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BACKGROUND/OBJECTIVES: According to the "obesity paradox", adults with obesity have a survival advantage following acute coronary syndrome, compared with those without obesity. Previous studies focused on peripheral obesity and whether this advantage is conferred by central obesity is unknown. The objective of this study was to describe the association of peripheral and central obesity indices with risk of in-hospital and 1-year mortality following acute coronary syndrome (ACS). SUBJECTS/METHODS: Gulf COAST is a prospective ACS registry that enrolled 4044 patients age ≥18 years from January 2012 through January 2013, across 29 hospitals in four Middle Eastern countries. Associations of indices of peripheral obesity (body-mass index, [BMI]) and central obesity (waist circumference [WC] and waist-to-height ratio [WHtR]) with mortality following ACS were analyzed in logistic regression models (odds ratio, 95% CI) with and without adjustment for Global Registry of Acute Coronary Events risk score. RESULTS: Of 3882 patients analyzed (mean age: 60 years; 33.3% women [n = 1294]), the prevalence of obesity was 34.5% (BMI ≥ 30.0 kg/m2), 72.2% (WC ≥ 94.0 cm [men] or ≥80.0 cm [women]) and 90.0% (WHtR ≥ 0.5). In adjusted models, deciles of obesity indices showed higher risk of mortality at extreme versus intermediate deciles (U-shaped). When defined by conventional cut-offs, peripheral obesity (BMI ≥ 30.0 versus 18.5-29.9 kg/m2) showed inverse association with risk of in-hospital mortality (0.64; 95% CI, 0.42-0.99; P = 0.04; central obesity showed trend toward reduced mortality). In contrast, for risk of 1-year mortality, all indices showed inverse association. Obesity, defined by presence of all three indices, versus nonobesity showed inverse association with risk of 1-year mortality (0.52; 95% CI, 0.35-0.75; P = 0.001). Results were similar among men and women. CONCLUSION: The degree of obesity paradox following ACS depends on the obesity index and follow-up time. Obesity indices may aid in risk stratification of mortality following ACS.
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Síndrome Coronariana Aguda/mortalidade , Mortalidade Hospitalar , Obesidade , Síndrome Coronariana Aguda/complicações , Índice de Massa Corporal , Causas de Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Obesidade/classificação , Obesidade/complicações , Obesidade/mortalidade , Prevalência , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Circunferência da Cintura , Razão Cintura-EstaturaRESUMO
INTRODUCTION: Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple strategy of integrated approach of AF management: A-Avoid stroke; B-Better symptom control; C-Cardiovascular comorbidity risk management. AIMS: Evaluation of the AF treatment compliance to ABC pathway in DM patients in the Middle East. Assessment of the impact of ABC pathway adherence on all-cause mortality and the composite outcome of stroke/systemic embolism, all-cause death and cardiovascular hospitalisations. METHODS: From 2043 patients in the Gulf SAFE registry, 603 patients (mean age 63; 48% male) with DM were included in an analysis of ABC pathway compliance: A-appropriate use of anticoagulation according to CHA2 DS2 -VASc score; B-AF symptoms management according to the European Heart Rhythm Association (EHRA) scale; C-Optimised cardiovascular comorbidities management. RESULTS: 86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC group vs non-ABC (5.8% vs 15.9%, P = .0014, respectively). On multivariate analysis, ABC compliance was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI: 0.42-0.75 and OR 0.54; 95% Cl: 0.30-1.00, respectively) and at 1 year (OR 0.30; 95% Cl: 0.11-0.76 and OR 0.57; 95% Cl: 0.33-0.97, respectively) vs the non-ABC group. CONCLUSIONS: Compliance with the ABC pathway care was independently associated with the reduced risk of all-cause death and the composite outcome in DM patients with AF, highlighting the importance of an integrated approach to AF management.
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Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Complicações do Diabetes , Diabetes Mellitus , Inibidores da Agregação Plaquetária/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Idoso , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Doenças Cardiovasculares , Causas de Morte , Embolia/etiologia , Embolia/prevenção & controle , Feminino , Fidelidade a Diretrizes , Fatores de Risco de Doenças Cardíacas , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Oriente Médio , Mortalidade , Guias de Prática Clínica como Assunto , Sistema de Registros , Acidente Vascular Cerebral/etiologiaRESUMO
OBJECTIVE: To evaluate the association of dual versus single antiplatelet therapy with major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) in the Arabian Gulf. SUBJECTS AND METHODS: Data were analyzed from 3,559 patients with a diagnosis of ACS admitted to 29 hospitals in 4 Arabian Gulf countries (Bahrain, Kuwait, Oman, and United Arab Emirates) from January 2012 to January 2013. Dual antiplatelet therapy (DAPT), consisting of aspirin and clopidogrel, was compared to aspirin alone. MACE included 12-months cumulative stroke/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and readmissions for cardiac reasons, post discharge. Analyses were performed using multivariable logistic regression. RESULTS: A total of 74% (n = 2,634) of the patients were on DAPT. At 12-month follow-up, patients on DAPT were significantly less likely to experience MACE events (adjusted OR [aOR] 0.73; 95% CI: 0.61-0.86; p < 0.001). Lower cardiovascular (CV) event rates were also consistent across the following MACE components; MI (aOR 0.66; 95% CI: 0.49-0.88; p = 0.005), all-cause mortality (aOR 0.69; 95% CI: 0.51-0.94; p = 0.018), and readmissions for cardiac reasons (aOR 0.79; 95% CI: 0.66-0.95; p = 0.011). Conversely, DAPT was adversely associated with increased risk of stroke/TIA (aOR 1.68; 95% CI: 1.05-2.69; p = 0.030). CONCLUSIONS: DAPT, compared to aspirin therapy alone, was generally associated with better CV outcomes after an ACS event. However, DAPT was adversely associated with increased risk of stroke/TIA in ACS patients in the Arabian Gulf.
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Síndrome Coronariana Aguda/tratamento farmacológico , Aspirina/farmacologia , Clopidogrel/farmacologia , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação Plaquetária/farmacologia , Adulto , Idoso , Sistema Cardiovascular/efeitos dos fármacos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Oriente Médio , Readmissão do Paciente , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate the association between peripheral artery disease (PAD) and major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) in the Arabian Gulf. METHODS: Data from 4,044 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013 were analyzed. PAD was defined as any of the following: claudication, amputation for arterial vascular insufficiency, vascular reconstruction, bypass surgery, or percutaneous intervention in the extremities, documented aortic aneurysm or an ankle brachial index of <0.8 in any of the legs. MACE included stroke/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and readmissions for cardiac reasons diagnosed between hospital admission and at 1-year post discharge. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The overall mean age of the cohort was 60 ± 13 years and 66% (n = 2,686) were males. A total of 3.3% (n = 132) of the patients had PAD. Patients with PAD were more likely to be associated with smoking, prior MI, hypertension, diabetes mellitus, and stroke/TIA. At the 1-year follow-up, patients with PAD were significantly more likely to have MACE (adjusted OR [aOR], 2.07; 95% confidence interval [CI]: 1.41-3.06; p< 0.001). The higher rates of events were also observed across all MACE components; stroke/TIA (aOR, 3.22; 95% CI: 1.80-5.75; p< 0.001), MI (aOR, 2.15; 95% CI: 1.29-3.59; p =0.003), all-cause mortality (aOR, 2.21; 95% CI: 1.33-3.69; p =0.002), and readmissions for cardiac reasons (aOR, 1.83; 95% CI: 1.24-2.70; p =0.003). CONCLUSIONS: PAD was significantly associated with MACE in ACS patients in the Arabian Gulf.
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Síndrome Coronariana Aguda/complicações , Doença Arterial Periférica/complicações , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Comorbidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Sistema de Registros , Fatores de RiscoRESUMO
The relationships between acute coronary syndromes (ACS) adverse events and the associated risk factors are typically complicated and nonlinear, which poses significant challenges to clinicians' attempts at risk stratification. Here, we aim to explore the implementation of modern risk stratification tools to untangle how these complex factors shape the risk of adverse events in patients with ACS. We used an interpretable multi-algorithm machine learning (ML) approach and clinical features to fit predictive models to 1,976 patients with ACS in Kuwait. We demonstrated that random forest (RF) and extreme gradient boosting (XGB) algorithms, remarkably outperform traditional logistic regression model (AUCs = 0.84 & 0.79 for RF and XGB, respectively). Our in-hospital adverse events model identified left ventricular ejection fraction as the most important predictor with the highest interaction strength with other factors. However, using the 30-days adverse events model, we found that performing an urgent coronary artery bypass graft was the most important predictor, with creatinine levels having the strongest overall interaction with other related factors. Our ML models not only untangled the non-linear relationships that shape the clinical epidemiology of ACS adverse events but also elucidated their risk in individual patients based on their unique features.
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Síndrome Coronariana Aguda , Humanos , Volume Sistólico , Kuweit/epidemiologia , Função Ventricular Esquerda , Hospitais , Aprendizado de MáquinaRESUMO
The use of beta-blockers (BB) in reduced left ventricular ejection fraction (LVEF) post-myocardial infarction (MI) is associated with reduced 1-year mortality, while their role in patients with mid-range and preserved LVEF post-MI remains controversial. We studied 31,620 patients who presented with acute coronary syndrome (ACS) enrolled in seven Arabian Gulf registries between 2005 and 2017. Patients with LVEF ≤40% were excluded. The remaining cohort was divided into two groups: BB group (n = 15,541) and non-BB group (n = 2,798), based on discharge medications. Patients in the non-BB group were relatively younger (55.3 vs. 57.4, P = .004) but higher risk at presentation; with higher Global Registry of Acute Coronary Events (GRACE) score (119.2 vs 109.2, P < .001), higher percentage of cardiogenic shock (3.5 vs 1.4%, P < .001), despite lower prevalence of comorbidities, such as hypertension and hyperlipidemia. BB use was associated with lower 1-year mortality in a multivariate logistic regression analysis, adjusting for major confounders [adjusted odds ratio (OR): 0.71 (95% CI 0.51-0.99)]. This remained the case in a sensitivity analysis using propensity score matching [adjusted OR: 0.34 (95% CI 0.16-0.73)]. In this study, using Arabian Gulf countries registries, the use of BB after ACS with LVEF >40% was independently associated with lower 1-year mortality.
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Objectives: Studies on the association between non-steroidal anti-inflammatory drugs (NSAIDs) and major adverse cardiovascular events (MACE) in the Arabian Gulf are scarce. The aim of this study was to evaluate the association between NSAIDs use and MACE in acute coronary syndrome (ACS) patients in the Arabian Gulf region. Methods: Data were analyzed from 3007 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013, as well as being on prior NSAIDs use during the index admission. The MACE included stroke/transient ischemic attacks (TIAs), myocardial infarction (MI), all-cause mortality and readmissions for cardiac reasons. Results: The overall mean age of the cohort was 62 ± 12 years, and 9.6% (n = 290) of the patients were on prior NSAID use during the index admission. At 12-months follow-up, after adjusting for confounding factors, patients on NSAIDs were significantly more likely to have had MACE (adjusted OR (aOR), 1.89; 95% confidence interval (CI): 1.44-2.48; p < 0.001). Specifically, the higher event rates observed were stroke/TIA (aOR, 2.50; 95% CI: 1.51-4.14; p < 0.001) and readmissions for cardiac reasons (aOR, 2.09; 95% CI: 1.59-2.74; p < 0.001), but not MI (aOR, 1.26; 95% CI: 0.80-1.99; p = 0.320) and all-cause mortality (aOR, 0.79; 95% CI: 0.46-1.34; p = 0.383). Conclusions: NSAIDs use was associated with significant stroke/TIA events as well as readmissions for cardiac reasons. However, NSAIDs were not associated with increased MIs or all-cause mortality rates in patients with ACS in the Arabian Gulf.
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Objective: To describe and compare the determinants of 1-year mortality after premature vs non-premature acute coronary syndrome (ACS). Patients and Methods: Participants presenting with ACS were enrolled in a prospective registry of 29 hospitals in 4 countries, from January 22, 2012 to January 22, 2013, with 1-year of follow-up data. The primary outcome was all-cause 1-year mortality after premature ACS (men aged <55 years and women aged <65 years) and non-premature ACS (men aged ≥55 years and women aged ≥65 years). The associations between the baseline patient characteristics and 1-year mortality were analyzed in models adjusting for the Global Registry of Acute Coronary Events (GRACE) score and reported as adjusted odds ratio (aOR) (95% CI). Results: Of the 3868 patients, 43.3% presented with premature ACS that was associated with lower 1-year mortality (5.7%) than those with non-premature ACS. In adjusted models, women experienced higher mortality than men after premature (aOR, 2.14 [1.37-3.41]) vs non-premature ACS (aOR, 1.28 [0.99-1.65]) (P interaction=.047). Patients lacking formal education vs any education had higher mortality after both premature (aOR, 2.92 [1.87-4.61]) and non-premature ACS (aOR, 1.78 [1.36-2.34]) (P interaction=.06). Lack of employment vs any employment was associated with approximately 3-fold higher mortality after premature and non-premature ACS (P interaction=.72). Using stepwise logistic regression to predict 1-year mortality, a model with GRACE risk score and 4 characteristics (education, employment, body mass index [kg/m2], and statin use within 24 hours after admission) had higher discrimination than the GRACE risk score alone (area under the curve, 0.800 vs 0.773; P comparison=.003). Conclusion: In this study, women, compared with men, had higher 1-year mortality after premature ACS. The social determinants of health (no formal education or employment) were strongly associated with higher 1-year mortality after premature and non-premature ACS, improved mortality prediction, and should be routinely considered in risk assessment after ACS.
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INTRODUCTION: The characteristics of young adults with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndrome (ACS) has not been well described. The mean age of gulf citizens in ACS registries is 10-15 years younger than their western counterparts, which provided us with a unique opportunity to investigate the characteristics and predictors of OHCA in young adults presenting with ACS. METHODOLOGY: This was a retrospective cohort study using data from 7 prospective ACS registries in the Gulf region. In brief, all registries included consecutive adults who were admitted with ACS. OHCA was defined as cardiac arrest upon presentation (i.e., before admission to the hospital). We described the characteristics of young adults (< 50 years) who had OHCA and performed multivariate logistic regression analysis to assess independent predictors of OHCA. RESULTS: A total of 31,620 ACS patients were included in the study. There were 611 (1.93%) OHCA cases in the whole cohort [188/10,848 (1.73%) in young adults vs 423/20,772 (2.04%) in older adults, p = 0.06]. Young adults were predominantly males presenting with ST-elevation myocardial infarction (STEMI) [182/188 (96.8%) and 172/188 (91.49%), respectively]. OHCA was the sentinel event of coronary artery disease (CAD) in 70% of young adults. STEMI, male sex, and non-smoking status were found to be independent predictors of OHCA [OR = 5.862 (95% CI 2.623-13.096), OR: 4.515 (95% CI 1.085-18.786), and OR = 2.27 (95% CI 1.335-3.86), respectively]. CONCLUSION: We observed a lower prevalence of OHCA in ACS patients in our region as compared to previous literature from other regions. Moreover, OHCA was the sentinel event of CAD in the majority of young adults, who were predominantly males with STEMIs. These findings should help risk-stratify patients with ACS and inform further research into the characteristics of OHCA in young adults.
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Síndrome Coronariana Aguda , Doença da Artéria Coronariana , Parada Cardíaca Extra-Hospitalar , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Masculino , Adulto Jovem , Idoso , Criança , Adolescente , Feminino , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/epidemiologia , Parada Cardíaca Extra-Hospitalar/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Estudos Retrospectivos , Estudos Prospectivos , Sistema de RegistrosRESUMO
Little is known about the impact of thrombolytic agents on in-hospital outcomes in the Middle East. The objective of this study was to evaluate the impact of thrombolytic agents on in-hospital outcomes in ST-segment elevation myocardial infarction (STEMI) patients in six Middle Eastern countries. Gulf Registry of Acute Coronary Events was a prospective, multinational, multicentre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in 2006 and 2007. Out of 1,765 STEMI patients admitted to hospitals within 12 h of symptoms onset, 25, 43, and 30% were treated with streptokinase, reteplase, and tenecteplase, respectively. Median age of the study cohort was 50 (45-59) years and majority were males (89%). The overall median symptom onset-to-presentation and median door-to-needle times were 130 min (65-240) and 45 min (30-75), respectively. Streptokinase patients had worse GRACE risk scores compared to patients who received fibrin specific thrombolytics. Academic hospitals and cardiologists as admitting physicians were associated with the use of fibrin specific thrombolytics. After significant covariate adjustment, both reteplase [odds ratio (OR), 0.38; 95% CI: 0.18-0.79; P = 0.009] and tenecteplase (OR, 0.30; 95% CI: 0.12-0.77; P = 0.012) were associated with lower all-cause in-hospital mortality compared with streptokinase. No significant differences in other in-hospital outcomes were noted between the thrombolytic agents. In conclusion, in light of the study's limitations, fibrin specific agents, reteplase and tenecteplase, were associated with lower all-cause in-hospital mortality compared to the non-specific fibrin agent, streptokinase. However, the type of thrombolytic agent used did not influence other in-hospital outcomes.
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Fibrinolíticos/uso terapêutico , Hospitalização/tendências , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/epidemiologia , Adulto , Idoso , Feminino , Fibrinolíticos/classificação , Mortalidade Hospitalar/tendências , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Infarto do Miocárdio/mortalidade , Estudos Prospectivos , Proteínas Recombinantes/uso terapêutico , Sistema de Registros , Tenecteplase , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
The purpose of this study was to assess the prognostic value of the Killip classification at the presentation in patients with acute coronary syndrome (ACS). In 2007 and over 5 months, 6704 consecutive patients with ACS were enrolled in the Gulf Registry of Acute Coronary Events. Patients were categorized according to Killip classification at presentation (Classes I, II, III, and IV). Patients' characteristics and in-hospital outcomes were analyzed. High Killip classes were defined in 22% of patients. In comparison to Killip Class I, patients with higher Killip class had greater prevalence of cardiovascular risk factors, presented late, were less likely to have angina, and were less likely to receive antiplatelet, statins, and ß-blockers. Classes II, III, and IV were associated with higher adjusted odds of death in ST-elevation myocardial infarction (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.25-3.69; OR 6.1, 95% CI 3.41-10.86; and OR 28, 95% CI 15.24-54.70, respectively) and non-ST-elevation acute coronary syndrome (adjusted OR 2.4, 95% CI 1.24-4.82; OR 3.2,95% 1.49-7.02; and OR 9.8, 95% CI 3.79-25.57, respectively). In conclusion, across ACS, patients with higher Killip class had worse clinical profile and were less likely to be treated with evidence-based therapy. High Killip class was independent predictors of mortality in ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. Physician in the emergency department should be aware of the importance of clinical examination in the risk stratification in patients presenting with ACS.
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Síndrome Coronariana Aguda/diagnóstico , Técnicas de Apoio para a Decisão , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/mortalidade , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Angina Pectoris/diagnóstico , Angina Pectoris/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Inibidores da Agregação Plaquetária/uso terapêutico , Prognóstico , Sistema de Registros/estatística & dados numéricos , Fatores de RiscoRESUMO
Acute coronary syndromes (ACS) are a leading cause of deaths worldwide, yet the diagnosis and treatment of this group of diseases represent a significant challenge for clinicians. The epidemiology of ACS is extremely complex and the relationship between ACS and patient risk factors is typically non-linear and highly variable across patient lifespan. Here, we aim to uncover deeper insights into the factors that shape ACS outcomes in hospitals across four Arabian Gulf countries. Further, because anemia is one of the most observed comorbidities, we explored its role in the prognosis of most prevalent ACS in-hospital outcomes (mortality, heart failure, and bleeding) in the region. We used a robust multi-algorithm interpretable machine learning (ML) pipeline, and 20 relevant risk factors to fit predictive models to 4,044 patients presenting with ACS between 2012 and 2013. We found that in-hospital heart failure followed by anemia was the most important predictor of mortality. However, anemia was the first most important predictor for both in-hospital heart failure, and bleeding. For all in-hospital outcome, anemia had remarkably non-linear relationships with both ACS outcomes and patients' baseline characteristics. With minimal statistical assumptions, our ML models had reasonable predictive performance (AUCs > 0.75) and substantially outperformed commonly used statistical and risk stratification methods. Moreover, our pipeline was able to elucidate ACS risk of individual patients based on their unique risk factors. Fully interpretable ML approaches are rarely used in clinical settings, particularly in the Middle East, but have the potential to improve clinicians' prognostic efforts and guide policymakers in reducing the health and economic burdens of ACS worldwide.
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Síndrome Coronariana Aguda , Mortalidade Hospitalar , Aprendizado de Máquina , Modelos Cardiovasculares , Admissão do Paciente , Sistema de Registros , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Anemia/mortalidade , Anemia/terapia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Medição de RiscoRESUMO
BACKGROUND AND AIMS: Disorders of plasma lipids remain key risk factors for the development of atherosclerotic cardiovascular disease (ASCVD) in the Middle East and are estimated to increase more dramatically in the next decade than in any other global region except Africa. This statement is an update to the 2016 consensus clinical recommendations for the management of plasma lipid disorders in the Middle East, following the evaluation of newer cholesterol-lowering agents in randomised controlled cardiovascular outcome trials, as well as the publication of revised international guidelines. METHODS: A multidisciplinary panel of regional experts was convened to update the consensus clinical recommendations for the management of plasma lipids in the Middle East. The recommendations constructed in 2016 were reviewed against emerging research since publication. RESULTS: Newly developed Middle East ASCVD risk categories were established using the multiple risk group categories from the recently updated international guidelines and the epidemiological evidence from the Gulf Region. These consensus recommendations support a more intensive reduction of LDL-C across cardiovascular risk categories. Alongside low-density lipoprotein cholesterol, we recommend non-high-density lipoprotein cholesterol as a primary treatment target. Lifestyle modifications remain the first-line treatment recommendation for all patients. The first-line pharmacological treatment in patients with dyslipidaemia is statin therapy, with a number of second-line agents available. The selection of a second lipid-lowering agent for combination therapy with statin should be based on the lipid-lowering target of the patient. Guidance is also provided on the management of underlying conditions and special populations; of particular pertinence in the region are familial hypercholesterolaemia, diabetes and metabolic dyslipidaemia. New therapies have emerged from research that found positive outcomes in reducing low-density lipoprotein cholesterol levels. The initial results of these newly researched drugs strongly indicate their inclusion as future therapies in dyslipidaemia management in the Middle East. CONCLUSIONS: These updated consensus clinical recommendations provide practicing clinicians with comprehensive, region-specific guidance to improve the detection and management of plasma lipid disorders in patients in the Middle East.
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Doenças Cardiovasculares , Dislipidemias , Inibidores de Hidroximetilglutaril-CoA Redutases , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , LDL-Colesterol , Consenso , Dislipidemias/diagnóstico , Dislipidemias/tratamento farmacológico , Dislipidemias/epidemiologia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipolipemiantes/uso terapêutico , Fatores de RiscoRESUMO
Background: The prognostic impact of obesity on patients with atrial fibrillation (AF) remains under-evaluated and controversial. Methods: Patients with AF from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) registry were included, who were recruited from six countries in the Middle East Gulf region and followed for 12 months. A multivariable model was established to investigate the association of obesity with clinical outcomes, including stroke or systemic embolism (SE), bleeding, admission for heart failure (HF) or AF, all-cause mortality, and a composite outcome. Restricted cubic splines were depicted to illustrate the relationship between body mass index (BMI) and outcomes. Sensitivity analysis was also conducted. Results: A total of 1,804 patients with AF and recorded BMI entered the final analysis (mean age 56.2 ± 16.1 years, 47.0% female); 559 (31.0%) were obese (BMI over 30 kg/m2). In multivariable analysis, obesity was associated with reduced risks of stroke/systematic embolism [adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI), 0.18-0.89], bleeding [aOR 0.44, 95%CI, 0.26-0.74], HF admission (aOR 0.61, 95%CI, 0.41-0.90) and the composite outcome (aOR 0.65, 95%CI, 0.50-0.84). As a continuous variable, higher BMI was associated with lower risks for stroke/SE, bleeding, HF admission, all-cause mortality, and the composite outcome as demonstrated by the accumulated incidence of events and restricted cubic splines. This "protective effect" of obesity was more prominent in some subgroups of patients. Conclusion: Among patients with AF, obesity and higher BMI were associated with a more favorable prognosis in the Gulf SAFE registry. The underlying mechanisms for this obesity "paradox" merit further exploration.
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Atrial fibrillation (AF) is often asymptomatic. The prognosis of asymptomatic AF is at least similar or worse than symptomatic AF, but there are no such data from Middle East patients with AF. The Gulf-SAFE (Gulf Survey of Atrial Fibrillation Events) registry is a multicenter prospective survey of patients presenting with AF to participate medical institutions in 6 countries in the Gulf region. We investigated the prognostic outcomes of patients with asymptomatic AF in relation to clinical subtypes. A total of 2043 patients with AF were included; 541 were identified as having asymptomatic AF (26.5%) who tended to be older, with higher prevalences of hypertension, heart failure, coronary artery disease, diabetes, stroke, renal dysfunction, chronic obstructive pulmonary disease, and had higher Congestive heart failure, Hypertension, Age ≥75, Stroke (2 points), Congestive heart failure, Hypertension, Age ≥75 (2 points), Diabetes, Stroke (2 points), Vascular disease, Age 65-74, Sex category (CHA2DS2-VASc), and Hypertension, Age ≥65, Stroke, Bleeding history, liable INR, Elderly, Drug or alcohol use (HAS-BLED) scores (all p <0.05). After multivariable adjustment, asymptomatic AF was associated with higher risks of stroke/systematic embolism (SE) (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.10 to 4.34), all-cause mortality (aOR 2.85, 95% CI 1.90 to 4.28), and the composite outcome of stroke/SE, bleeding, and all-cause mortality (aOR 1.74, 95% CI 1.26 to 2.41). Patients with asymptomatic AF had fewer admissions for AF (aOR 0.53, 95% CI 0.32 to 0.83) and heart failure (aOR 0.58, 95% CI 0.38 to 0.86). The increased risk of stroke/SE in asymptomatic AF was more prominent among paroxysmal AF subtype (p for interaction = 0.028). In conclusion, in the Gulf-SAFE registry, patients with asymptomatic AF represent a nonbenign entity with worse outcomes compared with symptomatic AF. In paroxysmal AF, the higher risks of events were more prominent. The absence of "warning signs" and lack of timely admission in asymptomatic AF may be major reasons for the unfavorable prognosis.
Assuntos
Fibrilação Atrial , Diabetes Mellitus , Embolia , Insuficiência Cardíaca , Hipertensão , Acidente Vascular Cerebral , Idoso , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Diabetes Mellitus/induzido quimicamente , Embolia/epidemiologia , Insuficiência Cardíaca/complicações , Hemorragia/epidemiologia , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Prognóstico , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologiaRESUMO
BACKGROUND AND OBJECTIVES: Stroke is a potential complication of acute myocardial infarction (AMI). The aim of this study was to identify the incidence, risk factors predisposing to stroke and in-hospital outcome during the index admission with AMI among patients in the Middle East. METHODS: For a period of 6 months in 2006 and 2007, 5,833 consecutive AMI patients were enrolled from 64 hospitals in 6 Middle East countries. RESULTS: The incidence of in-hospital stroke following AMI was 0.85%. Most cases were ST segment elevation AMI-related and ischemic in nature. Patients with in-hospital stroke were older than patients without stroke and were more likely to be female (36 vs. 18.6%, p = 0.0033). They were also more likely to have diabetes mellitus, dyslipidemia, prior AMI, or percutaneous/surgical coronary revascularization. Patients with stroke were more likely to present with advanced Killip class II-IV, higher mean heart rate and higher serum creatinine. Independent predictors of stroke were age, prior stroke, prior coronary artery bypass surgery, anterior AMI and systolic blood pressure >190 mm Hg on presentation. Early administration of statins was independently associated with reduced stroke risk (odds ratio, OR, 0.4, 95% confidence interval, CI, 0.19-0.90, p = 0.025). Stroke was fatal in 44% of the cases and was independently associated with in-hospital mortality (adjusted OR 12.5, 95% CI 5.7-27.4, p < 0.01). CONCLUSION: There is a low incidence of in-hospital stroke in Middle-Eastern patients presenting with AMI but with very high fatality rates. Early statin therapy was associated with a significant reduction in stroke risk. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.
Assuntos
Infarto do Miocárdio/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores Etários , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipertensão/complicações , Incidência , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controleRESUMO
BACKGROUND: While glucose levels on admission are clearly a much stronger predictor of short term adverse outcomes than diabetes status, there is a paucity of data on how diabetes status impacts the hyperglycemia-induced increased risk. METHODS: 2786 patients admitted to the hospital with acute coronary syndrome (ACS) and diabetic level hyperglycemia (random >11.1 mmol/L or fasting >7 mmol/L) were identified from a Gulf registry of ACS. We divided the cohort into two groups. Those who were previously known to have diabetes mellitus were identified as the known diabetes group, and the non-diabetic group included those without a previous diabetes diagnosis. We used logistic regression models to assess the effect of glycemic status on hospital mortality and other patient outcomes including heart failure, stroke, recurrent ischemia, cardiogenic shock, major bleeding, and ventilation. RESULTS: About two-thirds of the hyperglycemics on admission had been diagnosed previously with diabetes. After adjusting for age, in-hospital mortality was significantly higher in the non-diabetic group (OR: 2.36; 95% CI 1.54-3.61) compared to the diabetic group. As for the other outcomes, known diabetes patients had significantly lower incidences of heart failure, cardiogenic shock, and ventilation compared to non-diabetic patients. CONCLUSION: The effects of hyperglycemia are mitigated by the presence of the chronic diabetic state, and thus, hyperglycemia has a worse effect in those not known to have chronic diabetes. These findings are important and call for further investigation.
Assuntos
Síndrome Coronariana Aguda/mortalidade , Complicações do Diabetes/mortalidade , Diabetes Mellitus/mortalidade , Hiperglicemia/metabolismo , Sistema de Registros , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/etiologia , Síndrome Coronariana Aguda/terapia , Adulto , Idoso , Complicações do Diabetes/sangue , Complicações do Diabetes/terapia , Diabetes Mellitus/sangue , Diabetes Mellitus/terapia , Feminino , Hospitalização , Humanos , Hiperglicemia/sangue , Hiperglicemia/complicações , Hiperglicemia/terapia , Kuweit/epidemiologia , Masculino , Pessoa de Meia-IdadeRESUMO
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.
Assuntos
Síndrome Coronariana Aguda/complicações , Hipertensão/complicações , Infarto do Miocárdio/complicações , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Fatores Etários , Transtornos Cerebrovasculares/complicações , Complicações do Diabetes/epidemiologia , Eletrocardiografia , Feminino , Mortalidade Hospitalar , Humanos , Hiperlipidemias/complicações , Hipertensão/epidemiologia , Hipertensão/terapia , Masculino , Pessoa de Meia-Idade , Oriente Médio , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Doença Arterial Periférica/complicações , Prevalência , Estudos Prospectivos , Fatores de Risco , Fumar/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVE: Little is known about the prevalence and prognostic implications of major bleeding complications among patients admitted with acute coronary syndrome (ACS) in the Middle East. We describe the prevalence and outcome of ACS in Middle Eastern patients with and without major bleeding complications. METHODS: The Gulf Registry of Acute Coronary Events (Gulf RACE) is a prospective, multinational registry conducted for 6 months in 2007 for patients hospitalized with the final diagnosis of ACS in 65 centres in six adjacent Middle Eastern countries. There were no exclusion criteria. A total of 8166 patients were stratified according to the development of major bleeding complications during the index admission. RESULTS: Compared to patients without bleeding complications, patients with major bleeding (68 patients, 0.83%) were significantly older, and had ST-segment elevation myocardial infarction. However, there were no significant differences between the two groups with regard to sex, other cardiovascular risk factors, or use of antiplatelet and antithrombotic therapy. Patients with bleeding complications had worse in-hospital outcomes including death, congestive heart failure, cardiogenic shock, recurrent myocardial infarction, and stroke. After adjusting for baseline characteristics, major bleeding was independently associated with a more than 5-fold increase in in-hospital mortality (odds ratio 5.2, 95% confidence interval 2.8-10.1, P < 0.001). CONCLUSION: Similar to Western studies, bleeding in the setting of ACS is a powerful and independent predictor of poor in-hospital outcomes in patients admitted with ACS in the Middle East.
Assuntos
Síndrome Coronariana Aguda/complicações , Hemorragia/epidemiologia , Hemorragia/etiologia , Síndrome Coronariana Aguda/terapia , Idoso , Distribuição de Qui-Quadrado , Feminino , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Oriente Médio/epidemiologia , Prevalência , Prognóstico , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Estatísticas não ParamétricasRESUMO
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.