GALNT2 rs4846914 SNP Is Associated with Obesity, Atherogenic Lipid Traits, and ANGPTL3 Plasma Level.

N-Acetylgalactosaminyltransferase 2 (GALNT2) is associated with serum lipid levels, insulin resistance, and adipogenesis. Additionally, angiopoietin-like (ANGPTL) proteins have emerged as regulators of lipoprotein lipase and lipid metabolism. In this study, we evaluated the association between GALNT2 rs4846914 variant, known for its association with lipid levels in European cohorts, with plasma levels of ANGPTL proteins, apolipoproteins, lipids, and obesity traits in individuals of Arab ethnicity. GALNT2 rs4846914 was genotyped in a cohort of 278 Arab individuals from Kuwait. Plasma levels of ANGPTL3 and ANGPTL8 were measured by ELISA and apolipoproteins by Luminex multiplexing assay. Allele-based association tests were performed with Bonferroni-corrected p-value thresholds. The GALNT2 rs4846914_G allele was associated with increased ANGPTL3 (p-values ≤ 0.05) but not with ANGPTL8 plasma levels. The allele was associated significantly with higher BMI and weight (p-values < 0.003), increased ApoC1 levels (p-values ≤ 0.006), and reduced HDL levels (p-values ≤ 0.05). Individuals carrying the GG genotype showed significantly decreased HDL and increased BMI, WC, ApoC1, and TG. Interactions exist between (AG+GG) genotypes and measures of percentage body fat, ApoA1A, ApoC1, and ApoB48-mediated HDL levels. GALNT2 is confirmed further as a potential link connecting lipid metabolism and obesity and has the potential to be a drug target for treating obesity and dyslipidemia.

Point-of-Care Ultrasound to Detect Dilated Coronary Sinus in Adults.

Detecting dilated coronary sinus when assessing patients in an acute emergency with point-of-care ultrasound (POCUS) is important for differential diagnosis, including the detection of persistent left superior vena cava (PLSVC) and right ventricular dysfunction. Cardiac POCUS with agitated saline injections through the left and right antecubital veins is a simple bedside test to make the diagnosis. We present a 42-year-old woman with first-time rapid atrial flutter in whom POCUS confirmed the presence of dilated coronary sinus and PLSVC.

ANGPTL3 Variants Associate with Lower Levels of Irisin and C-Peptide in a Cohort of Arab Individuals.

ANGPTL3 is an important regulator of lipid metabolism. Its inhibition in people with hypercholesteremia reduces plasma lipid levels dramatically. Genome-wide association studies have associated ANGPTL3 variants with lipid traits. Irisin, an exercise-modulated protein, has been associated with lipid metabolism. Intracellular accumulation of lipids impairs insulin action and contributes to metabolic disorders. In this study, we evaluate the impact of ANGPTL3 variants on levels of irisin and markers associated with lipid metabolism and insulin resistance. ANGPTL3 rs1748197 and rs12130333 variants were genotyped in a cohort of 278 Arab individuals from Kuwait. Levels of irisin and other metabolic markers were measured by ELISA. Significance of association signals was assessed using Bonferroni-corrected p-values and empirical p-values. The study variants were significantly associated with low levels of c-peptide and irisin. Levels of c-peptide and irisin were mediated by interaction between carrier genotypes (GA + AA) at rs1748197 and measures of IL13 and TG, respectively. While levels of c-peptide and IL13 were directly correlated in individuals with the reference genotype, they were inversely correlated in individuals with the carrier genotype. Irisin correlated positively with TG and was strong in individuals with carrier genotypes. These observations illustrate ANGPTL3 as a potential link connecting lipid metabolism, insulin resistance and cardioprotection.

Epidemiology of adult congenital heart disease among the general population in Kuwait.

BACKGROUND: Adult congenital heart disease (ACHD) is a highly underrepresented entity in medical literature, especially in the middle-eastern region. HYPOTHESIS: This study is the first to assess the prevalence of adult congenital heart disease among the population of Kuwait. METHODS: After a retrospective register review of patients in Kuwait being followed up in the chest diseases hospital was conducted, patients who fit the inclusion criteria were enrolled in the study. Using the American College of Cardiology Task Force 1 of the 32nd Bethesda conference classification of the severity of ACHD, the patients were classified into those with simple, moderate, and complex congenital heart diseases. The age and gender of the patients, as well as the type repair performed, and the residual cardiac findings were recorded to assess the association between the complexity and residuals. Associations were assessed using STATA 15. RESULTS: A total of 611 patients were evaluated over a period of 18 months. The youngest participant was 20 years of age, and the oldest participant was 88 years old. Male participants with moderate congenital heart disease class were more common in our study population. Patients with complex congenital heart disease have more residual cardiac lesion than the moderate or simple groups. Almost (70%) of patients with complex cardiac anomalies have undergone either partial or complete repair. The most prevalent cardiac defect was atrial septal defect (21.5%). Tetralogy of Fallot was the most prevalent defect in the moderate group, representing (13%) of the group. The most prevalent anomaly in the complex group was double outlet right ventricle (DORV) representing (15.38%). CONCLUSION: Adult Congenital heart disease is a growing entity of heart disease due to advanced repair techniques. This population requires registries to document cases and assign specialists for the management and care of this special group of patients. HIGHLIGHTS: First database of adult congenital heart disease in Kuwait. The most prevalent heart defect was ASD in Kuwait. TOF was the most prevalent defect in the moderate group; and DORV was the most prevalent in the complex group. Patients with moderate ACHD tended to have a more complete repair than those in the complex group.

Acute Myocardial Infarction Secondary to Paradoxical Embolism.

Patent foramen ovale is a risk factor for systemic embolic events such as cryptogenic stroke. Far less commonly, patent foramen ovale is associated with non-cerebral systemic embolic events. Paradoxical coronary artery embolism is a rare and underdiagnosed cause of acute myocardial infarction. It should be considered in patients presenting with myocardial infarction and an otherwise low-risk profile for atherosclerotic coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST elevation myocardial infarction. Echocardiography demonstrated patent foramen ovale with a significant shunt. In addition to the treatment of the acute coronary event, patent foramen ovale closure was performed to prevent recurrent paradoxical embolic events. LEARNING POINTS: Coronary artery embolism is an established cause of acute coronary syndrome, but paradoxical coronary artery embolism causing myocardial infarction is rare and requires a high degree of clinical suspicion for diagnosis.Recognition of this condition is important as it has an influence on management and prognosis. A search for venous thrombosis and underlying prothrombotic conditions should be undertaken.Percutaneous device closure of the patent foramen ovale should be considered to prevent future embolic events.

The Two Faces of ACE2: The Role of ACE2 Receptor and Its Polymorphisms in Hypertension and COVID-19.

The mechanism for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requires the binding of the virus to the angiotensin-converting enzyme 2 (ACE2) receptor, well-known for its role in counteracting ACE. ACE2 is involved in modulating blood pressure and establishing blood pressure homeostasis. Recently, a critical debatable question has arisen whether using antihypertensive medications will have a favorable impact on people infected with SARS-CoV-2 or a deleterious one, mainly because angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-receptor blocker (ARB) therapy can modulate the expression of ACE2 protein. The concern is that the use of ACEIs and ARBs will increase the expression of ACE2 and increase patient susceptibility to viral host cell entry and propagation. On the other hand, several genetic association studies have examined the relationship between ACE2 genetic variants and the risk of developing hypertension in different ethnic populations. In this review, we discuss the ongoing arguments in the literature about ACE2's role in mortality rate among coronavirus disease 2019 (COVID-19) patients comorbid with hypertension and critically evaluate the current debate about the usage or discontinuation of ACEI/ARB antihypertensive drugs. Moreover, we explore the two opposing roles that ACE2 genetic variants might be playing in COVID-19 by reducing ACE2 receptor effectiveness and mitigating SARS-CoV-2 infectivity.

Investigating the Role of Myeloperoxidase and Angiopoietin-like Protein 6 in Obesity and Diabetes.

Myeloperoxidase (MPO) is positively associated with obesity and diet-induced insulin resistance. Angiopoietin-like protein 6 (ANGPTL6) regulates metabolic processes and counteract obesity through increased energy expenditure. This study aims to evaluate the plasma MPO and ANGPTL6 levels in obese and diabetic individuals as well as MPO association with biochemical markers of obesity. A total of 238 participants were enrolled, including 137 control and 101 type 2 diabetes (T2D) patients. ANGPTL6 and MPO levels and other biomarkers were measured via ELISA. ANGPTL6 levels were significantly higher in the diabetic population and obese individuals. When the group was stratified based on T2D, ANGPTL6 levels were significantly higher in obese-diabetic participants compared with non-obese-diabetics, but obese-non-diabetic individuals had similar ANGPTL6 levels to their controls. MPO levels were higher in obese compared with non-obese participants but did not differ between T2D and control participants. MPO levels were upregulated in obese compared with non-obese in both diabetics and non-diabetics. MPO was positively associated with ANGPTL6, triglyceride, BMI, TNF-alpha, high-sensitivity C-reactive protein, interleukin-6, and plasminogen activator inhibitor-1. Taken together, our findings suggest that both MPO and ANGPTL6 may regulate obesity, although MPO exerts this effect independent of diabetes while ANGPTL6 may have a modulatory role in diabetes.

Higher Levels of ANGPTL5 in the Circulation of Subjects With Obesity and Type 2 Diabetes Are Associated With Insulin Resistance.

Objective: The family of angiopoietin-like proteins (ANGPTLs) is composed of eight ANGPTLs members that are involved in regulating various metabolic processes and have been implicated in type 2 diabetes (T2D) and obesity. ANGPTL5 is an understudied member of this family that has been suggested to regulate triglyceride metabolism with a potential role in obesity. This study was designed to investigate the expression levels of ANGPTL5 protein in the circulation of subjects with obesity and T2D. Methods: A total of 204 subjects were enrolled in this cross-sectional study, of which 95 had diagnosed T2D and 109 did not (non-T2D). Within the non-T2D group, 39 subjects were obese (BMI ≥ 30 Kg/m2) and 70 were not (BMI < 30 Kg/m2). Among subjects with T2D, 61 were obese and 34 were non-obese. Circulating ANGPTL5 plasma levels were measured by enzyme-linked immunosorbent assay (ELISA). Results: In this study, we showed that ANGPTL5 levels were higher in the plasma of subjects with T2D [mean ± standard error of the mean (SEM): 5.78 ± 2.70 ng/mL] compared with individuals without T2D (mean ± SEM: 4.42 ± 2.22 ng/mL; P < 0.001). Obese and non-T2D subjects had significantly higher levels of ANGPTL5 (mean ± SEM: 5.115 ± 0.366 ng/mL) compared with non-obese, non-T2D subjects (mean ± SEM: 4.02 ± 0.271 ng/mL; P = 0.003). Similarly, among subjects with diagnosed T2D, those who were obese had higher ANGPTL5 plasma levels than non-obese subjects, although this difference did not reach statistical significance (P = 0.088). Correlation analyses revealed that ANGPTL5 levels positively associated with fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), triglycerides (TGL), and insulin resistance as measured by HOMA-IR. Conclusion: our data shows for the first time that circulating ANGPTL5 levels were higher in obese individuals and those with T2D. Further analysis will be required to better understand the interaction between ANGPTL5 and other metabolic related biomarkers to shed more light on its role in diabetes and obesity.

Increased plasma and adipose tissue levels of ANGPTL8/Betatrophin and ANGPTL4 in people with hypertension.

BACKGROUND: Hypertension is a risk factor for both cardiovascular diseases (CVDs) and type 2 diabetes (T2D). Angiopoietin-like proteins (ANGPTLs), mainly ANGPTL3, ANGPTL4 and ANGPTL8, are associated with increased plasma lipid content due to their role in regulating the activity of lipoprotein lipase, a key enzyme in metabolism of the lipoprotein in circulation. Dyslipidaemia is a risk factor for hypertension development; however, the roles of ANGPTL3, ANGPTL4 and ANGPTL8 in subjects with hypertension have not yet been established. This study compared the plasma and adipose tissue levels of ANGPTL3, ANGPTL4 and ANGPTL8 in age- and body mass index-matched subjects with and without hypertension. METHODS: A total of 119 subjects, including 69 hypertensive and 50 non-hypertensive subjects, were enrolled. ANGPTL3, ANGPTL4 and ANGPTL8 plasma levels were measured by ELISA, whereas their levels in adipose tissue were assessed via real-time PCR. RESULTS: We found that ANGPTL4 (202.49 ± 17.44 ng/mL vs. 160.64 ± 10.36 ng/mL, p = 0.04) and ANGPTL8 levels (2310.96 ± 194.88 pg/mL vs. 1583.35 ± 138.27 pg/mL, p = 0.001) were higher in hypertensive subjects than non-hypertensive subjects. However, ANGPTL3 levels were not significantly different between the two populations. Similarly, ANGPTL4 and ANGPTL8 levels were also elevated in subjects with T2D and hypertension than in those with T2D but not hypertension. Additionally, people with highest tertiles of ANGPTL8 had higher odds of having hypertension (odd ratio [OR] = 3.8, 95% confidence interval [CI] = (1.5-9.8), p-Value = 0.005. Similar to its plasma levels, ANGPTL4 and ANGPTL8 were higher in adipose tissue. CONCLUSIONS: In conclusion, our data illustrate that ANGPTL4 and ANGPTL8 levels in both plasma and adipose tissues are increased in subjects with hypertension. The elevated levels of ANGPTL4 and ANGPTL8 in hypertensive subjects highlight their potential involvement, their potential role as biomarkers for hypertension and their therapeutic value in hypertension given their roles in regulating lipid metabolism.

Efficacy and Safety Assessment of Hypertension Management with Coveram (Perindopril/Amlodipine Fixed Combination) in Patients with Previous Angiotensin Receptor Blocker (ARB) Treatment: Arabian Gulf STRONG Study.

OBJECTIVE: We evaluated the safety and efficacy of hypertension management with Coveram (perindopril/amlodipine combination) in patients with uncontrolled blood pressure (BP). All patients were on previous angiotensin receptor blocker (ARB) treatment. METHODS: This was a 3 country, multi-centre (7 cities), open-label, observational study in the Arabian Gulf. Patients (≥18 years) were recruited between October 2012 and November 2013 and followed-up for 3 months after enrolment. Outcomes included changes in BP from baseline and BP goal attainment rates as per Joint National Committee- 8 (<140/90 mmHg for diabetics and those <60 years of age and <150/90 mmHg for those ≥60 years of age without diabetes). Medication tolerance was also assessed from both patient and physician perspectives. RESULTS: Hypertensive patients (n=760; mean age: 51±10 years; 67% were males) were included. A total of 178 patients (23%) were lost to follow-up. The perindopril/amlodipine combination was associated with an overall reduction in systolic BP (SBP) (31 mmHg; p<0.001) and diastolic BP (DBP) (18 mmHg; p<0.001) from baseline. An overall BP control rate was achieved in 87% (n=507) of the participants. There were significant incremental BP reductions with dose up-titration, especially SBP (p<0.001). Those with high SBP (>180 mmHg) at baseline were associated with a mean reduction of 59 mmHg (p<0.001). The perindopril/amlodipine combination had excellent tolerance levels over the study period from both patient and physician perspectives (at 99% and 98%, respectively; p<0.001). CONCLUSIONS: The perindopril/amlodipine combination is an effective and well tolerated anti-hypertensive option in patients on previous ARB treatment.

The obesity paradox in patients with acute coronary syndrome: results from the Gulf RACE-2 study.

We investigated the association between in-hospital and peri-hospital mortality and body mass index (BMI)/waist circumference (WC) in a prospective acute coronary syndrome (ACS) registry in the Arabian Gulf. No significant associations with in-hospital mortality were found. Normal BMI had highest peri-hospital mortality, notably those with high WC. In logistic regression of mortality on obesity measures and potential confounders, the effects of obesity measures were no longer significant. In-hospital death increased by 5% with age and decreased by 42% in males. Mortality increased 3.7-fold with ST-elevation myocardial infarction (STEMI) and 3.0-fold with heart failure (HF) but decreased by 33% with dyslipidemia. Peri-hospital death increased by 4% with age and decreased by 30% in males. Mortality increased 2.8-fold with STEMI and 2.4-fold with HF. In- and peri-hospital mortality in ACS is significantly associated with age, gender, STEMI, HF, and dyslipidemia but not obesity measures.

Primary coronary intervention versus thrombolytic therapy in myocardial infarction patients in the Middle East.

BACKGROUND: Little is known about predictors and outcome differences of primary percutaneous coronary intervention (PPCI) and thrombolytic therapy (TT) in ST-segment elevation myocardial infarction (STEMI) patients in the Middle East. OBJECTIVE: To compare predictors as well as in-hospital outcomes of PPCI and TT in STEMI patients in six Middle Eastern countries. SETTING: Sixty-five hospitals (covering at least 85 % of the population) in Oman, United Arab Emirates, Qatar, Bahrain, Kuwait and Yemen. METHODS: This was a prospective, multinational, multicentre, observational survey of consecutive acute coronary syndrome patients who were admitted to 65 hospitals during May 8, 2006 to June 6, 2006 and from January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were performed using univariate and multivariate statistical techniques. MAIN OUTCOME MEASURES: Predictors as well as in-hospital outcomes of PPCI and TT in STEMI patients. RESULTS: Out of 2,155 STEMI patients admitted to hospitals within 12 h of symptoms onset, 92 % received reperfusion (8 % PPCI and 84 % TT). TT use included reteplase (43 %), tenecteplase (30 %), streptokinase (25 %), and alteplase (2 %). Median age of the study cohort was 50 (44-58) years with majority being males (90 %). There were no significant differences in median onset time to presentation between the TT and PPCI groups (130 vs. 120 min; P = 0.422). Median door-to-needle time and door-to-balloon time were 45 min (29-75) and 75 min (58-120), respectively. Predictors of PPCI included prior PCI, hospitals with catheterization laboratory facilities as well as those involved with academia. Multivariate logistic regression model demonstrated that patients that had PPCI were less likely to have recurrent ischemic attacks than those that had TT (odds ratio, 0.18; 95 % CI, 0.06-0.56; P = 0.003). CONCLUSIONS: The main reperfusion strategy for STEMI patients in the Arab Middle East region is thrombolytic therapy. Predictors of primary percutaneous coronary intervention included prior percutaneous coronary intervention, hospitals with catheterization laboratory facilities as well as those involved with academia. Primary percutaneous coronary intervention resulted in significant reductions in recurrent ischemic events when compared to thrombolytic therapy.

Impact of diabetes and smoking epidemic in the Middle East on the presentation with acute coronary syndrome in very young patients.

We describe the baseline characteristics, management, and outcomes of acute coronary syndrome (ACS) in patients of age ≤ 40 in the Gulf region of the Middle East. We studied 8176 hospitalized patients (≤ 40 years) with ACS. Ten percent (805) of the recruited patients were ≤ 40 years. The mean age was 37 years and 89% were males. The prevalence of smoking and diabetes in the young patients was high (58% and 21%, respectively). The most common ACS was ST elevation myocardial infarction. Younger patients were more aggressively treated with more frequent use of glycoprotein inhibitors, thrombolytics, and primary percutaneous coronary intervention. They had less in-hospital heart failure, left ventricular dysfunction, shock, stroke, and low rate of in-hospital mortality (1%). Measures to combat the rising prevalence of diabetes and smoking are needed.

Early stroke following acute myocardial infarction: incidence, predictors and outcome in six Middle-Eastern countries.

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.

Initial hospital pulse pressure and cardiovascular outcomes in acute coronary syndrome.

BACKGROUND: The association between admission pulse pressure (PP) and cardiovascular outcomes in acute coronary syndrome (ACS) is not well defined. AIM: To explore the prognostic value of initial PP in ST-segment elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). METHODS: Over a 5-month period in 2007, 6704 consecutive patients with ACS were categorized into five groups according to initial PP: P1, PP ≤0; P2, PP 31-40; P3, PP 41-50; P4, PP 51-60; P5, PP>60mmHg. Patient characteristics and in-hospital outcomes were analysed. RESULTS: Mean PP was lower in men versus women (55±19 vs. 61±22), young versus old (53±17 vs. 59±21), STEMI vs. NSTE-ACS (51±18 vs. 60±18) and patients who died versus survived (46±22 vs. 57±19mmHg) (P<0.001 for all). Most patients with low PP had a high Global Registry of Acute Coronary Events risk score. Compared with P5, crude odds ratios (ORs) (95% confidence intervals) for death were: P1, 9 (5.78-13.35); P2, 3 (1.71-4.06); P3, 1.5 (1.01-2.49); P4, 0.90 (0.51-1.58). After adjustment, low PP was associated with high mortality and stroke rates in ACS (adjusted ORs 7.5 [3.77-14.72] and 4.5 [1.20-18.88], respectively), high rates of recurrent ischaemia in NSTE-ACS (adjusted OR 2.8 [1.52-5.22]) and a high heart failure rate in STEMI (adjusted OR 2.1 [1.18-3.76]). Women with low PP had a higher mortality rate than men. CONCLUSION: In ACS, all blood pressure variables were significantly correlated. Low PP was an independent predictor for stroke and mortality in overall ACS. Although PP was not superior to systolic blood pressure, only low PP was an independent predictor for recurrent ischaemia in NSTE-ACS.

Clinical characteristics and outcomes of patients with acute coronary syndrome and prior coronary artery bypass grafting in a large middle eastern cohort.

BACKGROUND: Acute Coronary Syndrome (ACS) can occur in patients with prior coronary artery bypass grafting (CABG). In the Gulf Registry of acute coronary events (Gulf RACE), we identified the clinical characteristics and in-hospital outcomes of these patients. METHODS: Clinical characteristics and in-hospital outcomes for 461 ACS patients with prior CABG are compared to 7715 ACS patients without prior CABG enrolled from 64 hospitals in 6 Gulf countries over a 6-month period. RESULTS: The overall incidence of ACS with prior CABG was 5.6% out of 8176 patients. The ACS with prior CABG were older (63 vs 55 years, P<0.0001), had more history of diabetes (62.3 vs 37.6%, P <0.0001), dyslipidemia (70.3 vs 29.5%, P<0.0001), and hypertension (75.7 vs 47.8%, P<0.0001) compared with the non-CABG group. They presented more frequently with dyspnea (14.8 vs 9.5%, P<0.0005), non-ST segment elevation myocardial infarction (41.4 vs 31.6%, P<0.0001) and echocardiographic evidence of left ventricular dysfunction (49.4 vs 29.8%, P<0.0001) than ACS without prior CABG. They had a complicated in-hospital course with more recurrent ischemia (13.9 vs 9.3%, P=0.0011), heart failure (24.1 vs 15.7%), and stroke (2.2 vs 0.6%) compared with those without CABG. The in-hospital mortality rate was 5.6% in the CABG group compared with 3.5% in the ACS without prior CABG group. After adjusting for confounders, prior CABG was independently associated with recurrent ischemia and shock, more in patients presenting with ST elevation than non-ST elevation ACS. CONCLUSIONS: Patients with ACS and prior CABG are a high-risk group with poor outcomes irrespective of their older age and comorbidities. They should be identified and treated differently to improve their outcomes.

Impact of diabetic status on the hyperglycemia-induced adverse risk of short term outcomes in hospitalized patients with acute coronary syndromes in the Middle East: findings from the Gulf registry of Acute Coronary Events (Gulf RACE).

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.

Occlusion of Fontan fenestrations using Amplatzer septal occluder.

The objective of the study is to assess efficacy and safety of the Amplatzer septal device for percutaneous occlusion of Fontan fenestration. Fenestration improves postoperative outcomes in children undergoing Fontan repair. Many of these fenestrations close spontaneously; persistent fenestrations ultimately cause desaturation and can be a potential cause of paradoxical embolism. This is a retrospective review of 26 consecutive patients who underwent transcatheter closure of Fontan fenestration in a tertiary cardiac center in Kuwait. After assessment of hemodynamic suitability for fenestration closure, appropriate balloon sizing of fenestration was obtained. The median age was 9.2 years (range = 1.5-18.3 years). Occlusion was accomplished using a 4-7 ml single Amplatzer septal device in 12 patients and 8-13 ml devices in the other 13 patients; 2 devices were deployed in one patient. Median fluoroscopic and procedure times were 22 and 143.5 min, respectively. One immediate complication was the embolization and successful retrieval of the Amplatzer duct occluder. The fenestration was subsequently occluded by Amplatzer septal device. A 100% occlusion rate of fenestration was achieved in both lateral tunnel and extracardiac conduit types of Fontans. Mean (SD) arterial oxygen saturation increased from 84.7% (4.7) to 95.2% (1.7, P < 0.001) 10 min after deployment of the occluder; Fontan mean circuit pressure had a minimal acceptable increment from 12.9 mmHg (3.2) to 14.6 mmHg (2.6, P < 0.001). No complications or device failures were seen during follow up. The Amplatzer septal occluder device is effective in closing both Fontan fenestrations. Longer single or dual anti-platelet therapy may be considered to prevent thrombotic events. Long-term outpatients follow up with transthoracic echocardiographic monitoring for systemic venous congestion or thrombosis is warranted.

Iatrogenic cyanosis and clubbing: 25 years of chronic hypoxia after the repair of an atrial septal defect.

A case of sinus venosus atrial septal defect repair of the inferior vena caval type with an unintentional diversion of the inferior vena caval blood to the left atrium is reported. Long-standing, anatomical, right-to-left shunting with cyanosis and hypoxia are associated with systemic and cerebrovascular complications. Cardiac risks depend on the presence or absence of pulmonary hypertension, the associated hematological abnormalities and the degree of anatomical, right-to-left shunting. Cardiac magnetic resonance imaging clarified the etiology of the unexplained cyanosis and delineated the surgical anatomy.