Sodium-glucose cotransporter-2 inhibitors improve cardiovascular outcomes post-acute coronary syndrome complicated by acute heart failure.

Background: Acute coronary syndrome (ACS) remains a risk factor for heart failure (HF). Therefore, we aimed to assess the cardioprotective role of sodium-glucose cotransporter-2 (SGLT2) inhibitors post-ACS in patients with acute HF (AHF) and diabetes. Methods: We conducted a retrospective observational cohort study employing propensity score matching. This study involved patients with diabetes admitted with ACS complicated by AHF, defined as either new clinical HF requiring diuretics during the index admission or having an ejection fraction (EF) of <40%. The study population was divided into two groups; (1) SGLT2 inhibitor users and (2) SGLT2 inhibitor non-users. The Cox proportional hazard regression analysis was used to evaluate the outcomes. Results: A total of 465 patients (93% male; mean age, 55 ± 10 years) were included in this study. Using a 1 : 1 propensity score matching, 78 patients were included per arm with an absolute standardized difference of <0.1 for all baseline characteristics. The use of SGLT2 inhibitors resulted in lower composite outcomes of ACS, HF hospitalization, and all-cause mortality at 1 month and 12 months [1 month: 2.6% vs. 11.5%, HR = 0.20 (0.04-0.94), p = 0.041; 12 months: 14.1% vs. 23.1%, HR = 0.46 (0.22-0.99), p = 0.046]. Conclusion: The findings suggest that SGLT2 inhibitors may confer cardioprotective effects in ACS-induced AHF, thereby widening the spectrum for indications of SGLT2 inhibitors.

Acute thrombotic occlusion involving three coronary arteries. A unique association with COVID-19 pneumonia.

Key Clinical Message: Respiratory viruses, particularly COVID-19, can be associated with severe cases of myocardial infarction (MI). Physicians should have a low threshold for MI in COVID-19 patients who present with persistent chest pain as MI in rapidly deteriorating cases can be missed. Prompt response includes both timely diagnosis and swift treatment. Abstract: The coronavirus disease 2019 (COVID-19) is associated with coronary artery thrombosis. Many cases of single-vessel and few cases of two-vessel thrombosis were reported. Herein, we report a unique association in a middle-aged man diagnosed with COVID-19 and presented later with acute myocardial infarction causing cardiogenic shock. The patient was found to have three-vessel thrombosis.

Predictors of 30-Day Re-admission in Cardiac Patients at Heart Hospital, Qatar.

Background: Cardiovascular disease patients are more likely to be readmitted within 30 days of being discharged alive. This causes an enormous burden on health-care systems in terms of poor care of patients and misutilization of resources. Aims and Objective: This study aims to find out the risk factors associated with 30-day readmission in cardiac patients at Heart Hospital, Qatar. Methods: A total of 10,550 cardiac patients who were discharged alive within 30 days at the heart hospital in Doha, Qatar, from January 2015 and December 2019 were analyzed. The bootstrap method, an internal validation statistical technique, was applied to present representative estimates for the population. Results: Out of the 10,550 cardiac patients, there were 8418 (79.8%) index admissions and 2132 (20.2%) re-admitted at least once within 30 days after the index admission. The re-admissions group was older than the index admission group (65.6 ± 13.2 vs. 56.0 ± 13.5, P = 0.001). Multinomial regression analysis showed that females were 30% more likely to be re-admitted than males (adjusted odds ratio [aOR] 1.30, 95% confidence interval [CI]: 1.11-1.50, P = 0.001). Diabetes (aOR 1.36, 95% CI: 1.20-1.53, P = 0.001), chronic renal failure (aOR 1.93, 95% CI: 1.66-2.24, P = 0.001), previous MI (aOR 3.22, 95% CI: 2.85-3.64, P = 0.001), atrial fibrillation (aOR 2.17, 95% C.I. : 1.10-2.67, P = 0.01), cardiomyopathy (aOR 1.72, 95% CI 1.47-2.02, P = 0.001), and chronic heart failure (aOR 1.56, 95% C.I.: 1.33-1.82, P = 0.001) were also independent predictors for re-admission in the regression model. C-statistics showed these variables could predict 82% accurately hospital readmissions within 30 days after being discharged alive. Conclusion: The model was more than 80% accurate in predicting 30-day readmission after being discharged alive. The presence of five or more risk factors was found to be crucial for readmissions within 30 days. The study may help design interventions that may result in better outcomes with fewer resources in the population.

Smoking in Acute Myocardial Infarction Patients: Observations from a Registry Heart Hospital, Qatar.

Introduction: Studies from the US and Europe showed a decline in smoking among patients with acute myocardial infarction (AMI), but limited data are available from the Middle East. In this study, we describe the temporal trend in the prevalence, associated risk factors, and outcomes of smoking among patients with AMI in Qatar. Materials and Methods: A total of 27,648 AMI patients were analyzed from the cardiology registry at Heart Hospital, Doha, Qatar. This spans from January 1991 to May 2022. Results: Of the total, 13,562 patients (49.1%, 95% confidence interval [CI]: 48%-50%) were smokers, with a clear majority of males (98.5%). Smoking habit was found to decrease in AMI patients with increasing age (age 51-60 years, adjusted odds ratio [OR]: 0.71, 95% CI: 0.67-0.76, P = 0.001, and age ≥61 years, adjusted OR: 0.45, 95% CI: 0.42-0.48, P = 0.001, in comparison to age ≤50 years). Smoking was associated with a lower risk of inhospital mortality (adjusted OR: 0.61, 95% CI: 0.54-0.70, P = 0.001), but triglyceride, obesity, and old myocardial infarction risk factors were associated with a higher risk. A decreasing trend in current smoking habits in each quantile of the 1996-2000 year (adjusted OR: 0.82, 95% CI: 0.71-0.93, P = 0.001), 2001-2005 year (adjusted OR: 0.70, 95% CI: 0.62-0.80, P = 0.001), 2006-2010 year (adjusted OR: 0.75, 95% CI: 0.67-0.84, P = 0.001), 2011-2015 year (adjusted OR: 0.48, 95% CI: 0.42-0.54, P = 0.001), 2016-2020 year (adjusted OR: 0.48, 95% CI: 0.43-0.54, P = 0.001), and ≥2021 year (adjusted OR: 0.46, 95% CI: 0.40-0.53, P = 0.001) was observed in comparison to the quantile 1991-1995 year. Similar results were also observed in the young population (age ≤50 years) including the non-Qataris, who had 25% more smokers in comparison to Qatari nationals. Conclusion: Smoking trended down significantly; however, it remained prevalent in 50% of patients among AMI patients. Smokers were younger, with fewer traditional risk factors, and had lower inhospital mortality.

Revisiting nitrates use in pre-shock state of contemporary cardiogenic shock classification.

Patients at each shock stage may behave and present differently with a spectrum of shock severity and adverse outcomes. Shock severity, shock aetiology, and several factors should be integrated in management decision-making. Although the contemporary shock stages classification provided a standardized shock severity assessment, individual agents or management strategy has not yet been studied in the context of each shock stage. The pre-shock state may comprise a wide range of presentations. Nitrate therapy has potential benefit in myocardial infarction and acute heart failure. Herein, this review aims to discuss the potential use of nitrate therapy in the context of the pre-shock state or stage B of the contemporary shock classification given its various presentations.

Has low-dose intracoronary thrombolysis gained ground in primary percutaneous intervention?

Reducing thrombus burden would improve patient's outcomes. Low-dose intracoronary thrombolytic agent administration has been considered to improve myocardial microcirculation, cardiac function, and major adverse cardiovascular events in patients presenting with ST-segment elevation myocardial infarction and high thrombus burden. This paper discusses published meta-analyses on intracoronary thrombolysis in primary percutaneous intervention.

Cost-Effectiveness Analysis of Sacubitril/Valsartan for Reducing the Use of Implantable Cardioverter-Defibrillator (ICD) and the Risk of Death in ICD-Eligible Heart Failure Patients with Reduced Ejection Fraction.

Although previous cost-effectiveness evaluations of sacubitril/valsartan have demonstrated cardiovascular and economic benefits in heart failure patients with reduced ejection fraction (HFrEF), whether sacubitril/valsartan is cost-effective for reducing the need for implantable cardioverter-defibrillator (ICD) implantation and the risk of death in ICD-eligible patients has not been investigated in patients with HFrEF. Herein, we evaluated the cost-effectiveness of sacubitril/valsartan versus standard of care in reducing the need for ICD implantation and the death rate in HFrEF. A Markov model was developed from the Qatari hospital perspective, comprised of 'survival' and 'death' health states, and was based on 1-monthly Markovian cycles, a 20-years follow-up horizon, and a 3% discount rate. The model inputs were obtained from the literature and local sources. Sacubitril/valsartan resulted in a relative increase of 0.04 quality-adjusted life year (QALY) and 0.67 years of life lived (YLL)/person, with an incremental cost increase of QAR13,952 (USD3,832). Sacubitril/valsartan was associated with incremental cost effectiveness ratio of QAR341,113 (USD93,687)/QALYs gained and QAR24,431 (USD6,710)/YLL. Sensitivity analyses confirmed robustness, with the cost-effectiveness maintained in ≥96.5% of simulated cases. To conclude, sacubitril/valsartan is a cost-effective alternative to standard care against QALY gained and YLL in reducing the need for an ICD therapy and the rate of death among ICD-eligible HFrEF patients.

Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials.

BACKGROUND: Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden. OBJECTIVES: This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS: A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)). RESULTS: Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85-7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60-8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48-11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13-0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes. CONCLUSIONS: Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.

A Comparative Study of High-intensity Rosuvastatin Versus Atorvastatin Therapy Post-acute Coronary Syndrome Using Real-world Data.

A high-intensity statin is recommended for the secondary prevention of cardiovascular diseases (CVD). However, real-world evidence of the effectiveness of rosuvastatin following acute coronary syndrome (ACS) is scarce. This retrospective cohort study included patients diagnosed with ACS to compare between the 2 high-intensity statin therapies (rosuvastatin vs atorvastatin) in terms of a primary composite outcome of CVD-associated death, non-fatal ACS, and non-fatal stroke at 1 month and 12 months post discharge. The primary effectiveness outcome did not differ between the 2 groups at 1 month (1.3% vs 1%; aHR = 1.64, 95% CI 0.55-4.94, P= 0.379) and at 12 months (4.8% vs 3.5%; aHR = 1.48, 95% CI 0.82-2.67, P= 0.199). Similarly, the 2 groups had comparable safety outcomes. In conclusion, the use of high-intensity rosuvastatin compared to high-intensity atorvastatin therapy in patients with ACS had resulted in comparable cardiovascular effectiveness and safety outcomes.

Prolonged ventricular pause associated with ticagrelor use: A case report.

CASE: We report a case of a 76-year-old female who presented with non-ST elevation myocardial infarction and developed a 22-second ventricular pause with ticagrelor that did not recur after shifting to clopidogrel. Based on the Naranjo algorithm, the likelihood that our patient's prolonged ventricular pause was due to ticagrelor exposure was probable. CONCLUSION: Ticagrelor use is associated with prolonged ventricular pauses, warranting close monitoring, particularly during the first week of therapy.

Acute Myocardial Infarction Attributed to Coronary Artery Embolism in a Patient with Atrial Fibrillation Secondary to Thyrotoxicosis - An Underrecognized Entity: A Case Report and Literature Review.

Nonatherosclerotic causes of acute myocardial infarction (MI) are infrequent, with atrial fibrillation as the most common etiology in cases of embolic MI. This entity, however, along with other causes of coronary embolus remains underappreciated as a probable cause of acute coronary syndromes.[1] Our case delineates a rare presentation of STEMI due to cardioembolic origin secondary to atrial fibrillation in a patient with thyrotoxicosis, previously undiagnosed to have an abnormal cardiac rhythm.

The significance of upright T wave in lead V1 in predicting myocardial ischemia A literature review.

Chest pain is still representing one of the most common and serious presentations to the emergency department worldwide. ECG is a crucial tool in evaluating patients with chest pain; however, only around 50% of patients with acute coronary syndrome (ACS) will have a diagnostic ECG upon their presentation; the rest may either have a completely normal ECG or what is called nonspecific ST segment and T wave (NSSTTW) changes, hence it is essential to recognize the subtle ECG changes and know its significance. One of the ECG changes that can be easily missed is when the T wave in V1 is upright, especially when it is either a Tall Upright T wave (TTV1) or a New Tall Upright T-wave (NTTV1). Although upright T wave in lead V1 can be a normal variant, it has been linked in a few studies and observations to cardiovascular disease, especially myocardial ischemia. In this article, we are trying to highlight the importance of this subtle ECG change in predicting cardiovascular disease through a concise review of the available evidence on this topic.

Medications adherence post-primary percutaneous coronary intervention in acute myocardial infarction: A population-based cohort study.

WHAT IS KNOWN AND OBJECTIVE: The use of medications for secondary prevention is the cornerstone in the treatment of coronary artery disease (CAD). However, adherence to these medications is still suboptimal worldwide. This retrospective observational study aimed to assess the adherence to post-percutaneous coronary intervention (PCI) medications, along with predictors of non-adherence. METHODS: We conducted a retrospective observational cohort study to assess the adherence to post-PCI medications by determining the rate of prescription refills for 12 months after discharge among STEMI patients, as well as predictors of non-adherence. Adherence was assessed by medication availability 80% of the time monitored by the prescription refills rate for 1 year post-discharge. RESULTS AND DISCUSSION: A total of 1334 patients who presented with STEMI and underwent primary PCI were included in our retrospective analysis. The majority of patients included were male (96%) with a mean age of 51 ± 10.2 years. The overall adherence rate for all medications was only 28.4%, with an individual adherence rate of 50.5% for aspirin, 49.9% for P2 Y12 inhibitors, 48.1% for statins, 39.6% for beta-blockers and 42.9% for angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB). Factors that increased the likelihood of non-adherence were prolonged hospital length of stay and getting the medications with charge (aOR = 1.94, 95% CI 1.1-3.3; p-value = 0.017, aOR = 1.87, 95% CI 1.1-3.3; p-value = 0.029, respectively), while having a regular follow-up after discharge and attending the first clinic appointment were significantly associated with decreased likelihood of non-adherence (aOR = 0.01, 95% CI 0.004-0.04; p-value < 0.001, aOR = 0.06, 95% CI 0.03-0.1; p-value < 0.001, respectively). WHAT IS NEW AND CONCLUSION: The adherence rate to post-PCI medications among patients with STEMI was relatively low; however, attending the first outpatient clinic appointment and having a regular follow-up reduced the likelihood of non-adherence.

Clinical outcomes of high-intensity doses of atorvastatin in patients with acute coronary syndrome: A retrospective cohort study using real-world data.

AIMS: To compare the effectiveness and safety of 2 high-intensity atorvastatin doses (40 mg vs 80 mg) among acute coronary syndrome (ACS) patients. METHODS: This retrospective observational cohort study using real-world data included patients admitted with ACS to the Heart Hospital in Qatar between 1 January 2017 and 31 December 2018. The primary endpoint was a composite of cardiovascular disease-associated death, nonfatal ACS and nonfatal stroke. Cox proportional hazard regression analysis was used to determine the association between the 2 high-intensity atorvastatin dosing regimens and the primary outcome at 1 month and 12 months postdischarge. RESULTS: Of the 626 patients included in the analyses, 475 (75.9%) received atorvastatin 40 mg, while 151 (24.1%) received atorvastatin 80 mg following ACS. Most of the patients were Asian (73%), male (97%) with a mean age of 50 years and presented with ST-elevation myocardial infarction (60%). The incidence of the primary effectiveness outcome did not differ between the atorvastatin 40-and 80-mg groups at 1 month (0.8 vs 1.3%; adjusted hazard ratio = 0.59, 95% confidence interval 0.04-8.13, P = .690) and at 12 months (3.2 vs 4%; adjusted hazard ratio = 0.57, 95% confidence interval 0.18-1.80, P = .340). Similarly, the use of the 2 doses of atorvastatin resulted in comparable safety outcomes, including liver toxicity, myopathy and rhabdomyolysis with an event rate of <1% in both groups. CONCLUSION: The use of atorvastatin 40 mg in comparison to atorvastatin 80 mg in patients with ACS resulted in similar cardiovascular effectiveness and safety outcomes.

Clinical Profile, Management, and Outcome in Patients With Out-of-Hospital Cardiac Arrest and ST Segment Elevation Myocardial Infarction: Insights From a 20-Year Registry.

AIM OF THE STUDY: We studied the clinical profile, management, and outcomes of patients with out-of-hospital cardiac arrest (OHCA) with and without ST-elevation myocardial infarction (STEMI). METHODS: Retrospective analysis of the 20-year registry data (January 1991- June 2010) was conducted on patients with cardiac disease hospitalized at Hamad General Hospital and Qatar Heart Hospital, Doha, Qatar. RESULTS: A total of 987 patients with OHCA were admitted to the cardiology department during the study period; among them, 296 (30%) patients had STEMI. Compared to the patients with OHCA without STEMI, the patients who had OHCA with STEMI were younger (53 ± 13 vs 58 ± 16 years; P = .001), more likely to be male (78% vs 34%; P = .001), smokers (35% vs 14%) but less likely to have hypertension (30% vs 48%; P = .001), diabetes (32% vs 47%, P = .001), and chronic renal failure (3.4% vs 9%; P = .002). The use of thrombolytic treatment in patients with STEMI increased from 21.6% (period 1991-1095) to 44.4% (period 2006-2010); P = .04. CONCLUSION: Percutaneous coronary intervention had increased significantly during the last quarter of the study. There was a decline in the in-hospital mortality among patients with STEMI during the last quarter of the study.

Clinical profile, management, and outcome in patients with out of hospital cardiac arrest: insights from a 20-year registry.

BACKGROUND: There is limited information regarding the clinical characteristics and outcome of out of hospital cardiac arrest (OHCA) in Middle Eastern patients. The aim of this study was to evaluate clinical characteristics, treatment, and outcomes in patients admitted following OHCA at a single center in the Middle East over a 20-year period. METHODS: The data used for this hospital-based study were collected for patients hospitalized with OHCA in Doha, Qatar, between 1991 and 2010. Baseline clinical characteristics, in-hospital treatment, and outcomes were studied in comparison with the rest of the admissions. RESULTS: A total of 41,453 consecutive patients were admitted during the study period, of whom 987 (2.4%) had a diagnosis of OHCA. Their average age was 57±15 years, and 72.7% were males, 56.5% were Arabs, and 30.9% were South Asians. When compared with the rest of the admissions taken as a reference, patients with OHCA were more likely to have diabetes mellitus (42.8% versus 39.1%, respectively, P=0.02), prior myocardial infarction (21.8% versus 19.2%, P=0.04), and chronic renal failure (7.4% versus 3.9%, P=0.001), but were less likely to have dyslipidemia (16.9% versus 25.4%, P=0.001). Further, 52.6% of patients had preceding symptoms, the most common of which was chest pain (27.2%) followed by dyspnea (24.8%). An initially shockable rhythm (ventricular fibrillation or ventricular tachycardia) was present in 25.1% of OHCA patients, with ST segment elevation myocardial infarction documented in 30.0%. Severely reduced left ventricular systolic function (ejection fraction ≤35%) was present in 53.2% of OHCA patients; 42.9% had cardiogenic shock requiring use of inotropes at presentation. An intra-aortic balloon pump was inserted in 3.6% of cases. Antiarrhythmic medications were used in 27.4% and thrombolytic therapy in 13.9%, and 10.8% underwent a percutaneous coronary procedure (coronary angiography ± percutaneous coronary intervention). The in-hospital mortality rate was 59.8%. CONCLUSION: OHCA was associated with higher incidences of diabetes, prior myocardial infarction, and chronic kidney disease as compared with the remaining admissions. Approximately half of the patients had no preceding symptoms. In-hospital mortality was high (59.8%), but similar to the internationally published data.