Abdurrazzak Gehani

Myocardial Infarction with Normal Coronary Angiography Compared with Severe Coronary Artery Disease without Myocardial Infarction: The Crucial Role of Smoking

Background Why do some patients suffer acute myocardial infarction (MI) despite angiographically normal coronary arteries (NL+MI) whereas others enjoy an acute MI-free life despite extensive three-vessel disease (3VD-MI)? The present study contrasts these two groups to identify some differences in the risk profile. Methods In 10 000 patients admitted to the cardiology service, a first MI was confirmed in 2356 patients, of whom 1609 underwent coronary angiography. In 77 patients with MI, coronary angiography was found to be entirely normal (NL+MI, 77/1609, 4.1%). These were contrasted to 123 patients with severe three-vessel coronary disease but no MI (3VD-MI). Results Patients with NL+MI were 13 years younger (42 ± 8.3 vs 55 ± 10.5, P < 0.05), with 33 patients (43%) under the age 40 years, in contrast to only 9 patients (7.3%) in the 3VD group being this age. Patients with NC+MI were more often current smokers (80.5% vs 29% in the 3VD group; P < 0.01). Patients with 3VD-MI were, on the other hand, more often diabetic (54% vs 9% in the NL + MI group; P < 0.01) and had a higher cholesterol level (5.6 ± 1.1 vs 4.9 ± 1.0 Mmol/l, P < 0.01) as well as a higher incidence of chronic stable angina (52% vs 22%; P < 0.01) and heart failure (6% compared with 0% in the NL+MI group). Sixty-one out of 77 (79%) NL+MI patients had a single risk factor, and in 87%, this was smoking alone. Diabetes mellitus was rare and never occurred alone in this group. Conclusion In patients who suffer MI despite normal coronary angiography, smoking is a major risk factor: In contrast, in patients with extensive coronary artery disease on angiography but no MI, diabetes rather than smoking is the dominant risk factor. The findings of this study support the view that the risk factors for stable and unstable coronary artery disease are different, as reflected by the contrast of the above groups at the extremes of the spectrum. Smoking appears to be a major risk factor for acute MI (even with normal coronary angiography), whereas diabetes is a major risk factor for more severe but more stable coronary artery disease.

Acute Myocardial Infarction in a Professional Diver After Jellyfish Sting

To our knowledge, acute myocardial infarction after jellyfish envenomation has not been reported previously. We describe a previously healthy 45-year-old male diver who had an acute inferior myocardial infarction with right ventricular involvement after a jellyfish sting on his left forearm while diving in the Gulf Sea. The patient had a normal controlled ascent after the incident. He had no risk factors for coronary artery disease, and cardiac catheterization revealed normal coronary arteries. Acute myocardial infarction should be considered in patients who experience chest pain or have hemodynamic compromise after jellyfish envenomation.

The effect of hypertension as a predictor of risk for congestive heart failure patients over a 10-year period in a newly developed country.

Aims: Cardiovascular disease is the leading cause of mortality and morbidity in the western world and has reached epidemic proportions. The incidence of congestive heart failure (CHD) and hypertension is also rising rapidly in many of the affluent Arab nations and cardiovascular diseases continue to be a leading cause of morbidity and mortality among adult Qataris and Asians residing in Qatar. Objective: The objective of this study is to assess the effect of hypertension among patients admitted to hospital in Qatar with CHD and to identify risk factors that contribute to the development of CHD in hypertensive subjects. Design: This is a retrospective cohort study. Setting: Hamad General Hospital, Hamad Medical Corporation. Subjects: All patients who were hospitalized with CHD with or without hypertension in the Hamad General Hospital, State of Qatar, from 1991 to 2001. Methods: The diagnostic classification of definite CHD was made in accordance with criteria based on the International Classification of Disease, ninth revision (ICD‐9]. Result: A total of 20 856 patients were treated during the 10‐year period; 8446 were Qataris. Among them, 60% were males and 40% females. Among the total patients (3713) hospitalized with CHD, 1744 (46.9%) had hypertension. Furthermore, the incidence of hypertension was slightly higher in males than in females (56.4 vs 43.6%). A statistically significant difference was found between hypertensive and non‐hypertensive cases with diabetes mellitus and angina. Hypertensive subjects were more likely to have diabetes (p < 0.001) and angina (p < 0.030). The mortality rate of CHD patients with hypertension was higher among Qataris than among non‐Qataris (p < 0.038). Conclusion: Hypertension was the most common risk factor for CHD; it contributed a large proportion of heart failure cases in this population‐based sample. Preventive strategies directed toward earlier detection of elevated blood pressure and its control are likely to offer the greatest promise for reducing the incidence of CHD and its associated mortality.

Primary coronary angioplasty for ST-Elevation Myocardial Infarction in Qatar: First nationwide program

Abstract: In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as ‘high volume’, both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.

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.

NIAMI: Towards the optimization of results in primary PCI

The NAIMI trial has recently been published. It assessed one of the most contemporary and challenging issues in the management of acute myocardial infarction (AMI), namely prevention of reperfusion injury (RPI) after primary PCI for ST-elevation myocardial infarction (STEMI). It investigated the effect of the intravenous administration of Na nitrite given immediately prior to primary PCI for STEMI in 229 patients (118 in the treatment group, and 111 in placebo). The myocardial infarction (MI) size did not differ between the two groups as observed by cardiac MRI (CMR) with gadolinium enhancement at 6–8 days or plasma Troponin-I and creatine kinase (CK), or by left ventricular (LV) volume and ejection fraction (EF) as measured by echocardiography at 6–8 days and again at 6 months. They concluded that IV nitrites did not reduce the infarct size. There was, however, a trend towards benefit in diabetic patients in the post-hoc analysis. The small number of these subjects has probably lead to inconclusive outcome in this subset.

IMPACT OF THE 2005 RESUSCITATION GUIDELINES ON PATIENT SURVIVAL: EXPERIENCE FROM A PROSPECTIVE REGISTRY IN A MIDDLE-EASTERN COUNTRY (2002-2010)

The influence of implementing the 2005 resuscitation guidelines in developing countries remains unknown. The aim of the current study is to determine if survival to hospital discharge has improved following the adoption of the 2005 guidelines in the state of Qatar which has implemented training and