Predictors of prolonged hospital stay and in-hospital mortality in female patients with acute myocardial infarction with specific reference to diabetes

This study aimed to determine predictors of prolonged length of stay (LOS) and mortality in female STEMI patients with diabetes in comparison to female STEMI patients without diabetes. This retrospective single-center study was conducted between 2015 and 2020 as part of the STEMI registry in our center and included all STEMI patients. RESULTS: Out of 3081 STEMI patients, 16% (N = 498) were female, and 64% (n = 318) of them had diabetes. Diabetic patients were less commonly presented with anterior wall myocardial infarction (AWMI) (47% vs 65%, p = 0.001), but tended to have a higher prevalence of left main (LM) significant disease compared to non-diabetic patients (4% vs 1%, p = 0.06). Of the patients, 36% had prolonged LOS (≥5 days), and they were more obese with a higher incidence of hemoglobin drop ≥ 3 g/dL, higher admission troponin, and peak creatinine. 22% of patients with prolonged LOS came to the hospital after receiving lytic therapy and showed a higher prevalence of multivessel stenosis. Prolonged LOS patients had a higher incidence of pulmonary edema and cardiac arrest, which necessitated ventilation, although they did not show a significant difference in mortality from the group with LOS < 5 days. Our study found a significant negative correlation between glycosylated hemoglobin (HbA1c) and left ventricular ejection fraction (LVEF) (p = 0.02), but a positive correlation was noticed between HbA1c and LOS (p < 0.001). Regression analysis showed that diabetes mellitus, hemoglobin drop, creatinine level, and LVEF were significant predictors of prolonged LOS among females, although HbA1c, BMI ≥ 30, STEMI type, and peak creatinine level were independent predictors of prolonged LOS among female diabetic patients. Age ≥ 65 years and LVEF were significant independent predictors of mortality (p = 0.04, 0.02 respectively) in STEMI female patients. CONCLUSIONS: Diabetes mellitus, bleeding, renal impairment, and LVEF were found to be significant independent predictors of prolonged LOS among STEMI females. Age ≥ 65 years and LVEF were significant predictors of mortality among STEMI female patients.

Cardiac dysfunction and their determinants in patients treated for breast cancer and lymphoma: A cardio-oncology center experience

OBJECTIVE

Cancer and cardiovascular diseases both have adverse effects on each other. We aim in the current study to investigate cardiac dysfunction including its prevalence, and associated factors in patients treated for breast cancer and lymphoma in a unique cardiac oncology center.

METHODS

A single-center retrospective study included 180 patients with cancer breast and lymphoma who presented and were treated at our oncology center from January 2019 to February 2022.

RESULT

Out of 180 consecutive patients, 155 patients (86 %) were diagnosed with cancer breast and 25 patients (14 %) were diagnosed with lymphoma. Patients with lymphoma were older age, less obese, and showed more prevalence of diabetes mellitus (DM) (P = 0.026, 0.05, and 0.04 respectively). They also showed more post-therapy left ventricular (LV) dilatation and lower values of global longitudinal strain (GLS); however, they did not develop more LV dysfunction compared to cancer breast patients. Moreover, lymphoma patients showed poor in-hospital outcomes (P = 0.04, 0.001, and 0.015 for infection, pericardial effusion, and mortality respectively). Cancer therapy-related cardiac dysfunction (CTRCD) was observed in 41 patients (23 %) of our population. The independent predictors of CTRCD in the current study were DM, low body mass index (BMI), and the use of trastuzumab.

CONCLUSIONS

Some patients treated for breast cancer and lymphoma develop LV dysfunction. Lymphoma patients showed more subclinical LV dysfunction and poor in-hospital outcomes compared to patients with cancer breast. DM, low body mass index (BMI), and the use of trastuzumab were the independent predictors of cardiac dysfunction among our patients.

Cardiogenic Shock Among Patients with Acute ST-Segment Elevation Myocardial Infarction in a Middle Eastern Country: A Single-Center Experience

Background

Cardiogenic Shock (CS) remains the most common cause of death in hospitalized acute ST-segment elevation myocardial infarction (STEMI) patients. Predictors of outcomes in those patients include clinical, laboratory, radiologic variables, and management strategies. The present study aimed to evaluate the incidence, characteristics, predictors of cardiogenic shock and mortality among acute ST-segment elevation myocardial infarction patients in our center.

Methods

This was a retrospective, single-center study conducted at KAMC, Makkah during 2015-2020. All acute ST-segment elevation myocardial infarction patients during this era were divided into two groups CS group and non-CS group.

Results

In this study total 3074 acute ST-segment elevation myocardial infarction patients of which 132(4.3%) patients had CS. CS group tended to have higher ages than non-CS group. Pilgrims were more complicated by CS than nonpilgrims. Subsequently, CS patients had a highly significant (p < 0.001 for all) increase in the incidence of in-hospital complications including pulmonary oedema, cardiac arrest and ventilation. There was a significant increase in hospital stay length and in-hospital mortality among CS patients. Renal impairment, peak troponin level, haemoglobin drop≥3 gm/dl, and Left ventricular ejection fraction (EF) were significant independent predictors of cardiogenic shock among our patients. However, STEMI type, left main disease, and EF was the independent predictors of CS among our patients with diabetes with EF cut-off value of 35% with a sensitivity of 74.6% and a specificity of 65.3%. Age was the only independent predictor of mortality among CS patients. Though age, female gender, and diabetes were found to be the independent predictors for in-hospital mortality among our patients.

Conclusion

High-income middle eastern countries have comparable outcomes to Europe and USA among patients with acute ST-segment elevation myocardial infarction patients with higher improvement of medical care in the last 2 to 3 decades. Renal impairment, peak troponin, severe bleeding and ejection fraction were significant independent predictors of CS in acute ST-segment elevation myocardial infarction patients. However, STEMI type, left main disease, and ejection fraction were the independent predictors of CS in acute ST-segment elevation myocardial infarction patients with diabetes. Age was the only independent predictor of mortality among CS patients.

Severe Left Ventricular Dysfunction Earlier after Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: Predictors and In-Hospital Outcome– A Middle Eastern Tertiary Center Experience

Improving or maintaining heart function following percutaneous coronary intervention (PPCI) is not identified in all patients. Our aim in the current study is to investigate the prevalence, factors associated with early left ventricular (LV) dysfunction following successful revascularization of myocardial infarction patients.

Methods

A single-center retrospective study included 2863 myocardial infarction patients who were admitted to our center and treated with successful PPCI.

Results

Out of 2863 consecutive patients who underwent PPCI from May 2018 to August 2021, 1021 (36%) developed server LV dysfunction. They showed a higher history rate of ischemic heart disease and previous revascularization before AMI (P = 0.05 and 0.001 respectively). Also, they presented more with anterior myocardial infarction (P < 0.001) and heavy thrombus burden (P = 0.002 and 0.004 for indication of peri-procedural glycoprotein IIb/IIIa inhibitors use and thrombus aspiration) compared to the other group of patients. Moreover, they also had a more critical anatomy of coronary artery disease (P < 0.001 for both left main and multi-vessel coronary artery disease). The independently associated predictors for early severe LV dysfunction post-AMI treated with PPCI were anterior localization of AMI, the greater value of troponin, renal impairment, and severe coronary artery disease (P= <0.001, 0.036, 0.002, and <0.07 respectively). Despite optimal treatment for those patients, they showed poor outcomes including in-hospital morbidity and mortality (P < 0.001).

Conclusion

Sizable proportion of patients following successful PPCI develop severe LV systolic dysfunction and associated with poor clinical outcomes. Larger myocardial infarction, renal impairment, and severe coronary artery disease are independent predictors of severe LV systolic dysfunction post-PPCI.

Myocardial recovery after percutaneous coronary intervention in coronary artery disease patients with impaired systolic function- predictive utility of global longitudinal strain

OBJECTIVE

Coronary revascularization is associated with better outcomes in coronary artery disease patients. We aim to investigate the prevalence, and factors associated with left ventricular (LV) improvement following successful percutaneous coronary intervention (PCI) of patients with impaired systolic function with specific reference to the value of baseline GLS.

METHODS

This retrospective study reviewed the records of coronary artery disease patients with impaired systolic function who were admitted and treated with PCI.

RESULT

Out of 420 consecutive acute coronary syndrome patients with an impaired systolic function who were admitted and treated with PCI during the period from January 2021 to December 2021, 147 patients (35%) showed no improvement in the Left ventricular ejection fraction (LVEF) post PCI and 273 patients (65%) showed improvement of the LVEF post PCI in their follow up echocardiogram. Larger myocardial injury dilated LV dimension at the acute phase showed a strong impact on further improving LV systolic function. Baseline GLS showed a higher statistical difference between the Non-improving LVEF and improving LVEF groups. Moreover, the early GLS and further LV systolic function improvement were strongly correlated (P < 0.001) with higher sensitivity and specificity. A receiver operating characteristic curve (ROC) analysis demonstrated that GLS values greater than 9% are a predictor of significant LVEF improvement in the follow-up stage.

CONCLUSION

Sizable proportion of patients with impaired systolic function following successful PCI show further LV systolic recovery. We demonstrated that the baseline GLS values of more than 9% are an accurate predictor of significant LVEF improvement.

Clinical Characteristics and Short-Term Outcomes of Patients Presenting with Acute Myocardial Infarction having Multi-vessel disease - A Single Middle- eastern Tertiary-Care Center Experience

Objective

Patients with multi-vessel coronary artery disease (MVD) compared to single-vessel coronary artery disease (CAD) have more comorbidities and poor in-hospital outcomes. We aim to analyze MVD-AMI patients regarding clinical data and short-term outcomes.

Methods

This is a retrospective analysis of the prospectively collected data registry, a single-center study reviewing the clinical details and hospital outcome measures of AMI patients referred to our center for early revascularization from 2016 to 2019.

Result

Out of 3041 patients presented with AMI, 491 (16%) had MVD on coronary angiogram. MVD-AMI patients were older, had a higher prevalence of DM, HTN, and prior history of ischemic heart disease compared to the non- MVD -AMI group (p < 0.001 for all). However, they presented more with non-anterior myocardial infarction, showed higher rates of post-myocardial infarction LV dysfunction, and mortality (p < 0.001). Older MVD-AMI patients showed higher rates of in-hospital morbidities and mortality compared to younger ones (p < 0.001). MVD- AMI women and Middle Eastern patients were older and showed a higher prevalence of cardiovascular risk factors compared to MVD-AMI men and South Asian patient population respectively. There were no significant differences recorded among the different subgroups of MVD-AMI patients regarding the hospital outcome measures.

Conclusion

Our study highlighted the clinical characters and poor outcomes of a high-risk group of MVD-AMI with different demographic backgrounds. Although age was a strong predictor for in-hospital poor outcomes, neither gender nor ethnicity affected the outcomes in them.

Cardiomyopathy Management and In-Hospital Outcomes in a Tertiary Care Center: Clinical Components and Venues of Advanced Care

Background

There are few reports on the prevalence of different types of cardiomyopathy, clinical presentation, severity, short-term outcomes, and implementation of advanced heart failure treatment. This study aimed to assess the prevalence, clinical background of different types of cardiomyopathy and to identify the candidate for advanced treatment in a tertiary care cardiac center with many advantages 

Method

A single-center retrospective cohort study included 1069 patients admitted to our center and diagnosed with cardiomyopathy during 2019 and 2020 

Results

Out of 1069 cardiomyopathy patients admitted and diagnosed at our center between 2019 and 2020, 62% had ischemic cardiomyopathy (ICM), 36% had dilated cardiomyopathy (DCM), and 2% had hypertrophic cardiomyopathy (HOCM). ICM patients were older, showed a higher prevalence of both male gender and pilgrims, and they had more frequent cardiovascular risk factors compared to dilated cardiomyopathy group of patients. However, DCM patients with more severe heart failure symptoms (NYHA class III/IV), much worse LVEF, were subsequently considered deemed for aggressive diuretic therapy, and further advanced therapy (Sacubitril-Valsartan and device therapy) compared to ICM patients. ICM patients showed poor in-hospital outcomes compared to DCM group of patients (0.05 and <0.001) for an indication for mechanical ventilation and in-hospital mortality, respectively). Increased age, presence of renal dysfunction and lower LVEF were found the independent predictors of in-hospital mortality among our studied patients 

Conclusion

There are discrepancies between DCM and ICM patients. Although DCM patients were younger at age and had fewer cardiovascular risk factors, they presented with severe symptoms and dysfunction, hence more eligible candidates for advanced heart failure treatment, and finally showed a lower mortality rate. Increased age, presence of renal dysfunction and lower LVEF were found the independent predictors of in-hospital mortality. 

Incidence and Predictors of Left Ventricular (LV) Thrombus after ST-Elevation Myocardial Infarction (STEMI) in the Holy Capital of Saudi Arabia

Background

Patients with acute myocardial infarction (AMI) especially those with large MI (myocardial infarction) as identified by ST elevation in multiple contiguous ECG leads or anterior MI, may suffer significant myocardial damage leading to impaired wall motion and contractility which may lead to the formation of left ventricular thrombus (LVT) in the patient. This study was aimed to establish the incidence of LV thrombus and determine the predictors associated with the formation of LV thrombus in patients with AMI.

Methods

This retrospective study was held at the only cardiothoracic centre of Makkah, which provides tertiary level cardiac services. A total of 3084 consecutive patients with acute MI between 2016 and 2019 were identified and divided into two groups i.e. group I (with LVT) and group II (without LVT). The case notes, echocardiography data and cardiac catheterization lab records were reviewed to identify patients with LV thrombus. Regression analysis was employed to evaluate the predictors responsible for the formation of LV thrombus.

Results

The overall incidence for LV thrombus was determined as 8.4% (n = 260/3084), while in the subpopulation of pilgrims, it was 8.2% (83/1001). Mean age for patients with and without LVT was 54 ± 11 years vs 56 ± 12 years (p < 0.003), respectively. There was no significant difference between the two groups with respect to gender, diabetes, hypertension, smoking, Arabic speaking or BMI>30. Coronary thrombus aspiration was utilized in 17% vs 12% (p < 0.023) patients with LVT and without LVT, respectively. It was observed that the patients with cardiac arrest tend to develop more LVT i.e. 8.5% vs 5.2% (p < 0.033). However, LV thrombus formation was significantly associated with anterior STEMI with incidence of LVT reaching 13.4% and low ejection fraction (all MI types) i-e. 32 ± 9% vs 42 ± 11%, with p < 0.000 for both independent predictors.

Conclusions

LV thrombus is a relatively common occurrence in patients with acute MI, especially those with anterior STEMI and low ejection fraction<30%. Appropriate imaging studies are required for all acute MI patients in order to ascertain the presence or absence of LV thrombus as it has major influence on further management.

Disparities of demographics, clinical characteristics, and hospital outcomes of AMI pilgrims vs non-pilgrims—tertiary center experience

Background

Acute myocardial infarction (AMI) is usually caused by rupture of an atherosclerotic plaque leading to thrombotic occlusion of a coronary artery. Cardiovascular disease has recently emerged as the leading cause of death during hajj. Our aim is to demonstrate the AMI pilgrim’s related disparities and comparing them to non-pilgrim patients.

Result

Out of 3044 of patients presented with AMI from January 2016 to August 2019, 1008 (33%) were pilgrims. They were older in age (P < 0.001) and showed significantly lower rates cardiovascular risk factors (P < 0.001 for DM, smoking, and obesity). Pilgrims were also less likely to receive thrombolytic therapy (P < 0.001), show lower rate of late AMI presentation (P < 0.001), develop more LV dysfunction post AMI (P < 0.001), and have critical CAD anatomy in their coronary angiography (P < 0.001 for MVD and = 0.02 for LM disease) compared to non-pilgrim AMI patients. Despite AMI pilgrims recorded higher rate of primary percutaneous coronary intervention (PPCI) procedures, they still showed poor hospital outcomes (P < 0.001, 0.004, < 0.001, 0.05, and 0.001, respectively for pulmonary edema, cardiogenic shock, mechanical ventilation, cardiac arrest, and in-hospital mortality, respectively). Being a pilgrim and presence of significant left ventricular systolic dysfunction, post AMI was the two independent predictors of mortality among our studied patients (P = 0.005 and 0.001, respectively).

Conclusion

Although AMI pilgrims had less cardiovascular risk factors and they were early revascularized, they showed higher rates of post myocardial infarction complication and poor hospital outcomes. Implementation of pre-hajj screening, awareness and education programs, and primary and secondary preventive measures should be taken in to consideration to improve AMI pilgrim’s outcome.

Early discharge (within 24-72 h) in low-risk AMI patients treated with PCI: feasibility and safety-Hajj study

BACKGROUND

Shortening of the hospital stay in patients admitted with the diagnosis of acute myocardial infarction (AMI) has been observed within the last decades. Our center is the only cardiac center in the region providing tertiary care facility and hence receives all AMI patients deemed suitable for invasive assessment and management and this leads to huge required demand. Our aim is to assess feasibility and safety of the early discharge of selected proportion of AMI patients.

RESULT

Out of 557 of patients presented with AMI and treated with percutaneous coronary intervention (PCI), 310 (56%) were discharged early. Men patients and pilgrims were more prevalent among the early discharge group. Early discharged patients had significantly less comorbidities compared to the other group of patients. Moreover, they presented mainly with ST-elevation myocardial infarction (P = 0.04) and treated more with primary percutaneous coronary intervention (PPCI) (P = 0.04). They had favorable coronary anatomy (P = 0.01 and 0.02 for left main and multi-vessel coronary artery disease, respectively), better hospital course, and higher left ventricular ejection fraction compared to non-early discharged patients (P = 0.006 and < 0.001 for pulmonary edema and left ventricular ejection fraction post myocardial infarction). Follow-up of those early discharged patients were promising as majority of them were asymptomatic (95%) and did well post-discharge.

CONCLUSION

Our study demonstrated data that support safety of early discharge in a carefully selected group of AMI patients. Early but safe discharge may have a huge impact on increasing bed availability, reducing hospital costs, and improving patient's satisfaction.

Epidemiological Variation of Acute Myocardial Infarction Relevant to In-Hospital Outcomes-Tertiary Center Experience-Saudi Arabia

Background

Epidemiological related differences in patients presenting with ST-elevation myocardial infarction (STEMI) have not yet been fully characterized in the Middle East countries. The aim of this study was to assess gender, ethnic and racial variation in clinical profiles, presentation and treatment strategies with relation to the in-hospital outcomes.

Method

This is a retrospective, single center study reviewing the epidemiological details of STEMI patients who were admitted to our center during the period between October 2015 and August 2019.

Result

Out of 3079 patients presented with STEMI, 498 (16%) were women, 2170 (70%) were from Middle Eastern Countries and only 1200 (39%) were non- Arabic speakers. Women were older in age compared to men (60.04 ± 11.2 vs 55.35 ± 11.8; P < 0.001). They showed significantly higher rates of cardiovascular risk factors (P < 0.001 for diabetes mellitus (DM), hypertension (HTN) and obesity) and lower prevalence of smoking and old history of previous revascularization (P < 0.001 and 0.007, respectively). Middle Eastern Countries- STEMI patients were elderly, showed higher prevalence of DM, HTN, smoking and obesity compared to South Asian patients (p = 0.001, 0.057, <0.001, <0.001 respectively). Arabic speaking - STEMI patients showed more prevalence of DM, smoking and obesity compared to non-Arabic speaking patients (p < 0.001). Regarding STEMI localization, post myocardial infarction complications and in-hospital length of stay, there were no detected significant gender, ethnic or racial variation. Women showed higher rates of all in-hospital mortality compared to men (5% vs 3%; p = 0.027) however, no ethnic/racial mortality difference was recorded among STEMI patients. Being elderly, presence of multivessel coronary artery disease and left ventricular systolic dysfunction (LVEF < 30%) are the three independent predictors of mortality among our patients (p = 0.013, 0.048 and <0.0001 respectively).

Conclusion

Our study demonstrates that there are gender, ethnic/racial-related differences in the demographics and clustered cardiovascular risk factors. However, there were no significant detected variation between both genders and different ethnic groups regarding post MI complications, management provided, and hospital outcomes except for increased the mortality rates among women. Old age, presence of multi-vessel disease and severe left ventricular systolic dysfunction have the greatest effect on in-hospital mortality among STEMI patients.