Ali T. Al-Hinai

Dietary Patterns and the Risk of Acute Myocardial Infarction in 52 Countries Results of the INTERHEART Study

Background— Diet is a major modifiable risk factor for cardiovascular disease, but it varies markedly in different regions of the world. The objectives of the present study were to assess the association between dietary patterns and acute myocardial infarction (AMI) globally. Methods and Results— INTERHEART is a standardized case-control study involving participants from 52 countries. The present analysis included 5761 cases and 10 646 control subjects. We identified 3 major dietary patterns using factor analysis: Oriental (high intake of tofu and soy and other sauces), Western (high in fried foods, salty snacks, eggs, and meat), and prudent (high in fruit and vegetables). We observed an inverse association between the prudent pattern and AMI, with higher levels being protective. Compared with the first quartile, the adjusted ORs were 0.78 (95% CI 0.69 to 0.88) for the second quartile, 0.66 (95% CI 0.59 to 0.75) for the third, and 0.70 (95% CI 0.61 to 0.80) for the fourth (P for trend <0.001). The Western pattern showed a U-shaped association with AMI (compared with the first quartile, the adjusted OR for the second quartile was 0.87 [95% CI 0.78 to 0.98], whereas it was 1.12 [95% CI 1.00 to 1.25] for the third quartile and 1.35 [95% CI 1.21 to 1.51] for the fourth quartile; P for trend <0.001), but the Oriental pattern demonstrated no relationship with AMI. Compared with the first quartile, the OR of a dietary risk score derived from meat, salty snacks, fried foods, fruits, green leafy vegetables, cooked vegetables, and other raw vegetables (higher score indicating a poorer diet) increased with each quartile: second quartile 1.29 (95% CI 1.17 to 1.42), third quartile 1.67 (95% CI 1.51 to 1.83), and fourth quartile 1.92 (95% CI 1.74 to 2.11; P for trend <0.001). The adjusted population-attributable risk of AMI for the top 3 quartiles compared with the bottom quartile of the dietary risk score was 30%. Conclusions— An unhealthy dietary intake, assessed by a simple dietary risk score, increases the risk of AMI globally and accounts for ≈30% of the population-attributable risk.

Heritability of Determinants of the Metabolic Syndrome among Healthy Arabs of the Oman Family Study

The metabolic syndrome, as defined by the International Diabetes Federation, was investigated in five large, extended, highly consanguineous, healthy Omani Arab families of a total of 1277 individuals. Heritability (h2) of the phenotypic abnormalities that make up the syndrome and other related traits was estimated by variance decomposition method using SOLAR software. The overall prevalence of the syndrome was 23%. The prevalence of abnormalities making the syndrome in a descending order were: obligatory waist circumference, hypertension, raised fasting blood glucose, low serum high‐density lipoprotein (HDL), and raised serum triglycerides (TGs). Highly significant, but widely spread, h2 values were obtained for: height (0.68), weight (0.68), BMI (0.68), serum HDL (0.63), serum leptin (0.55), percentage body fat (0.53), total serum cholesterol (0.53), fasting serum insulin (0.51), homeostasis model assessment‐insulin resistance index (0.48), serum TG (0.43), waist circumference (0.40), diastolic blood pressure (0.38), and 2‐hour glucose level (0.17), whereas for the metabolic syndrome itself, h2 was 0.38. The wide spread of h2 results (0.07 to 0.68) indicates that some determinants, such as weight, BMI, and HDL level, are under significant genetic influence among the Omani Arabs. Other determinants such as insulin resistance, abdominal obesity, diastolic blood pressure, and TG levels seem to be more environmentally driven.

Association of risk factors with acute myocardial infarction in Middle Eastern countries: the INTERHEART Middle East study.

Background and objectives Mortality from cardiovascular disease in the Middle East (ME) is projected to increase substantially by 2020. There are no large studies on the impact of risk factors for acute myocardial infarction (AMI) in the region. This is a report on the association of nine risk factors with AMI in the ME. Methods and results As part of the INTERHEART (IH) study, we enrolled 1364 cases of first AMI and 1525 matching controls from eight ME countries. The age at first AMI was 51.2 ± 10.3 years, which is the youngest, and with the largest proportion of patients <40 years in the entire IH population. The overall population attributable risk (PAR) of the nine risk factors to AMI was higher in the ME (97.5%) than worldwide (90.4%). Elevated apolipoprotein (Apo)B/ApoA1 had the strongest association with AMI, with odds ratio (OR) of 3.43 and PAR of 57.1%, followed by smoking (OR 3.63 and PAR 45.6%). ApoB/ApoA1 had greater association than the conventional low-density lipoprotein (LDL)/high-density lipoprotein (HDL) cholesterol ratio. Both diabetes (OR 3.42, PAR 16.4%) and hypertension (OR 1.89, PAR 10.7%) had greater association with AMI in women than men. Abdominal obesity (OR 2.12, PAR 26.1%) and depression (OR 1.97, PAR 45.3%), but not conventional BMI, were significantly associated with AMI (p < 0.0001). Conclusion This is the largest prospective population study of risk factors associated with AMI in the ME. AMI occurs at younger age in the ME than all other regions. The PAR for the nine risk factors was higher in the ME (97.5%) than the rest of the world. These findings should guide serious prevention strategies.

Insertion-Deletion Polymorphism in the Angiotensin-Converting Enzyme (ACE) Gene Among Sudanese, Somalis, Emiratis, and Omanis

ABSTRACT The angiotensin-converting enzyme (ACE) gene in humans contains an insertion-deletion polymorphism in its intron 16. Because of its involvement with the renin-angiotensin system, the insertion-deletion polymorphism of the ACE gene has been widely investigated in different populations and in case-control studies. However, similar studies for Arab populations are limited in number. Therefore we have investigated the frequencies of the *I and *D alleles of the ACE gene among Sudanese, Somalis, and Arab nationals of the United Arab Emirates and Oman using previously described methods. Our data indicate a preponderance of the *D allele among the Arab and African populations studied (Sudanese, 0.64; Somalis, 0.73; Emiratis, 0.61; and Omanis, 0.71).

Frequency of CYP2C9 Genotypes among Omani Patients Receiving Warfarin and Its Correlation with Warfarin Dose

Objectives: This study was conducted to determine the frequency of CYP2C9 alleles in Omani patients receiving warfarin and to correlate genotyping data with warfarin dosage. The Omani population has Asian and African ethnicities. Methods: CYP2C9 genotypes were determined by the polymerase chain reaction restriction fragment length polymorphism method. Non-parametric Kruskal-Wallis test was used to compare groups of continuous data for significance differences. Results: Genotyping data showed that 12.7 and 5.8% of the samples were heterozygous for the CYP2C9*2 and CYP2C9*3 alleles, respectively. The CYP2C9*2 allele frequency was 0.074 in our population. It was 0.029 for CYP2C9*3. Conclusion: This is the first report on the presence of CYP2C9*2 allele homozygocity in any Asian or African population.

Centralized Pan-Middle East Survey on the Undertreatment of Hypercholesterolemia: Results From the CEPHEUS Study in Arabian Gulf Countries

The Centralized pan-Middle East Survey on the undertreatment of hypercholesterolemia (CEPHEUS) survey evaluated the attainment of low-density lipoprotein cholesterol (LDL-C) goals among patients on lipid-lowering drugs (LLDs) according to the updated National Cholesterol Education Program (NCEP)-Adult Treatment Panel (ATP-III) guideline. The survey was conducted in 6 Arabian Gulf countries. Patients aged ≥18 years on LLDs for at least ≥3 months (stable medication for ≥6 weeks) were recruited. Fasting blood samples were collected at a single visit. In this survey, 5276 (58.2% male) patients were included in the final analysis. The LDL-C goal was attained in 91.1% of low-risk, 52.7% of high-risk, and 32.0% in very-high-risk categories. Goal attainment was directly related to female gender, age <40 years, history of diabetes, and family history of cardiovascular disease. The results of this survey highlight the suboptimal management of hypercholesterolemia across Arabian Gulf countries.

Saphenous vein graft vs. radial artery graft searching for the best second coronary artery bypass graft

Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.

First Case Report of Familial Hypercholesterolemia in an Omani Family Due to Novel Mutation in the Low-Density Lipoprotein Receptor Gene

Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder. Mutations have been found in at least 3 genes: the low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB), and proprotein convertase subtilisin/kexin type 9 (PCSK9). We report the first case of FH in an Omani family due to a novel mutation in the LDLR gene. A 9-year-old female was referred to our lipid clinic with eye xanthelasmata and thickening of both Achilles tendons. Evaluation of the lipid profile showed the off treatment total cholesterol of 896 mg/dL (23.2 mmol/L), low-density lipoprotein cholesterol (LDL-C) of 853 mg/dL (22.1 mmol/L), APOB of 4.5 g/L, triglyceride of 71 mg/dL (0.8 mmol/L), and high-density lipoprotein cholesterol of 0.74 mmol/L. Genetic analysis of the LDLR gene showed a homozygous frameshift deletion mutation (272delG) at exon 3. The female patient was treated with a combination of rosuvastatin/ezetimibe and LDL apheresis.

Therapeutic lipid target achievements among high and highest risk patients: results from the CEPHEUS study in the Arabian Gulf

Abstract Objective: To determine lipid target achievements of low-density lipoprotein cholesterol (LDL-C), non-high density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B (apo B) in the Centralized Pan-Middle East Survey on the undertreatment of hypercholesterolemia (CEPHEUS) in Arabian Gulf States patients with high and highest risk according to the joint Consensus Statement of the American Diabetes Association (ADA) and American College of Cardiology Foundation (ACC). Methods: CEPHEUS was conducted in patients (≥18 years of age) in six Middle Eastern countries between November 2009 and July 2010 on lipid lowering drugs (LLDs). Serum samples collected included total cholesterol (TC), LDL-C, HDL-C, triglycerides (TGs), apo B, and apolipoprotein A1 (apo A1). Results: The overall mean age of the cohort (n = 5275) was 56 ± 13 years, 58% (n = 3060) were male and 69% (n = 3635) were highest risk. LDL-C target was achieved in 25%, non-HDL-C in 36% and apo B in 38% of patients in the highest risk cohort compared with LDL-C 46%, non-HDL-C 58% and apo B 51% in the high risk group. In patients with TGs ≥2.2 mmol/L, LDL-C target was achieved in 16% and apo B in 15% of patients in the highest risk group compared with LDL-C 32% and apo B 22% in the high risk cohort. Conclusion: Despite being on LLDs, a large proportion of high and highest risk patients in the Arabian Gulf are not at recommended lipid targets and remain at a substantial residual risk for cardiovascular diseases. Apo B may be used as an additional target in patients with triglycerides ≥2.2 mmol/L. The findings should be interpreted in light of the study’s limitations.

Safety of simvastatin and goal attainment for low-density lipoprotein cholesterol in sultan qaboos university hospital.

OBJECTIVES Despite the scientific evidence of reducing cardiac events with HMG Co-A reductase inhibitors (statins) therapy in both primary and secondary preventions, these therapies continue to be underutilized in patients receiving convictional care. Simvastatin, a HMG Co-A inhibitor agent, is the most commonly used statin in Sultan Qaboos University Hospital. The aim of this study is to review the safety and the effectiveness of achieving LDL-C targets with Simvastatin according to the NCEP-ATP3 guidelines in patients with different cardiovascular risk categories at Sultan Qaboos University Hospital. METHODS A retrospective chart review was conducted for 160 patients. Patients were identified by outpatient prescriptions provided by pharmacy department from April 2008 to May 2008. RESULTS 98% of the patients were prescribed simvastatin 20 mg and only 2% received 40 mg. The mean age of patients was 57 years +/- 12. While 49% of the patients were male and 45% had diabetes mellitus, 50% had cardiovascular disease, 2.5% were smokers, 67% were hypertensive, and 3% had positive family history of coronary artery disease. 75% of patients were classified as high risk, 7% moderate risk and 18% low risk for coronary artery disease. Among all lipid profiles, only LDL-C was changed from baseline with simvastatin treatment in all patients (3.60±1.03 to 3.25±1.34 mmol/L). LDL-C level at baseline was higher in the high risk group (4.11±1.06 mmol/L) compared to low and moderate risk groups (3.68±0.89, 3.42±1.15) respectively. Achievement of LDL-C goals was achieved in only 43% for high risk, 50% in moderate risk, and 90% in low risk patients. There was no significant increase in liver enzymes and creatinine kinase. CONCLUSION This study identified that more than half of the high risk patients were not at the target LDL-C goals which place them at a continuous risk of coronary heart disease. More appropriate lipid lowering therapy using more potent statins or combination therapy should be optimized to improve achievement of LDL-C goals according to ATP-III guidelines.