Abdulhalim J. Kinsara

Single Atrium Associated with Persistent Left Superior Vena Cava in Asymptomatic Adult: Case Report and Review of Literature

We report a rare case of an adult patient with single atrium without the characteristics of an endocardial cushion defect, associated with persistent left superior vena cava draining to the left side of the atrium. The patient was reasonably active and asymptomatic till the third decade of his life when the cardiac anomaly was discovered and surgically corrected.

Do we need echocardiography before commencing thrombolytic therapy

We report a case of a 41-year-old man who had fatal multiple cerebral and bilateral renal infarcts 1 hour after initiation of thrombolytic therapy for acute ST elevation myocardial infarction. Echocardiography study disclosed dilated left ventricle with severe global hypokinesia suggestive of preexisting cardiomyopathy and a disintegrated left ventricular apical thrombus pointing out to the source of the embolic complication. This raises the question whether echocardiography before initiating thrombolytic therapy would affect the decision of commencing thrombolytic therapy and help avoiding such lethal embolic complications.

Metformin in heart failure patients

Summary The use of metformin was considered a contraindication in heart failure patients because of the potential risk of lactic acidosis; however, more recent evidence has shown that this should no longer be the case. We reviewed the current literature and the recent guideline to correct the misconception.

The role of selenium deficiency in dilated cardiomyopathy in Saudi Arabia.

BACKGROUND Selenium deficiency is implicated in the etiology of endemic juvenile dilated cardiomyopathy in China, and in sporadic cases in other countries. The aim of this study was to evaluate the role of selenium deficiency in the pathophysiology of dilated cardiomyopathy in the Saudi Arabian population. PATIENTS AND METHODS Plasma and urine selenium concentrations from 72 Saudi patients with confirmed dilated cardiomyopathy were compared with corresponding values from 70 control subjects of the same national origin who had normal ventricular function. RESULTS Plasma and urine selenium concentrations (mean+/-SD) were 1.347plusmn;0.45 and 0.49+/-0.37 micromol/L, respectively, for the patient group, and 1.32+/-0.41 and 0.60+/-0.41 micromol/L, respectively, for the control group. The differences in the values between the two groups were statistically insignificant. CONCLUSION In the Saudi population, dilated cardiomyopathy is not caused by selenium deficiency.

Prophylactic use of carvedilol to prevent ventricular dysfunction in patients with cancer treated with doxorubicin

Objective Deterioration in ventricular function is often observed in patients treated with anthracyclines for cancer. There is a paucity of evidence on interventions that might provide cardio-protection. We investigated whether prophylactic use of carvedilol can prevent doxorubicin-induced cardiotoxicity and whether any observed effect is dose related. Methods A prospective, randomized, double-blind study in patients treated with doxorubicin, comparing placebo (n = 38) with different doses of carvedilol [6.25 mg/day (n = 41), 12.5 mg/day (n = 38) or 25 mg/day (n = 37)]. The primary endpoint was the measured change in left ventricular ejection fraction (LVEF) from baseline to 6 months. Results LVEF decreased from 62 ± 5% at baseline to 58 ± 7% at 6-months (p = 0.002) in patients assigned to placebo but no statistically significant changes were observed in any of the 3 carvedilol groups. At 6 months, only one of 116 patients (1%) assigned to carvedilol had an LVEF < 50% compared to four of the 38 assigned to placebo (11%), (p = 0.013). No significant differences were noted between carvedilol and placebo in terms of the development of diastolic dysfunction, clinically overt heart failure or death. Conclusions Carvedilol might prevent deterioration in LVEF in cancer patients treated with doxorubicin. This effect may not be dose related within the studied range.

The Gulf Familial Hypercholesterolemia Registry (Gulf FH): Design, Rationale and Preliminary Results

Aim: To determine the prevalence, genetic characteristics, current management and outcomes of familial hypercholesterolaemia (FH) in the Gulf region. Methods: Adult (18-70 years) FH patients were recruited from 9 hospitals and centres across 5 Arabian Gulf countries. The study was divided into 4 phases and included patients from 3 different categories. In phase 1, suspected FH patients (category 1) were collected according to the lipid profile and clinical data obtained through hospital record systems. In phase 2, patients from category 2 (patients with a previous clinical diagnosis of FH) and category 1 were stratified into definitive, probable and possible FH according to the Dutch Lipid Clinic Network criteria. In phase 3, 500 patients with definitive and probable FH from categories 1 and 2 will undergo genetic testing for 4 common FH genes. In phase 4, these 500 patients with another 100 patients from category 3 (patients with previous genetic diagnosis of FH) will be followed for 1 year to evaluate clinical management and cardiovascular outcomes. The Gulf FH cohort was screened from a total of 34,366 patients attending out-patient clinics. Results: The final Gulf FH cohort consisted of 3,317 patients (mean age: 47±12 years, 54% females). The number of patients with definitive FH is 203. In this initial phase of the study, the prevalence of (probable and definite) FH is 1/232. Conclusion: The prevalence of FH in the adult population of the Arabian Gulf region is high. The Gulf FH registry, a first-of-a-kind multi-national study in the Middle East region, will help in improving underdiagnosis and undertreatment of FH in the region.

Ambulatory blood pressure monitoring in daily practice

Ambulatory blood pressure monitoring is a useful diagnostic tool that still underutilized by community physicians. It is a cost effective, diagnostic and prognostic tool that had been emphasized by the guidelines.

STEMI vs NSTEACS management trends in non-invasive hospital.

Objectives To compare the clinical features, management, and in-hospital outcomes of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTEACS), in the Western Region of Saudi Arabia. Methods A total of 71 patients were enrolled in a longitudinal study at a tertiary hospital without cardiac catheterization facility. These data were collected from Saudi Project for Assessment of Coronary Events registry. Results Twenty-three patients with STEMI were compared to 48 patients with NSTEACS. Mean age for STEMI was younger, 57.4 ± 13.7 years compared to 63.2 ± 13.9 years respectively (p = 0.19). Forty-four percent arrived at the hospital by ambulance. History of hypertension and hyperlipidemia were more frequent in NSTEACS (p = 0.05), while both groups showed no difference in diabetes mellitus, 17% vs 22% and smoking, 30% vs 17%. In-hospital medications were: Aspirin (100%) both groups, Clopidogrel (91% vs 100%) (p = 0.03). There was more aggressive use of beta-blockers (74% vs 95%) (p = 0.01) and statins (87% vs 100%) (p = 0.01) in NSTEACS. In-hospital outcomes showed one recurrent myocardial infarction and one death in NSTEACS group (2%). Other outcome in the two groups showed recurrent ischemia (13% vs 29%) (p = 0.14) and cardiogenic shock (9% vs 2%) (p = 0.17). No stroke or major bleeding was reported in both groups. Conclusion NSTEACS patients in western province of KSA present at an older age are mostly males and have higher prevalence of hypertension and hyperlipidemia compared with STEMI patients. It is therefore important to identify patients with high-risk profile and put implement measures to reduce these factors.

Does ACS Management Differs in Different Region of Saudi Arabia

Objectives: To compare the clinical features, management, and in-hospital outcomes of acute coronary syndrome (ACS) between patients in the Western region, non-invasive hospital (NIH) and other hospitals from Saudi Arabia that were involved in SPACE registry. Methods: We compared NIH data; Seventy-one patients to 5055 patients enrolled in SPACE registry study for ST-elevation myocardial infarction (STEMI), and nonST elevation acute coronary syndrome (NSTEACS) including: non-ST elevation myocardial infarction and unstable angina. Results: The mean age of the 71 patients tends to be higher in NIH (61.14 ± 13.9) in comparison to the registry patients (58.0 ±12.9 years). No difference was noted in the male ratio; 69.7% vs. 77.4, hypertension 67.6% vs. 55.3 and hyper lipidemia 52.1 % vs. 41.4. NIH patients had higher BMI of 28.03 kg/m2 compared to 27.6 in the registry group. However, lower prevalence of DM was observed (45% vs. 58.1%) and proportion of smokers was 21.1%vs. 32.4 for NIH and registry groups respectively. Thirty-two percent of NIH patients had STEMI, in contrast to 41% in the registry and NIH had used ambulances more (15.2 % vs. 5.1%). In-hospital medications showed similar use of clopidogrel (88.7% vs. 83.7 %), no difference in the use of Aspirin (98.6% vs. 97.7%), angiotensin converting enzyme inhibitors/angiotensin receptor blockers (73.2% vs. 75.1%), and statins (94.4% vs. 93.3%). However, beta-blockers use was significantly higher in the NIH group compared to the registry (91.5% vs. 81.6%, p=0.03). In-hospital outcomes were not different in terms of recurrent myocardial infarction (1.4% vs. 1.5%), cardiogenic shock (4.2% vs. 4.3%), stroke (0 vs. 0.9%), major bleeding (0% vs. 1.3). There was significant difference; in terms of recurrent ischemia (19.7% vs. 12.6%, p<0.05) and In-hospital mortality (1.4 vs. 3.0%). Conclusion: ACS patients in NIH of KSA present at an older age, have similar prevalence of HTN and dyslipidemia, more access to ambulance use and higher recurrent ischemia compared with patients in the other regions of Saudi Arabia. There was appropriate use of evidence based guided therapy

Abnormal chest x-ray postmyocardial infarction

Pulmonary hemorrhage is a rare complication of fibrinolytic therapy. Only a few cases are reported in the literature. We present a patient who had myocardial infarction, treated with fibrinolytic therapy and developed pulmonary hemorrhage. We discuss the features that suggest and support the diagnosis.