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Aims: The aim of this study is to determine the impact of diabetes mellitus on all-cause mortality and rehospitalization rates at 3 months and at 1 year in patients admitted with acute heart failure (AHF) stratified by left ventricular ejection fraction (EF)., Methods and Results: We analysed consecutive patients admitted to 47 hospitals in seven Middle Eastern countries (Saudi Arabia, Oman, Yemen, Kuwait, United Arab Emirates, Qatar, and Bahrain) with AHF from February to November 2012 with AHF who were enrolled in Gulf CARE, a multinational registry of patients with heart failure (HF). AHF patients were stratified into three groups: HF patients with reduced (EF) (HFrEF) (<40%), HF with mid-range EF (HFmrEF) (40-49%), and HF patients with preserved EF (HFpEF) (≥50%). Analyses were performed using univariate and multivariate statistical techniques. The mean age of the cohort was 59 ± 15 years (ranging from 18 to 99 years), and 63% (n = 2887) of the patients were males. A total of 2258 (49%) AHF patients had diabetes mellitus. The mean EF was 37 ± 14%. A reduced EF was observed in 2683 patients (59%), whereas 962 patients (21%) had mid-range and 932 patients (20%) had preserved EF. Multivariable analyses demonstrated no significant differences in all-cause mortality between diabetics and non-diabetics in all the three types of HF; at 3 months follow-up: HFrEF [adjusted odds ratio (aOR), 1.30; 95% confidence interval (CI): 0.94-1.80; P = 0.119], HFmrEF (aOR, 0.98; 95% CI: 0.51-1.87; P = 0.952), and HFpEF (aOR, 0.69; 95% CI: 0.38-1.26; P = 0.225); and at 12-months follow-up: HFrEF (aOR, 1.25; 95% CI: 0.97-1.62; P = 0.080), HFmrEF (aOR, 1.07; 95% CI: 0.68-1.68; P = 0.783), and HFpEF (aOR, 1.07; 95% CI: 0.67-1.72; P = 0.779). There were also no significant differences in rehospitalization rates between diabetics and non-diabetics in all the three types of HF; at 3 months follow-up: HFrEF (aOR, 0.94; 95% CI: 0.74-1.19; P = 0.581), HFmrEF (aOR, 0.82; 95% CI: 0.53-1.26; P = 0.369), and HFpEF (aOR, 1.06; 95% CI: 0.64-1.78; P = 0.812); and at 12-months follow-up: HFrEF (aOR, 0.93; 95% CI: 0.73-1.17; P = 0.524), HFmrEF (aOR, 0.81; 95% CI: 0.56-1.17; P = 0.257), and HFpEF (aOR, 1.29; 95% CI: 0.82-2.05; P = 0.271)., Conclusions: There were no significant differences in 3 and 12 months all-cause mortality as well as rehospitalization rates between diabetics and non-diabetic patients in all the three types of AHF patients stratified by left ventricular ejection fraction., (© 2019 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

The prognostic impact of beta-blockers (BB) in coronary artery disease (CAD) is controversial, especially in the post-reperfusion era. We studied in-hospital cardiovascular events in patients hospitalized for acute HF, a previous history of CAD and a left ventricular ejection fraction (LVEF) ≥40%, in relation to BB on admission; and 1-year outcome in relation to BB on discharge, in the GULF aCute heArt failuRe (GULF-CARE) registry. From a total of 5005 patients included in the GULF-CARE registry, 303 patients with a previous history of CAD and a LVEF ≥40% on BB were propensity-matched to 303 patients without BB on admission. In-hospital mortality (OR= 0.82; 95% CI [0.35-1.94]), stroke and cardiogenic shock were not reduced by BB. On discharge, 306 patients on BB, including the ones newly diagnosed with myocardial infarction as a precipitating cause of HF, were propensity-scored matched with 306 patients without BB. Mortality (OR= 0.86; 95%CI [0.51-1.45], hospitalization for HF or PCI/CABG at 1 year were also not reduced by BB at discharge. In summary, our data show that BB have a neutral effect on in-hospital and 1-year outcomes in acute heart failure patients with a previous history of CAD and a LVEF ≥40%., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background Smoker's paradox has been observed with several vascular disorders, yet there are limited data in patients with acute heart failure (HF). We examined the effects of smoking in patients with acute HF using data from a large multicenter registry. The objective was to determine if the design and analytic approach could explain the smoker's paradox in acute HF mortality. Methods and Results The data were sourced from the acute HF registry (Gulf CARE [Gulf Acute Heart Failure Registry]), a multicenter registry that recruited patients over 10 months admitted with a diagnosis of acute HF from 47 hospitals in 7 Middle Eastern countries. The association between smoking and mortality (in hospital) was examined using covariate adjustment, making use of mortality risk factors. A parallel analysis was performed using covariate balancing through propensity scores. Of 5005 patients hospitalized with acute HF, 1103 (22%) were current smokers. The in-hospital mortality rates were significantly lower in current smoker's before (odds ratio, 0.71; 95% CI, 0.52-0.96) and more so after (odds ratio, 0.47; 95% CI, 0.31-0.70) covariate adjustment. With the propensity score-derived covariate balance, the smoking effect became much less certain (odds ratio, 0.63; 95% CI, 0.36-1.11). Conclusions The current study illustrates the fact that the smoker's paradox is likely to be a result of residual confounding as covariate adjustment may not resolve this if there are many competing prognostic confounders. In this situation, propensity score methods for covariate balancing seem preferable. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01467973.

We evaluated the impact of clopidogrel use on 3- and 12-months all-cause mortality in patients with acute heart failure (AHF) stratified by coronary artery disease (CAD) in patients admitted to 47 hospitals in 7 Middle Eastern countries with AHF from February to November 2012. Clopidogrel use was associated with significantly lower risk of all-cause mortality at 3 months (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI]: 0.42-0.87; P = .007) and 12 months (aOR, 0.61; 95% CI: 0.47-0.79; P < .001). When the analysis was stratified by CAD, the clopidogrel group in those with AHF and CAD was also associated with significantly lower risk of all-cause mortality at 3 months (aOR, 0.56; 95% CI: 0.38-0.83; P = .003) and 12 months (aOR, 0.58; 95% CI: 0.44-0.77; P < .001). However, in AHF patients without CAD, clopidogrel use was not associated with any survival advantages, neither at 3 months (aOR, 0.99; 95% CI: 0.32-3.11; P = .987) nor at 12 months (aOR, 0.80; 95% CI: 0.37-1.72; P = .566). Clopidogrel use was associated with short- and long-term all-cause mortality in patients with AHF and CAD. In AHF patients without CAD, clopidogrel use did not offer any survival advantage.

Aims: To evaluate the impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs)/ Angiotensin Receptors Blockers (ARBs) on in-hospital, 3- and 12-month all-cause mortality in Acute Heart Failure (AHF) patients with left ventricular systolic dysfunction in 7 countries of the Middle East., Methods and Results: Data was analysed from 2,683 consecutive patients admitted with AHF and Left Ventricular Ejection Fraction (LVEF) (<40%) from 47 hospitals from February to November 2012. Analyses were evaluated using univariate and multivariate statistics. The overall mean age of the cohort was 58±15, 72% (n=1,937) were males, 62% (n=1,651) had coronary artery disease, 57% (n=1,539) were hypertensives and 47% (n=1,268) had diabetes. Overall cumulative mortality at inhospital, 3- and 12-month follow-up was 5.8% (n=155), 12.6% (n=338) and 20.4% (n=548), respectively. Adjusting for demographic and clinical characteristics as well as medication in a multivariate logistic regression model, ACEIs were associated with lower risk of in-hospital mortality (adjusted odds ratio (aOR), 0.48; 95% Confidence Interval (CI): 0.25 to 0.94; p=0.031). At 3-month follow-up, both ACEIs (aOR, 0.64; 95% CI: 0.43 to 0.95; p=0.025) and ARBs (aOR, 0.34; 95% CI: 0.18 to 0.62; p<0.001) were associated with lower risk of mortality. Additionally, at 12-month follow-up, those prescribed ACEIs (aOR, 0.71; 95% CI: 0.53 to 0.96; p=0.027) and ARBs (aOR, 0.47; 95% CI: 0.31 to 0.71; p<0.001) were still associated with lower risk of mortality., Conclusion: ACEIs and ARBs treatments were associated with lower mortality risk during admission and up to 12-month of follow-up in Middle East AHF patients with left ventricular systolic dysfunction., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Objectives: The aim of the study was to investigate the in-hospital and one-year clinical outcome of patients treated with percutaneous coronary intervention (PCI) in a tertiary hospital in Oman., Methods: We conducted a retrospective, single-center, observational study looking at patients > 18 years old who underwent a PCI from 1 January to 31 December 2013. The primary end point was the occurrence of a major adverse cardiovascular event (MACE), defined as death, any myocardial infarction (MI), cerebrovascular accident (CVA), and target vessel revascularization (TVR) with either repeat PCI or coronary artery bypass surgery (CABG). Secondary end-points included procedural success rate, angina status, stent thrombosis, and the rate of redo-PCI/CABG for in-stent restenosis., Results: A total of 1 045 consecutive patients were analyzed. The mean age of the cohort was 58.2±11.2 years. Hyperlipidemia (66.8%), hypertension (55.1%), and diabetes mellitus (45.9%) were the predominant risk factors. Stable angina, ST-elevation MI, non-ST-elevation MI, and post-acute coronary syndrome (ACS) were common indications (approximately 20.0% each). The angiographic and procedural success rate was 95.0%. Forty-six percent of patients had single-vessel disease, 34.4% had double vessel disease, and triple vessel disease was seen in 19.1% of patients. Ninety-eight percent had balloon angioplasty with stenting, and only 1.9% of patients had balloon angioplasty without stenting. The majority of patients had single-vessel stenting (81.3%). A drug-eluting stent was used in 88.4% of patients, and a bare-metal stent in 11.6%. In-hospital MACE was 3.6%. There were 19 in-hospital deaths (1.8%), and four patients (0.4%) had CVA/MI. Out of 1 026 patients discharged, 100 patients were lost to follow-up. Among the 926 patients followed-up, 673 patients (72.7%) were asymptomatic. One-year MACE was 17.0%, including 5.0% death and 6.0% MI. Repeat revascularization was performed in 53 patients (5.7%) for documented in-stent restenosis. Definite stent thrombosis was documented in 10 (1.1%) patients. At discharge, the majority of patients were on post-ACS evidence-based medications, aspirin (100%), clopidogrel (99.6%), statin (97.6%), beta-blocker (88.7%), and angiotensin-converting-enzyme inhibitors (83.9%)., Conclusions: Omani patients treated with PCI were much younger than Western patients with a high prevalence of risk factors. Successful PCI was achieved in a large percentage of patients with a low incidence of in-hospital complications and mortality. At one-year follow-up, the majority patients had a good clinical outcome.

In the absence of other associated cardiac anomalies, single coronary artery (SCA) per se is a rare anomaly detected during coronary angiography or autopsy. Various types of SCA detected during coronary angiography have already been described. We herein report a type of SCA originating from the right sinus of Valsalva, with the right circumflex, left circumflex, and left anterior descending coronary arteries arising from the proximal part of the SCA in a 76-year-old female patient. She developed ventricular fibrillation during coronary angiography, which calls for caution while performing a coronary angiogram in such patients.

Objectives: We sought to describe the demographics, clinical characteristics, management and outcomes of patients in Oman with acute heart failure (AHF) as part of the Gulf aCute heArt failuRe rEgistry (CARE) project., Methods: Data were analyzed from 988 consecutive patients admitted with AHF to 12 hospitals in Oman between 14 February and 14 November 2012., Results: The mean age of our patients was 63±12 years. Over half (57%) were male and 95% were Omani citizens. Fifty-seven percent of patients presented with acute decompensated chronic heart failure (ADCHF) while 43% had new-onset AHF. The primary comorbid conditions were hypertension (72%), coronary artery disease (55%), and diabetes mellitus (53%). Ischemic heart disease (IHD), hypertensive heart disease, and idiopathic cardiomyopathy were the most common etiologies of AHF in Oman. The median left ventricular ejection fraction of the cohort was 36% (27-45%) with 56% of the patients having heart failure with reduced ejection fraction (< 40%). Atrial fibrillation was seen in 15% of patients. Acute coronary syndrome (ACS) and non-compliance with medications were the most common precipitating factors. At discharge, angiotensin converting enzyme inhibitors and beta-blockers were prescribed adequately, but aldosterone antagonists were under prescribed. Within 12-months follow-up, one in two patients were rehospitalized for AHF. In-hospital mortality was 7.1%, which doubled to 15.7% at three months and reached 26.4% at one-year post discharge., Conclusions: Oman CARE was the first prospective multicenter registry of AHF in Oman and showed that heart failure (HF) patients present at a younger age with recurrent ADCHF and HF with reduced ejection fraction. IHD was the most common etiology of HF with a low prevalence of AHF, but a high prevalence of acute coronary syndrome and non-compliance with medications precipitating HF. A quarter of patients died at one-year follow-up even though at discharge medical therapy was nearly optimal. Our study indicates an urgent need for prevention, early diagnosis, and treatment of AHF in Oman.

Objective: To compare Middle East Arabs and Indian subcontinent acute heart failure (AHF) patients., Methods: AHF patients admitted from February 14, 2012 to November 14, 2012 in 47 hospitals among 7 Middle East countries., Results: The Middle Eastern Arab group (4157) was older (60 vs. 54 years), with high prevalence of coronary artery disease (48% vs. 37%), valvular heart disease (14% vs. 7%), atrial fibrillation (12% vs. 7%), and khat chewing (21% vs. 1%). Indian subcontinent patients (382) were more likely to be smokers (36% vs. 21%), alcohol consumers (11% vs. 2%), diabetic (56% vs. 49%) with high prevalence of AHF with reduced ejection fraction (76% vs. 65%), and with acute coronary syndrome (46% vs. 26%). In-hospital mortality was 6.5% with no difference, but 3-month and 12-month mortalities were significantly high among Middle East Arabs, (13.7% vs. 7.6%) and (22.8% vs. 17.1%), respectively., Conclusions: AHF patients from this region are a decade younger than Western patients with high prevalence of ischemic heart disease, diabetes mellitus, and AHF with reduced ejection fraction. There is an urgent need to control risk factors among both groups, as well as the need for setting up heart failure clinics for better postdischarge management., (Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Objectives: Cardiogenic shock (CS) is still the leading cause of in-hospital mortality in patients presenting with acute myocardial infarction (AMI). The aim of this study was to determine the in-hospital mortality and clinical outcome in AMI patients presenting with CS in a tertiary hospital in Oman., Methods: This retrospective observational study included patients admitted to the cardiology department between January 2013 and December 2014. A purposive sampling technique was used, and 63 AMI patients with CS admitted to (36.5%) or transferred from a regional hospital (63.5%) were selected for the study., Results: Of 63 patients, 73% (n = 46) were Omani and 27% (n = 17) were expatriates: 79% were male and 21% were female. The mean age of patients was 60±12 years. The highest incidence of CS (30%) was observed in the 51-60 year age group. Diabetes mellitus (43%) and hypertension (40%) were the predominant risk factors. Ninety-two percent of patients had ST-elevation MI, 58.7% patients were thrombolysed, and 8% had non-ST-elevation MI. Three-quarters (75%) of CS patients had severe left ventricular systolic dysfunction (defined as ejection fraction <30%). Coronary angiogram showed single vessel disease in 17%, double vessel disease in 40%, and triple vessel disease in 32% and left main disease in 11%. The majority of the patients (93.6%) underwent percutaneous coronary intervention (PCI), among them 23 (36.5%) underwent primary PCI. In-hospital mortality was 52.4% in this study., Conclusions: CS in AMI patients presenting to a tertiary hospital in Oman have high in-hospital mortality despite the majority undergoing PCI. Even though the in-hospital mortality is comparable to other studies and registries, there is an urgent need to determine the causes and find any remedies to provide better care for such patients, specifically concentrating on the early transfer of patients from regional hospitals for early PCI.

Objectives: This study aimed to describe the epidemiology of diabetes mellitus over the past two decades in Oman, particularly in terms of its prevalence and incidence. In addition, the study sought to estimate the future incidence of diabetes in Oman., Methods: Three national and three regional surveys conducted between 1991 and 2010 were analysed to obtain the age-adjusted prevalence and undiagnosed proportion of type 2 diabetes mellitus (T2DM) among Omani subjects aged ≥20 years. Diabetes mellitus registers and published studies were used to determine incidence rates of both type 1 diabetes mellitus (T1DM) and T2DM in Oman. Linear regression was used to determine trends and projections for diabetes in 2050., Results: The age-adjusted prevalence of T2DM in Oman varied from 10.4% to 21.1%, while the highest prevalence of impaired fasting glucose was found in males (35.1%). In comparison to men, higher incidence rates of T2DM were found in women (2.7 cases compared to 2.3 cases per 1,000 person-years, respectively). No significant trends were observed for the prevalence or incidence of T2DM in both genders. Undiagnosed T2DM was more common in men (range: 33-68%) than women (range: 27-53%). The results of this study show that by 2050, there will be an estimated 350,000 people with T2DM living in Oman (a 174% increase compared to estimates for 2015)., Conclusion: Health authorities need to prioritise diabetes prevention and control in order to prevent or delay long-term complications and avert a potential epidemic of diabetes in Oman.

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.)

Choosing the best anticoagulant therapy for a pregnant patient with a mechanical prosthetic valve is controversial and the published international guidelines contain no clear-cut consensus on the best approach. This is due to the fact that there is presently no anticoagulant which can reliably decrease thromboembolic events while avoiding damage to the fetus. Current treatments include either continuing oral warfarin or substituting warfarin for subcutaneous unfractionated heparin or low-molecular-weight heparin (LMWH) in the first trimester (6-12 weeks) or at any point throughout the pregnancy. However, LMWH, while widely-prescribed, requires close monitoring of the blood anti-factor Xa levels. Unfortunately, facilities for such monitoring are not universally available, such as within hospitals in developing countries. This review evaluates the leading international guidelines concerning anticoagulant therapy in pregnant patients with mechanical prosthetic valves as well as proposing a simplified guideline which may be more relevant to hospitals in this region.

A 38-year-old obese woman presented with recurrent polymorphic ventricular tachycardia secondary to persistent hypokalemia necessitating more than 40 DC shocks. All endocrine investigations for hypokalemia were negative with impression of "mysterious hypokalemia." On repeated inquiry, a hidden history of licorice use was elicited causing persistent hypokalemia. The case highlights a life threatening complication of licorice use. In addition, it reiterates the importance of repeated history taking in a patient with undiagnosed hypokalemia and torsade de pointes which avoided a device therapy., (©2013 Wiley Periodicals, Inc.)

This report describes the case of an 18-year-old post-Senning patient noted to have a residual ventricular septal defect and severe tricuspid regurgitation together with a shunt from the right atrium to the left ventricle detected several years after surgery.

Little is known about the impact of thrombolytic agents on in-hospital outcomes in the Middle East. The objective of this study was to evaluate the impact of thrombolytic agents on in-hospital outcomes in ST-segment elevation myocardial infarction (STEMI) patients in six Middle Eastern countries. Gulf Registry of Acute Coronary Events was a prospective, multinational, multicentre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in 2006 and 2007. Out of 1,765 STEMI patients admitted to hospitals within 12 h of symptoms onset, 25, 43, and 30% were treated with streptokinase, reteplase, and tenecteplase, respectively. Median age of the study cohort was 50 (45-59) years and majority were males (89%). The overall median symptom onset-to-presentation and median door-to-needle times were 130 min (65-240) and 45 min (30-75), respectively. Streptokinase patients had worse GRACE risk scores compared to patients who received fibrin specific thrombolytics. Academic hospitals and cardiologists as admitting physicians were associated with the use of fibrin specific thrombolytics. After significant covariate adjustment, both reteplase [odds ratio (OR), 0.38; 95% CI: 0.18-0.79; P = 0.009] and tenecteplase (OR, 0.30; 95% CI: 0.12-0.77; P = 0.012) were associated with lower all-cause in-hospital mortality compared with streptokinase. No significant differences in other in-hospital outcomes were noted between the thrombolytic agents. In conclusion, in light of the study's limitations, fibrin specific agents, reteplase and tenecteplase, were associated with lower all-cause in-hospital mortality compared to the non-specific fibrin agent, streptokinase. However, the type of thrombolytic agent used did not influence other in-hospital outcomes.

A 60-year-old femalepresented with progressive dysphagia and was found to have a right-sided aortic arch with external posterior compression of the upper esophagus due to severe compression from a Kommerell's diverticulum with an aberrant left subclavian artery. This patient underwent division of the diverticulum with an aorto-subclavian graft implantation under femoro-femoral bypass and recovered uneventfully. A review of the literature and discussion of the surgical management is presented., (© 2011 Wiley Periodicals, Inc.)

A 44-year-old man presented with acute coronary syndrome. He was administered glycoprotein IIb/IIIa receptor antagonist (tirofiban) for a left anterior descending artery thrombus detected during percutaneous coronary intervention. He developed very severe thrombocytopenia 24 h after tirofiban infusion with no signs of bleeding. The thrombocytopenia spontaneously resolved after stopping tirofiban without any significant clinical sequelae. To our knowledge, this is the first case report of tirofiban-induced severe thrombocytopenia from the Middle East. Clinicians using this drug should be aware of this potentially lethal adverse drug reaction. Close monitoring of platelet count early after the initiation of tirofiban infusion is suggested and discontinuation of tirofiban infusion can reverse thrombocytopenia spontaneously.

We describe the case of a 54-year-old man with no symptoms of a cardiac disease who, in the preoperative assessment for eye surgery was diagnosed to have a left atrial myxoma coupled with coronary artery disease. After thorough investigations, the patient underwent resection of the left atrial tumor and coronary artery bypass grafting with a succesful outcome. The histopathological examination revealed a myxoma. This case report highlights the importance of preoperative evaluation in patients with unsuspected coexisting cardiac diseases, treatment options and the anesthetic concerns.

Acute coronary syndrome (ACS) is the most common cause of cardiovascular mortality and morbidity in Western countries. International guidelines for diagnosis and treatment have been developed based on randomised clinical trials. However, data from international registries report a lack of association between guideline recommendations and actual clinical practice. Similarly, the Gulf Heart Association initiated a registry called Gulf Registry of Acute Coronary Events (Gulf RACE). This registry was developed to determine the characteristics and management of ACS in the Gulf countries including Oman. Here, we report on the results of the various Gulf RACE registry studies from Oman and compare our results with the main Gulf RACE data as well as other international registries.

A Gerbode defect is a left ventricle to right atrial communication. The type I defect (direct, acquired) results in a direct shunt through the atrioventricular part of membranous septum, while a type II (indirect, congenital) defect results in an indirect shunt through a perimembranous ventricular septal defect (VSD) and a defect in the septal tricuspid valve leaflet. We report a rare type of Gerbode defect wherein a small perimembranous VSD is completely covered by an elongated sail-like anterior tricuspid leaflet forming an aneurysm and directing the shunt into right atrium., (© 2011, Wiley Periodicals, Inc.)

Objective: To assess gender-related differences in the presentation, management, and in-hospital outcomes among acute coronary syndrome (ACS) patients from Oman., Methods: Data were analyzed from 1579 consecutive ACS patients from Oman during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were conducted using univariate and multivariate statistical techniques., Results: In this study, 608 (39%) patients were women with mean age 62 ± 12 vs. 57 ± 13 years (p < 0.001). More women were seen in the older age groups (age <55 years: 25% vs. 43%, 55-74 years: 60% vs. 49% and >75 years: 15% vs. 8%; p < 0.001). Women had higher frequencies of diabetes, hypertension, hyperlipidemia, obesity, angina, and aspirin use, but less history of smoking. Women were significantly less likely to have ischemic chest pain, ST-elevation myocardial infarction (STEMI), non-STEMI and were more likely to have dyspnea, unstable angina, ST depression and left bundle branch block. Both groups received ACS medications and cardiac catheterization equally; however, women received anticoagulants (88% vs. 79%; p < 0.001), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (70% vs. 65%; p = 0.050) more and clopidogrel less (20% vs. 29%; p < 0.001). Women experienced more recurrent ischemia and heart failure but with similar in-hospital mortality (4.6% vs. 4.3%) even after adjusting for age (p = 0.500)., Conclusions: Women admitted with ACS were older than men, had more risk factors, presented differently with no difference in hospital mortality. This is similar to Gulf RACE study except for mortality. Women received anticoagulants/ACEIs /ARBs more but were under-treated with clopidogrel.

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

Coronary artery anomalies are uncommon and the occurrence of a single coronary artery with no structural heart disease is very rare. We report a hitherto undescribed type of single coronary artery originating from the right aortic sinus giving rise to left main coronary artery and right coronary artery that was hypoplastic proximally.

It is known that a dynamic left ventricular outflow tract (LVOT) obstruction exists in patients, following aortic valve replacement (AVR) and is usually considered to be benign. We present a patient with dynamic LVOT obstruction following AVR, who developed refractory cardiogenic shock and expired inspite of various treatment strategies. This phenomenon must be diagnosed early and should be considered as a serious and potentially fatal complication following AVR. The possible mechanisms and treatment options are reviewed.

Objective: To determine clinical characteristics, management, and in-hospital outcomes of diabetic and non-diabetic patients admitted with acute coronary syndrome (ACS) in Oman., Methods: Data were analyzed from 1583 consecutive patients admitted to various hospitals in Oman with ACS from May 8 to June 6, 2006, and from January 29 to June 29, 2007, as part of the Gulf RACE (Registry of Acute Coronary Events). The ACS patients were stratified into those with and without diabetes mellitus., Results: In this study, 588 (37%) patients were diabetic with a mean age of 59 years and included more female than male diabetics (43% versus 33%; p<0.001). Diabetic patients were more likely to present with unstable angina (55% versus 44%; p<0.001) and less likely to present with ST elevation myocardial infarction (20% versus 27%; p=0.001). Both groups received ACS treatment equally; however, diabetic patients were more likely to be treated with glycoprotein IIb/IIIa antagonists and angiotensin-converting enzyme inhibitors or receptor blockers. Diabetic patients experienced more recurrent ischemia (12% versus 8%; p=0.043), heart failure (29% versus 23%; p=0.009), cardiogenic shock (7.5% versus 4.6%; p=0.018), and ventilator requirement (7.3% versus 4.1%; p=0.006). When adjusted for age and gender, diabetes status was an independent risk factor of in-hospital mortality in ACS patients (adjusted odd ratio, 1.68; 95% confidence interval, 1.022.77; p=0.042)., Conclusion: Diabetic ACS patients have different clinical characteristics and poorer outcomes. Present treatment strategies are not sufficient to counter the adverse impact of diabetes. More effective and evidence-based therapeutic strategies should be identified and used in diabetic ACS patients.

Splanchnic vein thrombosis in patients with polycythemia rubra vera is well-known. Development of mobile right heart thrombus in these patients has not been reported previously. We describe a young patient with Polycythemia rubra vera and splanchnic vein thrombosis with ischemic bowel who underwent small bowel resection. He developed a large mobile right atrial thrombus and bilateral pulmonary embolism. He also had upper gastrointestinal bleed. His management was complicated and challenging due to multiple risk factors and co-morbid conditions. Thrombolysis was contraindicated and he refused surgical intervention. He was treated with anticoagulation with complete resolution of right atrial thrombus.

Coronary arteries of anomalous origin are uncommon and all three coronary arteries arising from a single sinus of Valsalva is very rare. Percutaneous coronary intervention of such arteries is technically difficult and challenging. We report the case of a patient with all three coronary arteries arising from the right sinus of Valsalva who presented with acute coronary syndrome. Coronary angiography showed significant stenosis of the left circumflex and left anterior descending coronary arteries followed by successful angioplasty and stenting of these arteries.