Shukri AlSaif

Prognostic Significance of Prevalent and Incident Atrial Fibrillation Among Patients Hospitalized with Acute Coronary Syndrome Findings from the Gulf RACE-2 Registry

There is a paucity of data on atrial fibrillation (AF) complicating acute coronary syndrome (ACS) in Arabian Gulf countries. Thus, we assessed the incidence of AF in patients with ACS in these countries and examined the associated in-hospital, 30-day, and 1-year adverse outcomes. The population comprised 7930 patients enrolled in the second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Of 7930 patients with ACS, 217 (2.7%) had AF. Compared with patients without AF, patients with AF were less likely to be male (65.9 vs 79.1%) and were older (mean age 64.6 vs 56.6 years). Compared with patients without AF, in-hospital, 30-day, and 1-year mortality were significantly higher in patients with any AF (odds ratio [OR]: 2.7, 2.2, 1.9, respectively; P < .001) and in patients with new-onset AF (OR: 5.2, 3.9, 3.1, respectively; P < .001. In conclusion, AF in patients with ACS was associated with significantly higher short- and long-term mortality.

Glomerular filtration rate estimated by the CKD-EPI formula is a powerful predictor of in-hospital adverse clinical outcomes after an acute coronary syndrome.

The prognostic value of admission estimated glomerular filtration rate (eGFR) calculated by the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula for cardiovascular adverse outcomes in acute coronary syndrome (ACS) was explored. Baseline eGFR was classified as no renal dysfunction (>90 mL/min per 1.73 m2), borderline (90-60.1 mL/min per 1.73 m2), moderate (60-30.1 mL/min per 1.73 m2), or severe (≤30 mL/min per 1.73 m2) renal dysfunction. Of the 5034 patients, 3415 (67.8%) had eGFR <90. Compared to patients with an eGFR ≥60 mL/min per 1.73 m2, patients with <60 mL/min per 1.73 m2 were less likely to be treated with β-blockers, angiotensin-converting enzyme inhibitors, or statins, or to undergo percutaneous coronary interventions. Lower eGFR showed a stepwise association with significantly worse adverse in-hospital outcomes. The adjusted odds ratio of in-hospital death with an eGFR <30 mL/min per 1.73 m2 was 3.1 (95% confidence interval 1.1-8.4, P = .0324), compared with an eGFR >90 mL/min per 1.73 m2. Estimated glomerular filtration rate calculated by the new CKD-EPI is an independent predictor of major adverse cardiac outcomes in patients with ACS.

The prognostic impact of in-hospital worsening of renal function in patients with acute coronary syndrome

BACKGROUND Renal impairment is strongly linked to adverse cardiovascular (CV) events. Baseline renal dysfunction is a strong predictor of CV mortality and morbidity in patients admitted with acute coronary syndrome (ACS). However, the prognostic importance of worsening renal function (WRF) in these patients is not well characterized. METHODS ACS patients enrolled in the SPACE (Saudi Project for Assessment of Coronary Events) registry who had baseline and pre-discharge serum creatinine data available were eligible for this study. WRF was defined as a 25% reduction from admission estimated glomerular filtration rate (eGFR) within 7 days of hospitalization. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared. RESULTS Of the 3583 ACS patients, WRF occurred in 225 patients (6.3%), who were older, had more cardiovascular risk factors, were more likely to be female, have past vascular disease, and presented with more non-ST-segment elevation myocardial infarction than patients without WRF (39.5% vs. 32.8%; p=0.042). WRF was associated with an increased risk of in-hospital death, heart failure, cardiogenic shock, and stroke. After adjusting for potential confounders, WRF was an independent predictor of in-hospital death (adjusted odd ratio 28.02, 95% CI 13.2-60.28, p<0.0001). WRF was more predictive of mortality than baseline eGFR. CONCLUSION These results indicate that WRF is a powerful predictor for in-hospital mortality and CV complications in ACS patients.

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.

Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia.

BACKGROUND AND OBJECTIVES Gender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored. DESIGN AND SETTINGS A prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis. PATIENTS AND METHODS Patients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed. RESULTS Of 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given β-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7–5.5; P=.14). CONCLUSION These data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Absence of obesity paradox in Saudi patients admitted with acute coronary syndromes: insights from SPACE registry.

BACKGROUND AND OBJECTIVES To describe the distribution of body mass index (BMI) and its relationship with clinical features, management, and in-hospital outcomes of patients admitted with acute coronary syndromes (ACS). DESIGN AND SETTINGS The Saudi Project for Assessment of Coronary Events is a prospective registry. ACS patients admitted to 17 hospitals from December 2005–2007 were included in this study. METHODS BMI was available for 3469 patients (68.6%) admitted with ACS and categorized into 4 groups: normal weight, overweight, obese, and morbidly obese. RESULTS Of patients admitted with ACS, 72% were either overweight or obese. A high prevalence of diabetes (57%), hypertension (56.6%), dyslipidemia (42%), and smoking (32.4%) was reported. Increasing BMI was significantly associated with diabetes, hypertension, and hyperlipidemia. Overweight and obese patients were significantly younger than the normal-weight group (P=.006). However, normal-weight patients were more likely to be smokers and had 3-vessel coronary artery disease, worse left ventricular dysfunction, and ST elevation myocardial infarction. Glycoprotein IIb-IIIa antagonists were used significantly more in overweight, obese, and morbidly obese ACS patients than in normal-weight patients (P≤.001). Coronary angiography and percutaneous intervention were reported more in overweight and obese patients than in normal-weight patients (P≤.001). In-hospital outcomes were not significantly different among the BMI categories. CONCLUSION High BMI is prevalent among Saudi patients with ACS. BMI was not an independent factor for in-hospital outcomes. In contrast with previous reports, high BMI was not associated with improved outcomes, indicating the absence of obesity paradox observed in other studies.

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.

Incidence of ventricular arrhythmia and associated patient outcomes in hospitalized acute coronary syndrome patients in Saudi Arabia: findings from the registry of the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE).

BACKGROUND AND OBJECTIVES Mortality in acute coronary syndrome (ACS) patients with ventricular arrhythmia (VA) has been shown to be higher than those without VA. However, there is a paucity of data on VA among ACS patients in the Middle Eastern countries. DESIGN AND SETTING Prospective study of patients admitted in 17 government hospitals with ACS between December 2005 and December 2007. PATIENTS AND METHODS Patients were categorized as having VA if they experienced either ventricular fibrillation (VF) or sustained ventricular tachycardia (VT) or both. RESULTS Of 5055 patients with ACS enrolled in the SPACE registry, 168 (3.3%) were diagnosed with VA and 151 (98.8%) occurred in-hospital. The vast majority (74.4%) occurred in patients with ST-segment elevation myocardial infarction. In addition, males were twice as likely to develop VA than females (OR 1.7; 95% CI 1.1–3). Killip class >I (OR 2.0; 95% CI 1.3–3.1); and systolic blood pressure <90 mm Hg (OR 6.4; 95% CI 3.5–11.8) were positively associated with VA. Those admitted with hyperlipidemia (OR 0.49; 95% CI 0.3–0.7) had a lower risk of developing VA. Adverse in-hospital outcomes including re-myocardial infarction, cardiogenic shock, congestive heart failure, major bleeding, and stroke were higher for patients with VA (P≤.01 for all variables) and signified a poor prognosis. The in-hospital mortality rate was significantly higher in VA patients compared with non-VA patients (27% vs 2.2%; P=.001). CONCLUSIONS In-hospital VA in Saudi patients with ACS was associated with remarkably high rates of adverse events and increased in-hospital mortality. Using a well-developed registry data with a large number of patients, our study documented for the first time the prevalence and risk factors of VA in unselected population of ACS.

Predictors and Impact of In-Hospital Recurrent Myocardial Infarction in Patients With Acute Coronary Syndrome: Findings From Gulf RACE-2

Background: Little is known about the predictors and prognostic impact of recurrent in-hospital ischemia and infarction in patients with acute coronary syndrome (ACS). Our objectives were to determine the baseline characteristics, risk factors, and long-term outcomes of patients with recurrent myocardial infarction (Re-MI). Methods: We evaluated patients with ACS who were enrolled in the second Gulf Registry of Acute Coronary Events from October 2008 to June 2009. Results: Of 7925 patients with ACS, 167 (2.1%) developed in-hospital Re-MI. Patients with Re-MI were older (mean age: 58.7 ± 13.4 vs 56.8 ± 12.6; P = .045), had higher rates of hyperlipidemia (42.5% vs 32.6%; P = .019), and were more likely to present with ST-segment elevation myocardial infarction (STEMI; 74.25% vs 43.9%; P < .001) and Killip class 4 (8.4% vs 3.2%; P < .001) than patients without Re-MI. Patients with Re-MI were less likely to receive evidence-based therapies upon admission, including aspirin (94.6% vs 98.5%; P < .001), β-blockers (59.3% vs 74.7%; P < .001), and statins (86.8% vs 94.9%; P < .001), and were less frequently assessed with coronary angiography (29.3% vs 32.5%; P = .029). Predictors of recurrent events included history of angina, hypotension on presentation, admission diagnosis of STEMI, and decreased use of evidence-based therapies including aspirin, statins, and β-blockers upon admission. Patients with Re-MI had more in-hospital complications, including congestive heart failure (44.3% vs 12.4%) and cardiogenic shock (26.4% vs 5.3%), as well as higher mortality rates during hospitalization (23.4% vs 4.1%) and after a discharge period of 30 days (27% vs 7.8%) and 1 year (30.5% vs 11.7%; P < .001 for all comparisons). Conclusion: In our study, patients with Re-MI were less likely to receive evidence-based therapies and had a worse prognosis in terms of in-hospital complications and higher mortality rates. High-risk patients should be monitored and managed differently to prevent secondary attacks.

Disparities in health care delivery and hospital outcomes between non-Saudis and Saudi nationals presenting with acute coronary syndromes in Saudi Arabia.

Background Saudi Arabia has a non-Saudi workers population. We investigated the differences and similarities of expatriate non-Saudi patients (NS) and Saudi nationals (SN) presenting with acute coronary syndromes (ACS) with respect to therapies and clinical outcomes. Methods The study evaluated 2031 of the 5055 ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) from 2005 to 2007. Propensity score matching and logistic regression analysis were performed to account for major imbalances in age and sex in the two groups. Results The mean patient age was 56.2±9.8, and 83.5% of the study cohort were male. SN were more likely to have risk factors of atherosclerosis. ST-elevation MI (STEMI) was the most common ACS presentation in NS, while non-ST ACS was more common in SN. The median symptom-to-door time was significantly greater in NS patients (Median 175 min (197) vs. 130 min (167), p=0.027). The only difference in pharmacological therapies between the two groups was that NS were more likely to receive fibrinolytic therapy. NS were less likely than SN to undergo percutaneous coronary interventions (PCI; 32.6% vs. 42.8%, p=0.0001) or primary PCI (7.8% vs. 22.8%, p<0.001). Hospital mortality, cardiogenic shock, and heart failure were significantly higher in NS compared to SN. After adjusting for baseline variables and therapies, the odds ratios for hospital mortality and cardiogenic shock in NS were 2.9 (95% CI 1.5–6.2, p=0.004) and 2.8 (95% CI 1.5–4.9, p<0.001), respectively. Conclusion Our findings indicate disparities in hospital care between NS and SN ACS patients. NS patients had worse hospital outcomes, which may reflect unequal health coverage and access-to-care issues.