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Background: Data about the use of positive inotropic agents in patients hospitalized with acute decompensated heart failure (ADHF) is limited., Methods: The records of 8066 patients with ADHF who were hospitalized at Hamad Medical Corporation, Qatar from 1991 to 2013 were analyzed to explore demographics and clinical characteristics of the patients according to inotropic agents use., Results: Eight hundred fifty eight patients [10.6%, 95% CI (10 to 11.3%)] received intravenous inotropic support. Patients receiving inotropes were more likely to be female and have preserved ejection fraction when compared to those not receiving inotropic agents. Comorbidities associated with higher likelihood of receiving inotropic treatment included acute myocardial infarction, chronic renal impairment, dyslipidemia, hypertension, obesity and hyperglycemia. Patient on inotropes were more likely to undergone percutaneous coronary intervention (PCI), intra-aortic balloon pump support and intubation. There were no differences in the mean plasma BNP and CK-MB levels between the 2 groups. Heart failure patients receiving inotropes also were more likely to have complications including ventricular tachycardia (2.0% vs. 0.9%, p = 0.003), prolonged hospital stay (8.0 vs. 5.0 days, p = 0.001), cardiac arrest (14.6% vs. 3.2%, p = 0.001) and in-hospital mortality (30.8% vs. 9.1 %, p = 0.001). Over the study period there was an increase use of inotropic agents and decreased mortality rates., Conclusion: Inotropic use increased over the period whereas; female gender and conventional cardiac risk factors were predictors of inotropic agents use in the study.

Background: Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries., Methods: Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015., Results: We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes., Conclusion: Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

Background: The primary objective of this study was to evaluate the impact of polypharmacy on primary and secondary adherence to evidence-based medication (EBM) and to measure factors associated with non-adherence among patients who underwent percutaneous coronary intervention (PCI)., Methods: We conducted a retrospective analysis for patients who underwent PCI at a tertiary cardiac care hospital in Qatar. Patients who had polypharmacy (defined as ≥6 medications) were compared with those who had no polypharmacy at hospital discharge in terms of primary and secondary adherence to dual antiplatelet therapy (DAPT), beta-blockers (BB), angiotensin converting enzyme inhibitors (ACEIs) and statins., Results: A total of 557 patients (mean age: 53±10 years; 85%; males) who underwent PCI were included. The majority of patients (84.6%) received ≥6 medications (polypharmacy group) while only 15.4% patients received ≥5 medications (nonpolypharmacy group). The two groups were comparable in term of gender, nationality, socioeconomic status and medical insurance. The non-polypharmacy patients had significantly higher adherence to first refill of DAPT compared with patients in the polypharmacy group (100 vs. 76.9%; p=0.001). Similarly, the non-polypharmacy patients were significantly more adherent to secondary preventive medications (BB, ACEI and statins) than the polypharmacy group., Conclusion: In patients who underwent PCI, polypharmacy at discharge could play a negative role in the adherence to the first refill of EBM. Further studies should investigate other parameters that contribute to long term non-adherence.

Background and Objectives: In Qatar, ACS (Acute Coronary Syndrome) has become the leading cause of morbidity and mortality. Guidelines recommend that ACS patients should receive indefinite treatment with antiplatelets, β-blockers, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) and statins. The study objectives were to assess the use of evidence-based secondary prevention medication at discharge among ACS patients in Qatar and to determine the clinical and demographic characteristics associated with the use of these medications., Setting and Methods: A retrospective medical record review was conducted at the Heart Hospital in Qatar. A random sample of 1068 ACS patients was selected. Patient characteristics were summarized. Prevalence of medications at discharge were computed for each medication as well as for medication combinations. Multiple logistic regression was used to detect patient variables that were associated with the outcomes. A p≤0.05 was considered significant., Main Outcome Measures: -Percentage of ACS patients discharged on each of the following medications: antiplatelets (aspirin, clopidogrel), β-blockers, ACEI or ARBs and statins and on the combination of these medications-Association between the use of these medications and patient characteristics., Results: In total, 1064 records were reviewed. The majority were males (85.3%) and about 1 in 5 (18.7%) were Qatari. At discharge, patients were prescribed the following: aspirin (96.0%), clopidogrel (92.0%), β-blockers (90.6%) and statins (97.7%). ACEI and ARBs were prescribed to 63.5 and 11.3%, respectively. The concurrent 4 medications (aspirin or clopidogrel, statins or other lowering cholesterol medication, β-blockers and ACEI or ARB) were prescribed to 773 patients (77.8%; 95% confidence interval: 75.2-80.4%). Being overweight or obese, and having PCI (percutaneous coronary intervention) or hypertension were associated with higher prescription of the concurrent medications. Those with diabetes had a 52% increase in the odds of prescribing the 4 medications. Those with kidney disease had a 67% reduction in the odds of prescribing., Conclusion: Most ACS patients were prescribed antiplatelets, β-blockers and statins, but the use of ACEIs or ARBs was suboptimal. Strategies are needed to enhance ACEI or ARB prescribing, especially for high risk patients who would have the greatest therapeutic benefit from these drugs.

Shikany et al used data from 17,418 participants in the REGARDS study, a national, population-based, longitudinal study of white and black adults aged ≥ 45 years, enrolled between 2003-2007. They examined 536 acute coronary heart disease events at follow-up (median 5.8 years) in relation to five dietary patterns (Convenience, Plant-based, Sweets, Southern, and Alcohol and Salad). After adjustment for baseline variables, the highest consumers of the Southern pattern experienced a 56% higher hazard for acute CHD.

The Copenhagen City Heart Study, also known as "Østerbroundersøgelsen", is a large prospective cardio-vascular population study of 20,000 women and men that was launched in 1975 by Dr Peter Schnohr and Dr Gorm Jensen together with statistician Jørgen Nyboe and Prof. A. Tybjærg Hansen. The original purpose of the study was to focus on prevention of coronary heart disease and stroke. During the years many other aspects have been added to the study: pulmonary diseases, heart failure, arrhythmia, alcohol, arthrosis, eye diseases, allergy, epilepsia, dementia, stress, vital exhaustion, social network, sleep-apnoe, ageing and genetics. In this review we highlight unique aspects of the Copenhagen City Heat Study (CCHS) and its outcome in investigations of clinical and molecular aspects of health and disease in the regional and global population. To increase the impact of population studies with a focus on risk and prevention of cardiovascular and related diseases and to maximize the likelihood of identifying disease causes and effective therapeutics, lessons learned from past research should be applied to the design, implementation and interpretation of future studies.

Between 1991 and 2013, we evaluated the demographics, presentations, and final diagnosis of patients hospitalized with acute cardiac events and left bundle branch block (LBBB). Of 50 992 patients, 768 (1.5%) had LBBB. Compared with non-LBBB patients, patients with LBBB were mostly older, female, diabetic, and had hypertension and chronic kidney failure (CKF; P < .001 for all). Dyspnea (P < .001) and dizziness (P = .037) were more frequent in patients with LBBB. The most frequent cause of admission with LBBB was congestive heart failure (CHF; 54.2%), followed by ST-elevation myocardial infarction (STEMI; 13.3%), valvular heart disease (9.4%), unstable angina (8.3%) and Non-STEMI (7.7%). On multivariate analysis, CKF (odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.09-3.70) and LBBB (OR: 2.96, 95% CI: 2.01-4.42) were predictors of in-hospital mortality in the entire study population. Further analysis of patients with LBBB showed that CKF (OR: 2.93, 95% CI: 1.40-6.12) was the only predictor of in-hospital mortality. Regardless the presenting symptoms, CHF was the final diagnosis in most cases with LBBB., (© The Author(s) 2014.)

Objectives: Atrial fibrillation (AF)/atrial flutter (AFL) during pregnancy in these women is associated with adverse outcome of pregnancy., Background: The incidence, timing, and consequences of AF or AFL during pregnancy in patients with heart disease are not well known., Methods: Between January 2008 to June 2011, 60 hospitals in 28 countries prospectively enrolled 1,321 pregnant women with congenital heart disease, valvular heart disease, ischemic heart disease, or cardiomyopathy in the ROPAC (Registry of Pregnancy and Cardiac Disease). We studied the incidence, onset, and predictors of AF/AFL during pregnancy and assessed the pregnancy outcome. An overview of the existing literature is provided., Results: Seventeen women (1.3%) developed AF/AFL during pregnancy, mainly in the second trimester (61.5%). Univariable analysis identified the following pre-pregnancy risk factors for AF/AFL in pregnancy: AF/AFL before pregnancy (odds ratio [OR]: 7.1, 95% confidence interval [CI]: 1.5 to 32.8); mitral valvular heart disease (OR: 6.9, 95% CI: 2.6 to 18.3); beta-blocker use (OR: 3.3, 95% CI: 1.2 to 9.0); and left-sided lesions (OR: 2.9, 95% CI: 1.0 to 8.3). Maternal mortality was higher in women with than in women without AF/AFL (11.8% vs. 0.9%; p = 0.01), although heart failure was not seen more often. Low birth weight (<2,500 g) occurred more often in women with than in women without AF/AFL (35% vs. 14%; p = 0.02)., Conclusions: AF/AFL occurs in 1.3% of pregnant patients with structural heart disease with a peak at the end of the second trimester. AF/AFL during pregnancy in cardiac patients is associated with unfavorable maternal outcome and also has an impact on fetal birth weight., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: The purpose of this study was to describe the clinical characteristics, management, and outcomes of acute heart failure (HF) patients from the Gulf acute heart failure registry (Gulf CARE)., Methods and Results: Data from 5005 HF patients admitted to 47 hospitals in seven Gulf countries during February to November 2012 were analysed. Fifty-five per cent of patients presented with acute decompensated chronic HF, while 45% had new-onset HF. Mean age was 59 ± 15 years, 63% were males, and 83% were Gulf citizens. Co-morbid conditions were hypertension (61%), diabetes mellitus (50%), CAD (47%), and atrial fibrillation or flutter (14%). The median LVEF was 35% (25-45%) with 69% presenting as HF with reduced EF (HFrEF). CAD was the most prevalent aetiology (53%) followed by idiopathic cardiomyopathy (18%), hypertensive heart disease (16%), and valvular heart disease (9%). At discharge, 71% and 78% of patients received beta-blockers and ACE inhibitors/ARBs, respectively. Use of coronary intervention and device therapy was <10%. In-hospital mortality was 6.3%. Re-hospitalization and cumulative mortality at 3 and 12 months were 18%/13% and 40%/20%, respectively., Conclusions: Gulf CARE results show that patients from this region are a decade younger than their Western counterparts, with a high prevalence of diabetes and HFrEF, and a lower prevalence of AF. Use of coronary intervention and device therapy was low, with high re-hospitalization rates. Short- and long-term mortality rates were similar to those of Western registries, but should be interpreted in the light of the younger age of Gulf CARE patients., (© 2015 The Authors. European Journal of Heart Failure © 2015 European Society of Cardiology.)

The decrease in cardiovascular death rates in the United States has been slower in blacks than whites, especially in patients < 65 years of age. The Dallas Heart Study was designed as a single-site, multiethnic, population-based probability sample to produce unbiased comparison of cardiovascular health among multiple ethnicities.

Background: Diabetes mellitus (DM) remains a health care challenge worldwide. We evaluated the trends and outcome of DM in patients presenting with cardiovascular diseases (CVD) over a 22-year period in Qatar., Methods and Results: A retrospective analysis was performed between 1991 and 2012, including 48,803 patients admitted to the tertiary Heart Hospital (HH). The average CVD hospitalization rate was 37 admissions per 10,000 people, of which, 2 out of 5 patients had DM. Diabetic males were 6 years younger than females. DM was more prevalent in Arabs (68 vs. 32%), but its burden showed a decreasing trend over time compared with South Asians. More diabetics presented with ST-elevation myocardial infarction (47.5 vs. 22.7%), which tended to occur 8 years earlier compared with heart failure. Over the study period, beta-blocker use increased substantially (from 10 to 71%). However, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) were underutilized (from 30 to 56%). There were 4.4 deaths per 100 CVD admissions, which is equivalent to 97 deaths per year. Of this, 52% had DM (2.3 deaths per 100 CVD admissions). The overall case fatality rate (CFR) of DM was 5.6%. Diabetic Asian patients died 9 years earlier than diabetic Arabs at the HH. Multivariate regression analysis revealed that predictors of mortality in DM patients in the HH included lack of beta-blocker use (OR 4.35; 95% CI: 0.20 - 0.27), lack of ACEI/ARBs use (OR 3.58; 95% CI: 0.23 - 0.32), myocardial infarction (OR 3.20; 95% CI: 2.77 - 3.68), lack of aspirin use (OR 2.56; 95% CI: 0.34 - 0.45), congestive heart failure (OR 1.75; 95% CI: 1.50 - 2.04) and age (OR 1.03; 95% CI: 1.02 - 1.04) (P=0.001 for all)., Conclusion: DM remains a healthcare challenge in Qatar. Although the admission rate of diabetic patients is increasing at the HH, the mortality rate is decreasing. The use of evidence-based medication is still far from the guideline recommendation; however, it has substantially improved. The lack of evidence-based CVD medications in diabetic patients was associated with an increased mortality up to 4-fold in the HH. Moreover, there is a need to enhance public awareness regarding CVD risk factors and DM through education programs for the adoption of healthier lifestyles and nutrition. Great efforts are needed for more efficient primary and secondary prevention strategies in diabetic patients.

Background: Several polymorphisms of a locus on chromosome 1p13.3 have a significant effect on low-density lipoprotein cholesterol (LDL-C), atherosclerosis, and acute coronary syndrome (ACS)., Methods: We aimed to investigate the association between rs599839, rs646776, and rs4970834 of locus 1p13.3 and serum LDL-C and severity of coronary artery stenosis in ACS patients. Genotyping of the rs599839, rs646776, and rs4970834 polymorphisms was performed on Arab patients undergoing coronary angiography for ACS. Patients were divided into group A (ACS with insignificant stenosis (<50%)) and group B (with significant stenosis (≥ 50%))., Results: Patients carrying the minor G allele in rs599839 had significantly lower mean of LDL-C (2.58 versus 3.44 mM, P = 0.026) than homozygous A allele carriers (GG versus AA). Carriers of minor C allele in rs64776 had significantly higher mean of HDL-C (2.16 versus 1.36 mM, P = 0.004) than carriers of the T alleles (AA versus GG). The odd ratio and 95% confidence interval for dominant model for G allele carriers of rs599839 were 0.51 (0.30-0.92), P = 0.038, among patients with significant stenosis., Conclusions: Polymorphisms rs646776 and rs599839 of locus 1p13.3 were significantly associated with LDL-C and other lipid parameters. In addition, the G-allele carriers of variant rs599839 had a significant protective effect against the atherosclerosis.

Diabetic patients have higher risk of stroke when compared to non-diabetics and in 25% of patients the cause of stroke is unknown. Marfella et al hypothesized that subclinical episodes of atrial fibrillation may be a common etiologic factor. 464 type-2 diabetic patients were compared to 240 health controls and were followed-up for 37 months. Silent cerebral infarcts at baseline were more common among diabetic patients with silent AF (176 patients) when compared to non-silent AF group (288 patients) (61% vs. 29%; p < 0.001) and was associated with higher number of stroke at follow-up.

Background: Sudden cardiac arrest is an important cause of cardiovascular mortality. The impact of gender on the outcome of cardiac arrest is not clear and data about that is limited., Objective: Understanding the influence of gender on cardiac arrest through a systematic review of the published literature., Methods: A search of all published studies in English between January 1970 and May 2013 was performed using the electronic databases PubMed and MEDLINE, using the key words 'cardiac arrest', 'outcome', and 'gender'., Results: Eleven studies were included in this review, all of which were observational studies conducted using national-based database registries of cardiac arrest. A total of 548,440 patients were enrolled in these studies with 220,646 (40.3%) of them being female patients. In general, there was a lower percentage of women in the reported studies compared to men. Women were older in age and more likely to have non-shockable rhythms as the initial rhythm. Women also had a lower rate of witnessed arrest, a lower rate of bystander resuscitation, a higher rate of survival until hospital admission and a lower rate of in-hospital survival compared to men. Women also had a more favorable one month survival and neurological outcome., Conclusion: In the reported literature female gender seems to offer survival and outcome advantages following out-of-hospital cardiac arrest over male gender. This is in contrast to most other aspects of heart disease in which women tend to have a worse prognosis.

Cardiovascular diseases are the leading cause of death, worldwide, with disproportionate representation in low- and middle-income countries (LMICs). The Registro Nacional de los Síndromes Coronarios Agudos II (RENASICA II) investigators reported smoking, hypertension and diabetes were the main risk factors among Mexican patients presenting with ST-elevation myocardial infarction (STEMI). Fibrinolytic therapy was administered to 37%. Primary percutaneous coronary intervention (PPCI) was performed in only 15% of patients. 30-day mortality was 10%. This study highlights the importance of conducting regional registries for quality improvement.

The NAIMI trial has recently been published. It assessed one of the most contemporary and challenging issues in the management of acute myocardial infarction (AMI), namely prevention of reperfusion injury (RPI) after primary PCI for ST-elevation myocardial infarction (STEMI). It investigated the effect of the intravenous administration of Na nitrite given immediately prior to primary PCI for STEMI in 229 patients (118 in the treatment group, and 111 in placebo). The myocardial infarction (MI) size did not differ between the two groups as observed by cardiac MRI (CMR) with gadolinium enhancement at 6-8 days or plasma Troponin-I and creatine kinase (CK), or by left ventricular (LV) volume and ejection fraction (EF) as measured by echocardiography at 6-8 days and again at 6 months. They concluded that IV nitrites did not reduce the infarct size. There was, however, a trend towards benefit in diabetic patients in the post-hoc analysis. The small number of these subjects has probably lead to inconclusive outcome in this subset.

Objective: To evaluate the epidemiology and predictors of asymptomatic peripheral artery disease (PAD) in patients with a single previous coronary or cerebrovascular event in the Arabian Gulf., Methods: This was a cross-sectional, multicenter, observational survey in consecutive patients (≥18 years) with documented previous coronary and/or cerebrovascular atherothrombotic event in the United Arab Emirates (UAE), Kuwait and Qatar (64 centers), from October 2008 to December 2010. PAD was defined as an ankle brachial index <0.9 in at least one leg., Results: The overall mean age of the cohort (n = 2110) was 54 ± 11 years with only 14% being female (n = 303). The prevalence of asymptomatic PAD was 13.7%, with the highest prevalence seen in Kuwait (16.3%) and the UAE (14.7%) and the lowest in Qatar (5.3%). There were significant differences in the prevalence of asymptomatic PAD among the ethnic groups (p < 0.001): it was highest among the local Arabs and Caucasians at 19% and lowest among South East Asians (6%). The multivariate logistic model demonstrated that the most significant predictors of PAD were old age (adjusted odds ratio [OR], 1.04; 95% CI: 1.02-1.05; p < 0.001), female gender (OR, 1.56; 95% CI: 1.06-2.29; p = 0.024), ethnicity (OR, 0.39; 95% CI: 0.19-0.79; p = 0.009), smoking (OR, 1.70; 95% CI: 1.22-2.37: p = 0.002) and diabetes mellitus (OR, 1.49; 95% CI: 1.14-1.94; p = 0.004)., Conclusions: PAD is prevalent in the Arabian Gulf and is more likely to be associated with old age, females, ethnicity, smokers and those with diabetes mellitus.

Obesity and metabolic syndrome frequently co-exist and are major health problems worldwide. Prior research has questioned whether obesity without cardiometabolic abnormalities "metabolically healthy obesity" (MHO), has adverse effects on overall cardiovascular disease risk (CVD). The association between MHO and the first development of acute myocardial infarction and heart failure (HF) was evaluated in the second HUNT (Nord-Trøndelag Health).

Background: Limited data exist on the prognostic impacts of diabetes mellitus (DM) and new-onset hyperglycaemia (NOH) on cardiovascular outcomes in Middle Eastern patients with acute coronary syndrome (ACS). Here, we explored this relationship in a large contemporary Middle Eastern ACS registry: the second Gulf Registry of Acute Coronary Events (Gulf RACE-2)., Patients and Methods: Our analysis included 6362 consecutive ACS patients enrolled from October 2008 to June 2009, with or without a known DM diagnosis, and with an available fasting blood sugar measurement from the index hospitalization. Baseline demographics, risk factors for atherosclerosis, medical history, investigations and therapies were registered. Adverse hospital outcomes, as well as short-term and long-term mortalities were compared. Comparisons for categorical data were performed using χ or Fisher's exact tests, whereas analysis of variance or the Kruskal-Wallis test was used for continuous variables. Multiple logistic regression models were used to estimate the odds ratio., Results: Almost half of the ACS cohort had been diagnosed previously with DM, and 8.8% had NOH. DM patients were more frequently older, female and Arab Gulf nationals. Compared with nondiabetic patients, DM patients had higher rates of adverse in-hospital clinical events, and 30-day and 1-year mortality. NOH was an independent predictor of in-hospital mortality, major bleeding and cardiogenic shock. Patients with NOH had higher in-hospital mortality (8.29 vs. 5.37%, P=0.035), ventricular arrhythmia (4.97 vs. 1.91%, P<0.001) and cardiogenic shock rates (6.45 vs. 4.12%, P=0.019) compared with DM patients not requiring insulin., Conclusion: DM was very common among ACS patients in the Arab Gulf area, and ACS patients with NOH were at a higher risk compared with euglycaemic patients and diabetic patients not requiring insulin. Further studies are needed to examine the clinical impact of in-hospital intensive glycaemic control in these patients and to explore the long-term glycaemic status of ACS patients with NOH.

Generally, patients with prior coronary artery bypass graft (CABG) are often under-represented in acute coronary syndrome (ACS) clinical trials. Nevertheless, there is growing global attention concerning their short- and long-term prognosis. Some reports suggest prior CABG as an independent risk factor for increased mortality, while others report an equal or a more favorable prognosis despite their adverse baseline clinical characteristics. The reasons for this 'risk-mortality paradox' need to be further evaluated. More recent reports showed a significant reduction in in-hospital morbidity and mortality over a 20-year period of follow up that may be attributed to the improvement in surgical CABG techniques and increased use of evidence-based therapies over the past two decades. In the current review we discuss the available literature regarding outcomes of prior CABG patients who are presenting with ACS.

Objectives: To assess the impact of on-admission heart rate (HR) in patients presenting with acute coronary syndrome (ACS)., Methods: Data were collected retrospectively from the second Gulf Registry of Acute Coronary Events. Patients were divided according to their initial HR into: (I: < 60, II: 60-69, III: 70-79, IV: 80-89 and V: ≥ 90 bpm). Patients' characteristics and hospital and one- and 12-month outcomes were analyzed and compared., Results: Among 7939 consecutive ACS patients, groups I to V represented 7%, 13%, 20%, 23.5%, and 37%, respectively. Mean age was higher in groups I and V. Group V were more likely males, diabetic and hypertensive. ST-elevation myocardial infarction was the main presentation in groups I and V. Reperfusion therapies were less likely given to group V. Beta blockers were more frequently prescribed to group III in comparison to groups with higher HR. Groups I and V were associated with worse hospital outcomes. Multivariate analysis showed initial tachycardia as an independent predictor for heart failure (OR 2.2; 95%CI: 1.39-3.32), while bradycardia was independently associated with higher one-month mortality (OR 2.0; 95%CI: 1.04-3.85) CONCLUSION: The majority of ACS patients present with tachycardia. However, low or high HR is a marker of high risk that needs more attention and management.

Aims: To evaluate the presentation and outcome of South Asian (SAP) to Middle Eastern Arabs (MEAP) patients presenting with acute coronary syndrome., Methods: Data were collected retrospectively in Qatar between 1991 and 2010, and were analyzed according to patient ethnicity., Results: Of 14,593 acute coronary syndrome patients, 49% were MEAP and 51% were SAP. When compared with MEAP, SAP were younger, males and smokers (p < 0.01). Other cardiovascular risk factors were less common in SAP when compared with MEAP. ST-elevation myocardial infarction and the use of evidence-based medications were more prevalent among SAP (all p < 0.001). Compared to MEAP, SAP had better in-hospital outcomes; however, ethnicity was not an independent predictor of in-hospital mortality., Conclusion: In contrary to data from Western countries, SAP living in the Middle East are younger with lower cardiovascular risk profile and better outcomes when compared with Arab patients. However, further studies are warranted.

Diabetes mellitus (DM) and obesity are associated with significant morbidity and mortality. Recent large-scale trials of intensive medical management for obesity and diabetes have been disappointing. Observational studies and small-scale trials of bariatric surgery on DM patients have shown promising results. The effects of sleeve gastrectomy and gastric bypass in a larger cohort of patients with DM and obesity was tested in the STAMPEDE trial over a 3-year follow-up.

We aimed to define the temporal trend in the initial Acute Myocardial Infarction (AMI) management and outcome during the last two decades in a Middle Eastern country. A total of 10,915 patients were admitted with initial AMI with mean age of 53 ± 11.8 years. Comparing the two decades (1991-2000) to (2001-2010), the use of antiplatelet drugs increased from 84% to 95%, β -blockers increased from 38% to 56%, and angiotensin converting enzyme inhibitors (ACEI) increased from 12% to 36% (P < 0.001 for all). The rates of PCI increased from 2.5% to 14.6% and thrombolytic therapy decreased from 71% to 65% (P < 0.001 for all). While the rate of hospitalization with Initial MI increased from 34% to 66%, and the average length of hospital stay decreased from 6.4 ± 3 to 4.6 ± 3, all hospital outcomes parameters improved significantly including a 39% reduction in in-hospital Mortality. Multivariate logistic regression analysis showed that higher utilization of antiplatelet drugs, β -blockers, and ACEI were the main contributors to better hospital outcomes. Over the study period, there was a significant increase in the hospitalization rate in patients presenting with initial AMI. Evidence-based medical therapies appear to be associated with a substantial improvement in outcome and in-hospital mortality.

Background: There is paucity of data on heart failure (HF) in the Gulf Middle East. The present paper describes the rationale, design, methodology and hospital characteristics of the first Gulf acute heart failure registry (Gulf CARE)., Materials and Methods: Gulf CARE is a prospective, multicenter, multinational registry of patients >18 year of age admitted with diagnosis of acute HF (AHF). The data collected included demographics, clinical characteristics, etiology, precipitating factors, management and outcomes of patients admitted with AHF. In addition, data about hospital readmission rates, procedures and mortality at 3 months and 1-year follow-up were recorded. Hospital characteristics and care provider details were collected. Data were entered in a dedicated website using an electronic case record form., Results: A total of 5005 consecutive patients were enrolled from February 14, 2012 to November 13, 2012. Forty-seven hospitals in 7 Gulf States (Oman, Saudi Arabia, Yemen, Kuwait, United Gulf Emirates, Qatar and Bahrain) participated in the project. The majority of hospitals were community hospitals (46%; 22/47) followed by non-University teaching (32%; 15/47 and University hospitals (17%). Most of the hospitals had intensive or coronary care unit facilities (93%; 44/47) with 59% (28/47) having catheterization laboratory facilities. However, only 29% (14/47) had a dedicated HF clinic facility. Most patients (71%) were cared for by a cardiologist., Conclusions: Gulf CARE is the first prospective registry of AHF in the Middle East, intending to provide a unique insight into the demographics, etiology, management and outcomes of AHF in the Middle East. HF management in the Middle East is predominantly provided by cardiologists. The data obtained from this registry will help the local clinicians to identify the deficiencies in HF management as well as provide a platform to implement evidence based preventive and treatment strategies to reduce the burden of HF in this region.

Acute coronary syndrome (ACS) represents one of the most common causes of death worldwide. Several practice guidelines have been developed in Europe and North America to improve outcome of ACS patients through implementation of the recommendations into clinical practice. It is well know that there is wide gap between guidelines and implementation in real practice as was demonstrated in registry findings mainly conducted in the developed world. Here in we review main gaps in the management of ACS patients observed from two recent registries conducted in the Middle East.

Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. The prevalence of PAD in the developed world is approximately 12% among adult population, which is age-dependent and with men being affected slightly more than women. Despite the strikingly high prevalence of PAD, the disease is underdiagnosed. Surprisingly, more than 70% of primary health care providers in the US were unaware of the presence of PAD in their patients. The clinical presentation of PAD may vary from asymptomatic to intermittent claudication, atypical leg pain, rest pain, ischemic ulcers, or gangrene. Claudication is the typical symptomatic expression of PAD. However, the disease may remains asymptomatic in up to 50% of all PAD patients. PAD has also been reported as a marker of poor outcome among patients with coronary artery disease. Despite the fact that the prevalence of atherosclerotic disease is increasing in the Middle East with increasing cardiovascular risk factors (tobacco use, diabetes mellitus and the metabolic syndrome), data regarding PAD incidence in the Middle East are scarce.

In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as 'high volume', both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.

A prospective registry was made of all patients hospitalized with atrial fibrillation (AF) in the State of Qatar from 1991 to 2010. Clinical characteristics, management, and outcomes were compared according to ethnicity (Middle Eastern Arab vs South Asian). During this 20-year period, 2857 Arabs and 548 Asians were hospitalized for AF. Arabs were 9 years older and more likely to have hypertension, diabetes mellitus (DM), chronic renal impairment, and dyslipidemia than the Asians. Valvular heart disease and acute coronary syndromes were more common among Asians, while congestive heart failure was more common in Arabs. The overall inhospital mortality was lower in Asians than that of Arabs, while stroke rates were comparable. There was an increase in the prevalence of DM and hypertension in both the groups in the latter years of the study period, but there was no change in mortality trends. Our findings underscore the need to study AF according to ethnicity.

Background: Most of the published research on atrial fibrillation (AF) is limited to studies in the developed world and included mainly Caucasian patients. Data about women with AF among other ethnicities is very limited., Objectives: The aim of this study was to compare the clinical characteristics, treatment and outcome of women to men hospitalized with AF in a middle-eastern country., Methods: Retrospective analysis of prospective registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made. Clinical characteristics, management, and outcomes of AF patients were compared according to gender., Results: During the 20-years period; 1417 women and 2432 men were hospitalized for AF. Women were 5 years older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment and were also less likely to be current smokers and to have ischemic heart disease and impaired left ventricular function when compared to men. There was no gender preference in the use of anticoagulation. The prevalence of concomitant ischemic heart disease and hypertension increased, while the prevalence of valvular heart disease and heart failure decreased among patients hospitalized with AF over the study period. In-hospital mortality and stroke rates were comparable between the two groups., Conclusions: Women hospitalized with atrial fibrillation were older in age and had higher prevalence of co-morbid cardiovascular risk factors compared to men whereas, mortality and stroke rates were comparable., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background/objectives: This study assesses adherence to performance measures for acute myocardial infarction (AMI) in six Middle-Eastern countries, and its association with in-hospital mortality. Few studies have previously assessed these performance measures in the Middle East., Methods: This cohort study followed 5813 patients with suspected AMI upon admission to discharge. Proportions of eligible participants receiving the following performance measures were calculated: medications within 24 hours of admission (aspirin and beta-blocker) and on discharge (aspirin, beta-blockers, angiotensin converting enzyme inhibitors [ACEI], and lipid-lowering therapy), reperfusion therapy, and low-density lipoprotein (LDL) cholesterol measurement. A composite adherence score was calculated. Associations between performance measures and clinical characteristics were assessed using multivariate logistic regression., Results: Adherence was above 90% for aspirin, reperfusion, and lipid-lowering therapies; between 60% and 82% for beta-blockers, ACEI, statin therapy, time-to-balloon within 90 minutes, and LDL-cholesterol measurement; and 33% for time-to-needle within 30 minutes. After adjustment, factors associated with high composite performance score (>85%) included Asian ethnicity (Odds Ratio, OR=1.3; p=0.01) and history of hyperlipidemia (OR=1.4; p=0.001). Factors associated with a lower score included atypical symptoms (OR=0.6; p=0.003) and high GRACE score (OR=0.6; p<0.001). Lower in-hospital mortality was associated with provision of reperfusion therapy (OR=0.54, p=0.047) and beta-blockers within 24 hours (OR=0.33, p=0.005)., Conclusions: Overall adherence was lowest among the highest-risk patients. Lower in-hospital mortality was independently associated with adherence to early performance measures, comprising observational evidence for their effectiveness in a Middle East cohort. These data provide a focus for regional quality improvement initiatives and research., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: It is currently unclear whether acute coronary syndrome patients who access hospitals with catheterization facilities, with or without an on-site percutaneous coronary intervention (PCI), have better outcomes in real-life clinical practice., Methods and Results: This 9-month prospective study was carried out in six Arabian Gulf countries. Patients in hospitals with catheterization facilities [20/65 hospitals; 3615/6847 (52.8%) patients] were more likely to show evidence of cardiovascular risk factors (P<0.001) and more likely to undergo revascularization procedures that were mostly performed (≥80%) in low-risk and intermediate-risk patients. Patients in these centres experienced significantly higher rates of medical therapies and shorter door-to-needle times [median (IQR): 33 (40) vs. 43.5 (43) min, P<0.001]; 14.1% had primary PCI. They also had less in-hospital recurrent ischaemia, recurrent myocardial infarction, congestive heart failure and stroke, but more cardiogenic shock and major bleeding, and they had similar adjusted mortality rates in-hospital [odds ratio (OR): 1.06, 95% confidence interval (CI): 0.88-1.27] and at 30-day (OR: 1.11, 95% CI: 0.91-1.36) and 1-year (OR: 1.06, 95% CI: 0.89-1.27) follow-ups., Conclusion: Access to hospitals with catheterization facilities, with or without on-site PCI, was associated with a reduction in recurrent myocardial infarction and recurrent ischaemia, but not mortality. Further efforts are required to target revascularization procedures for higher risk patients as well as to widely implement primary PCI programmes.

Background: Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar., Methods: Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991-2010) and were analyzed according to gender., Results: Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27-1.79)., Conclusions: Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.

Although atrial fibrillation (AF) is the most common sustained arrhythmia seen during daily cardiovascular physician practice, its management remained a challenge for cardiology physician as there was no single anti-arrhythmic agents proved to be effective in converting atrial fibrillation and kept its effectiveness in maintaining sinus rhythm over long term. Moreover all the anti-arrhythmic agents that are used in treatment of AF were potentially pro-arrhythmic especially in patients with coronary artery disease and structurally abnormal heart. Some of these drugs also have serious non cardiac side effects that limit its long term use in the management of atrial fibrillation. Several new and investigational anti-arrhythmic agents are emerging but data supporting their effectiveness and safety are still limited. In this systematic review we examine the efficacy and safety of these medications supported by the major published randomized trials, meta-analyses and review articles and conclude with a summary of guidelines recommendations.

Context: Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients., Aims: To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS)., Methods and Material: Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: ≤50 years, 51-70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months., Statistical Analysis Used: One-way ANOVA test for continuous variables, Pearson chi-square (X (2)) test for categorical variables and multivariate logistic regression analysis for predictors were performed., Results: Among 7930 consecutive ACS patients; 2755 (35%) were ≤50 years, 4110 (52%) were 51-70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients ≤50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03-1.60), heart failure (OR 2.8; 95% CI 2.17-3.52) and major bleeding (OR 4.02; 95% CI 1.37-11.77) and in-hospital mortality (age 51-70: OR 2.67; 95% CI 1.86-3.85, and age >70: OR 4.71; 95% CI 3.11-7.14)., Conclusion: Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

We investigated the association of adiponectin gene polymorphisms (+T45G and +G276T) and adiponectin levels with acute coronary syndrome (ACS) among Arabs in Qatar. A case-control study was performed in 142 Arab patients with ACS and 122 controls. Genotypes were determined using TaqMan real-time polymerase chain reaction assay. The TT, TG, and GG genotype frequencies of the T45G variant were significantly different among cases and controls (P = .023) but not significant for G276T genotypic frequencies. It was found that only the +45G allele was significantly associated with 3-fold increased risk of ACS (odds ratio = 2.77; 1.03-6.96; P = .043) among patients, using the genetic recessive model. Carriers of GG alleles had significantly lower adiponectin levels compared to TT/TG carriers of T45G in patients with ACS. The present study suggests that only T45G single-nucleotide polymorphism in the adiponectin gene is associated with higher odds for ACS events and has an effect on serum adiponectin levels among Arab populations.

This article reviews current knowledge in khat (cathinone) research and its health impacts and toxicity in the cardiac system of khat chewers based on current evidence. The authors describe the process by which khat is postulated to induce multiple cardiac abnormalities by illustrating multiple case reports as described from around the world. The role of free radicals in inducing cardiac disease is also discussed. Future research areas are proposed to enhance our understanding of the mode of action of this toxicological drug., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Fasting during the month of Ramadan is a religious obligation that is practiced by millions of people around the world yet there is no clear scientific consensus on its effects on cardiovascular disease. This study was performed to inform physicians as well as patients of evidence based recommendations on this subject., Aim: The study was undertaken to assess: (1) any alteration in the incidence of acute cardiac illness during Ramadan fasting; (2) whether fasting during the month of Ramadan alters the clinical status of patients with stable cardiac disease; and (3) the impact of Ramadan fasting on cardiovascular risk factors in normal subjects, in patients with stable cardiac disease, metabolic syndrome, dyslipidemia, type 2 diabetes and systemic hypertension., Study Design: Systematic review of the literature., Method: A Medline search of the English literature published between January 1980 and September 2012., Results: The incidence of acute cardiac illness during Ramadan fasting was similar to non-fasting days, although the timing of symptom onset may be different, with significant increase in events during the period of 'breaking fast' when compared to non-fasting days. The majority of patients with stable cardiac illness can undergo Ramadan fasting without any clinical deterioration. Body mass index, lipid profile, and blood pressure showed significant improvement in normal healthy subjects, patients with stable cardiac illness, metabolic syndrome, dyslipidemia and hypertension during Ramadan fasting. The lipid profile of diabetic patients deteriorated significantly during Ramadan fasting., Conclusions: Ramadan fasting is not associated with any change in incidence of acute cardiac illness and the majority of cardiac patients can fast without any difficulty. Improvement in lipid profile, especially 30% to 40% increment in high-density lipoprotein, as reported in some studies, appear promising. Diabetic patients should be carefully monitored during Ramadan fasting.

In spite of there being several case reports, coronary stent fracture is not a well-recognized entity and incidence rates are likely to be underestimated. In this article, we review different aspects of stent fracture, including incidence, classification, predictors, outcome, diagnosis, and management.

Objectives: Ventricular arrhythmia (VA) in the setting of acute coronary syndrome (ACS) carries an ominous prognosis; however, long-term prognosis associated with VA in ACS in the Middle East is unknown. Accordingly, we sought to assess the incidence, in-hospital outcomes, and 1-year mortality of in-hospital VA in patients with ACS., Methods and Results: The Second Gulf Registry of Acute Coronary Events (Gulf RACE-2) is a multinational observational study of patients with ACS, which enrolled 7930 patients. Of these, 333 (4.2%) developed VA during hospitalization. Patients with VA were significantly older (mean age 58.3 vs. 56.8 years), and had a significantly higher rate of prior stroke/transient ischemic attack (7.5 vs. 4.2%), smoking (36.6 vs. 35.6%), congestive heart failure (11.0 vs. 6.5%), and peripheral artery disease (6.5 vs. 1.7%), compared with patients without VA. They had significantly less diabetes mellitus (35.4 vs. 40.3%), hypertension (43.2 vs. 47.9%), percutaneous coronary intervention (6.1 vs. 9.4%), and dyslipidemia (22.4 vs. 38.2%). The adjusted odds ratios for in-hospital, 30-day, and 1-year mortality in VA complicating all ACS were 25.8, 11.1, and 7.3; ST-elevation myocardial infarctions were 18.3, 11.7, and 6.3; and unstable angina and non-ST elevation myocardial infarctions were 47.4, 10.3, and 18.7, respectively (all P<0.001)., Conclusion: In-hospital VA in patients with ACS with and without ST elevation was associated with significantly higher in-hospital, 30-day, and 1-year mortality. Noticeably higher long-term mortality among Middle Eastern patients with ACS having VA compared with other reports requires further study and warrants immediate attention.

We evaluated the prevalence, predictors, and outcome of peripheral arterial disease (PAD) among hemodialysis (HD) patients (n = 252) in a prospective study (3-year follow-up) conducted in Qatar. Those with PAD (n = 97; 38.5%) were older and more likely to be males and to have diabetes mellitus, prior coronary artery disease (CAD), or cerebrovascular disease. Diabetic retinopathy was an independent predictor of PAD (adjusted odds ratio: 2.7; P = .004). Women had a higher mortality. Three-year all-cause mortality was high in the PAD group (adjusted hazard ratios [HRs] 2.92; 95% confidence interval [CI] 1.55-5.51). Other predictors of mortality were age (HR 1.06; 95% CI 1.04-1.10), number of vascular access (HR 2.3; 95% CI 1.04-5.01), and prior CAD (HR 1.8; 95% CI 1.05-3.49). Prevalence of PAD was high among HD patients. Early detection of PAD as well as diabetic retinopathy is of value in identifying an even higher risk population among HD patients.

Background: Gender-related differences in mortality of acute coronary syndrome (ACS) have been reported. The extent and causes of these differences in the Middle-East are poorly understood. We studied to what extent difference in outcome, specifically 1-year mortality are attributable to demographic, baseline clinical differences at presentation, and management differences between female and male patients., Methodology/principal Findings: Baseline characteristics, treatment patterns, and 1-year mortality of 7390 ACS patients in 65 hospitals in 6 Arabian Gulf countries were evaluated during 2008-2009, as part of the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). Women were older (61.3±11.8 vs. 55.6±12.4; P<0.001), more overweight (BMI: 28.1±6.6 vs. 26.7±5.1; P<0.001), and more likely to have a history of hypertension, hyperlipidemia or diabetes. Fewer women than men received angiotensin-converting enzyme inhibitors (ACE), aspirin, clopidogrel, beta blockers or statins at discharge. They also underwent fewer invasive procedures including angiography (27.0% vs. 34.0%; P<0.001), percutaneous coronary intervention (PCI) (10.5% vs. 15.6%; P<0.001) and reperfusion therapy (6.9% vs. 20.2%; P<0.001) than men. Women were at higher unadjusted risk for in-hospital death (6.8% vs. 4.0%, P<0.001) and heart failure (HF) (18% vs. 11.8%, P<0.001). Both 1-month and 1-year mortality rates were higher in women than men (11% vs. 7.4% and 17.3% vs. 11.4%, respectively, P<0.001). Both baseline and management differences contributed to a worse outcome in women. Together these variables explained almost all mortality disparities., Conclusions/significance: Differences between genders in mortality appeared to be largely explained by differences in prognostic variables and management patterns. However, the origin of the latter differences need further study.

Introduction: Patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are individually associated with a higher incidence of stroke as compared with the general population. Over the last two decades, an increase in prevalence of AF is seen in patients with CKD. While long-term anticoagulation with warfarin is well established to reduce the risk of thromboembolic event in patients with AF, its safety and efficacy has not been documented in patients with severe CKD., Areas Covered: In this review, the authors analyze the risk and benefit of long term anticoagulation across the spectrum of AF patients with CKD and explore the role of novel agents in this unique patient population. A Medline search of the English literature published between 1980 and 2012 was performed using the heading 'chronic kidney disease' combined with 'atrial fibrillation', 'hemodialysis', 'warfarin', 'anticoagulation' and 'new oral anticoagulants'., Expert Opinion: Long-term anticoagulation with warfarin under strict monitoring appears to be the cornerstone of therapy in patients with CKD to prevent stroke. Further research is warranted to explore the safety and efficacy of newer anticoagulant agents in these high-risk patients in order to reduce the incidence of disabling stroke.

Unlabelled: BACKGROUND & HYPOTHESIS: Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear., Methods: A total of 5334 patients presenting with ACS in 65 hospitals in 6 Middle East countries in the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2) were studied according to their marital status (5024 married, 100 single, and 210 widowed patients)., Result: When compared to married patients, widowed patients were older and more likely to be female. Widowed patients were more likely to have diabetes mellitus, hypertension, history of heart failure, and peripheral vascular disease and were less likely to be tobacco users when compared to the other groups. Widowed patients were also more likely to present with atypical symptoms and have advanced Killip class. Widowed patients were more likely to present with non-ST-elevation myocardial infarction (NSTEMI) when compared to the other 2 groups. Widowed patients were more likely to have heart failure (P = 0.001), cardiogenic shock (P = 0.001), and major bleeding (P = 0.002) when compared to the other groups. No statistically significant difference was observed in regard to duration of hospital stay, door to needle time in STEMI patients, or cardiac arrhythmias between the various groups. Widowed patients had higher in-hospital, 30-day, and 1-year mortality rates (P = 0.001). Marital status was an independent predictor for in-hospital mortality., Conclusion: Widowed marital status was associated with worse cardiovascular risk profile, and worse in-hospital and 1-year outcome. Future work should be focused on whether the provision of psychosocial support will result in improved outcomes among this high-risk group., (© 2012 Wiley Periodicals, Inc.)

Background: Most studies on atrial fibrillation (AF) epidemiology, treatment, and outcomes have included mainly Caucasians patients. The world literature on AF in other ethnicities is very limited particularly in the elderly., Aims: The aim of this study was to compare the clinical characteristics, treatment and outcome of elderly and younger patients hospitalized with AF in a Middle-Eastern country and examine the trends of AF etiologies over a 20-year period., Methods: A retrospective analysis of a prospective registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made. Patients were divided into three groups; group 1: patients ≤50 years old, group 2: patients between 51 and 70 years old, and group 3: patients >70 years old. Clinical characteristics, management, and outcomes of AF patients were compared according to age., Results: Between the year 1991 and the end of 2010, a total 3848 consecutive patients were admitted with AF. One thousand three hundred and forty-five patients were ≤50 years, 1759 were between 51 and 70 years and 744 patients were >70 years old. Elderly patients were more likely to have hypertension and chronic renal impairment. There was a higher prevalence of associated coronary artery disease and aortic stenosis in elderly patients with a lower left ventricular ejection fraction than the younger age groups. A lower use of anticoagulation in the elderly group was observed but there was no underuse of other evidence-based medications. The older AF patients had significantly higher in-hospital mortality and stroke rates with no significant changes in mortality trends over the 20 years of study. An increasing trend of the associated acute coronary syndromes, hypertension and diabetes mellitus prevalence was observed in the elderly group., Conclusion: Anticoagulation remains underutilized in elderly patients with AF despite proven efficacy and increasing trends of cardiovascular comorbidities. The current study underscores the urgent need for prospective studies to investigate warfarin contraindications, relative warfarin efficacy and bleeding risks in our region to help guide healthcare providers in warfarin prescribing in this frail patient population and consequently reduce the risk of AF-related disabling strokes and mortality.

Objectives: Previous studies demonstrated women presenting with acute coronary syndrome (ACS) have poor outcomes when compared with men 'the gender gap phenomenon'. The impact of prior coronary artery bypass graft (CABG) on women presenting with ACS is unknown. We hypothesised that the gender gap is altered in ACS patients with prior CABG. The aim of this study was to evaluate patients presenting with ACS according to their gender and history of prior CABG., Design: Retrospective, observational (cohort) study., Setting: Data were collected from hospital-based registry of patients hospitalised with ACS in Doha, Qatar, from 1991 through 2010. The data were analysed according to their gender and history of prior CABG., Participants: A total of 16 750 consecutive patients with ACS were studied. In total, 693 (4.3%) patients had prior CABG; among them 125 (18%) patients were women., Primary and Secondary Outcome Measures: Comparisons of clinical characteristics, inhospital treatment, and outcomes, including inhospital mortality and stroke were made., Results: Women with or without prior CABG were older, less likely to be smokers, but more likely to have diabetes mellitus (DM), hypertension and renal impairment than men (p=0.001). Women were less likely to receive reperfusion and early invasive therapies. When compared with men, women without prior CABG carried higher inhospital mortality (11% vs 4.9%; p=0.001) and stroke rates (0.9% vs 0.3%; p=0.001). Female gender was independent predictor of poor outcome. Among prior CABG patients, despite the fact that women had worse baseline characteristics and were less likely to receive evidence-based therapy, there were no significant differences in mortality or stroke rates between the two groups., Conclusions: Consistent with the world literature, women presenting with ACS and without prior CABG had higher death rates compared with men. Patients with prior CABG had comparable death rates regardless of the gender status.

The association between age, risk factors, and outcome of non-Caucasian patients hospitalized with heart failure (HF) is not clear. A total of 7066 consecutive patients hospitalized with HF at Hamad General Hospital, Doha, Qatar, from 1991 through 2010 were studied. Patients were divided into 3 groups according to age: group 1, 50 years and younger; group 2, older than 50 and up to 70 years; and group 3, older than 70 years. The prevalence of hypertension, chronic renal impairment, and atrial fibrillation increased with increased age. On admission, the older the age of the HF patient, the less likely they were to receive β-blockers and vasodilators. In-hospital mortality rate was higher in older patients when compared with the younger groups (10.6% group 3 vs 7% group 1 and 7.2% group 2; P=.001). During the study period, the relative reduction in mortality rates was higher in the younger when compared with the older patients (55%, 49%, and 41%, respectively). The clinical characteristics of Middle-Eastern HF patients vary considerably according to age. Over time, an overall marked improvement in hospital survival for HF was observed, which was associated with progressively increased treatment with evidence-based therapies. This survival improvement over time appears to be less pronounced in the elderly., (© 2012 Wiley Periodicals, Inc.)

Aim: The authors evaluated the prevalence and effect of the various tobacco use modalities among patients presenting with acute coronary syndrome (ACS) and compared them with non-tobacco and ex-tobacco users., Methods: An analysis of the 2nd Gulf Registry of Acute Coronary Events conducted between October 2008 and June 2009 and which included 7930 consecutive patients hospitalised with ACS was made. Patients initially were divided into non-tobacco users, ex-tobacco users and current tobacco users. Subanalysis according to the tobacco modality used was subsequently made: cigarette, waterpipe or smokeless tobacco users., Results: Overall, 2834 (36%) patients were current tobacco users, 306 (3.9%) patients were waterpipe smokers and 240 patients (3%) were oral tobacco users. When compared with non-tobacco and ex-tobacco users, overall current tobacco users were younger, more likely to be male subjects and less likely to have diabetes mellitus, hypertension and dyslipidaemia. Mortality rate (p=0.001) and overall cardiovascular events (p=0.001) were lower among current tobacco users when compared with the other two groups. After adjustment for baseline variables, tobacco use was not an independent predictor of adverse events. Subset analysis demonstrates oral tobacco users and waterpipe smokers were older and more likely to be women when compared with cigarette smokers. Among the various tobacco groups, inhospital mortality rates were significantly higher among the waterpipe smokers when compared with the other two groups., Conclusions: Clinical characteristics and outcomes of ACS patients depend on the tobacco modality used. Further studies are required to evaluate the impact of emerging tobacco use modalities on patients with coronary artery disease.