Effects of a team Quality Improvement method in a national clinical audit programme of four clinical specialties in Ministry of Health hospitals in Saudi Arabia.

In 2018, the Ministry of Health (MoH) in Saudi Arabia developed a clinical excellence strategy. An objective was to reduce variation in clinical practices in MoH hospitals, particularly for conditions with high mortality in Saudi Arabia, by applying best practice clinical standards and using the clinical audit process to measure clinical practice. The strategy included working with multiprofessional teams in hospitals to implement improvements needed in clinical practice. To test the feasibility of carrying out national clinical audits in MoH hospitals, audits were carried out in 16 MoH hospitals on four clinical subjects-acute myocardial infarction, major trauma, sepsis, and stroke. Clinical expert groups, including Saudi clinicians and an international clinical expert, developed clinical care standards for the four conditions from analyses of international and Saudi clinical guidelines. The audits were designed with the expert groups. Multiprofessional teams were appointed to carry out the audits in designated MoH hospitals. Data collectors in each hospital were trained to collect data. Workshops were held with the teams on the clinical care standards and how data would be collected for the audits, and later, on the findings of data collection and how to use the improvement process to implement changes to improve compliance with the standards. After 4 months, data collection was repeated to determine if compliance with the clinical care standards had improved. Data collected from each hospital for both cycles of data collection were independently reliably tested. All designated hospitals participated in the audits, collecting and submitting data for two rounds of data collection and implementing improvement plans after the first round of data collection. All hospitals made substantial improvements in clinical practices. Of a total of 84 measures used to assess compliance with a total of 52 clinical care standards for the four clinical conditions, improvements were made by hospital teams in 58 (69.1%) measures. Improvements were statistically significant for 34 (40.5%) measures. The project demonstrated that well-designed and executed audits using evidence-based clinical care standards can result in substantial improvements in clinical practices in MoH hospitals in Saudi Arabia. Keys to success were the improvement methodology built into the audit process and the requirement for hospitals to appoint multiprofessional teams to carry out the audits. The approach adds to evidence on the effectiveness of clinical audits in achieving improvements in clinical quality and can be replicated in national audit programmes.

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

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

Immediate and one-year outcome of patients presenting with acute coronary syndrome complicated by stroke: findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2).

BACKGROUND: Stroke is a potential complication of acute coronary syndrome (ACS). The aim of this study was to identify the prevalence, risk factors predisposing to stroke, in-hospital and 1-year mortality among patients presenting with ACS in the Middle East. METHODS: For a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries. RESULTS: The prevalence of in-hospital stroke following ACS was 0.70%. Most cases were ST segment elevation MI-related (STEMI) and ischemic stroke in nature. Patients with in-hospital stroke were 5 years older than patients without stroke and were more likely to have hypertension (66% vs. 47.6%, P = 0.001). There were no differences between the two groups in regards to gender, other cardiovascular risk factors, or prior cardiovascular disease. Patients with stroke were more likely to present with atypical symptoms, advanced Killip class and less likely to be treated with evidence-based therapies. Independent predictors of stroke were hypertension, advanced killip class, ACS type -STEMI and cardiogenic shock. Stroke was associated with increased risk of in-hospital (39.3% vs. 4.3%) and one-year mortality (52% vs. 12.3%). CONCLUSION: There is low incidence of in-hospital stroke in Middle-Eastern patients presenting with ACS but with very high in-hospital and one-year mortality rates. Stroke patients were less likely to be appropriately treated with evidence-based therapy. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

Impact of evidence-based cardiac medication on short- and long-term mortality in 7,567 acute coronary syndrome patients in the Gulf RACE-II registry.

OBJECTIVE: To evaluate the impact of evidence-based cardiac medications (EBMs) on 1-month and 1-year mortality among discharged acute coronary syndrome (ACS) patients in the Middle East. METHODS: Data were analyzed from 7,567 consecutive ACS patients admitted to 66 hospitals in 6 Middle Eastern countries enrolled in the Gulf RACE II in October 2008 to June 2009. Individual EBMs or concurrent use of the EBM combination consists of an anti-platelet therapy, angiotensin-converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker (ARB)), ß-blocker, and a statin at discharge, were evaluated. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The mean age of the cohort was 56 +/- 12 years with 79% being males. 65% of the patients received the concurrent EBM combination at discharge. Aspirin, clopidogrel, statins, b-blockers and ACEIs/ARBs use was 96%, 71%, 95%, 82% and 81%, respectively. 70% of the patients were prescribed both aspirin and clopidogrel concurrently at discharge. Adjusting for demographic, clinical, revascularization, and country characteristics, the multivariable logistic regression models demonstrated no differences in mortality at both 1-month (3.0 vs. 3.6%; p = 0.828) and 1-year (3.5 vs. 3.5%; p = 0.976) between the concurrent EBM combination users and non-users. CONCLUSION: The majority of the ACS patients in the Middle East were prescribed the guideline recommended EBM combination at discharge. However, potential still remains for further optimization of management. Further studies are required to examine the long term effect of concurrent use of the EBM combination on mortality in the region.

Impact of anemia on in-hospital, one-month and one-year mortality in patients with acute coronary syndrome from the Middle East.

AIM: The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS). METHODS: Data were analyzed from 7922 consecutive patients admitted to hospitals throughout six Middle-Eastern countries with the final diagnosis of ACS, as part of Gulf RACE II (Registry of Acute Coronary Events II). Anemia at admission was defined according to the World Health Organization definition (<13 g/dL in men and <12 g/dL in women). Analyses were conducted using univariate and multivariate statistical techniques. RESULTS: The median age of the cohort was 56 (48-65) years, with the majority being male (79%). Anemia at admission was present in 2241 patients (28%). Patients with anemia were more likely to have in-hospital complications including heart failure, recurrent ischemia, re-infarction, cardiogenic shock, stroke, and major bleed. Even after adjustment, anemia was still associated with mortality at in-hospital (odds ratio [OR]=1.71, 95% confidence interval [CI], 1.34-2.17; P<0.001), at one-month (OR=1.34, 95% CI, 1.06-1.71; P=0.016), and at one-year (OR=1.22, 95% CI, 1.01-1.49; P=0.049) post-admission with ACS. CONCLUSIONS: Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year. Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.

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

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

Saudi Heart Association Guidelines on Best Practices in the Management of Chronic Coronary Syndromes.

Background: The prevalence of both chronic coronary syndrome (CCS) and its risk factors is alarming in Saudi Arabia and only a minority of patients achieve optimal medical management. Context-specific CCS guidelines outlining best clinical practices are therefore needed to address local gaps and challenges. Consensus panel: A panel of experts representing the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to local clinical practice considering the characteristics of the Saudi population, the Saudi healthcare system, its resources and medical expertise. They were reviewed by external experts to ensure scientific and medical accuracy. Consensus findings: Recommendations are provided on the clinical assessment and management of CCS, along with supporting evidence. Risk reduction through non-pharmacological therapy (lifestyle modifications) remains at the core of CCS management. Great emphasis should be placed on the use of available pharmacological options (anti-anginal therapy and event prevention) only as appropriate and necessary. Lifestyle counseling and pharmacological strategy must be optimized before considering revascularization, unless otherwise indicated. Revascularization strategies should be carefully considered by the Heart Team to ensure the appropriate choice is made in accordance to current guidelines and patient preference. Conclusion: Conscientious, multidisciplinary, and personalized clinical management is necessary to navigate the complex landscape of CCS in Saudi Arabia considering its population and resource differences. The reconciliation of international evidence and local characteristics is critical for the improvement of healthcare outcomes among CCS patients in Saudi Arabia.

Transfer of Patients with ST Elevation Myocardial Infarction for Primary Percutaneous Coronary Intervention During Ordinary & Pandemic Times Position statement of the Saudi Arabian Cardiac Intervention Society.

Primary percutaneous coronary intervention is the most effective therapy in the management of acute ST Elevation Myocardial Infarction. Evidence recommends keeping the period from symptom onset to reperfusion to a minimum in order to preserve left ventricular function, improve outcome and reduce mortality. This position statement describes the recommendations of the Saudi Arabian Cardiac Intervention Society for optimal conditions and timing for the acute management of patients presenting with ST Elevation Myocardial Infarction during ordinary and pandemic times.

Saudi Heart Association (SHA) guidelines for the management of heart failure.

Heart failure (HF) is the leading cause of morbidity and mortality worldwide and negatively impacts quality of life, healthcare costs, and longevity. Although data on HF in the Arab population are scarce, recently developed regional registries are a step forward to evaluating the quality of current patient care and providing an overview of the clinical picture. Despite the burden of HF in Saudi Arabia, there are currently no standardized protocols or guidelines for the management of patients with acute or chronic heart failure. Therefore, the Heart Failure Expert Committee, comprising 13 local specialists representing both public and private sectors, has developed guidelines to address the needs and challenges for the diagnosis and treatment of HF in Saudi Arabia. The ultimate aim of these guidelines is to assist healthcare professionals in delivering optimal care and standardized clinical practice across Saudi Arabia.

Short-term and long-term adverse cardiovascular events across the glycaemic spectrum in patients with acute coronary syndrome: the Gulf Registry of Acute Coronary Events-2.

BACKGROUND: Limited data exist on the prognostic impacts of diabetes mellitus (DM) and new-onset hyperglycaemia (NOH) on cardiovascular outcomes in Middle Eastern patients with acute coronary syndrome (ACS). Here, we explored this relationship in a large contemporary Middle Eastern ACS registry: the second Gulf Registry of Acute Coronary Events (Gulf RACE-2). PATIENTS AND METHODS: Our analysis included 6362 consecutive ACS patients enrolled from October 2008 to June 2009, with or without a known DM diagnosis, and with an available fasting blood sugar measurement from the index hospitalization. Baseline demographics, risk factors for atherosclerosis, medical history, investigations and therapies were registered. Adverse hospital outcomes, as well as short-term and long-term mortalities were compared. Comparisons for categorical data were performed using χ or Fisher's exact tests, whereas analysis of variance or the Kruskal-Wallis test was used for continuous variables. Multiple logistic regression models were used to estimate the odds ratio. RESULTS: Almost half of the ACS cohort had been diagnosed previously with DM, and 8.8% had NOH. DM patients were more frequently older, female and Arab Gulf nationals. Compared with nondiabetic patients, DM patients had higher rates of adverse in-hospital clinical events, and 30-day and 1-year mortality. NOH was an independent predictor of in-hospital mortality, major bleeding and cardiogenic shock. Patients with NOH had higher in-hospital mortality (8.29 vs. 5.37%, P=0.035), ventricular arrhythmia (4.97 vs. 1.91%, P<0.001) and cardiogenic shock rates (6.45 vs. 4.12%, P=0.019) compared with DM patients not requiring insulin. CONCLUSION: DM was very common among ACS patients in the Arab Gulf area, and ACS patients with NOH were at a higher risk compared with euglycaemic patients and diabetic patients not requiring insulin. Further studies are needed to examine the clinical impact of in-hospital intensive glycaemic control in these patients and to explore the long-term glycaemic status of ACS patients with NOH.

Initial heart rate and cardiovascular outcomes in patients presenting with acute coronary syndrome.

OBJECTIVES: To assess the impact of on-admission heart rate (HR) in patients presenting with acute coronary syndrome (ACS). METHODS: Data were collected retrospectively from the second Gulf Registry of Acute Coronary Events. Patients were divided according to their initial HR into: (I: < 60, II: 60-69, III: 70-79, IV: 80-89 and V: ≥ 90 bpm). Patients' characteristics and hospital and one- and 12-month outcomes were analyzed and compared. RESULTS: Among 7939 consecutive ACS patients, groups I to V represented 7%, 13%, 20%, 23.5%, and 37%, respectively. Mean age was higher in groups I and V. Group V were more likely males, diabetic and hypertensive. ST-elevation myocardial infarction was the main presentation in groups I and V. Reperfusion therapies were less likely given to group V. Beta blockers were more frequently prescribed to group III in comparison to groups with higher HR. Groups I and V were associated with worse hospital outcomes. Multivariate analysis showed initial tachycardia as an independent predictor for heart failure (OR 2.2; 95%CI: 1.39-3.32), while bradycardia was independently associated with higher one-month mortality (OR 2.0; 95%CI: 1.04-3.85) CONCLUSION: The majority of ACS patients present with tachycardia. However, low or high HR is a marker of high risk that needs more attention and management.

Impressive echocardiographic images of a rare pathology: Aneurysm of the mitral valve - Report of two cases and review of the literature.

Aneurysm of the mitral valve (AMV) is rarely reported. The etiology of this unusual pathology is commonly attributed to aortic valve endocarditis (AVE) with aortic regurgitation (AR) or connective tissue disease. We present two recent cases of AMV with good correlation between pre-operative trans-esophageal echocardiography (TEE), intra-operative real-time 3-dimensional echocardiography (RT-3D-Echo) and surgical findings. The importance of diligent surveillance by TEE in patients with AVE for occurrence of AMV is emphasized. The literature on this topic is briefly reviewed.

Prevalence and prognosis of congestive heart failure in Saudi patients admitted with acute coronary syndrome (from SPACE registry).

OBJECTIVES: The aim of this study was to assess the prevalence, clinical features, and in-hospital outcomes of heart failure in patients with acute coronary syndrome (ACS). MATERIALS AND METHODS: The Saudi Project for Assessment of Coronary Events recruited patients admitted with ACS from 17 hospitals in Saudi Arabia from 2005 to 2007. The outcomes of ACS patients with congestive heart failure (CHF) compared with those without CHF were analyzed. RESULTS: A total of 4523 patients with ACS were identified, of whom 905 (20%) had CHF. Compared with no CHF, patients with CHF were older (62±13.1 vs. 57±12.9 years; P=0.001), less likely to be men (70 vs. 79%; P=0.001), likely to present with non-ST-segment elevation myocardial infarction (48 vs. 36%; P=0.001), likely to have diabetes (71 vs. 54%; P=0.001), hypertension (64 vs. 54%; P=0.001) and previous history of coronary artery disease (53 vs. 43%; P=0.001), and likely to have significant left ventricular systolic dysfunction (left ventricular ejection fraction <35%) (56 vs. 30%; P=0.001). Patients with CHF were less likely to receive in-hospital ß-blockers (74 vs. 86%; P=0.001) and a percutaneous coronary intervention (19 vs. 50%; P=0.001). Adjusted in-hospital mortality and cardiogenic shock were higher in the CHF group (odds ratio 4.43, 95% confidence interval 2.52-7.78; and odds ratio 3.51, 95% confidence interval 2.23-5.52), respectively. CONCLUSION: ACS patients with CHF in the Saudi Project for Assessment of Coronary Events were older, more likely to have more cardiac risk factors, and less likely to be treated with optimum medical treatment on admission. These findings were associated with higher incidence of their in-hospital adverse outcomes. More aggressive treatment is warranted to improve prognosis.

Gender disparities in the presentation, management and outcomes of acute coronary syndrome patients: data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2).

BACKGROUND: Gender-related differences in mortality of acute coronary syndrome (ACS) have been reported. The extent and causes of these differences in the Middle-East are poorly understood. We studied to what extent difference in outcome, specifically 1-year mortality are attributable to demographic, baseline clinical differences at presentation, and management differences between female and male patients. METHODOLOGY/PRINCIPAL FINDINGS: Baseline characteristics, treatment patterns, and 1-year mortality of 7390 ACS patients in 65 hospitals in 6 Arabian Gulf countries were evaluated during 2008-2009, as part of the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). Women were older (61.3±11.8 vs. 55.6±12.4; P<0.001), more overweight (BMI: 28.1±6.6 vs. 26.7±5.1; P<0.001), and more likely to have a history of hypertension, hyperlipidemia or diabetes. Fewer women than men received angiotensin-converting enzyme inhibitors (ACE), aspirin, clopidogrel, beta blockers or statins at discharge. They also underwent fewer invasive procedures including angiography (27.0% vs. 34.0%; P<0.001), percutaneous coronary intervention (PCI) (10.5% vs. 15.6%; P<0.001) and reperfusion therapy (6.9% vs. 20.2%; P<0.001) than men. Women were at higher unadjusted risk for in-hospital death (6.8% vs. 4.0%, P<0.001) and heart failure (HF) (18% vs. 11.8%, P<0.001). Both 1-month and 1-year mortality rates were higher in women than men (11% vs. 7.4% and 17.3% vs. 11.4%, respectively, P<0.001). Both baseline and management differences contributed to a worse outcome in women. Together these variables explained almost all mortality disparities. CONCLUSIONS/SIGNIFICANCE: Differences between genders in mortality appeared to be largely explained by differences in prognostic variables and management patterns. However, the origin of the latter differences need further study.

Impact of access to hospitals with catheterization facilities in the second Gulf Registry of Acute Coronary Events (Gulf RACE-2).

OBJECTIVES: It is currently unclear whether acute coronary syndrome patients who access hospitals with catheterization facilities, with or without an on-site percutaneous coronary intervention (PCI), have better outcomes in real-life clinical practice. METHODS AND RESULTS: This 9-month prospective study was carried out in six Arabian Gulf countries. Patients in hospitals with catheterization facilities [20/65 hospitals; 3615/6847 (52.8%) patients] were more likely to show evidence of cardiovascular risk factors (P<0.001) and more likely to undergo revascularization procedures that were mostly performed (≥80%) in low-risk and intermediate-risk patients. Patients in these centres experienced significantly higher rates of medical therapies and shorter door-to-needle times [median (IQR): 33 (40) vs. 43.5 (43) min, P<0.001]; 14.1% had primary PCI. They also had less in-hospital recurrent ischaemia, recurrent myocardial infarction, congestive heart failure and stroke, but more cardiogenic shock and major bleeding, and they had similar adjusted mortality rates in-hospital [odds ratio (OR): 1.06, 95% confidence interval (CI): 0.88-1.27] and at 30-day (OR: 1.11, 95% CI: 0.91-1.36) and 1-year (OR: 1.06, 95% CI: 0.89-1.27) follow-ups. CONCLUSION: Access to hospitals with catheterization facilities, with or without on-site PCI, was associated with a reduction in recurrent myocardial infarction and recurrent ischaemia, but not mortality. Further efforts are required to target revascularization procedures for higher risk patients as well as to widely implement primary PCI programmes.

Age and clinical outcomes in patients presenting with acute coronary syndromes.

CONTEXT: Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients. AIMS: To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS). METHODS AND MATERIAL: Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: ≤50 years, 51-70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months. STATISTICAL ANALYSIS USED: One-way ANOVA test for continuous variables, Pearson chi-square (X (2)) test for categorical variables and multivariate logistic regression analysis for predictors were performed. RESULTS: Among 7930 consecutive ACS patients; 2755 (35%) were ≤50 years, 4110 (52%) were 51-70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients ≤50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03-1.60), heart failure (OR 2.8; 95% CI 2.17-3.52) and major bleeding (OR 4.02; 95% CI 1.37-11.77) and in-hospital mortality (age 51-70: OR 2.67; 95% CI 1.86-3.85, and age >70: OR 4.71; 95% CI 3.11-7.14). CONCLUSION: Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

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.

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

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

Clinical Profile and Mortality of ST-Segment Elevation Myocardial Infarction Patients Receiving Thrombolytic Therapy in the Middle East.

OBJECTIVE: Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy. PATIENTS AND METHODS: This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics. RESULTS: Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use. CONCLUSIONS: Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.

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

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