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Abstract: Background: There is a paucity of data regarding acute myocardial infarction (MI) complicated by cardiogenic shock (AMI-CS) in the Gulf region. This study addressed this knowledge gap by examining patients experiencing AMI-CS in the Gulf region and analyzing hospital and short-term follow-up mortality. Methods: The Gulf-Cardiogenic Shock registry included 1,513 patients with AMI-CS diagnosed between January 2020 and December 2022. Results: The incidence of AMI-CS was 4.1% (1,513/37,379). The median age was 60 years. The most common presentation was ST-elevation MI (73.83%). In-hospital mortality was 45.5%. Majority of patients were in SCAI (Society for Cardiovascular Angiography and Interventions shock classification) stage D and E (68.94%). Factors associated with hospital mortality were previous coronary artery bypass graft (odds ratio [OR]: 2.49; 95% confidence interval [CI]: 1.321-4.693), cerebrovascular accident (OR: 1.621; 95% CI: 1.032-2.547), chronic kidney disease (OR: 1.572; 95% CI: 1.158-2.136), non-ST-elevation MI (OR: 1.744; 95% CI: 1.058-2.873), cardiac arrest (OR: 5.702; 95% CI: 3.640-8.933), SCAI stage D and E (OR: 19.146; 95% CI: 9.902-37.017), prolonged QRS (OR: 10.012; 95% CI: 1.006-1.019), right ventricular dysfunction (OR: 1.679; 95% CI: 1.267-2.226), and ventricular septal rupture (OR: 6.008; 95% CI: 2.256-15.998). Forty percent had invasive hemodynamic monitoring, 90.02% underwent revascularization, and 45.80% received mechanical circulatory support (41.31% had intra-aortic balloon pump and 14.21% had extracorporeal membrane oxygenation/Impella devices). Survival at 12 months was 51.49% (95% CI: 46.44%-56.29%). Conclusions: The study highlighted the significant burden of AMI-CS in this region, with high in-hospital mortality. The study identified several key risk factors associated with increased hospital mortality. Despite the utilization of invasive hemodynamic monitoring, revascularization, and mechanical circulatory support in a substantial proportion of patients, the 12-month survival rate remained relatively low., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by the Shock Society.)

Background: Shock index is a bedside reflection of integrated response of the cardiovascular and nervous systems. We aimed to evaluate the utility of shock index (heart rate/systolic blood pressure) in patients presenting with acute coronary syndrome (ACS)., Methods: We analyzed pooled data from seven Arabian Gulf registries; these ACS registries were carried out in seven countries (Qatar, Bahrain, Kuwait, UAE, Saudi Arabia, Oman and Yemen) between 2005 and 2017. A standard uniform coding strategy was used to recode each database using each registry protocol and clinical research form. Patients were categorized into two groups based on their initial shock index (low vs . high shock index). Optimal shock index cutoff was determined according to the receiver operating characteristic curve (ROC). Primary outcome was hospital mortality., Results: A total of 24,636 ACS patients met the inclusion criteria with a mean age 57±13 years. Based on ROC analysis, the optimal shock index was 0.80 (83.5% had shock index <0.80 and 16.5% had shock index ≥0.80). In patients with high shock index, 55% had ST-elevation myocardial infarction and 45% had non-ST-elevation myocardial infarction. Patients with high shock index were more likely to have diabetes mellitus, late presentation, door to electrocardiogram >10 min, symptom to Emergency Department > 3 h, anterior myocardial infarction, impaired left ventricular function, no reperfusion post-therapy, recurrent ischemia/myocardial infarction, tachyarrhythmia and stroke. However, high shock index was associated significantly with less chest pain, less thrombolytic therapy and less primary percutaneous coronary intervention. Shock index correlated significantly with pulse pressure ( r = -0.52), mean arterial pressure ( r = -0.48), Global Registry of Acute Coronary Events score ( r =0.41) and Thrombolysis In Myocardial Infarction simple risk index ( r = -0.59). Shock index ≥0.80 predicted mortality in ACS with 49% sensitivity, 85% specificity, 97.6% negative predictive value and 0.6 negative likelihood ratio. Multivariate regression analysis showed that shock index was an independent predictor for in-hospital mortality (adjusted odds ratio (aOR) 3.40, p <0.001), heart failure (aOR 1.67, p <0.001) and cardiogenic shock (aOR 3.70, p <0.001)., Conclusions: Although shock index is the least accurate of the ones tested, its simplicity may argue in favor of its use for early risk stratification in patients with ACS. The utility of shock index is equally good for ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. High shock index identifies patients at increased risk of in-hospital mortality and urges physicians in the Emergency Department to use aggressive management.

Background: This pilot study describes the overall design and results of the Program for the Evaluation and Management of the Cardiac Events registry for the Middle East and North Africa (MENA) Region., Methods: This prospective, multi-center, multi-country study included patients hospitalized with acute myocardial infarction (AMI) and/or acute heart failure (AHF). We evaluated the clinical characteristics, socioeconomic and educational levels, management, in-hospital outcomes, and 30-day mortality rate of patients that were admitted to one tertiary-care center in each of 14 Arab countries in the MENA region., Results: Between 22 April and 28 August 2018, 543 AMI and 381AHF patients were enrolled from 14 Arab countries (mean age, 57±12 years, 82.5% men). Over half of the patients in both study groups had low incomes with limited health care coverage, and limited education. Nearly half of the cohort had a history of diabetes mellitus, hypertension, or hypercholesterolemia. Among patients with ST-elevation myocardial infarctions, 56.4% received primary percutaneous interventions, 24% received thrombolysis, and 19.5% received no acute reperfusion therapy. The main causes of AHF were ischemic heart diseases (55%) and primary valvular heart diseases (15%). The in-hospital and 30-day mortality rates were 2.0% and 3.5%, respectively, for AMI, and 5.4% and 7.0%, respectively, for AHF., Conclusions: This pilot study revealed a high prevalence of cardiovascular risk factors in patients with AMI and AHF in Arab countries, and low levels of socioeconomic and educational status. Future phases of the study will improve our understanding of the impact that these factors have on the management and outcomes of cardiac events in these patient populations., Competing Interests: Roche Diagnostic Middle East FZCO is the commercial funder of the study."This does not alter our adherence to PLOS ONE policies on sharing data and materials.”

Background: The prognostic impact of β-blockers (BB) in acute coronary syndrome (ACS) patients without heart failure (HF) or left ventricular dysfunction is controversial, especially in the postreperfusion era. We sought to determine whether a BB therapy before admission for ACS has a favorable in-hospital outcome in patients without HF, and whether they also reduce 12-month mortality if still prescribed on discharge., Methods and Results: The GULF-RACE 2 (Gulf Registry of Acute Coronary Events-2) is a prospective multicenter study of ACS in 6 Middle Eastern countries. We studied in-hospital cardiovascular events in patients hospitalized for ACS without HF in relation to BB on admission, and 1-year mortality in relation to BB on discharge. Among the 7903 participants, 7407 did not have HF, of whom 5937 (80.15%) patients were on BB. Patients on BB tended to be older and have more comorbidities. However, they had a lower risk of in-hospital mortality, mitral regurgitation, HF, cardiogenic shock, and ventricular tachycardia/ventricular fibrillation. Furthermore, 4208 patients were discharged alive and had an ejection fraction ≥40%. Among those, 84.1% had a BB prescription. At 12 months, they also had a reduced risk of mortality as compared with the non-BB group. Even after correcting for confounding factors in 2 different models, in-hospital and 12-month mortality risk was still lower in the BB group., Conclusions: In this cohort of ACS, BB therapy before admission for ACS is associated with decreased in-hospital mortality and major cardiovascular events, and 1-year mortality in patients without HF or left ventricular dysfunction if still prescribed on discharge., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: A U-shaped relationship has been reported between BMI and cardiovascular events among patients with acute heart failure (AHF). We hypothesized that an obesity paradox also governs the relationship between BMI and mortality in patients with type 2 diabetes (T2D) and AHF., Methods: We studied 3-month and 12-month mortality in patients with T2D hospitalized for AHF according to 5 BMI categories: Underweight (<20kg/m 2 ), normal weight (referent group, 20-24.9kg/m 2 ), overweight, (25-29.9kg/m 2 ), obese (30-34.9kg/m 2 ) and severely obese (≥35kg/m 2 ), in the Gulf aCute heArt failuRe rEgistry (GULF-CARE)., Results: Among the 5005 participants in this cohort, 2492 (49.8%) had T2D. Underweight patients had a higher 3-month and 12-month mortality risk (OR 2.04, 95% CI [1.02-4.08]; OR 2.44, 95% CI [1.35-4.3]; respectively), compared to normal weight. Severe obesity was associated with a lower 3-month and 12-month mortality risk (OR 0.53, 95% CI [0.34-0.83]; OR 0.58, 95% CI [0.42-0.81]; respectively). After adjustment for several risk variables in 2 different models, the primary outcome was still significantly increased in underweight patients, and decreased in severely obese patients, at 3months and 12months. Further, the odds of mortality decreases with increasing BMI by 0.38 at 3months and at 0.45 at 12months in a near-linear shape (p=0.007; p=0.037; respectively)., Conclusions: In this cohort of patients with AHF, BMI was inversely correlated to the risk of mortality in patients with T2D. Moreover, severe obesity was associated with less mortality risk., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: The purpose of this study was to report the prevalence, clinical characteristics, contributing factors, management and outcome of patients with chronic obstructive pulmonary disease (COPD) among patients hospitalized with heart failure (HF)., Methods: Data were derived from Gulf Care (Gulf acute heart failure registry), a prospective multicenter study of 5005 consecutive patients hospitalized with acute heart failure during February to November 2012 in seven Middle Eastern countries. Data were described and compared for demographics, management and outcomes., Results: The prevalence of COPD among HF patients was 10%. COPD patients were older, more likely to be female and to have diabetes, hypertension, chronic kidney disease and sleep apnea (P = 0.001 for all) when compared to non-COPD patients. Contributing factors for hospitalization were systemic infection and atrial arrhythmias in COPD patients compared to acute coronary syndrome, uncontrolled hypertension and anemia in the non-COPD patients. Left-ventricular ejection fraction was higher in COPD patients; while BNP levels were comparable between the two groups. Non-invasive ventilation was used more frequently among COPD patients compared to non-COPD patients (P = 0.001). On multivariate logistic regression analysis, COPD was not associated with increased risk in-hospital and one-year death among acute heart failure (AHF) population and β blockers treatment appear to have neutral mortality effect in COPD patients with HF., Conclusion: COPD have distinct cardiovascular risk profile and precipitating factors for hospitalization with HF when compared to non-COPD patients. COPD history had no impact on the short-term and one-year mortality.

Objectives: The purpose of this study is to report the prevalence, clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with acute heart failure (HF)., Design: Retrospective analysis of prospectively collected data., Setting: Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicentre study of consecutive patients hospitalised with acute HF in 2012 in seven Middle Eastern countries and analysed according to the presence or absence of prior stroke; demographics, management and outcomes were compared., Participants: A total of 5005 patients with HF., Outcome Measures: In-hospital and 1-year outcome., Results: The prevalence of prior stroke in patients with HF was 8.1%. Patients with stroke with HF were more likely to be admitted under the care of internists rather than cardiologists. When compared with patients without stroke, patients with stroke were more likely to be older and to have diabetes mellitus, hypertension, atrial fibrillation, hyperlipidaemia, chronic kidney disease, ischaemic heart disease, peripheral arterial disease and left ventricular dysfunction (p=0.001 for all). Patients with stroke were less likely to be smokers (0.003). There were no significant differences in terms of precipitating risk factors for HF hospitalisation between the two groups. Patients with stroke with HF had a longer hospital stay (mean±SD days; 11±14 vs 9±13, p=0.03), higher risk of recurrent strokes and 1-year mortality rates (32.7% vs 23.2%, p=0.001). Multivariate logistic regression analysis showed that stroke is an independent predictor of in-hospital and 1-year mortality., Conclusions: This observational study reports high prevalence of prior stroke in patients hospitalised with HF. Internists rather than cardiologists were the predominant caregivers in this high-risk group. Patients with stroke had higher risk of in-hospital recurrent strokes and long-term mortality rates., Trial Registration Number: NCT01467973., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background and Objectives: Primary percutaneous coronary intervention (pPCI) has been recognized as an effective management strategy for acute ST-segment-elevation myocardial infarction (STEMI). However, there is no first-hand information regarding the quality of pPCI procedures in the Arabian Gulf countries. This study aims to explore the quality of pPCI practice., Design and Settings: The Gulf Race II was designed as a prospective, multinational, multicentre registry of acute coronary events, focusing on the epidemiology, management practices, and outcomes of patients with acute coronary syndrome. The study recruited consecutive patients aged 18 years and above from 65 hospitals in 6 adjacent Middle Eastern countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen)., Patients and Methods: We used data from the Gulf Registry of Acute Coronary Events (Gulf RACE 2). We analyzed data on patients who received pPCI to assess the guidelines-supported performance measure of door-to-balloon (D2B).

Background: Atrial fibrillation (AF) is the most common serious cardiac arrhythmia, and its prevalence is expected to increase. There is lack of data about patient characteristics, practice patterns, and outcomes of AF in the Arab Middle East., Methods and Results: The Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) is a prospective, observational registry of patients with AF with a 12-month follow-up. The registry was emergency room based. Between October 2009 and June 2010, 2043 consecutive patients with AF were enrolled from 23 hospitals in 6 Middle Eastern Gulf countries. Data were collected on a standardized case report form and entered online. Data collected included patient demographics, medical history, type of AF, treatment, and outcome of emergency room visit. If patients were admitted, details of their treatment, investigations, and outcomes during hospital stay were collected. Completion of 12-month follow-up is expected by July 2011. The mean age was 57 years, and 52% were men. The most common concomitant condition was hypertension, present in 1072 (52%) patients. At enrollment, 28% of patients had a history of coronary artery disease, 30% had diabetes, and 16% had rheumatic valve disease. History of stroke and transient ischemic attacks were reported in 9% and 4% of patients, respectively. The most common type of AF, first attack AF, occurred in 37%, whereas 19% of patients had lone AF., Conclusions: Gulf SAFE will provide valuable insights into AF management and outcomes in the Gulf region of the Middle East.

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.

Objective: To identify the characteristics, treatments and hospital outcomes for patients diagnosed with acute coronary syndromes (ACS) in the Gulf area., Methods: Prospective, multinational, multicentre, observational survey of consecutive ACS patients who were admitted to 65 hospitals during May 2006., Results: A total of 1484 ACS patients were recruited. The mean age was 55 years, and 76% were men. The final discharge diagnosis was ST-segment elevation myocardial infarction (STEMI) in 37%, non-ST-segment elevation myocardial infarction (NSTEMI) in 32%, left bundle branch block myocardial infarction (LBBB MI) in 2%, and unstable angina in 29%. Among patients with STEMI and LBBB MI, the reperfusion rate was 65%, with use of primary percutaneous coronary intervention in 7% and thrombolytic therapy in 93%. When thrombolytic therapy was used, the median door to needle time was 45 minutes, with 37% receiving it within 30 minutes of hospital presentation. During the first day of hospitalization, aspirin was administered to 94%, clopidogrel to 51%, and beta blockers to 65%. Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers and statins were used in 62% and 82%, respectively. Coronary angiography during hospitalization was performed in 21%. In-hospital mortality was 3%., Conclusion: We were able to determine the characteristics, treatments and in-hospital outcomes of patients hospitalized with ACS in our region. There is room for improvement in using medications, reducing needle to door time and utilizing more cardiac catheterization services.