Amar M Salam

Impact of religious Ramadan fasting on cardiovascular disease: a systematic review of the literature

Abstract Background: Fasting during the month of Ramadan is a religious obligation that is practiced by millions of people around the world yet there is no clear scientific consensus on its effects on cardiovascular disease. This study was performed to inform physicians as well as patients of evidence based recommendations on this subject. Aim: The study was undertaken to assess: (1) any alteration in the incidence of acute cardiac illness during Ramadan fasting; (2) whether fasting during the month of Ramadan alters the clinical status of patients with stable cardiac disease; and (3) the impact of Ramadan fasting on cardiovascular risk factors in normal subjects, in patients with stable cardiac disease, metabolic syndrome, dyslipidemia, type 2 diabetes and systemic hypertension. Study design: Systematic review of the literature. Method: A Medline search of the English literature published between January 1980 and September 2012. Results: The incidence of acute cardiac illness during Ramadan fasting was similar to non-fasting days, although the timing of symptom onset may be different, with significant increase in events during the period of ‘breaking fast’ when compared to non-fasting days. The majority of patients with stable cardiac illness can undergo Ramadan fasting without any clinical deterioration. Body mass index, lipid profile, and blood pressure showed significant improvement in normal healthy subjects, patients with stable cardiac illness, metabolic syndrome, dyslipidemia and hypertension during Ramadan fasting. The lipid profile of diabetic patients deteriorated significantly during Ramadan fasting. Conclusions: Ramadan fasting is not associated with any change in incidence of acute cardiac illness and the majority of cardiac patients can fast without any difficulty. Improvement in lipid profile, especially 30% to 40% increment in high-density lipoprotein, as reported in some studies, appear promising. Diabetic patients should be carefully monitored during Ramadan fasting.

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.

Women hospitalized with atrial fibrillation: Gender differences, trends and outcome from a 20-year registry in a middle eastern country (1991–2010)

BACKGROUND Most of the published research on atrial fibrillation (AF) is limited to studies in the developed world and included mainly Caucasian patients. Data about women with AF among other ethnicities is very limited. OBJECTIVES The aim of this study was to compare the clinical characteristics, treatment and outcome of women to men hospitalized with AF in a middle-eastern country. METHODS Retrospective analysis of prospective registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made. Clinical characteristics, management, and outcomes of AF patients were compared according to gender. RESULTS During the 20-years period; 1417 women and 2432 men were hospitalized for AF. Women were 5 years older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment and were also less likely to be current smokers and to have ischemic heart disease and impaired left ventricular function when compared to men. There was no gender preference in the use of anticoagulation. The prevalence of concomitant ischemic heart disease and hypertension increased, while the prevalence of valvular heart disease and heart failure decreased among patients hospitalized with AF over the study period. In-hospital mortality and stroke rates were comparable between the two groups. CONCLUSIONS Women hospitalized with atrial fibrillation were older in age and had higher prevalence of co-morbid cardiovascular risk factors compared to men whereas, mortality and stroke rates were comparable.

Platelet glycoprotein IIb/IIIa antagonists in clinical trials for the treatment of coronary artery disease.

There is a growing understanding of the central role that platelets play in coronary artery disease. The glycoprotein IIb/IIIa receptor has recently been identified as the final common pathway for platelet aggregation and hence has been the focus of many clinical trials to influence various aspects of coronary artery disease. In this report we give an overview of these clinical trials.

The therapeutic potential of ximelagatran to become the anticoagulant of choice in medicine: a review of recently completed clinical trials

Ximelagatran (Exanta™, AstraZeneca) is a novel oral direct thrombin inhibitor that inhibits the final step in the coagulation process – namely, the conversion of fibrinogen to insoluble fibrin by thrombin. Recently completed large clinical trials have evaluated the efficacy and safety of ximelagatran compared to standard anticoagulation therapy with warfarin and heparins in several thrombotic disorders including the treatment and prevention of venous thromboembolism following major orthopaedic surgery; stroke prevention in atrial fibrillation; and after acute myocardial infarction. This article reviews these recent clinical trials and explores the therapeutic potential of ximelagatran to become the oral anticoagulant of first choice in medicine.

Immediate and one-year outcome of patients presenting with Acute Coronary Syndrome complicated by stroke: Findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2)

BackgroundStroke is a potential complication of acute coronary syndrome (ACS). The aim of this study was to identify the prevalence, risk factors predisposing to stroke, in-hospital and 1-year mortality among patients presenting with ACS in the Middle East.MethodsFor a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries.ResultsThe prevalence of in-hospital stroke following ACS was 0.70%. Most cases were ST segment elevation MI-related (STEMI) and ischemic stroke in nature. Patients with in-hospital stroke were 5 years older than patients without stroke and were more likely to have hypertension (66% vs. 47.6%, P = 0.001). There were no differences between the two groups in regards to gender, other cardiovascular risk factors, or prior cardiovascular disease. Patients with stroke were more likely to present with atypical symptoms, advanced Killip class and less likely to be treated with evidence-based therapies. Independent predictors of stroke were hypertension, advanced killip class, ACS type –STEMI and cardiogenic shock. Stroke was associated with increased risk of in-hospital (39.3% vs. 4.3%) and one-year mortality (52% vs. 12.3%).ConclusionThere is low incidence of in-hospital stroke in Middle-Eastern patients presenting with ACS but with very high in-hospital and one-year mortality rates. Stroke patients were less likely to be appropriately treated with evidence-based therapy. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

Selective aldosterone blockade with eplerenone in patients with congestive heart failure

In the Eplerenone Postacute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) the effects of selective aldosterone blockade with eplerenone on cardiovascular mortality and morbidity were studied in patients with reduced left ventricular function postacute myocardial infarction. Data from this landmark study suggest that eplerenone can be an effective addition to the therapy of patients with congestive heart failure and is associated with fewer side effects than spironolactone. Further research is warranted concerning the possible benefits of this new agent in disease states other than congestive heart failure in which an activated renin-angiotensin-aldosterone system system has been implicated.

Secular Trends, Treatments, and Outcomes of Middle Eastern Arab and South Asian Patients Hospitalized With Atrial Fibrillation: Insights From a 20-Year Registry in Qatar (1991-2010)

A prospective registry was made of all patients hospitalized with atrial fibrillation (AF) in the State of Qatar from 1991 to 2010. Clinical characteristics, management, and outcomes were compared according to ethnicity (Middle Eastern Arab vs South Asian). During this 20-year period, 2857 Arabs and 548 Asians were hospitalized for AF. Arabs were 9 years older and more likely to have hypertension, diabetes mellitus (DM), chronic renal impairment, and dyslipidemia than the Asians. Valvular heart disease and acute coronary syndromes were more common among Asians, while congestive heart failure was more common in Arabs. The overall inhospital mortality was lower in Asians than that of Arabs, while stroke rates were comparable. There was an increase in the prevalence of DM and hypertension in both the groups in the latter years of the study period, but there was no change in mortality trends. Our findings underscore the need to study AF according to ethnicity.

Rate control versus rhythm control for the management of atrial fibrillation: the verdict of the AFFIRM trial.

Atrial fibrillation is the most common sustained cardiac arrhythmia encountered in clinical practice that affects cardiovascular morbidity and mortality and generates significant healthcare costs. There are two approaches for the management of atrial fibrillation: rate control and rhythm control. Rate-control strategy involves using rate-controlling agents such as β-blockers, calcium channel blockers or digoxin, or a combination thereof to control symptoms while allowing atrial fibrillation to persist. Rhythm-control strategy involves cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm. Although each strategy has its own advantages as well as limitations, it has long been debated which of the strategies offers better long-term outcomes and thus should be the preferred and recommended approach for the management of patients with atrial fibrillation. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was the first large-scale randomised study to address this important issue. In this article, the long awaited verdict of the AFFIRM study with its implications for the clinical management of patients with atrial fibrillation is discussed.

Effect of age on treatment, trends and outcome of patients hospitalized with atrial fibrillation: insights from a 20-years registry in a middle-eastern country (1991–2010)

Background: Most studies on atrial fibrillation (AF) epidemiology, treatment, and outcomes have included mainly Caucasians patients. The world literature on AF in other ethnicities is very limited particularly in the elderly. Aims: The aim of this study was to compare the clinical characteristics, treatment and outcome of elderly and younger patients hospitalized with AF in a Middle-Eastern country and examine the trends of AF etiologies over a 20-year period. Methods: A retrospective analysis of a prospective registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made. Patients were divided into three groups; group 1: patients ≦50 years old, group 2: patients between 51 and 70 years old, and group 3: patients >70 years old. Clinical characteristics, management, and outcomes of AF patients were compared according to age. Results: Between the year 1991 and the end of 2010, a total 3848 consecutive patients were admitted with AF. One thousand three hundred and forty-five patients were ≦50 years, 1759 were between 51 and 70 years and 744 patients were >70 years old. Elderly patients were more likely to have hypertension and chronic renal impairment. There was a higher prevalence of associated coronary artery disease and aortic stenosis in elderly patients with a lower left ventricular ejection fraction than the younger age groups. A lower use of anticoagulation in the elderly group was observed but there was no underuse of other evidence-based medications. The older AF patients had significantly higher in-hospital mortality and stroke rates with no significant changes in mortality trends over the 20 years of study. An increasing trend of the associated acute coronary syndromes, hypertension and diabetes mellitus prevalence was observed in the elderly group. Conclusion: Anticoagulation remains underutilized in elderly patients with AF despite proven efficacy and increasing trends of cardiovascular comorbidities. The current study underscores the urgent need for prospective studies to investigate warfarin contraindications, relative warfarin efficacy and bleeding risks in our region to help guide healthcare providers in warfarin prescribing in this frail patient population and consequently reduce the risk of AF-related disabling strokes and mortality.