found to be high in the UAE population, and the majority of them have had one or more risk factors with a higher 10-years risk for CHDs.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension.

ABSTRACT: Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y12 Receptor Antagonists in the Asia-Pacific Region: Special Populations.

Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.

Sex differences in the antihypertensive treatment and risk of uncontrolled hypertension in 5308 hypertensive patients in the United Arab Emirates.

BACKGROUND: Sex differences in the antihypertensive medications used to control blood pressure and risk factor control in hypertensive patients is poorly understood. METHODS: We conducted a retrospective review of the patients newly diagnosed with hypertension registered for treatment in 52 outpatient settings across Abu Dhabi province between 1 January and 31 December 2017. We explored sex differences in risk factors and treatment management over 6 months of the follow-up period of each patient. Multiple logistic regression models were used to identify factors associated with poor BP control. RESULTS: A total of 5308 patients (2559 men and 2849 women) were identified. We observed an increase in SBP and DBP levels in men (1.72/1.13 mmHg) and only SBP in women (0.87/-0.021 mmHg) with increased incidence of comorbidities overtime. The overall BP control was suboptimal (65%) (<140/90 mmHg) with no significant difference between women (65.3%) and men (64.2%). In men with dyslipidemia, use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker with diuretics and in women, only calcium channel blockers showed higher for BP control. Factors significantly associated with poor BP control in men are being overweight and obese, and dyslipidemia in men. After the age of 50, women in contrast to men, with dyslipidemia and heart rate >80 beats per minute are less likely to maintain hypertension control. CONCLUSION: Sex-specific analysis indicated that BP control among United Arab Emirates men and women was suboptimal (65%). Interventions aiming to achieve better control of BP in hypertensive patients with metabolic syndrome should be emphasized.

Antithrombotic therapy after percutaneous coronary intervention of bifurcation lesions.

Coronary bifurcations exhibit localised turbulent flow and an enhanced propensity for atherothrombosis, platelet deposition and plaque rupture. Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with an increased risk of thrombotic events. Such risk is modulated by anatomical complexity, intraprocedural factors and pharmacological therapy. There is no consensus on the appropriate PCI strategy or the optimal regimen and duration of antithrombotic treatment in order to decrease the risk of ischaemic and bleeding complications in the setting of coronary bifurcation. A uniform therapeutic approach meets a clinical need. The present initiative, promoted by the European Bifurcation Club (EBC), involves opinion leaders from Europe, America, and Asia with the aim of analysing the currently available evidence. Although mainly derived from small dedicated studies, substudies of large trials or from authors' opinions, an algorithm for the optimal management of patients undergoing bifurcation PCI, developed on the basis of clinical presentation, bleeding risk, and intraprocedural strategy, is proposed here.

Precipitating Factors Leading to Hospitalization and Mortality in Heart Failure Patients: Findings from Gulf CARE.

Aim: To investigate the precipitating factors that contribute to hospitalization and mortality in postacute heart failure (AHF) hospitalization in the Middle-East region. Methods: We evaluated patient data from the Gulf AHF registry (Gulf CARE), a prospective multicenter study conducted on hospitalized AHF patients in 47 hospitals across seven Middle Eastern Gulf countries in 2012. We performed analysis by adjusting confounders to identify important precipitating factors contributing to rehospitalization and 90- to 120-day follow-up mortality. Results: The mean age of the cohort (n = 5005) was 59.3 ± 14.9 years. Acute coronary syndrome (ACS) (27.2%), nonadherence to diet (19.2%), and infection (14.6%) were the most common precipitating factors identified. After adjusting for confounders, patients with AHF precipitated by infection (hazard ratio [HR], 1.40; 95% confidence interval [CI] 1.10-1.78) and ACS (HR-1.23; 95% CI: 0.99-1.52) at admission showed a higher 90-day mortality. Similarly, AHF precipitated by infection (HR-1.13; 95% CI: 0.93-1.37), and nonadherence to diet and medication (HR-1.12; 95% CI: 0.94-1.34) during hospitalization showed a persistently higher risk of 12-month mortality compared with AHF patients without identified precipitants. Conclusion: Precipitating factors such as ACS, nonadherence to diet, and medication were frequently identified as factors that influenced frequent hospitalization and mortality. Hence, early detection, management, and monitoring of these prognostic factors in-hospital and postdischarge should be prioritized in optimizing the management of HF in the Gulf region.

Effect of Vasodilatory Medications on Blood Pressure in Patients Undergoing Transradial Coronary Angiography: A Comparative Study.

BACKGROUND: In patients undergoing coronary intervention, different vasodilators are used to prevent the radial artery spasm (RAS). To date, no studies investigated the effect of these vasodilators in blood pressure (BP) reduction. AIM: The study aimed to investigate and compare the effect of vasodilatory medications on BP reduction in patients undergoing transradial coronary angiography procedure. METHODS: We consecutively included 300 patients undergoing transradial coronary angiography procedures and randomly assigned them into three equal groups to compare the effect of verapamil (2.5 mg), nitroglycerin (200 µg), and combination (verapamil 2.5 mg with nitroglycerin 200 (µg) was diluted in 5 ml of normal saline and given through radial sheath. Changes in the BP, heart rate (HR), and other clinical parameters were assessed and presented as standardized mean differences (SMD) with 95% confidence intervals (CIs). ANOVA test was performed to analyze the differences in the BP and other clinical parameters between the three groups. RESULTS: Overall, the mean age of the study population was 53.26 years (standard deviation: 9.27), male patients (84%), with dyslipidemia (62.6%), and diabetes (45%). At baseline, the mean systolic BP (SBP) was 150.91 ± 31.66 mmHg, HR (72.34 ± 12.71 beats/min). After the administration of vasodilators, the combination group reduced SBP significantly (SMD: -33.35 [95% CI]: -40.27--26.42, P < 0.001). There was a statistically significant difference between groups for the SBP (F [2,296] =3.38, P = 0.035). Verapamil alone showed a significant decrease in the SBP by -27.23 mmHg and diastolic BP by -4.980 mmHg. CONCLUSION: Intra-arterial administration of verapamil alone showed lower BP reduction compared to the combination of vasodilators. Verapamil could be a safer and effective alternative to prevent RAS with no deleterious effect on BP and HR in patients undergoing transradial coronary angiography.

Statin Therapy and Low-Density Lipoprotein Cholesterol Reduction after Acute Coronary Syndrome: Insights from the United Arab Emirates.

BACKGROUND AND AIMS: Attaining guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals (<70 mg/dl or ≥ 50% reduction) with statin therapy remains suboptimal after an acute coronary syndrome (ACS). This study aimed to assess the level of lipid-lowering therapy (LLT) utilization and achievement of LDL-C targets after ACS hospitalization in the United Arab Emirates (UAE). METHODS: A retrospective, observational, longitudinal database analysis of Emirati patients with ACS or stable coronary heart disease was evaluated from January 2015 to June 2018. Patients were divided based on whether or not they were treated with LLT at index hospitalization with ACS. LDL-C target level achievement was assessed according to the 2013 American College of Cardiology/American Heart Association and European Society of Cardiology/European Atherosclerosis Society guidelines. RESULTS: A total of 3,066 patients (mean age 65.5 ± 14 years) met the inclusion criteria. Overall, 58.1% (n = 1782) of the patients in the cohort were on LLT during the ACS hospitalization. At discharge, the mean LDL-C level was 84.8 ± 39.0 mg/dl, and 28%, 21%, and 9% received high-, moderate-, and low-intensity statins, respectively. At 6 months (n = 2046; 66.7%), 27.7% and 16.7% achieved an LDL-C of <70 mg/dl and 70-100 mg/dl, respectively. The highest level of LDL-C reduction by 50% within 6 months was observed among patients using moderate-intensity statin (37.2%). CONCLUSION: A large proportion of Emirati patients were not on LLT after ACS, and the rate of LDL-C target value attainment was extremely poor (27.7%). Optimal statin utilization by closely implementing the guidelines in the UAE is recommended.

Clinical presentation and outcomes of peripartum cardiomyopathy in the Middle East: a cohort from seven Arab countries.

AIMS: Published data on the clinical presentation of peripartum cardiomyopathy (PPCM) are very limited particularly from the Middle East. The aim of this study was to examine the clinical presentation, management, and outcomes of patients with PPCM using data from a large multicentre heart failure (HF) registry from the Middle East. METHODS AND RESULTS: From February to November 2012, a total of 5005 consecutive patients with HF were enrolled from 47 hospitals in 7 Middle East countries. From this cohort, patients with PPCM were identified and included in this study. Clinical features, in-hospital, and 12 months outcomes were examined. During the study period, 64 patients with PPCM were enrolled with a mean age of 32.5 ± 5.8 years. Family history was identified in 11 patients (17.2%) and hypertension in 7 patients (10.9%). The predominant presenting symptom was dyspnoea New York Heart Association class IV in 51.6%, class III in 31.3%, and class II in 17.2%. Basal lung crepitations and peripheral oedema were the predominant signs on clinical examination (98.2% and 84.4%, respectively). Most patients received evidence-based HF therapies. Inotropic support and mechanical ventilation were required in 16% and 5% of patients, respectively. There was one in-hospital death (1.6%), and after 1 year of follow-up, nine patients were rehospitalized with HF (15%), and one patient died (1.6%). CONCLUSIONS: A high index of suspicion of PPCM is required to make the diagnosis especially in the presence of family history of HF or cardiomyopathy. Further studies are warranted on the genetic basis of PPCM.

Age-Related Sex Differences in Clinical Presentation, Management, and Outcomes in ST-Segment-Elevation Myocardial Infarction: Pooled Analysis of 15 532 Patients From 7 Arabian Gulf Registries.

Background No studies from the Arabian Gulf region have taken age into account when examining sex differences in ST-segment-elevation myocardial infarction (STEMI) presentation and outcomes. We examined the relationship between sex differences and presenting characteristics, revascularization procedures, and in-hospital mortality after accounting for age in patients hospitalized with STEMI in the Arabian Gulf region from 2005 to 2017. Methods and Results This study was a pooled analysis of 31 620 patients with a diagnosis of acute coronary syndrome enrolled in 7 Arabian Gulf registries. Of these, 15 532 patients aged ≥18 years were hospitalized with a primary diagnosis of STEMI. A multiple variable regression model was used to assess sex differences in revascularization, in-hospital mortality, and 1-year mortality. Odds ratios and 95% CIs were calculated. Women were, on average, 8.5 years older than men (mean age: 61.7 versus 53.2 years; absolute standard mean difference: 68.9%). The age-stratified analysis showed that younger women (aged <65 years) with STEMI were more likely to seek acute medical care and were less likely to receive thrombolytic therapies or primary percutaneous coronary intervention and guideline-recommended pharmacotherapy than men. Women had higher crude in-hospital mortality than men, driven mainly by younger age (46-55 years, odds ratio: 2.60 [95% CI, 1.80-3.7]; P<0.001; 56-65 years, odds ratio: 2.32 [95% CI, 1.75-3.08]; P<0.001; and 66-75 years, odds ratio: 1.79 [95% CI, 1.33-2.41]; P<0.001). Younger women had higher adjusted in-hospital and 1-year mortality rates than younger men (P<0.001). Conclusions Younger women (aged ≤65 years) with STEMI were less likely to receive guideline-recommended pharmacotherapy and revascularization than younger men during hospitalization and had higher in-hospital and 1-year mortality rates.

Agreement between cardiovascular disease risk assessment tools: An application to the United Arab Emirates population.

INTRODUCTION: Evidence regarding the performance of cardiovascular disease (CVD) risk assessment tools is limited in the United Arab Emirates (UAE). Therefore, we assessed the agreement between various externally validated CVD risk assessment tools in the UAE. METHODS: A secondary analysis of the Abu Dhabi Screening Program for Cardiovascular Risk Markers (AD-SALAMA) data, a large population-based cross-sectional survey conducted in Abu Dhabi, UAE during the period 2009 until 2015, was performed in July 2019. The analysis included 2,621 participants without type 2 Diabetes and without history of cardiovascular diseases. The CVD risk assessment tools included in the analysis were the World Health Organization for Middle East and North Africa Region (WHO-MENA), the systematic coronary risk evaluation for high risk countries (SCORE-H), the pooled cohort risk equations for white (PCRE-W) and African Americans (PCRE-AA), the national cholesterol education program Framingham risk score (FRAM-ATP), and the laboratory Framingham risk score (FRAM-LAB). RESULTS: The overall concordance coefficient was 0.50. The agreement between SCORE-H and PCRE-W, PCRE-AA, FRAM-LAB, FRAM-ATP and WHO-MENA, were 0.47, 0.39, 0.0.25, 0.42 and 0.18, respectively. PCRE-AA classified the highest proportion of participants into high-risk category of CVD (16.4%), followed by PCRE-W (13.6%), FRAM-LAB (6.9%), SCORE-H (4.5%), FRAM-ATP (2.7%), and WHO-MENA (0.4%). CONCLUSIONS: We found a poor agreement between various externally validated CVD risk assessment tools when applied to a large data collected in the UAE. This poses a challenge to choose any of these tools for clinical decision-making regarding the primary prevention of CVD in the country.

Precipitating Factors for Hospitalization with Heart Failure: Prevalence and Clinical Impact Observations from the Gulf CARE (Gulf aCute heArt failuRe rEgistry).

OBJECTIVE: Despite the expanding burden of heart failure (HF) worldwide, data on HF precipitating factors (PFs) in developing countries, particularly the Middle East, are very limited. We examined PFs in patients hospitalized with acute HF in a prospective multicenter HF registry from 7 countries in the Middle East. METHOD: Data were derived from the Gulf CARE (Gulf aCute heArt failuRe rEgistry) for a prospective, multinational, multicenter study of consecutive patients hospitalized with HF in 47 hospitals in 7 Middle Eastern countries between February 2012 and November 2012. PFs were determined by the treating physician from a predefined list at the time of hospitalization. RESULTS: The study included 5,005 patients hospitalized with acute HF, 2,276 of whom (45.5%) were hospitalized with acute new-onset HF (NOHF) and 2,729 of whom (54.5%) had acute decompensated chronic HF (DCHF). PFs were identified in 4,319 patients (86.3%). The most common PF in the NOHF group was acute coronary syndromes (ACS) (39.2%). In the DCHF group, it was noncompliance with medications (27.8%). Overall, noncompliance with medications was associated with a lower inhospital mortality (OR 0.47; 95% CI 0.28-0.80; p = 0.005) but a higher 1-year mortality (OR 1.43; 95% CI 1.1-1.85; p = 0.007). ACS was associated with higher inhospital mortality (OR 1.84; 95% CI 1.26-2.68; p = 0.002) and higher 1-year mortality (OR 1.62; 95% CI 1.27-2.06; p = 0.001). CONCLUSION: Preventive and therapeutic interventions specifically directed at noncompliance with medications and ACS are warranted in our region.

The Incidence of Adverse Drug Reactions in Patients Treated with Statins in the Emirates: A Retrospective Cohort Study.

AIM: We investigated the incidence of adverse drug reactions (ADRs) in patients treated with statins for cardiovascular (CV) risk among the United Arab Emirates (UAE) population. METHODS: This is a retrospective cohort study conducted among statin users attending 2 tertiary care centres: Al Ain and Tawam hospitals in Al Ain city, UAE. We retrieved the clinical profile of all the patients taking statins from January 2011 to January 2015 using our electronic database (Cerner®). RESULTS: Among 556 patients (418 men; 138 women) taking statins, 237 ADRs were reported (186 men; 51 women). The incidence of ADRs was 40.7%, and was more frequent among patients at "high CV disease (CVD) risk" and "moderate CVD risk" than other risk categories. High CVD risk (odds ratio, 1.67; 95% confidence interval [CI], 1.19-2.34), vitamin D deficiency 1.45 (95% CI, 0.89-2.38), type 2 diabetes 1.22 (95% CI, 0.84-1.77) and hypertension 1.13 (95% CI, 0.70-1.83) are some of the factors that were associated with statin ADRs. CONCLUSION: The incidence of ADRs among statin users was 42.6%, and frequent ADRs (49%) were noted in patients with high CVD risk. Early identification of these ADRs should improve patient adherence to life-saving statin treatment.

Diabetes and Mortality in Acute Coronary Syndrome: Findings from the Gulf COAST Registry.

BACKGROUND: The prevalence of traditional risk factors such as diabetes mellitus (DM) and obesity are increasing in patients with acute coronary syndrome (ACS). Furthermore, outcomes after ACS are worse in patients with DM. The high prevalence of DM and an early age at onset of ACS have been described in prior publications from the Gulf Coast Database. AIMS: We aimed to define the effect of DM on total mortality following ACS presentation at 30-days and 1 year based on the Gulf COAST registry database. METHODS: The Gulf COAST registry is a prospective, multinational, longitudinal, observational cohort study conducted among Gulf citizens admitted with a diagnosis of ACS. The outcomes among patients with DM following ACS were stratified into 2 groups based on their DM status. Cumulative survival stratified by groups and subgroup categories was assessed by the Kaplan-Meier method. RESULTS: Of 3,576 ACS patients, 2,730 (76.3%) presented with non ST-segment elevation myocardial infarction (NSTEMI) and 846 (23.6%) with STEMI. Overall, 1906 patients (53.3%) had DM. A significantly higher in-hospital (4.8%), 30-day (6.7%) and 1-year (13.7%) mortality were observed in patients with DM compared with those without DM. The Kaplan-Meier survival curve showed significant differences in survival of ACS patients with or without DM, with a short period of time-to-event for DM patients with STEMI (30-days) and the longest (1-year) for NSTEMI patients without DM. CONCLUSION: DM patients presenting with ACS-STEMI have poor short-term outcomes while DMNSTEMI patients have poor long-term outcomes. This highlights the need for strategies to evaluate DM control and integration of care to control vascular risk among this high-risk population.

A systematic review and meta-analysis of the prevalence and complications of paraphenylenediamine-containing hair dye poisoning in developing countries.

BACKGROUND: Suicide is a public health problem, and the number of paraphenylenediamine (PPD)-containing hair dye poisoning with suicidal intentions is increasing in developing countries. In order to better understand this situation, we aimed to conduct a systematic review and meta-analysis to estimate the prevalence and complications associated with hair dye poisoning in developing countries. METHODS: We conducted a systematic review of epidemiological studies using MeSh terms and text keywords to identify studies from the inception to March 2016 about hair dye poisoning with suicidal intentions in developing countries. A meta-analysis was used to calculate the pooled prevalence proportion of hair dye poisoning and its major complications. Data extraction, data analysis, and risk of bias assessment were performed. RESULTS: Thirty-two studies were included in the systematic review and 29 of these studies containing 5,559 subjects covering six countries were included in the meta-analysis. The pooled prevalence proportion of hair dye poisoning with suicidal intentions was 93.5% (95% confidence interval [CI] = 91.6-95.4) with a mortality rate of 14.5% (95% CI = 11.1-17.9). Of these, 73.8% were female, and 26.2% were male (sex ratio: 2.7:1). The occurrence of angioneurotic edema in hair poisoning patients was 67.1% (95% CI = 56.6-77.6), and tracheostomy intervention was considered in 47.9% (95% CI = 22.7-73.2) patients with respiratory distress. Acute renal failure was noticed in 54.7% (95% CI = 34.5-74.9) of the pooled samples and mortality rates were 14.5% (95% CI = 11.1-17.9). The pooled rate of the population studied from Asia and Africa showed 94.6% (95% CI = 92.5-96.7) and 82.9% (95% CI = 70.6-95.3), respectively, ingested hair dye with suicidal intentions. Further, studies carried out in Africa showed slightly higher mortality of 15.1% (95% CI = 6.56-23.7) than the Asians 14.3% (95% CI = 10.5-18.1). CONCLUSION: This meta-analysis provided clear evidence of the prevalence of hair dye poisoning among individuals with suicidal intentions and had given robust evidence for policy making to curtail emerging PPD-containing hair dye poisoning in developing countries.

Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.

Background Smoker's paradox has been observed with several vascular disorders, yet there are limited data in patients with acute heart failure (HF). We examined the effects of smoking in patients with acute HF using data from a large multicenter registry. The objective was to determine if the design and analytic approach could explain the smoker's paradox in acute HF mortality. Methods and Results The data were sourced from the acute HF registry (Gulf CARE [Gulf Acute Heart Failure Registry]), a multicenter registry that recruited patients over 10 months admitted with a diagnosis of acute HF from 47 hospitals in 7 Middle Eastern countries. The association between smoking and mortality (in hospital) was examined using covariate adjustment, making use of mortality risk factors. A parallel analysis was performed using covariate balancing through propensity scores. Of 5005 patients hospitalized with acute HF, 1103 (22%) were current smokers. The in-hospital mortality rates were significantly lower in current smoker's before (odds ratio, 0.71; 95% CI, 0.52-0.96) and more so after (odds ratio, 0.47; 95% CI, 0.31-0.70) covariate adjustment. With the propensity score-derived covariate balance, the smoking effect became much less certain (odds ratio, 0.63; 95% CI, 0.36-1.11). Conclusions The current study illustrates the fact that the smoker's paradox is likely to be a result of residual confounding as covariate adjustment may not resolve this if there are many competing prognostic confounders. In this situation, propensity score methods for covariate balancing seem preferable. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01467973.

Association between Peripheral Artery Disease and Major Adverse Cardiovascular Events in Patients with Acute Coronary Syndrome: Findings from the Gulf COAST Registry.

OBJECTIVE: To evaluate the association between peripheral artery disease (PAD) and major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) in the Arabian Gulf. METHODS: Data from 4,044 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013 were analyzed. PAD was defined as any of the following: claudication, amputation for arterial vascular insufficiency, vascular reconstruction, bypass surgery, or percutaneous intervention in the extremities, documented aortic aneurysm or an ankle brachial index of <0.8 in any of the legs. MACE included stroke/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and readmissions for cardiac reasons diagnosed between hospital admission and at 1-year post discharge. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The overall mean age of the cohort was 60 ± 13 years and 66% (n = 2,686) were males. A total of 3.3% (n = 132) of the patients had PAD. Patients with PAD were more likely to be associated with smoking, prior MI, hypertension, diabetes mellitus, and stroke/TIA. At the 1-year follow-up, patients with PAD were significantly more likely to have MACE (adjusted OR [aOR], 2.07; 95% confidence interval [CI]: 1.41-3.06; p< 0.001). The higher rates of events were also observed across all MACE components; stroke/TIA (aOR, 3.22; 95% CI: 1.80-5.75; p< 0.001), MI (aOR, 2.15; 95% CI: 1.29-3.59; p =0.003), all-cause mortality (aOR, 2.21; 95% CI: 1.33-3.69; p =0.002), and readmissions for cardiac reasons (aOR, 1.83; 95% CI: 1.24-2.70; p =0.003). CONCLUSIONS: PAD was significantly associated with MACE in ACS patients in the Arabian Gulf.