Habib A. Dakik

Temporal Trends and Outcomes of Patients Undergoing Percutaneous Coronary Interventions for Cardiogenic Shock in the Setting of Acute Myocardial Infarction: A Report From the CathPCI Registry

OBJECTIVES The purpose of this study was to examine the temporal trends in demographics, clinical characteristics, management strategies, and in-hospital outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS-AMI) who underwent percutaneous coronary intervention (PCI) from the Cath-PCI Registry (2005 to 2013). BACKGROUND The authors examined contemporary use and outcomes of PCI in patients with CS-AMI. METHODS The authors used the Cath-PCI Registry to evaluate 56,497 patients (January 2005 to December 2013) undergoing PCI for CS-AMI. Temporal trends in clinical variables and outcomes were assessed. RESULTS Compared with cases performed from 2005 to 2006, CS-AMI patients receiving PCI from 2011 to 2013 were more likely to have diabetes, hypertension, dyslipidemia, previous PCI, dialysis, but less likely to have chronic lung disease, peripheral vascular disease, or heart failure within 2 weeks (p < 0.01). Between 2005 and 2006 to 2011 and 2013, intra-aortic balloon pump use decreased (49.5% to 44.9%; p < 0.01), drug-eluting stent use declined (65% to 46%; p < 0.01), and the use of bivalirudin increased (12.6% to 45.6%). Adjusted in-hospital mortality; increased (27.6% in 2005 to 2006 vs. 30.6% in 2011 to 2013, adjusted odds ratio: 1.09, 95% confidence interval: 1.005 to .173; p = 0.04) for patients who were managed with an early invasive strategy (<24 h from symptoms). CONCLUSIONS Our study shows that despite the evolution of medical technology and use of contemporary therapeutic measures, in-hospital mortality in CS-AMI patients who are managed invasively continues to rise. Additional research and targeted efforts are indicated to improve outcomes in this high-risk cohort.

Upper gastrointestinal bleeding in patients with acute coronary syndromes: clinical predictors and prophylactic role of proton pump inhibitors.

Objectives To determine the risk and the clinical predictors of in-hospital upper gastrointestinal (UGI) bleeding in patients with acute coronary syndromes (ACS), and to study the prophylactic role of proton pump inhibitors (PPI) in this setting. Background Patients with ACS are usually treated by a combination of antiplatelet, antithrombotic and thrombolytic medications, thereby increasing the risk of bleeding. Study A retrospective study of 1023 patients hospitalized with ACS at the American University of Beirut Medical Center from September 2001 to November 2005. The main outcome measurements were the incidence of in-hospital UGI bleeding and its predictors; the utilization rate of PPI and its determinants. Results Seven patients developed in-hospital UGI bleeding (0.7%) and 2 had major bleeding (0.2%). All required blood transfusion and none died in the hospital. Significant predictors of UGI bleeding were prior history of UGI bleeding or peptic ulcer disease (P<0.01), creatinine > 2 mg/dL (P=0.01), and home intake of aspirin, clopidogrel (P<0.05), or nonsteroidal anti-inflammatory drugs (P<0.05). Sixty-nine percent of patients received PPI during their hospital stay. There was no significant difference in the incidence of UGI bleeding between patients receiving and those not receiving PPI (0.7% vs. 0.6%, P= 0.88). Conclusions The risk of UGI bleeding is relatively low in patients hospitalized with ACS and does not appear to be significantly reduced by the use of PPI. The utilization rate of PPI was relatively high. Better patient selection and risk stratification for the prophylactic use of PPI are warranted.

Response to a cardiac event in relation to cardiac knowledge and risk perception in a Lebanese sample: A cross sectional survey

BACKGROUND Heart disease is the leading cause of morbidity and mortality in many countries, including Lebanon. The continuing advances in the treatment of heart disease have improved patient outcomes significantly over the years. Nevertheless, prompt treatment remains essential to treatment success, which depends on the persons early recognition of cardiac symptoms and quick seeking of care. OBJECTIVE The purpose of the study was to examine the relationship between knowledge of symptoms of heart disease, perceived cardiac risk and the potential response to a heart attack in a sample of Lebanese adults. DESIGN A cross sectional descriptive survey design was used. A convenience sample of 399 adult hospital visitors who did not have heart disease were interviewed in two major referral hospitals in Beirut. MEASURES The Illness Perception Questionnaire and the Behavioral Risk Factor Surveillance System were used; in addition an open-ended question was asked to elicit what the visitor would do in case he/she experienced cardiac symptoms. RESULTS While most participants (94%) correctly recognized major symptoms of heart disease (like chest pain and dyspnea), they also reported irrelevant symptoms to be associated with heart disease (like irritability by 68% and muscle cramps by 52%). Only 21% of participants reported that they would seek emergency care as their first response if they were experiencing a heart attack. Knowledge of symptoms and perceived cardiac risk were not associated with the response to a heart attack. Being single was the only significant predictor of choosing the appropriate response when experiencing a cardiac event. CONCLUSION The findings suggest lack of adequate knowledge of cardiac symptoms and a high potential for inappropriate responses when symptoms occur. Public health heart health campaigns are needed to raise awareness about heart disease in Lebanon.

Drug points: Ticlopidine associated with acute arthritis.

Ticlopidine is an antiplatelet thienopyridine drug that works by non-competitive antagonism of the ADP receptor. It is used widely to prevent thrombosis after coronary stent placement and has been shown to be at least as effective as aspirin in preventing events in patients with cerebrovascular disease. 1 2 Its most common side effects include diarrhoea, nausea, vomiting, and skin rash.3 It also has serious—but rare—side effects such as neutropenia, thrombotic thrombocytopenic purpura, and bone marrow aplasia.3 We report a case of acute arthritis associated with ticlopidine. A 65 year old woman was admitted to hospital because of chest pain. She was known to be taking insulin …

Acute coronary syndromes: clinical characteristics, management, and outcomes at the American University of Beirut Medical Center, 2002-2005.

Data on acute coronary syndromes (ACS) in developing countries is scarce. In this report, we analyze the temporal trends in the management and outcomes of a large series of ACS patients hospitalized at the American University of Beirut Medical Center (AUBMC), a tertiary referral university hospital located in a middle income Middle Eastern developing country.

Blood Transfusion and the Risk of Acute Kidney Injury Among Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Background—Acute kidney injury (AKI) complicating percutaneous coronary intervention (PCI) is associated with adverse clinical outcomes. To date, no studies have evaluated the association of blood transfusion with AKI in patients undergoing PCI. Methods and Results—We used a retrospective cohort study of all patients with acute coronary syndrome undergoing PCI from CathPCI Registry (n=1 756 864). The primary outcome was AKI defined as the rise in serum creatinine post procedure ≥0.5 mg/dL or ≥25% above baseline values. AKI developed in 9.0% of study sample. Patients with AKI were older, more often women, and had high prevalence of comorbidities, including diabetes mellitus, hypertension, and advanced stages of chronic kidney disease at baseline. Blood transfusion was utilized in 2.2% of patients. In the overall sample, AKI developed in 35.1% of patients who received transfusion versus 8.4% of patients without transfusion (adjusted odds ratio, 4.87 [4.71–5.04]). In the subgroup of patients who sustained bleeding event and received transfusion, the rate of AKI was significantly increased across all preprocedure hemoglobin levels versus no blood transfusion. Similar findings were seen in the subgroup of patients with no bleeding event. Conclusions—Blood transfusion is strongly associated with AKI in patients with acute coronary syndrome undergoing PCI. Further investigation is needed to determine whether a restrictive blood transfusion strategy might improve PCI outcomes by reducing the risk of AKI.

The challenges of cardiovascular research in developing countries.

We read with interest the recent article by Prabhakaran et al. ([1][1]) reporting the results of the Global Cardiovascular Disease Research Survey. Not surprisingly, the study shows a low research output in developing (low-income and low-middle-income) countries. The authors postulate that a major

Asymptomatic Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia that could present as angina, acute myocardial infarction, or even sudden death. It occurs more commonly in women and it has been associated with autoimmune and collagen vascular diseases. The management and prognosis in these patients depend on the initial clinical presentation and the extent of dissection. In this article, we report 2 cases of asymptomatic SCAD that were diagnosed on routine preoperative evaluation. The management options and clinical implications are discussed. Copyright

Outdoor Air Pollution and Cardiovascular Diseases in Lebanon: A Case-Control Study

Outdoor air pollution is increasingly considered as a serious threat for cardiovascular diseases (CVD). The aim of this study is to investigate the association between outdoor pollutants and cardiovascular diseases among adults in Lebanon and to examine the possible moderator effect of cigarette smoking status on this association. A multicenter case-control study was conducted between October 2011 and October 2012. Cases were hospitalized patients diagnosed with CVD by a cardiologist while the control group subjects were free of any cardiac diseases. Information on sociodemographic characteristics, tobacco consumption, self-rated global health, pollution exposure, and other risk factors was collected using a questionnaire. The results of the logistic regression revealed that living near busy highway (OR 5.04, 95% CI (4.44–12.85), P < 0.001) and close to local diesel generator (OR 4.76, 95% CI (2.07–10.91), P < 0.001) was significantly associated with CVD. The association between the CVD and exposure to outside pollutants differed by cigarette smoking status. A clear difference was noted between nonsmokers and current smokers OR 4.6, 95% CI (1.10–19.25) and OR 10.11, 95% CI (7.33–20.23), respectively. Forthcoming studies are needed to clarify the potential link between outdoor air pollution and cardiovascular diseases in Lebanon. Public health interventions must be implemented to reduce air pollution and to improve air quality.

The yield of routine pre-operative cardiovascular evaluation in stable patients scheduled for elective non-cardiac surgery

Preoperative cardiovascular evaluation is commonly performed in patients scheduled for non-cardiac surgery. The recent ACC/AHA guidelines provide an algorithm for such an evaluation but whether all patients scheduled for surgery would benefit from it is not known. We determined the yield of preoperative cardiovascular evaluation in 522 stable patients, with no prior history of heart disease, who were scheduled for elective non-cardiac surgery. There were 14 patients (2.7%) in which the cardiac consultant requested further testing pre-operatively, and in 5 of them (1%), the findings on cardiac consultation and further testing would be considered to have impacted the decision on performing the surgery or the long term outcome of the patients. Using multivariable logistic regression analysis, the only clinical variable predictive of further testing was age > 65 years (OR = 4.47, p = 0.001). The yield of preoperative cardiovascular evaluation in stable patients scheduled for non-cardiac surgery is relatively low. Further studies are needed to identify what subgroup of patients might benefit most from it and those in whom it might not be warranted.