Advanced heart failure therapies in the Eastern Mediterranean Region: current status, challenges, and future directions.

While there has been a global decrease in rates of heart failure (HF) prevalence between 1990 and 2019, the Eastern Mediterranean region (EMR) is experiencing an increase. In 2019, approximately 1,229,766 individuals lived with moderate to severe HF in the EMR. Despite the growth in the utilization of advanced heart failure (AHF) therapies in the EMR in the past two decades, current volumes are yet to meet the growing AHF burden in the region. Heart transplantation (HT) volumes in EMR have grown from 9 in the year 2000 to 179 HTs in 2019. However, only a few centers provide the full spectrum of AHF therapies, including durable mechanical circulatory support (MCS) and HT. Published data on the utilization of left ventricular assist devices (LVAD) in the EMR are scarce. Notably, patients undergoing LVAD implantation in the EMR are on average, 13 year younger, and more likely to present with critical cardiogenic shock, as compared to their counterparts in the Western world. Furthermore, AHF care in the region is hampered by the paucity of multidisciplinary HF programs, inherent costs of AHF therapies, limited access to short and long-term MCS, organ shortage, and lack of public awareness and acceptance of AHF therapeutics. All stakeholders in the EMR should work together to strategize tackling the challenging AHF burden in the region.

Red Flags in Acute Myocarditis.

Acute myocarditis is an inflammatory disease of the heart that may occur in the setting of infection, immune system activation or exposure to certain drugs. Often, it is caused by viruses, whereby the clinical course is usually benign; however, it may also present with rapidly progressive fulminant myocarditis, which is associated with high morbidity and mortality. This review highlights the critical red flags - from the clinical, biochemical, imaging and histopathological perspectives - that should raise the index of suspicion of acute myocarditis. We also present an illustrative case of a young female patient with rapidly progressive cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation as a bridge to orthotopic heart transplantation. The patient showed no clinical or echocardiographic recovery signs and eventually underwent orthotopic heart transplantation. Furthermore, we elaborate on the classifications of acute myocarditis based on clinical presentation and histopathology classifications, focusing on identifying key red flags that will inform early diagnosis and appropriate management in such challenging cases.

Infectious aortic aneurysms: A case report and review of cases from the Middle East and North Africa (MENA) region.

An infectious aortic aneurysm is a rare disease entity. We report a challenging case of a 29-year-old male presenting with chest pain and constitutional symptoms. The patient was found to have three pseudoaneurysms of the aorta on imaging, significant pathological findings of necrotizing granulomatous lymphadenitis from a supraclavicular lymph node biopsy, and a highly suggestive clinical picture of tuberculous aortitis. He was referred to vascular surgery for intervention and discharged on antituberculous therapy for 6 months. To the best of our knowledge, only five cases of tuberculous aortic aneurysms have been reported from the Middle East and North Africa (MENA) region, all with favorable outcomes. A high index of suspicion, early detection, and prompt intervention are essential in managing such cases.

The prevalence of cardiorenal anemia syndrome among patients with heart failure and its association with all-cause hospitalizations: a retrospective single-center study from the Middle East.

Background and aim: Little is known about the burden of cardiorenal syndrome (CRS) and cardiorenal anemia syndrome (CRAS) in the Middle East Region. Furthermore, whether the occurrence rates of CRAS differ across heart failure (HF) phenotypes is not widely investigated. We aimed to examine the prevalence of CRS and CRAS in patients with HF, compare characteristics of patients with CRAS-HFrEF vs. CRAS-HFpEF, and investigate anemia association with 1-year all-cause hospitalizations. Methods: HF patients who visited a multidisciplinary HF clinic at a single center between 10-2015 and 06-2022 (n = 968) were retrospectively included. Differences in rates of CRAS prevalence, and patients' characteristics of those with CRAS-HFrEF vs. CRAS-HFpEF were determined using appropriate testing methods. Generalized estimating equation (GEE) models were used to determine if anemia was associated with higher rates of hospitalization. Results: CRS was prevalent in 34.4% of subjects, while 25.3% had CRAS. CRAS prevalence rates among patients with HFpEF vs. HFrEF were comparable (27.2% vs. 24.2%, p = 0.3). Compared to patients with HFrEF-CRAS, those with HFpEF-CRAS were more likely females (p < 0.001), had a higher burden of hypertension (p = 0.01), and lower hemoglobin (p = 0.02). In an adjusted GEE model, anemia was associated with an average increase of 1.8 admissions in CRS patients (p = 0.015). Conclusion: In patients with HF, 1 in 3 patients presented with CRS, and 1 in 4 patients had CRAS. The prevalence of CRAS was comparable among those HFpEF and HFrEF. Anemia was associated with an increased rate of 1-year all-cause hospitalization in CRS patients.

The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990-2019.

It has been estimated that in the next decade, IHD prevalence, DALYs and deaths will increase more significantly in EMR than in any other region of the world. This study aims to provide a comprehensive description of the trends in the burden of ischemic heart disease (IHD) across the countries of the Eastern Mediterranean Region (EMR) from 1990 to 2019. Data on IHD prevalence, disability-adjusted life years (DALYs), mortality, DALYs attributable to risk factors, healthcare access and quality index (HAQ), and universal health coverage (UHC) were extracted from the Global Burden of Disease (GBD) database for EMR countries. The data were stratified based on the social demographic index (SDI). Information on cardiac rehabilitation was obtained from publications by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), and additional country-specific data were obtained through advanced search methods. Age standardization was performed using the direct method, applying the estimated age structure of the global population from 2019. Uncertainty intervals were calculated through 1000 iterations, and the 2.5th and 97.5th percentiles were derived from these calculations. The age-standardized prevalence of IHD in the EMR increased from 5.0% to 5.5% between 1990 and 2019, while it decreased at the global level. In the EMR, the age-standardized rates of IHD mortality and DALYs decreased by 11.4% and 15.4%, respectively, during the study period, although both rates remained higher than the global rates. The burden of IHD was found to be higher in males compared to females. Bahrain exhibited the highest decrease in age-standardized prevalence (-3.7%), mortality (-65.0%), and DALYs (-69.1%) rates among the EMR countries. Conversely, Oman experienced the highest increase in prevalence (14.5%), while Pakistan had the greatest increase in mortality (30.0%) and DALYs (32.0%) rates. The top three risk factors contributing to IHD DALYs in the EMR in 2019 were high systolic blood pressure, high low-density lipoprotein cholesterol, and particulate matter pollution. The trend analysis over the 29-year period (1990-2019) revealed that high fasting plasma glucose (64.0%) and high body mass index (23.4%) exhibited increasing trends as attributed risk factors for IHD DALYs in the EMR. Our findings indicate an increasing trend in the prevalence of IHD and a decrease in mortality and DALYs in the EMR. These results emphasize the need for well-planned prevention and treatment strategies to address the risk factors associated with IHD. It is crucial for the countries in this region to prioritize the development and implementation of programs focused on health promotion, education, prevention, and medical care.

Outcomes of Transcatheter Aortic Valve Replacement in the United Arab Emirates: Real-world, Single-centre Experience from an Emerging Programme.

Background: Data on outcomes of transcatheter aortic valve replacement (TAVR) in the Middle East, particularly in the United Arab Emirates (UAE), are limited. Whether centres with a low volume of patients requiring the procedure can achieve similar outcomes as those reported in pivotal clinical trials remains unclear. This study evaluates procedural outcomes of patients undergoing TAVR in a newly established programme in the UAE. Methods: Procedural outcomes of consecutive patients who underwent transfemoral TAVR at a single centre in the UAE between January 2016 and November 2021 were compared with those at centres in the lowest quartile (Q1) of procedural volume in the Transcatheter Valve Therapy Registry, which covers centres in the US. Results: Among the 183 patients included in the study, the median age was 76 years (interquartile range [IQR] 71-82), and 42.1% of patients were women, with a median Society of Thoracic Surgeons predicted risk of mortality score of 4.6 (IQR 2.9-7.5). Most of the patients (93.3%) received a balloon-expandable valve. All-cause death within 30 days, stroke and major vascular complications occurred in 0.6%, 0.6% and 2.2% of patients, respectively, compared with 3.1%, 2.2% and 4% in patients treated at Q1 hospitals. Conclusion: Patients undergoing transfemoral TAVR at an emerging centre in the Middle East had favourable outcomes compared with those performed at Q1 hospitals in the US. These findings suggest that careful patient selection for TAVR is critical and may help optimise patient outcomes, especially when procedural volumes are low.

The Pandemic of Coronary Heart Disease in the Middle East and North Africa: What Clinicians Need to Know.

PURPOSE OF REVIEW: Coronary heart disease (CHD) is the leading cause of morbidity, mortality, and disability in the Middle East and North Africa (MENA). While the prevention, diagnosis, and management of CHD have been detailed in international guidelines, we aimed in this review to quantify the pandemic of CHD in the MENA region and highlight regional patient characteristics, clinical challenges, and future directions to optimize CHD care in the region. RECENT FINDINGS: Patients with CHD in the MENA feature younger age at presentation and worse prognosis in women. Despite the high burden of CHD risk factors, many of these factors remain underrecognized, undertreated, and uncontrolled. Additionally, CHD care is hampered by poor patient awareness, inefficient preventive strategies, and limited access to guideline-recommended therapeutics. All stakeholders involved in healthcare should work together to develop and execute strategies aimed at tackling the burden of CHD in the MENA.

Trends in the burden and determinants of hypertensive heart disease in the Eastern Mediterranean region, 1990-2019: an analysis of the Global Burden of Disease Study 2019.

Background: Hypertensive heart disease (HHD), one of the end-organ damage consequences of hypertension, is an important public health issue worldwide. Data on the HHD burden in the Eastern Mediterranean region (EMR) are scarce. We aimed to investigate the burden of HHD in the EMR, its member countries, and globally from 1990 to 2019. Methods: We used 2019 Global Burden of Disease (GBD) data to report the HHD age-standardised prevalence, disability adjusted life years (DALYs), years of life lost (YLLs), and mortality, as well as HHD risk factors attribution percent with their 95% uncertainty interval (UI). Global data are reported alongside EMR data, and its 22 respective countries. We compared the burden of HHD by socio-demographic index (SDI), sex, age groups, and countries. Findings: The age-standardised prevalence rate (per 100,000 population) of HHD was higher in the EMR (281.7; 95% UI: 204.5-383.4) in 2019, compared with the global prevalence (233.8; 95% UI: 170.5-312.9). The EMR age-standardised DALYs (per 100,000 population) for HHD in 2019 was 561.9 (361.0-704.1), compared with 268.2 (204.6-298.1) at the global level. There was an increase in HHD prevalence, reduction in mortality, and DALYs between 1990 and 2019 (4.01%, -7.6%, and -6.5%, respectively) in EMR. Among EMR countries, the highest versus lowest rates of age-standardised prevalence, mortality, and DALYs in 2019 [estimate (95% UI)] were in Jordan [561.62 (417.9-747.6)] versus Saudi Arabia [94.9 (69.5-129.0)]; Afghanistan [74.5 (23.7-112.3)] versus Saudi Arabia [4.3 (3.3-5.9)]; and Afghanistan [1374.1 (467.2-2020.7)] versus Qatar [87.11 (64.40-114.29)], respectively. Interpretation: HHD remains a significant problem in the EMR, with a higher burden than global levels. Serious efforts toward high-quality management and prevention are strongly recommended. Based on this study, our recommendation for the EMR is to adopt effective preventive strategies. For example, promoting healthy dietary patterns and prompt screening for undiagnosed HTN in public places, promoting regular blood pressure measurements at home, and creating community awareness about early detection of HTN. Funding: None.

Management of acute aortic services during the COVID-19 pandemic: a retrospective cohort study from the Middle East.

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, the authors investigated the impact of the COVID-19 pandemic on their urgent aortic program. Methods: The authors included consecutive patients presenting with TAAD (n=36) in the years 2019 and 2020 [pre-pandemic period (2019; n=16) and the pandemic era (2020; n=20)] at a tertiary care centre. Patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes, and length of stay were determined retrospectively using chart review and were compared between both years. Results: An increase occurred in the absolute number of TAAD referrals during the pandemic era. Patients were featured by younger age of presentation (pre-pandemic group: 47.6±18.7, and the pandemic group: 50.6±16.2 years, P=0.6) in contrast to Western data but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital stay [20 (10.8-56) vs. 14.5 (8.5-53.3) days, P=0.5] and intensive care unit stay [5 (2.3-14.5) vs. 5 (3.3-9.3) days, P=0.4] were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference. There was no significant difference in the rates of in-hospital mortality between both groups [12.5% (2) vs. 10% (2), P=0.93]. Conclusions: Compared with the pre-pandemic era (2019), there was no difference in resource utilisation and clinical outcomes of patients presenting with TAAD during the first year of COVID-19 pandemic (2020). Structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in critical healthcare scenarios. Future studies are required to further investigate aortic care delivery during such challenging pandemics.

Sustaining Life versus Altering Life-Saving Drugs: Insights to Explain the Paradoxical Effect of Extracorporeal Membrane Oxygenation on Drugs.

There has been a substantial increase in the use of extracorporeal membrane oxygenation (ECMO) support in critically ill adults. Understanding the complex changes that could affect drugs' pharmacokinetics (PK) and pharmacodynamics (PD) is of suitable need. Therefore, critically ill patients on ECMO represent a challenging clinical situation to manage pharmacotherapy. Thus, clinicians' ability to predict PK and PD alterations within this complex clinical context is fundamental to ensure further optimal and, sometimes, individualized therapeutic plans that balance clinical outcomes with the minimum drug adverse events. Although ECMO remains an irreplaceable extracorporeal technology, and despite the resurgence in its use for respiratory and cardiac failures, especially in the era of the COVID-19 pandemic, scarce data exist on both its effect on the most commonly used drugs and their relative management to achieve the best therapeutic outcomes. The goal of this review is to provide key information about some evidence-based PK alterations of the drugs used in an ECMO setting and their monitoring.

Worldwide and Country-Specific Impact of the COVID-19 Pandemic on Heart Transplantation Volumes: A Longitudinal Analysis of 2020 and 2021.

COVID-19 pandemic hampered operational efficiency of heart transplant (HT) programs worldwide. Little is known about the global and country-specific changes in HT volumes during the pandemic years 2020-2021. We aimed to describe the global and country-level impact of the COVID-19 pandemic on HT volumes in 2020-2021. This is a cross-sectional study of the Global Observatory on Donation and Transplantation, including the years 2019-2021. Among 60 countries that reported HT data in the years 2019-2020, we analyzed 52 countries with ≥1 transplant during each year. Overall, the number of HTs decreased during 2020 by 9.3% (1.82 to 1.65 PMP). While 75% (n = 39/52) of countries experienced a decrease in HT volumes in 2020, volumes were maintained/increased in the remaining countries. Countries with maintained HT volumes had a higher organ donation rate in 2020 compared to those with decreased volumes (P = 0.03), the only significant predictor of change in HT volumes (P = 0.005). In 2021, a 6.6% recovery from the previous year's drop in global HT rate was noticed, reaching 1.76 HT PMP. Only 1 in 5 countries with reduced volumes in 2020 recovered their baseline volumes in 2021. Only 30.8% of countries with maintained volumes in 2020 had continued growth in HT volumes in 2021. The latter group encompassed the United States of America, the Netherlands, Poland, and Portugal. Further work should define underlying causes of this heterogeneity in HT volume during the pandemic. Identifying policies and practices that helped certain countries mitigate the effect of the pandemic on HT activities may help other countries during similar health crises in the future.

Implementation of a multidisciplinary inpatient heart failure service and its association with hospitalized patient outcomes: First experience from the Middle East and North Africa region.

BACKGROUND: Multidisciplinary care models have been associated with improved clinical outcomes and an increase in adherence to guideline-directed medical therapy among patients hospitalized with heart failure (HF). OBJECTIVE: This study aims to evaluate the association between the creation of a multidisciplinary inpatient HF service and patient outcomes at a tertiary care center in the Middle East/ North Africa. METHODS: We used electronic health records to retrospectively identify patients hospitalized for acute HF between June-2015 and June-2018. Patients were categorized by whether they were hospitalized before (n = 71) or after (n = 86) the implementation of a multidisciplinary HF team (HF-MDT), starting on 1/1/2017. The groups were compared for optimal use of guideline-directed medical therapy, hospital length of stay, 30-day hospital readmission, and in-hospital mortality. RESULTS: The creation of the HF-MDT was associated with significantly better adherence to GDMT at discharge (27.5% vs. 55.4%, (OR 3.3, 95% CI [1.65-6.5]), P<0.001), shorter median hospital length of stay (8, IQR [4.8 - 19] vs. 5, IQR [3- 9], P = 0.02) and a reduction in 30-day hospital readmission (26.5% vs. 11%; OR 0.3, 95% CI [0.1-0.8], P = 0.02). However, there was no difference in-hospital mortality (10.5% vs. 3.5%; OR 0.3, 95% CI [0.1-1.2], P = 0.1). CONCLUSIONS: Implementing an HF-MDT in the care of patients hospitalized with HF is associated with better adherence to GDMT on discharge, reduced hospital length of stay, and lower 30-day readmission rates. The current data support the broader adoption of dedicated HF programs in the Middle East to improve outcomes of patients with HF.

Management of Patients With Tricuspid Valve Endocarditis and Ongoing Intravenous Drug Abuse: Less Is More.

Right-sided infective endocarditis in patients with intravenous drug abuse portends a worse prognosis. Data on optimal management strategy in this situation are scarce. We describe outcomes of 2 different treatment strategies, including a patient treated conservatively with favorable intermediate-term results and another who was treated surgically and developed recurrent endocarditis. (Level of Difficulty: Intermediate.).

Early Identification and Management of Heart Failure in Patients with Diabetes Mellitus in the United Arab Emirates: A Call to Action.

Heart failure (HF) is a common and serious complication of diabetes mellitus (DM) that remains widely under-recognized. Multidisciplinary management protocols for patients with concurrent DM and HF are not widely utilized in the Middle East/Gulf region, particularly in the United Arab Emirates. Since early identification of patients with DM and HF will likely lead to initiation of therapies known to prevent adverse cardiovascular events and subsequently improve patient prognosis, we aim to highlight the importance of early recognition of HF in diabetic patients. We will also describe existing management challenges in the region, especially the lack of multidisciplinary care and emphasize the role of newer anti-diabetic therapies in preventing and treating HF. Most importantly, this call-to-action proposes a collaborative approach to the care of diabetic patients with HF involving primary care physicians, endocrinologists, and cardiologists.

An overview of radiation-induced heart disease.

Radiation therapy (RT) has dramatically improved cancer survival, leading to several inevitable complications. Unintentional irradiation of the heart can lead to radiation-induced heart disease (RIHD), including cardiomyopathy, pericarditis, coronary artery disease, valvular heart disease, and conduction system abnormalities. Furthermore, the development of RIHD is aggravated with the addition of chemotherapy. The screening, diagnosis, and follow-up for RIHD in patients who have undergone RT are described by the consensus guidelines from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). There is compelling evidence that chest RT can increase the risk of heart disease. Although the prevalence and severity of RIHD are likely to be reduced with modern RT techniques, the incidence of RIHD is expected to rise in cancer survivors who have been treated with old RT regimens. However, there remains a gap between guidelines and clinical practice. Currently, therapeutic modalities followed in the treatment of RIHD are similar to the non-irradiated population. Preventive measures mainly reduce the radiation dose and radiation volume of the heart. There is no concrete evidence to endorse the preventive role of statins, angiotensin-converting enzyme inhibitors, and antioxidants. This review summarizes the current evidence of RIHD subtypes and risk factors and suggests screening regimens, diagnosis, treatment, and preventive approaches.

Temporal Trends in Brain-Death Organ Donation in Asia: Results From the Global Observatory on Donation and Transplantation.

BACKGROUND: Organ shortage is the main limiting factor for further dissemination of organ transplantation therapies; implementation of brain-death (BD) criteria for organ donation purposes is essential for overcoming this limitation. Investigating and characterizing the effects of this intervention on organ availability and subsequent orthotopic organ transplantation in Asia, the world's most populous continent, should shed light on a global issue. The aim of this study was to describe temporal trends in brain-death donors (BDDs) and deceased-donor transplants (DDTs) in the Asian continent. METHODS: We used data from the Global Observatory on Donation and Transplantation (GODT), the world's most comprehensive source of data relating to organ donation and transplantation activities. Available data on the number of BDDs and DDTs in 48 Asian countries was collated and analyzed for the years 2000-2019. RESULTS: The number of BDDs in Asia increased progressively, from 25 BBDs in 2000 to 5357 in 2019. The number of DDTs increased concomitantly, albeit with an initial decline between 2004 and 2008, with an exponential increase in the number of kidney and liver transplants, followed by heart and lung transplants. Data from the latest year with complete data (2019) demonstrated 25,557 deceased-donor organs were transplanted, representing a >3-fold increase in the number of transplanted organs compared with the nadir in 2008. CONCLUSION: Although the Asian continent has noticed a rapid increase in BD transplantation activities during the past 2 decades, it is self-evident that further dissemination and adoption of BD donation are fundamental to reducing organ shortage gap.