Inflammatory cytokines and atrial fibrillation: current and prospective views

Atrial fibrillation (AF) is the most common sustained arrhythmia and a challenging clinical problem encountered in daily clinical practice. There is an increasing body of evidence linking inflammation to a broad spectrum of cardiovascular conditions including AF. Historical evidence supports an association between AF and inflammation and is consistent with the association of AF with inflammatory conditions of the heart, such as myocarditis and pericarditis. AF has been associated with myocardial oxidative stress, and antioxidant agents have demonstrated antiarrhythmic benefit in humans. Increased plasma interleukin (IL)-6, C-reactive protein (CRP), and plasma viscosity support the existence of an inflammatory state among “typical” populations with chronic AF. These indexes of inflammation are related to the prothrombotic state and may be linked to the clinical characteristics of the patients (underlying vascular disease and comorbidities), rather than simply to the presence of AF itself. It has been suggested that inflammation may have a role in the development of atrial arrhythmias after cardiac surgery, and that a genetic predisposition to develop postoperative complications exists. Cytokines can have a prognostic significance; IL-6 levels, CRP, and other cytokines may have prognostic value in AF. Cytokine lowering therapies, statins, angiotensin converting enzyme inhibitors and other anti-inflammatory agents may have a role in the treatment of AF. The present article provides an overview of the evidence linking inflammatory cytokines to AF and their therapeutic and prognostic implications

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar

Aims: There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar. Methods: This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015. Results: There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25–0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30–6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0–1.04, p = 0.02). Conclusions: North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.Peer reviewedFinal Accepted Versio

Peripheral Arterial Disease in Patients Presenting with Acute Coronary Syndrome in Six Middle Eastern Countries

To describe prevalence and impact of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS), data were collected over 5 months from 6 Middle Eastern countries. Patients were divided into 2 groups (with and without PAD). Out of 6705 consecutive ACS patients, PAD was reported in 177 patients. In comparison to non-PAD, PAD patients were older and more likely to have cardiovascular risk factors. They were more likely to have high Killip class, high GRACE risk score, and non-ST elevation ACS (NSTEACS) at presentation. Thrombolytics, antiplatelet use, and coronary intervention were comparable in both groups. When presented with ST-elevation myocardial infarction (STEMI), patients with PAD had worse outcomes, while in NSTEACS; PAD was associated with higher rate of heart failure in comparison to non-PAD patients. In diabetics, PAD was associated with 2-fold increase in mortality when compared to non-PAD (P = 0.028). After adjustment, PAD was associated with high mortality in STEMI (adjusted OR 2.6; 95% CI 1.23–5.65, P = 0.01). Prevalence of PAD in ACS in the Gulf region is low. Patients with PAD and ACS constitute a high risk group and require more attention. PAD in patients with STEMI is an independent predictor of in-hospital death

Nonspecific chest pain and 30-day unplanned readmissions in the United States (From the Nationwide Readmission Database)

Chest pain is a common reason for admission to hospital and little is known regarding 30-day unplanned readmissions after an admission with a primary discharge diagnosis of nonspecific chest pain. We analyzed patients with a primary diagnosis of nonspecific chest pain in the Nationwide Readmission Database who were admitted in 2010 to 2014. Rates, causes, and predictors of 30-day unplanned readmissions were determined. A total of 1,842,270 patients had a diagnosis of nonspecific chest pain. The 30-day unplanned readmission rate was 8.6%. From 2010 to 2014, there was an increase in 30-day unplanned readmissions from 8.1% to 9.5%. The majority of 30-day unplanned readmissions were for noncardiac reasons (73.4%). The 3 most prevalent noncardiac causes for readmissions were neuropsychiatric (10.9%), gastrointestinal (10.5%), and infections (9.9%), while the 3 most prevalent cardiac causes were coronary artery disease including angina (8.4%), arrhythmias (6.6%), and heart failure 5.5%. The strongest predictors of readmission were alcohol misuse ([OR] odds ratio 1.74 95% [CI] confidence interval 1.66-1.81), renal failure (OR 1.82 95%CI 1.76-1.87), cancer (OR 2.40 95%CI 2.27-2.53), discharge to a nursing home (OR 2.26 95%CI 2.18-2.34), and discharge against medical advice (OR 1.94 95%CI 1.86-2.02). The rate of 30-day unplanned readmission was 6.1% among those who received any test compared to 9.3% in those who did not receive any test. Rates of early unplanned readmissions occur following 1 in 12 admissions for nonspecific chest pain with noncardiac causes being the most common reason. Patients who receive a cardiovascular investigation appear to have fewer unplanned readmissions

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar

Peer reviewe

Cardiopulmonary resuscitation of out-of-hospital traumatic cardiac arrest in Qatar : A nationwide population-based study

Background: Traumatic cardiac arrest studies have reported improved survival rates recently, ranging from 1.7-7.5%. This population-based nationwide study aims to describe the epidemiology, interventions and outcomes, and determine predictors of survival from out-of-hospital traumatic cardiac arrest (OHTCA) in Qatar. Methods: An observational retrospective population-based study was conducted on OHTCA patients in Qatar, from January 2010 to December 2015. Traumatic cardiac arrest was redefined to include out-of-hospital traumatic cardiac arrest (OHTCA) and in-hospital traumatic cardiac arrest (IHTCA). Results: A total of 410 OHTCA patients were included in the 6-year study period. The mean annual crude incidence rate of OHTCA was 4.0 per 100,000 population, in Qatar. OHTCA mostly occurred in males with a median age of 33. There was a preponderance of blunt injuries (94.3%) and head injuries (66.3%). Overall, the survival rate was 2.4%. Shockable rhythm, prehospital external hemorrhage control, in-hospital blood transfusion, and surgery were associated with higher odds of survival. Adrenaline (Epinephrine) lowered the odds of survival. Conclusion: The incidence of OHTCA was less than expected, with a low rate of survival. Thoracotomy was not associated with improved survival while Adrenaline administration lowered survival in OHTCA patients with majority blunt injuries. Interventions to enable early prehospital control of hemorrhage, blood transfusion, thoracostomy and surgery improved survival. (C) 2017 Elsevier B.V. All rights reserved.Peer reviewe

Polyvascular Disease in Patients Presenting with Acute Coronary Syndrome: Its Predictors and Outcomes

We evaluated prevalence and clinical outcome of polyvascular disease (PolyVD) in patients presenting with acute coronary syndrome (ACS). Data for 7689 consecutive ACS patients were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were divided into 2 groups (ACS with versus without PolyVD). All-cause mortality was assessed at 1 and 12 months. Patients with PolyVD were older and more likely to have cardiovascular risk factors. On presentation, those patients were more likely to have atypical angina, high resting heart rate, high Killip class, and GRACE risk scoring. They were less likely to receive evidence-based therapies. Diabetes mellitus, renal failure, and hypertension were independent predictors for presence of PolyVD. PolyVD was associated with worse in-hospital outcomes (except for major bleedings) and all-cause mortality even after adjusting for baseline covariates. Great efforts should be directed toward primary and secondary preventive measures

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.Gulf CARE (Gulf Acute Heart Failure Registry) is an investigator- initiated study conducted under the auspices of the Gulf Heart Association and funded by Servier, Paris, France; and (for centers in Saudi Arabia), by the Saudi Heart Association (The Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia [research group number: RG -1436- 013]). This does not alter our adherence to policies on sharing data and materials; and the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The publication of this article was funded by the Qatar National Library