A Case-based Implementation of Heart Failure Therapies, a Consensus Pathway by the Saudi Heart Failure Working Group.

The implementation of guideline-directed medical therapy (GDMT) in heart failure (HF) has many challenges in real-world clinical practice. The consensus document is written considering the variability of the clinical presentation of HF patients. HF medical therapies need frequent dose adjustment during hospital admission or when patients develop electrolyte imbalance, acute kidney injury, and other acute illnesses. The paper describes clinical scenarios and graphs that will aid the managing physicians in decision-making for HF therapy optimization.

Phosphodiesterase type 5 inhibitors as treatment for erectile dysfunction: a webinar-based poll unveiling perceptions of healthcare professionals.

Aim: Erectile dysfunction (ED) is marked by a recurring incapacity to achieve or uphold a satisfactory erection during sexual activities. The study aims to increase awareness about male reproductive health, dispel misconceptions about ED and encourage physician-patient discussions. Materials & methods: A live online poll was conducted during a 3-day webinar titled "Turning the Tide of Men's Health" organized by Viatris™ in collaboration with the Saudi Society of Family and Community Medicine and attended by healthcare professionals (HCPs) from diverse specialties. The attendees voluntarily responded to nine poll questions on adherence to ED medication, use of phosphodiesterase type 5 inhibitors (PDE5is) as cure versus management of ED and patients' challenges. The responses to the poll questions were recorded and assessed to understand the perceptions of HCPs. Results: The poll garnered 10,423 responses from 5831 attendees on the second day of the webinar. The key findings included HCPs' perceptions that PDE5is contribute to ED management not complete cure. The respondents acknowledged that adherence to ED medications might decline on days without planned sexual activity, and long-term adherence on a daily PDE5i is exhibited by a relatively modest percentage of ED patients. The consensus among respondents was that PDE5is do not enhance or generate sexual desire, and the daily schedule of ED treatment may be burdensome for some patients. Conclusion: The findings from this poll offer insights into the perspectives of HCPs regarding the usage of PDE5is to treat ED. Responders of the poll generally agreed that PDE5is can help manage ED without affecting desire, though adherence may be lower on days without planned sexual activity. Furthermore, most respondents acknowledged that adhering to a daily pill regimen posed a greater burden than waiting for the medication to take effect.

Utilization of Prophylactic Antibiotics for Cardiac Patients Undergoing Dental Procedures in Saudi Arabia: A Retrospective Study.

Objectives: This study aimed to determine the characteristics of antibiotic prophylaxis (AP) utilization and the level of adherence of King Saud University Medical City (KSUMC) staff to the latest American Heart Association (AHA) guidelines for AP for infective endocarditis (IE) in cardiac patients undergoing dental procedures. Methods: The study was conducted as a retrospective cohort study to investigate the relationship between AP in dental procedures and cardiac patients admitted in the surgical wards of KSUMC between 2015 and 2021. All cardiac patients who underwent dental procedures were included in the study. We excluded patients with long-term or concurrent antibiotic use for other indications. Results: Overall, 170 (69.4%) cardiac patients received AP before undergoing a dental procedure. The most common comorbidities were hypertension (39.1%) and diabetes (34.2%). Most of the low-risk (69.4%) and moderate-risk (70.5%) patients received AP, despite the guideline's recommendation to limit AP to high-risk patients only. Moreover, only 53.8% of high-risk patients were prescribed AP. In total, 95.9% of the 170 patients who received AP did so without following the recommendations. Only one patient developed IE during the 1-year follow-up. Tooth extraction was the only significant predictor of AP prescription in our study (P = 0.001; OR: 3.73; 95% CI; 1.678-8.298). Conclusion: There was an exceeding level of inconsistency (95.9%) in AP utilization by cardiac patients in our sample compared with the recommendations of the latest AHA guidelines.

2023 National Heart Center/Saudi Heart Association Focused Update of the 2019 Saudi Heart Association Guidelines for the Management of Heart Failure.

Background: The burden of cardiovascular diseases is undeniable in local populations, who have high mortality rates and a young age of disease onset. A systematic review of emerging evidence and update of the Saudi Heart Association (SHA) 2019 heart failure (HF) guidelines was therefore undertaken. Methodology: A panel of expert cardiologists reviewed recommendations of the 2019 guidelines following the Saudi Heart Association methodology for guideline recommendations. When needed, the panel provided updated and new recommendations endorsed by the national heart council that are appropriate for clinical practice and local resources in Saudi Arabia. Recommendations and conclusion: The focused update describes the appropriate use of clinical assessment as well as invasive and non-invasive modalities for the classification and diagnosis of HF. The prevention of HF was emphasized by expanding on both primary and secondary prevention approaches. Pharmacological treatment of HF was supplemented with recommendations on newer therapies, such as SGLT-2 inhibitors. Recommendations were also provided on the management of patients with cardiovascular and non-cardiovascular co-morbidities, with a focus on cardio-oncology and pregnancy. Updated clinical algorithms were included in support of HF management in both the acute and chronic settings. The implementation of this focused update on HF management in clinical practice is expected to lead to improved patient outcomes by providing evidence-based comprehensive guidance for practitioners in Saudi Arabia.

A strategy to improve adherence to guideline-directed medical therapy (GDMT) and the role of the multidisciplinary team in a heart-failure programme.

BACKGROUND: Heart failure (HF) patients place a heavy burden on the healthcare system because of their frequent need for in-patient treatment, emergency room visits and subsequent hospital stays. To provide proper care and effective therapy, practitioners have streamlined delivery techniques such as clinical pathways, checklists and pocket manuals. However, a description of the establishment of a disease-management programme, including a multidisciplinary team of physicians, clinical pharmacists and nurse specialists is required. The aim of this study was to highlight the role of the multidisciplinary team in a heart-failure programme by assessing the improvement in adherence to guideline-directed medical therapy. METHODS: A retrospective, observational research was undertaken on patients with HF at a cardiac centre in Riyadh, to observe the HF patients' management before (January to December 2014) and after (January to December 2015) the establishment of a programme. RESULTS: The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers was 75.59% in 2014 at discharge and 81.17% in 2015 (p = 0.249). Beta-blockers use at release increased from 87.83% in 2014 to 94.53% in 2015 (p = 0.021). The flu vaccine was given to 48.24% of patients in 2014 and 75.13% of the patients in 2015 (p < 0.001). The pneumococcal vaccine was administered to 44.22% of patients in 2014 and 75.13% of patients in 2015 (p < 0.001). The ejection fraction improved from 30.21% in the first month to 39.56% in the 12th month (p = 0.001) in patients managed in 2015. CONCLUSION: The multidisciplinary heart-failure programme resulted in a positive effect, in the form of improved patient care after including the clinical pharmacist and nurse specialist.

Incidence, clinical predictors, and clinical effect of new-onset atrial fibrillation in myocardial infarction patients: A retrospective cohort study.

OBJECTIVES: To calculate the incidence of new-onset atrial fibrillation (NOAF) in myocardial infarction (MI) patients and examine associated predictors and clinical outcomes of NOAF patients. METHODS: A retrospective cohort study was used to carry out this study. All MI patients admitted to King Khaled University Hospital, Riyadh, Saudi Arabia, between January 2015 to 2020 were eligible for inclusion. The study excluded those with a previous diagnosis of atrial fibrillation and patients who died at presentation. RESULTS: A total of 281 patients were analyzed with a mean age of 58.7±12.7. Incidence of NOAF was 7.8%. Significant predictors identified by multivariate logistic regression analysis included older age (p=0.004), history of MI (p=0.012), and undergoing coronary artery bypass graft surgery (CABG) as treatment (p=0.016). New-onset atrial fibrillation was associated with higher odds of major adverse cardiovascular event (p=0.039), ventricular tachycardia (p=0.001), and mortality (p=0.031). CONCLUSION: New-onset atrial fibrillation is a relatively common complication of MI, and in our study, it was associated with higher odds of further complications including death. Therefore, identification of MI patients at risk of developing NOAF is crucial. Our study suggests that older age, a previous history of MI, and undergoing CABG are significant predictors of NOAF development.

Ischemic cardiomyopathy versus non-ischemic cardiomyopathy in diabetic patients: clinical characteristics, management, and long-term outcomes.

BACKGROUND: Diabetes mellitus causes ischemic heart disease (IHD) through macrovascular or microvascular involvement. Diabetes-associated hypertension, dyslipidemia, and obesity further increase coronary artery disease risk and can cause left ventricular hypertrophy leading to heart failure with preserved ejection fraction independent of IHD. This study was undertaken to evaluate the differences in demographics, clinical characteristics, Echocardiographic parameters, management, and outcomes between non-ischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM) patients in cohort of diabetes patients. METHODS: This retrospective study included diabetes patients with reduced ejection fraction (≤40) who were hospitalized with heart failure between January 2014 and February 2020. Patients were divided into two groups: group 1; ICM and group 2; NICM. Data obtained on above mentioned features including mortality and heart failure readmissions were compared between the two groups. RESULTS: A total of 612 diabetes patients admitted with acute heart failure were screened of which 442 were included. Group 1 (ICM) had 361 patients (81.7%) and group 2 (NICM) had 81 patients (18.3%). Patients in group 1 were older, predominantly males and with higher prevalence of hypertension, smoking and insulin dependent Diabetes while group 2 patients had higher BMI and higher prevalence of cardiac rhythm problems. No significant difference was detected in 5-year-mortality between the two groups (P=0.165). However, heart failure associated hospitalizations were higher in group 2 though it was not statistically significant (P=0.062). CONCLUSION: There was no difference in 5-years mortality between ICM and NICM in diabetes patients. However, NICM patients had higher prevalence of obesity and rhythm problems.

Pattern of coronary arterial lesions amongst Saudi Arabians: a cross-sectional coronary fluoroscopic angiography study.

INTRODUCTION: Coronary artery disease (CAD) is a major cardiovascular disease (CVD) that affects a large population globally. This study aimed at determining coronary arterial lesions (CAL), particularly in terms of age, gender, coronary artery/arteries involved, number of lesions, and dominant coronary artery in the Kingdom of Saudi Arabia (KSA). METHODS: A cross-sectional study was conducted at the King Khalid Hospital and Prince Sultan Centre for Health Care in Al-Kharj between January 2017 and March 2018. The patients with CAD lesion/s, fulfilling the inclusion criteria, were recruited from the cardiovascular medicine unit. Demographic information and the location and extent of their CAD lesions were extracted and documented in electronic case report form (eCRF). SPSS 22.0 was used for statistical analysis, and p value ≤ 0.05 was considered as significant. RESULTS: Of the 262 patients, male and female preponderance was 74.8% and 25.2%, respectively. The majority of the patients were adults above the age of 50 (72%). About half of all patients were active smokers (53%). Diabetes, hypertension, and hyperlipidaemia were recorded in 63%, 53.7% and 25% respectively. The incidence of cardiovascular lesions was documented after coronary angiography; left circumflex artery lesions had the highest incidence (85.3%), followed by left anterior descending artery lesions (82.4%) and right circumflex artery lesions (74.3%). Left main coronary artery lesions had the lowest incidence (10.3%). Most patients (59.6%) had three concomitant lesions, whereas a minority of patients had two (22.8%) and one lesion (17.7%). CONCLUSION: The pattern of CALs is different among the Saudi population as compared to other countries.

Surgical mitral valve replacement using direct implantation of Sapien 3 valve in a patients with severe mitral annular calcification without adjunctive techniques, a case report.

BACKGROUND: Mitral annular calcification (MAC) occurs represents a challenge to surgeons during mitral valve (MV) surgery with increased perioperative risk. CASE PRESENTATION: We describe a challenging case of an elderly female patient with multiple comorbidities who presented with symptoms and signs of heart failure with a previous history of mechanical aortic valve replacement 15 years prior to presentation. Echocardiogram showed severe mitral stenosis and regurgitation with severe calcification of the mitral annulus. Given her high-risk profile and unavailability of suitable percutaneous therapeutic options we decided to replace her mitral valve with Sapien 3 valve under direct exposure. The case describes the technical details for the valve implantation and demonstrates the viability of this option in high risk surgical patients without the need for adjunct techniques like predilatation, additional supporting sutures or patches with a review of the literature on open surgical implantation of Sapien 3 valve. CONCLUSION: Direct open surgical implantation of Sapien 3 valve can be implanted safely in patients with severe MAC, without predilatation and without the use of other adjunctive techniques like fixation sutures or patches.

The Primary Management Strategies for ST-Elevation Myocardial Infarction Patients in Saudi Arabia: A Sub-Study of the Saudi Acute Myocardial Infarction Registry.

Background and objective Not all patients with ST-elevation myocardial infarction (STEMI) in Saudi Arabia are managed with a primary percutaneous coronary intervention (PPCI). We analyzed the management strategies for STEMI patients in the Saudi Acute Myocardial Infarction Registry (STARS). The strategies include PPCI, revascularization with thrombolytic therapy, and conservative management. This study involved a sub-study of the STARS. Methods STEMI patients were categorized into three groups. Group 1 was managed with PPCI, group 2 with revascularization with thrombolytic therapy, and group 3 with conservative approaches. The data were collected at presentation, at one month, and at one year after discharge. Results The sample consisted of 1,471 patients. The mean age of the participants was 54 ±12 years; 51% were Saudi citizens, and the majority (89%) were male. Their background revealed a high coronary risk profile, with 48% diagnosed with diabetes mellitus (DM) and 44% with hypertension (HTN); 54% were active or ex-smokers, 30% had a high lipid profile, and 74% were overweight. PPCI was performed in 42%, and 29% were managed with revascularization using thrombolytic therapy. A conservative approach was followed in 29% of the patients. Patients who had a stroke were treated conservatively due to the risk of bleeding. The patients in group 1 were mostly hypertensive with recurrent angina and a history of prior revascularization, with PPCI or coronary artery bypass grafting (CABG). The crude all-cause mortality at one year was 11%; it was 7% at one month for group 1, 8% for group 2, and 9% for group 3, which was not statistically significant. Conclusions Controlling the risk factors and improving access to PPCI in hospitals are fundamental in the management of STEMI patients. PPCI is still underused. Guideline-directed medical therapy (GDMT) is a reasonable approach if PPCI is not available.

Left ventricular diastolic dysfunction in patients with obesity hypoventilation syndrome.

BACKGROUND: Obesity hypoventilation syndrome (OHS) can be complicated by several cardiovascular conditions. We assessed the prevalence and factors associated with left ventricular diastolic dysfunction (LVDD) in patients with OHS. METHODS: In this prospective observational study, all consecutive OHS patients referred to the sleep disorders clinic between January 2002 to December 2016 were included (n=113). Demographic data, echocardiography, sleep parameters, arterial blood gases (ABGs), and lung functions were recorded. RESULTS: Of 113 patients with OHS who participated, 76 patients (67%) had LVDD. More than two-thirds had grade 1 LVDD. Median body mass index (BMI) was 42.8 kg/m2. Median PaCO2 was 55.8 mmHg. Median apnea hypopnea index (AHI) was 52 (25-38.5). Eighty-four (75.7%) patients were hypertensive, and 60 (54.1%) were diabetic. To minimize the effect of fluctuations in intrathoracic pressure during the obstructive respiratory events on the cardiac function, 38 OHS patients with mild to moderate OSA (AHI <30) were identified. Twenty-seven (71%) had LVDD. When compared to OHS patients without LVDD, patients with LVDD had higher BMI (47.4±6.5 versus 41.5±4.5, P=0.009). Hypertension was more common in OHS patients with LVDD than without LVDD (89.3% versus 54.5%, P=0.03). Correlation analysis revealed that hypertension (r=-0.37, P=0.016) had significant correlations with LVDD. CONCLUSIONS: Diastolic left ventricular dysfunction is prevalent among OHS patients even in the absence of severe OSA. Hypertension and obesity were significantly more common in patients with LVDD. Assessment of diastolic dysfunction should be included in the initial evaluation of OHS patients to encourage the early institution of therapy.

Congenital ventricular diverticulum and MI - Diagnostic challenges and implications.

The use of modern cardiac imaging techniques suggests that congenital ventricular diverticulum (CVD) may be more common than generally believed and may present asymptomatically in adult life. We present a case of congenital left ventricular diverticulum diagnosed in a patient presenting with myocardial infarction (MI). The case highlights the importance of the differential diagnosis of CVD from post infarct left ventricular aneurysms (PILVA) and suggests that adult studies using modern imaging techniques are needed to define the prognosis for asymptomatic CVD in order to guide management.

The prevalence, clinical characteristics, and prognosis of diastolic heart failure: a clinical study in elderly Saudi patients with up to 5 years follow-up.

Data from 519 patients older than 65 years with congestive heart failure (CHF) were analyzed after 5 years of clinical follow-up. Two groups were included in the analysis: 321 patients with ejection fractions > or =50% (group with diastolic heart failure) and 198 patients with reduced ejection fraction <50% (group with systolic heart failure). Hypertension (81%) was the strongest predictor of congestive heart failure, followed by diabetes (46%) and coronary disease (33%). Diastolic heart failure was more predominant in elderly female (P=.007), hypertensive (P=.0001), and hypertrophic (P=.001) patients. Length of hospital stay, readmission rate, all-cause morbidity, and cumulative mortality were not statistically significant between both groups (P=.09).

Immediate and intermediate results of intracoronary stand-alone bolus administration of eptifibatide during coronary intervention (ICE) study.

BACKGROUND: This study evaluated the immediate and intermediate results of intracoronary (i.c.) eptifibatide administration during percutaneous coronary intervention (PCI). Several studies tested intravenous (i.v.) bolus and continuous administration of eptifibatide during PCI. However, limited data are available regarding giving eptifibatide as i.c. bolus alone during PCI. METHODS: We studied clinical outcomes of 376 patients who received coronary stent(s) and eptifibatide by 3 applications during PCI and were followed up over 24 months. Group A (119 patients) had i.c. eptifibatide bolus only, group B (119 patients) had i.c. bolus and i.v. infusion, and group C (138 patients) had i.v. bolus and infusion. The standard 2 boluses of eptifibatide 180 microg/kg were given either via i.c. or i.v. route, and only groups B and C received i.v. infusion at 2 microcg x kg(-1) x min(-1) for 18 to 24 hours. RESULTS: There were 256 males and 120 females, with a mean age of 57 +/- 11 years. Among them, 52% were diabetic. The 6-, 12-, and 24-month cumulative composite end point of death and myocardial infraction was lower in group A (2.5%) compared with group C (10.8%, odds ratio [OR] 4.3, P = .029) and group B (5.8%, OR 2.6, P = .17). Compared with group A, target vessel revascularization was 3-fold in group C (OR 3.3, P = .001) and 2-fold in group B (OR 2.0, P = .061). Bleeding was significantly higher in group C (OR 5.4, P < .0001) and group B (OR 3.4, P = .007) compared with group A. Rehospitalization was significantly lower in group A (10.9%) compared with group B (16.8%) and group C (28%) (P = .0009). CONCLUSION: The i.c.-bolus-alone application of eptifibatide may be safer and superior to the i.v. route, and continuous infusion may not be necessary. Large-scale prospective randomized trials are needed to further validate these findings.

Cardiac unilateral pulmonary edema: is it really a rare presentation?

Unilateral pulmonary edema is a distinctly unusual clinical entity that presents interesting and confusing diagnostic challenges. It is usually described as occurring with re-expansion of a collapsed lung after rapid thoracocentesis of pleural air or pleural fluid. Unilateral pulmonary edema as an initial presenting manifestation for heart failure is uncommon and can be confused with other more common causes of alveolar or interstitial infiltrate, which can lead to a significant delay in treatment.

Successful bailout percutaneous coronary intervention for immediate surgical complication.

This case report describes a 36-year-old male with acute complete occlusion of his dominant left circumflex coronary artery after mechanical mitral valve replacement. The patient was successfully treated with percutaneous catheter intervention using drug-eluting coronary stents.

Successful lysis of intra-cardiac thrombi with streptokinase in patients with renal failure; two case reports and review of the literature.

In situ formation of thrombi within the cardiac cavities carries a substantial risk of morbidity and mortality due to the inherent danger of embolization to vital organs. This typically occurs in patients with underlying cardiac disorders associated with low flow state favoring regional stagnation of blood and subsequent clotting. Occasionally, extra-cardiac conditions such as renal failure predispose to the development of intra-cardiac thrombi in the presence or absence of identifiable cardiac abnormalities. Once identified, the appropriate treatment of such thrombi remains highly controversial. Here, we report on the successful and safe use of streptokinase in two patients with end stage renal disease with high risk left ventricular, right ventricular and right atrial thrombi.