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ObjectiveTo characterize risk profile of acute coronary syndrome (ACS) patients in different age groups and compare management provided to in-hospital outcome.DesignProspective multi-hospital registry.SettingSeventeen secondary and tertiary care hospitals in Saudi Arabia.PatientsFive thousand and fifty-five patients with ACS. They were divided into four groups: ⩽40years, 41–55years, 56–70years and ⩾70years. Main outcome measures: prevalence, utilization and mortality.Results: Ninety-four percent of patients 70years were men. Diabetes was present in 70% of patients aged 56–70years. Smoking was present in 66% of those 70years. Fifty-three percent of the patients >70years and 25% of those 70years. Thirty-four percent of patients >70years compared to 10% of patients 12h from symptom onset with STEMI. Fifty-four percent of patients >70 compared to 64–71% of those 70 compared to 34–40% of those 56years compared to 11% in patients 70years compared to 1.6–3% in patients

We evaluated prevalence and clinical outcome of polyvascular disease (PolyVD) in patients presenting with acute coronary syndrome (ACS). Data for 7689 consecutive ACS patients were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were divided into 2 groups (ACS with versus without PolyVD). All-cause mortality was assessed at 1 and 12 months. Patients with PolyVD were older and more likely to have cardiovascular risk factors. On presentation, those patients were more likely to have atypical angina, high resting heart rate, high Killip class, and GRACE risk scoring. They were less likely to receive evidence-based therapies. Diabetes mellitus, renal failure, and hypertension were independent predictors for presence of PolyVD. PolyVD was associated with worse in-hospital outcomes (except for major bleedings) and all-cause mortality even after adjusting for baseline covariates. Great efforts should be directed toward primary and secondary preventive measures.

ObjectivesThe Saudi Project for Assessment of Coronary Events (SPACE) registry is the first in Saudi Arabia to study the clinical features, management, and in-hospital outcomes of acute coronary syndrome (ACS) patients.MethodsWe conducted a prospective registry study in 17 hospitals in Saudi Arabia between December 2005 and December 2007. ACS patients included those with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction and unstable angina; both were reported collectively as NSTEACS (non-ST elevation acute coronary syndrome).Results5055 patients were enrolled with mean age±SD of 58±12.9years; 77.4% men, 82.4% Saudi nationals; 41.5% had STEMI, and 5.1% arrived at the hospital by ambulance. History of diabetes mellitus was present in 58.1%, hypertension in 55.3%, hyperlipidemia in 41.1%, and 32.8% were current smokers; all these were more common in NSTEACS patients, except for smoking (all P

The prognostic value of admission estimated glomerular filtration rate (eGFR) calculated by the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula for cardiovascular adverse outcomes in acute coronary syndrome (ACS) was explored. Baseline eGFR was classified as no renal dysfunction (>90 mL/min per 1.73 m2), borderline (90-60.1 mL/min per 1.73 m2), moderate (60-30.1 mL/min per 1.73 m2), or severe (≤30 mL/min per 1.73 m2) renal dysfunction. Of the 5034 patients, 3415 (67.8%) had eGFR 2, patients with 2 were less likely to be treated with β-blockers, angiotensin-converting enzyme inhibitors, or statins, or to undergo percutaneous coronary interventions. Lower eGFR showed a stepwise association with significantly worse adverse in-hospital outcomes. The adjusted odds ratio of in-hospital death with an eGFR 2 was 3.1 (95% confidence interval 1.1-8.4, P = .0324), compared with an eGFR >90 mL/min per 1.73 m2. Estimated glomerular filtration rate calculated by the new CKD-EPI is an independent predictor of major adverse cardiac outcomes in patients with ACS.

Introduction: Low Pulse Pressure (PP) predicts mortality in chronic symptomatic Heart Failure (HF). Data in Acute HF (AHF) are lacking. Our aim was to examine the prognostic value of PP in AHF for short- and long-term outcomes. Methodology: Data from the Heart Function Assessment Registry Trial (HEARTS) were analyzed. AHF patients were prospectively enrolled from October 2009 to December 2010, with a mortality follow-up until January 2013. Comparisons were done according to PP median value (50 mmHg). Primary outcomes were hospital adverse events and short and long-term mortality rates. Results: 2609 patients were included. In crude comparisons, patients with low PP had higher rates of recurrence of HF (35.4% vs. 26.5%; P

The aim was to report the prevalence and significance of hypertension (HTN) in patients with acute coronary syndrome (ACS).Over a 6-month period in 2007, 8171 consecutive patients (49.4% hypertensive and 50.6% non-hypertensive) presenting with ACS were enrolled in a prospective, multicenter study from six Middle Eastern adjacent countries. Patients with HTN were older (59.2 vs 53.1 years, p0.001), and more likely to be female (34% vs 14.4%, p0.001) when compared with patients without HTN. Patients with HTN were also more likely to have diabetes mellitus, hyperlipidemia, cerebrovascular disease, prior history of coronary artery disease, peripheral artery disease but less likely to be cigarette smokers. At admission, HTN patients had higher Killip class, heart rate and GRACE risk scoring. In-hospital mortality was higher in hypertensive patients with ST-elevation myocardial infarction (STEMI) but not in patients with non-STEMI or unstable angina. The incidence of heart failure complications was significantly higher among patients with HTN in overall ACS type (OR = 1.2, 95% CI 1.001-1.338, p= 0.04).In this large cohort of patients with ACS, HTN was an independent predictor of heart failure and was associated with an increased rate of in-hospital mortality in STEMI only.

OBJECTIVE: To evaluate the prevalence of gastroesophageal reflux disease (GERD) in patients presenting with asthma and chronic cough.PATIENTS AND METHODS: The charts of 358 consecutive patients who were referred for ambulatory gastroesophageal pH monitoring to the Lung Centre in Vancouver, British Columbia, were reviewed, and the data of 108 (30%) patients with asthma and 134 (37%) patients with chronic cough were analyzed. The maintenance treatment for GERD was discontinued before patients underwent the pH monitoring study. One hundred eighteen (33%) patients were excluded.RESULTS: Reflux episodes identified reflux events as the percentage of time where the pH was less than four. For asthma patients, 70 (64.8%) had distal total reflux, 50 (46.3%) had distal upright reflux, 41 (38.3%) had distal supine reflux and 73 (67.6%) had other distal refluxes. Proximal total reflux in asthmatic patients was present in 56 (52%), proximal upright reflux in 55 (51%) and proximal supine reflux in 56 (52%) patients. For chronic cough patients, 70 (52.6%) had distal total reflux, 59 (44.4%) had distal upright reflux, 45 (34.4%) had distal supine reflux and 75 (56%) patients had other distal refluxes. In chronic cough patients, proximal total reflux was present in 70 (52%), proximal upright reflux in 80 (60%) and proximal supine reflux in 59 (44%). Presenting respiratory and/or reflux symptoms were absent in approximately 25% of patients with asthma and reflux, and in approximately 50% of patients with chronic cough and reflux. During pH monitoring, symptoms did not differ significantly between those with and without distal reflux in both study groups, except for more significant heartburn in patients with chronic cough and reflux (RR 2.0).CONCLUSIONS: The data of the present study support the observation that there is a high prevalence of GERD in patients with asthma or chronic cough. The use of different pH parameters for detecting acid reflux during 24 h ambulatory pH monitoring, such as proximal esophageal acid measurement, should be considered as part of the routine interpretation of such testing. A low threshold for diagnosing GERD in patients with asthma or chronic cough is essential, because respiratory and/or reflux symptoms can be absent or atypical in some of these patients.

Background Little is know about the outcomes of acute heart failure (AHF) with acute coronary syndrome (ACS-AHF), compared to those without ACS (NACS-AHF). Methods We conducted a prospective registry of AHF patients involving 18 hospitals in Saudi Arabia between October 2009 and December 2010. In this sub-study, we compared the clinical correlates, management and hospital course, as well as short, and long-term outcomes between AHF patients with and without ACS. Results Of the 2609 AHF patients enrolled, 27.8 % presented with ACS. Compared to NACS-AHF patients, ACS-AHF patients were more likely to be old males (Mean age = 62.7 vs. 60.8 years, p = 0.003, and 73.8 % vs. 62.7 %, p

Saudi Arabia has a large expatriate population. We explored the difference and similarities between Non-Saudi patients (NS) presenting with an acute coronary syndrome and Saudi nationals (SN) with respect to therapies and clinical outcomes. Methods: ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) from 2005 to 2007 are the subjects of this analysis. 5055 patients were enrolled in SPACE. Propensity score matching and logistic regression analysis were performed to account for major imbalances in age and gender. Results: 2031 ACS patients were available for analysis. The mean age was 56.2 ± 9.8, and males formed 83.5% of the study cohort. SN were more likely to have risk factors of atherosclerosis. ST-elevation MI (STEMI) was the most common ACS presentation in NS, while Non-ST ACS was more common in SN. The median symptom to door time was significantly longer in NS patients (175 min (197) vs. 130 min (167), p = 0.027). There were no differences in pharmacological therapies between the two groups, Except that NS were more likely to receive fibrinolytic therapy. NS were less likely to undergo percutaneous coronary interventions (PCI), or primary PCI compared to Saudis (32.6% vs. 42.8%, p = 0.0001, and 7.8% vs. 22.8%, p

The aim of this study was to compare the clinical features, predictors, and clinical outcomes of patients hospitalized with acute heart failure (AHF), with and without worsening heart failure (WHF).We used data from a multicentre prospective registry of AHF patients created in Saudi Arabia. WHF was defined as recurrence of heart failure symptoms or signs-with or without cardiogenic shock. In-hospital short- and long-term outcomes, as well as predictors of WHF are described. Of the 2609 AHF patients enrolled, 33.8% developed WHF. WHF patients were more likely to have a history of heart failure and ischaemic heart disease. Use of intravenous vasodilators, inotropic agents, furosemide infusions, and discharge beta-blockers was significantly higher in WHF patients, while use of discharge ACE inhibitors was higher in patients without WHF. Length of hospital stay was significantly longer for WHF patients than for those without WHF [median (interquartile range) 13 (14) vs. 7 (7) days, P0.001]. In-hospital, 30-day, 1-year, and 2-year mortality rates were higher in WHF patients than in non-WHF patients. The adjusted odds ratios for in-hospital, 30-day, and 1-year mortality were 4.13 [95% confidence interval (CI) 2.74-6.20, P0.001], 3.17 (95% CI 2.21-4.56, P0.001), and 1.34 (95% CI 1.04-1.71, P = 0.021), respectively. The strongest predictors for WHF were having ischaemic cardiomyopathy, AHF with concomitant acute coronary syndrome, and low haemoglobin.In real-world clinical practice, WHF during hospitalization for AHF is a strong predictor for short- and intermediate-term mortality, and a cause for longer hospital stays.

To assess, according to age groups, patients' characteristics according to region of origin, the chronic therapeutic management, prognostic utility of clinical variables, and natriuretic peptides.The GREAT registry consisted of patients identified as presenting with acute heart failure at the emergency department. Four groups of patients were defined according to age: the young patient group (65 years); 'middle-old' (65-74 years), 'old-old' (75-84 years) and the 'oldest-old' (85-94 years). Follow-up at 1 year was performed via personal contact or national data registries at 1 year. Dataset consisted of 14 758 patients aged up to 95 years, with the 'oldest-old' group being more prevalent in North America and Western Europe. The 30-day mortality rate were, respectively, 8.1%, 8.9%, 10.3%, and 16.3% among the four age groups and 1-year mortality rates were, respectively, 3.1%, 17.1%, 24.7%, and 39.9%. Chronic heart failure treatment was less frequently administered with age (percentage of the 'fully treated' group was 14% in the 'young' compared with 2% in the 'oldest-old' patient group). Reduced left ventricular ejection fraction was present in 70%, 62.3%, 52.5%, and 46.8% among the four age groups, respectively. The prognostic utility of most variables for short- and long-term outcome was attenuated with age, with the exception of natriuretic peptides.This study found a large heterogeneity in age among geographic regions and that the eldest are less likely to be treated in accordance with recommendations of current heart failure guidelines. Natriuretic peptide concentrations retained prognostic value in patients across age strata.

Aim: The heart function assessment registry trial in Saudi Arabia (HEARTS) is a national multicenter project that compared de novo versus acute-on-chronic heart failure (ACHF). Methods and Results: This is a prospective registry in 18 hospitals in Saudi Arabia between October 2009 and December 2010. The study enrolled 2610 patients: 940 (36%) de novo and 1670 (64%) ACHF. Patients with ACHF were significantly older (62.2 vs 60 years), less likely to be males (64% vs 69%) or smokers (31.6% vs 36.7%), and more likely to have history of diabetes mellitus (65.7% vs 61.3%), hypertension (74% vs 65%), and severe left ventricular dysfunction (52% vs 40%). The ACHF group had a higher adjusted 3-year mortality rate (hazard ratio, 1.6; 95% confidence interval [CI] 1.3-2.0; P < .001). Conclusion: Patients with ACHF had significantly higher long-term mortality rates than those with de novo acute heart failure (HF). Multidisciplinary HF disease management programs are highly needed for such high-risk populations.

Loop diuretics are a cornerstone in the management of Acute Decompensated Heart Failure (ADHF). However, the best therapeutic strategy in terms of intermittent boluses versus continuous infusion is still unclear.We set to examine the differences in hospital management and short-term and long-term mortality of patient receiving furosemide bolus or infusion treatment for ADHF.This is a retrospective cohort study of 207 patients admitted to KKUH with ADHF. Clinical data, labs, in-hospital outcomes and long-term mortality data were collected through review of medical records and HEARTS registry database. We stratified our cohort into two groups; furosemide infusion and bolus groups.The Mean age was 61.5 ± 13.87 years, and 66.2% were males. Approximately 42% had left ventricular ejection fraction LVEF

Objectives Beta blockers reduce mortality in heart failure (HF). However, it is not clear whether they should be temporarily withdrawn during acute HF. Design Analysis of prospectively collected data. Setting The Gulf aCute heArt failuRe rEgistry is a prospective multicentre study of patients hospitalised with acute HF in seven Middle Eastern countries. Participants 5005 patients with acute HF. Outcome measures We studied the effect of beta blockers non-withdrawal on intrahospital, 3-month and 12-month mortality and rehospitalisation for HF in patients with acute decompensated chronic heart failure (ADCHF) and acute de novo heart failure (ADNHF) and a left ventricular ejection fraction (LVEF)

Ingestion of sodium is essential to health, but excess sodium intake is a risk factor for hypertension and cardiovascular disease. Defining an optimal range of sodium intake in populations has been challenging and controversial. Clinical trials evaluating the effect of sodium reduction on blood pressure have shown blood pressure lowering effects down to sodium intake of less than 1.5 g/day. Findings from these blood pressure trials form the basis for current guideline recommendations to reduce sodium intake to less than 2.3 g/day. However, these clinical trials employed interventions that are not feasible for population-wide implementation (i.e. feeding studies or intensive behavioural interventions), particularly in low and middle-income countries. Prospective cohort studies have identified the optimal range of sodium intake to reside in the moderate range (3-5 g/day), where the risk of cardiovascular disease and death is lowest. Therefore, there is consistent evidence from clinical trials and observational studies to support reducing sodium intake to less than 5 g/day in populations, but inconsistent evidence for further reductions below a moderate intake range (3-5 g/day). Unfortunately, there are no large randomized controlled trials comparing low sodium intake (5 g/day), which should be embedded within an overall healthy dietary pattern.

Background: Recent reports have suggested that there are gender differences in the presentation of young adults with acute coronary syndromes (ACS). How these differences may affect ACS outcomes remains unclear, however. The aim of the current study was to examine the prognostic impact of gender in young adults with ACS in a multicenter multinational ACS registry from the Middle East. Methods: For a period of 9 months in 2008 to 2009, 7,930 consecutive patients with ACS were enrolled from 65 hospitals in 6 Middle East countries. A cohort of 3933 patients in the age group 55 years and younger were selected of whom 552 were women (14%). Gender differences in presentation and clinical features were examined. Multivariate analysis of in-hospital and one year mortality was also performed. Results: The mean age for women was 46 years and for men 48 years. Women had significantly higher rates of diabetes mellitus (50.4% vs. 30.7%), hypertension (57.4% vs. 34.5%), obesity (32% vs. 17%), dyslipidemia (37.5% vs. 26%) and renal impairment (4.1% vs. 1.2%) whereas men were more likely to be smokers (72.4% vs. 14%) [all P Conclusions: Our study shows that female gender independently and significantly increases the risk of immediate and long term mortality in young patients with ACS.

OBJECTIVES: It is well recognized that cardiac autonomic neuropathy associated with diabetes mellitus (DM) can cause silent myocardial ischemia, however there is limited research examining how the cardiac symptoms reported by patients with DM presenting with acute coronary syndromes (ACS) can affect the immediate and long term outcomes. The aim of the current study was to examine the prognostic impact of lack of chest pain symptoms in DM patients presenting with ACS and enrolled in a multicenter multinational ACS registry from the Middle East. METHODS: For a period of 9 months in 2008 to 2009, 7,930 consecutive patients with ACS were enrolled from 65 hospitals in 6 Middle East countries. A cohort of 3135 patients with DM were selected of whom 2686 (85.7%) presented with chest pain while 449 patients (14.3%) had no chest pain. Clinical features and outcomes were examined and compared among the two groups. RESULTS: Diabetic patients without chest pain were 5 years older and had significantly higher rates of hypertension (76.1% vs. 63.2%), prior myocardial infarction (35.9% vs. 24.3%), chronic kidney disease (CKD) (17.1% vs. 5.9%) and had significantly higher GRACE risk scores (55.3% vs. 21.4%) at presentation compared to patients with chest pain [All P CONCLUSIONS: DM patients with ACS presenting without chest pain are at an increased risk of immediate and long term mortality. Understanding the factors associated with atypical presentations of ACS in patients with DM may help in the earlier detection and more appropriate management of these high risk patients.

Background: Atrial Fibrillation (AF) and heart failure (HF) are two common prevalent conditions that may present independent of each other or coexist. The impact of AF on mortality in patients with HF and reduced (HFrEF) or preserved ejection fraction (HFpEF) is unclear with conflicting results. Methods: We analyzed data from the Gulf acute HF registry, a prospective, multinational registry of patients admitted with acute HF in 47 hospitals in 7 Middle Eastern Arab Gulf countries (recruited between February 13, 2012 and November 13, 2012). We compared the 12-month mortality in patients with AF versus sinus rhythm (SR) in both types of HF (HFrEF and HFpEF). Results: Among 5005 patients admitted with HF, 835 patients (16.7%) had AF and 3964 (79.2 %) had no history of AF and were in SR. Remaining percentage included patients with rhythms other than AF or SR (e.g. junctional rhythm). After excluding patients with no available echocardiography and those with other rhythms, the number of patients in our study population was 4394 patients where 770 patients (17.5 %) were in the AF group ( 10.2% with HFrEF and 7.3% with HFpEF) and 3624 patients (82.5 %) were in the SR group (56.2% with HFrEF and 26.3% with HFpEF). The mortality at 12 month was significantly higher in the AF compared to SR group (21.1% vs. 16.3%; P = 0.001), even after covariate adjustment (odds ratio [OR] = 1.23, 95% C.I 1.01-1.5; P = 0.04). Furthermore, subgroup analysis revealed that AF was associated with a higher risk of 12 month mortality in patients with HFrEF (23.7% vs. 16.6%; P = 0.001) but not among patients with HFpEF (17.5% vs. 15.8%; P = 0.48), even after covariate adjustment (adjusted OR among patients with HFrEF = 1.40, 95% C.I. 1.10-1.80; P=0.009 while adjusted OR among patients with HFpEF = 0.93. 95% C.I.:0.65 - 1.32; P=0.67). Conclusion: AF is associated with significantly higher 12-month mortality among patients with HFrEF, but not among those with HFpEF, suggesting a stronger impact of AF in patients with systolic HF.

Background: Chronic heart failure (CHF) is a known risk for stroke and morbidities and mortalities are known to be higher in CHF patients compared to stroke patients without CHF we here study the prevalence and the clinical significance in a group of patient with stroke or transient ischemic attack (TIA) who were admitted to hospital with acute heart failure (AHF) compared to those without stroke and are admitted with acute heart failure Methods: Data were derived from a prospective, multicenter, multinational study of 5005 patients hospitalized with AHF from February 2013 to November 2012. Data were analyzed according to the presence or absence of Stroke or bronchial TIA. Demographic, management, in-hospital and 1-year outcomes were compared Results: Stroke patients were likely to have a decompensation of chronic failure rather than De-Novo AHF when compared to those without Stroke/TIA (see table). Stroke patients were older; more likely to be female, have history of DM, HTN, dyslipidemia and CKD. Stroke patients were likely to have Atrial fibrillation, PVD, systolic LV dysfunction as well as CAD when compared to those without Stroke, they were also more likely receive NIV, IV inotropes and likely to have had cardiac PCI prior to this admission with AHF. Stroke patients had higher recurrence of stroke and one-year mortality rates. Conclusion: Patients who presented with AHF and history of stroke/TIA were having different clinical characteristics as well as comorbidities as compared to those without Stroke, with worse in-hospital and one-year outcome. The current study underlies the need to aggressively manage these high-risk patients.

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).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 was10%. In-hospital mortality was 6.3%. Re-hospitalization and cumulative mortality at 3 and 12 months were 18%/13% and 40%/20%, respectively.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.

To assess the impact of on-admission heart rate (HR) in patients presenting with acute coronary syndrome (ACS).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.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.

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

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).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.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%, P0.001) and cardiogenic shock rates (6.45 vs. 4.12%, P=0.019) compared with DM patients not requiring insulin.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.

Background Contrast-induced nephropathy (CIN) is a leading cause of hospital-acquired acute kidney injury. Limited data exists about CIN in Saudi Arabia. We sought to explore the incidence, and characteristics of CIN victims in a Saudi tertiary care center. Methods Patients who underwent cardiac catheterization (CC) or renal denervation between January 1st, 2012 and June 30th, 2013 were screened. CIN was defined as ⩾25% increase in Creatinine, occurring within 24–7 h after contrast exposure. Baseline characteristics, and incidence of CIN were described. Results 437 patients were eligible for this analysis. Of those 434 underwent CC and 3 renal denervation. The mean age of the study cohort was 56.9 (±11.8). 56.6% were Saudi nationals, and 78.2% were males. Diabetes, hypertension, and pre-existing chronic kidney disease were found in 52.5%, 59.12%, and 5.35%, respectively. 73.7% were hydrated prior to the procedure, and 42.9% were hydrated following the procedure. Overall incidence of contrast-induced nephropathy was 31.3%. 56.5% developed CIN within 48 h after the index procedure; while 35.6% developed it after 96 h. All patients developing CIN recovered without dialysis. Baseline estimated GFR, and HTN were the only independent predictors for CIN. Conclusion Our study is the first study in Saudi Arabia reporting the incidence of CIN. CIN incidence is relatively high though the overall short-term prognosis is favorable.

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

The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS) is a national multicentre project, studying clinical features, management, short- and long-term outcomes, and mortality predictors in patients admitted with acute decompensated heart failure (ADHF).Our prospective registry enrolled 2610 ADHF patients admitted to 18 hospitals in Saudi Arabia between October 2009 and December 2010, and followed mortality rates until January 2013. The patients included 66% men and 85.5% Saudis, with a median age (interquartile range) of 61.4 (15) years; 64% had acute on chronic heart failure (HF), 64.1% diabetes mellitus, 70.6% hypertension, and 55.7% CAD. Exacerbating factors for hospital admission included acute coronary syndromes (37.8%), infections (20.6%), non-compliance with low-salt diet (25.2%), and non-compliance with HF medications (20%). An LVEF40% was found in 73%. In-hospital use of evidence-based medications was high. All-cause cumulative mortality rates at 30 days, 6 months, 1 year, 2 years, and 3 years were 8.3, 13.7, 19.5, 23.5, and 24.3%, respectively. Important independent predictors of mortality were history of stroke, acute on chronic HF, systolic blood pressure90 mmHg upon presentation, estimated glomerular filtration rate60 mL/min, and haemoglobin10 g/dL.Patients with ADHF in Saudi Arabia presented at a younger age and had higher rates of CAD risk factors compared with those in developed countries. Most patients had reduced LV systolic function, mostly due to ischaemic aetiology, and had poor long-term prognosis. These findings indicate a need for nationwide primary prevention and HF disease management programmes.

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

Objective: Data on hypertension prevalence, awareness, treatment and control are sparse in the Middle East especially in the different socio-demographic characteristics (age, sex, community location, education) and comorbid status like diabetes and cardiovascular disease. We report the prevalence, awareness, treatment, and control of hypertension across four Middle Eastern countries (Iran, Occupied Palestinian Territory (OPT), Saudi Arabia, and United Arab Emirates (UAE)), using a standardized and uniform method. Design and Method: The Prospective Urban Rural Epidemiology (PURE) study enrolled 10,516 participants, from 52 urban and 35 rural communities from four countries in the Middle East. Hypertension is defined as blood pressure > = 140/90 mmHg using an automated digital device. Those who reported knowing they had hypertension or using blood pressure lowering medications among those with hypertension were considered as being aware. Control was defined as those on blood pressure lowering medications and blood pressure lower than 140/90 mmHg among the hypertensives. Results: Among participants, 33% had hypertension; of these 49% were aware, 47% were treated with. only 19% being controlled. Prevalence, awareness, treatment, and control of blood pressure were higher among women and older (50–69 years) participants compared with men and younger individuals (30–49 years). (P Conclusions: Findings from this study indicate the need for improvements in hypertension diagnosis and treatment in the Middle East, especially in rural communities, men and younger individuals.

BACKGROUND AND OBJECTIVES: Mortality in acute coronary syndrome (ACS) patients with ventricular arrhythmia (VA) has been shown to be higher than those without VA. However, there is a paucity of data on VA among ACS patients in the Middle Eastern countries. DESIGN AND SETTING: Prospective study of patients admitted in 17 government hospitals with ACS between December 2005 and December 2007. PATIENTS AND METHODS: Patients were categorized as having VA if they experienced either ventricular fibrillation (VF) or sustained ventricular tachycardia (VT) or both. RESULTS: Of 5055 patients with ACS enrolled in the SPACE registry, 168 (3.3%) were diagnosed with VA and 151 (98.8%) occurred in-hospital. The vast majority (74.4%) occurred in patients with ST-segment elevation myocardial infarction. In addition, males were twice as likely to develop VA than females (OR 1.7; 95% CI 1.1–3). Killip class >I (OR 2.0; 95% CI 1.3–3.1); and systolic blood pressure

OBJECTIVE: To evaluate the impact of evidence-based cardiac medications (EBMs) on 1-month and 1-year mortality among discharged acute coronary syndrome (ACS) patients in the Middle East. METHODS: Data were analyzed from 7,567 consecutive ACS patients admitted to 66 hospitals in 6 Middle Eastern countries enrolled in the Gulf RACE II in October 2008 to June 2009. Individual EBMs or concurrent use of the EBM combination consists of an anti-platelet therapy, angiotensin-converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker (ARB)), β-blocker, and a statin at discharge, were evaluated. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The mean age of the cohort was 56 +/- 12 years with 79% being males. 65% of the patients received the concurrent EBM combination at discharge. Aspirin, clopidogrel, statins, b-blockers and ACEIs/ARBs use was 96%, 71%, 95%, 82% and 81%, respectively. 70% of the patients were prescribed both aspirin and clopidogrel concurrently at discharge. Adjusting for demographic, clinical, revascularization, and country characteristics, the multivariable logistic regression models demonstrated no differences in mortality at both 1-month (3.0 vs. 3.6%; p = 0.828) and 1-year (3.5 vs. 3.5%; p = 0.976) between the concurrent EBM combination users and non-users. CONCLUSION: The majority of the ACS patients in the Middle East were prescribed the guideline recommended EBM combination at discharge. However, potential still remains for further optimization of management. Further studies are required to examine the long term effect of concurrent use of the EBM combination on mortality in the region.

The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS).Data were analyzed from 7922 consecutive patients admitted to hospitals throughout six Middle-Eastern countries with the final diagnosis of ACS, as part of Gulf RACE II (Registry of Acute Coronary Events II). Anemia at admission was defined according to the World Health Organization definition (13 g/dL in men and12 g/dL in women). Analyses were conducted using univariate and multivariate statistical techniques.The median age of the cohort was 56 (48-65) years, with the majority being male (79%). Anemia at admission was present in 2241 patients (28%). Patients with anemia were more likely to have in-hospital complications including heart failure, recurrent ischemia, re-infarction, cardiogenic shock, stroke, and major bleed. Even after adjustment, anemia was still associated with mortality at in-hospital (odds ratio [OR]=1.71, 95% confidence interval [CI], 1.34-2.17; P0.001), at one-month (OR=1.34, 95% CI, 1.06-1.71; P=0.016), and at one-year (OR=1.22, 95% CI, 1.01-1.49; P=0.049) post-admission with ACS.Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year. Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.

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

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

Objective: To evaluate the baseline demographic/clinical characteristics, in-hospital treatment and outcomes among patients with or without prior coronary artery bypass graft surgery (CABG) presenting as acute coronary syndrome (ACS) from six Middle East countries. Methods: Data was derived from a prospective, multinational, multicenter registry of 7881 consecutive patients hospitalized with ACS in six Middle East countries. Data were analyzed according to their history of prior CABG. Results: Of 7881 ACS patients, 336 (4.2%) had a his- tory of CABG. Patients with prior CABG were older (mean 63±10.8 vs. 56±12.6 years; P=0.001) and more frequently to be men (76%) with significantly more prior angina, infarction and percutaneous revascularization. They were more likely to have hypertension, diabetes, hyper - lipidemia, prior congestive heart failure, stroke, renal failure, peripheral arterial disease and had higher prevalence of previous treatment with evidence-based medications. They were more likely to present with unstable angina (45.5% vs. 23.4%), followed by non-ST elevation myocardial infarction (STEMI) (43.8% vs. 29.5%), STEMI (10.7% vs. 47.1%) (All P=0.001) with less prominent peak values of cardiac biomark- ers than patients without prior CABG. Patients with prior CABG were more likely to present with significantly worse Killip class ( ≥2), higher Global Registry of Acute Coronary Events (GRACE) risk score, multivessel disease, severe left ventricular (LV) dysfunction (LV ejection fraction ≤30%) and developed significantly higher cardiogenic shock and major bleeding. In patients with prior CABG, no significant difference was observed in in-hospital mortality (4.2% vs. 4.6%, P=0.735) or mortality at one month (6.5% vs. 8.2%, P=0.277) or after one year (15% vs. 12.4%, P=0.204) when compared to patients without prior CABG. Conclusions: ACS patients from Middle East countries with prior CABG have adverse baseline characteristics, reported higher GRACE risk score, multivessel disease, more severe LV dysfunction, cardiogenic shock, in-hospital major bleeding, but with less incidence of STEMI with less prominent surge of cardiac biomarkers. However, there was no significant differ - ence in mortality during hospitalization, at 30 days and at one year between ACS patients with and without prior CABG. The reasons for this 'risk-mortality' paradox need to be further evaluated. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

the other presented at 5 months of age with profound cyanosis and left heart dilatation without congenital heart disease and without lung hypoplasia, both patients underwent successful occlusion of the fistula by amplatzer occluding devices with normalization of saturation without complications at five years of follow up. Conclusion: Diagnosis of large pulmonary fistula is feasible in the fetus and early infancy with excellent outcome by catheter intervention in absence of congenital heart disease or lung hypoplasia.

We assessed the prevalence, predictors, and in-hospital and long-term outcomes of conservative medical management for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) compared with percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This prospective study conducted from October 2008 to June 2009 in 65 hospitals from 6 Arabian Gulf countries included 30-day and 1-year mortality follow-up for 3661 patients. Compared with conservative management group (2859 patients; 78.1%), the PCI group (638; 17.4%) had significantly better unadjusted and adjusted in-hospital (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17-0.97), 30-day (OR: 0.44, 95% CI: 0.24-0.76) and 1-year (OR: 0.58, 95% CI: 0.40-0.87) mortality rates. Comparison with the CABG group (164; 4.5%) yielded similar results with inclusion of patients scheduled for CABG after hospital discharge. Independent predictors of conservative medical management were mainly country of residence and history of prior CABG.

We evaluated the relationship between admission white blood cell (WBC) count and in-hospital outcomes in acute coronary syndrome (ACS) patients from the Middle East. Data were analyzed from 7806 consecutive patients with ACS who were divided into 4 groups (G) according to their WBC count (×109/L; G1

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.

Objectives: To study the short-term mortality from ST-segment elevation myocardial infarction (STEMI) in the Arabian Gulf region of the Middle East, and to examine whether these geographically and culturally related countries had similar or different outcomes. Subjects and Methods: The Gulf Registry of Acute Coronary Events recruited consecutive acute coronary syndrome patients from six Middle Eastern countries over a 5-month period. Results: Of 6,706 patients recruited, 2,626 (39%) had STEMI, and a total of 165 patients died in hospital, with a crude mortality rate of 6.3%. However, mortality rates varied geographically between 10% in Yemen, 9.6% in Oman and 3.3% in the other countries. The unadjusted odds ratio of mortality for Yemen was 3.2 (95% CI: 2.2–4.7), and 3.1 (95% CI: 1.9–4.8) for Oman, compared to other Gulf countries. Even after adjusting for age and gender, the mortality remained significantly higher, almost double, in Oman and Yemen compared to other countries. This could be understood in the light of significant differences in a number of practice pattern variables such as reperfusion therapy, timely presentation and use of evidence-based medications. Conclusion: We found significant variability in STEMI mortality among Gulf Arab countries and identified areas requiring further efforts to reduce excess mortality in the region.

Objectives ― To identify the characteristics, management and hospital outcomes of acute coronary syndrome (ACS) patients in the Gulf region of the Middle East. Methods and results ― Overall, 8176 consecutive patients with the final diagnosis of ACS were recruited in 6 months, from 64 hospitals in 6 countries. The mean age of patients was 56 years. At presentation, 40% of patients had diabetes and 38% were current smokers. Of 2268 patients eligible for reperfusion, 183 (8%) underwent primary percutaneous coronary intervention, 1856 (82%) received thrombolytic therapy and 219 patients (10%) did not receive any reperfusion. The median door-to-needle time was 45 minutes. The majority of patients received aspirin (96%), beta-blockers (77%), angiotensin-converting enzyme inhibitors (77%) and statins (83%) at discharge. Less than I in 5 patients received coronary angiography (19%). Low-risk patients were more likely to undergo coronary angiography than high-risk patients (odds ratio 1.35, 95% confidence interval 1.15 to 1.58, P

Objective The delay between the availability of clinical evidence and its application to the care of patients with acute coronary syndrome (ACS) in the Kingdom of Saudi Arabia remains undefined. The Saudi Project for Assessment of Coronary Events (SPACE) registry provides a comprehensive view of the current diagnostic and treatment strategies for patients with ACS; thus, the registry may be used to identify opportunities to improve the care of these patients. Methods Eight hospitals in different regions of Saudi Arabia were involved in the pilot phase of the registry, from December 2005 to July 2006. The study patients included individuals with ST segment elevation myocardial infarction (STEMI), non-STEMI and unstable angina. Results A total of 435 patients (77% men and 80% Saudis) with a mean age of 57.1 years were enrolled. Medical history included previously diagnosed ischemic heart disease (32%), percutaneous coronary intervention (12%), diabetes mellitus (53%), hypertension (48%), current smoking (39%), hyperlipidemia (31%) and family history of premature coronary artery disease (11%). The median door-to-needle time for fibrinolytic therapy received by patients with STEMIs was 90 min. Inhospital medications included acetylsalicylic acid (98%), clopidogrel (73%), angiotensin-converting enzyme inhibitors (74%), beta-blockers (73%), statins (88%), unfractionated heparin (80%), low-molecular weight heparin (22%) and glycoprotein IIb/IIIa inhibitors (9%). The inhospital mortality rate was 5%. Conclusion The first nationwide registry of patients with ACS in the Kingdom of Saudi Arabia is presented. In contrast to registries from developed countries, our cohort is characterized by a younger age at presentation and a much higher prevalence of diabetes mellitus. Most patients with STEMIs did not receive fibrinolytic therapy within the time recommended in the American College of Cardiology/American Heart Association guidelines. The results of the present pilot study show potential targets for improvement in care.