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.

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.

Resistant Hypertension in Patients With Type-2 Diabetes Mellitus: A Single-Center, Cross-Sectional Study.

Background The prevalence of resistant hypertension in Saudi patients with type-2 diabetes mellitus (T2DM) has not been previously estimated. Therefore, our objective was to assess the prevalence and characteristics of resistant hypertensive patients with T2DM at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Methods This cross-sectional study included patients with hypertension and T2DM who presented to our center in 2018. We examined 1960 patients with T2DM during the study period; 809 were hypertensives. We compared T2DM patients with controlled hypertension versus resistant hypertension. Results The prevalence of resistant hypertension in patients with T2DM was 137/809 (16.93%). The mean age was 66.38±10.80 years, and females presented 56% of the study population (n= 451). Obstructive sleep apnea (OSA; OR: 2.60 [1.15- 5.87]; P=0.02) and ischemic heart disease (IHD; OR: 3.01 [2.04- 4.45]; P˂0.001) were significantly associated with resistant hypertension. The most common medications used with resistant hypertension were calcium channel blockers (CCBs; 89.05%), ß-blockers (76.64%), and angiotensin-2 receptor blockers (ARBs; 62.77%). Conclusions Resistant hypertension in patients with T2DM is common in Saudi Arabia. Resistant hypertension could be associated with OSA and IHD. Further studies are required to evaluate the temporal relationship between resistant hypertension and risk factors.

The prevalence of masked hypertension in a group of young healthy soldiers.

BACKGROUND: To assess the prevalence of masked hypertension (MH) in young Saudi National Guard soldiers based on 24h ambulatory blood pressure monitoring (ABPM). METHODS: A prospective study of 196 soldiers, aged between 21-50 years, without a history of hypertension or antihypertensive medication use. Each participant was fitted with a 24h-ABPM. Patients were considered to have MH if the office blood pressure (OBP) was <140/90 mm Hg and the 24h-ABPM average was ≥130/80 mmHg. RESULTS: The mean age of the MH group was 34.5 years compared to 32.4 years of the normotensive group. By pairing the average OBP with the 24h-ABPM, the prevalence of MH was estimated to be 29/196 (14.8%), with the SBP (systolic blood pressure) and DPB MH (diastolic BP) prevalence 12.8% and 7.7%, respectively. For the systolic BP, the OBP compared with the 24h-ABPM was 120.0±8.1 vs. 134.7±4.5 (P<0.001) and for the diastolic BP, 70.7±7.0 vs. 79.9±4.2 (P<0.001). CONCLUSIONS: The prevalence of MH among this sample of healthy military soldiers was 14.8%. It is important not to rely solely on the OBP and to consider MH when screening for hypertension in apparently healthy individuals.

Interventional procedures versus medical therapy alone: outcome of cardiac patient management - a systematic review.

Cardiac patients are managed medically or with an intervention. This review aimed to explore the survival benefit of each approach in the management of cardiac patients. We reviewed updated evidence of survival benefit from the most recent trials and guidelines. Patients with ST-segment-elevation myocardial infarction (STEMI) have a mortality benefit when a primary cardiac intervention is implemented. No similar benefit has been shown in chronic stable coronary artery disease. Heart failure patients show a mortality benefit using medication and similarly, mild or moderate valve disease patients do not require an intervention. In atrial fibrillation, the CABANA trial using ablation therapy, had no mortality benefit. Hypertension drug therapy showed a significant mortality benefit, a similar benefit was noted with drug therapy for the treatment of dyslipidemia, when achieving the target lipid goal. Not all interventional procedures result in a mortality benefit. Medical therapy alone increases survival in many cardiac diseases.

Diagnostic Comparability and Interchangeability Between Daytime Ambulatory Blood Pressure Monitoring and 24-Hour Ambulatory Blood Pressure Monitoring in Detecting Masked Hypertension.

Background The primary aim of this study was to evaluate the level of diagnostic overlap between daytime ambulatory blood pressure (BP) monitoring (DT-ABPM) and 24-hour ambulatory BP monitoring (24-h ABPM) in detecting masked hypertension (MH). Methods This is a prospective study that was performed in a sample of 196 soldiers aged between 21 and 50 years (without a history of hypertension) undergoing ABPM testing. The diagnosis of MH based on DT-ABPM defined as (office blood pressure (OBP) <140/90 and DT-ABPM ≥135/85) was compared with the 24-h ABPM defined as (OBP <140/90 mm Hg and 24-h ABPM ≥130/80 mm Hg). We critically analyzed the results to see the agreement between the two methods. Results The number of subjects classified as having MH based on both DT-ABPM and 24-h ABPM, only on 24-h ABPM, and only on DT-ABPM were 11 (5.6%), 29 (14.8%), and 18 (9.2%), respectively. The sensitivity, specificity, and positive and negative predictive values for DT-ABPM in detecting MH were: sensitivity = 100% (95% CI: 97.82% - 100%), specificity = 62.07% (95% CI: 42.26% - 79.31%), PPV = 93.82% (95% CI: 90.50% - 96.03%), and NPV = 100%, respectively. The level of agreement between DT-ABPM and 24-h ABPM in diagnosing MH was 94.4% and discordance in 5.6% (11/196); (kappa=0.736, p < 0.001). Conclusion The sensitivity, specificity, positive and negative predictive values all showed agreement between the two BP methods to confirm the diagnoses of MH. DT-ABPM can be used as an alternative to the 24-h ABPM. DT-ABPM eliminates sleep disturbance attributable to ABPM and maximizes patient compliance with the ABPM test. A further larger trial is needed for more confirmation and to affect the guidelines for using daytime ABPM.

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.

Uncommon cause of complicated myocardial infarction with normal coronary arteries in a Saudi patient.

A case of a young Saudi patient with a previous diagnosis of bronchial asthma, nasal polyps, and chronic smoker, presented with atypical chest pain, elevated serum troponin and borderline ischemic electrocardiogram (ECG) changes, with no significant regional wall motion abnormalities at bedside echocardiography is reported. The patient was admitted to the coronary care unit for continuous monitoring as possible acute coronary syndrome, non-ST elevation myocardial infarction (STEMI). One hour after admission, the patient had ventricular fibrillation (VF) cardiac arrest that required three DC shocks and amiodarone bolus before returning of spontaneous circulation, which followed the fourth shock. The resuscitation took 15 minutes of cardiopulmonary resuscitation (CPR). An immediate 12-leads ECG showed significant ST elevation in precordial leads that mandate an urgent coronary angiogram that revealed patent coronary arteries, therefore spasm of normal coronary arteries was postulated as the operative factor. The cardiac magnetic resonance image (MRI) showed a picture of transmural anterior myocardial infarction, which correlates with the follow up echocardiogram reporting hypokinetic anterior wall. A complete history was taken and no use of illicit drugs or alcohol was found. The unusual presentation in such a patient with evidence of extensive anterior STEMI and normal coronary arteries raise the thought of considering uncommon causes. In view of previous medical history and laboratory evidence of eosinophilia, Kounis syndrome was considered dominant in the differential diagnosis.

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.

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.

Worsening heart failure in 'real-world' clinical practice: predictors and prognostic impact.

AIMS: The aim of this study was to compare the clinical features, predictors, and clinical outcomes of patients hospitalized with acute heart failure (AHF), with and without worsening heart failure (WHF). METHODS AND RESULTS: We used data from a multicentre prospective registry of AHF patients created in Saudi Arabia. WHF was defined as recurrence of heart failure symptoms or signs-with or without cardiogenic shock. In-hospital short- and long-term outcomes, as well as predictors of WHF are described. Of the 2609 AHF patients enrolled, 33.8% developed WHF. WHF patients were more likely to have a history of heart failure and ischaemic heart disease. Use of intravenous vasodilators, inotropic agents, furosemide infusions, and discharge beta-blockers was significantly higher in WHF patients, while use of discharge ACE inhibitors was higher in patients without WHF. Length of hospital stay was significantly longer for WHF patients than for those without WHF [median (interquartile range) 13 (14) vs. 7 (7) days, P < 0.001]. In-hospital, 30-day, 1-year, and 2-year mortality rates were higher in WHF patients than in non-WHF patients. The adjusted odds ratios for in-hospital, 30-day, and 1-year mortality were 4.13 [95% confidence interval (CI) 2.74-6.20, P < 0.001], 3.17 (95% CI 2.21-4.56, P < 0.001), and 1.34 (95% CI 1.04-1.71, P = 0.021), respectively. The strongest predictors for WHF were having ischaemic cardiomyopathy, AHF with concomitant acute coronary syndrome, and low haemoglobin. CONCLUSION: In real-world clinical practice, WHF during hospitalization for AHF is a strong predictor for short- and intermediate-term mortality, and a cause for longer hospital stays.

Sex Differences in Patients With Acute Decompensated Heart Failure: Insights From the Heart Function Assessment Registry Trial in Saudi Arabia.

We assessed sex-specific differences in clinical features and outcomes of patients with acute heart failure (AHF). The Heart function Assessment Registry Trial in Saudi Arabia (HEARTS), a prospective registry, enrolled 2609 patients with AHF (34.2% women) between 2009 and 2010. Women were older and more likely to have risk factors for atherosclerosis, history of heart failure (HF), and rheumatic heart and valve disease. Ischemic heart disease was the prime cause for HF in men and women but more so in men (P < .001). Women had higher rates of hypertensive heart disease and primary valve disease (P < .001, for both comparisons). Men were more likely to have severe left ventricular systolic dysfunction. On discharge, a higher use of angiotensin-converting enzyme inhibitors, ß-blockers, and aldosterone inhibitors was observed in men (P < .001 for all comparisons). Apart from higher atrial fibrillation in women and higher ventricular arrhythmias in men, no differences were observed in hospital outcomes. The overall survival did not differ between men and women (hazard ratio: 1.0, 95% confidence interval: 0.8-1.2, P = .981). Men and women with AHF differ significantly in baseline clinical characteristics and management but not in adverse outcomes.

Disparities in health care delivery and hospital outcomes between non-Saudis and Saudi nationals presenting with acute coronary syndromes in Saudi Arabia.

BACKGROUND: Saudi Arabia has a non-Saudi workers population. We investigated the differences and similarities of expatriate non-Saudi patients (NS) and Saudi nationals (SN) presenting with acute coronary syndromes (ACS) with respect to therapies and clinical outcomes. METHODS: The study evaluated 2031 of the 5055 ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) from 2005 to 2007. Propensity score matching and logistic regression analysis were performed to account for major imbalances in age and sex in the two groups. RESULTS: The mean patient age was 56.2±9.8, and 83.5% of the study cohort were male. SN were more likely to have risk factors of atherosclerosis. ST-elevation MI (STEMI) was the most common ACS presentation in NS, while non-ST ACS was more common in SN. The median symptom-to-door time was significantly greater in NS patients (Median 175 min (197) vs. 130 min (167), p=0.027). The only difference in pharmacological therapies between the two groups was that NS were more likely to receive fibrinolytic therapy. NS were less likely than SN to undergo percutaneous coronary interventions (PCI; 32.6% vs. 42.8%, p=0.0001) or primary PCI (7.8% vs. 22.8%, p<0.001). Hospital mortality, cardiogenic shock, and heart failure were significantly higher in NS compared to SN. After adjusting for baseline variables and therapies, the odds ratios for hospital mortality and cardiogenic shock in NS were 2.9 (95% CI 1.5-6.2, p=0.004) and 2.8 (95% CI 1.5-4.9, p<0.001), respectively. CONCLUSION: Our findings indicate disparities in hospital care between NS and SN ACS patients. NS patients had worse hospital outcomes, which may reflect unequal health coverage and access-to-care issues.

Abnormal Chest X-ray Postmyocardial Infarction.

Pulmonary hemorrhage is a rare complication of fibrinolytic therapy. Only a few cases are reported in the literature. We present a patient who had myocardial infarction, treated with fibrinolytic therapy and developed pulmonary hemorrhage. We discuss the features that suggest and support the diagnosis.

Clinical features, management, and short- and long-term outcomes of patients with acute decompensated heart failure: phase I results of the HEARTS database.

AIMS: The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS) is a national multicentre project, studying clinical features, management, short- and long-term outcomes, and mortality predictors in patients admitted with acute decompensated heart failure (ADHF). METHODS AND RESULTS: Our prospective registry enrolled 2610 ADHF patients admitted to 18 hospitals in Saudi Arabia between October 2009 and December 2010, and followed mortality rates until January 2013. The patients included 66% men and 85.5% Saudis, with a median age (interquartile range) of 61.4 (15) years; 64% had acute on chronic heart failure (HF), 64.1% diabetes mellitus, 70.6% hypertension, and 55.7% CAD. Exacerbating factors for hospital admission included acute coronary syndromes (37.8%), infections (20.6%), non-compliance with low-salt diet (25.2%), and non-compliance with HF medications (20%). An LVEF<40% was found in 73%. In-hospital use of evidence-based medications was high. All-cause cumulative mortality rates at 30 days, 6 months, 1 year, 2 years, and 3 years were 8.3, 13.7, 19.5, 23.5, and 24.3%, respectively. Important independent predictors of mortality were history of stroke, acute on chronic HF, systolic blood pressure<90 mmHg upon presentation, estimated glomerular filtration rate<60 mL/min, and haemoglobin<10 g/dL. CONCLUSION: Patients with ADHF in Saudi Arabia presented at a younger age and had higher rates of CAD risk factors compared with those in developed countries. Most patients had reduced LV systolic function, mostly due to ischaemic aetiology, and had poor long-term prognosis. These findings indicate a need for nationwide primary prevention and HF disease management programmes.

Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia.

BACKGROUND AND OBJECTIVES: Gender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored. DESIGN AND SETTINGS: A prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis. PATIENTS AND METHODS: Patients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed. RESULTS: Of 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given b-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7-5.5; P=.14). CONCLUSION: These data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Incidence of ventricular arrhythmia and associated patient outcomes in hospitalized acute coronary syndrome patients in Saudi Arabia: findings from the registry of the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE).

BACKGROUND AND OBJECTIVES: Mortality in acute coronary syndrome (ACS) patients with ventricular arrhythmia (VA) has been shown to be higher than those without VA. However, there is a paucity of data on VA among ACS patients in the Middle Eastern countries. DESIGN AND SETTING: Prospective study of patients admitted in 17 government hospitals with ACS between December 2005 and December 2007. PATIENTS AND METHODS: Patients were categorized as having VA if they experienced either ventricular fibrillation (VF) or sustained ventricular tachycardia (VT) or both. RESULTS: Of 5055 patients with ACS enrolled in the SPACE registry, 168 (3.3%) were diagnosed with VA and 151 (98.8%) occurred in-hospital. The vast majority (74.4%) occurred in patients with ST-segment elevation myocardial infarction. In addition, males were twice as likely to develop VA than females (OR 1.7; 95% CI 1.13). Killip class >I (OR 2.0; 95% CI 1.3-3.1); and systolic blood pressure <90 mm Hg (OR 6.4; 95% CI 3.5-11.8) were positively associated with VA. Those admitted with hyperlipidemia (OR 0.49; 95% CI 0.3-0.7) had a lower risk of developing VA. Adverse in-hospital outcomes including re-myocardial infarction, cardiogenic shock, congestive heart failure, major bleeding, and stroke were higher for patients with VA (P≤.01 for all variables) and signified a poor prognosis. The in-hospital mortality rate was significantly higher in VA patients compared with non-VA patients (27% vs 2.2%; P=.001). CONCLUSIONS: In-hospital VA in Saudi patients with ACS was associated with remarkably high rates of adverse events and increased in-hospital mortality. Using a well-developed registry data with a large number of patients, our study documented for the first time the prevalence and risk factors of VA in unselected population of ACS.

Age and its relationship to acute coronary syndromes in the Saudi Project for Assessment of Coronary Events (SPACE) registry: The SPACE age study.

OBJECTIVE: To characterize risk profile of acute coronary syndrome (ACS) patients in different age groups and compare management provided to in-hospital outcome. DESIGN: Prospective multi-hospital registry. SETTING: Seventeen secondary and tertiary care hospitals in Saudi Arabia. PATIENTS: Five thousand and fifty-five patients with ACS. They were divided into four groups: ⩽40 years, 41-55 years, 56-70 years and ⩾70 years. MAIN OUTCOME MEASURES: prevalence, utilization and mortality. RESULTS: Ninety-four percent of patients <40 years compared to 68% of patients >70 years were men. Diabetes was present in 70% of patients aged 56-70 years. Smoking was present in 66% of those <40 years compared to 7% of patients >70 years. Fifty-three percent of the patients >70 years and 25% of those <40 years had history of ischemic heart disease. Sixty percent of patients <40 years presented with ST elevation myocardial infarction (STEMI) while non-ST elevation myocardial infarction was the presentation in 49% of patients >70 years. Thirty-four percent of patients >70 years compared to 10% of patients <40 years presented >12 h from symptom onset with STEMI. Fifty-four percent of patients >70 compared to 64-71% of those <70 years had coronary angiography. Twenty-four percent of patients >70 compared to 34-40% of those <70 years had percutaneous coronary intervention. Reperfusion shortfall for STEMI was 16-18% in patients >56 years compared to 11% in patients <40 years. Mortality was 7% in patients >70 years compared to 1.6-3% in patients <70 years. For all comparisons (p < 0.001). CONCLUSIONS: Young and old ACS patients have unique risk factors and present differently. Older patients have higher in-hospital mortality as they are treated less aggressively. There is an urgent need for a national prevention program as well as a systematic improvement in the care for patients with ACS including a system of care for STEMI patients. For older patients there is a need to identify medical as well as social factors that influence the therapeutic management plans.

Are acute coronary syndrome patients admitted during off-duty hours treated differently? An analysis of the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study.

BACKGROUND AND OBJECTIVES: It is often suggested that acute coronary syndrome (ACS) patients admitted during off-duty hours (OH) have a worse clinical outcome than those admitted during regular working hours (RH). Our objective was to compare the management and hospital outcomes of ACS patients admitted during OH with those admitted during RH. DESIGN AND SETTING: Prospective observational study of ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome study from December 2005 to December 2007. PATIENTS AND METHODS: ACS patients with available date and admission times were included. RH were defined as weekdays, 8 AM-5 PM, and OH was defined as weekdays 5 PM-8 AM, weekends, during Eid (a period of several days marking the end of two major Islamic holidays), and national days. RESULTS: Of the 2825 patients qualifying for this analysis, 1016 (36%) were admitted during RH and 1809 (64%) during OH. OH patients were more likely to present with heart failure and ST elevation myocardial infarction (STEMI) and to receive fibrinolytic therapy, but were less likely to undergo primary percutaneous coronary interventions (PCI). The median door to balloon time was significantly longer (P<.01) in OH patients (122 min) than in RH patients. No differences were observed in hospital outcomes including mortality between the two groups, except for higher heart failure rates in OH patients (11.1% vs 7.2%, P<.001). CONCLUSIONS: STEMI patients admitted during OH were disadvantaged with respect to use and speed of delivery of primary PCI but not fibrinolytic therapy. Hospitals providing primary PCI during OH should aim to deliver it in a timely manner throughout the day.