Awad Al-Qahtani

Acute Coronary Syndrome and Khat Herbal Amphetamine Use An Observational Report

Background— The khat plant is a stimulant similar to amphetamine and is thought to induce coronary artery spasm. Khat is widely chewed by individuals originating from the Horn of Africa and the Arabian Peninsula. The aim of this study was to evaluate the clinical characteristics and outcome of khat chewers presenting with acute coronary syndrome. Methods and Results— From October 1, 2008, through June, 30, 2009, 7399 consecutive patients with acute coronary syndrome were enrolled in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Nineteen percent of patients were khat chewers; 81% were not. Khat chewers were older, more often male, and less likely to have cardiovascular risk factors. Khat chewers were less likely to have a history of coronary artery disease and more likely to present late and to have higher heart rate and advanced Killip class on admission. Khat chewers were more likely to present with ST-segment–elevation myocardial infarction. Overall, khat chewers had higher risk of death, recurrent myocardial ischemia, cardiogenic shock, ventricular arrhythmia, and stroke compared with non–khat chewers. After adjustment for baseline variability, khat chewing was found to be an independent risk factor of death and for recurrent ischemia, heart failure, and stroke. Conclusions— Our data confirm earlier observations of worse in-hospital outcome among acute coronary syndrome patients who chew khat. This worse outcome persists up to 1 year from the index event. This observational report underscores the importance of improving education concerning the cardiovascular risks of khat chewing.

Atrial Fibrillation Post Cardiac Surgery Trends Toward Management

Post operative atrial fibrillation (POAF) is more common than before due to increased numbers of cardiac surgeries. This in turn is associated with increased incidence of post operative complication, length of hospital stay and subsequent increase the cost of hospitalization. Therefore preventing and/or minimizing atrial fibrillation by pharmacological or nonpharmacological means is a reasonable goal. POAF has also been associated with postoperative delirium and neurocognitive decline. The precise pathophysiology of POAF is unknown, however most of the evidence suggests it is multifactorial. Different risk factors have been reported, and many studies have evaluated the prophylactic effects of different interventions. This review article highlights the incidence, risk factors, and pathogenesis, prevention, and treatment strategies of POAF.

Comparison of Women Versus Men Hospitalized With Heart Failure (From a 20-Year Registry in a Middle-Eastern Country 1991–2010)

The aim of the present study was to compare the clinical characteristics, treatment, and outcomes of women and men hospitalized with heart failure (HF) in a Middle-Eastern country. A retrospective analysis of all patients hospitalized with HF in the State of Qatar from 1991 through 2010 was made. The clinical characteristics, management, and outcomes of the patients with HF were compared according to gender. A subset analysis according to ethnicity was also done (Middle Eastern Arabs vs South Asians). During the 20-year period, 2,379 women and 4,689 men were hospitalized for HF. The women were older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment compared to the male patients. The women were less likely to be current smokers and to have ischemic heart disease compared to the men. Impaired left ventricular function was more common among men. The in-hospital mortality rates were comparable between the 2 groups (7.7% in women vs 8.2% in men; p = 0.4) and significantly improved with time in the 2 groups (p = 0.001). The mortality rates were comparable among the women, regardless of the ethnicity. In conclusion, overall improvement occurred in survival in patients hospitalized with HF in a Middle-Eastern country, regardless of gender. Women hospitalized with HF had mortality rates comparable to those of men.

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.

Prevalence and outcome of Middle-eastern Arab and South Asian patients hospitalized with heart failure: insight from a 20-year registry in a Middle-eastern country (1991–2010)

Introduction: The clinical characteristics and outcome of patients hospitalized with heart failure vary according to ethnicities. Background: Limited epidemiologic data are available about the clinical characteristics and outcome of heart failure (HF) patients among non-Caucasian populations. Methods: Between 1 January 1991 and 31 December 2010; 41 453 consecutive patients were hospitalized at Hamad General Hospital, Doha, Qatar for cardiac reasons. Patients were into two groups; hospitalized with HF (n = 7069) and hospitalized for non-HF (no-HF). Among HF patients Sub-analysis was made according to ethnicity; Middle-eastern Arabs (MEA) (n = 5227) versus South Asian (SA) (n = 1289) patients. Results: HF patients were older and more likely to be female when compared to non-HF patients. HF patients were also more likely to have diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AF) and renal impairment when compared to non-HF patients. SA HF patients younger and less likely to have DM, HTN and AF when compared to MEA patients. Over the 20-years period there was decrease in in-hospital mortality and stroke rates regardless of ethnicity (death; 8.3% to 4.8%, stroke; 0.8% to 0.1%; all P = 0.001).Conclusion: HF patients in the Middle East present at relatively younger age regardless of ethnicity. In-hospital mortality and stroke rates decreased significantly over the 20-years.

Stent fracture: how frequently is it recognized?

In spite of there being several case reports, coronary stent fracture is not a well-recognized entity and incidence rates are likely to be underestimated. In this article, we review different aspects of stent fracture, including incidence, classification, predictors, outcome, diagnosis, and management.

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.

Impact of Polypharmacy on Adherence to Evidence-Based Medication in Patients who Underwent Percutaneous Coronary Intervention

BACKGROUND The primary objective of this study was to evaluate the impact of polypharmacy on primary and secondary adherence to evidence-based medication (EBM) and to measure factors associated with non-adherence among patients who underwent percutaneous coronary intervention (PCI). METHODS We conducted a retrospective analysis for patients who underwent PCI at a tertiary cardiac care hospital in Qatar. Patients who had polypharmacy (defined as ≥6 medications) were compared with those who had no polypharmacy at hospital discharge in terms of primary and secondary adherence to dual antiplatelet therapy (DAPT), beta-blockers (BB), angiotensin converting enzyme inhibitors (ACEIs) and statins. RESULTS A total of 557 patients (mean age: 53±10 years; 85%; males) who underwent PCI were included. The majority of patients (84.6%) received ≥6 medications (polypharmacy group) while only 15.4% patients received ≥5 medications (nonpolypharmacy group). The two groups were comparable in term of gender, nationality, socioeconomic status and medical insurance. The non-polypharmacy patients had significantly higher adherence to first refill of DAPT compared with patients in the polypharmacy group (100 vs. 76.9%; p=0.001). Similarly, the non-polypharmacy patients were significantly more adherent to secondary preventive medications (BB, ACEI and statins) than the polypharmacy group. CONCLUSION In patients who underwent PCI, polypharmacy at discharge could play a negative role in the adherence to the first refill of EBM. Further studies should investigate other parameters that contribute to long term non-adherence.

Acute Coronary Syndrome in Patients with Prior Coronary Artery Bypass Surgery: Observations from a 20-Year Registry in a Middle-Eastern Country

Objectives Clinical characteristics and trends in the outcome of acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft surgery (CABG) are unclear. The aim of this study was to evaluate clinical characteristics, in-hospital treatment, and outcomes in patients presented with ACS with or without a history of prior CABG over 2 decades. Methods Data were derived from hospital-based study for collected data from 1991 through 2010 of patients hospitalized with ACS in Doha, Qatar. Data were analyzed according to their history of prior CABG. Baseline clinical characteristics, in-hospital treatment, and outcome were compared. Results A total 16,750 consecutive patients with ACS were studied, of which 693 (4.1%) had prior CABG. Patients with prior CABG were older (mean 60.5±11 vs. 53±12 years; P = 0.001), more likely to be females and have more cardiovascular risk factors than the non-CABG group. Prior CABG patients had larger infarct size, were less likely to receive reperfusion therapy, early invasive therapy and more likely to receive evidence-based therapies when compared to non-CABG patients. In-hospital mortality and stroke rates were comparable between the 2 groups. Over 2 decades, there was reduction in the in-hospital mortality rates and stroke rates in both groups (CABG, death; 13.2% to 4%, stroke; 1.9% to 0.0%, non-CABG, death; 10% to 3.2%, stroke 1.0% to 0.1%; all, p = 0.001). Conclusion Significant reduction in-hospital morbidity and mortality among ACS patients with prior CABG over a 20-year period.

Study exploring depression and cardiovascular diseases amongst Arabic speaking patients living in the State of Qatar: Rationale and methodology.

Abstract: In Qatar, cardiovascular diseases are the leading cause of death. Studies show that depression is associated with an increased morbidity and mortality among cardiovascular patients. Thus, early detection of, and intervention for, depression among cardiovascular patients can reduce cardiovascular morbidity and mortality, and save health care costs. To date there is no study in the Gulf region exploring depression among cardiovascular patients. The goals of our three-phase research program are to (1) understand the mental health issues, specifically depression, as experienced by cardiovascular patients living in the State of Qatar; (2) identify and implement strategies that would prevent depression and assist patients to deal with depression; and (3) evaluate, facilitate, and sustain strategies that are effective at reducing depression and foster its treatment among cardiovascular patients. This paper describe phase I of the research program. Using both quantitative and qualitative research methodologies, we will investigate (1) the prevalence and severity of depression among patients who have confirmed diagnosis of cardiovascular diseases (2) how contextual factors such as social, cultural, and economic factors contribute to the risk of depression and its management among cardiovascular patients, and (3) formulate effective intervention strategies that are expected to increase awareness, prevention of and treatment for depression among cardiovascular patients, thus reducing cardiovascular diseases morbidity and mortality in Qatar.