Acute heart failure with and without acute coronary syndrome: clinical correlates and prognostic impact (From the HEARTS registry).

BACKGROUND: Little is know about the outcomes of acute heart failure (AHF) with acute coronary syndrome (ACS-AHF), compared to those without ACS (NACS-AHF). METHODS: We conducted a prospective registry of AHF patients involving 18 hospitals in Saudi Arabia between October 2009 and December 2010. In this sub-study, we compared the clinical correlates, management and hospital course, as well as short, and long-term outcomes between AHF patients with and without ACS. RESULTS: Of the 2609 AHF patients enrolled, 27.8 % presented with ACS. Compared to NACS-AHF patients, ACS-AHF patients were more likely to be old males (Mean age = 62.7 vs. 60.8 years, p = 0.003, and 73.8 % vs. 62.7 %, p < 0.001, respectively), and to present with De-novo heart failure (56.6 % vs. 28.1 %, p < 0.001). Additionally they were more likely to have history of ischemic heart disease, diabetes, dyslipidemia, and less likely to have chronic kidney disease (p < 0.001 for all comparisons). The prevalence of severe LV systolic dysfunction (EF < 30 %) was higher in ACS-AHF patients. During hospital stay, ACS-AHF patients were more likely to develop shock (p < 0.001), recurrent heart failure (p = 0.02) and needed more mechanical ventilation (p < 0.001). ß blockers and Angiotensin Converting Enzyme inhibitors were used more often in ACS-AHF patients (p = 0.001 and, p = 0.004 respectively). ACS- AHF patients underwent more coronary angiography and had higher prevalence of multi-vessel coronary artery disease (p < 0.001 for all comparisons). The unadjusted hospital and one-month mortality were higher in ACS-AHF patients (OR = 1.6 (1.2-2.2), p = 0.003 and 1.4 (1.0-1.9), p = 0.026 respectively). A significant interaction existed between the level of left ventricular ejection fraction and ACS-AHF status. After adjustment, ACS-AHF status was only significantly associated with hospital mortality (OR = 1.6 (1.1-2.4), p = 0.019). The three-years survival following hospital discharge was not different between the two groups. CONCLUSION: AHF patients presenting with ACS had worse hospital prognosis, and an equivalent long-term survival compared to AHF patients without ACS. These findings underscore the importance of timely recognition and management of AHF patients with concomitant ACS given their distinct presentation and underlying pathophysiology compared to other AHF patients.

Morbidity and mortality of acute heart failure patients stratified by mitral regurgitation in the Arabian Gulf: Observations from the Gulf acute heart failure registry (Gulf CARE).

This study aimed to evaluate the clinical outcomes of patients with acute heart failure (AHF) stratified by mitral regurgitation (MR) in the Arabian Gulf. Patients from the Gulf CARE registry were identified from 47 hospitals in seven Arabian Gulf countries (Yemen, Oman, Kuwait, Qatar, Bahrain, the United Arab Emirates, and Saudi Arabia) from February to November 2012. The cohort was stratified into two groups based on the presence of MR. Univariable and multivariable statistical analyses were performed. The population cohort included 5005 consecutive patients presenting with AHF, of whom 1491 (29.8 %) had concomitant MR. The mean age of patients with AHF and concomitant MR was 59.2 ± 14.9 years, and 63.1 % (n = 2886) were male. A total of 58.6 % (n = 2683) had heart failure (HF) with reduced ejection fraction (EF) (HFrEF), 21.0 % (n = 961) had HF with mildly reduced EF (HFmrEF), and 20.4 % (n = 932) had HF with preserved EF (HFpEF). Patients with MR had a lower haemoglobin (Hb) level (12.4 vs. 12.7 g/dL; p < 0.001), and a higher prevalence of left atrial enlargement (80.2 % vs. 55.1 %; p < 0.001), cardiogenic shock (9.7 % vs. 7.3 %; p = 0.006) and atrial fibrillation (7.6 % vs. 5.6 %; p = 0.006), and HFrEF (71.0 % vs. 52.6 %; P < 0.001). Multivariable analysis demonstrated that MR was independently associated with increased all-cause mortality at 1-year and 3-month HF rehospitalization [1-year all-cause mortality, adjusted odds ratio (aOR), 1.40; 95 % confidence interval (Cl): 1.13-1.74; p = 0.002; 3-month HF rehospitalization, aOR, 1.26; 95 % Cl: 1.06-1.49; p = 0.009]. In an Arabian Gulf cohort with AHF, concomitant MR was associated with an increased risk of 1-year mortality and 3-months HF rehospitalization.

Polyvascular disease in patients presenting with acute coronary syndrome: its predictors and outcomes.

We evaluated prevalence and clinical outcome of polyvascular disease (PolyVD) in patients presenting with acute coronary syndrome (ACS). Data for 7689 consecutive ACS patients were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were divided into 2 groups (ACS with versus without PolyVD). All-cause mortality was assessed at 1 and 12 months. Patients with PolyVD were older and more likely to have cardiovascular risk factors. On presentation, those patients were more likely to have atypical angina, high resting heart rate, high Killip class, and GRACE risk scoring. They were less likely to receive evidence-based therapies. Diabetes mellitus, renal failure, and hypertension were independent predictors for presence of PolyVD. PolyVD was associated with worse in-hospital outcomes (except for major bleedings) and all-cause mortality even after adjusting for baseline covariates. Great efforts should be directed toward primary and secondary preventive measures.

Management of Latent Tuberculosis Infection in Saudi Arabia: Knowledge and Perceptions Among Healthcare Workers.

Background Tuberculosis (TB) continues to pose a serious threat to public health despite great efforts. For many years, management and screening for active TB cases have been the main focus of TB control programs. Latent TB is a stage where TB can be prevented and controlled. Therefore, designing a comprehensive TB control program that includes latent tuberculosis infection (LTBI) management diseases is needed to be implemented among the healthcare workers (HCWs) who have been found to be at a higher risk for active TB compared to the general population. The objective of the study The objective of the study is to assess the knowledge and perceptions of LTBI among HCWs. In addition to estimating the prevalence of LTBI among HCWs using closed-end questions in a self-administered questionnaire. Subjects and methods Through a cross-sectional study and non-random sampling technique, 324 (84%) healthcare workers who met the inclusion criteria completed and submitted the electronic questionnaire. Results Among all participants, the study reported a good knowledge about LTBI; however, a third of HCWs had poor knowledge about the difference between LTBI and active TB. Eighteen percent of participants were diagnosed with LTBI, and two-thirds accepted the treatment. Of all participants who started the treatment, 55% completed the treatment course. The compliance rate was high among young HCWs and physicians who had a short course of LTB treatment regimen.  Conclusion The study reported a low acceptance and completion rate of LTBI therapy among HCWs. Low knowledge about some clinical facts of LTBI, the long duration of treatment, and being the treatment optional in Saudi health institutes were all barriers to accepting and completing the treatment of LTBI. All of these factors need to be addressed to increase the compliance rate to LTBI treatment.

Prediction of pulmonary hypertension in patients with or without interstitial lung disease: reliability of CT findings.

PURPOSE: To study the reliability of pulmonary vascular measurements based on computed tomography (CT) in the prediction of pulmonary hypertension (PH) in patients with advanced interstitial lung disease (ILD) compared with those without ILD. MATERIALS AND METHODS: The study was approved by the Institutional Review Board. All patients gave written informed consent. A prospective study of 134 patients who underwent right-sided heart catheterization and chest CT scanning within 72 hours of admission was conducted. Patients were divided into two groups-one with ILD (group A, n = 100) and one without ILD (group B, n = 34). CT measurements of the main pulmonary artery diameter (PAD), the ratio of PAD to the ascending aorta diameter (AAD), right pulmonary artery diameter (RPAD), and left pulmonary artery diameter (LPAD) were obtained. Univariate logistic regression analysis was performed, and receiver operating characteristic curves were constructed to assess the predictive ability of vascular measurements obtained by using CT in the identification of PH. RESULTS: Main PAD was significantly greater in patients with PH than in those without PH in both groups (group A, P = .008; group B, P = .02). A PAD greater than 25 mm in patients with ILD was predictive of PH, with a sensitivity of 86.4% (32 of 37), a specificity of 41.2% (26 of 63), a positive predictive value of 46.3% (32 of 69), and a negative predictive value of 83.8% (26 of 31). In patients without ILD, a PAD greater than 31.6 mm and an LPAD greater than 21.4 mm were predictive of PH (sensitivity, 47.3% [nine of 19]; specificity, 93.3% [14 of 15]; positive predictive value, 90.0% [nine of 10]; and negative predictive value, 58.3% [14 of 24]). CONCLUSION: CT-derived vascular measurements were of limited utility in the prediction of PH in patients with ILD compared with those without ILD.

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.

The Prognostic Impact of Pulse Pressure in Acute Heart Failure: Insights from the HEARTS Registry.

BACKGROUND: Low pulse pressure predicts long-term mortality in chronic heart failure, but its prognostic value in acute heart failure is less understood. The present study was designed to examine the prognostic value of pulse pressure in acute heart failure. METHODS: Pulse pressure was tested for its impact on short- and long-term mortality in all patients admitted with acute heart failure from October 2009 to December 2010 in eighteen tertiary centers in Saudi Arabia (n = 2609). All comparisons were based on the median value (50 mmHg). Heart failure with reduced ejection fraction was defined as less than 40%. RESULTS: Low pulse pressure was associated with increased short-term mortality in the overall population (OR = 1.61; 95 CI 1.17, 2.22; P 0.004 and OR = 1.51; 95% CI 1.13, 2.01; P = 0.005, for hospital and thirty-day mortality, respectively), and short-term and two-year mortality in the reduced ejection fraction group (OR = 1.81; 95% CI 1.19, 2.74; P = 0.005, OR = 1.69; 95% CI 1.17, 2.45; P = 0.006, and OR = 1.29; 95% CI 1.02, 1.61; P = 0.030 for hospital, thirty-day, and two-year mortality, respectively). This effect remained after adjustment for relevant clinical variables; however, pulse pressure lost its predictive power both for short-term and long-term mortality after the incorporation of systolic blood pressure in the model. Conversely, low pulse pressure was an independent predictor of improved survival at two and three years in heart failure with preserved ejection fraction (OR = 0.43; 95% CI 0.24, 0.78, P = 0.005 and OR = 0.49; 95% CI 0.28, 0.88; P = 0.016, respectively). CONCLUSION: In acute heart failure with reduced ejection fraction, the prognostic value of low pulse pressure was dependent on systolic blood pressure. However, it inversely correlated with long-term survival in heart failure with preserved ejection fraction.

Impact of diabetes on mortality and rehospitalization in acute heart failure patients stratified by ejection fraction.

AIMS: The aim of this study is to determine the impact of diabetes mellitus on all-cause mortality and rehospitalization rates at 3 months and at 1 year in patients admitted with acute heart failure (AHF) stratified by left ventricular ejection fraction (EF). METHODS AND RESULTS: We analysed consecutive patients admitted to 47 hospitals in seven Middle Eastern countries (Saudi Arabia, Oman, Yemen, Kuwait, United Arab Emirates, Qatar, and Bahrain) with AHF from February to November 2012 with AHF who were enrolled in Gulf CARE, a multinational registry of patients with heart failure (HF). AHF patients were stratified into three groups: HF patients with reduced (EF) (HFrEF) (<40%), HF with mid-range EF (HFmrEF) (40-49%), and HF patients with preserved EF (HFpEF) (≥50%). Analyses were performed using univariate and multivariate statistical techniques. The mean age of the cohort was 59 ± 15 years (ranging from 18 to 99 years), and 63% (n = 2887) of the patients were males. A total of 2258 (49%) AHF patients had diabetes mellitus. The mean EF was 37 ± 14%. A reduced EF was observed in 2683 patients (59%), whereas 962 patients (21%) had mid-range and 932 patients (20%) had preserved EF. Multivariable analyses demonstrated no significant differences in all-cause mortality between diabetics and non-diabetics in all the three types of HF; at 3 months follow-up: HFrEF [adjusted odds ratio (aOR), 1.30; 95% confidence interval (CI): 0.94-1.80; P = 0.119], HFmrEF (aOR, 0.98; 95% CI: 0.51-1.87; P = 0.952), and HFpEF (aOR, 0.69; 95% CI: 0.38-1.26; P = 0.225); and at 12-months follow-up: HFrEF (aOR, 1.25; 95% CI: 0.97-1.62; P = 0.080), HFmrEF (aOR, 1.07; 95% CI: 0.68-1.68; P = 0.783), and HFpEF (aOR, 1.07; 95% CI: 0.67-1.72; P = 0.779). There were also no significant differences in rehospitalization rates between diabetics and non-diabetics in all the three types of HF; at 3 months follow-up: HFrEF (aOR, 0.94; 95% CI: 0.74-1.19; P = 0.581), HFmrEF (aOR, 0.82; 95% CI: 0.53-1.26; P = 0.369), and HFpEF (aOR, 1.06; 95% CI: 0.64-1.78; P = 0.812); and at 12-months follow-up: HFrEF (aOR, 0.93; 95% CI: 0.73-1.17; P = 0.524), HFmrEF (aOR, 0.81; 95% CI: 0.56-1.17; P = 0.257), and HFpEF (aOR, 1.29; 95% CI: 0.82-2.05; P = 0.271). CONCLUSIONS: There were no significant differences in 3 and 12 months all-cause mortality as well as rehospitalization rates between diabetics and non-diabetic patients in all the three types of AHF patients stratified by left ventricular ejection fraction.

Mortality and Morbidity in HFrEF, HFmrEF, and HFpEF Patients with Diabetes in the Middle East.

OBJECTIVES: We sought to estimate the mortality and morbidity in diabetic acute heart failure (AHF) patients stratified by left ventricular ejection fraction. METHODS: We analyzed the data of patients with AHF from seven Middle Eastern countries (Bahrain, Oman, Yemen, Kuwait, UAE, Qatar, and Saudi Arabia) from February to November 2012, who were enrolled in a multinational registry of patients with heart failure (HF). RESULTS: A total of 2258 AHF patients had diabetes mellitus. The mean age was 63.0±11.0 years (ranging from 18 to 99 years), and 60.3% (n = 1362) of the patients were males. The mean ejection fraction (EF) was 37.0±13.0%. HF with reduced EF (< 40%) (HFrEF) was observed in 1268 patients (56.2%), whereas 515 patients (22.8%) had mid-range (40-49%) (HFmrEF) and 475 patients (21.0%) had preserved EF (3 50%) (HFpEF). The overall cumulative all-cause mortalities at three- and 12-months follow-up were 11.8% (n = 266) and 20.7% (n = 467), respectively. Those with HFpEF were associated with lower three-months cumulative all-cause mortality compared to those with HFrEF (7.6% vs. 5.9%; adjusted odds ratio (aOR) = 0.54, 95% confidence interval (CI): 0.31-0.95; p = 0.031), but not significantly different when compared to those with HFmrEF (aOR = 0.86, 95% CI: 0.53-1.40; p = 0.554). There were largely no significant differences among the groups with regards to the 12-months all-cause cumulative mortality (11% vs. 11% vs. 10%; p = 0.984). There were also no significant differences in re-hospitalization rates between the three HF groups not only at three months (23% vs. 20% vs. 22%; p = 0.520), but at one-year follow-up (28% vs. 30% vs. 32%; p = 0.335). CONCLUSIONS: Three-month cumulative all-cause mortality was high in diabetic HFrEF patients when compared to those with HFpEF. However, there were no significant differences in mortality at one-year follow-up between the HF groups. There were also no significant differences in re-hospitalization rates between the HF groups not only at three months but also at one-year follow-up in the Middle East.

In-hospital ventricular arrhythmia in heart failure patients: 7 year follow-up of the multi-centric HEARTS registry.

AIMS: The aim of this study was to determine the incidence, predictors, and short-term and long-term outcomes associated with in-hospital sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) collectively termed ventricular arrhythmia (VA) in the heart failure (HF) patients. METHODS AND RESULTS: The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS registry) is a prospective national registry of patients with chronic HF from18 tertiary care hospitals across Saudi Arabia. Diagnosis of HF was in accordance with American Heart Association/European Society of Cardiology definition criteria. The registry had enrolled 2610 HF patients during the 14 month recruitment period between October 2009 and December 2010. Occurrence of in-hospital cardiac events, prognosis, and outcome were monitored during the 7 year follow-up period. The incidence of in-hospital VA in HF was 4.2%. VA was more common among men, and mean age was lesser than non-VA patients (58.5 ± 16: 61.5 ± 15 years; P = 0.042). Smoking and family history of cardiomyopathy were significant risk factors of VA. Previous history of arrhythmia, ST elevated myocardial infarction, infections, and hypotension remained significant predictors of in-hospital VA associated with three to seven times more risk. Patients with VA had higher rates of in-hospital events like recurrent HF, haemodialysis, shock, sepsis, major bleeding, intra-aortic balloon pump, and stroke compared with those without VA, all being highly significant (P < 0.001). After adjustment for age, gender, and co-morbidities, in-hospital VA increased the risk of cardiogenic shock by 24 times, dialysis and major bleeding by 10 times, and recurrent congestive HF and pacing by five times. Survival analysis showed that all-cause mortality was significantly higher in the VA patients (P < 0.001). Presence of VA increased in-hospital and 1 month mortality to 23 and 17 times, respectively. CONCLUSIONS: Lower mean age of VA complicated HF patients is a matter of concern in the Saudi population. HF associated with VA increased in-hospital events and all-cause mortality indicating poor prognosis and survival. These findings enable risk stratification and reflect on the importance of early recognition of the clinical markers and predictors of VA prompting immediate management.

A Tailored, Bundle Care Intervention Strategy to Reduce Cardiac Mortality During the Hajj: A Population-Based, Before and After Study.

BACKGROUND: Hajj is the largest human gathering with over 2 million people. We evaluated the effect of bundle care intervention on mortality. METHODS: A population-based, before and after study compared the effect of an intervention on mortality. The intervention included recruitment of cardiac team, introducing 24/7 catheterization service, cardiac coordination, standardized cardiac care pathways, and establishment of an effective transportation system. RESULTS: Cardiac mortality accounted for about 52% of all in-hospital deaths before intervention in 2009. This decreased significantly to 43.3%, 32.5%, and 19.7% in 2009, 2010, and 2011, respectively. In-hospital mortality of acute coronary syndromes was 4.7%, 4.6%, and 3.0%, in the years 2009, 2010, and 2011, respectively. Mortality due to other causes remained largely unaffected. There was no significant change in the national mortality due to cardiac causes over the same period provided a reassurance that the observed improvement in in-hospital acute coronary syndrome mortality was not due to overall improvement in health care. The numbers of cardiac catheterization procedures increased 3-fold and cardiac surgical procedures increased 5-fold between 2009 and 2011. CONCLUSIONS: In this study, we found that an evidence-based intensive bundle care intervention substantially reduced the cardiac mortality among the pilgrims assembling for Hajj in Makkah.

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.

Incidence and impact of cardiorenal anaemia syndrome on all-cause mortality in acute heart failure patients stratified by left ventricular ejection fraction in the Middle East.

AIMS: This study aims to evaluate the incidence and impact of cardiorenal anaemia syndrome (CRAS) on all-cause mortality in acute heart failure (AHF) patients stratified by left ventricular ejection fraction (LVEF) status in the Middle East. METHODS AND RESULTS: Data were analysed from 4934 consecutive patients admitted to 47 hospitals in seven Middle Eastern countries (Saudi Arabia, Oman, Yemen, Kuwait, United Arab Emirates, Qatar, and Bahrain) with AHF from February to November 2012. CRAS was defined as AHF with estimated glomerular filtration rate of <60 mL/min and low haemoglobin (<13 g/dL for men or <12 g/dL for women). Analyses were performed using univariate and multivariate statistical techniques. The overall mean age of the cohort was 59 ± 15 years, 62% (n = 3081) were men, and 27% (n = 1319) had CRAS. Co-morbid conditions were common including hypertension (n = 3014; 61%), coronary artery disease (n = 2971; 60%), and diabetes mellitus (n = 2449; 50%). A total of 79% (n = 3576) of the patients had AHF with reduced ejection fraction (HFrEF) (LVEF < 50%). CRAS patients were associated with major bleeding (1.29% vs. 0.6%; P = 0.017), blood transfusion (10.1% vs. 3.0%; P < 0.001), higher re-admission rate for AHF at 3 months' follow-up (27.6% vs. 18.8%; P < 0.001) and at 12 months' follow-up (34.3% vs. 26.2%; P < 0.001). Multivariate logistic regression demonstrated that patients with CRAS were associated with higher odds of all-cause mortality during hospital admission [adjusted odds ratio (aOR), 2.10; 95% confidence interval (CI): 1.34-3.31; P = 0.001], at 3 months' follow-up (aOR, 1.48; 95% CI: 1.07-2.06; P = 0.018), and at 12 months' follow-up (aOR, 1.45; 95% CI: 1.12-1.87; P = 0.004). Stratified analyses showed that CRAS patients with HFrEF were associated with higher odds of all-cause mortality during hospital admission (aOR, 2.03; 95% CI: 1.20-3.45; P = 0.009) and at 12 months' follow-up (aOR, 1.42; 95% CI: 1.06-1.89; P = 0.019) but not at 3 months' follow-up (aOR, 1.43; 95% CI: 0.98-2.09; P = 0.063). However, in AHF patients with preserved ejection fraction (LVEF ≥ 50%), CRAS was not associated with higher odds of all-cause mortality not only during hospital admission (aOR, 2.15; 95% CI: 0.84-5.55; P = 0.113) but also at 3 months' follow-up (aOR, 1.87; 95% CI: 0.93-3.76; P = 0.078) and at 12 months' follow-up (aOR, 1.59; 95% CI: 0.91-2.76; P = 0.101). CONCLUSIONS: The incidence of CRAS was 27%. CRAS was associated with higher odds of all-cause mortality in AHF patients in the Middle East, especially in those with HFrEF.

The first survey of the Saudi Acute Myocardial Infarction Registry Program: Main results and long-term outcomes (STARS-1 Program).

BACKGROUND: Prior acute coronary syndrome (ACS) registries in Saudi Arabia might not have accurately described the true demographics and cardiac care of patients with ACS. We aimed to evaluate the clinical characteristics, management, and outcomes of a representative sample of patients with acute myocardial infarction (AMI) in Saudi Arabia. METHODS: We conducted a 1-month snap-shot, prospective, multi-center registry study in 50 hospitals from various health care sectors in Saudi Arabia. We followed patients for 1 month and 1 year after hospital discharge. Patients with AMI included those with or without ST-segment elevation (STEMI or NSTEMI, respectively). This program survey will be repeated every 5 years. RESULTS: Between May 2015 and January 2017, we enrolled 2233 patients with ACS (mean age was 56 [standard deviation = 13] years; 55.6% were Saudi citizens, 85.7% were men, and 65.9% had STEMI). Coronary artery disease risk factors were high; 52.7% had diabetes mellitus and 51.2% had hypertension. Emergency Medical Services (EMS) was utilized in only 5.2% of cases. Revascularization for patients with STEMI included thrombolytic therapy (29%), primary percutaneous coronary intervention (PCI); (42.5%), neither (29%), or a pharmaco-invasive approach (3%). Non-Saudis with STEMI were less likely to undergo primary PCI compared to Saudis (35.8% vs. 48.7%; respectively, p <0.001), and women were less likely than men to achieve a door-to-balloon time of <90 min (42% vs. 65%; respectively, p = 0.003). Around half of the patients with NSTEMI did not undergo a coronary angiogram. All-cause mortality rates were 4%, 5.8%, and 8.1%, in-hospital, at 1 month, and at 1 year, respectively. These rates were significantly higher in women than in men. CONCLUSIONS: There is an urgent need for primary prevention programs, improving the EMS infrastructure and utilization, and establishing organized ACS network programs. AMI care needs further improvement, particularly for women and non-Saudis.

Baseline characteristics, management practices, and long-term outcomes among patients with first presentation acute myocardial infarction in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-II).

BACKGROUND AND OBJECTIVES: Limited data are available highlighting the different clinical aspects of acute coronary syndrome (ACS) patients, especially in Gulf countries. In this study, we aimed to compare patients who presented with acute myocardial infarction (AMI) as the first presentation of patients who have a history of ACS in terms of initial presentation, medical history, laboratory findings, and overall mortality. METHODS: We used the Second Gulf Registry of Acute Coronary Events (Gulf RACE-II), which is a multinational observational study of 7930 ACS patients. RESULTS: Among all patients, 4723 (59.6%) patients presented with AMI. First presentation AMI patients were older (mean age, 55 years vs. 53 years; p < 0.001) and had lower risk factors than patients with a history of ACS. Higher laboratory readings of cardiac markers and all aspects of mortality were significantly higher among patients with first presentation AMI. After adjustments for baseline variables, congestive heart failure [odds ratio (OR) = 1.08; 95% confidence interval (CI), 0.73-1.57], reinfarction (OR = 1.16; 95% CI, 0.58-2.30), cardiogenic shock (OR = 1.51; 95% CI, 0.74-3.08), stroke (OR = 2.30; 95% CI, 0.29-17.99), and overall mortality (OR = 1.16; 95% CI = 0.74-1.83) were independent predictive factors for first presentation AMI. CONCLUSIONS: First presentation AMI patients tend to be older and to have lower rates of risk factors. Adverse clinical outcomes such as congestive heart failure, reinfarction, cardiogenic shock, and stroke were higher among patients with first presentation AMI compared to patients with a history of ACS.

The prognostic impact of hyperglycemia on clinical outcomes of acute heart failure: Insights from the heart function assessment registry trial in Saudi Arabia.

BACKGROUND: The prognostic impact of hyperglycemia (HG) in acute heart failure (AHF) is controversial. Our aim is to examine the impact of HG on short- and long-term survival in AHF patients. METHODS: Data from the Heart Function Assessment Registry Trial in Saudi Arabia (HEARTS) for patients who had available random blood sugar (RBS) were analyzed. The enrollment period was from October 2009 to December 2010. Comparisons were performed according to the RBS levels on admission as either <11.1 mmol/L or ≥11.1 mmol/L. Primary outcomes were hospital adverse events and short- and long-term mortality rates. RESULTS: A total of 2511 patients were analyzed. Of those, 728 (29%) had HG. Compared to non-HG patients, hyperglycemics had higher rates of hospital, 30-day, and 1-year mortality rates (8.8% vs. 5.6%; p = 0.003, 10.4% vs. 7.2%; p = 0.007, and 21.8% vs. 18.4%; p = 0.04, respectively). There were no differences between the two groups in 2- or 3-year mortality rates. After adjustment for relevant confounders, HG remained an independent predictor for hospital and 30-day mortality [odds ratio (OR) = 1.6; 95% confidence interval (CI) 1.07-2.42; p = 0.021, and OR = 1.55; 95% CI 1.07-2.25; p = 0.02, respectively]. CONCLUSION: HG on admission is independently associated with hospital and short-term mortality in AHF patients. Future research should focus on examining the impact of tight glycemic control on outcomes of AHF patients.

Atrial Fibrillation in Patients Hospitalized With Heart Failure: Patient Characteristics and Outcomes From the HEARTS Registry.

Effect of atrial fibrillation (AF) on short- and long-term outcomes in heart failure (HF) is controversial. Accordingly, we examined this relationship in a national multicenter project using data from the Hearts Function Assessment Registry Trial in Saudi Arabia that studied the clinical features and outcomes of patients admitted with de novo and acute on chronic HF. Out of 2593 patients with HF, 449 (17.8%) had AF at presentation. Patients with AF were more likely to be males and older (mean age 65.2 ± 15.0 vs 60.5 ± 14.8 years) to have a history of ventricular tachycardia/ventricular fibrillation (3.1% vs 1.9%) or cerebrovascular accident (15.0% vs 8.5%). However, they were less likely to have diabetes (66.0% vs 55.9%) or coronary artery disease (55.6% vs 42.3%). The 1-, 2-, and 3-year crude mortality rates were significantly higher in patients with AF (23.2% vs 18.3%, 27.4% vs 22.3%, and 27.8% vs 23.2%, respectively). However, there was no significant difference in mortality after adjusting for covariates. Thus, in patients admitted with HF, AF upon presentation was not associated with increased mortality.

Impact of Clopidogrel on Mortality in Patients With Acute Heart Failure Stratified by Coronary Artery Disease: Findings From the Arabian Gulf Acute Heart Failure Registry (Gulf CARE).

We evaluated the impact of clopidogrel use on 3- and 12-months all-cause mortality in patients with acute heart failure (AHF) stratified by coronary artery disease (CAD) in patients admitted to 47 hospitals in 7 Middle Eastern countries with AHF from February to November 2012. Clopidogrel use was associated with significantly lower risk of all-cause mortality at 3 months (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI]: 0.42-0.87; P = .007) and 12 months (aOR, 0.61; 95% CI: 0.47-0.79; P < .001). When the analysis was stratified by CAD, the clopidogrel group in those with AHF and CAD was also associated with significantly lower risk of all-cause mortality at 3 months (aOR, 0.56; 95% CI: 0.38-0.83; P = .003) and 12 months (aOR, 0.58; 95% CI: 0.44-0.77; P < .001). However, in AHF patients without CAD, clopidogrel use was not associated with any survival advantages, neither at 3 months (aOR, 0.99; 95% CI: 0.32-3.11; P = .987) nor at 12 months (aOR, 0.80; 95% CI: 0.37-1.72; P = .566). Clopidogrel use was associated with short- and long-term all-cause mortality in patients with AHF and CAD. In AHF patients without CAD, clopidogrel use did not offer any survival advantage.

ß-Blocker Therapy Prior to Admission for Acute Coronary Syndrome in Patients Without Heart Failure or Left Ventricular Dysfunction Improves In-Hospital and 12-Month Outcome: Results From the GULF-RACE 2 (Gulf Registry of Acute Coronary Events-2).

BACKGROUND: The prognostic impact of ß-blockers (BB) in acute coronary syndrome (ACS) patients without heart failure (HF) or left ventricular dysfunction is controversial, especially in the postreperfusion era. We sought to determine whether a BB therapy before admission for ACS has a favorable in-hospital outcome in patients without HF, and whether they also reduce 12-month mortality if still prescribed on discharge. METHODS AND RESULTS: The GULF-RACE 2 (Gulf Registry of Acute Coronary Events-2) is a prospective multicenter study of ACS in 6 Middle Eastern countries. We studied in-hospital cardiovascular events in patients hospitalized for ACS without HF in relation to BB on admission, and 1-year mortality in relation to BB on discharge. Among the 7903 participants, 7407 did not have HF, of whom 5937 (80.15%) patients were on BB. Patients on BB tended to be older and have more comorbidities. However, they had a lower risk of in-hospital mortality, mitral regurgitation, HF, cardiogenic shock, and ventricular tachycardia/ventricular fibrillation. Furthermore, 4208 patients were discharged alive and had an ejection fraction ≥40%. Among those, 84.1% had a BB prescription. At 12 months, they also had a reduced risk of mortality as compared with the non-BB group. Even after correcting for confounding factors in 2 different models, in-hospital and 12-month mortality risk was still lower in the BB group. CONCLUSIONS: In this cohort of ACS, BB therapy before admission for ACS is associated with decreased in-hospital mortality and major cardiovascular events, and 1-year mortality in patients without HF or left ventricular dysfunction if still prescribed on discharge.