Molecular and pro-inflammatory aspects of COVID-19: The impact on cardiometabolic health.

Obesity, type 2 diabetes (T2DM), hypertension (HTN), and Cardiovascular Disease (CVD) often cluster together as "Cardiometabolic Disease" (CMD). Just under 50% of patients with CMD increased the risk of morbidity and mortality right from the beginning of the COVID-19 pandemic as it has been reported in most countries affected by the SARS-CoV2 virus. One of the pathophysiological hallmarks of COVID-19 is the overactivation of the immune system with a prominent IL-6 response, resulting in severe and systemic damage involving also cytokines such as IL2, IL4, IL8, IL10, and interferon-gamma were considered strong predictors of COVID-19 severity. Thus, in this mini-review, we try to describe the inflammatory state, the alteration of the adipokine profile, and cytokine production in the obese state of infected and not infected patients by SARS-CoV2 with the final aim to find possible influences of COVID-19 on CMD and CVD. The immunological-based discussion of the molecular processes could inspire the study of promising targets for managing CMD patients and its complications during COVID-19.

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.

Patterns of tobacco use in the United Arab Emirates Healthy Future (UAEHFS) pilot study.

INTRODUCTION: Self-reported tobacco use in the United Arab Emirates is among the highest in the region. Use of tobacco products other than cigarettes is widespread, but little is known about specific behavior use patterns. There have been no studies that have biochemically verified smoking status. METHODS: The UAE Healthy Future Study (UAEHFS) seeks to understand the causes of non-communicable diseases through a 20,000-person cohort study. During the study pilot, 517 Emirati nationals were recruited to complete a questionnaire, provide clinical measurements and biological samples. Complete smoking data were available for 428 participants. Validation of smoking status via cotinine testing was conducted based on complete questionnaire data and matching urine samples for 399 participants, using a cut-off of 200ng/ml to indicate active smoking status. RESULTS: Self-reported tobacco use was 36% among men and 3% among women in the sample. However, biochemical verification of smoking status revealed that 42% men and 9% of women were positive for cotinine indicating possible recent tobacco use. Dual and poly-use of tobacco products was fairly common with 32% and 6% of the sample reporting respectively. CONCLUSIONS: This is the first study in the region to biochemically verify tobacco use self-report data. Tobacco use in this study population was found to be higher than previously thought, especially among women. Misclassification of smoking status was more common than expected. Poly-tobacco use was also very common. Additional studies are needed to understand tobacco use behaviors and the extent to which people may be exposed to passive tobacco smoke. IMPLICATIONS: This study is the first in the region to biochemically verify self-reported smoking status.

Risk factors for death, stroke, and bleeding in 28,628 patients from the GARFIELD-AF registry: Rationale for comprehensive management of atrial fibrillation.

BACKGROUND: The factors influencing three major outcomes-death, stroke/systemic embolism (SE), and major bleeding-have not been investigated in a large international cohort of unselected patients with newly diagnosed atrial fibrillation (AF). METHODS AND RESULTS: In 28,628 patients prospectively enrolled in the GARFIELD-AF registry with 2-year follow-up, we aimed at analysing: (1) the variables influencing outcomes; (2) the extent of implementation of guideline-recommended therapies in comorbidities that strongly affect outcomes. Median (IQR) age was 71.0 (63.0 to 78.0) years, 44.4% of patients were female, median (IQR) CHA2DS2-VASc score was 3.0 (2.0 to 4.0); 63.3% of patients were on anticoagulants (ACs) with or without antiplatelet (AP) therapy, 24.5% AP monotherapy, and 12.2% no antithrombotic therapy. At 2 years, rates (95% CI) of death, stroke/SE, and major bleeding were 3.84 (3.68; 4.02), 1.27 (1.18; 1.38), and 0.71 (0.64; 0.79) per 100 person-years. Age, history of stroke/SE, vascular disease (VascD), and chronic kidney disease (CKD) were associated with the risks of all three outcomes. Congestive heart failure (CHF) was associated with the risks of death and stroke/SE. Smoking, non-paroxysmal forms of AF, and history of bleeding were associated with the risk of death, female sex and heavy drinking with the risk of stroke/SE. Asian race was associated with lower risks of death and major bleeding versus other races. AC treatment was associated with 30% and 28% lower risks of death and stroke/SE, respectively, compared with no AC treatment. Rates of prescription of guideline-recommended drugs were suboptimal in patients with CHF, VascD, or CKD. CONCLUSIONS: Our data show that several variables are associated with the risk of one or more outcomes, in terms of death, stroke/SE, and major bleeding. Comprehensive management of AF should encompass, besides anticoagulation, improved implementation of guideline-recommended therapies for comorbidities strongly associated with outcomes, namely CHF, VascD, and CKD. TRIAL REGISTRATION: ClinicalTrials.gov NCT01090362.

Control of Risk Factors for Cardiovascular Disease among Multinational Patient Population in the Arabian Gulf.

We evaluated the control of cardiovascular disease (CVD) risk factors among patients with atherosclerotic cardiovascular disease (ASCVD) in the Centralized Pan-Middle East Survey on the undertreatment of hypercholesterolaemia (CEPHEUS) in the Arabian Gulf. Of the 4398 enrolled patients, overall mean age was 57 ± 11 years, 60% were males, 13% were smokers, 76% had diabetes, 71% had metabolic syndrome and 78% had very high ASCVD risk status. The proportion of subjects with body mass index <25 kgm2, HbA1c <7% (in diabetics), low-density lipoprotein cholesterol (LDL-C) <2.6 mmol/L (100 mg/dL) and <1.8 mmol/L (70 mg/dL) for high and very high ASCVD risk cohorts, respectively and controlled blood pressure (<140/90 mmHg) was 14, 26, 31% and 60%, respectively. Only 1.4% of the participants had all of their CVD risk factors controlled with significant differences among the countries (P < .001). CVD risk goal attainment rates were significantly lower in those with very high ASCVD risk compared with those with high ASCVD risk status (P < .001). Females were also, generally, less likely to attain goals when compared with males (P < .001).

Elusive Cardiac Angiosarcoma in a Young Pregnant Female: Rare Presentation With Fatal Outcome.

Heart tumors are rare occurrences. They can present diagnostic challenges and severe complications especially in pregnant women. We report a rare case of angiosarcoma (AS) cordis of the right atrium in a young healthy pregnant female. Her diagnosis remained elusive for some time until development of advanced disease symptomatology. The diagnosis was unfortunately clinched when her tumor grew to be detected by imaging modalities. An emergency cesarean section was performed delivering a healthy baby. The patient was aggressively treated with chemotherapy to no avail. She passed away 2 months after her diagnosis was established. Only few cases of the occurrence of aggressive cardiac AS and human pregnancy are documented. The course of this disastrous combination is usually marked by severe complications, difficult therapeutic options and ultimately fast demise. Physicians need to be more aware of such diagnosis and diligently try to diagnose it as early as possible.

A case report of a right ventricular mass in a patient with Behçet's disease: Myxoma or thrombus?

INTRODUCTION: Behçet's disease (BD) is a multi-system, chronic and relapsing disorder classified as "vasculitic syndrome". It typically affects young adult females between 20 and 40 years of age. There are some typical clinical manifestations associated with this disease, however, at times; rare sign and symptoms pose a challenge to the treating physician and making a definitive diagnosis. Presentations with cardiac symptoms are one of the extremely rare manifestations of the Behçet's disease. METHODS: The authors present clinical, laboratory and imaging findings of a patient who presented with a cardiac mass which was the first presenting feature or manifestation of Behçet's disease. RESULTS: A 19-year-old boy was admitted to our hospital for the investigation of "fever of unknown origin", weight loss, shortness of breath and a scrotal ulcer of recent on-set. X-ray chest and electrocardiograms were inconclusive. Transthoracic echocardiography revealed a right ventricular (RV) mass attached to the interventricular septum measuring 1.5 × 1.5 cms (Panel A). Cardiac MRI identified it as a RV Myxoma. In addition, on CT scan of the chest pulmonary embolism was noted. The patient underwent excision biopsy of the tumor under cardiopulmonary bypass via right atriotomy (Panel B). Histopathology of the mass described it as "an organizing thrombus with a few groups of interrupted myocardial fibers and some infiltration of lymphocytes and plasma cells". Moreover his HLA typing was found positive for HLA-B51 (5). In view of the above findings and associated lesions, the patient was diagnosed as a case of Behçet's disease. The medical management included immunosuppressant and anticoagulation. CONCLUSION: Behçet's disease, even in the absence of the typical clinical features, should be considered in the differential diagnosis of right ventricular mass, especially when dealing with young adults from the Mediterranean basin and the Middle-East.

Short-term and long-term mortality associated with ventricular arrhythmia in patients hospitalized with acute coronary syndrome: findings from the Gulf RACE registry-2.

OBJECTIVES: Ventricular arrhythmia (VA) in the setting of acute coronary syndrome (ACS) carries an ominous prognosis; however, long-term prognosis associated with VA in ACS in the Middle East is unknown. Accordingly, we sought to assess the incidence, in-hospital outcomes, and 1-year mortality of in-hospital VA in patients with ACS. METHODS AND RESULTS: The Second Gulf Registry of Acute Coronary Events (Gulf RACE-2) is a multinational observational study of patients with ACS, which enrolled 7930 patients. Of these, 333 (4.2%) developed VA during hospitalization. Patients with VA were significantly older (mean age 58.3 vs. 56.8 years), and had a significantly higher rate of prior stroke/transient ischemic attack (7.5 vs. 4.2%), smoking (36.6 vs. 35.6%), congestive heart failure (11.0 vs. 6.5%), and peripheral artery disease (6.5 vs. 1.7%), compared with patients without VA. They had significantly less diabetes mellitus (35.4 vs. 40.3%), hypertension (43.2 vs. 47.9%), percutaneous coronary intervention (6.1 vs. 9.4%), and dyslipidemia (22.4 vs. 38.2%). The adjusted odds ratios for in-hospital, 30-day, and 1-year mortality in VA complicating all ACS were 25.8, 11.1, and 7.3; ST-elevation myocardial infarctions were 18.3, 11.7, and 6.3; and unstable angina and non-ST elevation myocardial infarctions were 47.4, 10.3, and 18.7, respectively (all P<0.001). CONCLUSION: In-hospital VA in patients with ACS with and without ST elevation was associated with significantly higher in-hospital, 30-day, and 1-year mortality. Noticeably higher long-term mortality among Middle Eastern patients with ACS having VA compared with other reports requires further study and warrants immediate attention.

Prevalence and outcome of cigarette and waterpipe smoking among patients with acute coronary syndrome in six Middle-Eastern countries.

OBJECTIVE: We evaluated the prevalence and effect of cigarette smoking (CS) and waterpipe (WP) smoking on patients with acute coronary syndrome (ACS) in six Middle-Eastern countries. METHODS: Analysis of the Gulf Registry of Acute Coronary Events (Gulf RACE) survey, which included 6704 consecutive patients hospitalized with ACS, was made and patients were divided into four groups depending on whether they were smokers - cigarette-CS, waterpipe-WS, combined cigarette and waterpipe (CW) - or non-smokers (NS). RESULTS: Overall 38% of patients were smokers; 4.4% of patients were waterpipe smokers (1.4% WS and 3% CW). When compared to the three smokers' groups, non-smokers were older. Overall, smokers had fewer cardiovascular risk factors when compared to NS. ST-segment elevation myocardial infarction was more common among nicotine smokers (CS 54.4%, WS 57.3%, 47.3% CW vs 30% NS, p = 0.001) while NS were more likely to have non-ST elevation ACS. Cigarette (and not waterpipe) smokers were more likely to present early and with typical symptoms when compared to NS and WS. Admission heart rate and blood pressures were higher in the non-smoker group and WS. Non-smokers and WS were also more likely to present with Killip class >1. After adjustment for baseline variables, smoking was not an independent predictor of adverse cardiac events. CONCLUSION: Cigarette smoking is prevalent among Middle-Eastern patients presenting with acute coronary syndrome. Waterpipe smoking use is low; however it is relatively more frequent in women when compared to cigarette smoking. The current study underscores the need for further studies into the effects of different forms of nicotine smoking.

Prevalence, Predictors, and Impact of Low High-Density Lipoprotein Cholesterol on in-Hospital Outcomes Among Acute Coronary Syndrome Patients in the Middle East.

OBJECTIVE: To estimate the prevalence, predictors, and impact of low high-density lipoprotein cholesterol (HDL-C) on in-hospital outcomes among acute coronary syndrome (ACS) patients in the Middle East. METHODS: Data were collected prospectively from 6,266 consecutive patients admitted with a diagnosis of ACS and enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE). A low HDL-C was defined as a level <40 mg/Dl (1.0 mmol/L) for males and <50 mg/dL (1.3 mmol/L) for females. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The overall mean age of the cohort was 56±12 years and majority were males (77%). The overall prevalence of low HDL-C was 62%. During in-hospital stay and at discharge, the majority were on statin therapy (83%) while 10% were on other cholesterol lowering agents. After adjustment of demographic and clinical characteristics, the predictors for low HDL-C were higher body mass index (BMI), prior myocardial infarction (MI), diabetes mellitus, smoking and impaired renal function. Multivariable adjustment revealed that low HDL-C was associated with higher in-hospital mortality (odds ratio (OR), 1.54; 95% CI: 1.06-2.24; p=0.022) and cardiogenic shock (OR, 1.61; 95% CI: 1.20-2.14; p=0.001). CONCLUSIONS: ACS patients in the Middle East have a high prevalence of low HDL-C. Higher BMI, prior MI, diabetes mellitus, smoking, and impaired renal function were predictors of low HDL-C. Significantly higher in-hospital mortality and cardiogenic shock were associated with low HDL-C in men but not in women.

The prevalence and outcome of hypertension in patients with acute coronary syndrome in six Middle-Eastern countries.

AIMS: The aim was to report the prevalence and significance of hypertension (HTN) in patients with acute coronary syndrome (ACS). METHODS AND MAJOR FINDINGS: Over a 6-month period in 2007, 8171 consecutive patients (49.4% hypertensive and 50.6% non-hypertensive) presenting with ACS were enrolled in a prospective, multicenter study from six Middle Eastern adjacent countries. Patients with HTN were older (59.2 vs 53.1 years, p<0.001), and more likely to be female (34% vs 14.4%, p<0.001) when compared with patients without HTN. Patients with HTN were also more likely to have diabetes mellitus, hyperlipidemia, cerebrovascular disease, prior history of coronary artery disease, peripheral artery disease but less likely to be cigarette smokers. At admission, HTN patients had higher Killip class, heart rate and GRACE risk scoring. In-hospital mortality was higher in hypertensive patients with ST-elevation myocardial infarction (STEMI) but not in patients with non-STEMI or unstable angina. The incidence of heart failure complications was significantly higher among patients with HTN in overall ACS type (OR = 1.2, 95% CI 1.001-1.338, p= 0.04). MAIN CONCLUSION: In this large cohort of patients with ACS, HTN was an independent predictor of heart failure and was associated with an increased rate of in-hospital mortality in STEMI only.

Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States.

BACKGROUND: Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States. OBJECTIVE: To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE). METHODS: Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other). RESULTS: Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03-1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48-2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34-1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02-1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09-1.51), and current smoking (OR 1.30; 95% CI 1.13-1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED. CONCLUSION: Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

Prevalence and treatment of cardiovascular risk factors in outpatients with atherothrombosis in the Middle East.

OBJECTIVE: To characterise the risk-factor profile and treatment gaps among patients with, or at risk for, cardiovascular disease in the Middle East. DESIGN: Secondary analysis of a prospective observational study. SETTING: International multicentre study (Reduction of Atherothrombosis for Continued Health). PATIENTS: Stable outpatients with established cardiovascular disease or at least three risk factors for atherothrombosis. The present analysis was based on 840 patients from the Middle East. INTERVENTION: Observational study without a study-specific intervention. MAIN OUTCOME MEASURES: A treatment gap was defined as at least one of the following: current cigarette smoking, total cholesterol ≥200 mg/dl, serum glucose ≥126 mg/dl or blood pressure of ≥140/90. RESULTS: The majority of Middle Eastern patients had hypertension (80.2%), more than half had a history of diabetes mellitus (52.3%), and a third had hypercholesterolaemia (34.1%). There was a high prevalence of obesity (38.6%), and nearly half the patients were former or current smokers (46%). ß-Blockers and angiotensin-converting enzyme inhibitors were the most commonly prescribed antihypertensives (61.1% and 57.5%, respectively). Antiplatelet therapy (most commonly aspirin) and lipid-lowering drugs (most commonly a statin) were used in most patients (90.7% and 85.2%, respectively). Three-quarters of the participants (75.6%) had at least one uncontrolled risk factor. CONCLUSION: Patients with atherothrombosis in the Middle East have a high prevalence of risk factors including alarming rates of diabetes mellitus and obesity. At least one risk factor is uncontrolled in the majority of patients, presenting a pressing need for improving the care of such patients in the Middle East.

B-type natriuretic peptide levels predict functional capacity in postcardiac surgery patients.

OBJECTIVE: Plasma levels of B-type natriuretic peptide (BNP) are often increased in postcardiac surgery patients. The six-minute walking test (6MWT) is useful to assess functional capacity in postcardiac surgery patients. The aim of this study was to determine whether BNP levels are associated with exercise capacity evaluated by 6MWT in patients after cardiac surgery. METHODS: Plasma BNP was measured in 101 consecutive patients referred to our center 8 ± 5 days after cardiac surgery who underwent echocardiography and 6MWT. We considered age, sex, diabetes, renal insufficiency, anemia, chronic obstructive pulmonary disease, hypertension, atrial fibrillation, beta-blocker therapy, left ventricular ejection fraction (LVEF), E/E', indexed left atrial volume (iLAV), type of surgery, and plasma BNP levels as potential predictors of reduced performance at 6MWT evaluated as percentages of the predicted values calculated according to the regression equation obtained in healthy individuals. RESULTS: The mean distance walked at 6MWT was 325 ± 100 m corresponding to 65 ± 20% of the predicted values. This was independent of the LVEF, E/E' or iLAV. Female patients or patients with atrial fibrillation had a reduced performance compared with male patients or patients with sinus rhythm (52 ± 19 vs. 70 ± 19%, P < 0.001; 50 ± 19 vs. 66 ± 19%, P = 0.017, respectively). BNP levels were inversely related to the performance at 6MWT (Pearson's correlation coefficient = -0.25, P = 0.010). At multivariate analysis, female sex (P < 0.001), atrial fibrillation (P = 0.031), and BNP levels (P = 0.040) remained the only independent predictive factors for reduced exercise capacity. CONCLUSION: The increase in BNP levels in postcardiac surgery patients is associated with reduced exercise capacity.

Prominent crista terminalis mimicking a right atrial mass: case report.

The crista terminalis is a normal anatomical structure within the right atrium that is not normally visualised in the standard views obtained while performing a transthoracic echocardiogram. In this case report, transthoracic echocardiography suggested the presence of a right atrial mass in a patient with end stage renal disease. However, subsequent transesophageal echocardiography revealed that the right atrial mass was actually a thick muscular bridge in the right atrium consistent with a prominent crista terminalis. An understanding of the anatomy and the echocardiographic appearance of a prominent crista terminalis will minimize the misdiagnosis of this structure avoiding unnecessary expensive additional tests.

Inflammatory myofibroblastic tumor of the right atrium.

Cardiac inflammatory myofibroblastic tumor (IMT) is a rare entity and is associated with distinct clinical, pathological and molecular features. The clinical behavior, natural history, biological potential, management and prognosis of such tumors are unclear. We present herewith an adolescent girl who presented with similar entity involving the junction of the right atrium and the inferior vena cava (IVC) in association with thrombocytosis and IVC thrombosis leading to obstruction of blood flow. Diagnostic tools included imaging and immuno-histopathology studies. Surgical management included resection of the tumor and thrombo-embolectomy of the IVC under cardiopulmonary bypass. This case is unique due to association of complete obstruction of IVC caused by the strategic location of the tumor, thrombosis of vena cava and association of thrombocytosis. These features have not been reported yet in relation to the cardiac IMT. This report will help in better understanding and management of similar cases in terms of planning cannulation of femoral veins or application of total hypothermic circulatory arrest during cardiopulmonary bypass and prompt us to look for recurrence or metastasis during follow up using echocardiography and laboratory investigations. The possibility of IMT should be kept in the differential diagnosis of cardiac tumors especially in children and adolescents.

Relationship between B-type natriuretic peptide levels and echocardiographic indices of left ventricular filling pressures in post-cardiac surgery patients.

BACKGROUND: B-type natriuretic peptide (BNP) is increased in post-cardiac surgery patients, however the mechanisms underlying BNP release are still unclear. In the current study, we aimed to assess the relationship between postoperative BNP levels and left ventricular filling pressures in post-cardiac surgery patients. METHODS: We prospectively enrolled 134 consecutive patients referred to our Center 8 +/- 5 days after cardiac surgery. BNP was sampled at hospital admission and related to the following echocardiographic parameters: left ventricular (LV) diastolic volume (DV), LV systolic volume (SV), LV ejection fraction (EF), LV mass, relative wall thickness (RWT), indexed left atrial volume (iLAV), mitral inflow E/A ratio, mitral E wave deceleration time (DT), ratio of the transmitral E wave to the Doppler tissue early mitral annulus velocity (E/E'). RESULTS: A total of 124 patients had both BNP and echocardiographic data. The BNP values were significantly elevated (mean 353 +/- 356 pg/ml), with normal value in only 17 patients (13.7%). Mean LVEF was 59 +/- 10% (LVEF >or=50% in 108 pts). There was no relationship between BNP and LVEF (p = 0.11), LVDV (p = 0.88), LVSV (p = 0.50), E/A (p = 0.77), DT (p = 0.33) or RWT (p = 0.50). In contrast, BNP was directly related to E/E' (p < 0.001), LV mass (p = 0.006) and iLAV (p = 0.026). At multivariable regression analysis, age and E/E' were the only independent predictors of BNP levels. CONCLUSION: In post-cardiac surgery patients with overall preserved LV systolic function, the significant increase in BNP levels is related to E/E', an echocardiographic parameter of elevated LV filling pressures which indicates left atrial pressure as a major determinant in BNP release in this clinical setting.

Impact of fasting in Ramadan in patients with cardiac disease.

OBJECTIVES: To investigate whether Ramadan fasting has any effect on patients with heart disease. METHODS: We prospectively studied 465 outpatients with heart disease who were fasting during the month of Ramadan from October 24 to November 24, 2003. These studied subjects were from various medical centers in the Gulf region; State of Qatar, Kuwait, United Arab Emirates, and Bahrain. We performed detailed clinical assessments one month before Ramadan, during Ramadan and one month after Ramadan and analyzed predictors of outcome. RESULTS: Overall, the mean age was 55.9+/-11.3 years (age range 32-72). Of the 465 patients treated, 363 (78.1%) were males and 102 (21.9%) females. Among them, 119 (25.6%) patients had congestive heart failure, 288 (62%) patients with angina, 22 (4.7%) patients with atrial fibrillation and 11 (2.4%) patients with prosthetic metallic valves. Three hundred and seventy (79%) had prior myocardial infarction (MI), 195 (17.2%) had prior coronary artery bypass surgery (CABG), and 177 (38%) had prior percutaneous coronary interventions (PCI). At the time of follow-up, we found that 91.2% could fast and only 6.7% felt worse while fasting in Ramadan. Of the studied subjects, 82.8% were compliant with cardiac medications and 68.8% were compliant with dietary instructions. We hospitalized 19 patients during Ramadan for cardiac reasons (unstable angina, worsening heart failure, MI, uncontrolled hypertension, subtherapeutic anticoagulation or arrhythmias) CONCLUSION: The effects of fasting during Ramadan on stable patients with cardiac disease are minimal. Most patients with stable cardiac disease can fast.