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Background: Waste generation from health care facilities is significant. Quantifying and minimizing waste from cardiac catheterization laboratories (CCL) and cardiac operating theaters (COT) has received little attention in an effort to lessen its environmental impact. The purpose of this study was to assess the quantity of contaminated and recyclable waste resulting from invasive cardiac procedures. Methods: To assess the potential impact of recycling, quantify the amount of waste that ends up in landfills, and determine how much contaminated material needs to be managed, we audited the amount of hazardous and nonhazardous medical waste produced from CCL and COT in our cardiac center. Results: Every year, our cardiac center performs 350 cardiac surgeries and 2900 interventional cases. We estimated that annually 11,000 kg of recyclable waste and 30,000 kg of contaminated waste are generated. If this is extrapolated to all the CCL and COT globally, the anticipated annual waste production from invasive cardiac procedures is 150 million kg (150,000 metric tons). Conclusions: Cardiologists and cardiac surgeons must embrace sustainability as a critical need and join the effort to prevent global warming. One tiny action that each of us can take to improve the environment is to try to decrease waste while encouraging recycling.

Abstract Background The optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease. Methods This retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE). Results Emergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P

This study aimed to evaluate the clinical outcomes of patients with acute heart failure (AHF) stratified by mitral regurgitation (MR) in the Arabian Gulf. Patients from the Gulf CARE registry were identified from 47 hospitals in seven Arabian Gulf countries (Yemen, Oman, Kuwait, Qatar, Bahrain, the United Arab Emirates, and Saudi Arabia) from February to November 2012. The cohort was stratified into two groups based on the presence of MR. Univariable and multivariable statistical analyses were performed. The population cohort included 5005 consecutive patients presenting with AHF, of whom 1491 (29.8 %) had concomitant MR. The mean age of patients with AHF and concomitant MR was 59.2 ± 14.9 years, and 63.1 % (n = 2886) were male. A total of 58.6 % (n = 2683) had heart failure (HF) with reduced ejection fraction (EF) (HFrEF), 21.0 % (n = 961) had HF with mildly reduced EF (HFmrEF), and 20.4 % (n = 932) had HF with preserved EF (HFpEF). Patients with MR had a lower haemoglobin (Hb) level (12.4 vs. 12.7 g/dL; p

Lung cancer is the number one killer among all cancer types. For decades, clinicians have been using conventional chemotherapeutics, but they can’t rely on them alone anymore, because they poison bad cells and good cells as well. Researchers exploited nanotechnology as a potential tool to develop a platform for drug delivery to improve therapeutic efficiency. A quality by design synthesis of gefitinib-loaded starch nanoparticles (Gef-StNPs) has emerged as an essential tool to study and optimize the factors included in their synthesis. Therefore, we applied design of experiment (DOE) tools to attain the essential knowledge for the synthesis of high-quality Gef-StNPs that can deliver and concentrate the gefitinib (Gef) at A549 cells, thereby improving therapeutic efficacy and minimizing adverse effects. The in vitro cytotoxicity after exposing the A549 human lung cancer cells to the optimized Gef-StNPs was found to be much higher than that of the pure Gef (IC50 = 6.037 ± 0.24 and 21.65 ± 0.32 μg/mL, respectively). The optimized Gef-StNPs formula showed superiority over the pure Gef regarding the cellular uptake in A549 human cell line (3.976 ± 0.14 and 1.777 ± 0.1 μg/mL) and apoptotic population (77.14 ± 1.43 and 29.38 ± 1.11 %), respectively. The results elucidate why researchers have a voracious appetite for using natural biopolymers to combat lung cancer and paint an optimistic picture of their potential to be a promising tool in battling lung cancer.

Background Severe mitral regurgitation (MR) with left ventricular dysfunction portends worse outcomes. Over the course of the last two decades, transcatheter repair of the mitral valve offered an alternative therapeutic modality for those deemed inoperable or high risk. Landmark studies such as the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation and Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation trials have shown conflicting results with respect to all-cause death and heart failure rehospitalisations. The Gulf Mitral Transcatheter Edge to Edge Repair registry (Gulf MTEER registry) is a regional registry that captured outcomes in those undergoing transcatheter repair of the mitral valve. The objectives of this study were to describe the baseline characteristics of patients undergoing transcatheter mitral valve repair in the Gulf region and estimate the cardiovascular effects of the mitral transcatheter therapies in routine practice.Methods The Gulf MTEER registry is an observational, multicentre, retrospective registry that enrolled all patients undergoing transcatheter repair of the mitral valve from four of the Gulf countries (Saudi Arabia, Kuwait, Bahrain, Oman) between 1 January 2017 and 31 December 2019. Baseline characteristics, echocardiographic parameters and immediate procedural success were reported. The primary outcome was a composite of death and rehospitalisations at 1 year. The secondary outcomes were the individual components of the composite endpoint; that is, death and rehospitalisations at 1 year as well as residual or recurrent MR or worsening New York Heart Association class and a need for repeat repair.Results A total of 176 patients were enrolled. Men constituted 56.3% of the total. At 1 year the primary outcome occurred in 21.1% (95% CI 15.6, 27.9). The secondary outcomes of death occurred in 5.4% (CI 2.9, 10.0) and rehospitalisations occurred in 16.9% (CI 11.9, 23.3). Univariate analysis revealed that the odds of having death or re-hospitalisation was two times higher if the effective regurgitant orifice (ERO) >40 mm2 irrespective of the therapy.Conclusions The Gulf MTEER registry is the first registry in the Gulf region defining the patient population receiving MTEER therapies and evaluating 1-year outcomes. This is a low risk cohort with a high rate of immediate procedural success and low rate of all-cause death and rehospitalisations at 1 year. The odds of an event was two times higher if the ERO ≥40 mm2 with only a signal to higher odds for low left ventricular ejection fraction and larger end systolic dimension.

Introduction: Primary percutaneous coronary intervention (PPCI) represents a timely procedure that requires speedy revascularization. Moreover, PPCI in diffuse coronary lesions remains to be challenging even in the hands of experienced operators as the use of a long stent may increase the difficulty of the procedure in terms of stent delivery, deployment, and optimization. However, the practicability and clinical outcomes of deployment of a 60-mm-long stent in the setting of PPCI remain to be determined. Methods: The study is a retrospective observational analysis in a prospective cohort. The prospectively gathered data of consecutive patients from June 2016 to December 2019, who underwent PPCI with BioMime sirolimus-eluting stents 2.5–3.0/60 mm or 3.0–3.5/60 mm were analyzed at 1 year regarding the primary outcome of major adverse cardiovascular and cerebrovascular events (MACCE) and target lesion revascularization (TLR). Results: A total of 88 cases were included in the study; 23 cases underwent PPCI, whereas 65 underwent nonPPCI. The PPCI group had a mean age of 65.7 ± 10.9 years compared with 63.3 ± 9.6 years (P = 0.34) in the nonPPCI group. Eighty-three percentage of PPCI were males compared with 94% of their nonPPCI counterparts (P = 0.20). In addition, the prevalence of hypertension was more common in the PPCI group (87% vs. 63%, P = 0.03). There was no statistically significant difference between the two groups regarding other comorbidities. The most common culprit vessel was the left anterior descending artery (57%) in the PPCI group and the right coronary artery (58%) in the nonPPCI. The use of a stent with a diameter of 2.5–3.0 mm was more common in both groups (61% in PPCI vs. 66% in nonPPCI, P = 0.8). MACCE occurred in four patients during a year of follow-up. One occurred in the PPCI group (4%) compared with three in the nonPPCI group (5%) (P = 1.00). TLR was required in two cases, one in each group (4% vs. 2%, P = 0.46). Conclusion: The use of a 60-mm-long stent in the setting of PPCI has an excellent 12-month outcome in procedural success, MACCE, and TLR. Large randomized studies are required to confirm these results.

IntroductionThe characteristics of young adults with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndrome (ACS) has not been well described. The mean age of gulf citizens in ACS registries is 10-15 years younger than their western counterparts, which provided us with a unique opportunity to investigate the characteristics and predictors of OHCA in young adults presenting with ACS.MethodologyThis was a retrospective cohort study using data from 7 prospective ACS registries in the Gulf region. In brief, all registries included consecutive adults who were admitted with ACS. OHCA was defined as cardiac arrest upon presentation (i.e., before admission to the hospital). We described the characteristics of young adults (< 50 years) who had OHCA and performed multivariate logistic regression analysis to assess independent predictors of OHCA.ResultsA total of 31,620 ACS patients were included in the study. There were 611 (1.93%) OHCA cases in the whole cohort [188/10,848 (1.73%) in young adults vs 423/20,772 (2.04%) in older adults, p = 0.06]. Young adults were predominantly males presenting with ST-elevation myocardial infarction (STEMI) [182/188 (96.8%) and 172/188 (91.49%), respectively]. OHCA was the sentinel event of coronary artery disease (CAD) in 70% of young adults. STEMI, male sex, and non-smoking status were found to be independent predictors of OHCA [OR = 5.862 (95% CI 2.623-13.096), OR: 4.515 (95% CI 1.085-18.786), and OR = 2.27 (95% CI 1.335-3.86), respectively].ConclusionWe observed a lower prevalence of OHCA in ACS patients in our region as compared to previous literature from other regions. Moreover, OHCA was the sentinel event of CAD in the majority of young adults, who were predominantly males with STEMIs. These findings should help risk-stratify patients with ACS and inform further research into the characteristics of OHCA in young adults.

Introduction: The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function. Methods: This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE). Results: Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19–15.76], p < 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79–3.73]; p < 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71–1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90–1.39], p = 0.312). Conclusions: PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function.

Introduction: When the baseline anatomical syntax score-I (SxSI) is more than or equal to 33, percutaneous coronary intervention (PCI) of unprotected left main (UPLM) is discouraged and considered as high-risk of adverse cardiac events. We designed this study to compare the outcomes of UPLM-PCI between the low to intermediate-syntax score (SxSIlow/int.) group (defined as SxSI

The excimer laser has revolutionary impact on lesion preparation and chronic total occlusion outcomes. Furthermore, this technology has made huge progression in modern percutaneous intervention, especially in ones labeled as noncrossable lesions. This device has the advantage of crossing lesions that 0.14 wire pass through. The mechanism through which excimer laser coronary atherectomy (ELCA) works are photochemical, photothermal, and photomechanical. In this review cases article, we discuss the uses of ELCA in daily catheterization laboratory alone and with other plaque modification tools. We touch on acute coronary syndrome uses of ELCA, no-balloon crossing lesion, and intervening on deformed stents.

Aim: To investigate the precipitating factors that contribute to hospitalization and mortality in postacute heart failure (AHF) hospitalization in the Middle-East region. Methods: We evaluated patient data from the Gulf AHF registry (Gulf CARE), a prospective multicenter study conducted on hospitalized AHF patients in 47 hospitals across seven Middle Eastern Gulf countries in 2012. We performed analysis by adjusting confounders to identify important precipitating factors contributing to rehospitalization and 90- to 120-day follow-up mortality. Results: The mean age of the cohort (n = 5005) was 59.3 ± 14.9 years. Acute coronary syndrome (ACS) (27.2%), nonadherence to diet (19.2%), and infection (14.6%) were the most common precipitating factors identified. After adjusting for confounders, patients with AHF precipitated by infection (hazard ratio [HR], 1.40; 95% confidence interval [CI] 1.10–1.78) and ACS (HR-1.23; 95% CI: 0.99-1.52) at admission showed a higher 90-day mortality. Similarly, AHF precipitated by infection (HR-1.13; 95% CI: 0.93–1.37), and nonadherence to diet and medication (HR-1.12; 95% CI: 0.94–1.34) during hospitalization showed a persistently higher risk of 12-month mortality compared with AHF patients without identified precipitants. Conclusion: Precipitating factors such as ACS, nonadherence to diet, and medication were frequently identified as factors that influenced frequent hospitalization and mortality. Hence, early detection, management, and monitoring of these prognostic factors in-hospital and postdischarge should be prioritized in optimizing the management of HF in the Gulf region.

Abstract 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) (

Objectives: We sought to estimate the percentage achievements of non-high-density lipoprotein cholesterol (non-HDL-C) target in patients with very high atherosclerotic cardiovascular diseases (ASCVD) risk stratified by triglyceride (TG) levels despite statin-controlled low-density lipoprotein cholesterol (LDL-C) in the Centralized Pan-Middle East Survey on the under treatment of hypercholesterolemia. Methods: The non-HDL-C target achievement in patients with diabetes mellites (DM) and patients with established ASCVD was defined according to European Society of Cardiology and European Atherosclerosis Society 2019 guidelines for managing dyslipidemia. Patients were stratified to controlled LDL-C defined as < 70 mg/dL (< 1.8 mmol/L) with normal TG < 150 mg/dL (< 1.7 mmol/L) and high TG between 150–400 mg/dL (1.7–4.5 mmol/L). Results: The mean age of our cohort was 58.0±11.0 years, 6.8% (n = 717) were male, 9.7% (104) were smokers, and 48.4% (n = 518) had body mass index of ≥ 30 kg/m2. Those with high TG levels male (76.5% vs. 63.8%; p < 0.001), smokers (16.1% vs. 7.7%; p < 0.001), have metabolic syndrome (77.6% vs. 17.1%; p < 0.001), and low HDL-C levels (79.2% vs. 49.4%; p < 0.001). The majority (93.9%, n = 1008) were on statins (atorvastatin and rosuvastatin) with only 2.2% (n = 24) on the combined statins plus fenofibrate/gemfibrozil. Only 27.4% (n = 294) of patients had non-HDL-C goal attainment. Goal attainment rates in patients with diabetes (3.1% vs. 34,4%; p < 0.001), coronary artery disease (CAD) (2.4% vs. 37.9%; p < 0.001), diabetes plus CAD (0% vs. 40.0%; p < 0.001), and CVD (0% vs. 30.0%; p =0.048) were significantly lower in those with higher TG levels. Conclusions: A large proportion of statin-controlled LDL-C diabetic patients and patients with established ASCVD with high TGs did not achieve the non-HDL-C target. Our study did not demonstrate an association between ASCVD and high TG levels; and therefore, a follow-up study is highly required to assess long-term ASCVD outcomes in this cohort.

Background and aimsFamilial hypercholesterolemia (FH) is a common autosomal dominant disorder that can result in premature atherosclerotic cardiovascular disease (ASCVD). Limited data are available worldwide about the prevalence and management of FH. Here, we aimed to estimate the prevalence and management of patients with FH in five Arabian Gulf countries (Saudi Arabia, Oman, United Arab Emirates, Kuwait, and Bahrain).MethodsThe multicentre, multinational Gulf FH registry included adults (≥18 years old) recruited from outpatient clinics in 14 tertiary-care centres across five Arabian Gulf countries over the last five years. The Gulf FH registry had four phases: 1- screening, 2- classification based on the Dutch Lipid Clinic Network, 3- genetic testing, and 4- follow-up.ResultsAmong 34,366 screened patient records, 3713 patients had suspected FH (mean age: 49±15 years; 52% women) and 306 patients had definite or probable FH. Thus, the estimated FH prevalence was 0.9% (1:112). Treatments included high-intensity statin therapy (34%), ezetimibe (10%), and proprotein convertase subtilisin/kexin type 9 inhibitors (0.4%). Targets for low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol were achieved by 12% and 30%, respectively, of patients at high ASCVD risk, and by 3% and 6%, respectively, of patients at very high ASCVD risk (p ConclusionsThis snap-shot study was the first to show the high estimated prevalence of FH in the Arabian Gulf region (about 3-fold the estimated prevalence worldwide), and is a "call-to-action" for further confirmation in future population studies. The small proportions of patients that achieved target LDL-C values implied that health care policies need to implement nation-wide screening, raise FH awareness, and improve management strategies for FH.

Objectives: We sought to estimate the mortality and morbidity in diabetic acute heart failure (AHF) patients stratified by left ventricular ejection fraction. Methods: We analyzed the data of patients with AHF from seven Middle Eastern countries (Bahrain, Oman, Yemen, Kuwait, UAE, Qatar, and Saudi Arabia) from February to November 2012, who were enrolled in a multinational registry of patients with heart failure (HF). Results: A total of 2258 AHF patients had diabetes mellitus. The mean age was 63.0±11.0 years (ranging from 18 to 99 years), and 60.3% (n = 1362) of the patients were males. The mean ejection fraction (EF) was 37.0±13.0%. HF with reduced EF (< 40%) (HFrEF) was observed in 1268 patients (56.2%), whereas 515 patients (22.8%) had mid-range (40–49%) (HFmrEF) and 475 patients (21.0%) had preserved EF (≥ 50%) (HFpEF). The overall cumulative all-cause mortalities at three- and 12-months follow-up were 11.8% (n = 266) and 20.7% (n = 467), respectively. Those with HFpEF were associated with lower three-months cumulative all-cause mortality compared to those with HFrEF (7.6% vs. 5.9%; adjusted odds ratio (aOR) = 0.54, 95% confidence interval (CI): 0.31–0.95; p =0.031), but not significantly different when compared to those with HFmrEF (aOR = 0.86, 95% CI: 0.53–1.40; p =0.554). There were largely no significant differences among the groups with regards to the 12-months all-cause cumulative mortality (11% vs. 11% vs. 10%; p =0.984). There were also no significant differences in re-hospitalization rates between the three HF groups not only at three months (23% vs. 20% vs. 22%; p =0.520), but at one-year follow-up (28% vs. 30% vs. 32%; p =0.335). Conclusions: Three-month cumulative all-cause mortality was high in diabetic HFrEF patients when compared to those with HFpEF. However, there were no significant differences in mortality at one-year follow-up between the HF groups. There were also no significant differences in re-hospitalization rates between the HF groups not only at three months but also at one-year follow-up in the Middle East.

Objectives: The objective of this study is to describe contemporary management and 1-year outcomes of patients hospitalized with ST-segment elevation myocardial infarction (STEMI) in Arabian Gulf countries. Methods: Data of patients admitted to 29 hospitals in four Gulf countries [Bahrain, Kuwait, Oman, United Arab Emirates (UAE)] with the diagnosis of STEMI were analyzed from Gulf locals with acute coronary syndrome (ACS) events (Gulf COAST) registry. This was a longitudinal, observational registry of consecutive citizens, admitted with ACS from January 2012 to January 2013. Patient management and outcomes were analyzed and compared between the four countries. Results: A total of 1039 STEMI patients were enrolled in Gulf COAST Registry. The mean age was 58 years, and there was a high prevalence of diabetes (47%). With respect to reperfusion, 10% were reperfused with primary percutaneous coronary intervention, 66% with fibrinolytic therapy and 24% were not reperfused. Only one-third of patients who received fibrinolytic therapy had a door-to-needle time of 30 min or less. The in-hospital mortality rate was 7.4%. However, we noted a significant regional variability in mortality rate (3.8%–11.9%). In adjusted analysis, patients from Oman were 4 times more likely to die in hospital as compared to patients from Kuwait. Conclusions: In the Gulf countries, fibrinolytic therapy is the main reperfusion strategy used in STEMI patients. Most patients do not receive this therapy according to timelines outlined in recent practice guidelines. There is a significant discrepancy in outcomes between the countries. Quality improvement initiatives are needed to achieve better adherence to management guidelines and close the gap in outcomes.

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.

Differences in the management of atrial fibrillation (AF) between men and women were investigated by using Gulf SAFE data in the Middle East. The study included 2,043 patients presenting with AF to emergency room (ER) were prospectively enrolled and followed for one-year. Women were older, have higher body mass index (BMI), comorbidities, and health complications than men. With regard to management of AF, cardioversion was recommended more often for men (16.7% vs. 9.3%), and underwent electrical cardioversion (2.2% vs. 1.1%). Women were prescribed digoxin more frequently than men (25.6% vs. 17.4%) and a significant number women received warfarin alone (31.1% vs. 8.7%). No difference between the sexes was noticed in One-year rates of stroke/transient ischemic attacks (TIA) and all-cause of mortality after one-year follow-up (3.1% men vs. 3.3% women, and 7.5% vs. 7.4%). Older age (≥ 65 years), smoking, alcohol use, CHADS2 scores ≥5 were some of the significant risk factors in men with AF. Suboptimal use of anticoagulants, higher mortality and stroke/TIA events at one year are high but similar between the sexes. ER management revealed high use of rate control strategy and high rate of hospital admission was noticed in women.

BACKGROUND AND OBJECTIVES: Primary percutaneous coronary intervention (pPCI) has been recognized as an effective management strategy for acute ST-segment–elevation myocardial infarction (STEMI). However, there is no first-hand information regarding the quality of pPCI procedures in the Arabian Gulf countries. This study aims to explore the quality of pPCI practice. DESIGN AND SETTINGS: The Gulf Race II was designed as a prospective, multinational, multicentre registry of acute coronary events, focusing on the epidemiology, management practices, and outcomes of patients with acute coronary syndrome. The study recruited consecutive patients aged 18 years and above from 65 hospitals in 6 adjacent Middle Eastern countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen). PATIENTS AND METHODS: We used data from the Gulf Registry of Acute Coronary Events (Gulf RACE 2). We analyzed data on patients who received pPCI to assess the guidelines-supported performance measure of door-to-balloon (D2B) ≤ 90 minutes and its impact on morbidity and mortality. RESULTS: Of 3432 patients with STEMI, slightly more than half (53%, n=1832) were admitted to a hospital with a cardiac catheterization laboratory (Cath-Lab). Of these, only 1006 patients (55%) received reperfusion therapy, and pPCI was used in a small predominantly male subgroup (11% of the STEMI cohort admitted to hospitals with Cath-Lab, n=198). The median D2B time in the pPCI cohort was 85 minutes, and a D2B of ≤90 minutes was achieved in only 55%. Patients with timely pPCI (D2B ≤ 90 minutes) were less likely to have cardiogenic shock and require intra-aortic balloon pump. In-hospital, 1-month and 1-year mortality were not statistically in favor of timely pPCI. CONCLUSION: Primary PCI was underused in the Gulf region with low rate of acute reperfusion and no timely pPCI and thus no mortality benefit.

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.

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.

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.

Objective: Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy. Patients and Methods: This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics. Results: Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use. Conclusions: Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.

BACKGROUND AND OBJECTIVES: Limited data are available on patients with acute coronary syndromes (ACS) and their long-term outcomes in the Arabian Gulf countries. We evaluated the clinical features, management, in-hospital, and long-term outcomes in such a population. DESIGN AND SETTING: A 9-month prospective, multicenter study conducted in 65 hospitals from 6 countries that also included 30 day and 1-year mortality follow-up. PATIENTS AND METHODS: ACS patients included those with ST-elevation myocardial infarction (STEMI) and non–ST-elevation acute coronary syndrome (NSTEACS), including non-STEMI and unstable angina. The registry collected the data prospectively. RESULTS: Between October 2008 and June 2009, 7930 patients were enrolled. The mean age [standard deviation (SD)], 56 (17) years; 78.8% men; 71.2% Gulf citizens; 50.1% with central obesity; and 45.6% with STEMI. A history of diabetes mellitus was present in 39.5%, hypertension in 47.2%, and hyperlipidemia in 32.7%, and 35.7% were current smokers. The median time from symptom onset to hospital arrival for STEMI patients was 178 minutes (interquartile range, 210 minutes); 22.3% had primary percutaneous coronary intervention (PCI) and 65.7% thrombolytic therapy, with 34% receiving therapy within 30 minutes of arrival. Evidence-based medication rates upon hospital discharge were 68% to 95%. The in-hospital PCI was done in 21% and the coronary artery bypass graft surgery in 2.9%. The in-hospital mortality was 4.6%, at 30 days the mortality was 7.2%, and at 1 year after hospital discharge the mortality was 9.4%; 1-year mortality was higher in STEMI (11.5%) than in NSTEACS patients (7.7%; P

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