Jawad Al-Lawati

Comparison of men and women with acute coronary syndrome in six Middle Eastern countries.

The aim of this study was to evaluate the gender differences in baseline characteristics, therapy, and outcomes in patients with acute coronary syndromes in 6 Middle Eastern countries. Over a 6-month period in 2007, 8,169 consecutive patients (74% men, 24% women) presenting with acute coronary syndromes were enrolled in a prospective, multicenter study from 6 adjacent Middle Eastern countries. Women were 9 years older than men and more likely to have diabetes, hypertension, and dyslipidemia. Women were more likely to present with unstable angina and more often had atypical presentations of ST elevation myocardial infarction. Compared to men, women were significantly less treated with beta blockers and antiplatelet therapy, whereas reperfusion therapy was nonsignificantly less used in women. In all patients with acute coronary syndromes, women not only ranked higher on Global Registry of Acute Coronary Events risk score but also had increased in-hospital mortality, 1.75 times that of men. This mortality difference persisted after adjusting for all confounders (odds ratios 1.76, 95% confidence interval 1.1 to 2.8, p <0.01). In conclusion, in addition to presentation with higher risk factors, female gender also independently predicted poorer outcomes in patients with ST elevation myocardial infarction.

Management and outcomes of Middle Eastern patients admitted with acute coronary syndromes in the Gulf Registry of Acute Coronary Events (Gulf RACE).

Objectives — To identify the characteristics, management and hospital outcomes of acute coronary syndrome (ACS) patients in the Gulf region of the Middle East. Methods and results — Overall, 8176 consecutive patients with the final diagnosis of ACS were recruited in 6 months, from 64 hospitals in 6 countries.The mean age of patients was 56 years. At presentation, 40% of patients had diabetes and 38% were current smokers. Of 2268 patients eligible for reperfusion, 183 (8%) underwent primary percutaneous coronary intervention, 1856 (82%) received thrombolytic therapy and 219 patients (10%) did not receive any reperfusion.The median door-to-needle time was 45 minutes.The majority of patients received aspirin (96%), beta-blockers (77%), angiotensin-converting enzyme inhibitors (77%) and statins (83%) at discharge. Less than 1 in 5 patients received coronary angiography (19%). Low-risk patients were more likely to undergo coronary angiography than high-risk patients (odds ratio 1.35, 95% confidence interval 1.15 to 1.58, P < 0.001). Patients with recurrent ischaemia were 4 times more likely to undergo coronary angiography than those without;and patients who lived in UAE and Bahrain were about 3-4 times more likely to undergo this procedure than those who lived in other participating countries (P < 0.001 for both).The overall hospital mortality was 3.6%. Conclusions — Patients with ACS in the Arab Middle East are younger than in developed countries and have higher rates of diabetes and smoking. There is good adherence to evidence-based medications; however, improvement in door-to-needle time and utilisation of interventional procedures is needed.

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.

Prevalence of the Metabolic Syndrome in Patients With Acute Coronary Syndrome in Six Middle Eastern Countries

J Clin Hypertens (Greenwich).

Utilization and Determinants of In-Hospital Cardiac Catheterization in Patients With Acute Coronary Syndrome From the Middle East

We assessed the use and determinants of cardiac catheterization during index admissions, among patients with acute coronary syndrome (ACS) in the Middle East. Data were analyzed from 8150 consecutive ACS patients enrolled prospectively. The overall rate of cardiac catheterization was 20%. Major predictors of cardiac catheterization were university hospitals, hospitals with catheterization facilities, physician type, and Gulf citizenship. High-risk patients were catheterized less compared to low-risk patients; odds ratio (OR) 0.44, 95% confidence interval (CI): 0.33-0.60, P < .001 and OR 0.68, 95% CI: 0.48-0.98, P = .037 for patients with non-ST-elevation ACS and ST-elevation myocardial infarction, respectively. The use of cardiac catheterization in patients with ACS from Middle East is low. It is related more to hospital characteristics than to baseline risks. There is a need to explore ways to increase overall rate of in-hospital cardiac catheterization in the region and direct it to patients who would benefit most.

Marital Status and Outcome of Patients Presenting with Acute Coronary Syndrome: An Observational Report

Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear.

Prevalence, predictors, and outcomes of conservative medical management in non-ST-segment elevation acute coronary syndromes in Gulf RACE-2.

We assessed the prevalence, predictors, and in-hospital and long-term outcomes of conservative medical management for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) compared with percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This prospective study conducted from October 2008 to June 2009 in 65 hospitals from 6 Arabian Gulf countries included 30-day and 1-year mortality follow-up for 3661 patients. Compared with conservative management group (2859 patients; 78.1%), the PCI group (638; 17.4%) had significantly better unadjusted and adjusted in-hospital (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17-0.97), 30-day (OR: 0.44, 95% CI: 0.24-0.76) and 1-year (OR: 0.58, 95% CI: 0.40-0.87) mortality rates. Comparison with the CABG group (164; 4.5%) yielded similar results with inclusion of patients scheduled for CABG after hospital discharge. Independent predictors of conservative medical management were mainly country of residence and history of prior CABG.

Cardiovascular Risk Assessment in Diabetes Mellitus: Comparison of the General Framingham Risk Profile Versus the World Health Organization/ International Society of Hypertension Risk Prediction Charts in Arabs—Clinical Implications

We estimated the prevalence of cardiovascular disease (CVD) risk and its clinical implications among 1 110 Omani patients with type 2 diabetes mellitus (DM) using 2 different CVD risk tools: the general Framingham risk profile (GFRP) and the joint World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction charts. The GFRP tool identified higher proportion of patients compared with joint WHO/ISH tool at 10-year CVD risk 10% to <20% and at 20% to <30%. At CVD risk ≥30%, both assessment tools identified similar proportions of patients (22% vs 24%; P=.120). Compared with WHO/ISH charts, the GFRP identified almost double the number of men eligible for aspirin treatment at CVD risk thresholds of ≥10% (86% vs 43%). In women, the proportions were, 66% and 45%, respectively. For statins, the figures were, 60% and 37%, for men and 28% and 36%, for women. In conclusion, the GFRP overestimates the number of patients eligible for primary prevention of CVD compared with the joint WHO/ISH method.

Control of risk factors for cardiovascular disease among adults with previously diagnosed type 2 diabetes mellitus: a descriptive study from a middle eastern arab population.

Background: Despite the high burden of type 2 diabetes mellitus (T2DM) in Oman, there are scarce data from a nationally representative sample on the level of glycaemia and other cardiovascular (CVD) risk factor control. Objective: To estimate the proportion of patients with T2DM at goal for glycaemia and CVD risk factors using the National Diabetes Guidelines (NDG) and the American Diabetes Association (ADA) clinical care guidelines; and to assess the quality of selected services provided to patients with T2DM. Methods: A sample of 2,551 patients (47% men) aged ≥20 years with T2DM treated at primary health care centers was selected. Patient characteristics, medical history and treatment were collected from case notes, Diabetes Registers and computer frameworks including the use of the last 3 laboratory investigations results and blood pressure (BP) readings recorded in 2007. Results: The overall mean age of the cohort was 54±13 years with an average median duration of diabetes of 4 (range 2 to 6) years. Over 80% of patients were overweight or obese (body mass index (BMI) of ≥25 Kg/m2). Sixty-nine percent were on oral anti-diabetic medication, 52% on anti-hypertensives and 40% on lipid lowering drugs. Thirty percent of patients were at goal for glycosylated haemoglobin level (<7%), 26% for BP (systolic/diastolic <130/80 mmHg), 55% for total cholesterol (<5.2 mmol/l), 4.5% for low-density lipoprotein cholesterol (<1.8 mmol/l), 52% for high-density lipoprotein cholesterol (>1 mmol/l for men, >1.3 mmol/l for women), and 61% for triglycerides (<1.7 mmol/l). Over 37% had micro-albuminuria and 5% had diabetic nephropathy. Conclusion: Control of hyperglycaemia and other CVD risk factor appears to be suboptimal in Omani patients with T2DM and need to be addressed in the triad of patient, physician and health system.

The prevalence and outcome of hypertension in patients with acute coronary syndrome in six Middle-Eastern countries.

Abstract Aims. The aim was to report the prevalence and significance of hypertension (HTN) in patients with acute coronary syndrome (ACS). Methods and major findings. Over a 6-month period in 2007, 8171 consecutive patients (49.4% hypertensive and 50.6% non-hypertensive) presenting with ACS were enrolled in a prospective, multicenter study from six Middle Eastern adjacent countries. Patients with HTN were older (59.2 vs 53.1 years, p<0.001), and more likely to be female (34% vs 14.4%, p<0.001) when compared with patients without HTN. Patients with HTN were also more likely to have diabetes mellitus, hyperlipidemia, cerebrovascular disease, prior history of coronary artery disease, peripheral artery disease but less likely to be cigarette smokers. At admission, HTN patients had higher Killip class, heart rate and GRACE risk scoring. In-hospital mortality was higher in hypertensive patients with ST-elevation myocardial infarction (STEMI) but not in patients with non-STEMI or unstable angina. The incidence of heart failure complications was significantly higher among patients with HTN in overall ACS type (OR = 1.2, 95% CI 1.001–1.338, p= 0.04). Main conclusion. In this large cohort of patients with ACS, HTN was an independent predictor of heart failure and was associated with an increased rate of in-hospital mortality in STEMI only.