Association of Biomarkers for Dyslipidemia, Inflammation, and Oxidative Stress with Endothelial Dysfunction in Obese Youths: A Case-Control Study

Objective

The United Arab Emirates (UAE), with its characteristic local population, geography, and history, presents several risk factors for cardiovascular diseases (CVDs) in obese individuals. Obesity and its associated complications, including diabetes, atherogenic dyslipidemia, and CVDs leading to significant health risks. In the present study, "Youths" defined as young people between 18 and 22 years. We assessed dyslipidemia, inflammation, and oxidative stress biomarker levels and their association with endothelial dysfunction (ED) in both overweight/obese and normal weight youths of UAE.

Methods

There were 160 youths with overweight/obese (BMI ≥ 25 kg/m2) patients and healthy age- and sex-matched normal weight (BMI ≤ 24.9 kg/m2) as controls participated in this study. The anthropometric data and blood samples were collected to assess the biomarkers for dyslipidemia, inflammation, oxidative stress, ED from all the youths.

Results

The overall mean age and male-to-female ratio were 20±1.5years and 1.0:1.2, respectively. There was statistically significant difference in HDL-C (p<0.001), triglycerides (TG) (p<0.001), ApoA (p=0.002), ApoB/ApoA ratio (p=0.009) between the overweight/obese and normal weight youths. Among, inflammatory markers: hs-CRP, IL-6, TNF-α also showed significant p<0.001 and oxidative stress markers: DNA/RNA Damage, catalase and nitric oxide (NO) showed significant p<0.001 between groups. Spearman correlation of ED markers with lipid profile markers showed Vitamin C levels positively correlated with HDL-C (p<0.001) and negatively correlated with glucose (p<0.001). ICAM-1showed significant negative correlation with HDL-C (p<0.01) and ApoA (p<0.001) but positive correlation with TG (p<0.01) and HbA1c (p<0.001) among groups. Spearman correlation of ED markers with inflammatory/oxidative stress biomarkers showed Vitamin C levels negatively correlated with ferritin (p < 0.001), NO (p < 0.001), GGT (p < 0.001), and ALT (p < 0.001) levels. The ICAM-1showed significant positive correlation with hs-CRP (p < 0.01), IL-6 (p < 0.001), TNF-α (p < 0.01), GGT (p < 0.05), and ALT (p < 0.05) in both groups.

Conclusion

This study revealed a strong link between the biomarkers of dyslipidemia, inflammation, and oxidative stress with ED in overweight/obese patients. This study might be used to predict future cardiovascular events in this population.

Identifying risk factors and mortality rate of premature coronary artery disease in young Saudi population

Coronary artery disease is a leading cause of morbidity and mortality worldwide. It occurs due to a combination of genetics, lifestyle, and environmental factors. Premature coronary artery disease (PCAD) is a neglected clinical entity despite the rising number of cases worldwide. This study aimed to investigate the risk factors of premature coronary artery disease. In this study, we searched articles that had studied the risk factors of premature coronary artery diseases from January 2000 to July 2022 in Saudi Arabia in Web of Science, Pub Med, Scopus, Springer, and Wiley databases. The final analysis is based on seven articles. The smoking prevalence was 39%, diabetes mellitus 41%, hypertension 33%, overweight and obesity 18%, family history of coronary artery disease (CAD) 19%, dyslipidemia 37%, and the prevalence range of low-density lipoprotein cholesterol was 33.8-55.0%. The results revealed a mortality prevalence of 4% ranging from 2 to 8% which is similar to the prevalence in older patients which was 2-10%. Smoking, diabetes mellitus, hypertension, family history of CAD, dyslipidemia, and overweight/obesity are significantly and positively associated with premature coronary artery diseases. The health authorities should design and implement an intensive and effective prophylactic plan to minimize the subsequent impact of PCAD on the young population. In addition, early diagnosis of PCAD has great value in providing timely treatment, managing the patients, and minimizing the burden of the disease.

Cardiovascular disease burden in the Middle East and North Africa region

INTRODUCTION

Cardiovascular disease (CVD) remains the leading cause of death globally, including the Middle East and North Africa (MENA) region. However, limited research has been conducted on the burden of CVD in this region. Our study aims to investigate the burden of CVD and related risk factors in the MENA.

METHODS

We used data from the Global Burden of Disease (GBD) 2019 to examine CVD prevalence in 21 MENA countries. Prevalence and mortality were analyzed using Bayesian regression tools, demographic methods, and mortality-to-incidence ratios. Disability-adjusted life years (DALYs) were calculated, and risk factors were evaluated under the GBD's comparative risk assessment framework.

RESULTS

Between 1990 and 2019, CVD raw accounts in the MENA increased by 140.9%, while age standardized prevalence slightly decreased (-1.3%). CVD raw mortality counts rose by 78.3%, but age standardized death rates fell by 28%. Ischemic heart disease remained the most prevalent condition, with higher rates in men, while women had higher rates of CVA. Age standardized DALYs decreased by 32.54%. DALY rates varied across countries and were consistently higher in males. Leading risk factors included hypertension, high LDL-C, dietary risks, and elevated BMI.  The countries with the three highest DALYs in 2019 were Afghanistan, Egypt, and Yemen.

CONCLUSIONS

While strides have been made in lessening the CVD burden in the MENA region, the toll on mortality and morbidity, particularly from ischemic heart disease, remains significant. Country-specific variations call for tailored interventions addressing socio-economic factors, healthcare infrastructure, and political stability.

Burden of Ischemic Heart Disease and Its Attributable Risk Factors in North Africa and the Middle East, 1990 to 2019: Results From the GBD Study 2019

BACKGROUND

The North Africa and Middle East (NAME) region has one of the highest burdens of ischemic heart disease (IHD) worldwide. This study reports the contemporary epidemiology of IHD in NAME.

METHODS AND RESULTS

We estimated the incidence, prevalence, deaths, years of life lost, years lived with disability, disability-adjusted life years (DALYs), and premature mortality of IHD, and its attributable risk factors in NAME from 1990 to 2019 using the results of the GBD (Global Burden of Disease study 2019). In 2019, 0.8 million lives and 18.0 million DALYs were lost due to IHD in NAME. From 1990 to 2019, the age-standardized DALY rate of IHD significantly decreased by 33.3%, mostly due to the reduction of years of life lost rather than years lived with disability. In 2019, the proportion of premature death attributable to IHD was higher in NAME compared with global measures: 26.8% versus 16.9% for women and 18.4% versus 14.8% for men, respectively. The age-standardized DALY rate of IHD attributed to metabolic risks, behavioral risks, and environmental/occupational risks significantly decreased by 28.7%, 37.8%, and 36.4%, respectively. Dietary risk factors, high systolic blood pressure, and high low-density lipoprotein cholesterol were the top 3 risks contributing to the IHD burden in most countries of NAME in 2019.

CONCLUSIONS

In 2019, IHD was the leading cause of death and lost DALYs in NAME, where premature death due to IHD was greater than the global average. Despite the great reduction in the age-standardized DALYs of IHD in NAME from 1990 to 2019, this region still had the second-highest burden of IHD in 2019 globally.

Magnitude and associated factors of dyslipidemia among patients with severe mental illness in dire Dawa, Ethiopia: neglected public health concern

BACKGROUND

Lipid metabolism abnormalities are an emerging risk factor for cardiovascular diseases. Due to the nature of the condition and their unhealthy lifestyles, patients with mental illnesses have a doubled risk of morbidity and mortality from dyslipidemia compared to the general population. To our knowledge the magnitude of dyslipidemia in patients with mental illnesses in the eastern Ethiopia has not been reported in the literature to date. Therefore, the aim of the study was to assess and compare the magnitude of dyslipidemia and its predictors among patients with severe mental illnesses and non-mentally ill control patients.

METHODS

Nighty six subjects with serious psychiatric disorders and nighty six matched non-psychiatric control subjects who had no history of psychiatric illness were underwent a lipid profile test in Dire Dawa referral hospital, Ethiopia. The mentally ill clients were 18 years of age and older with schizophrenia, major depression, and bipolar disorders. Exposed study subjects were matched to control by age and sex. The data were cleaned and analyzed using SPSS software. A binary logistic regression model was used to determine the factors related to the magnitude of dyslipidemia. Both the crude odds ratio and the adjusted odds ratio with a 95% confidence interval were estimated.

RESULTS

The magnitude of dyslipidemia among mentally ill patients was significantly higher (63.54%) compared to non-exposed controls (31.9%) in the subjects studied. In multiple logistic regression, urban dwellers were six times (AOR = 6.14, 95% CI: 1.2, 16) more likely at risk of developing dyslipidemia compared to rural participants. Similarly, physically inactive participants were nearly two-times (AOR = 1.8, 95% CI: 1.1, 12.9) more likely to develop dyslipidemia compared to physically active study participants. Moreover, study participants who had raised body mass index were 2.1 times (AOR = 2.1, 95% CI: 1.17, 15.3) more likely having dyslipidemia than their counterparts.

CONCLUSIONS

This study revealed that the prevalence of dyslipidemia is higher among mentally ill patients compared to non-mentally ill control study participants. Place of residence, physical inactivity, and raised BMI were significantly associated with dyslipidemia. Therefore, intensive screening of patients for dyslipidemia and its components is necessary during follow-up.

Development and validation of a novel 10-year cardiovascular risk prediction nomogram for the United Arab Emirates national population

OBJECTIVES

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among United Arab Emirates (UAE) nationals. Recent studies have shown that current tools are poor in predicting the risk of incident ASCVD in Emiratis. To improve ASCVD risk prediction in this high-risk population, this study sought to develop and validate a novel and practical 10-year ASCVD risk nomogram using risk factors known to be significant in UAE nationals.

DESIGN

A 10-year retrospective cohort study.

SETTING

Outpatient clinics at a large public tertiary care hospital in Al-Ain, UAE.

PARTICIPANTS

Emiratis aged ≥18 years without prior cardiovascular disease (CVD) who had presented to Tawam Hospital's clinics between 1 April 2008 and 31 December 2008, were included. Patients' data were collected retrospectively until 31 January 2020.

EXPOSURE

Cox proportional hazards models were developed to estimate the 10-year ASCVD risk.

PRIMARY OUTCOME MEASURE

Model discrimination and calibration were assessed using the Harrell C-statistic and the Greenwood-Nam-D'Agostino (GND) χ² test, respectively. Receiver operating characteristic curve analysis was used to determine the optimal cut-off point of the nomogram for elevated ASCVD risk.

RESULTS

The study included 1245 patients, of whom 117 developed ASCVD within 10 years. The ASCVD risk nomogram comprised age, sex, family history of CVD, hypertension treatment, systolic blood pressure, total cholesterol, glycosylated haemoglobin A1c and estimated glomerular filtration rate. The Harrell C-statistic was 0.826 and the GND χ² was 2.83 (p=0.830), which indicated good discrimination and calibration of the nomogram model, respectively. The optimal cut-off point was determined to be 10% (sensitivity=79%; specificity=77%). The nomogram can be freely accessed as an online calculator at (https://ascvdriskuae.shinyapps.io/ASCVDrisk/).

CONCLUSIONS

The developed nomogram provides an accurate prognostic tool for 10-year ASCVD risk prediction in UAE nationals. These findings may help guide future research on CVD prevention in this high-risk population.

Cardiovascular risk profile of Middle Eastern immigrants living in the United States-the National Health Interview Survey

BACKGROUND

Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Although ME countries have a high burden of atherosclerotic cardiovascular disease (ASCVD), the cardiovascular health status among ME immigrants in the US has not been studied in detail. This study aims to characterize the cardiovascular health status (CVD risk factors and ASCVD burden) among ME immigrants in the US.

METHODS

We used 2012-2018 data from the National Health Interview Survey, a US nationally representative survey. ME origin, CVD risk factors, and ASCVD status were self-reported. We compared these to US-born non-Hispanic white (NHW) individuals in the US.

RESULTS

Among 139,778 adults included, 886 (representing 1.3 million individuals, mean age 46.8) were of ME origin, and 138,892 were US-born NHWs (representing 150 million US adults, mean age 49.3). ME participants were more likely to have higher education, lower income and be uninsured. The age-adjusted prevalence of hypertension (22.4% vs 27.4%) and obesity (21.4% vs 31.4%) were significantly lower in ME vs NHW participants, respectively. There were no significant differences between the groups in the age-adjusted prevalence of ASCVD, diabetes, hyperlipidemia, and smoking. Only insufficient physical activity was higher among ME individuals. ME immigrants living in the US for 10 years or more reported higher age-adjusted prevalence of hypertension, hyperlipidemia, and ASCVD.

CONCLUSIONS

ME immigrants in the US have lower odds of hypertension and obesity, and of having a suboptimal CRF profile compared to US-born NHWs. Further studies are needed to determine whether these findings are related to lower risk, selection of a healthier ME subgroup in NHIS, or possible under-detection of cardiovascular risk factors in ME immigrants living in the US.

Low Detection Rates of Genetic FH in Cohort of Patients With Severe Hypercholesterolemia in the United Arabic Emirates

Background: Programs to screen for Familial hypercholesterolemia (FH) are conducted worldwide. In Western societies, these programs have been shown to be cost-effective with hit/detection rates of 1 in 217-250. Thus far, there is no published data on genetic FH in the Gulf region. Using United Arab Emirates as a proxy for the Gulf region, we assessed the prevalence of genetically confirmed FH in the Emirati population sample. Materials and Methods: We recruited 229 patients with LDL-C >95^th percentile and employed a customized next generation sequencing pipeline to screen canonical FH genes (LDLR, APOB, PCSK9, LDLRAP1). Results: Participants were characterized by mean total cholesterol and low-density lipoprotein cholesterol (LDL-c) of 6.3 ± 1.1 and 4.7 ± 1.1 mmol/L respectively. Ninety-six percent of the participants were using lipid-lowering medication with mean corrected LDL-c values of 10.0 ± 3.0 mmol/L 15 out of 229 participants were found to suffer from genetically confirmed FH. Carriers of causal genetic variants for FH had higher on-treatment LDL-c compared to those without causal variants (5.7 ± 1.5 vs 4.7 ± 1.0; p = 3.7E-04). The groups did not differ regarding high-density lipoprotein cholesterol, triglycerides, body mass index, blood pressure, glucose, and glycated haemoglobin. Conclusion: This study reveals a low 7% prevalence of genetic FH in Emiratis with marked hypercholesterolemia as determined by correcting LDL-c for the use of lipid-lowering treatment. The portfolio of mutations identified is, to a large extent, unique and includes gene duplications. Our findings warrant further studies into origins of hypercholesterolemia in these patients. This is further supported by the fact that these patients are also characterized by high prevalence of type 2 diabetes (42% in the current study cohort) which already puts them at an increased risk of atherosclerotic cardiovascular disease. These results may also be useful in public health initiatives for FH cascade screening programs in the UAE and maybe the Gulf region.

Burden of ischemic heart disease and its attributable risk factors in 204 countries and territories, 1990-2019

AIMS

To report the prevalence, deaths, and disability-adjusted life years (DALYs) associated with ischemic heart disease (IHD) and its attributable risk factors in 204 countries and territories from 1990 to 2019, by age, sex, and socio-demographic index (SDI).

METHODS AND RESULTS

Ischemic heart disease was defined as acute myocardial infarction (MI) and chronic IHD (angina; asymptomatic IHD following MI). Cause of death ensemble modelling was used to produce fatality estimates. The prevalence of the non-fatal sequalae of IHD was estimated using DisMod MR 2.1. All estimates were presented as counts and age-standardized rates per 100 000 population. In 2019, IHD accounted for 197.2 million (177.7-219.5) prevalent cases, 9.1 million (8.4-9.7) deaths, and 182.0 million (170.2-193.5) DALYs worldwide. There were decreases in the global age-standardized prevalence rates of IHD [-4.6% (-5.7, -3.6)], deaths [-30.8% (-34.8, -27.2)], and DALYs [-28.6% (-33.3, -24.2)] from 1990 to 2019. In 2019, the global prevalence and death rates of IHD were higher among males across all age groups, while the death rate peaked in the oldest group for both sexes. A negative association was found between the age-standardized DALY rates and SDI. Globally, high systolic blood pressure (54.6%), high low-density lipoprotein cholesterol (46.6%), and smoking (23.9%) were the three largest contributors to the DALYs attributable to IHD.

CONCLUSION

Although the global age-standardized prevalence, death, and DALY rates all decreased. Prevention and control programmes should be implemented to reduce population exposure to risk factors, reduce the risk of IHD in high-risk populations, and provide appropriate care for communities.

A randomized, placebo-controlled, double-blind study on the effects of SZL on patients with mild to moderate depressive disorder with comparison to fluoxetine

ETHNOPHARMACOLOGICAL RELEVANCE

Kaixinsan (KXS) decoction, as an herbal formula, was used to treat the diseases, such as insomnia, amnesia, emotional disorders in ancient china. It has been demonstrated to be active in various animal models resembling human depression with multitarget effects. However, effective verification on the clinical application of KXS is still lacking. Supplements in this knowledge field are urgently needed.

AIM OF THE STUDY

This very first study evaluated the efficacy and tolerability of ShenZhiLing (SZL) tablets (KXS preparation), compared with fluoxetine (FLX, positive comparator), in patients with mild to moderate depressive disorder.

MATERIALS AND METHODS

In this randomized, double-blind, parallel-group study, 156 patients with mild to moderate depression without taken any antidepressants in the past 6 months or 4 continuous weeks were randomized to receive either 3.2 g/d SZL plus 20 mg/d FLX placebo (SZL group) or 20 mg/d FLX plus 3.2 g/d SZL placebo (FLX group), for 8 weeks. Their clinical presentations and some metabolic indexes were assessed during the 8 weeks' visiting period.

RESULTS

Patients in SZL group showed a statistically significant improvement after 8 weeks of treatment in HAM-D17 score (18.79±2.09 to 4.43±4.71, p<0.001) and self-rating depression scale (SDS) score (58.49±8.89 to 39.84±12.09, p<0.001), but not in N-back total respond time (1145.55±608.26 to 1128.47±387.49, p>0.05). In addition, no significant difference at 8 weeks of treatment was found between SZL and FLX groups in SDS score (39.84±12.09 vs. 36.63±12.44) and N-back respond time (1128.47±387.49 vs. 1089.43±352.08) as well as reduction of HAM-D17 score (14.79±4.88 vs. 15.24±4.29) (p>0.05 for all). However, the serum APOB, APOC3 and ALB levels and LDL-C/HDL-C ratio decreased significantly in patients after SZL treatment, while only APOB/APOA1 ratio decreased significantly in FLX group. Other metabolic indexes did not alter significantly after treated with SZL or FLX.

CONCLUSION

The efficacy and safety profile of SZL are comparable to that of fluoxetine in patients with mild to moderate depression. The beneficial effect of SZL is probably associated with improvement of lipid metabolic balance.

Global epidemiology of dyslipidaemias

Dyslipidaemias are alterations to the plasma lipid profile that are often associated with clinical conditions. Dyslipidaemias, particularly elevated plasma LDL-cholesterol levels, are major risk factors for cardiovascular disease, but some forms, such as hypertriglyceridaemia, are associated with severe diseases in other organ systems, including non-alcoholic fatty liver disease and acute pancreatitis. Dyslipidaemias can be genetically determined (primary or familial dyslipidaemias) or secondary to other conditions (such as diabetes mellitus, obesity or an unhealthy lifestyle), the latter being more common. Hypercholesterolaemia is the most common form of dyslipidaemia and is associated with an increased risk of cardiovascular disease, with elevated plasma LDL-cholesterol levels being the 15th leading risk factor for death in 1990, rising to 11th in 2007 and 8th in 2019. The global burden of dyslipidaemias has increased over the past 30 years. Furthermore, the combination of high triglyceride levels and low HDL-cholesterol levels (together with the presence of small, dense LDL particles), referred to as atherogenic dyslipidaemia, is highly prevalent in patients with diabetes or metabolic syndrome and increases their risk of cardiovascular disease. Given the increasing prevalence of diabetes worldwide, treating lipid abnormalities in these patients might reduce their risk of cardiovascular disease.

Clinical Characteristics and Prognosis of Young Middle Eastern Adults with ST-Elevation Myocardial Infarction: One-Year Follow-Up

AIMS

Few studies have investigated premature ST-elevation myocardial infarction (STEMI) in the Middle East. We aimed to compare the clinical characteristics and one-year prognosis of young (<45 years) and older (≥45 years) Middle Eastern adults with STEMI.

METHODS AND MATERIAL

A total of 706 patients with STEMI, who were prospectively enrolled in the First Jordanian Percutaneous Coronary Intervention Registry, were stratified into two groups (<45 or ≥45 years). Baseline clinical variables and one-year major adverse cardiovascular events (MACE) were evaluated.

RESULTS

Young patients (<45 years) comprised 17.4% of STEMI patients (123 of 706). Compared with older patients (≥45 years), young patients were mostly male (96% vs 82%, P<0.001), smokers (86% vs 49%, P<0.001) and less likely to have multi-vessel disease (26% vs 44%, P=0.001). Anterior STEMI was the most common diagnosis and left anterior descending artery was the most common culprit vessel in both groups. There were no significant differences between the younger and older patients in in-hospital (20% vs 19%, P=0.12) and one-year MACE (24% vs 26%, P=0.68). However, none (0%) of the young died during one-year follow-up while 21 (4%) of the older patients died (P=0.036).

CONCLUSIONS

Young adult patients in the Middle East with STEMI are more likely to be smoking men with multiple risk factors and single vessel disease by angiography. Although, younger patients had similar one-year MACE to older patients, their mortality rate appears to be better. A larger study is warranted to investigate this vulnerable group of patients to prevent future events.

Improvement initiative in LDL-C management in Saudi Arabia: A call to action

PURPOSE

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the Saudi Arabia (KSA). Over the last decade dyslipidemia has been the predominant risk factor in KSA. The linear relationship between low density lipoprotein cholesterol (LDL-C) levels, a marker for dyslipidemia, and progression of ASCVD is well established. The objective of this paper is to to provide an overview of the burden of disease, outline current clinical practice guidelines (CPG), examine gaps in care, and provide actionable recommendations to prevent, diagnose, and treat dyslipidemia in KSA.

RESULTS

Saudi Arabia has the highest prevalence of ASCVD in the Gulf region. Several gaps in the implementation of CPGs, including the underdiagnosis and undertreatment of dyslipidemia, inadequate primary and secondary prevention efforts, complicated by a fragmented health system have been identified. Compelling evidence indicates that target LDL-C levels are not achieved throughout the Middle East region. In addition, high-risk patients are often left unidentified with adequate treatment.

CONCLUSION

This statement recommends specific multilevel interventions to optimize the prevention, diagnosis, and treatment of ASCVD. These recommendations focus on strengthening primary and secondary prevention through education initiatives, establishment of specialized prevention and treatment centers, and development of local and regional CPGs.

Use of Cardiac Noninvasive Testing After Emergency Department Discharge: Association of Hospital Network Testing Intensity and Outcomes in Ontario, Canada

Background

The relationship between noninvasive cardiac diagnostic testing intensity and downstream clinical outcomes is unclear. Our objective was to examine the relationship between hospital network noninvasive cardiac diagnostic testing intensity and downstream clinical outcomes in patients who were discharged from the emergency department after assessment for chest pain.

Methods and Results

We employed a retrospective cohort study design of 387 809 patients evaluated for chest pain in the emergency department between April 1, 2010 and March 31, 2016. Hospital networks were divided into tertiles based on usage of noninvasive cardiac diagnostic testing. The primary outcome was a composite of acute myocardial infarction or all‐cause mortality. Adjusted Cox proportional hazards models were used to compare the hazard of the composite outcome of myocardical infarction and/or all‐cause mortality between the tertiles. After adjustment for clinically relevant covariates, patients evaluated for chest pain in intermediate noninvasive cardiac diagnostic testing usage tertile hospital networks did not have significantly different hazards of the composite outcome when compared with those evaluated in low usage tertile hospital networks >90 days (hazard ratio [HR], 1.00; 95% CI, 0.83–1.21), 6 months (HR, 1.07; 95% CI, 0.92–1.24), and 1 year (HR, 1.03; 95% CI, 0.94–1.14). Patients evaluated in the high usage tertile also did not have significantly different hazards of the composite outcome compared with those evaluated in the low usage tertile at 90 days (HR, 0.98; 95% CI, 0.80–1.19), 6 months (HR, 1.01; 95% CI, 0.87–1.17); and 1 year (HR, 0.95; 95% CI, 0.86–1.05).

Conclusions

Our population‐based study demonstrated that high noninvasive cardiac diagnostic testing use intensity was not associated with reductions in downstream myocardial infarction or all‐cause mortality.

External validation and clinical usefulness of three commonly used cardiovascular risk prediction scores in an Emirati population: a retrospective longitudinal cohort study

OBJECTIVES

Cardiovascular disease (CVD) risk prediction models are useful tools for identifying those at high risk of cardiovascular events in a population. No studies have evaluated the performance of such risk models in an Arab population. Therefore, in this study, the accuracy and clinical usefulness of two commonly used Framingham-based risk models and the 2013 Pooled Cohort Risk Equation (PCE) were assessed in a United Arab Emirates (UAE) national population.

DESIGN

A 10-year retrospective cohort study.

SETTING

Outpatient clinics at a tertiary care hospital, Al-Ain, UAE.

PARTICIPANTS

The study cohort included 1041 UAE nationals aged 30-79 who had no history of CVD at baseline. Patients were followed until 31 December 2019. Eligible patients were grouped into the PCE and the Framingham validation cohorts.

EXPOSURE

The 10-year predicted risk for CVD for each patient was calculated using the 2008 Framingham risk model, the 2008 office-based Framingham risk model, and the 2013 PCE model.

PRIMARY OUTCOME MEASURE

The discrimination, calibration and clinical usefulness of the three models for predicting 10-year cardiovascular risk were assessed.

RESULTS

In women, the 2013 PCE model showed marginally better discrimination (C-statistic: 0.77) than the 2008 Framingham models (C-statistic: 0.74-0.75), whereas all three models showed moderate discrimination in men (C-statistic: 0.69‒0.70). All three models overestimated CVD risk in both men and women, with higher levels of predicted risk. The 2008 Framingham risk model (high-risk threshold of 20%) classified only 46% of women who subsequently developed incident CVD within 10 years as high risk. The 2013 PCE risk model (high-risk threshold of 7.5%) classified 74% of men who did not develop a cardiovascular event as high risk.

CONCLUSIONS

None of the three models is accurate for predicting cardiovascular risk in UAE nationals. The performance of the models could potentially be improved by recalibration.

Predicting Diagnostic Gene Biomarkers Associated With Immune Infiltration in Patients With Acute Myocardial Infarction

Objective: The present study was designed to identify potential diagnostic markers for acute myocardial infarction (AMI) and determine the significance of immune cell infiltration in this pathology.

Methods: Two publicly available gene expression profiles (GSE66360 and GSE48060 datasets) from human AMI and control samples were downloaded from the GEO database. Differentially expressed genes (DEGs) were screened between 80 AMI and 71 control samples. The LASSO regression model and support vector machine recursive feature elimination (SVM-RFE) analysis were performed to identify candidate biomarkers. The area under the receiver operating characteristic curve (AUC) value was obtained and used to evaluate discriminatory ability. The expression level and diagnostic value of the biomarkers in AMI were further validated in the GSE60993 dataset (17 AMI patients and 7 controls). The compositional patterns of the 22 types of immune cell fraction in AMI were estimated based on the merged cohorts using CIBERSORT.

Results: A total of 27 genes were identified. The identified DEGs were mainly involved in carbohydrate binding, Kawasaki disease, atherosclerosis, and arteriosclerotic cardiovascular disease. Gene sets related to atherosclerosis signaling, primary immunodeficiency, IL-17, and TNF signaling pathways were differentially activated in AMI compared with the control. IL1R2, IRAK3, and THBD were identified as diagnostic markers of AMI (AUC = 0.877) and validated in the GSE60993 dataset (AUC = 0.941). Immune cell infiltration analysis revealed that IL1R2, IRAK3, and THBD were correlated with M2 macrophages, neutrophils, monocytes, CD4⁺ resting memory T cells, activated natural killer (NK) cells, and gamma delta T cells.

Conclusion: IL1R2, IRAK3, and THBD can be used as diagnostic markers of AMI, and can provide new insights for future studies on the occurrence and the molecular mechanisms of AMI.

Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Outpatients Evaluated for Stable Coronary Artery Disease

Background

Despite more than 4 million cardiac noninvasive diagnostic tests (NIT) being performed annually for stable coronary artery disease in the United States, it is unclear whether they are associated with downstream improvements in outcomes when compared with no testing. We sought to determine whether NIT was associated with reduced downstream major adverse cardiovascular events when compared with not testing.

Methods and Results

We conducted a population‐based study of ≈1.5 million patients undergoing chest pain evaluation in Ontario, Canada. Patients were categorized into NIT and no‐testing groups. Cause‐specific proportional hazards models were used to compare the rate of major adverse cardiovascular events (composite outcome of unstable angina, acute myocardial infarction or cardiovascular mortality and each constituent) between the 2 groups after adjusting for clinically relevant covariates. The rate of the composite outcome was ≈25% lower for patients undergoing noninvasive testing (hazard ratio [HR], 0.77; 95% CI, 0.75–0.79). The benefits of testing were consistent for all 3 constituents of the composite; unstable angina (HR, 0.87; 95% CI, 0.82–0.93 for the NIT versus the no‐testing group), myocardial infarction (HR, 0.83; 95% CI, 0.79–0.86 for the NIT versus the no‐testing group) and cardiovascular mortality (HR, 0.68; 95% CI, 0.65–0.72 for the NIT versus the no‐testing group).

Conclusions

Our large population‐based study reports an ≈25% reduction in major adverse cardiovascular events that was independently associated with NIT in outpatients being evaluated for stable angina. This study demonstrates the prognostic importance of NIT versus no testing on the health of contemporary populations.

Apolipoprotein B/A-I Ratio Predicts Lesion Severity and Clinical Outcomes in Diabetic Patients With Acute Coronary Syndrome

BACKGROUND

Dyslipidemia plays a crucial role in acute coronary syndrome (ACS). Paucity of data is available concerning the effect of apolipoprotein (apo) B/A-I ratio on the severity and outcomes in diabetic patients with ACS. This study investigated these associations in a Chinese cohort undergoing percutaneous coronary intervention.Methods and Results:In 2013, a total of 2,563 diabetic patients concomitant with ACS were included. Patients were divided into 2 groups based on the apoB/apoA-I ratio on admission: <0.63 (n=1,279, 49.9%) and ≥0.63 (n=1,284, 50.1%). Angiographic complexity and severity were determined by SYNTAX score (SS). A higher apo ratio was significantly associated with higher proportions of acute myocardial infarction (MI) and intermediate-high SS. Multivariable logistic regression analysis showed that the apo ratio was an independent factor of complicated lesions (OR 1.341, 95% confidence interval 1.039-1.730, P=0.024). Moreover, consistent results were found in the subgroups of normal concentrations of conventional lipid parameters. During a median follow-up period of 878 days, significant differences were found in periprocedural MI (1.0% vs. 2.2%, P=0.019) and total events of MI (2.0% vs. 3.3%, P=0.028). After adjusting for confounders, a high apo ratio remained independently predictive of MI, the risk of which was doubled during the periprocedural period and in the long term.

CONCLUSIONS

The ApoB/apoA-I ratio is an independent predictor for complicated lesions and future MI in patients with diabetes and ACS.

Serum ferritin levels is associated with acute myocardial infarction: a meta-analysis

OBJECTIVE

An association between increased serum ferritin levels and acute myocardial infarction (AMI) remains controversial. The purpose of this meta-analysis is to confirm the association between increased serum ferritin levels and AMI.

METHODS

We searched PubMed and China National Knowledge Infrastructure (CNKI) for relevant articles that assessed the association between serum ferritin and acute myocardial infarction using terms that included serum ferritin and acute myocardial infarction up to February 13, 2019.

RESULTS

A total of 11 studies were identified for analysis. All pooled analysis was based on a random-effects models. The variance was exhibited using a forest plot, and the heterogeneity among studies was examined using the I2 index, the publication bias was evaluated using a funnel plot. The pooled standard mean difference of ferritin levels between AMI and controls was 0.78 (95%CI,0.68-0.88).

CONCLUSION

The results of this meta-analysis demonstrate that serum ferritin in acute myocardial infarction patients is higher than that of healthy controls.

A Narrative Review and Expert Panel Recommendations on Dyslipidaemia Management After Acute Coronary Syndrome in Countries Outside Western Europe and North America

Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent atherosclerotic cardiovascular disease (CVD) events. Dyslipidaemia, a major risk factor for CVD, is poorly controlled post ACS in countries outside Western Europe and North America, despite the availability of effective lipid-modifying therapies (LMTs) and guidelines governing their use. Recent guideline updates recommend that low-density lipoprotein cholesterol (LDL-C), the primary target for dyslipidaemia therapy, be reduced by ≥ 50% and to < 1.4 mmol/L (55 mg/dL) in patients at very high risk of CVD, including those with ACS. The high prevalence of CVD risk factors in some regions outside Western Europe and North America confers a higher risk of CVD on patients in these countries. ACS onset is often earlier in these patients, and they may be more challenging to treat. Other barriers to effective dyslipidaemia control include low awareness of the value of intensive lipid lowering in patients with ACS, physician non-adherence to guideline recommendations, and lack of efficacy of currently used LMTs. Lack of appropriate pathways to guide follow-up of patients with ACS post discharge and poor access to intensive medications are important factors limiting dyslipidaemia therapy in many countries. Opportunities exist to improve attainment of LDL-C targets by the use of country-specific treatment algorithms to promote adherence to guideline recommendations, medical education and greater prioritisation by healthcare systems of dyslipidaemia management in very high risk patients.

Impacts of Treatment Modalities on Physical Activity After First Acute Myocardial Infarction in Jordan

BACKGROUND

Promoting physical activity is a priority after coronary revascularisation for effective long-term cardiovascular care and to avoid further disease progression and complications. But little is known about the effect of different types of acute myocardial infarction (AMI) treatment modalities in changes in physical activity level post-AMI.

OBJECTIVE

This study aimed to examine changes in physical activity among patients treated with different treatment modalities post-first AMI during early recovery phase at week 2 (time 1) and week 6 (Time 2) after hospitalization.

METHODS

A descriptive study was done using a repeated-measures design. Physical activity was measured by a body-worn activity monitor (activPAL3 monitor) for 24 hours a day for full 7 consecutive days at time 1 and time 2 after hospitalization. Demographic and clinical data were collected from patients' records. The study was conducted in 1 setting in Jordan. Participants were met at time 1 and time 2. The study recruited a convenience sample of 94 patients with AMI. Participants did not have access to cardiac rehabilitation. The participants were categorized according to type of AMI treatment modalities into 3 groups: ST-elevation myocardial infarction treated by primary percutaneous coronary intervention, ST-elevation myocardial infarction treated by thrombolytic therapy, and non-ST-elevation myocardial infarction treated by medication.

RESULTS

Patients treated by primary percutaneous coronary intervention had a statistically significant effect on changes in mean steps count and mean stepping time per day better than patients treated by other treatment modalities between weeks 2 and 6 after hospitalization.

CONCLUSION

The study showed that patients treated with primary percutaneous coronary intervention had better mean steps count and mean stepping time per day between weeks 2 and 6 after hospitalization in comparison with other treatment modalities. These findings could be used for development of effective intervention in the future. Further research using different research methods such as longitudinal studies among different cultures to confirm the finding of this study is recommended.

A cross-cultural translation and adaptation of the Arabic Cardiac Self-Efficacy Questionnaire for patients with coronary heart disease

AIM

The aim of this study is to cross-culturally translate and adapt the Cardiac Self-Efficacy Questionnaire into Arabic and subsequently evaluate the psychometric properties of that translation in a population of Arabic patients.

METHOD

The original English version of the Cardiac Self-Efficacy Questionnaire was translated into Arabic following a process recommended by the World Health Organization. A convenience sample consisting of 268 Jordanian patients with coronary heart disease was recruited from a university-affiliated hospital in Amman, Jordan. Data were collected from October 2018 to March 2019. The factor structure, face and content validities, and internal consistency of the Arabic Cardiac Self-Efficacy Questionnaire (A-CSEQ) were evaluated.

RESULTS

The factor structure analysis supported a three-factor high-order structure of the A-CSEQ. Face validity showed that the language used, style, and format were clear. The content validity demonstrated a very good content validity index. The reliability was good with ranging from 0.89 to 0.93 for all questionnaire subscales.

CONCLUSION

The A-CSEQ is a valid and reliable instrument to assess the cardiac self-efficacy of Arabic patients diagnosed with coronary heart disease. Further assessment of the psychometric properties of the A-CSEQ with different cardiac problems is now recommended.

Low Expression of FFAR2 in Peripheral White Blood Cells May Be a Genetic Marker for Early Diagnosis of Acute Myocardial Infarction

Objective

To find molecular markers for the diagnosis of acute myocardial infarction (AMI), this research further verified the relationship between the expression level of FFAR2 gene and AMI by expanding the sample size based on the previous gene chip results.

Methods

Peripheral venous leukocytes were collected from 113 patients with AMI and 94 patients with noncoronary artery disease as the experimental group and the control group, respectively. Real-time fluorescence quantitative polymerase chain reaction was used to detect the expression of the FFAR2 gene. Western blot analysis was applied to detect the relative expression of the FFAR2 gene at the level of protein. Furthermore, the relationship between gene expression and clinical data was also analyzed and compared.

Results

The level of expression of FFAR2 gene in peripheral blood of patients with AMI was significantly lower than that of the control group (0.33 [0.04–1.08], 0.62 [0.07–1.86], respectively; p < 0.05), which was 0.53 times that of the control group. Western blot results presented that the FFAR2 protein level in the peripheral blood of the AMI group was lower than that of the control group (0.114; p=0.004). Analyzing clinical data of the subjects indicated that the average age of the AMI group was significantly higher than the age of control group (p < 0.01). Also, the fasting blood glucose level was higher (p < 0.01), and the high-density lipoprotein cholesterol (HDL-C) level was lower (p=0.03). The FFAR2 mRNA level correlated positively with the HDL-C level (p < 0.01). Logistic regression analysis suggested that the low expression of the FFAR2 gene in peripheral blood may be a risk factor for AMI independent of age, family history of diabetes, fasting blood glucose level, and HDL-C level (p=0.025). Compared with the high FFAR2 expression group, the risk of AMI in the low FFAR2 expression group was 6.308 times higher.

Conclusion

The expression level of the FFAR2 gene in peripheral blood of patients with AMI was significantly lower than that in the control group. Low expression of the FFAR2 gene in peripheral blood is an independent risk factor for AMI. Hence, it may also be a potential biomarker to predict AMI.

Premature Myocardial Infarction in the Middle East and North Africa: Rationale for the Gulf PREVENT Study

The Middle East and North Africa (MENA) region has a high burden of morbidity and mortality due to premature (≤55 years in men; ≤65 years in women) myocardial infarction (MI) and acute coronary syndrome (ACS). Despite this, the prevalence of risk factors in patients presenting with premature MI or ACS is incompletely described. We compared lifestyle, clinical risk factors, and biomarkers associated with premature MI/ACS in the MENA region with selected non-MENA high-income countries. We identified English-language, peer-reviewed publications through PubMed (up to March 2018). We used the World Bank classification system to categorize countries. Patients with premature MI/ACS in the MENA region had a higher prevalence of smoking than older patients with MI/ACS but a lower prevalence of diabetes, hypertension, and dyslipidemia. Men with premature MI/ACS had a higher prevalence of smoking than women but a lower prevalence of diabetes and hypertension. The MENA region had sparse data on lifestyle, diet, psychological stress, and physical activity. To address these knowledge gaps, we initiated the ongoing Gulf Population Risks and Epidemiology of Vascular Events and Treatment (Gulf PREVENT) case-control study to improve primary and secondary prevention of premature MI in the United Arab Emirates, a high-income country in the MENA region.

Increases in statin eligibility to reduce cardiovascular risk according to the 2013 ACC/AHA cholesterol guidelines in the Africa Middle East region: a sub-analysis of the Africa Middle East Cardiovascular Epidemiological (ACE) study

BACKGROUND

With development of cholesterol management guidelines by the American College of Cardiology/American Heart Association (ACC/AHA), more individuals at risk of cardiovascular disease may be eligible for statin therapy. It is not known how this affects statin eligibility in the Africa and Middle East Region.

METHODS

Data were used from the Africa Middle East Cardiovascular Epidemiological (ACE) study. The percentage of subjects eligible for statins per the ACC/AHA 2013 cholesterol guidelines and the 2002 National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP III) recommendations were compared. Analyses were carried out according to age, gender, community (urban/rural), and country income categories based on World Bank definitions.

RESULTS

According to the ACC/AHA recommendations, 1695 out of 4378 subjects (39%; 95% confidence interval [CI], 37-40%) satisfied statin eligibility criteria vs. 1043/4378 (24%; 95% CI, 23-25%) per NCEP-ATP recommendations, representing a 63% increase in statin eligibility. Consistent increases in eligibility for statin therapy were seen according to the ACC/AHA vs. NCEP-ATP guidelines across sub-groups of age, gender, community, and country income. Notable increases for statin eligibility according to ACC/AHA vs. NCEP-ATP were seen, respectively, in subjects aged ≥65 years (86% vs. 39%), in males (46% vs. 25%), in low-income countries (28% vs. 14%), and rural communities (37% vs. 19%).

CONCLUSION

An increase in statin eligibility was seen applying ACC/AHA cholesterol guidelines compared with previous NCEP-ATP recommendations in the Africa Middle East region. The economic consequences of these guideline recommendations will need further research.

TRIAL REGISTRATION

The ACE trial is registered under NCT01243138 .

MIRKB: a myocardial infarction risk knowledge base

Myocardial infarction (MI) is a common cardiovascular disease and a leading cause of death worldwide. The etiology of MI is complicated and not completely understood. Many risk factors are reported important for the development of MI, including lifestyle factors, environmental factors, psychosocial factors, genetic factors, etc. Identifying individuals with an increased risk of MI is urgent and a major challenge for improving prevention. The MI risk knowledge base (MIRKB) is developed for facilitating MI research and prevention. The goal of MIRKB is to collect risk factors and models related to MI to increase the efficiency of systems biological level understanding of the disease. MIRKB contains 8436 entries collected from 4366 articles in PubMed before 5 July 2019 with 7902 entries for 1847 single factors, 195 entries for 157 combined factors and 339 entries for 174 risk models. The single factors are classified into the following five categories based on their characteristics: molecular factor (2356 entries, 649 factors), imaging (821 entries, 252 factors), physiological factor (1566 entries, 219 factors), clinical factor (2523 entries, 561 factors), environmental factor (46 entries, 26 factors), lifestyle factor (306 entries, 65 factors) and psychosocial factor (284 entries, 75 factors). MIRKB will be helpful to the future systems level unraveling of the complex mechanism of MI genesis and progression.

Effect of SLCO1B1 gene polymorphisms and vitamin D on statin-induced myopathy

Background Statin therapy used to lower cholesterol levels results in a substantial reduction in cardiovascular complications. Previous observations in different ethnic populations showed that rs2306283A>G, p.Asn130Asp and rs4149056T>C, p.Val174Ala in solute carrier organic anion transporter 1B1 (SLCO1B1) gene encoding the organic transporter protein may be responsible for statin uptake, thus explaining the majority of statin-associated symptoms. In addition to the genetic component, vitamin D (vit D) deficiency is common in Saudi Arabia and worldwide and may cause muscle dysfunction and ache. The aim of the present study was first to reveal an effect of vit D, rs2306283A>G, and rs4149056T>C and related haplotypes on statin-associated myopathy (SAM) and then to investigate a possible interaction between low vit D levels and the above-mentioned variants. Methods The genomic DNA obtained from 50 individuals diagnosed with hypercholesterolemia was genotyped using light SNiP hybridization probes. Results Low vit D levels were associated with SAM (OR=3.6, p=0.03); however, CK levels, rs2306283A>G, and rs4149056T>C did not show any association. Interestingly, rs4149056T>C was interacting with vit D to influence SAM (p=0.02). Haplotype analysis showed that SLCO1B1 *1B and *15 were more prevalent in individuals with SAM (p=0.05). When stratified according to vit D levels, rs2306283A allele showed an increase in individuals having SAM along with low vit D (p=0.03). Conclusions Although preliminary, our results show an involvement of vit D and rs4149056T>C of SLCO1B1 in SAM.

Depressive Symptoms and Complications Early after Acute Myocardial Infarction: Gender Differences

Background:

Cardiovascular disease is the first leading cause of death worldwide. Coronary heart disease is the most common manifestation of cardiovascular disease. Acute myocardial infarction is the primary manifestation of coronary heart disease. Depression is a common and predicted complication after acute myocardial infarction. Limited studies evaluated gender differences in depressive symptoms after acute myocardial infarction especially in developing countries.

Objective:

The study aimed to determine whether there was a difference in depression levels and rate of complications based on gender early after acute myocardial infarction.

Method:

This was a prospective comparative study on 230 patients (150 men and 80 women) with a confirmed diagnosis of acute myocardial infarction. All participants signed an informed consent, filled sociodemographic and clinical questionnaire and the Depression Subscale of the Hospital Anxiety and Depression Scale. Clinical data were abstracted from the participants’ medical record after discharge.

Results:

Eighty-six participants (37.4%), 54 men and 32 women, developed 1 or more complications during hospitalization. Female patients were more depressed (14.4±3.5 vs. 8.3 ± 2.6) and developed more complications (1.9 ± 0.9 vs. 0.8 ± 0.5) than male patients did. Depressive symptoms increased the occurrence of complication by 40% and 33% for female and male patients respectively after controlling for sociodemographic and clinical variables.

Conclusion:

Depressive symptoms independently predicted complications after acute myocardial infarction in both men and women. The inclusion of depression assessment tools in acute myocardial infarction treatment protocols is highly recommended.

Arab Men and Women's Conceptualization of Mental Health and Depression: A Qualitative Study from the Middle East

Cardiovascular diseases are the leading cause of death worldwide. Among cardiovascular patients, depression is associated with an increased morbidity and mortality. Understanding how depression is conceptualized from cardiovascular patients' perspective can help with prevention, early detection, and treatment for depression. This might reduce cardiovascular morbidity and mortality, and save health care costs. To the best of our knowledge, there is no study in the Gulf region exploring depression among Arab cardiovascular patients. The purpose of this exploratory ethnographic qualitative research is to investigate how Arab male and female patients with cardiovascular disease conceptualize mental health and depression. Two theoretical frameworks guided this research: (1) The Ecological Perspective, and (2) Kleinman's Explanatory Model of Health and Illness. Using maximum variation purposive sampling, thirty (30) male and twenty-five (25) female, self-identified, Arab cardiovascular patients were recruited as research participants. Individual in-depth interviews were conducted using a semi-structured questionnaire. Thematic analysis was performed to generate themes. Nvivo 10, a qualitative data analysis software, was used to organize the narrative data. The participants in this study placed great emphasis on the manifestations of mental illness and their impact on both themselves and their families. Four major themes were identified from their narratives: psychological and physical disturbances; unfavorable personal characteristics; work issues and financial constraints; lack of family and social support. The knowledge generated in this study might help increase awareness, prevention of and treatment for depression among cardiovascular patients in Qatar. The findings from this study can also be used to inform a multi-disciplinary and multi-sectoral intervention approach that is contextualized to meet the mental health care needs of Arab cardiovascular patients, thus reducing cardiovascular diseases morbidity and mortality in Qatar and the Gulf region.

Influence of smoking and smoking cessation on levels of urinary 11-dehydro thromboxane B2

Background

Thromboxane is a key clinical risk endpoint of smoking-induced inflammation which has been associated in the pathogenesis of cardiovascular disease. The goal of this review is to quantify the effect of smoking and smoking cessation on one of its urinary metabolites, 11-dehydrothromboxane_B2.

Methods

PubMed and SCOPUS were searched to identify publications which report urinary 11-dehydrothromboxane_B2 levels in smokers and non-smokers, as well as articles reporting the effect of smoking cessation on urinary 11-dehydrothromboxane_B2 excretion.

Results

We found ten studies assessing urinary 11-dehydrothroboxane_B2 levels in smokers and non-smokers. Four papers reported the amount of urinary 11-dehydrothromboxane_B2 excreted in 24 h while six reported the amount excreted adjusted for creatinine. The meta-analyses comparing the excretion of urinary 11-dehydrothromboxane in current smokers to non-smokers report increased levels in current smokers (mean difference = 0.31 μg/24-h [95%CI: 0.27-0.34] and 166.45 pg/mg creatinine [95%CI: 120.51-212.40]). There were not enough publications to perform meta-analyses on the effects of smoking cessation on urinary 11-dehydrothromboxane_B2 excretion.

Conclusions

Urinary 11-dehydrothromboxane_B2 levels are increased in cigarette smokers, however, more data are needed to elucidate the effects of smoking cessation on urinary 11-dehydrothromboxane_B2 excretion.

Gender differences in risk profile and outcome of Middle Eastern patients undergoing percutaneous coronary intervention

Objectives:

To determine the gender differences in cardiovascular risk profile and outcomes among patients undergoing percutaneous coronary intervention (PCI).

Methods:

In a prospective multicenter study of consecutive Middle Eastern patients managed with PCI from January 2013 to February 2014 in 12 tertiary care centers in Amman and Irbid, Jordan. Clinical and coronary angiographic features, and major cardiovascular events were assessed for both genders from hospital stay to 1 year.

Results:

Women comprised 20.6% of 2426 enrolled patients, were older (mean age 62.9 years versus 57.2 years), had higher prevalence of hypertension (81% versus 57%), diabetes (66% versus 44%), dyslipidemia (58% versus 46%), and obesity (44% versus 25%) compared with men, p<0.001. The PCI for ST-segment elevation myocardial infarction was indicated for fewer women than men (23% versus 33%; p=0.001). Prevalence of single or multi-vessel coronary artery disease was similar in women and men. More women than men had major bleeding during hospitalization (2.2% versus 0.6%; p=0.003) and at one year (2.5% versus 0.9%; p=0.007). There were no significant differences between women and men in mortality (3.1% versus 1.7%) or stent thrombosis (2.1% versus 1.8%) at 1 year.

Conclusion:

Middle Eastern women undergoing PCI had worse baseline risk profile compared with men. Except for major bleeding, no gender differences in the incidence of major adverse cardiovascular events were demonstrated.

Coronary Heart Disease in the Middle East and North Africa: Current Status and Future Goals

PURPOSE OF REVIEW

The Middle East and North Africa has witnessed a dramatic transformation over the last 30 years caused by rapid urbanization and modernization and significant changes to diet and lifestyle. This review attempts to highlight recent data in regards to ischemic heart disease and its risk factors from the region.

RECENT FINDINGS

Ischemic heart disease is now the leading cause of death in the region. Age at presentation with myocardial infarction and acute coronary syndrome appears to be significantly younger than global averages. Increased rates of all major risk factors including diabetes, hypertension, hyperlipidemia, smoking, obesity, and sedentary lifestyle have been noted. Specifically, significant changes to dietary habits and growing epidemic of use of alternative tobacco products are noted. This review article highlights the growing epidemic of ischemic heart disease in the region led by dramatic increases in incidence of its risk factors. This epidemic will require a multipronged approach to address the varied issues and mitigate the growing prevalence of the disease.

Logic Regression Analysis of Gene Polymorphisms and HDL Levels in a Nationally Representative Sample of Iranian Adolescents: The CASPIAN-III Study

BACKGROUND

To investigate the associations of genetic polymorphism with high-density lipoprotein-cholesterol (HDL-C) levels in Iranian adolescents.

METHODS

This multicentre study was conducted on 10 - 18 year-old students from 27 provinces in Iran. Logic regression approach was used to determine the main effects and interactions of polymorphisms related to HDL-C levels.

RESULTS

The rs708272 polymorphism was significantly related to HDL-C levels. Moreover, rs708272 increased HDL-C levels and had a protective effect on HDL-C. The interaction of rs2230808 and rs5880 polymorphisms as well as the interaction of rs320 and rs708272 polymorphisms were associated with lower HDL-C levels. Furthermore, the interaction of rs320 and rs1801177 polymorphisms was associated with lower HDL-C levels.

CONCLUSIONS

We found that not only single SNPs, but also interactions of several SNPs affect HDL-C levels. Given the high prevalence of low HDL-C in Middle Eastern populations, further genetic studies are required for detailed analysis.

Increased Ratio of Visceral to Subcutaneous Adipose Tissue in Septic Patients Is Associated With Adverse Outcome

OBJECTIVES

Visceral and subcutaneous adipose tissue may contribute differentially to the septic inflammatory response. Accordingly, we tested the hypothesis that the ratio of visceral to subcutaneous adipose tissue is associated with altered sepsis outcome.

DESIGN

A retrospective analysis from a cohort of sepsis patients admitted between 2004 and 2009.

SETTING

A mixed medical-surgical ICU at St. Paul's Hospital in Vancouver, Canada.

PATIENTS

Patients older than 16 years old who had sepsis and underwent abdominal CT scan (n = 257) for clinical reasons.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured the visceral adipose tissue and subcutaneous adipose tissue areas and calculated the visceral adipose tissue-to-subcutaneous adipose tissue ratio. Visceral adipose tissue/subcutaneous adipose tissue was not correlated with body mass index (r = -0.015, p = NS) and therefore provides additional unique information independent of body mass index. Sepsis patients with higher visceral adipose tissue/subcutaneous adipose tissue had greater 90-day mortality than patients with lower visceral adipose tissue/subcutaneous adipose tissue (log-rank test, linear-by linear association p < 0.005). After adjustment for significant covariates using Cox regression, increased visceral adipose tissue/subcutaneous adipose tissue quartile was significantly associated with increased 90-day mortality with hazard ratios of 2.01 (95% CI, 1.01-3.99) for the third visceral adipose tissue/subcutaneous adipose tissue quartile compared with the first quartile and 2.32 (95% CI, 1.15-4.69) for the highest visceral adipose tissue/subcutaneous adipose tissue quartile when compared with the first quartile. Increased mortality for patients with higher visceral adipose tissue/subcutaneous adipose tissue was found for both patients with body mass index less than 25 kg/m (p = 0.004) and for body mass index greater than or equal to 25 kg/m (p = 0.023). Furthermore, we found significantly greater need for mechanical ventilation, renal replacement therapy, and ICU stay in patients in the highest visceral adipose tissue/subcutaneous adipose tissue quartile. The ratio of proinflammatory (interleukin-8) to anti-inflammatory (interleukin-10) plasma cytokine levels was greater in patients with higher visceral adipose tissue/subcutaneous adipose tissue than in those with lower visceral adipose tissue/subcutaneous adipose tissue (p = 0.043).

CONCLUSIONS

Visceral obesity, defined by a high visceral adipose tissue-to-subcutaneous adipose tissue ratio, contributes to adverse outcome in sepsis patients perhaps because of a greater pro- versus anti-inflammatory response.

Major bleeding events in Jordanian patients undergoing percutaneous coronary intervention (PCI): Incidence, associated factors, impact on prognosis, and predictability of the CRUSADE bleeding risk score. Results from the First Jordanian PCR (PCR1)

Objective:

Determine the incidence of major bleeding events, their risk factors, and their impact on prognosis in Jordanian patients undergoing percutaneous coronary intervention (PCI). Evaluate the ability of the CRUSADE bleeding risk score (BRS) to predict major bleeding.

Methods:

Major bleeding events were defined according to the CRUSADE classification and their incidence was evaluated from hospital admission to one year of follow up. The CRUSADE bleeding risk score was calculated for each patient during the index admission. Incidence of major bleeding events was evaluated in each of the bleeding score quintiles. JoPCR1 is a prospective, observational, multicenter registry of consecutive patients who underwent PCI at 12 tertiary care centers in Jordan. A case report form was used to record data prospectively at hospital admission, at discharge, and at 1 and 12 months of follow-up.

Results:

The study included 2426 consecutive patients who underwent PCI. During the index hospitalization, major and minor bleeding events occurred in 0.95% and 2.6% of patients, respectively. Multivariate analysis showed that only two variables were significantly associated with major bleeding: female gender (OR=3.7; 95% CI 1.6, 8.5; p=0.002) and past history of cardiovascular disease (OR=2.6; 95% CI 1.1, 5.9; p=0.026). Patients who had in-hospital major bleeding events had higher cardiac mortality during index hospitalization (13.0% vs. 0.7%, p<0.005) and at one year of follow up (13.0% vs. 1.8%, p<0.005) compared to those who had no such events. Receiver operating characteristic curve analysis showed that the CRUSADE BRS has a high ability to predict major bleeding.

Conclusion:

Major bleeding events were uncommon in this ME registry of a contemporary cohort of patients undergoing PCI but were associated with a higher mortality rate compared with those who did not have major bleeding events. CRUSADE BRS was highly predictive of the incidence of major bleeding events.

Short- and long-term outcomes in Middle Eastern diabetic patients after percutaneous coronary intervention: results from The First Jordanian PCI Registry (JoPCR1)

INTRODUCTION

Diabetes mellitus (DM) is highly prevalent among Middle Eastern patients admitted with acute coronary syndrome (ACS) or who undergo percutaneous coronary intervention (PCI). This study used data from the First Jordanian PCI Registry (JoPCR1) to determine the short- and long-term outcomes in a subgroup of diabetic patients within a large PCI population.

METHODS

JoPCR1, a prospective, multicenter study of consecutive patients who underwent PCI from January 2013 to February 2014, assessed the incidence of major cardiovascular events (cardiac mortality, stent thrombosis, major bleeding events and coronary revascularization) in diabetic compared with nondiabetic patients from the index hospitalization to 1 year of follow-up.

RESULTS

Of 2426 patients enrolled, 1300 (53.6 %) were diabetics. Compared with nondiabetic patients, diabetic patients were older, more likely to be female and to have hypertension, hypercholesterolemia and chronic renal disease. Diabetic patients had higher prevalences of multivessel coronary artery disease and PCI than nondiabetic patients. Although both groups had similar proportions of patients undergoing PCI for ACS (76.3 vs. 78.4 %; p = 0.237), fewer diabetic patients had PCI for ST-segment elevation myocardial infarction than nondiabetics (27.5 vs. 33.7 %; p = 0.0002). Both groups had similar incidences of stent thrombosis (ST) during hospitalization (0.46 vs. 0.27 %; p = 0.665) and at 1 year (2.36 vs. 1.53 %; p = 0.196). Similarly, major bleeding events were not different between diabetic and nondiabetic patients during hospitalization (1.31 vs. 0.53 %; p = 0.077) and at 1 year (1.47 vs. 0.98 %; p = 0.377). Compared with nondiabetic patients, diabetic patients had a higher incidence of readmission for ACS and coronary revascularization at 1 year. Diabetic patients had higher incidences of cardiac mortality than nondiabetic patients during the index hospitalization (1.23 vs. 0.27 %; p = 0.015) and at 1 year (2.58 vs. 0.81 %; p = 0.002). In multivariate analysis, diabetic patients were four times more likely to die in the hospital compared to nondiabetic patients (odds ratio = 4.2; 95 % CI 1.2-14.8, p = 0.025).

CONCLUSIONS

Diabetic patients, who accounted for more than half of this Middle Eastern PCI population, had a higher risk of cardiac mortality, readmission for ACS and coronary revascularization at 1 year compared with nondiabetic patients.

Subclinical atherosclerosis detected by coronary computed tomographic angiography in Qatar: a comparison between Qataris and south Asian migrants

PURPOSE

There are limited data regarding subclinical atherosclerosis in Middle Eastern countries. We aimed to describe and compare coronary computed tomographic angiography (CCTA) findings in Qatari native and South Asian migrants at increased risk of coronary artery disease (CAD).

METHODS

We performed CCTA in 251 consecutive volunteers (126 South Asian, 125 Qatari, mean age 50.0 ± 7.3 years, 27.1% female) at increased risk of cardiovascular disease. Given differences in baseline risk factors, we employed propensity score matching to create a cohort of 162 subjects for comparative analyses. We compared CAD severity, extent, plaque morphology, adverse plaque characteristics, and quantitative measures of atherosclerotic burden in both subgroups.

RESULTS

After matching, no CAD was seen in 58.0% of South Asians and 49.4% of Qataris (p = 0.3), while obstructive CAD (≥50% luminal stenosis) was present in 40.7% of South Asians and 49.4% of Qataris (p = 0.3). There was a high prevalence of adverse plaque characteristics in both ethnicities, particularly positive remodeling. South Asians had significantly smaller vessel and lumen volumes, but the percent aggregate plaque volumes were not significantly different (2.9 ± 6.3% vs. 3.8 ± 8.0%, p = 0.4).

CONCLUSIONS

In this first study of CCTA findings performed in a Middle Eastern country, we observed a high prevalence of obstructive CAD in a middle-aged cohort. There were no significant differences in CCTA findings between Qataris and South Asians after adjustment for clinical risk factors. Future studies are needed to identify patterns of coronary atherosclerosis by CCTA in non-European populations where cardiovascular disease is increasingly prevalent.

Outcomes of Middle Eastern Patients Undergoing Percutaneous Coronary Intervention: The Primary Analysis of the First Jordanian PCI Registry

Aim:

This is a prospective multicenter registry designed to evaluate the incidence of adverse cardiovascular events in Middle Eastern patients undergoing percutaneous coronary interventions (PCI). The registry was also designed to determine the predictors of poor outcomes in such patients.

Methods and Results:

We enrolled 2426 consecutive patients who underwent PCI at 12 tertiary care centers in Jordan between January 2013 and February 2014. A case report form was used to record data prospectively at hospital admission, discharge, and 12 months of follow-up. Mean age was 56 ± 11 years, females comprised 21% of the study patients, 62% had hypertension, 53% were diabetics, and 57% were cigarette smokers. Most patients (77%) underwent PCI for acute coronary syndrome. In-hospital and 1-year mortality rates were 0.78% and 1.94%, respectively. Definite or probable stent thrombosis occurred in 9 patients (0.37%) during hospitalization and in 47 (1.94%) at 1 year. Rates of target vessel repeat PCI and coronary artery bypass graft surgery at 1 year were 3.4% and 0.6%, respectively. The multivariate analysis revealed that cardiogenic shock, congestive heart failure, ST-segment deviation, diabetes, and major bleeding were significantly associated with higher risk of 1-year mortality.

Conclusions:

In this first large Jordanian registry of Middle Eastern patients undergoing PCI, patients treated were relatively young age population with low in-hospital and 1-year adverse cardiovascular events. Certain clinical features were associated with worse outcomes and may warrant aggressive therapeutic strategies.

Depression in Cardiovascular Patients in Middle Eastern Populations: A Literature Review

Cardiovascular disease (CVD) is increasing in Middle Eastern countries. Depression is associated with increased morbidity and mortality rates among cardiovascular (CV) patients. Early detection of and intervention for depression among CV patients can reduce morbidity and mortality and save health care costs. Public information on mental health care needs of Arab CV patients living in Middle East regions is scattered and limited. This literature review surveyed and summarized research studies to learn what is known about the relationship between depression and CVD in Middle Eastern populations. The information will raise awareness among health care professionals and policy makers regarding the clinical significance of depression in Arab CV patients. It might contribute to development of culturally appropriate and effective mental health care services. Multiple databases were searched and 60 articles were assessed, including studies that investigated depression in Arab CV patient populations, physiological mechanisms of depression-CVD comorbidity, and intervention strategies that affect CV risk in depressed Arab patients. We discuss the extent to which this issue has been explored in Arab populations living in Middle East regions and Arab populations living abroad. We recommend that more comprehensive and in-depth research studies be conducted with Arab cardiac patients to enable implementation of culturally appropriate and effective mental health care interventions.

Consensus clinical recommendations for the management of plasma lipid disorders in the Middle East

BACKGROUND

Plasma lipid disorders are key risk factors for the development of atherosclerotic cardiovascular disease (ASCVD) and are prevalent in the Middle East, with rates increasing in recent decades. Despite this, no region-specific guidelines for managing plasma lipids exist and there is a lack of use of guidelines developed in other regions.

METHODS

A multidisciplinary panel of regional experts was convened to develop consensus clinical recommendations for the management of plasma lipids in the Middle East. The panel considered existing international guidelines and regional clinical experience to develop recommendations.

RESULTS

The panel's recommendations include plasma lipid screening, ASCVD risk calculation and treatment considerations. The panel recommend that plasma lipid levels should be measured in all at-risk patients and at regular intervals in all adults from the age of 20years. A scoring system should be used to calculate ASCVD risk that includes known lipid and non-lipid risk factors. Primary treatment targets include low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol. Lifestyle modifications should be first-line treatment for all patients; the first-line pharmacological treatment targeting plasma lipids in patients at moderate-to-high risk of ASCVD is statin therapy, with a number of adjunctive or second-line agents available. Guidance is also provided on the management of underlying conditions and special populations; of particular pertinence in the region are familial hypercholesterolaemia, diabetes and metabolic dyslipidaemia.

CONCLUSIONS

These consensus clinical recommendations provide practicing clinicians with comprehensive, region-specific guidance to improve the detection and management of plasma lipid disorders in patients in the Middle East.

Dyslipidaemia in the Middle East: Current status and a call for action

The increase in the cardiovascular disease (CVD)-associated mortality rate in the Middle East (ME) is among the highest in the world. The aim of this article is to review the current prevalence of dyslipidaemia and known gaps in its management in the ME region, and to propose initiatives to address the burden of dyslipidaemia. Published literature on the epidemiology of dyslipidaemia in the ME region was presented and discussed at an expert meeting that provided the basis of this review article. The high prevalence of metabolic syndrome, diabetes, familial hypercholesterolaemia (FH) and consanguineous marriages, in the ME region, results in a pattern of dyslipidaemia (low high-density lipoprotein cholesterol and high triglycerides) that is different from many other regions of the world. Early prevention and control of dyslipidaemia is of paramount importance to reduce the risk of developing CVD. Education of the public and healthcare professionals and developing preventive programs, FH registries and regional guidelines on dyslipidaemia are the keys to dyslipidaemia management in the ME region.

Identification and Treatment of Patients with Homozygous Familial Hypercholesterolaemia: Information and Recommendations from a Middle East Advisory Panel

We present clinical practice guidelines for the diagnosis and treatment of homozygous familial hypercholesterolaemia (HoFH) in the Middle East region. While guidelines are broadly applicable in Europe, in the Middle East we experience a range of confounding factors that complicate disease management to a point whereby the European guidance cannot be applied without significant modification. Specifically, for disease prevalence, the Middle East region has an established epidemic of diabetes and metabolic syndrome that can complicate treatment and mask a clinical diagnosis of HoFH. We have also a high incidence of consanguineous marriages, which increase the risk of transmission of recessive and homozygous genetic disorders. This risk is further augmented in autosomal dominant disorders such as familial 
hypercholesterolaemia (FH), in which a range of defective genes can be transmitted, all of which contribute to the phenotypic expression of the disease. In terms of treatment, we do not have access to lipoprotein apheresis on the same scale as in Europe, and there remains a significant reliance on statins, ezetimibe and the older plasma exchange methods. Additionally, we do not have widespread access to anti-apolipoprotein B therapies and microsomal transfer protein inhibitors. In order to adapt existing global guidance documents on HoFH to the Middle East region, we convened a panel of experts from Oman, Saudi Arabia, UAE, Iran and Bahrain to draft a regional guidance document for HoFH. We also included selected experts from outside the region. This panel statement will form the foundation of a detailed appraisal of the current FH management in the Middle Eastern population and thereby provide a suitable set of guidelines tailored for the region.

Mood disturbance and depression in Arab women following hospitalisation from acute cardiac conditions: a cross-sectional study from Qatar

OBJECTIVES

Depression is associated with increased morbidity and mortality rates among cardiovascular patients. Depressed patients have three times higher risk of death than those who are not. We sought to determine the presence of depressive symptoms, and whether gender and age are associated with depression among Arab patients hospitalised with cardiac conditions in a Middle Eastern country.

SETTING

Using a non-probability convenient sampling technique, a cross-sectional survey was conducted with 1000 Arab patients ≥20 years who were admitted to cardiology units between 2013 and 2014 at the Heart Hospital in Qatar. Patients were interviewed 3 days after admission following the cardiac event. Surveys included demographic and clinical characteristics, and the Arabic version of the Beck Depression Inventory Second Edition (BDI-II). Depression was assessed by BDI-II clinical classification scale.

RESULTS

15% of the patients had mild mood disturbance and 5% had symptoms of clinical depression. Twice as many females than males suffered from mild mood disturbance and clinical depression symptoms, the majority of females were in the age group 50 years and above, whereas males were in the age group 40-49 years. χ(2) Tests and multivariate logistic regression analyses indicated that gender and age were statistically significantly related to depression (p<0.001 for all).

CONCLUSIONS

Older Arab women are more likely to develop mood disturbance and depression after being hospitalised with acute cardiac condition. Gender and age differences approach, and routine screening for depression should be conducted with all cardiovascular patients, especially for females in the older age groups. Mental health counselling should be available for all cardiovascular patients who exhibit depressive symptoms.

Joint Association of Screen Time and Physical Activity with Cardiometabolic Risk Factors in a National Sample of Iranian Adolescents: The CASPIANIII Study

Metabolic syndrome (MetS) and its contributing factors are considered important health problems in the pediatric age group. This study was designed to assess the joint association of ST and PA with cardiometabolic risk factors among Iranian adolescents. A representative sample of 5625 (50.2% boys) school students with a mean age of 14.73 (SD: 2.41) were selected through multistage random cluster sampling method from urban and rural areas of 27 provinces in Iran. ST and PA were assessed by self-administered validated questionnaires. Anthropometric measures (height, weight and waist circumference (WC)) and MetS components (abdominal obesity, elevated blood pressure (BP), low high-density lipoprotein cholesterol (HDL-C), elevated triglycerides (TG) and high fasting blood sugar (FBG)) were measured according to standardized protocols. MetS was defined according to the Adult Treatment Panel III criteria modified for the pediatric age group. Moreover, elevated total cholesterol (TC), elevated low-density lipoprotein cholesterol (LDL-C), and generalized obesity were considered as other cardiometabolic risk factors. Students with high ST levels had significantly higher body mass index z-score (BMI z-score), WC, TG, LDL-C, and BP as well as lower HDL-C level; whereas those with high PA levels had significantly higher HDL-C levels as well as lower BMI z-score, TC, and BP. Adolescents with low PA/ high ST levels had significantly higher BMI, WC, LDL-C levels, as well as higher SBP and DBP compared to their other counterparts. In Multivariate model, joint effect of low PA/ high ST (compared to the high PA/low ST group) increased the odds of overweight, abdominal obesity and low HDL-C and decreased the odds of elevated TC. The findings of this study showed that joint association of high ST and low PA have direct association with abdominal obesity, overweight and low HDL-C and indirect association with elevated TC.

Prevalence and correlates of coronary heart disease: first population-based study in Lebanon

Background

Lebanon is experiencing a growing epidemic of coronary heart diseases (CHDs), as most low- and middle-income countries currently are. However, this growth can be attenuated if effective preventive strategies are adopted.

Purpose

To provide the first national population-based prevalence of CHD and to describe the profile of Lebanese adults with prevalent CHD.

Methods

We carried out a cross-sectional study using a multistage cluster sample across Lebanon. We interviewed residents aged 40 years and older using a questionnaire that captured the presence of CHDs and their risk factors (RFs).

Results

Our study showed that 13.4% of the Lebanese population aged ≥40 years suffer from a prevalent CHD. CHD seemed to appear more prematurely than in developed countries, and males seemed to be more subject to CHD than females until a certain age. CHD was associated with older age, male sex, a lower economic situation, hypercholesterolemia, hypertension, having a family history of premature cardiovascular diseases, and suffering from diabetes. However, smoking and waist circumference did not seem to have an independent effect on CHD, but rather an effect mediated by biological RFs.

Conclusion

This is the first nationwide endeavor conducted in Lebanon to assess the prevalence of CHD. This study also confirms the relevance of the classic RFs of CHD and their applicability to the Lebanese population, thus allowing for prevention strategies.