Atrial fibrillation in Middle Eastern Arabs and South Asians: a scoping review.

Most of the published literature on Atrial fibrillation (AF) originates from the northern hemisphere and mainly involves Caucasian patients, with limited studies in certain ethnicities and races. This scoping review was conducted to collect and summarize the pertinent evidence from the published scientific literature on AF in South Asians and Middle Eastern Arabs. MEDLINE, Embase and CENTRAL databases were included in our search. After screening 8995 records, 55 studies were selected; 42 from the Middle East and 13 from South Asia. Characteristics of the included studies were tabulated, and their data were summarized for study design, setting, enrolment period, sample size, demographics, prevalence or incidence of AF, co-morbidities, risk factors, AF types and symptoms, management, outcomes, and risk determinants. Identified literature gaps included a paucity of community or population-based studies that are representative of these two ethnicities/races. In addition, studies that addressed ethnic/racial in-equality and access to treatment were lacking. Our study underscores the urgent need to study cardiovascular disorders, particularly AF, in South Asians and Middle Eastern Arabs as well as in other less represented ethnicities and races.

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.

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

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

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.

Immediate and one-year outcome of patients presenting with acute coronary syndrome complicated by stroke: findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2).

BACKGROUND: Stroke is a potential complication of acute coronary syndrome (ACS). The aim of this study was to identify the prevalence, risk factors predisposing to stroke, in-hospital and 1-year mortality among patients presenting with ACS in the Middle East. METHODS: For a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries. RESULTS: The prevalence of in-hospital stroke following ACS was 0.70%. Most cases were ST segment elevation MI-related (STEMI) and ischemic stroke in nature. Patients with in-hospital stroke were 5 years older than patients without stroke and were more likely to have hypertension (66% vs. 47.6%, P = 0.001). There were no differences between the two groups in regards to gender, other cardiovascular risk factors, or prior cardiovascular disease. Patients with stroke were more likely to present with atypical symptoms, advanced Killip class and less likely to be treated with evidence-based therapies. Independent predictors of stroke were hypertension, advanced killip class, ACS type -STEMI and cardiogenic shock. Stroke was associated with increased risk of in-hospital (39.3% vs. 4.3%) and one-year mortality (52% vs. 12.3%). CONCLUSION: There is low incidence of in-hospital stroke in Middle-Eastern patients presenting with ACS but with very high in-hospital and one-year mortality rates. Stroke patients were less likely to be appropriately treated with evidence-based therapy. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

Effect of age on treatment, trends and outcome of patients hospitalized with atrial fibrillation: insights from a 20-years registry in a Middle-Eastern country (1991-2010).

BACKGROUND: Most studies on atrial fibrillation (AF) epidemiology, treatment, and outcomes have included mainly Caucasians patients. The world literature on AF in other ethnicities is very limited particularly in the elderly. AIMS: The aim of this study was to compare the clinical characteristics, treatment and outcome of elderly and younger patients hospitalized with AF in a Middle-Eastern country and examine the trends of AF etiologies over a 20-year period. METHODS: A retrospective analysis of a prospective registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made. Patients were divided into three groups; group 1: patients ≤50 years old, group 2: patients between 51 and 70 years old, and group 3: patients >70 years old. Clinical characteristics, management, and outcomes of AF patients were compared according to age. RESULTS: Between the year 1991 and the end of 2010, a total 3848 consecutive patients were admitted with AF. One thousand three hundred and forty-five patients were ≤50 years, 1759 were between 51 and 70 years and 744 patients were >70 years old. Elderly patients were more likely to have hypertension and chronic renal impairment. There was a higher prevalence of associated coronary artery disease and aortic stenosis in elderly patients with a lower left ventricular ejection fraction than the younger age groups. A lower use of anticoagulation in the elderly group was observed but there was no underuse of other evidence-based medications. The older AF patients had significantly higher in-hospital mortality and stroke rates with no significant changes in mortality trends over the 20 years of study. An increasing trend of the associated acute coronary syndromes, hypertension and diabetes mellitus prevalence was observed in the elderly group. CONCLUSION: Anticoagulation remains underutilized in elderly patients with AF despite proven efficacy and increasing trends of cardiovascular comorbidities. The current study underscores the urgent need for prospective studies to investigate warfarin contraindications, relative warfarin efficacy and bleeding risks in our region to help guide healthcare providers in warfarin prescribing in this frail patient population and consequently reduce the risk of AF-related disabling strokes and mortality.

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.

Hypertension in Middle Eastern Arab and South Asian Patients with Atrial Fibrillation: From a 20-Year Hospital Registry in Qatar (1990-2010).

Background: The vast majority of literature on atrial fibrillation (AF) is based on studies from the developed world that mainly includes Caucasian patients. Data on AF in other ethnicities is very limited. The aim of this hospital-based study is to evaluate the effect of concomitant hypertension (HTN) on the characteristics and outcomes of Middle Eastern Arab and South Asian patients with AF in the state of Qatar. Materials and Methods and Results: During the 20-year period, 3850 AF patients were hospitalized; 1483 (38.5%) had HTN, and 2367 (61.5%) without HTN. Patients with HTN were 11 years older, compared to non-HTN patients, and had a significantly higher prevalence of diabetes mellitus, chronic kidney disease, and dyslipidemia, compared to non-HTN patients. Furthermore, underlying coronary artery disease and heart failure were significantly more common but not valvular and rheumatic heart diseases which were more common in those without HTN. The rates of in-hospital mortality and stroke were significantly higher in the presence of HTN (5.3% versus 3.5%, and 0.7% versus 0.2% respectively, P = 0.001), compared to non-HTN patients. Conclusions: HTN is significantly associated with more comorbidities and worse clinical outcomes when it coexists with AF in hospitalized Middle Eastern Arab and South Asian patients.

Vasoactive pharmacologic therapy in cardiogenic shock: a critical review.

BACKGROUND: Cardiogenic shock (CS) is an acute complex condition leading to morbidity and mortality. Vasoactive medications, such as vasopressors and inotropes are considered the cornerstone of pharmacological treatment of CS to improve end-organ perfusion by increasing cardiac output (CO) and blood pressure (BP), thus preventing multiorgan failure. OBJECTIVE: A critical review was conducted to analyze the currently available randomized studies of vasoactive agents in CS to determine the indications of each agent and to critically appraise the methodological quality of the studies. METHODS: PubMed database search was conducted to identify randomized controlled trials (RCTs) on vasoactive therapy in CS. After study selection, the internal validity of the selected studies was critically appraised using the three-item Jadad scale. RESULTS: Nine studies randomized 2388 patients with a mean age ranged between 62 and 69 years, were identified. Seven of studies investigated CS in the setting of acute myocardial infarction (AMI). The studies evaluated the comparisons of norepinephrine (NE) vs. dopamine, epinephrine vs. NE, levosimendan vs. dobutamine, enoximone or placebo, and nitric oxide synthase inhibitors (NOSi) vs. placebo. The mean Jadad score of the nine studies was 3.33, with only three studies of a score of 5. CONCLUSIONS: The evidence from the studies of vasoactive agents in CS carries uncertainties. The methodological quality between the studies is variable due to the inherent difficulties to conduct a study in CS. Vasopressors and inotropes continue to have a fundamental role given the lack of pharmacological alternatives.

Opt-Out Consent at Different Levels of Attitude to Organ Donation: A Household Survey in Qatar.

PURPOSE: Demand for an organ transplant is surpassing the number of organ donors and hence increasing waiting lists worldwide, compelling many countries to adopt an opt-out consent system for organ donation. Opt-out is used in several European countries and has increased organ registration rate. No study on this subject has been published from the gulf region to associate sociodemographic characteristics, knowledge, attitude, beliefs, and intention domains regarding an opt-out consent for organ donation. MATERIALS AND METHODS: A household survey was conducted between October and November 2016 using a validated questionnaire. Integer codes were assigned for qualitative data to interpret results at par with quantitative data for each domain to allow data for advanced statistical analysis. RESULTS: Of 1044 surveyed participants, 724 (69.34%) those aged 37.7±10.4 agreed to adopting an opt-out consent system of which 231 (29.4%) were Qatari citizens and 353 (48.8%) were males. Mean levels of indices such as attitude, behavioral beliefs, and intention domains to organ donation were found higher in opt out participants. After adjusting statistical significant variables, multivariate analysis showed that attitude index was associated to opt out system (OR: 16.7, 95% C.I.:10.6-26.3, p=0.001) whereas; knowledge index (OR: 0.25, 95% C.I.: 0.07-0.83, p=0.03), behavioral beliefs (OR: 0.55, 95% C.I.: 0.35-0.86, p=0.009) and intention indices (OR: 0.42, 95% C.I.: 0.20-0.87, p=0.02) were associated with opt-in system for organ donation in Qatar. Regression model was able to discriminate (AUC: 84%, 95% C.I.:81% to 87%) for opt-out consent. Future probabilities for opt-out consent were 0.80, 0.88, 0.92,0.95,0.96,0.97,0.99 and 0.993 for 0.20, 0.30, 0.40, 0.50, 0.60, 0.70, 0.80 and 0.90 attitude levels after using 200 re-samples to make traditional multivariate regression model to realistic model for the population. CONCLUSION: The majority of the survey participants showed a good attitude but less knowledge, behavioral beliefs, and intention towards adopting an opt-out system for organ donation in Qatar.

Thrombosis Management and Challenges in COVID-19 Patients Presenting with Acute Coronary Syndromes.

Thrombotic complications in patients with coronavirus disease 2019 (COVID-19) infection have been increasingly recognized, particularly those affecting the cardiovascular system. Patients with COVID-19 infection can suffer from increased coagulopathy as well as myocardial injury. In this review, we discuss these complications with special focus on management challenges in patients with acute coronary disease based on the available evidence from published literature.

Efficacy and safety of PCSK9 monoclonal antibodies: an evidence-based review and update.

OBJECTIVE: Treatment of dyslipidemia lowers cardiovascular (CV) risk. Although statin use is a cornerstone therapy, many patients are not achieving their risk-specific low-density lipoprotein cholesterol (LDL-C) goals. The proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies have been extensively studied as lipid-lowering therapy (LLT). Herein, we present an updated evidence-based review of the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of familial and non-familial hypercholesterolemia. METHODS: PubMed database was searched to review Phase III studies on PCSK9 monoclonal antibodies. Then, the US National Institutes of Health Registry and the WHO International Clinical Trial Registry Platform were searched to identify and present the ongoing research. RESULTS: PCSK9 monoclonal antibodies were investigated for the treatment of dyslipidemia, as a single therapeutic agent or as an add-on therapy to the traditional LLT. They proved effective and safe in the treatment of familial and non-familial hypercholesterolemia, and in the prevention of adverse CV events. CONCLUSIONS: The use of PCSK9 monoclonal antibodies in the treatment of dyslipidemia is currently recommended to achieve risk-specific LDL-C goal to reduce adverse CV events. Future results of the ongoing research might expand their clinical generalizability to broader patient populations.

PCSK9 Monoclonal Antibodies: An Overview.

PCSK9 monoclonal antibodies are novel lipid-lowering therapy that have been extensively studied in patients with hypercholesterolemia either as monotherapy or as an add-on to other LLTs. PCSK9 monoclonal antibodies have significantly reduced the low-density lipoprotein cholesterol (LDL-C) plasma level resulting in a better LDL-C goal attainment. The commercially available PCSK9 monoclonal antibodies, alirocumab and evolocumab, have demonstrated reductions in major adverse cardiovascular events such as myocardial infarction, stroke, unstable angina, and the need for coronary revascularization but not mortality. PCSK9 monoclonal antibodies have demonstrated a favorable safety profile. The most reported side effects are mild injection site with no causal relationship proven between the inhibition of PCSK9 and neurocognitive or glycemic adverse events. In this overview, the efficacy and safety of PCSK9 monoclonal antibodies in the treatment of primary and familial hypercholesterolemia will be discussed.

Racing for COVID-19 Vaccine and Cure: Lessons and Tragedies in Human Subject Research.

Pressured by the enormous human and economic costs of the COVID-19 pandemic, certain countries and political figures have advocated the use of drugs and vaccines that did not go through the required regulatory stages of the development. Although the reason for bypassing these stages in a race to produce a treatment and vaccine for the COVID-19 patients could have been caused by good intentions to stop the human suffering from the pandemic, nonetheless, history has taught us that the results of this action could be catastrophic. In this article, we briefly review the lessons and tragedies in the evolution of human subject research regulations emphasizing the need for the proper evaluation of drugs and vaccines for COVID-19.

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.

Atrial Fibrillation in Middle Eastern Arabs and South Asians: Summary of Published Articles in the Arabian Gulf.

Seven studies are summarized herein focusing on different aspects of Atrial fibrillation (AF) in two unique ethnicities for which there is very limited literature published before; Middle Eastern Arabs and South Asians, using data from a national registry of cardiovascular diseases in Qatar over a 20-years period (1991-2010). These studies shed light upon important aspects of AF presentations and outcomes in these two ethnicities, thereby enriching the world literature on AF. In the process, several novel observations were reported and new questions were raised that warrant further investigations.

Clinical Presentation, Quality of Care, Risk Factors and Outcomes in Women with Acute ST-Elevation Myocardial Infarction (STEMI): An Observational Report from Six Middle Eastern Countries.

BACKGROUND: Most of the available literature on ST-Elevated myocardial infarction (STEMI) in women was conducted in the developed world and data from Middle-East countries was limited. AIMS: To examine the clinical presentation, patient management, quality of care, risk factors and inhospital outcomes of women with acute STEMI compared with men using data from a large STEMI registry from the Middle East. METHODS: Data were derived from the third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps), a prospective, multinational study of adults with acute STEMI from 36 hospitals in 6 Middle-Eastern countries. The study included 2928 patients; 296 women (10.1%) and 2632 men (89.9%). Clinical presentations, management and in-hospital outcomes were compared between the 2 groups. RESULTS: Women were 10 years older and more likely to have diabetes mellitus, hypertension, and hyperlipidemia compared with men who were more likely to be smokers (all p<0.001). Women had longer median symptom-onset to emergency department (ED) arrival times (230 vs. 170 min, p<0.001) and ED to diagnostic ECG (8 vs. 6 min., p<0.001). When primary percutaneous coronary intervention (PPCI) was performed, women had longer door-to-balloon time (DBT) (86 vs. 73 min., p=0.009). When thrombolytic therapy was not administered, women were less likely to receive PPCI (69.7 vs. 76.7%, p=0.036). The mean duration of hospital stay was longer in women (6.03 ± 22.51 vs. 3.41 ± 19.45 days, p=0.032) and the crude in-hospital mortality rate was higher in women (10.4 vs. 5.2%, p<0.001). However, after adjustments, multivariate analysis revealed a statistically non-significant trend of higher inhospital mortality among women than men (6.4 vs. 4.6%), (p=0.145). CONCLUSION: Our study demonstrates that women in our region have almost double the mortality from STEMI compared with men. Although this can partially be explained by older age and higher risk profiles in women, however, correction of identified gaps in quality of care should be attempted to reduce the high morbidity and mortality of STEMI in our women.

Circadian Rhythm and ST-Segment Elevation Myocardial Infarction: Insights From the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps).

Circadian rhythms have been identified in multiple physiological processes that may affect cardiovascular diseases, yet little is known about the impact of circadian rhythm on acute ST-segment elevation myocardial infarction (STEMI) onset and outcomes in the Middle East. The relationship between time of symptom onset during the 24-hour circadian cycle and prehospital delays and in-hospital death was assessed in 2909 patients with STEMI presenting in 6 Arabian Gulf countries. A sinusoidal smoothing function was used to show the average circadian trends. There was a significant association between time of symptom onset and the circadian cycle. The STEMIs were more frequent during the late morning and early afternoon hours ( P < .001). Patients with pain onset from 0.00 to 5:59 had median prehospital delays of 150 minutes versus 90 minutes from 6:00 to 11:59 and 12:00 to 17:59, respectively ( P < .001). Although there was no significant difference in mortality between the 4 groups ( P = .230), there was a significant association between time of symptom onset as sinusoidal function and in-hospital mortality ( P = .032). Patients with STEMI in the Middle East have significant circadian patterns in symptoms onset, prehospital delay, and timeliness of reperfusion. A circadian rhythm of in-hospital mortality was found over the 24-hour clock of symptom onset time.

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.

Impact of Chronic Kidney Disease on the Presentation and Outcome of Patients Hospitalized With Atrial Fibrillation: Insights From Qatar.

Atrial fibrillation (AF) with coexistent chronic kidney disease (CKD) is poorly described in the literature. We compared the presenting symptoms, clinical characteristics, treatment, and outcome of patients hospitalized with AF with and without CKD in a large clinical registry. Data of patients hospitalized with AF between 1991 and 2012 in Qatar were analyzed. Of 5201 patients hospitalized for AF, 264 (5.1%) had CKD. Patients with AF and CKD were older with higher prevalence of other comorbidities and left ventricular dysfunction and were more likely to present with shortness of breath and chest pain compared with patients with AF alone who were more likely to present with palpitation. The crude in-hospital mortality was 3 times higher in patients with dual disease. On multivariable adjustments, CKD was an independent predictor of mortality (odds ratio: 2.84; 95% confidence interval: 1.33-6.08, P = .001). Further studies are warranted to try to reduce the increased mortality observed in this high-risk population.