The Effect of Beta-Blocker Post-Myocardial Infarction With Ejection Fraction >40% Pooled Analysis From Seven Arabian Gulf Acute Coronary Syndrome Registries

The use of beta-blockers (BB) in reduced left ventricular ejection fraction (LVEF) post-myocardial infarction (MI) is associated with reduced 1-year mortality, while their role in patients with mid-range and preserved LVEF post-MI remains controversial. We studied 31,620 patients who presented with acute coronary syndrome (ACS) enrolled in seven Arabian Gulf registries between 2005 and 2017. Patients with LVEF ≤40% were excluded. The remaining cohort was divided into two groups: BB group (n = 15,541) and non-BB group (n = 2,798), based on discharge medications. Patients in the non-BB group were relatively younger (55.3 vs. 57.4, P = .004) but higher risk at presentation; with higher Global Registry of Acute Coronary Events (GRACE) score (119.2 vs 109.2, P < .001), higher percentage of cardiogenic shock (3.5 vs 1.4%, P < .001), despite lower prevalence of comorbidities, such as hypertension and hyperlipidemia. BB use was associated with lower 1-year mortality in a multivariate logistic regression analysis, adjusting for major confounders [adjusted odds ratio (OR): 0.71 (95% CI 0.51-0.99)]. This remained the case in a sensitivity analysis using propensity score matching [adjusted OR: 0.34 (95% CI 0.16-0.73)]. In this study, using Arabian Gulf countries registries, the use of BB after ACS with LVEF >40% was independently associated with lower 1-year mortality.

Clinical features, socioeconomic status, management, short and long-term outcomes of patients with acute myocardial infarction: Phase I results of PEACE MENA registry

BACKGROUND

The Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa (PEACE MENA) is a prospective registry program in Arabian countries that involves in patients with acute myocardial infarction (AMI) or acute heart failure (AHF).

METHODS

This prospective, multi-center, multi-country study is the first report of the baseline characteristics and outcomes of inpatients with AMI who were enrolled during the first 14-month recruitment phase. We report the clinical characteristics, socioeconomic, educational levels, and management, in-hospital, one month and one-year outcomes.

RESULTS

Between April 2019 and June 2020, 1377 patients with AMI were enrolled (79.1% males) from 16 Arabian countries. The mean age (± SD) was 58 ± 12 years. Almost half of the population had a net income < $500/month, and 40% had limited education. Nearly half of the cohort had a history of diabetes mellitus, hypertension, or hypercholesterolemia; 53% had STEMI, and almost half (49.7%) underwent a primary percutaneous intervention (PCI) (lowest 4.5% and highest 100%). Thrombolytics were used by 36.2%. (Lowest 6.45% and highest (90.9%). No reperfusion occurred in 13.8% of patients (lowest was 0% and highest 72.7%).Primary PCI was performed less frequently in the lower income group vs. high income group (26.3% vs. 54.7%; P<0.001). Recurrent ischemia occurred more frequently in the low-income group (10.9% vs. 7%; P = 0.018). Re-admission occurred in 9% at 1 month and 30% at 1 year, whereas 1-month mortality was 0.7% and 1-year mortality 4.7%.

CONCLUSION

In the MENA region, patients with AMI present at a young age and have a high burden of cardiac risk factors. Most of the patients in the registry have a low income and low educational status. There is heterogeneity among key performance indicators of AMI management among various Arabian countries.

The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990-2019

It has been estimated that in the next decade, IHD prevalence, DALYs and deaths will increase more significantly in EMR than in any other region of the world. This study aims to provide a comprehensive description of the trends in the burden of ischemic heart disease (IHD) across the countries of the Eastern Mediterranean Region (EMR) from 1990 to 2019. Data on IHD prevalence, disability-adjusted life years (DALYs), mortality, DALYs attributable to risk factors, healthcare access and quality index (HAQ), and universal health coverage (UHC) were extracted from the Global Burden of Disease (GBD) database for EMR countries. The data were stratified based on the social demographic index (SDI). Information on cardiac rehabilitation was obtained from publications by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), and additional country-specific data were obtained through advanced search methods. Age standardization was performed using the direct method, applying the estimated age structure of the global population from 2019. Uncertainty intervals were calculated through 1000 iterations, and the 2.5th and 97.5th percentiles were derived from these calculations. The age-standardized prevalence of IHD in the EMR increased from 5.0% to 5.5% between 1990 and 2019, while it decreased at the global level. In the EMR, the age-standardized rates of IHD mortality and DALYs decreased by 11.4% and 15.4%, respectively, during the study period, although both rates remained higher than the global rates. The burden of IHD was found to be higher in males compared to females. Bahrain exhibited the highest decrease in age-standardized prevalence (-3.7%), mortality (-65.0%), and DALYs (-69.1%) rates among the EMR countries. Conversely, Oman experienced the highest increase in prevalence (14.5%), while Pakistan had the greatest increase in mortality (30.0%) and DALYs (32.0%) rates. The top three risk factors contributing to IHD DALYs in the EMR in 2019 were high systolic blood pressure, high low-density lipoprotein cholesterol, and particulate matter pollution. The trend analysis over the 29-year period (1990-2019) revealed that high fasting plasma glucose (64.0%) and high body mass index (23.4%) exhibited increasing trends as attributed risk factors for IHD DALYs in the EMR. Our findings indicate an increasing trend in the prevalence of IHD and a decrease in mortality and DALYs in the EMR. These results emphasize the need for well-planned prevention and treatment strategies to address the risk factors associated with IHD. It is crucial for the countries in this region to prioritize the development and implementation of programs focused on health promotion, education, prevention, and medical care.

Development and Validation of R-hf Risk Score in Acute Heart Failure Patients in the Middle East

Objectives

The Rajan's heart failure (R-hf) score was proposed to aid risk stratification in heart failure patients. The aim of this study was to validate R-hf risk score in patients with acute decompensated heart failure.

Methods

R-hf risk score is derived from the product estimated glomerular filtration rate (mL/min), left ventricular ejection fraction (%), and hemoglobin levels (g/dL) divided by N-terminal pro-brain natriuretic peptide (pg/mL). This was a multinational, multicenter, prospective registry of heart failure from seven countries in the Middle East. Univariable and multivariable logistic regression was applied.

Results

A total of 776 patients (mean age = 62.0±14.0 years, 62.4% males; mean left ventricular ejection fraction = 33.0±14.0%) were included. Of these, 459 (59.1%) presented with acute decompensated chronic heart failure. The R-hf risk score group (≤ 5) was marginally associated with a higher risk of all-cause cumulative mortality at three months (adjusted odds ratio (aOR) = 4.28; 95% CI: 0.90-20.30; p =0.067) and significantly at 12 months (aOR = 3.84; 95% CI: 1.23-12.00; p =0.021) when compared to those with the highest R score group (≥ 50).

Conclusions

Lower R-hf risk scores are associated with increased risk of all-cause cumulative mortality at three and 12 months.

Trends in the burden and determinants of hypertensive heart disease in the Eastern Mediterranean region, 1990-2019: an analysis of the Global Burden of Disease Study 2019

Background

Hypertensive heart disease (HHD), one of the end-organ damage consequences of hypertension, is an important public health issue worldwide. Data on the HHD burden in the Eastern Mediterranean region (EMR) are scarce. We aimed to investigate the burden of HHD in the EMR, its member countries, and globally from 1990 to 2019.

Methods

We used 2019 Global Burden of Disease (GBD) data to report the HHD age-standardised prevalence, disability adjusted life years (DALYs), years of life lost (YLLs), and mortality, as well as HHD risk factors attribution percent with their 95% uncertainty interval (UI). Global data are reported alongside EMR data, and its 22 respective countries. We compared the burden of HHD by socio-demographic index (SDI), sex, age groups, and countries.

Findings

The age-standardised prevalence rate (per 100,000 population) of HHD was higher in the EMR (281.7; 95% UI: 204.5-383.4) in 2019, compared with the global prevalence (233.8; 95% UI: 170.5-312.9). The EMR age-standardised DALYs (per 100,000 population) for HHD in 2019 was 561.9 (361.0-704.1), compared with 268.2 (204.6-298.1) at the global level. There was an increase in HHD prevalence, reduction in mortality, and DALYs between 1990 and 2019 (4.01%, -7.6%, and -6.5%, respectively) in EMR. Among EMR countries, the highest versus lowest rates of age-standardised prevalence, mortality, and DALYs in 2019 [estimate (95% UI)] were in Jordan [561.62 (417.9-747.6)] versus Saudi Arabia [94.9 (69.5-129.0)]; Afghanistan [74.5 (23.7-112.3)] versus Saudi Arabia [4.3 (3.3-5.9)]; and Afghanistan [1374.1 (467.2-2020.7)] versus Qatar [87.11 (64.40-114.29)], respectively.

Interpretation

HHD remains a significant problem in the EMR, with a higher burden than global levels. Serious efforts toward high-quality management and prevention are strongly recommended. Based on this study, our recommendation for the EMR is to adopt effective preventive strategies. For example, promoting healthy dietary patterns and prompt screening for undiagnosed HTN in public places, promoting regular blood pressure measurements at home, and creating community awareness about early detection of HTN.

Funding

None.

Characteristics and predictors of out-of-hospital cardiac arrest in young adults hospitalized with acute coronary syndrome: A retrospective cohort study of 30,000 patients in the Gulf region

INTRODUCTION

The characteristics of young adults with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndrome (ACS) has not been well described. The mean age of gulf citizens in ACS registries is 10-15 years younger than their western counterparts, which provided us with a unique opportunity to investigate the characteristics and predictors of OHCA in young adults presenting with ACS.

METHODOLOGY

This was a retrospective cohort study using data from 7 prospective ACS registries in the Gulf region. In brief, all registries included consecutive adults who were admitted with ACS. OHCA was defined as cardiac arrest upon presentation (i.e., before admission to the hospital). We described the characteristics of young adults (< 50 years) who had OHCA and performed multivariate logistic regression analysis to assess independent predictors of OHCA.

RESULTS

A total of 31,620 ACS patients were included in the study. There were 611 (1.93%) OHCA cases in the whole cohort [188/10,848 (1.73%) in young adults vs 423/20,772 (2.04%) in older adults, p = 0.06]. Young adults were predominantly males presenting with ST-elevation myocardial infarction (STEMI) [182/188 (96.8%) and 172/188 (91.49%), respectively]. OHCA was the sentinel event of coronary artery disease (CAD) in 70% of young adults. STEMI, male sex, and non-smoking status were found to be independent predictors of OHCA [OR = 5.862 (95% CI 2.623-13.096), OR: 4.515 (95% CI 1.085-18.786), and OR = 2.27 (95% CI 1.335-3.86), respectively].

CONCLUSION

We observed a lower prevalence of OHCA in ACS patients in our region as compared to previous literature from other regions. Moreover, OHCA was the sentinel event of CAD in the majority of young adults, who were predominantly males with STEMIs. These findings should help risk-stratify patients with ACS and inform further research into the characteristics of OHCA in young adults.

Clinical Features, Socioeconomic Status, Management, and Outcomes of Acute Heart Failure: PEACE MENA Registry Phase I Results

INTRODUCTION

PEACE MENA (Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa) is a prospective registry in Arab countries for in-patients with acute myocardial infarction (AMI) or acute heart failure (AHF). Here, we report the baseline characteristics and outcomes of in-patients with AHF who were enrolled during the first 14 months of the recruitment phase.

METHODS

A prospective, multi-centre, multi-country study including patients hospitalized with AHF was conducted. Clinical characteristics, echocardiogram, BNP (B-type natriuretic peptide), socioeconomic status, management, 1-month, and 1-year outcomes are reported.

RESULTS

Between April 2019 and June 2020, a total of 1258 adults with AHF from 16 Arab countries were recruited. Their mean age was 63.3 (±15) years, 56.8% were men, 65% had monthly income ≤US$ 500, and 56% had limited education. Furthermore, 55% had diabetes mellitus, 67% had hypertension; 55% had HFrEF (heart failure with reduced ejection fraction), and 19% had HFpEF (heart failure with preserved ejection fraction). At 1 year, 3.6% had a heart failure-related device (0-22%) and 7.3% used an angiotensin receptor neprilysin inhibitor (0-43%). Mortality was 4.4% per 1 month and 11.77% per 1-year post-discharge. Compared with higher-income patients, lower-income patients had a higher 1-year total heart failure hospitalization rate (45.6 vs 29.9%, p=0.001), and the 1-year mortality difference was not statistically significant (13.2 vs 8.8%, p=0.059).

CONCLUSION

Most of the patients with AHF in Arab countries had a high burden of cardiac risk factors, low income, and low education status with great heterogeneity in key performance indicators of AHF management among Arab countries.

The "obesity paradox" in patients with atrial fibrillation: Insights from the Gulf SAFE registry

BACKGROUND

The prognostic impact of obesity on patients with atrial fibrillation (AF) remains under-evaluated and controversial.

METHODS

Patients with AF from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) registry were included, who were recruited from six countries in the Middle East Gulf region and followed for 12 months. A multivariable model was established to investigate the association of obesity with clinical outcomes, including stroke or systemic embolism (SE), bleeding, admission for heart failure (HF) or AF, all-cause mortality, and a composite outcome. Restricted cubic splines were depicted to illustrate the relationship between body mass index (BMI) and outcomes. Sensitivity analysis was also conducted.

RESULTS

A total of 1,804 patients with AF and recorded BMI entered the final analysis (mean age 56.2 ± 16.1 years, 47.0% female); 559 (31.0%) were obese (BMI over 30 kg/m2). In multivariable analysis, obesity was associated with reduced risks of stroke/systematic embolism [adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI), 0.18-0.89], bleeding [aOR 0.44, 95%CI, 0.26-0.74], HF admission (aOR 0.61, 95%CI, 0.41-0.90) and the composite outcome (aOR 0.65, 95%CI, 0.50-0.84). As a continuous variable, higher BMI was associated with lower risks for stroke/SE, bleeding, HF admission, all-cause mortality, and the composite outcome as demonstrated by the accumulated incidence of events and restricted cubic splines. This "protective effect" of obesity was more prominent in some subgroups of patients.

CONCLUSION

Among patients with AF, obesity and higher BMI were associated with a more favorable prognosis in the Gulf SAFE registry. The underlying mechanisms for this obesity "paradox" merit further exploration.

Outcomes of guideline-based medical therapy in patients with acute heart failure and reduced left ventricular ejection fraction: Observations from the Gulf acute heart failure registry (Gulf CARE)

This study aimed to report on the use, predictors and outcomes of guideline-based medical therapy (GBMT) in patients with acute heart failure (HF) with reduced ejection fraction of <40% (HFrEF), from seven countries in the Arabian Gulf.Patients with acute HFrEF (N = 2680), aged 18 years or older, and hospitalized February-November 2012 were recruited and data were collected post discharge at 3 months (n = 2477) and 1 year (n = 2418). The use and doses of GBMT were evaluated as per European, American and Canadian HF guidelines. Analyses were performed using multivariate logistic regression. This study was registered at clinicaltrials.gov (NCT01467973).The majority of patients were on dual (39%) and triple (39%) GBMT modalities, 14% received one GBMT medication, while 7.2% were not on any GBMT medications. On admission, 80% of patients were on renin-angiotensin system (RAS) blockers, 75% on b-blockers and 56% on mineralocorticoid receptor antagonists (MRAs), with a small proportion of these patients were taking target doses (RAS blockers 13%, b-blockers 7.3%, MRAs 14%). Patients taking triple GBMT were younger (P < .001), less likely to have comorbidities such as diabetes mellitus (P < .001) and CKD/dialysis (P < .001), less likely to receive in-hospital invasive treatments (P < .001), and more likely to be treated by a cardiologist (P < .001), than patients on a single medication. Patients taking triple GBMT showed significantly reduced all-cause mortality both at 3-months (P = .048), and at 12-months (P = .003), compared to patients taking no GBMT.Triple GBMT prescribing and dosing in patients with HFrEF were suboptimal in the Arabian Gulf. Further studies are required to investigate GBMT utilization and dosing in the outpatient setting.

Review of National Healthcare Systems in the Gulf Cooperation Council Countries for Noncommunicable Diseases Management

Objectives

Noncommunicable diseases (NCDs) are the leading cause of mortality in all Gulf Cooperation Council (GCC) member countries and place a substantial economic burden on the governments and people. The escalating demand for NCD-related health services takes an enormous toll on health systems in these countries. There is an urgent need to make significant advances in the healthcare infrastructure and develop strategies to overcome the NCD challenge. This review aims to provide the status of national healthcare systems and national NCD policies in GCC countries to highlight the challenges and identify opportunities towards strengthening NCD management and control.

Methods

We searched the PubMed database, the World Health Organization, and the Ministry of Health websites of GCC countries to identify relevant information.

Results

Future strategies and investments in healthcare infrastructure to overcome the NCD challenge include continuing high-level commitment towards multisectoral actions, redesigning healthcare delivery to advance universal healthcare coverage, enabling integration of healthcare services through organizational alignment to maintain care continuum, building the capacity of health workforce, developing effective treatment strategies through research based on local populations, integrating mental health into general public health policy, and lastly, establishing reliable NCD surveillance and monitoring programs.

Conclusions

Measures to address NCDs must be continued with focus on health-in-all policies, and whole-of-government and whole-of-society approaches.

Symptom Status, Clinical Subtypes, and Prognosis in Patients With Atrial Fibrillation from the Middle East Region (from the Gulf-SAFE Registry)

Atrial fibrillation (AF) is often asymptomatic. The prognosis of asymptomatic AF is at least similar or worse than symptomatic AF, but there are no such data from Middle East patients with AF. The Gulf-SAFE (Gulf Survey of Atrial Fibrillation Events) registry is a multicenter prospective survey of patients presenting with AF to participate medical institutions in 6 countries in the Gulf region. We investigated the prognostic outcomes of patients with asymptomatic AF in relation to clinical subtypes. A total of 2043 patients with AF were included; 541 were identified as having asymptomatic AF (26.5%) who tended to be older, with higher prevalences of hypertension, heart failure, coronary artery disease, diabetes, stroke, renal dysfunction, chronic obstructive pulmonary disease, and had higher Congestive heart failure, Hypertension, Age ≥75, Stroke (2 points), Congestive heart failure, Hypertension, Age ≥75 (2 points), Diabetes, Stroke (2 points), Vascular disease, Age 65-74, Sex category (CHA₂DS₂-VASc), and Hypertension, Age ≥65, Stroke, Bleeding history, liable INR, Elderly, Drug or alcohol use (HAS-BLED) scores (all p <0.05). After multivariable adjustment, asymptomatic AF was associated with higher risks of stroke/systematic embolism (SE) (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.10 to 4.34), all-cause mortality (aOR 2.85, 95% CI 1.90 to 4.28), and the composite outcome of stroke/SE, bleeding, and all-cause mortality (aOR 1.74, 95% CI 1.26 to 2.41). Patients with asymptomatic AF had fewer admissions for AF (aOR 0.53, 95% CI 0.32 to 0.83) and heart failure (aOR 0.58, 95% CI 0.38 to 0.86). The increased risk of stroke/SE in asymptomatic AF was more prominent among paroxysmal AF subtype (p for interaction = 0.028). In conclusion, in the Gulf-SAFE registry, patients with asymptomatic AF represent a nonbenign entity with worse outcomes compared with symptomatic AF. In paroxysmal AF, the higher risks of events were more prominent. The absence of "warning signs" and lack of timely admission in asymptomatic AF may be major reasons for the unfavorable prognosis.

The obesity paradox in patients with atrial fibrillation: an insight from the Gulf SAFE registry

Background

The prognostic role of obesity among patients with atrial fibrillation (AF) is unclear.

Methods

A total of 1804 patients with AF had body mass index (BMI) measures from the Gulf survey of atrial fibrillation events (Gulf SAFE) registry were implied. A multivariable model was established to investigate the role of obesity on clinical outcomes, including stroke or systemic embolism, bleeding, admission for heart failure (HF) or AF, all-cause mortality and composite event.

Results

559 (31.0%) patients were identified as obesity (BMI over 30kg/m2). In multivariable analyses, obesity was associated with reduced risks of stroke/systematic embolism (hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.18–0.89), major or clinical relevant bleeding (HR 0.44, 95% CI 0.26–0.74), HF admission (HR 0.61, 95% CI 0.41–0.90) and composite outcome (HR 0.65, 95% CI 0.50–0.84). Higher BMI was associated with lower risks of stroke/systemic embolism, bleeding, admission for HF, all-cause mortality, and composite outcomes as were demonstrated by accumulated incidence of events and restricted cubic splines.

Conclusion

Among patients with AF, higher BMI was associated with a more favorable prognosis.

The hazard ratio for BMI and outcomes

Funding Acknowledgement

Type of funding source: None

Symptom status, clinical subtypes and prognosis in Middle East patients with atrial fibrillation: a report from the Gulf-SAFE registry

Background

Atrial fibrillation (AF) is often asymptomatic. The prognosis of asymptomatic AF is similar or worse than symptomatic AF, but there are no such data from Middle East.

Method

The Gulf survey of AF events (Gulf SAFE) registry is a multi-center prospective survey of AF patients from six countries (23 centers) in the Gulf Region (n=2043). We investigated the prognostic outcomes of asymptomatic AF, in relation to clinical subtypes.

Result

541 (26.5%) AF patients were asymptomatic; they tended to be older, with higher prevalence of hypertension, heart failure (HF), diabetes, stroke, renal dysfunction, and higher CHADS2, CHA2DS2-VASc, and HAS-BLED scores (all p&lt;0.05). After multivariable adjustment, asymptomatic AF was associated with higher risks of stroke/systematic embolism (SE) (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.10–4.34), all cause-mortality (OR 2.85 [1.90–4.28]) and the composite outcome of stroke/SE, bleeding and all-cause mortality (OR 1.74 [1.26–2.41]).

Asymptomatic AF was associated with fewer admissions for AF (OR 0.53 [0.32–0.83]) and HF (OR 0.58 [0.38–0.86]).

The increased risk of stroke/SE in asymptomatic AF was associated with paroxysmal AF (Figure 1; P interaction=0.028).

Conclusion

In this large Middle East cohort, asymptomatic AF was common, less likely hospitalized but associated with unfavorable prognosis. When AF was asymptomatic, the paroxysmal subtype had a greater association with stroke/SE.

Adjusted odds ratio of clinical outcomes

Funding Acknowledgement

Type of funding source: None

Clinical presentation and outcomes of peripartum cardiomyopathy in the Middle East: a cohort from seven Arab countries

Aims

Published data on the clinical presentation of peripartum cardiomyopathy (PPCM) are very limited particularly from the Middle East. The aim of this study was to examine the clinical presentation, management, and outcomes of patients with PPCM using data from a large multicentre heart failure (HF) registry from the Middle East.

Methods and results

From February to November 2012, a total of 5005 consecutive patients with HF were enrolled from 47 hospitals in 7 Middle East countries. From this cohort, patients with PPCM were identified and included in this study. Clinical features, in‐hospital, and 12 months outcomes were examined. During the study period, 64 patients with PPCM were enrolled with a mean age of 32.5 ± 5.8 years. Family history was identified in 11 patients (17.2%) and hypertension in 7 patients (10.9%). The predominant presenting symptom was dyspnoea New York Heart Association class IV in 51.6%, class III in 31.3%, and class II in 17.2%. Basal lung crepitations and peripheral oedema were the predominant signs on clinical examination (98.2% and 84.4%, respectively). Most patients received evidence‐based HF therapies. Inotropic support and mechanical ventilation were required in 16% and 5% of patients, respectively. There was one in‐hospital death (1.6%), and after 1 year of follow‐up, nine patients were rehospitalized with HF (15%), and one patient died (1.6%).

Conclusions

A high index of suspicion of PPCM is required to make the diagnosis especially in the presence of family history of HF or cardiomyopathy. Further studies are warranted on the genetic basis of PPCM.

Descriptive epidemiology of coronavirus disease 2019 in Nigeria, 27 February-6 June 2020

The objective of this study was to describe the epidemiology of COVID-19 in Nigeria with a view of generating evidence to enhance planning and response strategies. A national surveillance dataset between 27 February and 6 June 2020 was retrospectively analysed, with confirmatory testing for COVID-19 done by real-time polymerase chain reaction (RT-PCR). The primary outcomes were cumulative incidence (CI) and case fatality (CF). A total of 40 926 persons (67% of total 60 839) had complete records of RT-PCR test across 35 states and the Federal Capital Territory, 12 289 (30.0%) of whom were confirmed COVID-19 cases. Of those confirmed cases, 3467 (28.2%) had complete records of clinical outcome (alive or dead), 342 (9.9%) of which died. The overall CI and CF were 5.6 per 100 000 population and 2.8%, respectively. The highest proportion of COVID-19 cases and deaths were recorded in persons aged 31-40 years (25.5%) and 61-70 years (26.6%), respectively; and males accounted for a higher proportion of confirmed cases (65.8%) and deaths (79.0%). Sixty-six per cent of confirmed COVID-19 cases were asymptomatic at diagnosis. In conclusion, this paper has provided an insight into the early epidemiology of COVID-19 in Nigeria, which could be useful for contextualising public health planning.

Mortality and Morbidity in HFrEF, HFmrEF, and HFpEF Patients with Diabetes in the Middle East

Objectives

We sought to estimate the mortality and morbidity in diabetic acute heart failure (AHF) patients stratified by left ventricular ejection fraction.

Methods

We analyzed the data of patients with AHF from seven Middle Eastern countries (Bahrain, Oman, Yemen, Kuwait, UAE, Qatar, and Saudi Arabia) from February to November 2012, who were enrolled in a multinational registry of patients with heart failure (HF).

Results

A total of 2258 AHF patients had diabetes mellitus. The mean age was 63.0±11.0 years (ranging from 18 to 99 years), and 60.3% (n = 1362) of the patients were males. The mean ejection fraction (EF) was 37.0±13.0%. HF with reduced EF (< 40%) (HFrEF) was observed in 1268 patients (56.2%), whereas 515 patients (22.8%) had mid-range (40-49%) (HFmrEF) and 475 patients (21.0%) had preserved EF (³ 50%) (HFpEF). The overall cumulative all-cause mortalities at three- and 12-months follow-up were 11.8% (n = 266) and 20.7% (n = 467), respectively. Those with HFpEF were associated with lower three-months cumulative all-cause mortality compared to those with HFrEF (7.6% vs. 5.9%; adjusted odds ratio (aOR) = 0.54, 95% confidence interval (CI): 0.31-0.95; p = 0.031), but not significantly different when compared to those with HFmrEF (aOR = 0.86, 95% CI: 0.53-1.40; p = 0.554). There were largely no significant differences among the groups with regards to the 12-months all-cause cumulative mortality (11% vs. 11% vs. 10%; p = 0.984). There were also no significant differences in re-hospitalization rates between the three HF groups not only at three months (23% vs. 20% vs. 22%; p = 0.520), but at one-year follow-up (28% vs. 30% vs. 32%; p = 0.335).

Conclusions

Three-month cumulative all-cause mortality was high in diabetic HFrEF patients when compared to those with HFpEF. However, there were no significant differences in mortality at one-year follow-up between the HF groups. There were also no significant differences in re-hospitalization rates between the HF groups not only at three months but also at one-year follow-up in the Middle East.

Implementation of Guideline-Recommended Therapies for Patients With Heart Failure and Reduced Ejection Fraction: A Regional Arab Middle East Experience

We describe the characteristics of ambulatory patients with heart failure with reduced ejection fraction (HFrEF) in the Gulf region (Middle East) and the implementation of guideline-recommended treatments. We included 2427 HFrEF outpatients (mean age 59 ± 13 years, 75% males and median left ventricular ejection fraction [LVEF] of 30%). A high proportion of patients received guideline-recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI] 87%, β-blocker 91%, mineralocorticoid antagonist [MRA] 64%). However, only a minority of patients received guideline-recommended target doses (ACEI/ARB/ARNI 13%, β-blocker 27%, and MRA 4.4%). Old age was a significant independent predictor for not prescribing treatment (P < .001 for ACEI/ARB/ARNI and MRA; and P = .002 for β-blockers). Other independent predictors were chronic kidney disease (for both ACEI/ARB/ARNI and MRA, P < .001) and higher LVEF (P = .014 for β-blockers and P < .001 for MRA). Patients with HFrEF managed by heart failure specialists more often received recommended target doses of ACEI/ARB/ARNI (40% vs 11%, P < .001) and β-blockers (56% vs 26%, P < .001) compared to those treated by general cardiologists. Although the majority of our patients with HFrEF received guideline-recommended medications, the doses they were prescribed were suboptimal. Understanding the reasons behind this is important for improved practice.

Beta-Blockers and Cardiovascular Outcomes in Acute Heart Failure with a History of Coronary Artery Disease and an Ejection Fraction ≥ 40

The prognostic impact of beta-blockers (BB) in coronary artery disease (CAD) is controversial, especially in the post-reperfusion era. We studied in-hospital cardiovascular events in patients hospitalized for acute HF, a previous history of CAD and a left ventricular ejection fraction (LVEF) ≥40%, in relation to BB on admission; and 1-year outcome in relation to BB on discharge, in the GULF aCute heArt failuRe (GULF-CARE) registry. From a total of 5005 patients included in the GULF-CARE registry, 303 patients with a previous history of CAD and a LVEF ≥40% on BB were propensity-matched to 303 patients without BB on admission. In-hospital mortality (OR= 0.82; 95% CI [0.35-1.94]), stroke and cardiogenic shock were not reduced by BB. On discharge, 306 patients on BB, including the ones newly diagnosed with myocardial infarction as a precipitating cause of HF, were propensity-scored matched with 306 patients without BB. Mortality (OR= 0.86; 95%CI [0.51-1.45], hospitalization for HF or PCI/CABG at 1 year were also not reduced by BB at discharge. In summary, our data show that BB have a neutral effect on in-hospital and 1-year outcomes in acute heart failure patients with a previous history of CAD and a LVEF ≥40%.

Precipitating Factors for Hospitalization with Heart Failure: Prevalence and Clinical Impact Observations from the Gulf CARE (Gulf aCute heArt failuRe rEgistry)

OBJECTIVE

Despite the expanding burden of heart failure (HF) worldwide, data on HF precipitating factors (PFs) in developing countries, particularly the Middle East, are very limited. We examined PFs in patients hospitalized with acute HF in a prospective multicenter HF registry from 7 countries in the Middle East.

METHOD

Data were derived from the Gulf CARE (Gulf aCute heArt failuRe rEgistry) for a prospective, multinational, multicenter study of consecutive patients hospitalized with HF in 47 hospitals in 7 Middle Eastern countries between February 2012 and November 2012. PFs were determined by the treating physician from a predefined list at the time of hospitalization.

RESULTS

The study included 5,005 patients hospitalized with acute HF, 2,276 of whom (45.5%) were hospitalized with acute new-onset HF (NOHF) and 2,729 of whom (54.5%) had acute decompensated chronic HF (DCHF). PFs were identified in 4,319 patients (86.3%). The most common PF in the NOHF group was acute coronary syndromes (ACS) (39.2%). In the DCHF group, it was noncompliance with medications (27.8%). Overall, noncompliance with medications was associated with a lower inhospital mortality (OR 0.47; 95% CI 0.28-0.80; p = 0.005) but a higher 1-year mortality (OR 1.43; 95% CI 1.1-1.85; p = 0.007). ACS was associated with higher inhospital mortality (OR 1.84; 95% CI 1.26-2.68; p = 0.002) and higher 1-year mortality (OR 1.62; 95% CI 1.27-2.06; p = 0.001).

CONCLUSION

Preventive and therapeutic interventions specifically directed at noncompliance with medications and ACS are warranted in our region.

Impact of diabetes on mortality and rehospitalization in acute heart failure patients stratified by ejection fraction

Aims

The aim of this study is to determine the impact of diabetes mellitus on all‐cause mortality and rehospitalization rates at 3 months and at 1 year in patients admitted with acute heart failure (AHF) stratified by left ventricular ejection fraction (EF).

Methods and results

We analysed consecutive patients admitted to 47 hospitals in seven Middle Eastern countries (Saudi Arabia, Oman, Yemen, Kuwait, United Arab Emirates, Qatar, and Bahrain) with AHF from February to November 2012 with AHF who were enrolled in Gulf CARE, a multinational registry of patients with heart failure (HF). AHF patients were stratified into three groups: HF patients with reduced (EF) (HFrEF) (<40%), HF with mid‐range EF (HFmrEF) (40–49%), and HF patients with preserved EF (HFpEF) (≥50%). Analyses were performed using univariate and multivariate statistical techniques. The mean age of the cohort was 59 ± 15 years (ranging from 18 to 99 years), and 63% (n = 2887) of the patients were males. A total of 2258 (49%) AHF patients had diabetes mellitus. The mean EF was 37 ± 14%. A reduced EF was observed in 2683 patients (59%), whereas 962 patients (21%) had mid‐range and 932 patients (20%) had preserved EF. Multivariable analyses demonstrated no significant differences in all‐cause mortality between diabetics and non‐diabetics in all the three types of HF; at 3 months follow‐up: HFrEF [adjusted odds ratio (aOR), 1.30; 95% confidence interval (CI): 0.94–1.80; P = 0.119], HFmrEF (aOR, 0.98; 95% CI: 0.51–1.87; P = 0.952), and HFpEF (aOR, 0.69; 95% CI: 0.38–1.26; P = 0.225); and at 12‐months follow‐up: HFrEF (aOR, 1.25; 95% CI: 0.97–1.62; P = 0.080), HFmrEF (aOR, 1.07; 95% CI: 0.68–1.68; P = 0.783), and HFpEF (aOR, 1.07; 95% CI: 0.67–1.72; P = 0.779). There were also no significant differences in rehospitalization rates between diabetics and non‐diabetics in all the three types of HF; at 3 months follow‐up: HFrEF (aOR, 0.94; 95% CI: 0.74–1.19; P = 0.581), HFmrEF (aOR, 0.82; 95% CI: 0.53–1.26; P = 0.369), and HFpEF (aOR, 1.06; 95% CI: 0.64–1.78; P = 0.812); and at 12‐months follow‐up: HFrEF (aOR, 0.93; 95% CI: 0.73–1.17; P = 0.524), HFmrEF (aOR, 0.81; 95% CI: 0.56–1.17; P = 0.257), and HFpEF (aOR, 1.29; 95% CI: 0.82–2.05; P = 0.271).

Conclusions

There were no significant differences in 3 and 12 months all‐cause mortality as well as rehospitalization rates between diabetics and non‐diabetic patients in all the three types of AHF patients stratified by left ventricular ejection fraction.

Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure

Background Smoker's paradox has been observed with several vascular disorders, yet there are limited data in patients with acute heart failure (HF). We examined the effects of smoking in patients with acute HF using data from a large multicenter registry. The objective was to determine if the design and analytic approach could explain the smoker's paradox in acute HF mortality. Methods and Results The data were sourced from the acute HF registry (Gulf CARE [Gulf Acute Heart Failure Registry]), a multicenter registry that recruited patients over 10 months admitted with a diagnosis of acute HF from 47 hospitals in 7 Middle Eastern countries. The association between smoking and mortality (in hospital) was examined using covariate adjustment, making use of mortality risk factors. A parallel analysis was performed using covariate balancing through propensity scores. Of 5005 patients hospitalized with acute HF, 1103 (22%) were current smokers. The in-hospital mortality rates were significantly lower in current smoker's before (odds ratio, 0.71; 95% CI, 0.52-0.96) and more so after (odds ratio, 0.47; 95% CI, 0.31-0.70) covariate adjustment. With the propensity score-derived covariate balance, the smoking effect became much less certain (odds ratio, 0.63; 95% CI, 0.36-1.11). Conclusions The current study illustrates the fact that the smoker's paradox is likely to be a result of residual confounding as covariate adjustment may not resolve this if there are many competing prognostic confounders. In this situation, propensity score methods for covariate balancing seem preferable. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01467973.

Utility of shock index in 24,636 patients presenting with acute coronary syndrome

BACKGROUND

Shock index is a bedside reflection of integrated response of the cardiovascular and nervous systems. We aimed to evaluate the utility of shock index (heart rate/systolic blood pressure) in patients presenting with acute coronary syndrome (ACS).

METHODS

We analyzed pooled data from seven Arabian Gulf registries; these ACS registries were carried out in seven countries (Qatar, Bahrain, Kuwait, UAE, Saudi Arabia, Oman and Yemen) between 2005 and 2017. A standard uniform coding strategy was used to recode each database using each registry protocol and clinical research form. Patients were categorized into two groups based on their initial shock index (low vs. high shock index). Optimal shock index cutoff was determined according to the receiver operating characteristic curve (ROC). Primary outcome was hospital mortality.

RESULTS

A total of 24,636 ACS patients met the inclusion criteria with a mean age 57±13 years. Based on ROC analysis, the optimal shock index was 0.80 (83.5% had shock index <0.80 and 16.5% had shock index ≥0.80). In patients with high shock index, 55% had ST-elevation myocardial infarction and 45% had non-ST-elevation myocardial infarction. Patients with high shock index were more likely to have diabetes mellitus, late presentation, door to electrocardiogram >10 min, symptom to Emergency Department > 3 h, anterior myocardial infarction, impaired left ventricular function, no reperfusion post-therapy, recurrent ischemia/myocardial infarction, tachyarrhythmia and stroke. However, high shock index was associated significantly with less chest pain, less thrombolytic therapy and less primary percutaneous coronary intervention. Shock index correlated significantly with pulse pressure (r= -0.52), mean arterial pressure (r= -0.48), Global Registry of Acute Coronary Events score (r =0.41) and Thrombolysis In Myocardial Infarction simple risk index (r= -0.59). Shock index ≥0.80 predicted mortality in ACS with 49% sensitivity, 85% specificity, 97.6% negative predictive value and 0.6 negative likelihood ratio. Multivariate regression analysis showed that shock index was an independent predictor for in-hospital mortality (adjusted odds ratio (aOR) 3.40, p<0.001), heart failure (aOR 1.67, p<0.001) and cardiogenic shock (aOR 3.70, p<0.001).

CONCLUSIONS

Although shock index is the least accurate of the ones tested, its simplicity may argue in favor of its use for early risk stratification in patients with ACS. The utility of shock index is equally good for ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. High shock index identifies patients at increased risk of in-hospital mortality and urges physicians in the Emergency Department to use aggressive management.

Shock Index in Patients Presenting With Acute Heart Failure: A Multicenter Multinational Observational Study

Shock index (SI) has a prognostic role in coronary heart disease; however, data on acute heart failure (AHF) are lacking. We evaluated the predictive values of SI in patients with AHF. Data were retrospectively analyzed from the Gulf Acute Heart Failure Registry. Patients were categorized into low SI versus high SI based on the receiver operating characteristic curves. Primary outcomes included cardiogenic shock (CS) and mortality. Among 4818 patients with AHF, 1143 had an SI ≥0.9. Compared with SI <0.9, patients with high SI were more likely males, younger, and having advanced New York Heart Association class, fewer cardiovascular risk factors and less prehospital β-blockers and angiotensin-converting enzyme inhibitor use. Shock index had significant negative correlations with age, pulse pressure, mean arterial pressure, and left ventricle ejection fraction and had positive correlation with hospital length of stay. Shock index ≥0.9 was significantly associated with higher composite end points, in-hospital, and 3-month mortality. Shock index ≥0.9 had 96% negative predictive value (NPV) and 3.5 relative risk for mortality. Multivariate regression analysis showed that SI was independent predictor of mortality and CS. With a high NPV, SI is a simple reliable bedside tool for risk stratification of patients with AHF. However, this conclusion needs further support.

Design and Rationale of Gulf Documentation of Ambulatory Sick Patients with Heart Failure (Gulf DYSPNEA) Registry

Aim:

The aim of this study is to describe the clinical characteristics of ambulatory patients with chronic heart failure (HF) in the Arabian Gulf and to examine several aspects including types of HF, causes, and adherence to management guidelines.

Methods:

Gulf documentation of ambulatory sick patients with HF (Gulf DYSPNEA) registry is a multicenter, cross-sectional study, recruiting adult ambulatory HF patients from 24 hospitals in five Arabian Gulf countries. Consecutive patients are recruited prospectively from participating clinics with no follow-up data collection. Recruitment started on November 07, 2016 and will stop when 3,500 patients are enrolled in this study. Collected data explore demographics, baseline patient characteristics, symptoms, previous medical history, comorbidities, physical signs, presenting electrocardiogram, echocardiographic findings, types of HF, and management.

Conclusion:

This registry is expected to provide useful data on several important aspects and features of ambulatory patients with chronic HF in Arabian Gulf countries. The trial registration number is “ClinicalTrials.gov number, NCT02793180”.

Incidence and impact of cardiorenal anaemia syndrome on all-cause mortality in acute heart failure patients stratified by left ventricular ejection fraction in the Middle East

AIMS

This study aims to evaluate the incidence and impact of cardiorenal anaemia syndrome (CRAS) on all-cause mortality in acute heart failure (AHF) patients stratified by left ventricular ejection fraction (LVEF) status in the Middle East.

METHODS AND RESULTS

Data were analysed from 4934 consecutive patients admitted to 47 hospitals in seven Middle Eastern countries (Saudi Arabia, Oman, Yemen, Kuwait, United Arab Emirates, Qatar, and Bahrain) with AHF from February to November 2012. CRAS was defined as AHF with estimated glomerular filtration rate of <60 mL/min and low haemoglobin (<13 g/dL for men or <12 g/dL for women). Analyses were performed using univariate and multivariate statistical techniques. The overall mean age of the cohort was 59 ± 15 years, 62% (n = 3081) were men, and 27% (n = 1319) had CRAS. Co-morbid conditions were common including hypertension (n = 3014; 61%), coronary artery disease (n = 2971; 60%), and diabetes mellitus (n = 2449; 50%). A total of 79% (n = 3576) of the patients had AHF with reduced ejection fraction (HFrEF) (LVEF < 50%). CRAS patients were associated with major bleeding (1.29% vs. 0.6%; P = 0.017), blood transfusion (10.1% vs. 3.0%; P < 0.001), higher re-admission rate for AHF at 3 months' follow-up (27.6% vs. 18.8%; P < 0.001) and at 12 months' follow-up (34.3% vs. 26.2%; P < 0.001). Multivariate logistic regression demonstrated that patients with CRAS were associated with higher odds of all-cause mortality during hospital admission [adjusted odds ratio (aOR), 2.10; 95% confidence interval (CI): 1.34-3.31; P = 0.001], at 3 months' follow-up (aOR, 1.48; 95% CI: 1.07-2.06; P = 0.018), and at 12 months' follow-up (aOR, 1.45; 95% CI: 1.12-1.87; P = 0.004). Stratified analyses showed that CRAS patients with HFrEF were associated with higher odds of all-cause mortality during hospital admission (aOR, 2.03; 95% CI: 1.20-3.45; P = 0.009) and at 12 months' follow-up (aOR, 1.42; 95% CI: 1.06-1.89; P = 0.019) but not at 3 months' follow-up (aOR, 1.43; 95% CI: 0.98-2.09; P = 0.063). However, in AHF patients with preserved ejection fraction (LVEF ≥ 50%), CRAS was not associated with higher odds of all-cause mortality not only during hospital admission (aOR, 2.15; 95% CI: 0.84-5.55; P = 0.113) but also at 3 months' follow-up (aOR, 1.87; 95% CI: 0.93-3.76; P = 0.078) and at 12 months' follow-up (aOR, 1.59; 95% CI: 0.91-2.76; P = 0.101).

CONCLUSIONS

The incidence of CRAS was 27%. CRAS was associated with higher odds of all-cause mortality in AHF patients in the Middle East, especially in those with HFrEF.

One-year risks of stroke and mortality in patients with atrial fibrillation from different clinical settings: The Gulf SAFE registry and Darlington AF registry

BACKGROUND

Differences exist in oral anticoagulation (OAC) use between different populations with atrial fibrillation (AF), which may be associated with varying outcomes.

PURPOSE

We aimed to provide patient level comparisons of two cohorts of patients with AF, from the United Kingdom (UK) and Middle East (ME).

METHODS

The clinical characteristics, prescription of OAC, one-year risk of stroke and mortality were compared between individual patients with AF included into the Darlington AF registry (UK, n = 2258) and the Gulf SAFE (Survey of atrial fibrillation events) registry (ME, n = 1740).

RESULTS

A high percentage of patients from the Darlington registry were candidates for OAC (i.e., CHA₂DS₂-VASc score ≥2 in males or ≥3 in females; 82.0% in Darlington and 57.1% in Gulf SAFE). OAC use was suboptimal (52.0% in Darlington vs 58.4% in Gulf SAFE). One-year rates of stroke and mortality were high in both populations, especially in those with CHA₂DS₂-VASc score ≥2 in males and ≥3 in females (Darlington vs. Gulf SAFE: 3.51% vs. 5.63 for stroke; 11.4% vs. 16.8% for mortality). On multivariate analyses, female sex and previous stroke were independently associated with stroke events; while elderly age, female sex, vascular disease and heart failure were independent risk factors for mortality (all p < 0.05). Patients from Gulf SAFE registry had higher risk of stroke (odds ratio, 2.18 [1.47-3.23]) and mortality (odds ratio, 1.67 [1.31-2.14]) compared with those from Darlington registry. The CHA₂DS₂-VASc score showed good discrimination in predicting one-year risk of stroke (area under curve, 0.71 [0.65-0.76] in non-anticoagulated patients) and mortality (area under curve, 0.70 [0.68-0.72]) in the whole study population, as well as in Darlington or Gulf SAFE registry separately.

CONCLUSIONS

Stroke prevention was generally suboptimal in patient cohorts from the two registries, which was associated with high one-year risks of stroke and mortality, particularly so among patients from the Gulf SAFE registry. The higher risks for stroke and mortality in AF patients from the Gulf SAFE registry (compared to a UK cohort) merit further implementation of cardiovascular prevention strategies.

Impact of Clopidogrel on Mortality in Patients With Acute Heart Failure Stratified by Coronary Artery Disease: Findings From the Arabian Gulf Acute Heart Failure Registry (Gulf CARE)

We evaluated the impact of clopidogrel use on 3- and 12-months all-cause mortality in patients with acute heart failure (AHF) stratified by coronary artery disease (CAD) in patients admitted to 47 hospitals in 7 Middle Eastern countries with AHF from February to November 2012. Clopidogrel use was associated with significantly lower risk of all-cause mortality at 3 months (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI]: 0.42-0.87; P = .007) and 12 months (aOR, 0.61; 95% CI: 0.47-0.79; P < .001). When the analysis was stratified by CAD, the clopidogrel group in those with AHF and CAD was also associated with significantly lower risk of all-cause mortality at 3 months (aOR, 0.56; 95% CI: 0.38-0.83; P = .003) and 12 months (aOR, 0.58; 95% CI: 0.44-0.77; P < .001). However, in AHF patients without CAD, clopidogrel use was not associated with any survival advantages, neither at 3 months (aOR, 0.99; 95% CI: 0.32-3.11; P = .987) nor at 12 months (aOR, 0.80; 95% CI: 0.37-1.72; P = .566). Clopidogrel use was associated with short- and long-term all-cause mortality in patients with AHF and CAD. In AHF patients without CAD, clopidogrel use did not offer any survival advantage.

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.

β-Blocker Therapy Prior to Admission for Acute Coronary Syndrome in Patients Without Heart Failure or Left Ventricular Dysfunction Improves In-Hospital and 12-Month Outcome: Results From the GULF-RACE 2 (Gulf Registry of Acute Coronary Events-2)

Background

The prognostic impact of β‐blockers (BB) in acute coronary syndrome (ACS) patients without heart failure (HF) or left ventricular dysfunction is controversial, especially in the postreperfusion era. We sought to determine whether a BB therapy before admission for ACS has a favorable in‐hospital outcome in patients without HF, and whether they also reduce 12‐month mortality if still prescribed on discharge.

Methods and Results

The GULF‐RACE 2 (Gulf Registry of Acute Coronary Events‐2) is a prospective multicenter study of ACS in 6 Middle Eastern countries. We studied in‐hospital cardiovascular events in patients hospitalized for ACS without HF in relation to BB on admission, and 1‐year mortality in relation to BB on discharge. Among the 7903 participants, 7407 did not have HF, of whom 5937 (80.15%) patients were on BB. Patients on BB tended to be older and have more comorbidities. However, they had a lower risk of in‐hospital mortality, mitral regurgitation, HF, cardiogenic shock, and ventricular tachycardia/ventricular fibrillation. Furthermore, 4208 patients were discharged alive and had an ejection fraction ≥40%. Among those, 84.1% had a BB prescription. At 12 months, they also had a reduced risk of mortality as compared with the non‐BB group. Even after correcting for confounding factors in 2 different models, in‐hospital and 12‐month mortality risk was still lower in the BB group.

Conclusions

In this cohort of ACS, BB therapy before admission for ACS is associated with decreased in‐hospital mortality and major cardiovascular events, and 1‐year mortality in patients without HF or left ventricular dysfunction if still prescribed on discharge.

Impact of Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptors Blockers on Mortality in Acute Heart Failure Patients with Left Ventricular Systolic Dysfunction in the Middle East: Observations from the Gulf Acute Heart Failure Registry (Gulf CARE)

AIMS

To evaluate the impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs)/ Angiotensin Receptors Blockers (ARBs) on in-hospital, 3- and 12-month all-cause mortality in Acute Heart Failure (AHF) patients with left ventricular systolic dysfunction in 7 countries of the Middle East.

METHODS AND RESULTS

Data was analysed from 2,683 consecutive patients admitted with AHF and Left Ventricular Ejection Fraction (LVEF) (<40%) from 47 hospitals from February to November 2012. Analyses were evaluated using univariate and multivariate statistics. The overall mean age of the cohort was 58±15, 72% (n=1,937) were males, 62% (n=1,651) had coronary artery disease, 57% (n=1,539) were hypertensives and 47% (n=1,268) had diabetes. Overall cumulative mortality at inhospital, 3- and 12-month follow-up was 5.8% (n=155), 12.6% (n=338) and 20.4% (n=548), respectively. Adjusting for demographic and clinical characteristics as well as medication in a multivariate logistic regression model, ACEIs were associated with lower risk of in-hospital mortality (adjusted odds ratio (aOR), 0.48; 95% Confidence Interval (CI): 0.25 to 0.94; p=0.031). At 3-month follow-up, both ACEIs (aOR, 0.64; 95% CI: 0.43 to 0.95; p=0.025) and ARBs (aOR, 0.34; 95% CI: 0.18 to 0.62; p<0.001) were associated with lower risk of mortality. Additionally, at 12-month follow-up, those prescribed ACEIs (aOR, 0.71; 95% CI: 0.53 to 0.96; p=0.027) and ARBs (aOR, 0.47; 95% CI: 0.31 to 0.71; p<0.001) were still associated with lower risk of mortality.

CONCLUSION

ACEIs and ARBs treatments were associated with lower mortality risk during admission and up to 12-month of follow-up in Middle East AHF patients with left ventricular systolic dysfunction.

Non-withdrawal of beta blockers in acute decompensated chronic and de novo heart failure with reduced ejection fraction in a prospective multicentre study of patients with acute heart failure in the Middle East

OBJECTIVES

Beta blockers reduce mortality in heart failure (HF). However, it is not clear whether they should be temporarily withdrawn during acute HF.

DESIGN

Analysis of prospectively collected data.

SETTING

The Gulf aCute heArt failuRe rEgistry is a prospective multicentre study of patients hospitalised with acute HF in seven Middle Eastern countries.

PARTICIPANTS

5005 patients with acute HF.

OUTCOME MEASURES

We studied the effect of beta blockers non-withdrawal on intrahospital, 3-month and 12-month mortality and rehospitalisation for HF in patients with acute decompensated chronic heart failure (ADCHF) and acute de novo heart failure (ADNHF) and a left ventricular ejection fraction (LVEF) <40%.

RESULTS

44.1% of patients were already on beta blockers on inclusion. Among those, 57.8% had an LVEF <40%. Further, 79.9% were diagnosed with ADCHF and 20.4% with ADNHF. Mean age was 61 (SD 13.9) in the ADCHF group and 59.8 (SD 13.8) in the ADNHF group. Intrahospital mortality was lower in patients whose beta blocker therapy was not withdrawn in both the ADCHF and ADNHF groups. This protective effect persisted after multivariate analysis (OR 0.05, 95% CI 0.022 to 0.112; OR 0.018, 95% CI 0.003 to 0.122, respectively, p<0.001 for both) and propensity score matching even after correcting for variables that remained significant in the new model (OR 0.084, 95% CI 0.015 to 0.468, p=0.005; OR 0.047, 95% CI 0.013 to 0.169, p<0.001, respectively). At 3 months, mortality was still lower only in patients with ADCHF in whom beta blockers were maintained during initial hospitalisation. However, the benefit was lost after correcting for confounding factors. Interestingly, rehospitalisation for HF and length of hospital stay were unaffected by beta blockers discontinuation in all patients.

CONCLUSION

In summary, non-withdrawal of beta blockers in acute decompensated chronic and de novo heart failure with reduced ejection fraction is associated with lower intrahospital mortality but does not influence 3-month and 12-month mortality, rehospitalisation for heart failure,and the length of hospital stay.

TRIAL REGISTRATION NUMBER

NCT01467973; Post-results.

Sex differences in management and outcomes of patients with atrial fibrillation in the Middle East: Gulf survey of atrial fibrillation events (Gulf SAFE)

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

BMI is inversely correlated to the risk of mortality in patients with type 2 diabetes hospitalized for acute heart failure: Findings from the Gulf aCute heArt failuRE (Gulf-CARE) registry

BACKGROUND

A U-shaped relationship has been reported between BMI and cardiovascular events among patients with acute heart failure (AHF). We hypothesized that an obesity paradox also governs the relationship between BMI and mortality in patients with type 2 diabetes (T2D) and AHF.

METHODS

We studied 3-month and 12-month mortality in patients with T2D hospitalized for AHF according to 5 BMI categories: Underweight (<20kg/m²), normal weight (referent group, 20-24.9kg/m²), overweight, (25-29.9kg/m²), obese (30-34.9kg/m²) and severely obese (≥35kg/m²), in the Gulf aCute heArt failuRe rEgistry (GULF-CARE).

RESULTS

Among the 5005 participants in this cohort, 2492 (49.8%) had T2D. Underweight patients had a higher 3-month and 12-month mortality risk (OR 2.04, 95% CI [1.02-4.08]; OR 2.44, 95% CI [1.35-4.3]; respectively), compared to normal weight. Severe obesity was associated with a lower 3-month and 12-month mortality risk (OR 0.53, 95% CI [0.34-0.83]; OR 0.58, 95% CI [0.42-0.81]; respectively). After adjustment for several risk variables in 2 different models, the primary outcome was still significantly increased in underweight patients, and decreased in severely obese patients, at 3months and 12months. Further, the odds of mortality decreases with increasing BMI by 0.38 at 3months and at 0.45 at 12months in a near-linear shape (p=0.007; p=0.037; respectively).

CONCLUSIONS

In this cohort of patients with AHF, BMI was inversely correlated to the risk of mortality in patients with T2D. Moreover, severe obesity was associated with less mortality risk.

Correction: Compositional engineering of the pi-conjugated small molecular VOPcPhO : Alq3 complex to boost humidity sensing

Correction for ‘Compositional engineering of the pi-conjugated small molecular VOPcPhO : Alq₃ complex to boost humidity sensing’ by Noshin Fatima et al., RSC Adv., 2017, 7, 19780–19786.

Compositional engineering of the pi-conjugated small molecular VOPcPhO : Alq3 complex to boost humidity sensing

This study exhibits a solution-processed organic semiconductor humidity sensor based on vanadyl 2,9,16,23-tetraphenoxy-29H,31H-phthalocyanine (VOPcPhO), tris-(8-hydroxy-quinoline)aluminum (Alq₃), and their composites.

Processable dodecylbenzene sulfonic acid (DBSA) doped poly(N-vinyl carbazole)-poly(pyrrole) for optoelectronic applications

A soluble poly (n-vinyl carbazole)–polypyrrole (PNVC–Ppy) copolymer was prepared through oxidative chemical polymerization wherein dodecyl benzene sulfonic acid (DBSA) was used as a dopant to facilitate polymer-organic solvent interaction and ammonium persulfate (APS) was used as an oxidant. Compared with undoped PNVC–Ppy, the DBSA-doped PNVC–Ppy copolymer showed higher solubility in some selected organic solvents. The composition and structural characteristics of the DBSA-doped PNVC–Ppy were determined by Fourier transform infrared, ultraviolet–visible, and X-ray diffraction spectroscopic methods. Field emission scanning electron microscopic method was employed to observe the morphology of the DBSA-doped PNVC–Ppy copolymer. The electrical conductivity of the DBSA-doped PNVC–Ppy copolymer was measured at room temperature. The conductivity increased with increasing concentration of APS oxidant, and the highest conductivity was recorded at 0.004 mol/dm³ APS at a polymerization temperature of −5 °C. The increased conductivity can be explained by the extended half-life of pyrrole free radical at a lower temperature and a gradual increase in chain length over a prolonged time due to the slow addition of APS. Furthermore, the obtained soluble copolymer exhibits unique optical and thermal properties different from those of PNVC and Ppy.

Coronary artery disease prevalence and outcome in patients hospitalized with acute heart failure: an observational report from seven Middle Eastern countries

OBJECTIVES

The purpose of this study was to report prevalence, clinical characteristics, precipitating factors, management and outcome of patients with coronary artery disease (CAD) among patients hospitalized with heart failure (HF) in seven Middle Eastern countries and compare them to non-CAD patients.

METHODS

Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicenter study of 5005 consecutive patients hospitalized with acute HF during February-November 2012 in 7 Middle Eastern countries.

RESULTS

The prevalence of CAD among Acute Heart Failure (AHF) patients was 60.2% and varied significantly among the 7 countries (Qatar 65.7%, UAE 66.6%, Kuwait 68.0%, Oman 65.9%, Saudi Arabia 62.5%, Bahrain 52.7% and Yemen 49.1%) with lower values in the lower income countries. CAD patients were older and more likely to have diabetes, hypertension, dyslipidemia and chronic kidney disease. Moreover, CAD patients were more likely to have history of cerebrovascular and peripheral vascular disease when compared to non-CAD patients. In-hospital mortality rates were comparable although CAD patients had more frequent re-hospitalization and worse long-term outcome. However, CAD was not an independent predictor of poor outcome.

CONCLUSION

The prevalence of CAD amongst patients with HF in the Middle East is variable and may be related to healthcare sources. Regional and national studies are needed for assessing further the impact of various etiologies of HF and for developing appropriate strategies to combat this global concern.

Implications of a History of Syncope in Patients Hospitalized With Heart Failure

We assessed the frequency and implications of a history of syncope of up to 1 year prior to hospitalization with acute heart failure (AHF) between February and November 2012. Data were collected for 5005 patients hospitalized with AHF and analyzed and compared according to the absence/presence of a history of syncope (group 1 vs group 2). Prior syncope among patients with heart failure was 5.3%. Age, gender, hypertension, atrial fibrillation, bundle branch block, left ventricular ejection fraction (LVEF), and obstructed coronary vessels were comparable in the 2 groups. Group 2 patients were more likely to smoke or have diabetes mellitus, stroke, and cardiac arrest. Group 2 patients frequently required aggressive treatment and had more worse in-hospital and 1-year outcomes compared to group 1. After adjustment for age, sex, ethnicity, and LVEF, multivariate regression analysis showed that history of syncope predicted in-hospital mortality (odds ratio: 2.61; 95% confidence interval: 1.707-4.002). History of syncope during the year prior to the index admission with AHF is a marker of worse outcomes regardless of patient age and LVEF. Further studies are required to confirm this observation and its clinical implications.

Validation of the 6-Month GRACE Score in Predicting 1-Year Mortality of Patients With Acute Coronary Syndrome Admitted to the Arabian Gulf Hospitals

Acute coronary syndromes (ACS) are the most common cardiovascular diseases and are associated with a significant risk of mortality and morbidity. The Global Registry of Acute Coronary Events (GRACE) risk score postdischarge is a widely used ACS prediction model for risk of mortality (low, intermediate, and high); however, it has not yet been validated in patients from the Arabian Gulf. This prospective multicenter study (second Gulf Registry of Acute Coronary Events) provides detailed information of the GRACE risk score postdischarge in patients from the Arabian Gulf. Its prognostic utility was validated at 1-year follow-up in over 5000 patients with ACS from 65 hospitals in 6 Arabian Gulf countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen). Overall, the goodness of fit (Hosmer and Lemeshow statistic P value = .826), calibration, and discrimination (area under the receiver operating characteristic curve = 0.695; 95% confidence interval: 0.668-0.722) were good. The GRACE risk score postdischarge can be used to stratify 1 year mortality risk in the Arabian Gulf population; it does not require further calibration and has a good discriminatory ability.

Demographics, Clinical Characteristics, Management, and Outcomes of Acute Heart Failure Patients: Observations from the Oman Acute Heart Failure Registry

OBJECTIVES

We sought to describe the demographics, clinical characteristics, management and outcomes of patients in Oman with acute heart failure (AHF) as part of the Gulf aCute heArt failuRe rEgistry (CARE) project.

METHODS

Data were analyzed from 988 consecutive patients admitted with AHF to 12 hospitals in Oman between 14 February and 14 November 2012.

RESULTS

The mean age of our patients was 63±12 years. Over half (57%) were male and 95% were Omani citizens. Fifty-seven percent of patients presented with acute decompensated chronic heart failure (ADCHF) while 43% had new-onset AHF. The primary comorbid conditions were hypertension (72%), coronary artery disease (55%), and diabetes mellitus (53%). Ischemic heart disease (IHD), hypertensive heart disease, and idiopathic cardiomyopathy were the most common etiologies of AHF in Oman. The median left ventricular ejection fraction of the cohort was 36% (27-45%) with 56% of the patients having heart failure with reduced ejection fraction (< 40%). Atrial fibrillation was seen in 15% of patients. Acute coronary syndrome (ACS) and non-compliance with medications were the most common precipitating factors. At discharge, angiotensin converting enzyme inhibitors and beta-blockers were prescribed adequately, but aldosterone antagonists were under prescribed. Within 12-months follow-up, one in two patients were rehospitalized for AHF. In-hospital mortality was 7.1%, which doubled to 15.7% at three months and reached 26.4% at one-year post discharge.

CONCLUSIONS

Oman CARE was the first prospective multicenter registry of AHF in Oman and showed that heart failure (HF) patients present at a younger age with recurrent ADCHF and HF with reduced ejection fraction. IHD was the most common etiology of HF with a low prevalence of AHF, but a high prevalence of acute coronary syndrome and non-compliance with medications precipitating HF. A quarter of patients died at one-year follow-up even though at discharge medical therapy was nearly optimal. Our study indicates an urgent need for prevention, early diagnosis, and treatment of AHF in Oman.