Does hospitalization for congestive heart failure occur more frequently in Ramadan: a population-based study (1991–2001)

Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative)

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

Burden and Patterns of Medical Emergencies during Ramadan Fasting: A Narrative Review

Introduction Acute medical problems may occur more frequently during Ramadan fasting (RF). We aimed to provide a narrative overview of the global literature on medical emergencies during RF.

Methods This is a nonsystematic review of the international literature from one major medical online database (PubMed, National Institutes of Health, United States). The relevant literature was narrated in a concise thematic account.

Results There is a variable impact in the burden and time distribution of emergency services and hospitalization during RF that may require readjustment of resource allocation. Studies of the risk of accidents and injuries may be increased overall or at specified times, around Iftar time. A classical impact of emergencies has been the risk of worsening peptic ulcer disease. RF impacts diabetic emergencies such as severe hypoglycemia, hyperglycemia, and diabetic ketoacidosis, particularly in type 1 diabetes and poorly controlled patients. Glucocorticoid replacement therapy may represent a challenge to patients and physicians that require education and dose adjustment. Acute neurological conditions of interest include the “first day of Ramadan headache,” epilepsy, and strokes. Several studies evaluated the risk of the acute coronary syndrome and heart failure with inconsistent findings. RF may impact the renal and urological systems through stone disease, renal colic, and acute kidney. The impact on hematological conditions was mostly focused on the safety of anticoagulant therapy during Ramadan.

Conclusion The review addresses the emergency medical encounters of the fasting patient during Ramadan to allow a holistic and ethnically sensitive approach to medical care under circumstances where decisions have to be taken with no delay.

The effect of Ramadan on elderly patients presenting to the emergency department

Background Patients visiting the emergency department (ED) may show variations by certain time periods such as Ramadan. We wished to ascertain whether Ramadan affects the ED presentations, clinical conditions and outcomes of patients aged 65 years or older. Methods . Patients aged 65 years or older who presented to ED in Ramadan and in the following month in 2018 were reviewed retrospectively. Results . A total of 1947 patients were enrolled, of whom 958 presented in Ramadan and 989 in the following month. The patients who presented in Ramadan most commonly (23.8%) presented between 8 p.m. and 11.59 p.m.; patients who presented in the following month most commonly (24%) presented between 8 a.m. and 11.59 a.m. (p=0.26). Complaints concerning the central nervous system (CNS) were more common in the month after Ramadan (p<0.0001). Diagnoses related to the cardiovascular system were more commonly made in Ramadan (p=0.037), whereas those related to CNS, otorhinolaryngology and oncology were more commonly made in the following month (p=0.0005, p=0.024 and p=0.003, respectively). No significant difference was found between the two groups with respect to outcomes (p=0.36). Compared to patients who presented in Ramadan, those that presented in the following month had a significantly longer ED stay (p=0.036). Conclusion . Our study detected no significant difference between the two groups with respect to the time of presentation and ED outcomes. Patients who presented in Ramadan had a lower incidence of CNS complaints; a higher incidence of cardiovascular diagnoses; lower incidences of CNS, oncological and otorhinolaryngological diagnoses and a significantly shorter length of ED stay.

Islamic fasting: cardiovascular disease perspective

INTRODUCTION

Ramadan is a month of obligatory fasting observed by the majority of 2 billion Muslims living around the globe. The guidelines for 'risk-free' fasting exist for chronic diseases, including diabetes mellitus, but recommendations for cardiovascular disease (CVD) patients are deficient due to the paucity of literature.

AREAS COVERED

Databases were screened to find relevant studies for an evidence-based consensus regarding the risk stratification and management of CVD. Using practical guidelines of the European Society of Cardiology (ESC), we categorized patients into low-, moderate-, and high-risk categories and proposed a pre-Ramadan checklist for the assessment of cardiac patients before fasting. Regular moderate-intensity exercise is recommended for most cardiac patients, which has been demonstrated to provide an anti-inflammatory and antioxidant effect that improves immune function.

EXPERT OPINION

In Ramadan, many physiological changes occur during fasting, which brings about a balanced metabolic homeostasis of the body. In addition, Ramadan fasting is a nonpharmacologic means of decreasing CV risk factors. As Islam exempts Muslims from fasting if they are unwell; therefore, patients with the acute coronary syndrome (ACS), advanced heart failure (HF), recent percutaneous coronary intervention (PCI), or cardiac surgery should avoid fasting.

Sex as a Biological Factor in the Changes in Disease Patients During Ramadan Intermittent Fasting: A Systematic Review

Background

During Ramadan, many patients with diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy choose to fast even against their doctor's advice. The impact of this intermittent fasting on health and disease could be different in men and women. The aim of this study was to determine the effect of sex as a factor in diseases outcomes of patients who opt to fast during Ramadan.

Main Body

The articles included in this study reported data on six diseases: diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy. A systematic search was performed on PubMed and Scopus for observational and clinical studies mentioning Ramadan, diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy in both men and women. Data was extracted by two independent reviewers using a standardized data-collection form. From 381 original articles, 38 studies were selected, including 25,023 patients of which 44.4% were women. Sex-based differences were reported by 18 studies for several variables such as body mass index, blood glucose, the frequency of hypoglycemia, renal colic, mortality, thrombosis, and gastrointestinal diseases in patients fasting during Ramadan. Most of the differences between men and women were reported both in the baseline period before Ramadan and during Ramadan. Indeed, during the period outside Ramadan, the frequency of renal colic, cardiovascular, gastrointestinal diseases, were higher in men; while body mass index, Thrombosis, and headache were higher in women. In the remaining 21 studies, it was reported that the sex factor was not associated with the effect of Ramadan fasting in the frequency and other outcomes of these diseases.

Conclusion

Currently, small attention is paid to sex as a determinant factor in patients while fasting during Ramadan. There appeared to be differences in the frequency and incidence of diseases in men and women during Ramadan. Closer attention to sex differences regarding the frequency and the progression of the diseases during fasting may help to improve patient care, especially to benefit those patients willing to fast during Ramadan.

[Maladies cardiaques et Ramadan : revue de la littérature]

We review the literature on the safety of fasting in cardiac patients. We examined the changes of blood pressure among hypertensive patients and the incidence of cardiac events during Ramadan in patients with coronary disease and heart failure. We also assess the modifications of INR levels in cardiac patients who take oral anticoagulant. We found that Ramadan fasting is safe in stable cardiac patients, even under several drugs. Fasting does not affect blood pressure. There is no difference in regards to cardiac event incidence between Ramadan and the non-fasting-months. The level of INR is slightly higher when fasting, it is thus recommended to monitor patients with high bleeding risk during Ramadan.

Does Ramadan fasting disrupt international normalised ratio control in warfarin-treated medically stable patients?

AIM

Warfarin is commonly used in patients with thrombotic diseases. This study aimed to evaluate the impact of Ramadan fasting on warfarin efficacy by investigating international normalised ratio (INR) stability in medically stable patients.

METHODS

A retrospective observational study was conducted at King Khalid University Hospital during Ramadan 2016 on fasting adult patients aged above 18 years and receiving warfarin. The INR values during pre-Ramadan, Ramadan and post-Ramadan periods were collected after satisfying the inclusion criteria. Time within the therapeutic range (TTR) during the whole period was estimated using the conventional method.

RESULTS

In total, 101 patients were included in the study. The mean age (SD) was 55.8 ± 15.5 years, and 52.4% were females. The target INR range for 62.4% was 2-3, while 37.6% had a target INR range of 2.5-3.5. An upward trend in the proportion of patients with therapeutic INR was noticed during Ramadan (59.4%) as compared to pre- (56.4%) and post-Ramadan periods (53.5%) respectively. Additionally, the proportions of patients with supratherapeutic and sub-therapeutic INR were the highest and lowest, 23% and 24% respectively post-Ramadan as compared to other periods. Based on target INR categorisation, achieving therapeutic INR during Ramadan was more feasible with the low INR (2-3) compared to the high INR (2.5-3.5) target patients, 63.5% vs 52.6% respectively. TTR estimation revealed 62.4% and 37.6% of the patients had good and poor, respectively, anticoagulation status throughout the study period.

CONCLUSION

Despite the changes in mean INR and proportion of patients with therapeutic INR during Ramadan compared to other non-fasting months, our results confirmed that short-term fasting during Ramadan has no significant influence on INR stability and, consequently, therapeutic efficacy in warfarin-treated medically stable patients.

Effects of long-term fasting and confinement on the cardiovascular activity

Fasting has been demonstrated to improve health and slow aging in human and other species; however, its impact on the human body in the confined environment is still unclear. This work studies the effects of long-term fasting and confined environment on the cardiovascular activities of human via a 10-day fasting experiment with two groups of subjects being in confined (6 subjects) and unconfined (7 subjects) environments respectively and undergoing the same four-stage fasting/feeding process. It is found that the confinement has significant influences on the autonomic regulation to the heart rate during the fasting process by altering the activity of the parasympathetic nervous system, which is manifested by the significant higher pNN50, rMSSD, and Ln-HF of heart rate variability (HRV) (p < 0.05) and slower heart rate (p < 0.01) in the confined group than that in the unconfined group. Furthermore, the long-term fasting induces a series of changes in both groups, including reduced level of serum sodium (p < 0.01), increased the serum calcium (p < 0.05), prolonged QTc intervals (p < 0.05), and reduced systolic blood pressures (p < 0.05). These effects are potentially negative to human health and therefore need to be treated with caution. Study of the effects of fasting and confinement on the cardiovascular activities.

Ramadan fasting: recommendations for patients with cardiovascular disease

Ramadan fasting is observed by most of the 1.8 billion Muslims around the world. It lasts for 1 month per the lunar calendar year and is the abstention from any food and drink from dawn to sunset. While recommendations on ‘safe’ fasting exist for patients with some chronic conditions, such as diabetes mellitus, guidance for patients with cardiovascular disease is lacking. We reviewed the literature to help healthcare professionals educate, discuss and manage patients with cardiovascular conditions, who are considering fasting. Studies on the safety of Ramadan fasting in patients with cardiac disease are sparse, observational, of small sample size and have short follow-up. Using expert consensus and a recognised framework, we risk stratified patients into ‘low or moderate risk’, for example, stable angina or non-severe heart failure; ‘high risk’, for example, poorly controlled arrhythmias or recent myocardial infarction; and ‘very high risk’, for example, advanced heart failure. The ‘low-moderate risk’ group may fast, provided their medications and clinical conditions allow. The ‘high’ or ‘very high risk’ groups should not fast and may consider safe alternatives such as non-consecutive fasts or fasting shorter days, for example, during winter. All patients who are fasting should be educated before Ramadan on their risk and management (including the risk of dehydration, fluid overload and terminating the fast if they become unwell) and reviewed after Ramadan to reassess their risk status and condition. Further studies to clarify the benefits and risks of fasting on the cardiovascular system in patients with different cardiovascular conditions should help refine these recommendations.

Does Ramadan fasting have effects on sleep, fatigue and blood pressure among patients with hypertension?

AIM

The aim of this study was to determine the effect of Ramadan fasting on blood pressure (BP), fatigue, sleeping and physical activity among hypertensive patients.

SUBJECTS AND METHODS

A cross-sectional study was conducted from April 2019 to July 2019. Of the total 1500 hypertensive patients approached, 1118 (74.5%) gave their consent. Data analysis included sociodemographics, lifestyle habits, anthropometric measurements and clinical biochemistry parameters at baseline, and after 3 months.

RESULTS

Out of 1118 subjects, 593(47.6%) were male and 653(52.4%) were female. There were statistically significant differences between males and females regarding age groups in years, educational level, occupational status, income, smoking habits, physical exercise, sports activities and fatigue. There were statistically significant differences for the biochemistry parameters regarding vitamin D, blood glucose, HbA1c level, creatinine, bilirubin, albumin, total cholesterol, triglycerides, HDL-C, LDL-C, uric acid and SBP for both males and females after the holy month of Ramadan as compared to before Ramadan. Also, BMI was significantly lower during the after month of Ramadan as compared to before Ramadan (P < 0.001). Multiple linear regression analysis results revealed that less hours of sleeping (P < 0.001), SBP (mmHg) (P < 0.001), DBP (mmHg) (P < 0.001), family size (P = 0.002), obesity BMI (kg/m2) (P = 0.013), fatigue (P = 0.022) and smoking cigarette (P = 0.029) were identified as statistically significant predictors of hypertensive patients with Ramadan fasting as contributing at higher risk factors.

CONCLUSION

This study confirmed that fasting during Ramadan has no effect on the BP, blood glucose, HbA1C level, sleep quality, fatigue and BMI among hypertensive patients.

Impact of Ramadan fasting on lipid profile and cardiovascular risk factors in patients with stable coronary artery disease

BACKGROUND

The effects of Ramadan fasting (RF) on cardiometabolic risk factors in patients with stable ischemic heart disease are not well known.

AIM

The aim of this study was to evaluate the impact of RF on lipid profile and cardiovascular risk factors in patients with a stable coronary heart disease.

METHODS

A prospective observational study carried out in the Cardiology department of Charles Nicolle Hospital (Tunisia). Eighty-four patients with a stable ischemic heart disease who intended to fast were enrolled during May 2020. Detailed clinical and biochemical assessments were performed before and after the holy month. Parameters of glycemic control, lipid profile, ultrasensitive C-reactive protein concentration (us-CRP) and homocysteine were performed before- and after- Ramadan (BR and AR, respectively).

RESULTS

Eighty-four patients including 79 males and 5 females, with a mean age of 57±7 years completed the study. Levels of cholesterol, triglycerides, low-density lipoprotein-cholesterol and apoprotein A were significantly improved AR fasting in comparison with their BR values. There was a significant decrease in blood fasting glucose, insulin level, Homeostasis model assessment of insulin resistance index and in us-CRP level.

CONCLUSION

In patients with stable ischemic heart disease, RF may be accompanied by an improvement of lipid profile and glycemic parameters without increase in coronary events.

The safety of Ramadan Fasting following Percutaneous Coronary Intervention

BACKGROUND

This work aimed to assess the safety of Ramadan Fasting following the Percutaneous Coronary Intervention.

METHODS

In our two centers' Prospective Cohort Study, We included 303 patients who had successful Percutaneous Coronary Intervention before the first day of Ramadan. We advised the patients that recent Percutaneous Coronary Intervention could be a valid excuse for not fulfilling Ramadan Fasting. However, many patients intended to fast the following Ramadan, and we included them in the fasting Group I. We added the patients who decided not to fast the following Ramadan as a control Group II. We followed all the patients during Ramadan and for 6 months after Ramadan.

RESULTS

The demographic data of both groups and the complexity of the coronary anatomy showed no statistically significant difference. Group I (n = 153) showed a statistically significant difference in the incidence of Major Adverse Cardiac Events compared to Group II with a P value (0.005). The logistic multivariate regression analysis showed that the duration from index PCI till the start of RF, SYNTAX score > 22, and Complex procedure were independent predictors of Major Adverse Cardiac Events in the fasting Group I with {P = 0.001, OR (2.302), P = 0.026, OR (2.419), and P = 0.032 OR (1.952)}, respectively. Major Adverse Cardiac Events in Group I occurred mainly during Ramadan Fasting, with 19 patients having Major Adverse Cardiac Events during Ramadan and four patients during the remaining of the follow-up period. The Receiver Operating Characteristic curve analysis showed the decline of the incidence of Major Adverse Cardiac Events after 90 days from Percutaneous Coronary Intervention till the start of Ramadan Fasting with Sensitivity and specificity (90% and 65%), respectively.

CONCLUSIONS

We suggest that low-risk patients with a normal systolic function who underwent Percutaneous Coronary Intervention may safely fast Ramadan. At the same time, Ramadan Fasting during the first 3 months following the Percutaneous Coronary Intervention may not be safe.

Clinicians' Perspectives on Caring for Muslim Patients Considering Fasting During Ramadan

This study explores clinicians' perspectives on factors affecting care provided to Muslim patients who decide to fast during Ramadan. Semi-structured interviews were conducted with a purposeful sample of clinicians in Egypt (11) and the USA (10). Framework analysis was conducted through mapping data to constructs within social cognitive theory. Data were mapped into clinician's belief in ability to care for those patients, belief in group's ability to provide care, anticipated consequences of providing such care, knowledge, learning by observing other clinicians, cultural norms and perceived acceptability and prevalence of care provision, environmental barriers and opportunities, and communication approach.

The effect of Ramadan fasting on cardiovascular events and risk factors in patients with type 2 diabetes: A systematic review

Ramadan is the fasting month in Islam. Muslims around the world observe Ramadan every year, including people with diabetes. Data on the association of fasting in people with diabetes are sparse. The purpose of this study is to assess the association of fasting on cardiovascular risk factors and events in people with diabetes. A comprehensive search was conducted in the following database: Embase, Medline, Cochrane library and CINAHL. The following key terms were used: Ramadan, Ramazan, Ramadhan, Muslim, Islam and fasting. Studies were eligible if they included people with Type 2 diabetes who fasted during Ramadan and reporting results on cardiovascular risk factors or events. Overall 22 studies met inclusion criteria for the review; five studies reported cardiovascular outcomes and 17 reported changes in risk factors. There is insufficient evidence to link Ramadan fasting with increased or reduced incidence of cardiovascular events in people with diabetes, though there were some indication stroke risk may be increased. Findings were inconsistent in term of risk factors as some favoured Ramadan and others did not.‬‬‬‬.

Atrial Fibrillation in Middle Eastern Arabs and South Asians: Summary of Published Articles in the Arabian Gulf

Seven studies are summarized herein focusing on different aspects of Atrial fibrillation (AF) in two unique ethnicities for which there is very limited literature published before; Middle Eastern Arabs and South Asians, using data from a national registry of cardiovascular diseases in Qatar over a 20-years period (1991-2010). These studies shed light upon important aspects of AF presentations and outcomes in these two ethnicities, thereby enriching the world literature on AF. In the process, several novel observations were reported and new questions were raised that warrant further investigations.

Effect of ramadan fasting on glycemic control and other essential variables in diabetic patients

Background

Fasting during the holy month of Ramadan is a religious obligation for all Muslims who represent 1.8 billion of the world population (24%). This study explores the effect of Ramadan fasting on the blood glucose, glycated hemoglobin (HbA1c), lipid profile, sleeping quality, and essential lifestyle parameters and also explores the safety of fasting for a whole month among diabetic patients.

Aim

The aim of the present study was to assess the impact of Ramadan fasting on the blood glucose, HbA1c, lipid profile, sleeping quality, and lifestyle parameters among patients with type 2 diabetes mellitus (T2DM) in Turkey.

Subjects and Methods

A total of 1780 diabetic patients were approached, and 1246 (70%) participated in this cross-sectional study carried out during the period from May 27, 2017, to June 24, 2017. Data analysis comprised sociodemographic features, lifestyle habits, blood pressure measurements, serum lipid profiles, serum calcium, Vitamin D 25-hydroxy, uric acid, and HbA1c at before 4 weeks and after 12 weeks from Ramadan.

Results

Out of 1246 patients, 593 (47.6%) were male and 653 (52.4%) were female. The mean ± standard deviation age of the patients was 50.39 ± 15.3 years. Males were significantly older than females (51.53 ± 12.56 vs. 49.26 ± 14.4; P = 0.003, respectively). Significant differences were found in Vitamin D, blood glucose, HbA1c level, creatinine, bilirubin, albumin, total cholesterol, triglycerides, high-density lipoprotein-cholesterol (female), low-density lipoprotein-cholesterol (male), uric acid, and systolic and diastolic blood pressure after and before the holy month of Ramadan (P < 0.05 for each). HbA1c (P < 0.001), physical activity (P < 0.001), hours of sleeping (P < 0.001), systolic blood pressure (BP) (mmHg) (P = 0.007), BMI (P = 0.016), diastolic BP (mmHg) (P = 0.018), family history (P = 0.021), and smoking (P = 0.045) were identified as significantly associated with Ramadan fasting as contributing factors.

Conclusion

In one of the largest studies of its kind, we show that Ramadan fasting has positive effects on T2DM patients as it reduces their blood pressure, blood glucose, HbA1C, and BMI. Furthermore, there are improvements in the duration of sleep and physical activity, the role of Ramadan fasting in diabetes therapy has been confirmed.

Assessment of risk of fasting during Ramadan under optimal diabetes care, in high-risk patients with diabetes and coronary heart disease through the use of FreeStyle Libre flash continuous glucose monitor (FSL-CGMS)

AIM

Most of Muslims patients with diabetes and Coronary Heart Disease (CHD) elect to fast in Ramadan, but the actual risk in this subset of patients with diabetes is largely unknown. We aimed to understand the safety of fasting in CHD patients with diabetes insisting on fasting Ramadan under optimal care. We also monitored the change in biophysical and biochemical parameters of these patients before and after Ramadan. We conducted this prospective study in a tertiary care hospital in Dubai during Ramadan 2016, (June 6th till July 5th).

PATIENTS AND METHODS

21 Patients with T2DM with stable known CHD during the three months prior to study and insisted on fasting despite advice against it were recruited for the study. All patients received continuous glucose monitoring with free style libre monitoring device (FSL-CGM) during and outside Ramadan period. We recorded DM or CVD-related emergency visit or hospitalisation, change in BMI, systolic and diastolic BP, lipids profile, e-GFR, HBA1c, and frequency of hypoglycemia during Ramadan fasting and not -fasting period.

RESULTS

This is first study using CGM in CHD patients with diabetes who observe fast in Ramadan. Patients had a significantly higher incidence (3.2 ± 2.8 vs 1.1 ± 1.6 episodes, p = 0.033) and prolonged duration of hypoglycemia (117.8 ± 87.2, 49.1 ± 59.1 min p 0.022) during fasting compared to non-fasting respectively. No significant alteration was seen in BMI, SBP and DBP, lipid profile and renal function. There is a significant improvement in HBA1c during Ramadan.

CONCLUSION

We could not associate any adverse cardiovascular effects with fasting Ramadan in patients with stable CHD under optimal diabetes care. FSL-CGMS data showed higher frequency of hypoglycemia during Ramadan fasting. Studies with larger sample size are needed for further validation of these findings.

Effects of Ramadan fasting on the symptoms of chronic heart failure

Objectives:

To investigate the effect of Ramadan fasting on the symptoms of chronic heart failure with a reduced ejection fraction (HFrEF). Globally, more than one billion Muslims fast during Ramadan. Data regarding the effect of fasting in heart failure patients with a reduced ejection fraction are limited.

Methods:

We prospectively studied 249 outpatients with HFrEF who undertook Ramadan fasting at tertiary care cardiac center in Saudi Arabia in 2017. We obtained information regarding the clinical assessment, diagnosis, emergency department visits, and hospitalization during and in the month preceding Ramadan.

Results:

We enrolled 249 patients, 227 (91%) undertook the fast for the entire month. During Ramadan, 209 (92%) patients remained hemodynamically stable, whereas 18 (8%) developed instability. The mean New York Heart Association (NYHA) functional class was significantly lower in the stable than in the unstable group (1.46±0.7 vs. 3.22±0.55, p<0.0001), although no intergroup differences were observed before Ramadan. Patients from the unstable vs. the stable group showed significantly less adherence to medications (67% vs. 94%, p<0.0001) and to diet (39% vs. 79%, p<0.0001), and a lower likelihood of demonstrating ischemic cardiomyopathy as an underlying etiology of HFrEF (33% vs. 57%, p=0.046). Dependent t-test analysis including all patients showed that the NYHA classification before Ramadan was significantly higher than during Ramadan (2.19±0.9 vs. 1.6±0.8, t-value 8.5, p<0.0001).

Conclusion:

In most patients with chronic HFrEF, Ramadan fasting is considered safe. Non-adherence to medication and diet are significantly associated with decompensated heart failure during Ramadan.

Acute heart failure presentations and outcomes during the fasting month of Ramadan: an observational report from seven Middle Eastern countries

BACKGROUND

Fasting during the month of Ramadan is practiced by over 1.5 billion Muslims worldwide. It remains unclear, however, how this change in lifestyle affects heart failure, a condition that has reached epidemic dimensions. This study examined the effects of fasting in patients with acute heart failure (AHF) using data from a large multi-center heart failure registry.

METHODS AND RESULTS

Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multi-center study of consecutive patients hospitalized with AHF during February-November 2012. The study included 4,157 patients, of which 306 (7.4%) were hospitalized with AHF in the fasting month of Ramadan, while 3,851 patients (92.6%) were hospitalized in other days. Clinical characteristics, precipitating factors, management, and outcome were compared among the two groups. Patients admitted during Ramadan had significantly lower prevalence of symptoms and signs of volume overload compared to patients hospitalized in other months. Atrial arrhythmias were significantly less frequent and cholesterol levels were significantly lower in Ramadan. Hospitalization in Ramadan was not independently associated with increased immediate or 1-year mortality.

CONCLUSIONS

The current study represents the largest evaluation of the effects of fasting on AHF. It reports an improved volume status in fasting patients. There were also favorable effects on atrial arrhythmia and total cholesterol and no effects on immediate or long-term outcomes.

Health Benefits of Fasting and Caloric Restriction

PURPOSE OF REVIEW

Obesity and obesity-related diseases, largely resulting from urbanization and behavioral changes, are now of global importance. Energy restriction, though, is associated with health improvements and increased longevity. We review some important mechanisms related to calorie limitation aimed at controlling of metabolic diseases, particularly diabetes.

RECENT FINDINGS

Calorie restriction triggers a complex series of intricate events, including activation of cellular stress response elements, improved autophagy, modification of apoptosis, and alteration in hormonal balance. Intermittent fasting is not only more acceptable to patients, but it also prevents some of the adverse effects of chronic calorie restriction, especially malnutrition. There are many somatic and potentially psychologic benefits of fasting or intermittent calorie restriction. However, some behavioral modifications related to abstinence of binge eating following a fasting period are crucial in maintaining the desired favorable outcomes.

Study of Human Biochemical Parameters During and After Ramadan

Ramadan fasting is obligatory for Muslims each year. They abstain from drinking, eating and intimate relationship between dawn and dusk during this month. Dietary restriction during Ramadan has various biochemical and physiological effects. It is shown to decrease the body weight, glucose and lipid profile. This study aims to analyze the changes in body weight, glucose and lipid profile during Ramadan in physiotherapy students in Pakistan. The study was conducted during June-July 2013 (Hijri year 1434). There were 80 students (50 males and 30 females) recruited in the experiment. They all were healthy adults between the age group of 18-24 (mean age 20.5) years. All subjects underwent a general physical examination and interview, and non-healthy subjects were excluded. On statistical analysis, quantitative data were expressed in terms of mean ± SD and a p value of ≤0.05 was believed statically significant. Paired t test was used to compare the variables. There was a little reduction in body weight (62.7 ± 8.8 vs. 62.3 ± 9.0; p value = 0.009) but a significant decline in glucose level (72.6 ± 12.5 vs. 57.9 ± 10.7; p value = 0.000), low-density lipoprotein level (2.9 ± 0.3 vs. 2.5 ± 0.3; p value = 0.000), total cholesterol (4.6 ± 0.4 vs. 4.2 ± 0.5; p value = 0.000) and triglycerides (1.4 ± 0.5 vs. 1.2 ± 0.5; p value = 0.000) was observed. Moreover, there was some reduction in high-density lipoprotein cholesterol level (1.2 ± 0.3 vs. 1.1 ± 0.3; p value = 0.045). This study shows that Ramadan fasting, a religious obligation for purification of body and soul, resulted in reduced body weight and a positive effect on glucose level and lipid profile.

Effect of Ramadan fasting on diabetes mellitus: a population-based study in Qatar

BACKGROUND

Over one billion Muslims fast worldwide during the month of Ramadan. Fasting during Ramadan is a radical change in lifestyle for the period of a lunar month, and it might affect the biochemical parameters among diabetic patients.

AIM

This study aimed to investigate the effect of Ramadan fasting on the blood levels of glucose, glycated hemoglobin (HbA1c), and lipid profile among diabetic patients observing fast during the Ramadan.

PATIENTS AND METHODS

An observational study recruiting 1301 Muslim diabetic patients above 18 years age was conducted in diabetic outpatient clinic of Hamad General Hospital, Hamad Medical Corporation, and Primary Health Care Center, Qatar, from July 2012 to September 2013. Data on sociodemographic characteristics (age, sex, nationality, marital status, education level, and occupation) and lifestyle habits (smoking and physical activity), blood pressures, and anthropometric measurements were obtained by a face-to-face interview and measurement using a structured questionnaire. Blood samples were collected for testing glucose, glycosylated hemoglobin (HbA1C), lipid profile, urea, and creatinine (by the licensed research assistants).

RESULTS

Slightly less than half of the participants were overweight (BMI: 25-29.9). Significantly higher proportion of female participants were obese as compared with male participants (P<0.001). Among both male participants and female participants, the average level of blood glucose, HbA1c, total cholesterol, low-density and high-density lipoprotein cholesterol, triglycerides, albumin, bilirubin, uric acid, and systolic and diastolic blood pressures were significantly lower during the Ramadan as compared with before Ramadan (P<0.001 each).

CONCLUSION

Results revealed that fasting during Ramadan is significantly associated with decrease in blood lipid profile, blood pressures, glucose, and HbA1C level among diabetic patients. Muslim diabetic patients after the consultation of their primary physician can fast during the month of Ramadan and it might be beneficial for their health.

Gender Discrepancy in Diabetic Patients Hospitalized With Heart Failure: Does Age Matter?

BACKGROUND

Gender discrepancy in the cardiovascular diseases has been evaluated in several studies. We studied the impact of gender disparity on the presentation and outcome of diabetic heart failure (DHF) patients.

METHODS

A retrospective analysis was conducted including all DHF patients admitted to the Heart Hospital between 1991 and 2013. Patients' demographics, presentation, management, and hospital outcomes were analyzed and compared based on gender and age.

RESULTS

Out of 8266 HF patients, 4684 (56.7%) were diabetic, of whom 1817 (39%) were females. Mean age was comparable in both genders. DHF female patients were more likely to be hypertensive (79% vs. 65%, P = 0.001) and obese (13% vs. 4.6%, P = 0.001). DHF females were less likely to receive beta-blockers and angiotensin-converting-enzyme inhibitors/angiotensinogen-receptor blockers (25% vs. 30%, P = 0.001, 54% vs. 57%, P = 0.01, respectively), but were more likely to be on insulin therapy (21% vs. 16%, P = 0.001). In-hospital atrial fibrillation (P =0.90), ventricular tachycardia (P = 0.07), stroke (P = 0.45), and cardiac arrest (P = 0.26) were comparable. Overall in-hospital mortality was comparable in both genders (P = 0.83). In age ≤50 years, male gender was associated with a 3-fold increase in death (13% vs. 4%, P = 0.01), however, this mortality difference disappeared in DHF patients aged >50 years (P = 0.62).

CONCLUSIONS

In DHF, female gender is characterized by having a high prevalence of metabolic syndrome components. Also, females are more likely to have better Left ventricular ejection fraction but less likely to receive cardiovascular evidence based medications. There is no significant difference in the overall hospital mortality between both genders, however, in the younger age; males have a significantly higher mortality.

Pharmacist–patient communication about medication regimen adjustment during Ramadan

Objectives

During Ramadan, Muslims fast from dawn to sunset while abstaining from food and drink. Although Muslim patients may be aware of their religious exemption from fasting, many patients still choose not to take that exemption and fast. This study examines pharmacists’ initiation and timing of communication about medication regimen adjustment (MRA) with patients related to Ramadan. Predictors for initiating this communication with patients were also explored.

Methods

A probability sample of community pharmacists in Alexandria, Egypt was surveyed. The self-administered instrument covered timing and likelihood of initiating discussion about MRA. Using ordered logistic regression, a model was estimated to predict pharmacists’ initiation of the conversation on MRA during Ramadan.

Results

Ninety-three percent of the 298 approached pharmacists completed surveys. Only 16% of the pharmacists reported that they themselves usually initiated the conversation on MRA. Pharmacists’ initiation of these conversations was associated with pharmacists’ perceived importance of MRA on pharmacy revenue odds ratio ((OR) = 1.24, CI = 1.03–1.48). Eighty percent of the responding pharmacists reported the MRA conversation for chronic conditions started either 1–3 days before, or during the first week of Ramadan.

Conclusion

These results suggest considerable pharmacist patient communication gaps regarding medication use during Ramadan. It is especially important for pharmacists and other health professionals to initiate communication with Muslim patients early enough to identify how best to help patients transition safely into and out of Ramadan as they fast.

Ramadan fasting is not usually associated with the risk of cardiovascular events: A systematic review and meta-analysis

Over one billion Muslims worldwide fast during the month of Ramadan. Ramadan fasting brings about some changes in the daily lives of practicing Muslims, especially in their diet and sleep patterns, which are associated with the risk of cardiovascular diseases. Over the years, many original studies have made the effort to identify the possible impact of the Ramadan fast on cardiovascular diseases. This systematic review and meta-analysis is an attempt to present the summary of key findings from those articles and an appraisal of selected literature. A systematic search using keywords of “;Ramadan fasting” and “;cardiovascular diseases” was conducted in primary research article and gray-literature repositories, in combination with hand searching and snow balling. Fifteen studies were finally selected for data extraction on the outcomes of stroke, myocardial infarction, and congestive heart failure. The analysis revealed that the incidence of cardiovascular events during the Ramadan fast was similar to the nonfasting period. Ramadan fast is not associated with any change in incidence of acute cardiovascular disease.

The cardiac patient in Ramadan

Ramadan is one of the five fundamental pillars of Islam. During this month, the majority of the 1.6 billion Muslims worldwide observe an absolute fast from dawn to sunset without any drink or food. Our review shows that the impact of fasting during Ramadan on patients with stable cardiac disease is minimal and does not lead to any increase in acute events. Most patients with the stable cardiac disease can fast safely. Most of the drug doses and their regimen are easily manageable during this month and may need not to be changed. Ramadan fasting is a healthy nonpharmacological means for improving cardiovascular risk factors. Most of the Muslims, who suffer from chronic diseases, insist on fasting Ramadan despite being exempted by religion. The Holy Quran specifically exempts the sick from fasting. This is particularly relevant if fasting worsens one's illness or delays recovery. Patients with unstable angina, recent myocardial infarction, uncontrolled hypertension, decompensated heart failure, recent cardiac intervention or cardiac surgery or any debilitating diseases should avoid fasting.

Inotropic agents use in patients hospitalized with acute decompensated heart failure: a retrospective analysis from a 22-year registry in a Middle-Eastern Country (1991-2013)

Background

Data about the use of positive inotropic agents in patients hospitalized with acute decompensated heart failure (ADHF) is limited.

Methods

The records of 8066 patients with ADHF who were hospitalized at Hamad Medical Corporation, Qatar from 1991 to 2013 were analyzed to explore demographics and clinical characteristics of the patients according to inotropic agents use.

Results

Eight hundred fifty eight patients [10.6 %, 95 % CI (10 to 11.3 %)] received intravenous inotropic support. Patients receiving inotropes were more likely to be female and have preserved ejection fraction when compared to those not receiving inotropic agents. Comorbidities associated with higher likelihood of receiving inotropic treatment included acute myocardial infarction, chronic renal impairment, dyslipidemia, hypertension, obesity and hyperglycemia. Patient on inotropes were more likely to undergone percutaneous coronary intervention (PCI), intra-aortic balloon pump support and intubation. There were no differences in the mean plasma BNP and CK-MB levels between the 2 groups. Heart failure patients receiving inotropes also were more likely to have complications including ventricular tachycardia (2.0 % vs. 0.9 %, p = 0.003), prolonged hospital stay (8.0 vs. 5.0 days, p = 0.001), cardiac arrest (14.6 % vs. 3.2 %, p = 0.001) and in-hospital mortality (30.8 % vs. 9.1 %, p = 0.001). Over the study period there was an increase use of inotropic agents and decreased mortality rates.

Conclusion

Inotropic use increased over the period whereas; female gender and conventional cardiac risk factors were predictors of inotropic agents use in the study.

Ramadan Fasting Decreases Body Fat but Not Protein Mass

BACKGROUND

Many studies have shown various results regarding the effects of Ramadan fasting on weight and body composition in healthy individuals.

OBJECTIVES

This study aimed to evaluate the effect of Ramadan fasting on body composition in healthy Indonesian medical staff.

OBJECTIVES

In this study, we examined the influence of Ramadan fasting on body composition in healthy medical staff.

PATIENTS AND METHODS

The longitudinal study was performed during and after Ramadan fasting in 2013 (August to October). Fourty-three medical staff members (physicians, nurses and nutritionists) at the Internal Medicine Ward of the Dr. Cipto Mangunkusumo General Hospital were measured to compare their calorie intake, weight, body mass index, waist-to-hip ratio (WHR), and body composition, including body fat, protein, minerals and water, on the first and 28(th) days of Ramadan and also 4-5 weeks after Ramadan fasting. Measurements were obtained for all 43 subjects on the 28(th) day of Ramadan, but they were obtained for only 25 subjects 4 - 5 weeks after Ramadan.

RESULTS

By the 28(th) day of Ramadan, it was found that the body weight, BMI, body fat, water and mineral measures had decreased significantly (-0.874 ± 0.859 kg, P < 0.001; -0.36 ± 0.371 kg/m(2), P < 0.001; -0.484 ± 0.597 kg, P < 0.001; -0.293 ± 0.486 kg, P = 0.001; -0.054 ± 0.059 kg, P < 0.001, respectively). Protein body mass and calorie intake did not significantly change (-0.049 ± 0.170 kg, P = 0.561; 12.94 ± 760.608 Kcal, P = 0.082 respectively). By 4 - 5 weeks after Ramadan, body weight and composition had returned to the same levels as on the first day of Ramadan.

CONCLUSIONS

Ramadan fasting resulted in weight loss even it was only a temporary effect, as the weight was quickly regained within one month after fasting. The catabolism catabolic state, which is related to protein loss, was not triggered during Ramadan fasting. Further research is needed to evaluate the effects of weight loss during Ramadan fasting in healthy individuals.

The effect of Ramadan fasting on cardiometabolic risk factors and anthropometrics parameters: A systematic review

Fasting during the month of Ramadan is a religious rituals of all healthy adult Muslims. However, there is no clear agreement on the effects of Ramadan fasting on cardiovascular disease. Comorbidities and factors such as age, gender, health status, daily duration of fasting, food intake before and after fasting may impact on a fasting individual’s cardiometabolic risk. This review was undertaken to assess the effects of Ramadan fasting on: the incidence of cardiovascular disease during the month of Ramadan; the clinical status of patients with stable cardiac disease; and any alterations in cardiometabolic risk profile.

Ramadan fast in patients with coronary artery disease

Background:

Fasting during the month of Ramadan is of vital significance amongst Muslims; however, little is known about the effects of this kind of fasting on patients with coronary artery disease (CAD).

Objectives:

This nonrandomized prospective observational pilot study was designed to investigate the effects of Ramadan fast on the symptoms of CAD.

Patients and Methods:

Patients with documented CAD were consecutively (nonrandomized) included in the study, and those with heart failure (ejection fraction < 50%), renal failure, gout, and insulin-treated diabetes were excluded. Patients had the choice of fasting during Ramadan if they so wished and to break their fast as soon as symptoms such as dyspnea and chest pain occurred (fasting group) or not fasting (control group).

Results:

A total of 148 patients completed the study. Mean (mean ± SD) age of the patients was 61.5 ± 11.7 years and 50% were male. Finally, 66 patients (44.6%) accomplished Ramadan fast with an average of 22.27 ± 10.46 days of fasting. Occurrence of chest pain was not significantly different between the fasting and non-fasting groups (4 out of 66 [6.1%] vs. 8 out of 82 [9.8%] respectively; P = 0.42). In addition, patients who fasted during Ramadan did not experience a higher frequency of a combined endpoint of chest pain and dyspnea (4 out of 66 cases in the fasting group [6.1%] vs. 11 out of 82 in non-fasting group [13.4%]; P = 0.14).

Conclusions:

In the present study, the patients with CAD were able to observe Ramadan fast safely and their combined endpoint of chest pain and dyspnea was not significantly different from that of the non-fasting ones. We would suggest that patients with CAD and normal left ventricular function could fast during Ramadan.

Fasting during the month of Ramadan among patients with chronic kidney disease: renal and cardiovascular outcomes

Background

Fasting during the month of Ramadan is a religious obligation for Muslims who represent 20% of the world population. This study explores the safety of fasting for a whole month among patients with chronic kidney disease (CKD) with the possible risk of dehydration and hyperviscosity leading to deterioration of kidney functions and vascular thrombosis.

Methods

We followed CKD patients with stable kidney function who chose to fast during the month of Ramadan. A group of nonfasting CKD patients served as controls. Serum creatinine was recorded at the beginning of the month, after 1 week of fasting, at the end of the month and 3 months later. Patients were followed for major adverse cardiovascular events (MACE).

Results

A total of 131 CKD patients were recruited and included in two groups: fasting and nonfasting (mean baseline estimated glomerular filtration rate 27.7, SD 13 and 21.5, SD 11.8 mL/min/1.73 m², respectively). A rise of serum creatinine was noted during fasting in 60.4% of patients by Day 7 and was associated with intake of renin angiotensin aldosterone system antagonists [relative risk (RR) 2, P = 0.002]. Adverse cardiovascular events were observed in six patients in the fasting cohort and were associated with a rise of serum creatinine after 1 week of fasting (P = 0.009) and the presence of pre-existing cardiovascular disease (RR 15, P = 0.001); the latter association was confirmed by logistic regression analysis. Only one event was recorded in the nonfasting group, P = 0.036.

Conclusions

MACE occurred more frequently among fasting CKD patients with pre-existing cardiovascular disease and were predicted by an early rise of serum creatinine.

Mortality Trends in Patients Hospitalized with the Initial Acute Myocardial Infarction in a Middle Eastern Country over 20 Years

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

Evaluation of forensic deaths during the month of Ramadan in Konya, Turkey, between 2000 and 2009

Ramadan is a holy month for Muslim people and includes long fasting periods. During Ramadan, practicing Muslims not only fast, but they also abstain from any kind of medication, smoking, sexual intercourse, and alcohol from sunrise to sunset. In the 10-year period between 2000 and 2009, it was determined that a total of 4881 death examinations and autopsies were performed at the Konya Branch of the Forensic Medicine Council (Turkey). All of the reports were retrospectively evaluated for demographic features of the cases and the manner of death. In the studied time period, a total of 491 deaths (10.1%) occurred in Ramadan. The manner of death was accident in 369 (75.2%) of the cases in Ramadan, 3107 (70.8%) of the other cases; suicide in 27 (5.5%) of the cases in Ramadan, 367 (8.4%) of the other cases; and homicide in 28 (5.7%) of the cases in Ramadan, 375 (8.5%) of the other cases. There was a significant statistical difference in terms of the manner of death between the deaths in Ramadan and in the remaining part of the year (P < 0.05). Our study suggested that there was an increase in accidental and natural deaths and a decrease in suicide and homicides in Ramadan.

The cardiac patient during Ramadan and Hajj

The holy month of Ramadan is one of the five pillars of Islam. During this month, fasting Muslims refrain from eating, drinking, smoking, and sex from dawn until sunset. Although the Quran exempts sick people from the duty of fasting, it is not uncommon for many heart disease patients to fast during Ramadan. Despite the fact that more than a billion Muslims worldwide fast during Ramadan, there is no clear consensus on its effects on cardiac disease. Some studies have shown that the effects of fasting on stable patients with cardiac disease are minimal and the majority of patients with stable cardiac illness can endure Ramadan fasting with no clinical deterioration. Fasting during Ramadan does not seem to increase hospitalizations for congestive heart failure. However, patients with decompensated heart failure or those requiring large doses of diuretics are strongly advised not to fast, particularly when Ramadan falls in summer. Patients with controlled hypertension can safely fast. However, patients with resistant hypertension should be advised not to fast until their blood pressure is reasonably controlled. Patients with recent myocardial infarction, unstable angina, recent cardiac intervention or cardiac surgery should avoid fasting. Physician advice should be individualized and patients are encouraged to seek medical advice before fasting in order to adjust their medications, if required. The performance of the Hajj pilgrimage is another pillar of Islam and is obligatory once in the lifetime for all adult Muslims who are in good health and can afford to undertake the journey. Hajj is a physically, mentally, emotionally, and spiritually demanding experience. Medical checkups one or two months before leaving for Hajj is warranted, especially for those with chronic illnesses such as cardiovascular disease. Patients with heart failure, uncontrolled hypertension, serious arrhythmias, unstable angina, recent myocardial infarction, or cardiac surgery should be considered unfit for undertaking the Hajj pilgrimage.

The Impact of Ramadan on lifestyle behaviours and implications for cardiac rehabilitation: A review

Introduction:

The Muslim population worldwide have a higher incidence of cardiovascular disease than that of the non-Muslim population, and this may become exaggerated during the religious observances of Ramadan. This review assessed the evidence regarding the impact of Ramadan on lifestyle behaviours in Muslims with cardiovascular disease.

Method:

This article reviews the literature concerning the impact of Ramadan on lifestyle behaviours and its effects on cardiac rehabilitation between 2000 and 2012. Studies were identified, using Academic Search Complete, Google Scholar, PsycInfo, PsycARTICLES, Medline and CINAHL Plus. The search terms used were: ‘cardiac rehabilitation’; ‘cardiovascular disease’; ‘Ramadan’; ‘fasting’; ‘physical activity’; ‘exercise’; ‘diet’; ‘smoking’; ‘sleep’; ‘behaviour change’; ‘medication’; and ‘treatment’.

Findings:

Evidence suggests that fasting during Ramadan can have a beneficial effect on factors such as cholesterol levels, body weight and blood pressure; however, benefits are rarely sustained in the long term. Other behavioural changes such as non-adherence to medication, and diet and exercise regimes have more negative consequences for sufferers of cardiac disease.

Conclusions:

Lifestyle behaviours adopted during Ramadan can have a negative impact on cardiovascular disease. Health professionals are urged to find innovative ways to engage this population in healthy lifestyle choices throughout this period.

Impact of religious Ramadan fasting on cardiovascular disease: a systematic review of the literature

BACKGROUND

Fasting during the month of Ramadan is a religious obligation that is practiced by millions of people around the world yet there is no clear scientific consensus on its effects on cardiovascular disease. This study was performed to inform physicians as well as patients of evidence based recommendations on this subject.

AIM

The study was undertaken to assess: (1) any alteration in the incidence of acute cardiac illness during Ramadan fasting; (2) whether fasting during the month of Ramadan alters the clinical status of patients with stable cardiac disease; and (3) the impact of Ramadan fasting on cardiovascular risk factors in normal subjects, in patients with stable cardiac disease, metabolic syndrome, dyslipidemia, type 2 diabetes and systemic hypertension.

STUDY DESIGN

Systematic review of the literature.

METHOD

A Medline search of the English literature published between January 1980 and September 2012.

RESULTS

The incidence of acute cardiac illness during Ramadan fasting was similar to non-fasting days, although the timing of symptom onset may be different, with significant increase in events during the period of 'breaking fast' when compared to non-fasting days. The majority of patients with stable cardiac illness can undergo Ramadan fasting without any clinical deterioration. Body mass index, lipid profile, and blood pressure showed significant improvement in normal healthy subjects, patients with stable cardiac illness, metabolic syndrome, dyslipidemia and hypertension during Ramadan fasting. The lipid profile of diabetic patients deteriorated significantly during Ramadan fasting.

CONCLUSIONS

Ramadan fasting is not associated with any change in incidence of acute cardiac illness and the majority of cardiac patients can fast without any difficulty. Improvement in lipid profile, especially 30% to 40% increment in high-density lipoprotein, as reported in some studies, appear promising. Diabetic patients should be carefully monitored during Ramadan fasting.

Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study

Background

Previous research has shown that Ramadan fasting has beneficial effects on cardiovascular risk factors, however there are controversies. In the present study, the effect of Ramadan fasting on cardiovascular risk factors has been investigated.

Method

This is a prospective observational study that was carried out in a group of patients with at least one cardiovascular risk factor (including history of documented previous history of either coronary artery disease (CAD), metabolic syndrome or cerebro-vascular disease in past 10 y). Eighty two volunteers including 38 male and 44 female, aged 29–70 y, mean 54.0 ± 10 y, with a previous history of either coronary artery disease, metabolic syndrome or cerebro-vascular disease were recruited. Subjects attended the metabolic unit after at least 10 h fasting, before and after Ramadan who were been fasting for at least 10 days. A fasting blood sample was obtained, blood pressure was measured and body mass index (BMI) was calculated. Lipids profile, fasting blood sugar (FBS) and insulin, homocysteine (hcy), high-sensitivity C-reactive protein (hs-CRP) and complete blood count (CBC) were analyzed on all blood samples.

Results

A significant improvement in 10 years coronary heart disease risk (based on Framingham risk score) was found (13.0 ± 8 before Ramadan and 10.8 ±7 after Ramadan, P <0.001, t test).There was a significant higher HDL-c, WBC, RBC and platelet count (PLT), and lower plasma cholesterol, triglycerides, LDL-c, VLDL-c, systolic blood pressure, body mass index and waist circumference after Ramadan (P <0.05, t test). The changes in FBS, insulin,Homeostasis Model Assessment Insulin Resistance (HOMA-IR), hcy, hs-CRP and diastolic blood pressure before and after Ramadan were not significant (P >0.05, t test).

Conclusions

This study shows a significant improvement in 10 years coronary heart disease risk score and other cardiovascular risk factors such as lipids profile, systolic blood pressure, weight, BMI and waist circumference in subjects with a previous history of cardiovascular disease.

Acute coronary syndrome in patients with prior coronary artery bypass surgery: observations from a 20-year registry in a middle-eastern country

Objectives

Clinical characteristics and trends in the outcome of acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft surgery (CABG) are unclear. The aim of this study was to evaluate clinical characteristics, in-hospital treatment, and outcomes in patients presented with ACS with or without a history of prior CABG over 2 decades.

Methods

Data were derived from hospital-based study for collected data from 1991 through 2010 of patients hospitalized with ACS in Doha, Qatar. Data were analyzed according to their history of prior CABG. Baseline clinical characteristics, in-hospital treatment, and outcome were compared.

Results

A total 16,750 consecutive patients with ACS were studied, of which 693 (4.1%) had prior CABG. Patients with prior CABG were older (mean 60.5±11 vs. 53±12 years; P = 0.001), more likely to be females and have more cardiovascular risk factors than the non-CABG group. Prior CABG patients had larger infarct size, were less likely to receive reperfusion therapy, early invasive therapy and more likely to receive evidence-based therapies when compared to non-CABG patients. In-hospital mortality and stroke rates were comparable between the 2 groups. Over 2 decades, there was reduction in the in-hospital mortality rates and stroke rates in both groups (CABG, death; 13.2% to 4%, stroke; 1.9% to 0.0%, non-CABG, death; 10% to 3.2%, stroke 1.0% to 0.1%; all, p = 0.001).

Conclusion

Significant reduction in-hospital morbidity and mortality among ACS patients with prior CABG over a 20-year period.

The implications of Ramadan fasting for human health and well-being

Islamic Ramadan is a 29-30 day fast in which food, fluids, medications, drugs and smoking are prohibited during the daylight hours which can be extended between 13 and 18 h · day(-1) depending on the geographical location and season. The majority of health-specific findings related to Ramadan fasting are mixed. The likely causes for these heterogeneous findings lie in the amount of daily time of fasting, number of subjects who smoke, take oral medications, and/or receive intravenous fluids, in the type of food and eating habits and in changes in lifestyle. During Ramadan fasting, glucose homeostasis is maintained by meals taken during night time before dawn and by liver glycogen stores. Changes in serum lipids are variable and depend on the quality and quantity of food intake, physical activity and exercise, and changes in body weight. Compliant, well-controlled type II diabetics may observe Ramadan fasting, but fasting is not recommended for type I, noncompliant, poorly controlled and pregnant diabetics. There are no adverse effects of Ramadan fasting on respiratory and cardiovascular systems, haematologic profile, endocrine, and neuropsychiatric functions.

CONCLUSIONS

Although Ramadan fasting is safe for all healthy individuals, those with various diseases should consult their physicians and follow medical and scientific recommendations.

Comparison of women versus men hospitalized with heart failure (from a 20-year registry in a middle-eastern country 1991-2010)

The aim of the present study was to compare the clinical characteristics, treatment, and outcomes of women and men hospitalized with heart failure (HF) in a Middle-Eastern country. A retrospective analysis of all patients hospitalized with HF in the State of Qatar from 1991 through 2010 was made. The clinical characteristics, management, and outcomes of the patients with HF were compared according to gender. A subset analysis according to ethnicity was also done (Middle Eastern Arabs vs South Asians). During the 20-year period, 2,379 women and 4,689 men were hospitalized for HF. The women were older and more likely to have diabetes mellitus, hypertension, and chronic renal impairment compared to the male patients. The women were less likely to be current smokers and to have ischemic heart disease compared to the men. Impaired left ventricular function was more common among men. The in-hospital mortality rates were comparable between the 2 groups (7.7% in women vs 8.2% in men; p = 0.4) and significantly improved with time in the 2 groups (p = 0.001). The mortality rates were comparable among the women, regardless of the ethnicity. In conclusion, overall improvement occurred in survival in patients hospitalized with HF in a Middle-Eastern country, regardless of gender. Women hospitalized with HF had mortality rates comparable to those of men.

The impact of diurnal fasting during Ramadan on the lipid profile, hs-CRP, and serum leptin in stable cardiac patients

AIM

To study the effect of strict prolonged fasting on lipid profile, serum leptin, and high- sensitivity C-reactive protein (hs-CRP) in patients with different stable cardiac illnesses and look for associated new cardiac events and any correlation between entire variables.

METHODS

A total of 56 patients of different stable cardiac illnesses were followed in our cardiology outpatient for 3 months. Data concerning their ability to fast were collected: New York Heart Association class of congestive cardiac failure, angina class, previous myocardial infarction, previous coronary artery bypass graft, percutaneous coronary intervention, severity of valvular lesion, metallic prosthetic valve, and traditional risk factors (diabetes mellitus, insulin requirement, hypertension, hypercholesterolemia, smoking habit, and obesity). Detailed clinical examination and electrocardiography were performed in all patients in three consecutive visits before, during, and after Ramadan. Echocardiographic and angiographic findings and medication plans were collected from patient records. Lipid profile, serum leptin, and hs-CRP were assessed before, during, and after Ramadan.

RESULTS

All patients fasted during Ramadan: 80.4% were male, 67.9% were aged >50 years, 71.4% had no change in their symptoms during fasting while 28.6% felt better. No patient has deteriorated. 91.1% of the patients were compliant with medicine during Ramadan, 73.2% after. 89.3% were compliant with diet during Ramadan with no significant change in body weight in the follow-up period. No cardiac or noncardiac morbidity or mortality was reported. High- density lipoprotein-cholesterol (HDL-C) decreased significantly during compared to before fasting (P = 0.012). Low-density lipoprotein-cholesterol (LDL-C) significantly increased during compared to before fasting (P = 0.022). No statistically significant changes were observed in total cholesterol (TC), triglycerides (TG), serum leptin, or hs-CRP. Significant correlation was observed between TC and hs-CRP during fasting (P = 0.036), but not with TG, LDL-C, or HDL-C (P > 0.05). Neither of these correlated with serum leptin (P > 0.05), but significant correlation was observed between hs-CRP and serum leptin (P < 0.05).

CONCLUSION

Ramadan fasting in stable cardiac patients has no effect on their clinical status, serum leptin, or hs-CRP, but results in decrease in HDL-C, increase in LDL-C, with significant correlation between TC and hs-CRP during Ramadan, but not with TG, LDL-C, or HDL-C, and with significant correlation between hs-CRP and serum leptin before, during, and after fasting.

Health is a spiritual thing: perspectives of health care professionals and female Somali and Bangladeshi women on the health impacts of fasting during Ramadan

OBJECTIVE

To explore perspectives of health care professionals and female Somali and Bangladeshi Muslim women on practices related to fasting during Ramadan, the impact of fasting on health and the role of health professionals during Ramadan.

DESIGN

A cross-sectional qualitative study was conducted. Two culturally specific focus groups were conducted with six Somali and seven Bangladeshi Muslim women who observed Ramadan and lived in an inner-city neighbourhood of Toronto, Canada. Individual semi-structured interviews were conducted with 22 health care professionals practicing in this inner-city area (three of whom were Muslim). Data were analysed using thematic qualitative analysis.

RESULTS

Both Muslim women and health care professionals recognised the spiritual significance of the Ramadan fast. Muslim participants considered the fast to be beneficial to health overall, whereas health care professionals tended to reflect on health concerns from fasting. Many health care professionals were not fully aware of fasting practices during Ramadan and some found it challenging to counsel patients about the health effects of fasting. Muslim women expressed disagreement regarding which medical interventions were permitted during fasting. They generally agreed that health care professionals should not specifically advise against fasting, but instead provide guidance on health maintenance while fasting. Both groups agreed that guidelines developed by the health care and faith communities together would be useful.

CONCLUSION

There are a variety of health beliefs and observances among female Muslim Somali and Bangladeshi women and a range of knowledge, experience and opinions among health care professionals related to fasting during Ramadan and health. Overall, there is a need for improved communication between members of the Muslim community and health professionals in Canada about health issues related to fasting during Ramadan. Strategies could include published practice guidelines endorsed by the Muslim community; patient education materials developed in collaboration with health and religious experts; or further qualitative research to help professionals understand the beliefs and observances of Muslim people.

The impact of religious fasting on human health

The past two decades have seen a rise in the number of investigations examining the health-related effects of religiously motivated fasts. Islamic Ramadan is a 28 - 30 day fast in which food and drink are prohibited during the daylight hours. The majority of health-specific findings related to Ramadan fasting are mixed. The likely causes for these heterogeneous findings are the differences between studies in the following: 1) the amount of daily fasting time; 2) the percentage of subjects who smoke, take oral medications, and/or receive intravenous fluids; and 3) the subjects' typical food choices and eating habits. Greek Orthodox Christians fast for a total of 180 - 200 days each year, and their main fasting periods are the Nativity Fast (40 days prior to Christmas), Lent (48 days prior to Easter), and the Assumption (15 days in August). The fasting periods are more similar than dissimilar, and they can each be described as a variant of vegetarianism. Some of the more favorable effects of these fasts include the lowering of body mass, total cholesterol, LDL-C, and the LDL-C/HDL-C ratio. The Biblical-based Daniel Fast prohibits the consumption of animal products, refined carbohydrates, food additives, preservatives, sweeteners, flavorings, caffeine, and alcohol. It is most commonly partaken for 21 days, although fasts of 10 and 40 days have been observed. Our initial investigation of the Daniel Fast noted favorable effects on several health-related outcomes, including: blood pressure, blood lipids, insulin sensitivity, and biomarkers of oxidative stress. This review summarizes the health-specific effects of these fasts and provides suggestions for future research.

Circadian rhythm of stroke onset during the month of Ramadan

BACKGROUND AND PURPOSE

The onset of acute stroke exhibits a circadian pattern occurring more frequently in late morning hours. The objective of this study was to investigate the diurnal pattern of stroke during the month of Ramadan.

PATIENTS AND METHODS

We studied consecutive stroke patients 1 month before Ramadan (BR) and during Ramadan (DR) over two successive years 2007 and 2008. The age, gender, risk factor profiles were analyzed. The National Institute of Health and Stroke Scale Score (NIHSS) was used for clinical assessment at admission. The exact time of stroke onset in both groups was obtained.

RESULTS

A total of 507 patients were studied: 245 patients in the DR group and 262 patients in the BR group. The age distribution of patients was not significantly different between the two groups. There was no statistically significant difference in the sex ratio, risk factors, and NIHSS score between the two groups (P > 0.05). The higher frequency of stroke onset time in the BR group was in the time between 6:00 a.m. and noon; whereas the frequency was higher between noon and 6:00 p.m. in the DR group.

CONCLUSION

A significant shift of the circadian pattern of stroke onset time from the period between 6:00 a.m. and noon to that between noon and 6:00 pm has been found during the month of Ramadan.