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Introduction: The purpose of our report is to describe the design and implementation of the first antimicrobial stewardship certificate program (ASCP) in the United Arab Emirates (UAE). Methods: The ASCP was implemented in January 2019. A needs assessment was conducted before the implementation of the program. The program delivery utilized a blended learning format with both a live and an experiential component. Learner assessments consisted of pre- and post-course assessments, as well as structured feedback throughout the course. Course assessments and post-course evaluation results were utilized to assess the certificate program (CP) outcomes. Results: Between January 2019 to March 2020, 24 pharmacists were trained through the program. All participants passed the post-course assessment. Participants scored a median of 40 percent on the pre-course assessment at the start of the program and a median of 80 percent on the post-course assessment (p-value < 0.0001), demonstrating a significant improvement in their baseline knowledge. Overall, participants were highly satisfied with the program and felt that it would enhance their ability to take care of patients and/or result in practice change in their institution. Conclusions: The ASCP enhanced the knowledge of pharmacists in antimicrobial stewardship. The implemented model provides a sustainable blueprint for future CPs in specialty areas of practice for the Middle East region.

Objective Management of the pandemic caused by the novel coronavirus SARS-CoV-2 challenges both scientists and physicians to rapidly develop, and urgently assess, effective diagnostic tests and therapeutic interventions. The initial presentation of the disease in symptomatic patients is invariably respiratory, with dry cough being the main symptom, but an increasing number of reports reveal multiple-organ involvement. The aim of this review is to summarize the potential role of the renin-angiotensin system activated phagocytes in the pathogenesis of COVID-19 disease. Methods Data for this review were identified by searches of PubMed and references from relevant articles using the search terms “SARS,” “COVID-19,” “renin-angiotensin-system,” “phagocyte,” “reactive free radical,” “antioxidant,” “ARDS,” “thrombosis,” “myocardial,” “ischaemia,” “reperfusion,” “microvascular,” and “ACE2.” Abstracts and reports from meetings were not included in this work. Only articles published in English between 1976 and 2020 were reviewed. Results The cellular target of SARS viruses is the angiotensin-converting enzyme 2, a critical regulating protein in the renin-angiotensin system. The elimination of this enzyme by the viral spike protein results in excessive activation of phagocytes, migration into the tissues via the high endothelial venules, and an oxidative burst. In the case of an overstimulated host immune response, not only devastating respiratory symptoms but even systemic or multiorgan involvement may be observed. Conclusions Early-stage medical interventions may assist in returning the exaggerated immune response to a normal range; however, some therapeutic delay might result in excessive tissue damages, occasionally mimicking a systemic disease with a detrimental outcome.

Coronavirus disease 2019 (COVID-19) arising from Wuhan, China, is currently outbreaking worldwide. The World Health Organization (WHO) has declared COVID-19 to be a global pandemic. COVID-19 could cause a wide range of symptoms ranging from self-limiting fever, sore throat, and cough to more severe symptoms that could lead to acute respiratory distress syndrome. As a result of the lockdown and increased demand, drug shortages could become a growing global issue. This article aims to shed light on the potential impact of drug shortages as a result of this pandemic on patient outcomes and the role of pharmacists and pharmacy policymakers in alleviating this emerging problem.

Heart transplantation (HT) has become a standard option for patients with end-stage heart failure (HF). However, the scarcity of donor availability remains a major hurdle for receiving this novel therapy, especially in the context of the rapidly spreading severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) pandemic. We report the case of a patient in the United Arab Emirates (UAE) with advanced HF who was glucose-6-phosphate dehydrogenase deficient and had a history of type 2 diabetes mellitus with diabetic retinopathy and nephropathy, chronic kidney disease stage II, and hyperlipidemia. He was referred for HT abroad and was subsequently caught in the midst of the COVID-19 pandemic in New York, the US state most affected by the crisis at the time. Despite limited experience with favipiravir, we judged it to be the most appropriate agent with this patient’s complex history given the lower risk for QT prolongation, no need for renal-dose adjustment, and no reported drug–drug interactions. Given the limited clinical experience with this agent, particularly for our patient, we decided to adopt strategies to mitigate and monitor the potential for QT prolongation. We outline the logistical, clinical, and pharmacological challenges that the poly-morbid patient and our HT program in the Middle-East faced under those novel circumstances.

The rate of venous and arterial thrombotic events among patients infected with severe acute respiratory syndrome coronavirus-2 (SAR-CoV-2) is high. This may be due to a hypercoagulable state induced by the severe inflammation that results from the SAR-CoV-2 infection. We aimed to determine hypercoagulable states’ incidence based on thromboelastography study and its association with thrombotic events in critically ill patients with coronavirus disease 2019 (COVID-19). Fifty-two COVID-19 patients who had thromboelastography study were retrospectively included. All patients received pharmacologic thromboprophylaxis. The hypercoagulable state was observed in 16 patients (30.8%). Among them, maximum amplitude and a-angle were elevated in 75% and 25%, respectively. Reaction time and K were low in only 12.5% for both of them. Inflammatory and coagulation markers, as well as thromboprophylaxis regimens, were not associated with a hypercoagulable state. Fourteen patients (27%) experienced a total of 16 thrombotic events, including 8 (57%) deep venous thrombosis, 6 (43%) pulmonary embolism, and 2 (14.3%) arterial thrombosis. The hypercoagulable state was not significantly associated with thrombotic events. In summary, we observed a lower rate of hypercoagulable state on thromboelastography study in critically ill COVID-19 patients. Also, the hypercoagulable state was not associated with the occurrence of thrombotic events.

Heart failure is a common disease state that can be encountered at different stages in the course of a COVID-19 patient presentation. New or existing heart failure in the setting of COVID-19 can present a set of unique challenges that can complicate presentation, management, and prognosis. A careful understanding of the hemodynamic and diagnostic implications is essential for appropriate triage and management of these patients. Abnormal cardiac biomarkers are common in COVID-19 and can stem from a variety of mechanisms that involve the viral entry itself through the ACE2 receptors, direct cardiac injury, increased thrombotic activity, stress cardiomyopathy, and among others. The cytokine storm observed in this pandemic can be a culprit in many of the observed mechanisms and presentations. A correct understanding of the two-way interaction between heart failure medications and the infection as well as the proposed COVID-19 medications and heart failure can result in optimal management. Guideline-directed medical therapy for heart failure should not be interrupted for theoretical concerns but rather based on tolerance and clinical presentation. Initiating specific cardiac or heart failure medications to prevent the infection or mitigate the disease is also not an evidence-based practice at this time. Heart failure patients on advanced therapies including those with heart transplantation will particularly benefit from involving the advanced heart failure team members in the overall management if they contract the virus.

Cardiac allograft vasculopathy (CAV)-mediated by a heterogeneous myriad of immune and non-immune factors, which contribute to the progressive and diffuse thickening of the arterial allograft's tunica intima in one distinct form of CAV, and the build-up of plaque in another-is a major limiting factor of long-term survival post heart transplantation. Information on the optimal pharmacotherapeutic approaches for the prevention and management of CAV is conflicting, scattered, and inconsistent, with numerous recent studies adding to the literature. In this paper, we present a go-to clinical resource with the most updated and comprehensive information on the topic. Immunosuppressant therapy remains a staple, with mTOR inhibitors and mycophenolate mofetil (MMF) showing direct correlation with CAV prevention. More data is now available with calcineurin inhibitor (CNI) minimizing or sparing regimens. More novel approaches are being investigated for the roles of monoclonal antibodies, anti-thymocyte globulin, and bortezomib in preventing or delaying CAV. On the other hand, statins' established efficacy is attributed to lipid-lowering and lipid-independent immunomodulatory effects, with early initiation associated with improved outcomes. The choice of statin is dependent on drug-drug interactions. Other aiding approaches for the prevention of CAV include antioxidant vitamins, aspirin, vasodilators, folate therapy, and, most pertinently, cytomegalovirus prophylaxis. Larger clinical trials are needed before these options are institutionalised. For management of established CAV, early initiation of augmented immunosuppressive therapies may be effective, as well as CNI conversion to mTOR inhibitors with or without standard MMF and azathioprine therapy. Risk of acute rejection needs to be monitored during conversion. Finally, preclinical investigations highlight novel potential therapies for CAV prevention and attenuation, however robust clinical trials are needed to test their efficacy and safety.

Purpose of review Two major complications compromise the outcomes and quality of life for left ventricular assist device (LVAD) patients. This review aims to discuss the mechanisms of thrombosis and bleeding, recent literature on the optimal approaches for antithrombotic therapy, and novel approaches to prevent bleeding. Recent findings Recent studies with the newly designed LVAD, the fully magnetically levitated rotor, show lower thrombotic risk but sustain similar bleeding risk. Small studies present options for less intense antithrombotic regimens with the newer devices. Bridging anticoagulation when needed in this patient population might require modified regimens and close monitoring to avoid anticoagulation overlap during the bridged periods. The necessity to add an antiplatelet to anticoagulation is particularly being challenged with the recent data. Antiplatelet responsiveness testing is an intriguing approach to customize regimens. In addition, novel approaches that target activation of the angiotensin II receptors and inflammatory responses might offer further protection against bleeding in implanted patients. Summary Close monitoring, novel, and patient-tailored approaches may offer the best antithrombotic strategies for LVAD patients. More clinical and long-term data are needed to establish the potential for less intense regimens particularly with the newly designed devices.

Background: Several reports linked the use of repurposed drugs such as hydroxychloroquine (HCQ), azithromycin, lopinavir/ritonavir, and favipiravir with QT interval prolongation in patients with SARS-CoV2 infection. Little is known about the risk factors for QT interval prolongation in this population. We sought to describe the prevalence and identify the main risk factors associated with clinically significant corrected QT (QTc) prolongation in this population. Methods: We conducted a retrospective analysis of critically ill patients who were admitted to our intensive care unit (ICU), had at least one electrocardiogram performed during their ICU stay, and tested positive for SARs-CoV-2. Clinically significant QTc interval prolongation was defined as QTc >500 milliseconds (ms). Results: Out of the 111 critically ill patients with SARS-CoV-2 infection, QTc was significantly prolonged in 47 cases (42.3%). Patients with a clinically significant QTc prolongation had significantly higher proportions of history of cardiac diseases/surgery (22 [46.8%] vs. 10 [15.6%], P < .001), hypokalemia (10 [21.3] vs. 5 [7.8%], P = .04), and male gender (95% vs. 82.8%, P = .036) than patients with QTc ≤500 ms, respectively. A total of 46 patients (41.4%) received HCQ, 28 (25.2%) received lopinavir/ritonavir, and 5 (4.5%) received azithromycin. Multivariate logistic regression analysis showed that a history of cardiac disease was the only independent factor associated with clinically significant QTc prolongation ( P = .004 for the likelihood-ratio test). Conclusion: The prevalence of clinically significant QTc prolongation in critically ill patients with SARS-CoV-2 infection was high and independent of drugs used. Larger prospective observational studies are warranted to elucidate independent risk factors associated with clinically significant QTc prolongation in this study population.

Coronavirus disease 2019 (COVID-19) is the second pandemic of the twenty-first century, with over one-hundred million infections and over two million deaths to date. It is a novel strain from the Coronaviridae family, named Severe Acute Respiratory Distress Syndrome Coronavirus-2 (SARS-CoV-2); the 7th known member of the coronavirus family to cause disease in humans, notably following the Middle East Respiratory syndrome (MERS), and Severe Acute Respiratory Distress Syndrome (SARS). The most characteristic feature of this single-stranded RNA molecule includes the spike glycoprotein on its surface. Most patients with COVID-19, of which the elderly and immunocompromised are most at risk, complain of flu-like symptoms, including dry cough and headache. The most common complications include pneumonia, acute respiratory distress syndrome, septic shock, and cardiovascular manifestations. Transmission of SARS-CoV-2 is mainly via respiratory droplets, either directly from the air when an infected patient coughs or sneezes, or in the form of fomites on surfaces. Maintaining hand-hygiene, social distancing, and personal protective equipment (i.e., masks) remain the most effective precautions. Patient management includes supportive care and anticoagulative measures, with a focus on maintaining respiratory function. Therapy with dexamethasone, remdesivir, and tocilizumab appear to be most promising to date, with hydroxychloroquine, lopinavir, ritonavir, and interferons falling out of favour. Additionally, accelerated vaccination efforts have taken place internationally, with several promising vaccinations being mass deployed. In response to the COVID-19 pandemic, countries and stakeholders have taken varying precautions to combat and contain the spread of the virus and dampen its collateral economic damage. This review paper aims to synthesize the impact of the virus on a global, micro to macro scale.

Background The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally. Methods Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases. Findings Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53.6%] women) from 56 countries were included in the study. Of these, 31 798 (75.4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84.2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46.2 years (IQR 34.3-58.0); median age at diagnosis of familial hypercholesterolaemia was 44.4 years (32.5-56.5), with 40.2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17.4% (2.1% for stroke and 5.2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81.1%) were receiving statins and 3691 (21.2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5.43 mmol/L (IQR 4.32-6.72) among patients not taking lipid-lowering medications and 4.23 mmol/L (3.20-5.66) among those taking them. Among patients taking lipid-lowering medications, 2.7% had LDL cholesterol lower than 1.8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1.8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p, Pfizer Independent Grant for Learning Change [16157823]; Amgen; Merck Sharp Dohme; Sanofi-Aventis; Daiichi Sankyo; Regeneron; National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, UK; NIHR; Czech Ministry of Health [NU20-02-00261]; Canadian Institutes of Health Research; Austrian Heart Foundation; Tyrolean Regional Government; Gulf Heart Association, The EAS FHSC is an academic initiative that has received funding from a Pfizer Independent Grant for Learning & Change 2014 (16157823) and from investigator-initiated research grants to the European Atherosclerosis Society-Imperial College London from Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron. KKR acknowledges support from the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, UK. KID acknowledges support from a PhD Studentship from NIHR under the Applied Health Research programme for Northwest London, UK (the views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health). TF was supported by a grant from the Czech Ministry of Health (NU20-02-00261). JG receives support from the Canadian Institutes of Health Research. The Austrian Familial Hypercholesterolaemia registry has been supported by funds from the Austrian Heart Foundation and the Tyrolean Regional Government. The Gulf Familial Hypercholesterolaemia registry was done under the auspices of the Gulf Heart Association.

Introduction Heart transplantation (HTx) is a successful treatment strategy for advanced heart failure. Survival rates exceed those achieved by medical therapy alone. Lack of suitable donors and cultural perception remain obstacles for receiving this novel therapy. Methods Overcoming challenges we adopted a first-of-a-kind multicenter HTx program, collaborating between Cardiac Centers in India and the United Arab Emirates (UAE). Patients were worked up as part of our newly established HTx program in the UAE, then referred to India for successful HTx. All post HTx follow-up care was continued in the UAE thereafter. Results We assessed 10 HTx recipients, [90% male; mean age 34 yrs]. Five patients required inotropes while one LVAD support pre transplant. Our data outline short waiting-list time and excellent 3 years clinical outcomes. All patients are maintained on Tacrolimus and Mycophenolate Mofetil. Two patient developed acute rejection (celluar and humoral) with graft dysfunction within 18 months. Seventy percent had non-ischemic cardiomyopathy pre-transplant. Three acquired donor transmitted coronary vascular disease. One patient developed aggressive allograft vasculopathy requiring coronary artery bypass grafting. Acute kidney injury requiring renal replacement therapy occurred in 1 patient. Conclusion Defying logistic challenges, donor availability and long HTx waiting list times, we have established a successful multi-center new concept HTx program with excellent mid-term outcome result. Diverse genetic background is evident in the presence of early coronary vascular disease in young donor hearts, requiring extra care in donor screening. This international collaboration has a promising future for new programs in the Middle East. Funding Acknowledgement Type of funding source: None

Summary The reported incidence rate of venous and arterial thrombotic events in critically ill patients with COVID‐19 infections is high, ranging from 20% to 60%. We adopted a patient‐tailored thromboprophylaxis protocol based on clinical and laboratory presentations for these patients in our institution. We hypothesised that patients who received high‐intensity thromboprophylaxis treatment would experience fewer thrombotic events. The aims of our study were to explore the incidence of thrombotic events in this population; to assess independent factors associated with thrombotic events and to evaluate the incidence of haemorrhagic events. A retrospective review of all adult patients with confirmed SARS‐CoV‐2 infection admitted to the intensive care unit (ICU) between 1 March and 29 May 2020 was performed. The primary outcome was a composite of venous and arterial thrombotic events diagnosed during the ICU stay. Multivariable logistic regression was used to identify the independent factors associated with thrombotic events. A total of 188 patients met the inclusion criteria. All received some type of thromboprophylaxis treatment except for six patients who did not receive any prophylaxis. Of the 182 patients who received thromboprophylaxis, 75 (40%) received high‐intensity thromboprophylaxis and 24 (12.8%) were treated with therapeutic anticoagulation. Twenty‐one patients (11.2%) experienced 23 thrombotic events (incidence rate of 12.2% (95%CI 7.9–17.8)), including 12 deep venous thromboses, 9 pulmonary emboli and 2 peripheral arterial thromboses. The multivariable logistic regression analysis showed that only D‐dimer (OR 2.80, p = 0.002) and high‐intensity thromboprophylaxis regimen (OR 0.20, p = 0.01) were independently associated with thrombotic events. Thirty‐one patients (16.5%) experienced haemorrhagic events; among them, 13 were classified as major bleeding according to the International Society on Thrombosis and Haemostasis criteria. Therapeutic anticoagulation, but not the high‐intensity thromboprophylaxis regimen, was associated with major bleeding. A proactive approach to the management of thromboembolism in critically ill COVID‐19 patients utilising a high‐intensity thromboprophylaxis regimen in appropriately selected patients may result in lower thrombotic events without increasing the risk of bleeding.

Background Hospitals in the Middle East Gulf region have experienced an influx of COVID-19 patients to their medical wards and intensive care units. The hypercoagulability of these patients has been widely reported on a global scale. However, many of the experimental treatments used to manage the various complications of COVID-19 have not been widely studied in this context. The effect of the current treatment protocols on patients’ diagnostic and prognostic biomarkers may thus impact the validity of the algorithms adopted. Case presentation In this case series, we report four cases of venous thromboembolism and 1 case of arterial thrombotic event, in patients treated with standard or intensified prophylactic doses of unfractionated heparin or low molecular weight heparin at our institution. Tocilizumab has been utilized as an add-on therapy to the standard of care to treat patients with SARS-CoV-2 associated acute respiratory distress syndrome, in order to dampen the hyperinflammatory response. It is imperative to be aware that this drug may be masking the inflammatory markers (e.g. IL6, CRP, fibrinogen, and ferritin), without reducing the risk of thrombotic events in this population, creating instead a façade of an improved prognostic outcome. However, the D-dimer levels remained prognostically reliable in these cases, as they were not affected by the drug and continued to be at the highest level until event occurrence. Conclusions In the setting of tocilizumab therapy, traditional prognostic markers of worsening infection and inflammation, and thus potential risk of acute thrombosis, should be weighed carefully as they may not be reliable for prognosis and may create a façade of an improved prognostic outcome instead. Additionally, the fact that thrombotic events continued to be observed despite decrease in inflammatory markers and the proactive anticoagulative approach adopted, raises more questions about the coagulative mechanisms at play in COVID-19, and the appropriate management strategy.

Background and aims Familial 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). Methods The 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. Results Among 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 Conclusions This 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.

Direct oral anticoagulants (DOACs) have proven efficacy to prevent cardioembolic strokes. Data are scarce about the appropriateness of DOAC dosing in the Middle East. We investigated the prevalence of inappropriate DOAC dosing in the region. A cross-sectional study was conducted at our hospital between April 2015 and February 2019 of patients receiving 1 of the 3 available DOACs. Patients with incomplete data sets, those prescribed DOACs for indications other than atrial fibrillation, on DOACs for

Background: Data on patient characteristics and provider practices in the management of lipids per the new guidelines in specific secondary prevention patients in the Middle East is limited.Objective: To explore patient characteristics and lipid management practices according to the new cholesterol guidelines in secondary prevention patients, up to one year following discharge for coronary artery bypass graft surgery (CABG).Methods: A retrospective chart review of patients discharged post CABG between February 2017 and February 2018 at a quaternary care centre in the Middle East. Patients were characterized by baseline demographics, comorbidities, and use of lipid lowering medications.Results: 189 patients were included in the analysis. Most were diabetic (70.9%) and classified as very high risk per the ACC/AHA guidelines (84.1%) and as extremely high risk per the AACE guidelines (85.2%). Most patients (93.1%) were discharged on high intensity statin. About one third (28.6%) were never seen or only followed once within the first 2 weeks post discharge. Of those who continued to follow up beyond 3 months and within 1 year of discharge (44.4%), about half (51.2%) had follow-up lipid panels performed. Patients who followed up and were seen by a cardiologist were five times more likely to have lipid panels ordered than those seen solely by a CT surgeon. Of those with follow-up lipid panels beyond 3 months: 59.3% achieved LDL goal of

Background Approved dose adjustment criteria for apixaban are based on the clinical trial. Adjustments require presence of 2 of 3 criteria. In the ARISTOTLE trial, 4.7% of patients met those criteria. Real world data show much higher utilization of the lower dose. Accurate statistics on the prevalence and predictors of such dosing in the Middle East Gulf region are lacking. Purpose We sought to explore the appropriateness of apixaban dosing and to predict the factors influencing physician dosing strategies at a tertiary care center in our United . Methods We performed a retrospective chart review of patients receiving apixaban for atrial fibrillation from our hospital-based outpatient pharmacy between April 1, 2015 and October 1, 2018. Patients with missing data or on apixaban for other indications were excluded. Results A total of 232 patients were included with a mean follow-up of 400 ± 271 days. The mean age was 66.0 ± 13.2 years, 45.5% female, mean weight 82.4 ± 44.7 kg, mean serum creatinine 1.0 ± 0.4 mg/dL, CHA2DS2VASc 3.7 ± 1.8, and 30.1% were on at least 1 concomitant antiplatelet drug. Seventy three patients (31.3%) received a reduced apixaban dose of 2.5 mg twice daily. Deviation from recommended criteria was seen in a total of 62 patients (26.6%), most being under-dosed (93.5%). The significant predictors of underdosing in our model were older age (risk of under-dosing increases by 7.2% for each additional year of age) and eGFR 30 to 60 mL/min/1.73 m2. Conclusion Under-dosing of apixaban is prevalent in the Middle East Gulf region. Advancing age and eGFR are the main predictors of under-dosing. More education is needed to optimize dosing of apixaban for stroke prevention in AF. Table 1 % Change in Odds Ratio Variables coef. std. error p expected min max Intercept -1.563 0.223 0.000 Age 0.069 0.022 0.002 7.2% 2.5% 12.1% eGFR (30-60 relative to >60) 1.583 0.625 0.011 386.9% 39.6% 1597.8% Table 1. Stepwise logistic regression model for predictors of apixaban underdosing. Adjusted for serum creatinine, weight, BMI, gender, CHADS2-VASc score, concomitant antiplatelets, and eGFR < 30 or > 60 mL/min/m2

Background Heart failure with reduced ejection fraction (HFrEF) outcomes are influenced by optimal guideline-directed medical therapy (GDMT). This includes target doses of mineralocorticoid receptor antagonists (MRA). The underuse and under-dosing of this particular class of GDMT have been reported before. Recent studies have also demonstrated that some of the perceived concerns, such as lowering systolic blood pressure (SBP) that might preclude utilization of MRA in HFrEF, may only be theoretical. This study aims to explore MRA utilization and associated factors in an advanced heart failure program at a quaternary care center in the Middle East- Gulf Region. Methods We conducted a retrospective electronic chart review of all HFrEF patients presenting to the outpatient clinic in our program and followed them for one year. The group of patients who achieved MRA target dose at the one-year visit were compared to those who did not reach this goal. Descriptive analysis was performed for patient characteristics and a logistic regression was specified to examine predictors of reaching MRA target dose. Results A total of 123 HFrEF patients were included in this study for a mean follow-up period of 363.8±31 days. Table 1 shows patient characteristics and GDMT use at baseline and at 1-year follow-up. While more patients were on target doses of beta blockers and ACE/ARB/ARNI at follow-up when compared to baseline (p-value Conclusion In our advanced heart failure and transplant program, renal function and serum potassium but not SBP are associated with the titration of MRA therapy. While such programs might have a better understanding of the correct utilization and associated outcomes with this class of medication, there still needs to be more adoption of this important therapy.

Heart failure readmissions are associated with significant morbidity and mortality. Adequate education on adherence and self-care behaviours can affect readmission rates positively and nurses are at the frontline of patient education. Such education is valuable when establishing heart failure programmes in developing countries, in light of the challenging socioeconomic circumstances in these. This study aimed to evaluate nurses' heart failure knowledge, to assess patients' baseline knowledge, and to evaluate the effectiveness of structured nurse-driven education. Methods: a total of 131 cardiac centre-based nurses and 30 chronic heart failure patients participated in the study in Kuwait. Patients were surveyed a second time 3 to 6 months later, while being followed at an advanced heart failure clinic by dedicated heart failure nurses. Results: the majority of the nurses (80%) had not received heart failure education previously, although they were able to recognise most heart failure symptoms. Significant improvement in patients' knowledge was noted between the initial and follow-up surveys. Conclusion: establishing a dedicated advanced heart failure programme to care for patients in a developing country can result in significant improvement in disease awareness and self-care behaviours when led by well-trained heart failure nurses. More research is needed to determine if these findings are shared by other countries in the Middle-East and other developing countries.

Background Patients with heart failure (HF) are best managed within specialized programs in order to improve clinical outcomes and quality of life. Such programs are very rare in the Middle East. The objective of this observational study is to describe the experience at our centre following the establishment of an advanced HF program in October 2015. Methods A retrospective chart review was conducted on patients first seen at our HF clinic between Oct 2015 and Nov 2016. Patients included were adults with HF and reduced ejection fraction (HFrEF) defined as LVEF ≤ 40%. Patients were excluded if no 6-month follow up data were available. Data collected included clinical characteristics, LVEF, and pharmacotherapy both at baseline and at 6 months. In addition, survival and hospital re-admission rates were captured. Chi-square and paired t-test comparisons were performed to compare changes from baseline to the 6-month follow up point. Results Out of a total of 174 patients screened, 95 met the inclusion/exclusion criteria. Six patients expired prior to the follow up (6-month survival rate of 93.7%). Most (69.5%) were males with an average age of 57.8 ± 14.5 years and 61.8% had an ischemic etiology. More than half (56.8%) had an improvement in their LVEF (mean increased from 26.5 ± 7.7% to 34.5 ± 13.1; p figure 1 ). 25.8% of patients had an HF-related admission during the 6-months, with a subsequent 30-day re-admission occurring in 17.4% of them ( Table 1 ). More patients were on target doses of beta blockers and ACEI/ARBs, although this did not reach statistical significance. A significant proportion of patients were switched to sacubitril/valsartan at 6-months follow up compared to baseline (36% vs. 11.6% p Conclusion Close follow up of patients with HFrEF was associated with symptomatic improvement, low 6-month HF hospitalizations, and higher doses of HF pharmacotherapy. These findings warrant more studies comparing patients followed in advanced HF programs to those followed by general cardiology and internal medicine providers, especially in developing countries.

Background In recent years, there has been an emphasis on multidisciplinary team (MDT) care of the heart failure (HF) patient. A dedicated HF MDT was created on the 1stof January 2017 at Cleveland Clinic Abu Dhabi; consisting of HF cardiologists, clinical pharmacists and HF nurses. This study aims to assess the impact of a dedicated HF MDT on the mortality, length of stay and readmission rate in patients who are admitted with acute HF decompensation. Methods A retrospective review of the patients’ charts was conducted. We identified patients who were admitted for acute exacerbation of HF between the years 2015 and 2017. Group 1 consisted of 90 patients who were admitted prior to the creation of the HF MDT, while Group 2 consisted of 94 patients who were admitted after the establishment of the team. The groups were propensity-matched in order to account for any confounding variables between the two patient populations. Results Table 1 shows the baseline characteristics on admission of patients in both Group 1 and Group 2. The majority of patients in both groups had HFrEF. There were no significant differences between the two groups in terms of the baseline characteristics outlined. Table 2 highlights the differences in outcomes between the two groups. After the establishment of the HF MDT, there was a significant decrease in the 30 day readmission rate (25.84 % vs 5.98 %, P Conclusions Management of patients with HF by a dedicated HF MDT in the inpatient and outpatient setting results in a significant reduction in morbidity; with reduced 30-day readmission rates, length of stay in hospital, number of days for follow up post-discharge and the need for inotropic support.

Background The 2017 ACC expert consensus decision pathway for optimization of heart failure (HF) treatment emphasizes the fact that target doses of medications are associated with the best outcomes. It has been reported that a significant portion of HFrEF patients are not on optimal doses of medical therapy, and gaps exist in longitudinal medication titration. The objective of this retrospective study is to describe medical therapy after 12 months of follow up in a newly established multidisciplinary HF program in the Middle East Gulf region. Methods A retrospective outpatient chart review was conducted on HF patients after initial outpatient clinic enrollment between October 2015 and July 2017. All patients with EF ≤ 40 were included. We documented baseline and follow-up evidence based HF medications including beta blockers, RAAS inhibitors, and MRA. Results Out of 305 enrolled patients, only 186 had a 12 month follow up appointment, out of which 139 had HFrEF and were included in this analysis. At baseline, 25.2%, 13.7%, and 42.4% of patients were receiving target doses of beta-blocker, ACEI/ARB/ARNI, and MRA, respectively. Only 2.9% were on target doses of all 3 classes of evidence based therapies. At 12 months, percentage of patients on target doses significantly increased to 51.8% for beta blockers and 31.7% for ACEI/ARB/ARNI, while there was no significant change in patients on target dose MRA (36.7%). More patients (10.1%) were on target doses of all 3 evidence based therapies (table 1). A significant increase was observed in the rate of adoption of ARNI from baseline to follow-up (10.1% vs 48.9%, p Conclusion Close follow up of patients with HFrEF was associated with statistically significant increase in those on target doses of both beta blockers and ACE/ARB/ARNI and patients on simultaneous target doses of all evidence based medications. Compared to recent western outpatient registries, our study shows that the success of longitudinal titration of evidence based medications and adoption of new ones can be enhanced when patients are followed by a specialized multidisciplinary program.