Flash'O real-world evidence programme - Attitude and practices toward the use of omega-3 FA by physicians from Middle East Countries.

The Flash'O project was designed to provide insights into the current use of prescription omega-3 and their perceived benefits by physicians in real-world clinical practice, in Russia, Saudi Arabia, Thailand, and Gulf countries, and to determine the adherence of physicians to dyslipidemia management guidelines. The present study focuses on Flash'O's process and results in Middle East countries. A total of 338 physicians and specialists completed the online questionnaire. Most responding physicians were male (91.7%), general practitioners (42.6%) with more than 5 years of seniority (80.4%) and saw more than 50 patients a week (71.5%). Most surveyed physicians (64.2%) reported using guidelines in their daily practice for the management of their patients with dyslipidemia. They mostly followed national guidelines (68.6%). American or European ones were less commonly used. Responding physicians thought that omega-3 supplementation could be more beneficial in all types of dyslipidemia, except high non- hight density lipoproteins, and for patients suffering from obesity, type 2 diabetes mellitus, acute coronary syndrome with ST-segment elevation myocardial infarction and high cardiovascular diseases risk (score ≥ 5% and < 10%), but less beneficial in chronic kidney disease. Respondents recommended omega-3 to their patients mainly after statin treatment in patients with dyslipidemia and for the treatment of dyslipidemia. This survey confirmed that omega-3 fatty acids are at the heart of the cardiovascular medical strategy.

Echocardiographic Imaging in Transcatheter Structural Intervention: An AAE Review Paper.

Transcatheter structural heart intervention (TSHI) has gained popularity over the past decade as a means of cardiac intervention in patients with prohibitive surgical risks. Following the exponential rise in cases and devices developed over the period, there has been increased focus on developing the role of "structural imagers" amongst cardiologists. This review, as part of a growing initiative to develop the field of interventional echocardiography, aims to highlight the role of echocardiography in myriad TSHIs available within Asia. We first discuss the various echocardiography-based imaging modalities, including 3-dimensional echocardiography, fusion imaging, and intracardiac echocardiography. We then highlight a selected list of structural interventions available in the region-a combination of established interventions alongside novel approaches-describing key anatomic and pathologic characteristics related to the relevant structural heart diseases, before delving into various aspects of echocardiography imaging for each TSHI.

Severe Rheumatic Mitral Stenosis, Worse Left Atrial Mechanics is Closely Associated with Echo Criteria for Intervention.

Background: Rheumatic mitral valve (MV) stenosis is associated with progressive left atrial (LA) fibrosis and functional impairment, Pulmonary artery systolic pressure (PASP) and right ventricular (RV) dysfunction. The aims of the study were to determine in those patients with severe MV stenosis if LA mechanical function as assessed by speckle tracking echocardiography could identify those with increased PASP, atrial fibrillation (AFib), and RV dysfunction. Subjects and Methods: Patients with severe MV stenosis were identified from the institutional echo database. Echocardiograms were read off line and measurements included atrial and ventricular strain. Patients were divided into tertiles of LA reservoir strain (LASr) values and data compared between the groups. Results: Ninety-seven patients, 67 females, mean age 47.4 ± 11.9 years, had MV mean gradient of 8.3 ± 5.1 mmHg, MV area by pressure half time of 1.3 ± 0.3 cm2 and LASr of 11.18% ± 6.4%. Those patients in the lowest LASr tertile had more AFib (72%, P = 0.0001), PASP >50 mm Hg (39%, P = 0.005), and worst RV impairment. In multivariable logistic regression analysis, LASr, age, and mean MV gradient were the independent predictors of AFib and PASP >50 mm Hg. Cutoffs, determined by receiver operating characteristic curve analysis had high specificity for the composite outcome of Afib and PASP >50 mmHg (85% for LASr <7.7%). Conclusion: In severe MV stenosis LASr, age and mean MV gradient, are independent predictors of Afib and PASP >50 mmHg. LASr <7.7% has high sensitivity and specificity in identifying those who meet ESC guideline 2017 criteria for valve intervention, suggesting its potentially helpful addendum to the surveillance of patients with MV stenosis.

Complications of White-coat Hypertension Compared to a Normotensive and Hypertensive Population.

BACKGROUND: Accumulating evidence demonstrates that white-coat hypertension (WCH) are associated with several risks and complications. In this study, we aimed to investigate the adverse effects of WCH compared with hypertensive and normotensive patients. METHODS: A retrospective cohort study was conducted over five years. Blood pressure (BP) data was collected from both clinic visits and 24-h ambulatory blood pressure monitoring (ABPM) reports. Epidemiological data and complications, cardiac and noncardiac, were also recorded. RESULTS: In total, 286 participants who were followed up for at least three years were included. The sample was divided into 99 normotensive patients (as a control group), 94 patients with clinically diagnosed hypertension (HTN), and 93 patients with WCH. Ischemic heart disease (IHD) was the most noted complication in the WCH group with a relative risk of 9.58 (1.23-74.16) (P = 0.008). Acute coronary syndrome (ACS) was significantly correlated with a relative risk of 2.06 (0.52-13.38). No significant correlation was noted with noncardiac complications. Both HTN and WCH groups showed a significant association with blood pressure variability (BPV). WCH was associated with an increased BPV in ambulatory daytime systolic measurements (P = 0.031) and a unique increase in diastolic measurement variability in office BP measurements (P = 0.020). CONCLUSION: WCH should be managed as HTN. WCH is associated with cardiac complications, particularly IHD, specifically in patients 55 years and older. WCH was significantly associated with a higher BPV in both ABPM and office-based measurements.

Gender differences in patients presenting with non-ST segment elevation myocardial infarction in the STAR registry.

BACKGROUND: In most acute coronary artery (ACS) related literature, the female gender constitutes a smaller proportion. This study is based on gender-specific data in the Saudi Acute Myocardial Infarction Registry Program (STARS-1 Program). A prospective multicenter study, conducted with patients diagnosed with ACS in 50 participating hospitals. RESULTS: In total, 762 (34.12%) patients were diagnosed with non-ST segment elevation myocardial infarction. Of this group, only 164 (21.52%) were women. The mean age (64.52 ± 12.56 years) was older and the mean body mass index (BMI) was higher (30.58 ± 6.23). A significantly proportion was diabetic or hypertensive; however, a smaller proportion was smoking. Hyperlipidemia was present in 48%. The history of angina/MI/stroke and revascularization was similar, except for renal impairment. The presentation was atypical as only 70% presented with chest pain, and the rest with shortness of breath or epigastric pain. At presentation, the female group were more tachycardiac, had higher blood pressure, and a higher incidence of being in class 11-111 Killip heart failure. Only 32% had a normal systolic function, and the majority had either mild or moderate systolic dysfunction. In particular, the rate of percutaneous coronary intervention was similar. The in-hospital mortality was similar (5%), with more women diagnosed with atrial fibrillation and heart failure at follow-up. CONCLUSIONS: Women had a higher prevalence of risk factors affecting the presentation and morbidity but not mortality. Improving these risk factors and the lifestyle is a priority to improve the outcome and decrease morbidity.

Embolisation of the Coronary Arterial Tree with Thick Contrast Material during Coronary Angiography.

A 58-year male was referred to our centre with an acute inferior ST elevation myocardial infarction (STEMI). During the primary percutaneous coronary intervention, he suddenly collapsed with severe hypotension and severe bradycardia. The symptoms were attributed to an accidental embolisation of his left coronary system with the thick contrast material. When the remaining contrast in the bottle was investigated, it contained abnormally thick contrast material. This is a rare case of contrast embolisation, which is completely preventable but fatal, if undetected. Key Words: Coronary angiography, Contrast material, Contrast embolisation.

Diagnóstico ecocardiográfico de una hernia de hiato. Reporte de un caso / Echocardiographic diagnosis of a Hiatus Hernia: A case report

The diagnosis of a hiatus hernia (HH) is typically confirmed with an upper gastrointestinal barium X-ray, gastroscopy or upper-intestinal endoscopy. In several cases, HH has been diagnosed with an echocardiogram. We here describe a case of an HH visible on an echocardiogram in a male patient with chest pain.

Abnormal mitral flow, what is the cause?

Diastolic mitral regurgitation is a unique Doppler finding that can be missed if special attention is not paid to it. There are a few causes of such abnormal flow, ranging from a conduction abnormality to abnormal valvular and left ventricle function. Failure to recognize it might lead to unnecessary investigations and delay the primary diagnosis. We are presenting a teaching case and discuss the associated pathology.

The Echocardiography Society of Saudi Heart Association Recommendation on Quality and Laboratory Accreditation Guideline and Standards.

OBJECTIVE: To create the Saudi Arabian Society of Echocardiography Accreditation Commission Guidelines and Standards. METHOD: A review of available the North American and European accreditation guidelines was conducted and a model, locally appropriate for Saudi echocardiography laboratories and applicable in the current settings, was developed. RESULTS: The document specifies the organizational setting as well as the following categories of personnel: medical director, technical director, medical staff, and technical staff. The guideline team also examined aspects related to the facility and the facility safety policies and protocols. Examination and procedural issues for Adult transthoracic echocardiography including instrumentation, archiving media, examination interpretation and reports are also included as well as the required components for the Adult transthoracic echocardiography report. The last section of the guidelines focuses on Key Performance Indicators. A similar approach was taken regarding the Adult Stress Echocardiography, Transesophageal Echo, and monitoring of the patients during the procedures. CONCLUSION: The development of the Saudi Echocardiography Guidelines and Standards is a basic requirement for accreditation and also mandatory to improve the quality and utilization of such an important investigation.

Mitral leaflet separation index for mitral valve assessment during balloon mitral valvuloplasty.

OBJECTIVE: The objective of the study was to evaluate the accuracy of the mitral leaflet separation index (MLSI) in selected patients with mitral stenosis, before and after percutaneous balloon mitral valvuloplasty (PBMV), compared to conventional methods with transthoracic echocardiography [TTE]. METHODS: A prospective study was conducted in 30 patients, ages 20-60 years, with severe symptomatic mitral stenosis (MS) who had PBMV in the Cardiology Department, Zagazig University and National Heart Institute. A mean of three to five measurements of MLSI was taken in diastole in the parasternal long-axis and apical four-chamber views. The MLSI was re-measured 24-48 hours after PBMV. We calculated the correlation of the MLSI, pre and post BMV, with two-dimensional (2D) MV planimetry and pressure half-time (PHT) methods to assess MVA. RESULTS: There was a positive, highly significant correlation between pre PBMV 2D planimetry and MLSI (r = .665, P-value < .001) as well as post PBMV 2D planimetry and MLSI (r = .410, P-value = .025). A positive highly significant correlation was also noted between pre PBMV PHT and MLSI (r = .678, P-value <.001) and between post PBMV PHT and MLSI (r = .706, P-value <.001). CONCLUSION: Mitral leaflet separation index is an easy and reliable measurement for the assessment of mitral stenosis before and after PBMV.

The validity of a daytime ambulatory blood pressure to diagnose masked hypertension.

Masked hypertension (MH) is traditionally diagnosed with 24-hour ambulatory blood pressure monitoring (24-ABPM). This is relatively costly and could cause discomfort during the night. We studied the validity of daytime ABP (DT-ABPM) in young National Guard soldiers and determined the prevalence in comparison to the standard 24-ABPM. A prospective study of 196 soldiers aged 21-50 years, without a history of hypertension or antihypertensive medication use. Each participant was fitted with a 12h-ABPM. Patients were diagnosed with MH if the office blood pressure (OBP) was <140/90 mmHg and the average DT-ABPM was ≥135/85 mmHg. By pairing the average OBP with the 12 h-ABPM, the prevalence of MH was estimated as 18/196 (9.2%), the SBP MH (systolic blood pressure) of 8.2% and the DPB MH (diastolic blood pressure) of 3.1%.  When we compared the daytime prevalence with the 24 h-ABPM, and the average OBP, the prevalence of MH was 29/196 (14.8%). No statistically significant difference was noted (kappa=0.74; 95% CI: 0.59 to 0.88). We conclude that DT-ABPM is a good method and convenient to detect MH, with no statistically significant difference when compared to the 24 h-ABPM. The prevalence of MH in young healthy soldiers was unexpectedly high.

Figure 8 Shadow, What is Your Diagnosis?

We report this case, which described the echocardiographic and chest X-ray appearance of the amplatzer device. The echo images raised suspicion of a mass in the left atrium, but a simple X-ray showed that the mass is an amplatzer device for left atrial appendage closure.

The effect of blood pressure variability on the prognosis of hypertensive patients.

OBJECTIVE: Our study aims to compare the effects of blood pressure variability (BPV) during ambulatory blood pressure measurement (ABPM) and visit-to-visit measurements to predict future cardiovascular complications among hypertensive patients. METHODS: This is a retrospective case-control study of patients with hypertension over 10 years. All adult patients with at least one recorded ABPM, and at least three recorded visit measurements were included. Patients with incomplete ABPM readings, a history of a tested outcome, or the occurrence of any of the tested outcomes within the measurement period were excluded. The outcome was the development of any of the following: acute coronary syndrome (ACS), chronic ischemic heart disease (IHD), heart failure (HF), or stroke. RESULTS: Of the 305 cases reviewed, 152 were included. The mean follow-up was 6.6±2.3 years. The mean age was 53.5±14.3 years. Eighty-two (53.9%) patients were male, while 70 (46.1%) were female. Risk factors included diabetes mellitus (53.9%), dyslipidemia (39.5%), obesity (16.4%), and smoking (8.6%). Comorbidities included stroke (2%), ACS (8.6%), IHD (20.4%), HF (2.6%), and renal failure (1.3%). One or more complications were seen in 22.4 % of the included patients. The variation of the daytime systolic ABP had been found to predict the future risk of developing IHD (OR=1.94; 95% CI=1.09-3.45; p=0.025). Moreover, IHD was associated with night-time systolic standard deviation (SD) in ABPM (OR=1.23; 95% CI=1.00-1.51; p=0.048). On the other side, ACS was found to be associated with systolic SD in visit-to-visit measurement (OR=1.10; 95% CI=1.01-1.21; p=0.04). CONCLUSION: Hypertensive patients with high variability of daytime and night-time SD in ABPM are more likely to have IHD. Whereas, having high variability in systolic SD in visit-to-visit measurements is associated with developing ACS.

Metformin in heart failure patients.

The use of metformin was considered a contraindication in heart failure patients because of the potential risk of lactic acidosis; however, more recent evidence has shown that this should no longer be the case. We reviewed the current literature and the recent guideline to correct the misconception.

Do We Need Cardiac Rehabilitation in Heart Failure.

Cardiac rehabilitation is a well established therapy for heart failure patients. Discussion is made of the different types, modalities, time and number of sessions and whether it is restricted to systolic heart failure or younger patients only. Elaboration will be made on how to make it more accessible to a larger proportion of population.

Prophylactic use of carvedilol to prevent ventricular dysfunction in patients with cancer treated with doxorubicin.

OBJECTIVE: Deterioration in ventricular function is often observed in patients treated with anthracyclines for cancer. There is a paucity of evidence on interventions that might provide cardio-protection. We investigated whether prophylactic use of carvedilol can prevent doxorubicin-induced cardiotoxicity and whether any observed effect is dose related. METHODS: A prospective, randomized, double-blind study in patients treated with doxorubicin, comparing placebo (n = 38) with different doses of carvedilol [6.25 mg/day (n = 41), 12.5 mg/day (n = 38) or 25 mg/day (n = 37)]. The primary endpoint was the measured change in left ventricular ejection fraction (LVEF) from baseline to 6 months. RESULTS: LVEF decreased from 62 ±â€¯5% at baseline to 58 ±â€¯7% at 6-months (p = 0.002) in patients assigned to placebo but no statistically significant changes were observed in any of the 3 carvedilol groups. At 6 months, only one of 116 patients (1%) assigned to carvedilol had an LVEF < 50% compared to four of the 38 assigned to placebo (11%), (p = 0.013). No significant differences were noted between carvedilol and placebo in terms of the development of diastolic dysfunction, clinically overt heart failure or death. CONCLUSIONS: Carvedilol might prevent deterioration in LVEF in cancer patients treated with doxorubicin. This effect may not be dose related within the studied range.

Ambulatory blood pressure monitoring in daily practice.

Ambulatory blood pressure monitoring is a useful diagnostic tool that still underutilized by community physicians. It is a cost effective, diagnostic and prognostic tool that had been emphasized by the guidelines.