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.

Marital status and outcome of patients presenting with acute coronary syndrome: an observational report.

UNLABELLED: BACKGROUND & HYPOTHESIS: Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear. METHODS: A total of 5334 patients presenting with ACS in 65 hospitals in 6 Middle East countries in the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2) were studied according to their marital status (5024 married, 100 single, and 210 widowed patients). RESULT: When compared to married patients, widowed patients were older and more likely to be female. Widowed patients were more likely to have diabetes mellitus, hypertension, history of heart failure, and peripheral vascular disease and were less likely to be tobacco users when compared to the other groups. Widowed patients were also more likely to present with atypical symptoms and have advanced Killip class. Widowed patients were more likely to present with non-ST-elevation myocardial infarction (NSTEMI) when compared to the other 2 groups. Widowed patients were more likely to have heart failure (P = 0.001), cardiogenic shock (P = 0.001), and major bleeding (P = 0.002) when compared to the other groups. No statistically significant difference was observed in regard to duration of hospital stay, door to needle time in STEMI patients, or cardiac arrhythmias between the various groups. Widowed patients had higher in-hospital, 30-day, and 1-year mortality rates (P = 0.001). Marital status was an independent predictor for in-hospital mortality. CONCLUSION: Widowed marital status was associated with worse cardiovascular risk profile, and worse in-hospital and 1-year outcome. Future work should be focused on whether the provision of psychosocial support will result in improved outcomes among this high-risk group.

Tobacco modalities used and outcome in patients with acute coronary syndrome: an observational report.

AIM: The authors evaluated the prevalence and effect of the various tobacco use modalities among patients presenting with acute coronary syndrome (ACS) and compared them with non-tobacco and ex-tobacco users. METHODS: An analysis of the 2nd Gulf Registry of Acute Coronary Events conducted between October 2008 and June 2009 and which included 7930 consecutive patients hospitalised with ACS was made. Patients initially were divided into non-tobacco users, ex-tobacco users and current tobacco users. Subanalysis according to the tobacco modality used was subsequently made: cigarette, waterpipe or smokeless tobacco users. RESULTS: Overall, 2834 (36%) patients were current tobacco users, 306 (3.9%) patients were waterpipe smokers and 240 patients (3%) were oral tobacco users. When compared with non-tobacco and ex-tobacco users, overall current tobacco users were younger, more likely to be male subjects and less likely to have diabetes mellitus, hypertension and dyslipidaemia. Mortality rate (p=0.001) and overall cardiovascular events (p=0.001) were lower among current tobacco users when compared with the other two groups. After adjustment for baseline variables, tobacco use was not an independent predictor of adverse events. Subset analysis demonstrates oral tobacco users and waterpipe smokers were older and more likely to be women when compared with cigarette smokers. Among the various tobacco groups, inhospital mortality rates were significantly higher among the waterpipe smokers when compared with the other two groups. CONCLUSIONS: Clinical characteristics and outcomes of ACS patients depend on the tobacco modality used. Further studies are required to evaluate the impact of emerging tobacco use modalities on patients with coronary artery disease.

Prior antiplatelet use and cardiovascular outcomes in patients presenting with acute coronary syndromes.

BACKGROUND: Although antiplatelet therapy effectively reduces ischemic events, the cardiovascular (CV) outcome in some cases is still unpredictable. OBJECTIVE: The objective of this study was to evaluate the impact of prior single or dual antiplatelet (PAP) use in patients presenting with acute coronary syndromes (ACS). METHODS: Data were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were grouped according to whether they were PAP users or not (NAP). Patients' characteristics and outcomes were analyzed and compared. Mortality was assessed at 1 and 12 months. RESULTS: Among 7827 consecutive ACS patients, 41% were PAP users (70% aspirin, 1% clopidogrel, and 29% dual antiplatelet agents). In comparison with NAP use, PAP use was associated with a higher rate of co-morbidities, atypical presentation, severe left ventricular dysfunction, three-vessel disease, and a high GRACE risk score. After adjustment for relevant covariates, PAP use was an independent predictor for recurrent ischemia in unstable angina (odds ratio [OR] 1.7; 95% CI 1.17, 2.57) and non-ST-elevation myocardial infarction (NSTEMI) [OR 1.9; 95% CI 1.38, 2.65] and for heart failure in NSTEMI (OR 1.5; 95% CI 1.11, 2.15) and STEMI (OR 1.4; 95% CI 1.08, 1.93). Although PAP use was associated with high mortality in STEMI and NSTEMI, it was not an independent predictor for mortality. Among PAP patients, percutaneous coronary intervention independently reduced the risk of hospital (adjusted OR 0.25; 95% CI 0.20, 0.32), 1-month (OR 0.31; 95% CI 0.26, 0.37), and 12-month mortality (OR 0.28; 95% CI 0.24, 0.33). CONCLUSION: PAP use identified a high-risk population across the ACS spectrum. Early coronary revascularization may improve CV outcomes in these patients.

Baseline characteristics, management practices, and long-term outcomes of Middle Eastern patients in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2).

BACKGROUND AND OBJECTIVES: Limited data are available on patients with acute coronary syndromes (ACS) and their long-term outcomes in the Arabian Gulf countries. We evaluated the clinical features, management, in-hospital, and long-term outcomes of in such a population. DESIGN AND SETTING: A 9-month prospective, multicenter study conducted in 65 hospitals from 6 countries that also included 30 day and 1-year mortality follow-up. PATIENTS AND METHODS: ACS patients included those with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTEACS), including non-STEMI and unstable angina. The registry collected the data prospectively. RESULTS: Between October 2008 and June 2009, 7930 patients were enrolled. The mean age (standard deviation), 56 (17) years; 78.8% men; 71.2% Gulf citizens; 50.1% with central obesity; and 45.6% with STEMI. A history of diabetes mellitus was present in 39.5%, hypertension in 47.2%, and hyperlipidemia in 32.7%, and 35.7% were current smokers. The median time from symptom onset to hospital arrival for STEMI patients was 178 minutes (interquartile range, 210 minutes); 22.3% had primary percutaneous coronary intervention (PCI) and 65.7% thrombolytic therapy, with 34% receiving therapy within 30 minutes of arrival. Evidence-based medication rates upon hospital discharge were 68% to 95%. The in-hospital PCI was done in 21% and the coronary artery bypass graft surgery in 2.9%. The in-hospital mortality was 4.6%, at 30 days the mortality was 7.2% , and at 1 year after hospital discharge the mortality was 9.4% ; 1-year mortality was higher in STEMI (11.5%) than in NSTEACS patients (7.7%; P<.001). CONCLUSIONS: Compared to developed countries, ACS patients in Arabian Gulf countries present at a relatively young age and have higher rates of metabolic syndrome features. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates are high, but coronary revascularization procedures are low. Long-term mortality rates increased severalfold compared with in-hospital mortality.

Acute coronary syndrome and khat herbal amphetamine use: an observational report.

BACKGROUND: The khat plant is a stimulant similar to amphetamine and is thought to induce coronary artery spasm. Khat is widely chewed by individuals originating from the Horn of Africa and the Arabian Peninsula. The aim of this study was to evaluate the clinical characteristics and outcome of khat chewers presenting with acute coronary syndrome. METHODS AND RESULTS: From October 1, 2008, through June, 30, 2009, 7399 consecutive patients with acute coronary syndrome were enrolled in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Nineteen percent of patients were khat chewers; 81% were not. Khat chewers were older, more often male, and less likely to have cardiovascular risk factors. Khat chewers were less likely to have a history of coronary artery disease and more likely to present late and to have higher heart rate and advanced Killip class on admission. Khat chewers were more likely to present with ST-segment-elevation myocardial infarction. Overall, khat chewers had higher risk of death, recurrent myocardial ischemia, cardiogenic shock, ventricular arrhythmia, and stroke compared with non-khat chewers. After adjustment for baseline variability, khat chewing was found to be an independent risk factor of death and for recurrent ischemia, heart failure, and stroke. CONCLUSIONS: Our data confirm earlier observations of worse in-hospital outcome among acute coronary syndrome patients who chew khat. This worse outcome persists up to 1 year from the index event. This observational report underscores the importance of improving education concerning the cardiovascular risks of khat chewing.

Association of khat chewing with increased risk of stroke and death in patients presenting with acute coronary syndrome.

OBJECTIVE: To evaluate the prevalence and significance of khat chewing in patients with acute coronary syndrome (ACS). PATIENTS AND METHODS: From January 29, 2007, through July 29, 2007, 8176 consecutive patients presenting with ACS were enrolled in a prospective, multicenter study from 6 adjacent Middle Eastern countries. RESULTS: Of the 8176 study patients, 7242 (88.6%) were non-khat chewers, and 934 (11.4%) were khat chewers, mainly of Yemeni origin. Khat chewers were older (57 vs 56 years; P=.01) and more likely to be men (85.7% vs 74.5%) compared with non-khat chewers. Non-khat chewers were more likely to have diabetes mellitus, hypertension, dyslipidemia, obesity, and prior history of coronary artery disease and revascularization. Cigarette smoking was more prevalent in khat chewers, and they were more likely to present greater than 12 hours after onset of symptoms compared with non-khat chewers. At admission, khat chewers had higher heart rate, Killip class, and Global Registry of Acute Coronary Events risk scores. Khat chewers had a significantly higher risk of cardiogenic shock, stroke, and mortality. After adjustment of baseline variables, khat chewing was an independent risk factor for in-hospital mortality (odds ratio, 1.9; 95% confidence interval, 1.3-2.7; P<.001) and stroke (odds ratio, 2.7; 95% confidence interval, 1.3-5.9; P=.01). CONCLUSION: In this large cohort of patients with ACS, khat chewing was prevalent and was associated with increased risk of stroke and death. In the context of increasing global migration, a greater awareness of potential widespread practices is essential.