Clinical profile and mortality of ST-Segment elevation myocardial- infarction patients receiving thrombolytic -Therapy in the Middle East

Objective: Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy. Patients and Methods: This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics. Results: Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use. Conclusions: Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase

Gender disparities in the presentation, management and outcomes of acute coronary syndrome patients: data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2).

BACKGROUND: Gender-related differences in mortality of acute coronary syndrome (ACS) have been reported. The extent and causes of these differences in the Middle-East are poorly understood. We studied to what extent difference in outcome, specifically 1-year mortality are attributable to demographic, baseline clinical differences at presentation, and management differences between female and male patients. METHODOLOGY/PRINCIPAL FINDINGS: Baseline characteristics, treatment patterns, and 1-year mortality of 7390 ACS patients in 65 hospitals in 6 Arabian Gulf countries were evaluated during 2008-2009, as part of the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). Women were older (61.3±11.8 vs. 55.6±12.4; P<0.001), more overweight (BMI: 28.1±6.6 vs. 26.7±5.1; P<0.001), and more likely to have a history of hypertension, hyperlipidemia or diabetes. Fewer women than men received angiotensin-converting enzyme inhibitors (ACE), aspirin, clopidogrel, beta blockers or statins at discharge. They also underwent fewer invasive procedures including angiography (27.0% vs. 34.0%; P<0.001), percutaneous coronary intervention (PCI) (10.5% vs. 15.6%; P<0.001) and reperfusion therapy (6.9% vs. 20.2%; P<0.001) than men. Women were at higher unadjusted risk for in-hospital death (6.8% vs. 4.0%, P<0.001) and heart failure (HF) (18% vs. 11.8%, P<0.001). Both 1-month and 1-year mortality rates were higher in women than men (11% vs. 7.4% and 17.3% vs. 11.4%, respectively, P<0.001). Both baseline and management differences contributed to a worse outcome in women. Together these variables explained almost all mortality disparities. CONCLUSIONS/SIGNIFICANCE: Differences between genders in mortality appeared to be largely explained by differences in prognostic variables and management patterns. However, the origin of the latter differences need further study

Comparison of Indian subcontinent and Middle East acute heart failure patients: Results from the Gulf Acute Heart Failure Registry

Objective: To compare Middle East Arabs and Indian subcontinent acute heart failure (AHF) patients. Methods: AHF patients admitted from February 14, 2012 to November 14, 2012 in 47 hospitals among 7 Middle East countries. Results: The Middle Eastern Arab group (4157) was older (60 vs. 54 years), with high prevalence of coronary artery disease (48% vs. 37%), valvular heart disease (14% vs. 7%), atrial fibrillation (12% vs. 7%), and khat chewing (21% vs. 1%). Indian subcontinent patients (382) were more likely to be smokers (36% vs. 21%), alcohol consumers (11% vs. 2%), diabetic (56% vs. 49%) with high prevalence of AHF with reduced ejection fraction (76% vs. 65%), and with acute coronary syndrome (46% vs. 26%). In-hospital mortality was 6.5% with no difference, but 3-month and 12-month mortalities were significantly high among Middle East Arabs, (13.7% vs. 7.6%) and (22.8% vs. 17.1%), respectively. Conclusions: AHF patients from this region are a decade younger than Western patients with high prevalence of ischemic heart disease, diabetes mellitus, and AHF with reduced ejection fraction. There is an urgent need to control risk factors among both groups, as well as the need for setting up heart failure clinics for better postdischarge management

In-hospital outcomes and 1-month and 1-year post discharge mortality of the study cohort by gender (n = 7930).

<p>Figures in parentheses are percentages.</p

Treatment on admission and at discharge of the study cohort stratified according to gender (n = 7930).

<p>Figures in parentheses are percentages. Abbreviations: BB, beta-blockers; CCB, calcium channel blockers; ACE, angiotensin-converting enzyme inhibitors; AIIRB, angiotensin II receptor blockers; OHA, oral hypoglycemic agents; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft.</p

Baseline characteristics of patients stratified by gender (n = 7930).

<p>Figures in parentheses are percentages and continuous variables are shown as mean±SD.</p><p>Abbreviations: SD, standard deviation; BMI, body mass index; CAD, coronary artery disease; MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; CHF, congestive heart failure; STEMI, ST elevation myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; UA, unstable angina.</p>*<p>Killip class (scale I–IV) a system used to stratify the severity of left ventricular dysfunction and determines clinical status of patients post myocardial infarction (MI).</p><p>Killip classification:</p><p>Class 1: No rales, no 3rd heart sound.</p><p>Class 2: Rales in <1/2 lung field or presence of a 3rd heart sound.</p><p>Class 3: Rales in >1/2 lung field–pulmonary edema.</p><p>Class 4: Cardiogenic shock–determined clinically.</p

Variables in model IV, and their effects on mortality.

<p>ORs for variables with multiple levels (country, diagnosis, and predominant symptoms) are not shown. The variables that were dropped out of the multivariable logistic regression using the stepwise-backward elimination method included: smoking, BMI, history of hypertension and hyperlipidaemia, clopidogrel as discharge medication, PCI, and CABG.</p>*<p>Predominant presenting symptoms includes: ischemic type chest pain, atypical chest pain, dyspnea, fatigue, loss of consciousness, cardiac arrest/aborted sudden death, palpitation and other symptoms.</p><p>Abbreviations: OR, odds ratio; CI, confidence interval; BB, beta-blockers; CCB, calcium channel blockers; ACE, angiotensin-converting enzyme inhibitors; AIIRB, angiotensin II receptor blockers.</p