Muath Alanbaei

Initial hospital pulse pressure and cardiovascular outcomes in acute coronary syndrome

BACKGROUND The association between admission pulse pressure (PP) and cardiovascular outcomes in acute coronary syndrome (ACS) is not well defined. AIM To explore the prognostic value of initial PP in ST-segment elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS). METHODS Over a 5-month period in 2007, 6704 consecutive patients with ACS were categorized into five groups according to initial PP: P1, PP ≤0; P2, PP 31-40; P3, PP 41-50; P4, PP 51-60; P5, PP>60mmHg. Patient characteristics and in-hospital outcomes were analysed. RESULTS Mean PP was lower in men versus women (55±19 vs. 61±22), young versus old (53±17 vs. 59±21), STEMI vs. NSTE-ACS (51±18 vs. 60±18) and patients who died versus survived (46±22 vs. 57±19mmHg) (P<0.001 for all). Most patients with low PP had a high Global Registry of Acute Coronary Events risk score. Compared with P5, crude odds ratios (ORs) (95% confidence intervals) for death were: P1, 9 (5.78-13.35); P2, 3 (1.71-4.06); P3, 1.5 (1.01-2.49); P4, 0.90 (0.51-1.58). After adjustment, low PP was associated with high mortality and stroke rates in ACS (adjusted ORs 7.5 [3.77-14.72] and 4.5 [1.20-18.88], respectively), high rates of recurrent ischaemia in NSTE-ACS (adjusted OR 2.8 [1.52-5.22]) and a high heart failure rate in STEMI (adjusted OR 2.1 [1.18-3.76]). Women with low PP had a higher mortality rate than men. CONCLUSION In ACS, all blood pressure variables were significantly correlated. Low PP was an independent predictor for stroke and mortality in overall ACS. Although PP was not superior to systolic blood pressure, only low PP was an independent predictor for recurrent ischaemia in NSTE-ACS.

Early Stroke following Acute Myocardial Infarction: Incidence, Predictors and Outcome in Six Middle-Eastern Countries

Background and Objectives: Stroke is a potential complication of acute myocardial infarction (AMI). The aim of this study was to identify the incidence, risk factors predisposing to stroke and in-hospital outcome during the index admission with AMI among patients in the Middle East. Methods: For a period of 6 months in 2006 and 2007, 5,833 consecutive AMI patients were enrolled from 64 hospitals in 6 Middle East countries. Results: The incidence of in-hospital stroke following AMI was 0.85%. Most cases were ST segment elevation AMI-related and ischemic in nature. Patients with in-hospital stroke were older than patients without stroke and were more likely to be female (36 vs. 18.6%, p = 0.0033). They were also more likely to have diabetes mellitus, dyslipidemia, prior AMI, or percutaneous/surgical coronary revascularization. Patients with stroke were more likely to present with advanced Killip class II–IV, higher mean heart rate and higher serum creatinine. Independent predictors of stroke were age, prior stroke, prior coronary artery bypass surgery, anterior AMI and systolic blood pressure >190 mm Hg on presentation. Early administration of statins was independently associated with reduced stroke risk (odds ratio, OR, 0.4, 95% confidence interval, CI, 0.19–0.90, p = 0.025). Stroke was fatal in 44% of the cases and was independently associated with in-hospital mortality (adjusted OR 12.5, 95% CI 5.7–27.4, p < 0.01). Conclusion: There is a low incidence of in-hospital stroke in Middle-Eastern patients presenting with AMI but with very high fatality rates. Early statin therapy was associated with a significant reduction in stroke risk. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

Impact of diabetes and smoking epidemic in the Middle East on the presentation with acute coronary syndrome in very young patients.

We describe the baseline characteristics, management, and outcomes of acute coronary syndrome (ACS) in patients of age ≤40 in the Gulf region of the Middle East. We studied 8176 hospitalized patients (≤40 years) with ACS. Ten percent (805) of the recruited patients were ≤40 years. The mean age was 37 years and 89% were males. The prevalence of smoking and diabetes in the young patients was high (58% and 21%, respectively). The most common ACS was ST elevation myocardial infarction. Younger patients were more aggressively treated with more frequent use of glycoprotein inhibitors, thrombolytics, and primary percutaneous coronary intervention. They had less in-hospital heart failure, left ventricular dysfunction, shock, stroke, and low rate of in-hospital mortality (1%). Measures to combat the rising prevalence of diabetes and smoking are needed.

Clinical characteristics and outcomes of patients with acute coronary syndrome and prior coronary artery bypass grafting in a large middle eastern cohort.

Background: Acute Coronary Syndrome (ACS) can occur in patients with prior coronary artery bypass grafting (CABG). In the Gulf Registry of acute coronary events (Gulf RACE), we identified the clinical characteristics and in-hospital outcomes of these patients. Methods: Clinical characteristics and in-hospital outcomes for 461 ACS patients with prior CABG are compared to 7715 ACS patients without prior CABG enrolled from 64 hospitals in 6 Gulf countries over a 6-month period. Results: The overall incidence of ACS with prior CABG was 5.6% out of 8176 patients. The ACS with prior CABG were older (63 vs 55 years, P<0.0001), had more history of diabetes (62.3 vs 37.6%, P <0.0001), dyslipidemia (70.3 vs 29.5%, P<0.0001), and hypertension (75.7 vs 47.8%, P<0.0001) compared with the non-CABG group. They presented more frequently with dyspnea (14.8 vs 9.5%, P<0.0005), non-ST segment elevation myocardial infarction (41.4 vs 31.6%, P<0.0001) and echocardiographic evidence of left ventricular dysfunction (49.4 vs 29.8%, P<0.0001) than ACS without prior CABG. They had a complicated in-hospital course with more recurrent ischemia (13.9 vs 9.3%, P=0.0011), heart failure (24.1 vs 15.7%), and stroke (2.2 vs 0.6%) compared with those without CABG. The in-hospital mortality rate was 5.6% in the CABG group compared with 3.5% in the ACS without prior CABG group. After adjusting for confounders, prior CABG was independently associated with recurrent ischemia and shock, more in patients presenting with ST elevation than non-ST elevation ACS. Conclusions: Patients with ACS and prior CABG are a high-risk group with poor outcomes irrespective of their older age and comorbidities. They should be identified and treated differently to improve their outcomes.

Impact of Diabetic Status on the Hyperglycemia-Induced Adverse Risk of Short Term Outcomes in Hospitalized Patients with Acute Coronary Syndromes in the Middle East: Findings from the Gulf Registry of Acute Coronary Events (Gulf RACE)

Background: While glucose levels on admission are clearly a much stronger predictor of short term adverse outcomes than diabetes status, there is a paucity of data on how diabetes status impacts the hyperglycemia-induced increased risk. Methods: 2786 patients admitted to the hospital with acute coronary syndrome (ACS) and diabetic level hyperglycemia (random >11.1 mmol/L or fasting >7 mmol/L) were identified from a Gulf registry of ACS. We divided the cohort into two groups. Those who were previously known to have diabetes mellitus were identified as the known diabetes group, and the non-diabetic group included those without a previous diabetes diagnosis. We used logistic regression models to assess the effect of glycemic status on hospital mortality and other patient outcomes including heart failure, stroke, recurrent ischemia, cardiogenic shock, major bleeding, and ventilation. Results: About two-thirds of the hyperglycemics on admission had been diagnosed previously with diabetes. After adjusting for age, in-hospital mortality was significantly higher in the non-diabetic group (OR: 2.36; 95% CI 1.54–3.61) compared to the diabetic group. As for the other outcomes, known diabetes patients had significantly lower incidences of heart failure, cardiogenic shock, and ventilation compared to non-diabetic patients. Conclusion: The effects of hyperglycemia are mitigated by the presence of the chronic diabetic state, and thus, hyperglycemia has a worse effect in those not known to have chronic diabetes. These findings are important and call for further investigation.

The obesity paradox in patients with acute coronary syndrome: results from the Gulf RACE-2 study.

We investigated the association between in-hospital and peri-hospital mortality and body mass index (BMI)/waist circumference (WC) in a prospective acute coronary syndrome (ACS) registry in the Arabian Gulf. No significant associations with in-hospital mortality were found. Normal BMI had highest peri-hospital mortality, notably those with high WC. In logistic regression of mortality on obesity measures and potential confounders, the effects of obesity measures were no longer significant. In-hospital death increased by 5% with age and decreased by 42% in males. Mortality increased 3.7-fold with ST-elevation myocardial infarction (STEMI) and 3.0-fold with heart failure (HF) but decreased by 33% with dyslipidemia. Peri-hospital death increased by 4% with age and decreased by 30% in males. Mortality increased 2.8-fold with STEMI and 2.4-fold with HF. In- and peri-hospital mortality in ACS is significantly associated with age, gender, STEMI, HF, and dyslipidemia but not obesity measures.

Efficacy and Safety Assessment of Hypertension Management with Coveram (Perindopril/Amlodipine Fixed Combination) in Patients with Previous Angiotensin Receptor Blocker (ARB) Treatment: Arabian Gulf STRONG Study

OBJECTIVE We evaluated the safety and efficacy of hypertension management with Coveram (perindopril/amlodipine combination) in patients with uncontrolled blood pressure (BP). All patients were on previous angiotensin receptor blocker (ARB) treatment. METHODS This was a 3 country, multi-centre (7 cities), open-label, observational study in the Arabian Gulf. Patients (≥18 years) were recruited between October 2012 and November 2013 and followed-up for 3 months after enrolment. Outcomes included changes in BP from baseline and BP goal attainment rates as per Joint National Committee- 8 (<140/90 mmHg for diabetics and those <60 years of age and <150/90 mmHg for those ≥60 years of age without diabetes). Medication tolerance was also assessed from both patient and physician perspectives. RESULTS Hypertensive patients (n=760; mean age: 51±10 years; 67% were males) were included. A total of 178 patients (23%) were lost to follow-up. The perindopril/amlodipine combination was associated with an overall reduction in systolic BP (SBP) (31 mmHg; p<0.001) and diastolic BP (DBP) (18 mmHg; p<0.001) from baseline. An overall BP control rate was achieved in 87% (n=507) of the participants. There were significant incremental BP reductions with dose up-titration, especially SBP (p<0.001). Those with high SBP (>180 mmHg) at baseline were associated with a mean reduction of 59 mmHg (p<0.001). The perindopril/amlodipine combination had excellent tolerance levels over the study period from both patient and physician perspectives (at 99% and 98%, respectively; p<0.001). CONCLUSIONS The perindopril/amlodipine combination is an effective and well tolerated anti-hypertensive option in patients on previous ARB treatment.