Social Determinants of Health and Mortality After Premature and Non-premature Acute Coronary Syndrome.

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.

Association of obesity indices with in-hospital and 1-year mortality following acute coronary syndrome.

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.

Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry.

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.

Clinical characteristics and outcomes of young adults with first myocardial infarction: Results from Gulf COAST.

INTRODUCTION: Limited data exists on the risk factor profile and outcomes of young patients suffering their first acute myocardial infarction (AMI). METHODS: We examined 1562 Gulf-Arabs without prior cardiovascular disease presenting with first AMI enrolled in the Gulf COAST prospective cohort. Clinical characteristics were compared in patients ≤50 years of age (young) vs. >50 years (older). Associations between age group and in-hospital adverse events (re-infarction, heart failure, cardiogenic shock, cardiac arrest, stroke, and in-hospital death) or post-discharge mortality were estimated using logistic regression. RESULTS: Young patients represented 26.1% (n = 407) of first AMI cases and were more likely to be men (82.8% vs. 66.5%), current smokers (49.9% vs 19.0%), obese (38.3% vs 28.0%), and have family history of premature coronary artery disease (21.4% vs 10.4%) compared with older patients (all P < 0.001). Young patients were more likely to receive ß-blockers (83.0% vs 74.4%; P < 0.001), clopidogrel (82.3% vs 76.0%; P = 0.009) and primary reperfusion therapy (85.6% vs. 75.6%; P = 0.003). Young adults had lower in-hospital death (adjusted odds ratio [aOR] = 0.37; 95%CI = 0.16-0.86) or any in-hospital adverse cardiovascular events (aOR = 0.53; 95%CI = 0.34-0.83). Young adults had lower likelihood of cumulative death at 12-month post-discharge (aOR = 0.34; 95%CI = 0.19-0.59) after adjusting for potential confounders. CONCLUSION: Young patients with first AMI were more likely to be obese, smokers and have family history of premature coronary artery disease compared to older adults. Young patients were more likely to receive guideline-proven therapies and have better in-hospital and post-discharge mortality. These data highlight important age-related care gaps in patients suffering AMI for the first time.

Compliance of Atrial Fibrillation Treatment with the Atrial Fibrillation Better Care (ABC) Pathway Improves the Clinical Outcomes in the Middle East Population: A Report from the Gulf Survey of Atrial Fibrillation Events (SAFE) Registry.

Atrial fibrillation (AF) is associated with substantially increased risk of cardiovascular events and overall mortality. The Atrial fibrillation Better Care (A-Avoid stroke, B-Better symptom management, C-Cardiovascular and comorbidity risk management) pathway provides a simple and comprehensive approach for integrated AF therapy. This study's goals were to evaluate the ABC pathway compliance and determine the main gaps in AF management in the Middle East population, and to assess the impact of ABC pathway adherence on the all-cause mortality and composite outcome in AF patients. 2021 patients (mean age 57; 52% male) from the Gulf SAFE registry were studied. We evaluated: A-appropriate implementation of OACs according to CHA2DS2-VASc score; B-symptom control according to European Heart Rhythm Association (EHRA) symptom scale; C-proper cardiovascular comorbidities management. The primary endpoints were the composite cardiovascular outcome (ischemic stroke or systemic embolism, all-cause death and cardiovascular hospitalization) and all-cause mortality. One-hundred and sixty-eight (8.3%) patients were optimally managed according to adherence with the ABC pathway. Over the one-year follow up (FU), there were 578 composite outcome events and 224 deaths. Patients managed with integrated care had significantly lower rates for the composite outcome and mortality comparing to non-ABC group (20.8% vs. 29.3%, p = 0.02 and 7.3% vs. 13.1%, p = 0.033, respectively). On multivariable analysis, ABC compliance was independently associated with reduced risk of composite outcome (HR 0.53; 95% CI 0.36-0.8, p = 0.002) and death (HR 0.46; 95% CI 0.25-0.86, p = 0.015). Integrated ABC pathway adherent care resulted in the reduced composite outcome and all-cause mortality in AF patients from Middle East, highlighting the necessity of promoting comprehensive holistic and integrated care management of AF.

Efficacy and Safety of Pharmacoinvasive Strategy Compared to Primary Percutaneous Coronary Intervention in the Management of ST-Segment Elevation Myocardial Infarction: A Prospective Country-Wide Registry.

Background: A pharmacoinvasive reperfusion strategy is recommended for ST-elevation myocardial infarction (STEMI) patients when primary percutaneous coronary intervention (PCI) cannot be achieved in a timely fashion. This is based on a limited number of trials. The effectiveness of this strategy in the real-world is unclear. Objectives: To compare the effectiveness of pharmacoinvasive strategy versus primary PCI using a nationwide prospective registry of STEMI patients. Methods: We examined 936 STEMI patients from the reperfusion in ST-elevation myocardial infarction in Kuwait (REPERFUSE Kuwait) registry who underwent either primary PCI or pharmacoinvasive reperfusion. A composite outcome was measured based on death, congestive heart failure, reinfarction or stroke prospectively ascertained during hospital stay and up to one-year follow-up. The association between reperfusion strategy and the composite outcome was assessed using multivariate regression and Poisson proportional hazard model. Results: Compared to the pharmacoinvasive group, those undergoing primary PCI had higher Killip class on presentation and required more blood transfusions during hospitalization. There was no significant difference between primary PCI and pharmacoinvasive strategy with regards to the incidence of the composite outcome during the in-hospital period (RR = 1.0; 95% CI 0.98-1.02; p = 0.96) after adjustment for possible confounders. Over one-year follow-up, the survival of the two groups was not different (p = 0.66). The incidence of major bleeding was similar in both groups. Conclusion: STEMI patients treated with a pharmacoinvasive strategy have comparable outcomes to those treated with primary PCI with no increased risk of major bleeding. These real-world data support the use of a pharmacoinvasive strategy when primary PCI cannot be achieved in a timely fashion.

Implementation of Guideline-Recommended Therapies for Patients With Heart Failure and Reduced Ejection Fraction: A Regional Arab Middle East Experience.

We describe the characteristics of ambulatory patients with heart failure with reduced ejection fraction (HFrEF) in the Gulf region (Middle East) and the implementation of guideline-recommended treatments. We included 2427 HFrEF outpatients (mean age 59 ± 13 years, 75% males and median left ventricular ejection fraction [LVEF] of 30%). A high proportion of patients received guideline-recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI] 87%, ß-blocker 91%, mineralocorticoid antagonist [MRA] 64%). However, only a minority of patients received guideline-recommended target doses (ACEI/ARB/ARNI 13%, ß-blocker 27%, and MRA 4.4%). Old age was a significant independent predictor for not prescribing treatment (P < .001 for ACEI/ARB/ARNI and MRA; and P = .002 for ß-blockers). Other independent predictors were chronic kidney disease (for both ACEI/ARB/ARNI and MRA, P < .001) and higher LVEF (P = .014 for ß-blockers and P < .001 for MRA). Patients with HFrEF managed by heart failure specialists more often received recommended target doses of ACEI/ARB/ARNI (40% vs 11%, P < .001) and ß-blockers (56% vs 26%, P < .001) compared to those treated by general cardiologists. Although the majority of our patients with HFrEF received guideline-recommended medications, the doses they were prescribed were suboptimal. Understanding the reasons behind this is important for improved practice.

One-year all-cause mortality risk among atrial fibrillation patients in Middle East with and without diabetes: The Gulf SAFE registry.

BACKGROUND: Atrial fibrillation (AF) poses a great risk of mortality, especially when associated with diabetes mellitus (DM). OBJECTIVES: We aimed to investigate the rate and risk factors for mortality among AF patients with and without DM in the population from the Middle East where it has never been investigated before. METHODS: We analyzed the Gulf-SAFE registry, involving patients with nonvalvular AF from the Middle East, for one-year all-cause mortality. The predictive capability of the CHA2DS2-VASc score for death was also investigated. RESULTS: Among a total of 2043 AF patients 606 had DM. Patients with DM were older and had significantly higher prevalence of multiple comorbidities (p < 0.05, respectively). Among patients with DM, age ≥ 75 (relative risk 2.34, 95% confidence interval 1.19-4.61), heart failure (HF) (RR 2.14, 95%CI 1.03-4.43), peripheral vascular disease (PVD) (RR 3.36, 95%CI 1.22-9.30) and chronic kidney disease (CKD) (RR 2.60, 95%CI 1.16-5.81) were independent risk factors for one year all-cause mortality. Patients with DM had significantly higher rates of heart failure and AF-related hospital admissions, all-cause mortality and composite outcome rates, in one year follow up. Among patients with DM, the CHA2DS2-VASc score was predictive of one-year all-cause mortality with c-index of 0.741 (95%CI 0.688-0.794). CONCLUSIONS: AF patients in Middle East with DM have a higher risk for all-cause mortality, HF and AF admission and composite outcome, compared to patients without DM. Multiple risk factors contribute to the higher mortality rate among patients with DM.

Impact of Dual versus Single Antiplatelet Therapy on Major Cardiovascular Outcomes in Patients with Acute Coronary Syndrome in the Arabian Gulf.

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.

Increases in statin eligibility to reduce cardiovascular risk according to the 2013 ACC/AHA cholesterol guidelines in the Africa Middle East region: a sub-analysis of the Africa Middle East Cardiovascular Epidemiological (ACE) study.

BACKGROUND: With development of cholesterol management guidelines by the American College of Cardiology/American Heart Association (ACC/AHA), more individuals at risk of cardiovascular disease may be eligible for statin therapy. It is not known how this affects statin eligibility in the Africa and Middle East Region. METHODS: Data were used from the Africa Middle East Cardiovascular Epidemiological (ACE) study. The percentage of subjects eligible for statins per the ACC/AHA 2013 cholesterol guidelines and the 2002 National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP III) recommendations were compared. Analyses were carried out according to age, gender, community (urban/rural), and country income categories based on World Bank definitions. RESULTS: According to the ACC/AHA recommendations, 1695 out of 4378 subjects (39%; 95% confidence interval [CI], 37-40%) satisfied statin eligibility criteria vs. 1043/4378 (24%; 95% CI, 23-25%) per NCEP-ATP recommendations, representing a 63% increase in statin eligibility. Consistent increases in eligibility for statin therapy were seen according to the ACC/AHA vs. NCEP-ATP guidelines across sub-groups of age, gender, community, and country income. Notable increases for statin eligibility according to ACC/AHA vs. NCEP-ATP were seen, respectively, in subjects aged ≥65 years (86% vs. 39%), in males (46% vs. 25%), in low-income countries (28% vs. 14%), and rural communities (37% vs. 19%). CONCLUSION: An increase in statin eligibility was seen applying ACC/AHA cholesterol guidelines compared with previous NCEP-ATP recommendations in the Africa Middle East region. The economic consequences of these guideline recommendations will need further research. TRIAL REGISTRATION: The ACE trial is registered under NCT01243138 .

Association between education and major adverse cardiac events among patients with acute coronary syndrome in the Arabian Gulf.

INTRODUCTION: The objective of this study was to evaluate the association between education and major adverse cardiac events in patients with acute coronary syndrome (ACS) in the Arabian Gulf. METHODS: Data were analysed from 3874 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013. Education was defined as any type of formal training from primary school and above. MACE included stroke/transient ischaemic attack (TIA), myocardial infarction (MI), all-cause mortality and readmissions for cardiac reasons. RESULTS: The overall mean age was 60±13 years and 67% (n=2579) were men. A total of 53% (n=2039) of the patients had some form of school education. Adjusting for demographic and clinical characteristics as well as socioeconomic measures (insurance type and employment), at 12-month follow-up, educated patients were significantly less likely to have had MACE (adjusted OR (aOR): 0.55; 95% CI 0.44 to 0.68; p<0.001) than those with no formal education. The lower rate of events was also consistent across all MACE components: stroke/TIA (aOR: 0.56; 95% CI 0.33 to 0.94; p=0.030), MI (aOR: 0.58; 95% CI 0.38 to 0.86; p=0.008), all-cause mortality (aOR: 0.58; 95% CI 0.39 to 0.87; p=0.009) and readmissions for cardiac reasons (aOR: 0.61; 95% CI 0.48 to 0.77; p<0.001). MACE outcomes were consistent across men and women and across countries. CONCLUSIONS: Education was associated with lower MACE events in patients with ACS in the Arabian Gulf. Interventions promoting healthy lifestyles and management of clinical risk factors for patients with low health literacy are urgently required.

Secondary stroke prevention and guideline adherent antithrombotic treatment in patients with atrial fibrillation: Insights from the Gulf Survey of atrial fibrillation events (Gulf SAFE).

BACKGROUND: Anticoagulation therapy in patients with atrial fibrillation (AF) is well established as effective thromboprophylaxis. However, AF patients with prior stroke are often treated with suboptimal antithrombotic treatment (ATT). In the present study, we investigated clinical characteristics and outcomes in AF patients with versus without prior stoke, in relation to guideline adherence in ATT. METHODS: We used data from the Gulf SAFE registry, which included patients with AF who presented to hospitals in Gulf countries of the Middle East. Adherence to guideline recommended ATT was assessed against the European Society of Cardiology guidelines. RESULTS: Of 1860 patients, 15.4% had a history of stroke (secondary stroke prevention). For secondary stroke prevention, 62.0% of patients were prescribed oral anticoagulants, while 27.9% were still prescribed antiplatelet therapy alone and 10.1% received no ATT. Overall, 49.0% were treated with guideline adherent ATT, 25.5% were undertreated, and 25.4% were overtreated. On multivariable logistic regression analysis, undertreatment (OR; 2.763, 95% CI; 1.426-5.352, p = 0.003) was significantly associated with an increased risk of 1-year stroke. On the other hand, overtreatment was significantly associated with an increased risk of 1-year bleeding (OR; 3.294, 95% CI; 1.517-7.152, p = 0.003). CONCLUSIONS: Only half of the AF patients received optimal ATT for stroke prevention if we apply guideline recommendations. Guideline adherent ATT significantly reduced the risk of stroke and bleeding compared with non-guideline adherent ATT.

Effect of evidence-based cardiac drug therapy on mortality in patients with acute coronary syndrome: Findings from the Gulf COAST registry.

AIM: To evaluate the prevalence and impact of the prescribing of an evidence-based cardiac medication (EBM) combination on 1-month, 6-months, and 12-months all-cause mortality in patients with acute coronary syndrome (ACS). METHODS: Data were analyzed from 3681 consecutive patients diagnosed with ACS admitted to 29 hospitals in 4 Middle Eastern countries from January 2012 to January 2013. The EBM combination consisted of concurrent prescribing of an antiplatelet therapy, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), ß-blocker, and a statin, at hospital discharge. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The overall mean age of the cohort was 60 ± 13 years, 66% (n = 2436) were males. In all, 69% (n = 2542) of the patients received the quadruple EBM combination at discharge. Two-way interactions between EBM and age (P = 0.824), EBM and GRACE risk score (P = 0.873) and between EBM and discharge diagnosis (P = 0.836) were all not statistically significant. Adjusting for demographic and clinical characteristics, the prescribing of EBM combination was associated with significantly lower cumulative all-cause mortality at 1-month (adjusted OR (aOR), 0.43; 95% confidence interval (CI): 0.24-0.79; P = 0.007), which persisted at 6-months (aOR, 0.52; 95% CI: 0.38-0.72; P < 0.001) and at 12-months of follow-up (aOR, 0.58; 95% CI: 0.44-0.75; P < 0.001) posthospital discharge. CONCLUSIONS: Among patients discharged after an ACS event, concurrent EBM prescribing was associated with lower all-cause mortality that persists for up to 12-months posthospital discharge. The relative benefits of EBMs were also consistent across age, GRACE risk score, and discharge diagnosis.

Prevalence, management, and outcomes of familial hypercholesterolemia in patients with acute coronary syndromes in the Arabian Gulf.

BACKGROUND: Information on the epidemiology of familial hypercholesterolemia (FH) in the Arabian Gulf region, which has an elevated rate of consanguinity and type II diabetes, is scarce. OBJECTIVES: To assess the prevalence of FH, its management, and impact on atherosclerotic cardiovascular disease (ASCVD) outcomes in a multicenter cohort of Arabian Gulf patients with acute coronary syndrome (ACS). METHODS: Patients (N = 3224) hospitalized with ACS were studied. FH was diagnosed using the Dutch Lipid Clinic Network criteria. A composite endpoint of nonfatal myocardial infarction, stroke, transient ischemic attack, and mortality between the "probable/definite" and the "unlikely" FH patients was assessed after 1 year. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: At admission, the proportion of "probable/definite", "possible", and "unlikely" FH in ACS patients was 3.7% (n = 119), 28% (n = 911), and 68% (n = 2194), respectively. Overall, 54% (n = 1730) of patients had diabetes, whereas 24% (n = 783) were current smokers. The "probable/definite" FH group was younger (50 vs 63 years; P < .001), had a greater prevalence of early coronary disease (38% vs 8.8%; P < .001), and previous statin use (87% vs 57%; P < .001) when compared with the "unlikely" FH group. After 1 year, the "probable/definite" FH cohort had worse lipid control (13% vs 23%; P < .001) and presented with a greater association with the composite ASCVD endpoint when compared with the "unlikely" FH group (odds ratio: 1.85; 95% confidence interval: 1.01-3.38; P = .047) after multivariable adjustment. CONCLUSIONS: In Arabian Gulf citizens, FH was common in ACS patients, was undertreated, and was associated with a worse 1-year prognosis.

Cardiovascular risk factor burden in Africa and the Middle East across country income categories: a post hoc analysis of the cross-sectional Africa Middle East Cardiovascular Epidemiological (ACE) study.

BACKGROUND: A significant number of cardiovascular disease (CVD)-related deaths occur in developing countries. An increasing prevalence of CVD is associated with a change in the macro-economy of these countries. In this post hoc analysis, CVD risk factor (CVDRF) prevalence is evaluated across countries based on national income in the Africa and Middle East Region (AfME). METHODS: Data from the Africa Middle East Cardiovascular Epidemiological (ACE) study were used; a cross-sectional study in 14 AfME countries (94 clinics) from July 2011-April 2012, which evaluated CVDRF prevalence in stable adult outpatients. World Bank definitions were used to classify countries as low-income (LI), lower-middle-income (LMI), upper-middle-income (UMI) or high-income (HI) countries. Four thousand three hundred seventy-eight subjects were recruited where 260 (6%), 1324 (30%), 1509 (35%) and 1285 (29%) were from LI, LMI, UMI, and HI countries, respectively. RESULTS: Of all the CVDRFs evaluated, almost two-thirds of the study population across the national income groups had abdominal obesity and dyslipidemia. Countries in the HI category were associated with a higher prevalence of diabetes (32%), obesity (44%) and smoking (16%). UMI and HI countries were associated with higher clustering of CVDRFs where at least one-third of subjects having four or more CVDRFs. Lower income countries had lower blood pressure control rates and lower percentages of outpatients achieving LDL-cholesterol targets. CONCLUSION: The burden of CVDRFs in stable outpatients is high across the national income categories in the AfME region, with HI countries showing a higher prevalence of CVDRFs. The high burden in lower income countries is associated with sub-optimal control of dyslipidemia and hypertension. Lowering the CVDRF burden would need specific public health actions in line with positive changes in the macro-economy of these countries. TRIAL REGISTRATION: The ACE trial is registered under NCT01243138.

Design and Rationale of Gulf Documentation of Ambulatory Sick Patients with Heart Failure (Gulf DYSPNEA) Registry.

AIM: The aim of this study is to describe the clinical characteristics of ambulatory patients with chronic heart failure (HF) in the Arabian Gulf and to examine several aspects including types of HF, causes, and adherence to management guidelines. METHODS: Gulf documentation of ambulatory sick patients with HF (Gulf DYSPNEA) registry is a multicenter, cross-sectional study, recruiting adult ambulatory HF patients from 24 hospitals in five Arabian Gulf countries. Consecutive patients are recruited prospectively from participating clinics with no follow-up data collection. Recruitment started on November 07, 2016 and will stop when 3,500 patients are enrolled in this study. Collected data explore demographics, baseline patient characteristics, symptoms, previous medical history, comorbidities, physical signs, presenting electrocardiogram, echocardiographic findings, types of HF, and management. CONCLUSION: This registry is expected to provide useful data on several important aspects and features of ambulatory patients with chronic HF in Arabian Gulf countries. The trial registration number is "ClinicalTrials.gov number, NCT02793180".

ß-Blockers on Discharge From Acute Atrial Fibrillation Are Associated With Decreased Mortality and Lower Cerebrovascular Accidents in Patients With Heart Failure and Reduced Ejection Fraction.

The benefits of ß-blockers in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) are controversial. The Gulf Survey of Atrial Fibrillation Events was a prospective, multinational, observational registry of consecutive patients with AF recruited from the emergency department (ED). We studied the incidence of 6- and 12-month mortality, hospitalization for HF or AF, and stroke/transient ischemic attacks (TIAs) in patients with HFrEF, in relation to ß-blockers on discharge from the ED or the subsequent hospital stay. Of the 344 patients with HFrEF and AF in the GULF-SAFE, 177 patients (53%) were discharged on ß-blockers. Mortality was lower in those patients compared with the non-ß-blockers group at 6 and 12 months (odds ratios [ORs] 0.31, 95% CI [0.16-0.61]; OR 0.30, 95% CI [0.16-0.55]; P = .001 for both, respectively), so was the risk of stroke/TIAs. However, hospitalizations for AF increased in the ß-blockers group. Even after adjustment for several risk variables in 2 different models, the beneficial effect of ß-blockers on mortality persisted, at the cost of more hospitalization for AF.

Gender Differences among Patients with Acute Coronary Syndrome in the Middle East.

BACKGROUND: There is controversy regarding the relationship between gender and acute coronary syndrome (ACS). OBJECTIVE: To study the impact of gender on presentation, management, and mortality among patients with ACS in the Middle East. METHODOLOGY: From January 2012 to January 2013, 4057 patients with ACS were enrolled from four Arabian Gulf countries (Kuwait, Oman, United Arab Emirates, and Qatar), representing more than 85% of the general hospitals in each of the participating countries. RESULTS: Compared to men, women were older and had more comorbidities. They also had atypical presentation of ACS such as atypical chest pain and heart failure. The prevalence of non-ST-segment elevation myocardial infarction (49 vs. 46%; P < 0.001) and unstable angina (34 vs. 24%; P < 0.001) was higher among women as compared to men. In addition, women were less likely to receive evidence-based medications such as aspirin, clopidogrel, beta-blocker, and angiotensin-converting enzyme inhibitors on admission and on discharge. During hospital stay, women suffered more heart failure (15 vs. 12%; P = 0.008) and were more likely to receive blood transfusion (6 vs. 3%; P < 0.001). Women had higher 1-year mortality (14 vs. 11%; P < 0.001), the apparent difference that disappeared after adjusting for age and other comorbidities. CONCLUSION: Although there were differences between men and women in presentation, management, and in-hospital outcomes, gender was shown to be a nonsignificant contributor to mortality after adjusting for confounders.

Disparity in ST-segment Elevation Myocardial Infarction Practices and Outcomes in Arabian Gulf Countries (Gulf COAST Registry).

OBJECTIVES: The objective of this study is to describe contemporary management and 1-year outcomes of patients hospitalized with ST-segment elevation myocardial infarction (STEMI) in Arabian Gulf countries. METHODS: Data of patients admitted to 29 hospitals in four Gulf countries [Bahrain, Kuwait, Oman, United Arab Emirates (UAE)] with the diagnosis of STEMI were analyzed from Gulf locals with acute coronary syndrome (ACS) events (Gulf COAST) registry. This was a longitudinal, observational registry of consecutive citizens, admitted with ACS from January 2012 to January 2013. Patient management and outcomes were analyzed and compared between the four countries. RESULTS: A total of 1039 STEMI patients were enrolled in Gulf COAST Registry. The mean age was 58 years, and there was a high prevalence of diabetes (47%). With respect to reperfusion, 10% were reperfused with primary percutaneous coronary intervention, 66% with fibrinolytic therapy and 24% were not reperfused. Only one-third of patients who received fibrinolytic therapy had a door-to-needle time of 30 min or less. The in-hospital mortality rate was 7.4%. However, we noted a significant regional variability in mortality rate (3.8%-11.9%). In adjusted analysis, patients from Oman were 4 times more likely to die in hospital as compared to patients from Kuwait. CONCLUSIONS: In the Gulf countries, fibrinolytic therapy is the main reperfusion strategy used in STEMI patients. Most patients do not receive this therapy according to timelines outlined in recent practice guidelines. There is a significant discrepancy in outcomes between the countries. Quality improvement initiatives are needed to achieve better adherence to management guidelines and close the gap in outcomes.