Sex differences in clinical features, utilization of oral anticoagulant agents, and 1-year outcome in Middle Eastern patients with atrial fibrillation

OBJECTIVE

Studies have revealed that sex can predict differences in multiple aspects of atrial fibrillation (AF). These differences are underreported in the Middle East. This study aims to describe sex-specific differences in risk factors, symptomatology, management, and outcomes in Middle Eastern patients with AF.

METHODS

The JoFib (Jordan-Atrial-Fibrillation) study is an observational, prospective, multicenter, nationwide registry in AF. Comparisons were made between female and male patients using Pearson chi-square and Mann-Whitney U tests. Multivariable regression models were constructed to investigate whether the female sex was predictive of any AF-related outcomes (all-cause death, cardiovascular death, ischemic stroke or systemic embolism [IS/SE], major bleeding, and clinically relevant non-major bleeding).

RESULTS

Of 2,020 patients with AF, 54% (n = 1091) were females. Females with AF were older (median age 71 vs. 69, p <.001), but had less heart failure (20.9% vs. 27.2%, p = .001) and coronary artery disease (7.5% vs. 14.7%, p <.001). Females with AF were more symptomatic (74.7% vs. 66.5%, p <.001) and frequently received anticoagulant therapy (84.4% vs. 78.9%, p = .001). Rhythm control was pursued less frequently in females (23.4% vs. 27.3%, p = .04). All studied outcomes occurred with similar frequencies in females and males, and sex was not significantly predictive of any outcome.

CONCLUSION

Females with AF are more symptomatic, yet they are treated less with rhythm control. Despite higher risk, females have similar risk-adjusted all-cause cardiovascular death and stroke rates compared to males. Future studies should explore how treatments and interventions can influence quality-of-life and cardiovascular outcomes in females with AF.

Clinical Profiles and One-Year Outcome in Middle Eastern Patients With Atrial Fibrillation and Hypertension: Analysis From the Jordan Atrial Fibrillation Study

Studies on the impact of hypertension (HTN) on the outcome of patients with atrial fibrillation (AF) in the Middle East are scarce. The aim of this contemporary multicenter study is to evaluate the effect of the coexisting HTN on the baseline clinical profiles and 1-year prognosis in a cohort of Middle Eastern patients with AF. Consecutive AF patients in 29 hospitals and cardiology clinics were enrolled in the Jordan AF study (May 2019-December 2020). Patients were prospectively followed up for 1 year, and the study had no influence on their treatment, which was at the discretion of the treating physician. We compared clinical features, use of medications, and 1-year prognosis in patients with AF/HTN compared with AF/no HTN. Among 1849 non-valvular AF patients, 76.4% had HTN, with higher prevalence of diabetes, dyslipidemia, coronary heart disease, stroke, and left ventricular hypertrophy in HTN patients. There was a higher thromboembolic and bleeding risk among HTN patients. At 1 year, HTN patients had significantly higher rates of stroke and systemic embolism (SSE) (4.5%), acute coronary syndrome (ACS) (2.4%), rehospitalization (27.9%), and major bleeding events (3.0%) compared with non-HTN patients. In this cohort, the coexistence of HTN was associated with worse baseline clinical profile and 1-year outcomes.

Medication Adherence and Its Influencing Factors among Patients with Heart Failure: A Cross Sectional Study

Background and objectives: The chronic nature of heart failure requires long-lasting consumption of various medications. Despite the therapeutic benefits of heart failure medications, about 50% of patients with heart failure don't adequately adhere to their medications as prescribed globally. This study aimed to determine medication adherence levels among Jordanians with heart failure and its influencing factors. Materials and Methods: A cross-sectional study was conducted among 164 patients with heart failure attending cardiac clinics in the north of Jordan. The Medication Adherence Scale was used to measure medication adherence. Results: Overall, 33.5% of patients had high adherence, and 47% had partial to poor adherence. The proportion of patients with good to high adherence was significantly higher among patients younger than 60 years, having >high school level of education, being married, living with somebody, and having insurance. Conclusions: Patient-centered approach, targeting age, level of education, marital status, and health insurance coverage, should be developed using evidence-based guidelines to enhance adherence to medication and health outcomes in Jordanian patients with heart failure. The development and implementation of new and feasible strategies, particularly suited to Jordan's healthcare system capabilities, is important to improve medication adherence.

Thromboembolism and Major Bleeding in Patients with Atrial Fibrillation and EHRA Type 2 Valvular Heart Disease: The Jordan Atrial Fibrillation (JoFib) Study

Aim

The risks of thromboembolism and major bleeding in atrial fibrillation (AF) patients were assessed according to the "Evaluated Heartvalves, Rheumatic or Artificial" (EHRA) classification. Additionally, the safety and efficacy of vitamin K antagonists (VKAs) and non-VKA oral anticoagulants (NOACs) were compared in AF patients with EHRA type 2 valvular heart disease (VHD) versus those with no VHD.

Methods

AF patients enrolled in the "Jordan Atrial Fibrillation (JoFib)" study were followed up for thromboembolic events and major bleeding at 30, 180, and 365 days. Patients in the EHRA type 2 VHD and non-VHD groups were sub-grouped to compare different OACs.

Results

2020 AF patients were recruited. The thromboembolic risk was higher in EHRA type 2 VHD patients compared to non-VHD controls. Major bleeding also occurred at higher rates in EHRA type 2 patients. In addition, NOACs were more effective in preventing thromboembolic events than VKAs and non-anticoagulation in EHRA type 2 VHD patients. Furthermore, EHRA type 2 VHD patients taking rivaroxaban had significantly less thromboembolic risk than their non-anticoagulated counterparts. At the same time, apixaban and warfarin did not significantly lower the risk of thromboembolism compared to non-anticoagulation.

Conclusion

AF patients with EHRA type 2 VHD are at significant risk of thromboembolism and major bleeding. Furthermore, NOACs were more effective than VKAs in preventing thromboembolic events in this group of patients without conferring an added risk of major bleeding. Moreover, rivaroxaban appears to be particularly efficacious.

Development of a telemedicine group educational program for patients with heart failure: A delphi study

Aims

Evidence regarding the most effective and feasible videoconferencing group educational program for patients with heart failure is still equivocal. This study aimed to reach consensus about the structure, acceptability, and feasibility of videoconferencing for people with heart failure in Jordan that improves access to healthcare and clinical outcomes.

Methods

There were two Delphi survey studies of three rounds each. Delphi one survey involved 32 healthcare staff, experienced in heart failure clinical practice and telehealth, to obtain a consensus of opinion on a proposed group videoconferencing program for patients with heart failure. Delphi two involved seven staff of the information technology center, experienced in videoconferencing and using supporting applications, to obtain their consensus on the current capabilities of the healthcare system and patients about information technology. Descriptive statistics were used for each item to determine whether consensus was achieved or not. Items that received 80% disagreement or 80% agreement of participants were not presented for re-rating in the third round, while the items that scored varying degrees of agreement were presented for experts for re-rating.

Results

In Delphi one a group of items reached consensus regarding structure, factors influencing, and effectiveness of the videoconferencing program. In Delphi two, the findings indicated that videoconferencing modality is applicable and feasible in Jordan.

Conclusion

This is the first study that addresses the equivocal evidence for the design and implementation of heart failure videoconferencing programs. The framework of the current proposed program can be utilized as a guideline to test or develop a future videoconference program.

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.

Sleep quality among different classes of heart failure patients in Jordan: A STROBE compliant cross-sectional study

Many researchers emphasize the importance of studying sleep quality among patients with heart failure (HF). Because of the importance of this topic, many studies have been conducted to address the different aspects of sleep-in various populations of patients with HF. The purposes of our study were: to assess the types of disturbances in sleep within the different classes of HF, and to assess whether there were differences in the levels of sleep quality and types of disturbances in sleep within the different classes in non-hospitalized Jordan patients with HF. Data were gathered from 2 cardiac clinics and 2 medical clinics at 3 Jordan hospitals. A minimum sample of 200 people was recruited to participate in this study based on these criteria and factors. The prevalence of low sleep quality and types of disturbances in sleep were increased with the increase in New York Heart Association class. Nearly 3 quarters of the study sample had poor sleep quality 73.5% (n = 147). Using a score of 5 as a cut point, 147 patients with HF in our study sample had poor sleep quality. The most common types in all classes were waking up for urination, waking in the middle of the night or early morning, waking up due to coughing and snoring, and difficulty falling asleep within 30 minutes. However, waking up due to feeling cold or hot were rarely reported in all classes of patients with HF. Poor sleep quality negatively affects the quality of life in patients with HF by decreasing physical cognitive and psychosocial performance in those patients. This is the first study in literature study sleep quality in the different New York Heart Association functional classes.

Myocardial injury and its correlation to mortality in hospitalized COVID-19 patients: A retrospective cohort study

Purpose

This retrospective observational study was conducted to assess the clinical characteristics and outcomes of hospitalized COVID-19 patients with positive cardiac enzymes in the King Abdullah University Hospital (KAUH) in Irbid, Jordan.

Patients and methods

A total of 676 patients admitted to KAUH for moderate-to-severe COVID-19 were included in the study. Clinical and mortality data were collected from patients' electronic medical records.

Results

A significant association was found between myocardial injury and In-hospital mortality. Seven comorbidities were identified as risk factors for myocardial injury: Hypertension, diabetes mellitus (DM), previous cerebrovascular accident (CVA), ischemic heart disease (IHD), heart failure, chronic kidney disease (CKD), and cardiac arrhythmias. The need for intensive care unit (ICU) for invasive ventilation was also associated with myocardial injury. Acute kidney injury (AKI) during hospitalization had a significantly higher incidence of myocardial injury and mortality. Acute myocardial infarction (MI) and acute peripheral vascular disease (PVD) were also associated with higher mortality.

Conclusion

Myocardial injury is an important predictor of mortality in patients with moderate-to-severe COVID-19 disease. Patients with a history of hypertension, diabetes mellitus, any vascular diseases, cardiac arrhythmias or heart failure are considered high-risk for adverse outcome. Additionally, COVID-19 patients with myocardial injury and acute kidney injury were recognized with the highest mortality rate.

COVID-19 Fear and Anxiety among Patients with Chronic Heart Failure: A Cross Sectional Study

Although the current management of COVID-19 is mainly focused on efficacious vaccine and infection control, the most common psychological reactions (such as fear and anxiety) associated with the COVID-19 pandemic have not been investigated and even neglected in patients with heart failure who are at greater risk for morbidity and mortality. We assessed COVID-19 related fear and anxiety among patients with heart failure and determined their associated factors. A cross sectional survey was conducted among 300 consecutive patients with heart failure during the period of March 2021−June 2021. Almost 50.7% of patients had fear of COVID-19 and 36.3% had coronavirus anxiety. Age > 55 was significantly associated with increased odds of fear (OR = 2.6) and anxiety (OR = 4.3). Patients with angina were more likely to have fear (OR = 3.0) and anxiety (OR = 2.2) and patients with chronic lung disease were more likely to have fear (OR = 3.0) and anxiety (OR = 3.3). Increased age, having angina, and having chronic lung disease were associated with increased odds of fear of COVID-19 and coronavirus anxiety. Psychological support needs to be integrated in patient care with special attention to physiological risk factors that are associated with COVID-19 comorbidities.

Development of videoconferencing group educational program for patients with heart failure: A Delphi study

Funding Acknowledgements

Type of funding sources: None.

Background

During the COVID-19 outbreak, videoconference technology can help people avoid physical contact and minimise the exposure of healthcare providers to sick people as well as respiratory secretions. Videoconferencing can be beneficial for people with chronic conditions (such as heart failure) who have restricted mobility, live in remote and rural areas, or experience social loneliness. However, evidence for the effectiveness of using internet videoconferencing and its components accounted for the positive outcomes (such as knowledge, quality of life, self-care, healthcare utilization) is still lacking.

Purpose

To develop a feasible videoconferencing program for patients with heart failure that meets patients’ needs and preferences in Jordan.

Methods

The study involved two Delphi survey studies of three rounds each. The first Delphi survey involved 32 healthcare staff, with heart failure clinical experience, to obtain a consensus of opinion on a proposed group videoconferencing program for patients with heart failure. The second Delphi study involved seven staff of the information technology center, with experience in videoconferencing and using supporting applications, to obtain their consensus on the current capabilities, needs, barriers and facilitators of the healthcare system (providers) and patients (users) about information technology. For both Delphi studies, content analysis was used to analyze responses of participants in the first-Delphi round. Items resulting from the first-round analysis were summarized, listed, and rated (5-point Likert scale) in order to provide input and develop the second-round questionnaire. The percent agreement of participants was defined to be 80% or above to indicate their consensus.

Results

Healthcare providers prefer sessions to be led by the cardiologists and cardiac nurses, moving from simple to a complex topic, and the dose of information and frequency should be varied according to the needs and severity of heart failure. Videoconferencing strategy could improve patients’ satisfaction, knowledge and self-care, and adherence with their therapy plans. Jordan healthcare system has a capability to use videoconferencing strategy in Jordan.

Conclusion

This study addresses the equivocal evidence for the effectiveness of using internet videoconferencing between healthcare provider and patients. Establishing an effective videoconferencing program assists with meeting patients’ needs and preferences, accessing healthcare during COVID-19, reducing travel burden/costs as well as the risk of exposure to the virus, and ultimately improving clinical outcomes. This study will capture attention of healthcare providers to perform further studies targeting videoconferencing heart failure management programs

COVID-19 pandemic stresses trigger ST-elevation and non-ST-elevation acute myocardial infarction in Middle Eastern individuals not infected with the virus

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Abdul Hameed Showman Foundation

OnBehalf

The Jordan COVID-19 AtheRosclerotic Cardiovascular Events (JoCORE) Study Investigators

Background. The vicarious stresses associated with the covid-19 pandemic have been reported to cause psychosocial behavioral changes in individuals not infected with the virus. No reports have evaluated the effect of these stresses on triggering acute ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI, respectively) in such individuals. Purpose. We sought to study the nature of MI triggers and clinical profiles in non covid-19 individuals during the pandemic. Methods: Patients not infected with the covid-19 virus admitted to 9 hospitals with STEMI and NSTEMI during the pandemic crisis in Jordan from February through December 2020 were evaluated for pre-MI exposure to psychosocial and economic triggers related to the pandemic, lockdown and shutdown. Results: Of 144 patients enrolled, 58 (40.3%) had STEMI and 86 (59.7%) had NSTEMI. Compared with the NSTEMI group, the STEMI group tended to be younger (59.0 + 13.8 vs. 62.3 + 12.7 years, p = 0.14), had significantly more men than women (94.9% vs. 75.6%, p = 0.005), were more likely to be smokers (75.9% vs. 55.8, p = 0.02) and had lower prevalence of prior coronary revascularization (17.2% vs. 45.3%, p = 0.001). In-hospital mortality among the 133 patients who were alive upon hospital arrival was 1.5%. All patients reported exposure to at least one psychosocial stressful trigger, including lockdown and loneliness stress (65.3%), fear of contacting covid-19 infection or of uncertainty (26.4%), anger (18.8%), and death of a significant person during the pandemic (4.2%) Financial hardship and volatile income were reported by 42.4% of patients. STEMI and NSTEMI patients did not have significant differences in the frequency of psychosocial (100% vs. 99.9%, respectively, p = NS) or economic triggers (34.5% vs. 47.7%, respectively, p = NS). Conclusions. Exposure to psychosocial and financial stresses related to the covid-19 pandemic and its related lockdown can trigger acute MI. An increase in the number of these events may become a potentially serious health issue with longer duration of the unremitting pandemic.

Diagnostic value of electrocardiogram during routine electroencephalogram

INTRODUCTION

A single-lead electrocardiogram (EKG) is routinely recorded with electroencephalogram (EEG). This study investigates the frequency and types of EKG abnormalities during routine EEG.

METHODS

All routine EEGs (20-60 min) over one year were retrospectively analyzed. A blinded cardiologist interpreted EKG recordings. An epileptologist evaluated EEGs. Demographic data, underlying comorbidities, and indications for the EEG were extracted.

RESULTS

A total of 433 recordings for 365 patients were included. Mean (±SD) age was 46.8 (±21.3) years and 50.4% were females. EKG abnormalities were detected in 28.5% of patients; sinus tachycardia (11%), premature ventricular contractions (7.9%), atrial fibrillation (Afib) (6.3%), sinus bradycardia (2.2%) and premature atrial contractions (1.1%). Afib was more common in females than males (p = 0.020), confirmed in six out of seven patients and discovered in 17 patients. Age (OR: 1.67, 95%CI: 1.05-2.66, p = 0.031), prior diagnosis of epilepsy (OR: 2.25, 95% CI: 1.22 - 4.14, p = 0.009), history of seizure (OR: 1.97,  95%CI: 1.09-3.54, p = 0.024), abnormal EEG (OR: 2.14, 95%CI: 1.25 - 3.66, p = 0.005) and EEGs evaluating seizures/epilepsy (OR: 4.18, 95% CI: 1.32 - 13.21, p = 0.015) or syncope (OR: 3.21, 95% CI: 1.16 - 8.84, p = 0.024) were independently associated with abnormal EKG.

CONCLUSION

The frequency of EKG abnormalities captured during routine EEGs was high, with Afib being the most significant. Older age, history of epilepsy or seizure, abnormal EEGs, and EEGs evaluating seizures/epilepsy or syncope were significant predictors. These findings suggest neurologists to become more vigilant to EKG recorded during routine EEG as such findings might have diagnostic and therapeutic implications.

Utilization of Guidelines-recommended secondary cardiovascular preventive medications in a decade or more survivors after coronary revascularization in the Middle East; analysis form the DECADE PLUS S

Background

There is scarcity of studies from the Middle East had address the use of guideline-recommended secondary cardiovascular prevention medications among individuals who survived at least one decade after coronary revascularization (CR) by percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG).

Purpose

An objective of the DECADE-PLUS study was to evaluate the use of antiplatelet agents (APA), statins, beta blockers (BB) and renin-angiotensin system inhibitors (RASI) in such patients.

Methods

We enrolled consecutive patients seen at ambulatory or in-patient settings with the following inclusion criteria: patient had PCI or CABG &gt;10 years ago, age &gt;18 years at the time of the index CR, and availability of data of currently used medications.

Results

Of 892 patients enrolled, 600 (67.3%) had PCI and 292 (32.7%) had CABG. Patients had CR &gt;20 years ago (100; 11.2%), 11–19 years ago (536; 60.1%) or 10 years ago (256; 28.7%). Women comprised 13.8% of the whole cohort, and mean age at index CR was 53.4+9.4 years. Hypertension, diabetes mellitus, and dyslipidemia were present in 398 (44.6%), 351 (39.3%) and 290 (32.5%), respectively at the time of CR. Overall, aspirin was used in 745 (83.5%), and a second APA in 329 (36.9%). Statins, BB and RASI were used in 83.7%, 71.7% and 54.3%, respectively. Univariate analysis of predictors of lower rates of use of these medications showed that survival time (10 years vs. &gt;20 years), and revascularization type (PCI vs. CABG) had no impact on use of these medications. However, nondiabetics were less often prescribed second APA (odds ratio (OR) 0.78, p=0.005) and RASI (OR 0.85, p=0.007) compared with diabetics. Furthermore, compared with men, women were less often prescribed aspirin (OR 0.66, p&lt;0.0001), statin (OR 0.67, p&lt;0.0001), BB (OR 0.71, p=0.005), and RASI (OR 0.79, p=0.005).

Conclusion

Middle East patients surviving at least one decade after coronary revascularization have a high rate of utilization of secondary cardiovascular medications compared with western data. However, women and non-diabetic individuals have lower rate of use of these medications compared with diabetics and men, respectively. Larger studies are warranted to explore the reasons behind these discrepancies and thus represent potential targets for positive intervention.

Funding Acknowledgement

Type of funding source: None

The use of echocardiographic and clinical data recorded on admission to simplify decision making for elective percutaneous coronary intervention: a prospective cohort study

BACKGROUND

Coronary artery disease (CAD), a leading cause of mortality, affects patient health-related quality of life (HRQoL). Elective percutaneous coronary interventions (ePCIs) are usually performed to improve HRQoL of CAD patients. The aim of this study was to design models using admission data to predict the outcomes of the ePCI treatments on the patients' HRQoL.

METHODS

This prospective cohort study was conducted with CAD patients who underwent ePCIs at the King Abdullah University Hospital in Jordan from January 2014 through May 2015. Six months after their ePCI procedures, the participants completed the improved MacNew (QLMI-2) questionnaire, which was used for evaluating three domains (physical, emotional and social) of HRQoL. Multivariate linear regression was used to design models to predict the three domains of HRQoL from echocardiographic findings and clinical data that are routinely measured on admission.

RESULTS

The study included 239 patients who underwent ePCIs and responded to the QLMI-2 questionnaire. The mean age (± standard deviation) of the participants was 55.74 ± 11.84 years, 54.58 ± 11.37 years for males (n = 174) and 59.11 ± 12.49 years for females (n = 65). The average scores for physical, emotional and social HRQoL were 4.38 ± 1.27, 4.4 ± 1.11, and 4.37 ± 1.32, respectively. Out of the 42 factors inputted to the models to predict HRQoL scores, 10, 9, and 9 factors were found to be significant determinants for physical, emotional and social domains, respectively, with adjusted coefficients of determination of 0.630, 0.604 and 0.534, respectively. Basophil levels on admission showed a significant positive correlation with the three domains of HRQoL, while aortic root diameter showed a negative correlation. Scores for the three domains were significantly lower in women than in men. Hypertensive and diabetic patients had significantly lower HRQoL scores than patients without hypertension and diabetes.

CONCLUSION

The prediction of HRQoL scores 6 months after an ePCI is possible based on data acquired on admission. The models developed here can be used as decision-making tools to guide physicians in identifying the efficacy of ePCIs for individual patients, hence decreasing the rate of inappropriate ePCIs and reducing costs and complications.

The Most and the Least Performed Self-Care Behaviors Among Patients With Heart Failure in Jordan

Assessing self-care is important aspects among patients with heart failure. However, few studies were conducted to assess self-care among patients with heart failure in Jordan. Therefore, this study aimed to assess the most and the least performed maintenance self-care behaviors and to examine the relationship between maintenance self-care behaviors and selected sociodemographics. A cross-sectional design utilizing a convenience sample of 226 patients with heart failure was used. The maintenance self-care mean was 53.89 and considered below the clinical target level (≥70). Asking for low salt item and performing physical exercises were the most performed self-care behaviors, while "trying to avoid getting sick" and "checking ankles for swelling" were the least performed self-care behaviors. Limited self-care behaviors indicated the need to implement cardiac education that may improve self-care behaviors. Cardiac education should target mainly patients with low income, low educational level, elderly, living alone, unemployed, and who are using traditional treatment.

Reality of obesity paradox: Results of percutaneous coronary intervention in Middle Eastern patients

Objective

The aim of this study was to assess the baseline clinical characteristics, coronary angiographic features, and adverse cardiovascular events during hospitalization and at 1 year of follow-up in obese patients compared with overweight and normal/underweight patients.

Methods

A prospective, multicenter study of consecutive patients undergoing percutaneous coronary intervention was performed.

Results

Of 2425 enrolled patients, 699 (28.8%) were obese, 1178 (48.6%) were overweight, and 548 (22.6%) were normal/underweight. Obese patients were more likely to be female and to have a higher prevalence of diabetes, hypertension, hypercholesterolemia, or previous percutaneous coronary intervention. Acute coronary syndrome was the indication for percutaneous coronary intervention in 77.0% of obese, 76.4% of overweight, and 77.4% of normal/underweight patients. No significant differences in the prevalence of multi-vessel coronary artery disease or multi-vessel percutaneous coronary intervention were found among the three groups. Additionally, no significant differences were found in stent thrombosis, readmission bleeding rates, or cardiac mortality among the three groups during hospitalization, at 1 month, and at 1 year.

Conclusion

The major adverse cardiovascular event rate was the same among the three groups throughout the study period. Accordingly, body mass index is considered a weak risk factor for cardiovascular comorbidities in Arab Jordanian patients.

Cardiovascular risk factors in Middle Eastern patients undergoing percutaneous coronary intervention: Results from the first Jordanian percutaneous coronary intervention study

Background and aims: Cardiovascular disease (CVD) is the leading cause of death in the Middle East. We sought to study the prevalence and coexistence of 6 cardiovascular risk factors (RFs) among patients who underwent percutaneous coronary intervention (PCI), and to evaluate the impact of age and gender on the presence of multiple RFs.

METHODS AND RESULTS

In this prospective, multicenter study, 2426 consecutive patients were enrolled. Mean age was 59.0 ± 10.1 years and 500 (20.6%) were women. Acute coronary syndrome and stable coronary disease were the indications for PCI in 77.1% and 22.9%, respectively. Hypertension was present in 62.3%, diabetes in 53.8%, hypercholesterolemia in 48.8%, smoking in 43.5%, family history of premature CVD 39.4% and obesity in 28.8%. Only 3.8% did not have any of these RFs. Presence of ⩾3 and ⩾4 RFS was observed in 57.4% and 29.5% of patients, respectively. Presence of ⩾3 RFs was more common in women than men (69.0% vs. 54.5%, p < 0.0001), and among patients 41-65 years of age than older or younger patients (60.1% vs. 52.0% vs. 48.3%, respectively, p = 0.017). Conclusions: Cardiovascular RFs are highly prevalent in this PCI Middle Eastern population undergoing PCI. More than half and more than one-fourth of the patients had at least 3 or 4 RFs; respectively. More women than men and more middle aged patients than older or younger patients had significantly higher rates of presence of multiple RFs.

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.

Heart response to horizontal impulse

Lumped body parameters linear and nonlinear models have been developed and used for the analysis of the response of the heart in a seated human body due to impulsive horizontal inputs at various body segments. The acceleration transfer magnitude and phase due to impulsive inputs at various body segments are reported. Time histories of the heart acceleration transfer were obtained for both linear and nonlinear models. The results indicate that the largest acceleration transfer occurs at 2-3 Hz frequency. Inputs at the upper body segments excite a second peak and in the acceleration transfer at 10-12 Hz. The nonlinear model shows large attenuation at the high frequency range (larger than 10 Hz) and less attenuation at the 1-5 Hz frequency range.

Human body model response to mechanical impulse

Despite our understanding of the importance of falling, previous studies have ignored the effects of falls from standing height. In this article, lumped parameter linear and nonlinear models of a standing human have been used to simulate the impact response of the body segments due to inputs at the shoes. The acceleration transfer and frequency response were determined. The effect of nonlinear damping was simulated. Nonlinear effects were found to be most significant when the input amplitude increases. Frequency response attenuation was significant, resulting in almost a shift in the magnitude plots in the range (0.1-100 Hz) of frequency. When the input amplitude was reduced, the nonlinear effects became apparent only in the medium frequency range. In the case simulating a human subject exposed to impulse at the foot, a large amount of energy is dissipated in the joints due to the friction resulting in a joint disorder. This is most significant at the medium frequency range that is expected to be induced by a running human subject.

Three-year experience with glutaraldehyde-stabilized umbilical vein for limb salvage

During the past 3 years, 361 vascular reconstructions were performed employing glutaraldehyde-stabilized umbilical veins. The distal anastomosis terminated at the popliteal segment (n = 183), at either of the tibial arteries (n = 108) or at the peroneal artery (n = 70). One hundred and forty-one (77 per cent) of the popliteal reconstructions were below the knee. Many of the patients undergoing these bypasses had a previous failed reconstruction and were operated upon for limb salvage. Operative mortality rates for the popliteal, tibial and peroneal reconstructions were 2·7, 2·8 and 4·3 per cent respectively. Cumulative graft patency rates at 36 months for each of the three types of reconstruction were 76·4 per cent (popliteal), 63·4 per cent (tibial) and 39·8 per cent (peroneal). Failures were usually due to inappropriate case selection or progressive disease, particularly in the distal circulation. Two grafts were removed because of wound and secondary graft infection. There were no instances of biodegradation, either by aneurysm formation or by myointimal proliferation. These data confirm that attempts at revascularization are definitely preferable to amputation. The use of the glutaraldehyde-stabilized umbilical vein has facilitated the performance of these operations. In appropriately selected cases and with expert surgical technique, long term graft function with limb salvage can be obtained.

Synchronous aortofemoral or iliofemoral bypass with revascularization of the lower extremity

Bypassing aortoiliac stenosing lesions to the profunda femoria alone, even with extensive end-arterectomy and angioplasty of the latter, will not provide predictable excellent results in the presence of gangrene and occlusion in the femoral popliteal system. With severe pregangrene and rest pain, residual ischemic complaints are also common, and if lesions are present, healing is incomplete or, at best, delayed. Alternatively, femoropopliteal or tibial bypass, in the presence of even moderately diminished inflow, is subject to either early or delayed closure, unless proximal repair is also performed in appropriately selected patients. Synchronous correction of tandem lesions involving the aortoiliac and femoropopliteal segments should, therefore, be considered for limb salvage only and particularly in the presence of focal gangrene, excision or debridement of which can be anticipated to heal after successful bypass. Major diminution in femoral inflow usually indicates the need for proximal repair only, even in the presence of distal lesions. Noninvasive studies and intraoperative flow determinations are not uniformly helpful in patient selection. Synchronous aortofemoral or iliofemoral and femoropopliteal or tibial reconstructions were performed upon 38 patients, 15 of whom had no prior vascular operation and 23 of whom had previously undergone either aortofemoral or femoropopliteal bypasses that had failed. Graft patency for all patients was 76 per cent, and although it was better for the patients in group 1 than for those in group 2, no statistical significance existed between the two groups. Improved patient selection and criteria for performing synchronous reconstructions might originally have been of benefit for the patients in group 2, avoiding more difficult secondary repairs. It must be emphasized, however, that synchronous reconstructions should not be done routinely in the presence of multilevel disease. Rather, specific indications do exist and should be considered on an individual basis.