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1.  Clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with heart failure: an observational report from the Middle East 
BMJ Open  2015;5(4):e007148.
The purpose of this study is to report the prevalence, clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with acute heart failure (HF).
Retrospective analysis of prospectively collected data.
Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicentre study of consecutive patients hospitalised with acute HF in 2012 in seven Middle Eastern countries and analysed according to the presence or absence of prior stroke; demographics, management and outcomes were compared.
A total of 5005 patients with HF.
Outcome measures
In-hospital and 1-year outcome.
The prevalence of prior stroke in patients with HF was 8.1%. Patients with stroke with HF were more likely to be admitted under the care of internists rather than cardiologists. When compared with patients without stroke, patients with stroke were more likely to be older and to have diabetes mellitus, hypertension, atrial fibrillation, hyperlipidaemia, chronic kidney disease, ischaemic heart disease, peripheral arterial disease and left ventricular dysfunction (p=0.001 for all). Patients with stroke were less likely to be smokers (0.003). There were no significant differences in terms of precipitating risk factors for HF hospitalisation between the two groups. Patients with stroke with HF had a longer hospital stay (mean±SD days; 11±14 vs 9±13, p=0.03), higher risk of recurrent strokes and 1-year mortality rates (32.7% vs 23.2%, p=0.001). Multivariate logistic regression analysis showed that stroke is an independent predictor of in-hospital and 1-year mortality.
This observational study reports high prevalence of prior stroke in patients hospitalised with HF. Internists rather than cardiologists were the predominant caregivers in this high-risk group. Patients with stroke had higher risk of in-hospital recurrent strokes and long-term mortality rates.
Trial registration number
PMCID: PMC4410120  PMID: 25908674
2.  Age and clinical outcomes in patients presenting with acute coronary syndromes☆ 
Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients.
To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS).
Methods and material
Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: ≤50 years, 51–70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months.
Statistical analysis used
One-way ANOVA test for continuous variables, Pearson chi-square (X2) test for categorical variables and multivariate logistic regression analysis for predictors were performed.
Among 7930 consecutive ACS patients; 2755 (35%) were ≤50 years, 4110 (52%) were 51–70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients ≤50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03–1.60), heart failure (OR 2.8; 95% CI 2.17–3.52) and major bleeding (OR 4.02; 95% CI 1.37–11.77) and in-hospital mortality (age 51–70: OR 2.67; 95% CI 1.86–3.85, and age >70: OR 4.71; 95% CI 3.11–7.14).
Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.
PMCID: PMC3770118  PMID: 24027372
Acute coronary syndrome; Age; Elderly
3.  Case-finding of chronic obstructive pulmonary disease with questionnaire, peak flow measurements and spirometry: a cross-sectional study 
BMC Research Notes  2014;7:241.
Spirometry is commonly accepted as the gold standard for the diagnosis of COPD, but the reality remains that quality assured spirometry is not or cannot be provided universally around the globe. Adding PEF measurement to a screening questionnaire may rule out airflow limitation compatible with COPD rationalizing spirometry testing.
We conducted a cross-sectional survey in a sample of individuals 40–80 yrs. old in Dubai, UAE. They were invited to answer a short socio-demographic questionnaire including a report on current, past history of smoking, and had PEF measured, then they conducted spirometry to identify airflow limitation compatible with COPD.
Overall, 525 (91.0%) participants performed PEF and spirometry (68% male, with a mean age of 59 years, 17% UAE Nationals), 24% reported smoking of different sorts. Overall, 68 participants (12.9%, 95% C.I. 10.3% to 16.1%) had airflow limitation compatible with COPD. PEFR alone identified 141participants with airflow limitation compatible with COPD, with specificity of 80% and sensitivity of 73.5%.
PEFR could be an easy, cheap, and non-biased tool to assist with the case-finding of COPD before confirmation with spirometry.
PMCID: PMC3996099  PMID: 24739210
4.  Results of the Dyslipidemia International Study (DYSIS)-Middle East: Clinical Perspective on the Prevalence and Characteristics of Lipid Abnormalities in the Setting of Chronic Statin Treatment 
PLoS ONE  2014;9(1):e84350.
Therapeutic intervention with low-density lipoprotein cholesterol-lowering agents known as statins has been demonstrated to reduce cardiovascular risk. However, many patients on statin treatment have persistent dyslipidemia and remain at a high risk of cardiovascular disease. Therefore, the objective of this study was to assess the frequency of lipid abnormalities in patients receiving chronic statin treatment.
As part of an international, cross-sectional, observational study, DYSIS-Middle East enrolled 2,182 patients in the United Arab Emirates (UAE), Saudi Arabia, Lebanon and Jordan. All patients were over 45 years of age and had been on statin treatment for at least three months. Data on demographics, lipid parameters and cardiovascular risk profile were recorded. Cardiovascular risk was defined according the guidelines of the European Society of Cardiology.
The majority of patients (82.6%) were classified as being at very high risk of cardiovascular events, and 61.8% of all patients did not attain LDL-C target levels. Low high-density lipoprotein cholesterol levels and elevated triglyceride levels were noted in 55.5% and 48.5% of patients, respectively. Multivariate logistical regression modeling indicated that factors independently associated with LDL-C levels not being at goal were lifestyle choices, diabetes mellitus, ischemic heart disease, and blood pressure ≥ 140/90 mmHg.
Almost two-thirds of statin-treated patients in the United Arab Emirates, Saudi Arabia, Lebanon and Jordan had inadequately controlled lipid levels. More comprehensive surveillance, awareness and treatment regimens, as well as modification of lifestyle choices, is necessary to halt the rise in cardiovascular disease-related mortality.
PMCID: PMC3882235  PMID: 24400085
5.  Design and Rationale of Gulf locals with Acute Coronary Syndrome Events (Gulf Coast) Registry 
To describe the risk profile, management and one-year outcomes of patients hospitalized with acute coronary syndrome (ACS) in the Gulf region of the Middle East.
Subjects and Methods:
The Gulf locals with acute coronary syndrome events (Gulf COAST) registry is a prospective, multinational, longitudinal, observational, cohort-based registry of consecutive citizens, from the Gulf region of the Middle East, admitted from January 2012 to January 2013 to 29 hospitals with a diagnosis of ACS. Data entered online included patient demographics, cardiovascular risk profiles, past medical history, physical findings on admission, in-hospital diagnostic tests and therapeutic management, as well as one year outcomes.
3188 patients were recruited. The mean age was 60.4 ± 12.6years (range: 22-112), 2104 (66%) were males and 1084 (34%) females. The discharge diagnosis was ST-segment elevation myocardial infarction (STEMI) in 741 (23.2%), new-onset left bundle branch block myocardial infarction (LBBBMI) in 30 (0.9%), non-ST-segment elevation myocardial infarction (NSTEMI) in 1486 (46.6%) and unstable angina in 931 (29.2%). At hospital presentation, 2105 (66%), 1779 (55.8%), 1703 (53.4%) and 740 (23.2%) had history of hypertension, dyslipidemia, diabetes mellitus and active smoking, respectively.
Patients with ACS in our region are young with very high risk profile. The Gulf COAST registry is an example of successful regional collaboration and will provide information on contemporary management of ACS in the region.
PMCID: PMC4197526  PMID: 25328551
Acute coronary syndromes; Gulf; Middle East; registries.
6.  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) 
PLoS ONE  2013;8(2):e55508.
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.
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.
PMCID: PMC3566183  PMID: 23405162
7.  Characteristics and in-hospital outcomes of patients with acute coronary syndromes and heart failure in the United Arab Emirates 
BMC Research Notes  2012;5:534.
Heart failure (HF) is a serious complication of acute coronary syndromes (ACS), and is associated with high in-hospital mortality and poor long-term survival. The aims of this study were to describe the clinical characteristics, management and in-hospital outcomes of coronary syndrome (ACS) patients with HF in the United Arab Emirates.
The study was selected from the Gulf Registry of Acute Coronary Events (Gulf RACE), a prospective multi-national, multicenter registry of patients hospitalized with ACS in six Middle East countries. The present analysis was focused on participants admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 and were analyzed in terms of HF (Killip class II/III and IV) on admission. Of 1691 patients (mean age: 52.6 ± 11.7 years; 210 Females, 1481 Males) with ACS, 356 (21%) had an admission diagnosis of HF (Killip class II/III and IV). HF patients were less frequently males (19.2% vs. 34.3%; P < 0.001). HF was more frequently associated with hypertension (64.3% vs. 43.9%; P < 0.001), hyperlipidemia (49.4% vs. 31.8%; P < 0.001) and diabetes mellitus (DM) (51.1% vs. 36.2%; P < 0.001). HF was significantly associated with in-hospital mortality (OR = 11.821; 95% CI: 5.385-25.948; P < 0.001). In multivariate logistic regression, age, hyperlipidemia, heart rate and DM were associated with higher in-hospital HF.
HF is observed in about 1 in 5 patients with ACS in the UAE and is associated with a significant increase in in-hospital mortality and other adverse outcomes.
PMCID: PMC3527184  PMID: 23014157
Heart failure; Acute coronary syndrome; United Arab Emirates
8.  Immediate and one-year outcome of patients presenting with Acute Coronary Syndrome complicated by stroke: Findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2) 
Stroke is a potential complication of acute coronary syndrome (ACS). The aim of this study was to identify the prevalence, risk factors predisposing to stroke, in-hospital and 1-year mortality among patients presenting with ACS in the Middle East.
For a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries.
The prevalence of in-hospital stroke following ACS was 0.70%. Most cases were ST segment elevation MI-related (STEMI) and ischemic stroke in nature. Patients with in-hospital stroke were 5 years older than patients without stroke and were more likely to have hypertension (66% vs. 47.6%, P = 0.001). There were no differences between the two groups in regards to gender, other cardiovascular risk factors, or prior cardiovascular disease. Patients with stroke were more likely to present with atypical symptoms, advanced Killip class and less likely to be treated with evidence-based therapies. Independent predictors of stroke were hypertension, advanced killip class, ACS type –STEMI and cardiogenic shock. Stroke was associated with increased risk of in-hospital (39.3% vs. 4.3%) and one-year mortality (52% vs. 12.3%).
There is low incidence of in-hospital stroke in Middle-Eastern patients presenting with ACS but with very high in-hospital and one-year mortality rates. Stroke patients were less likely to be appropriately treated with evidence-based therapy. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.
PMCID: PMC3480946  PMID: 22894647
Acute coronary syndrome; Myocardial infarction; Stroke; Risk factors; Prognosis
9.  Characteristics, Management, and In-Hospital Outcomes of Diabetic Patients with Acute Coronary Syndrome in the United Arab Emirates 
The Scientific World Journal  2012;2012:698597.
We describe the baseline characteristics, management, and in-hospital outcomes of patients in the United Arab Emirates (UAE) with DM admitted with an acute coronary syndrome (ACS) and assess the influence of DM on in-hospital mortality. Data was analyzed from 1697 patients admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 as part of the 1st Gulf RACE (Registry of Acute Coronary Events). Of 1697 patients enrolled, 668 (39.4%) were diabetics. Compared to patients without DM, diabetic patients were more likely to have a past history of coronary artery disease (49.1% versus 30.1%, P < 0.001), hypertension (67.2% versus 36%, P < 0.001), and prior revascularization (21% versus 11.4%, P < 0.001). They experienced more in-hospital recurrent ischemia (8.5% versus 5.1%; P = 0.004) and heart failure (20% versus 10%; P < 0.001). The mortality rate was 2.7% for diabetics and 1.6% for nondiabetics (P = 0.105). After age adjustment, in-hospital mortality increased by 3.5% per year of age (P = 0.016). This mortality was significantly higher in females than in males (P = 0.04). ACS patients with DM have different clinical characteristics and appear to have poorer outcomes.
PMCID: PMC3385598  PMID: 22778703
10.  Clinical Profile and Mortality of ST-Segment Elevation Myocardial Infarction Patients Receiving Thrombolytic Therapy in the Middle East 
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.
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.
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.
PMCID: PMC3424777  PMID: 22919446
Acute coronary syndrome; GRACE score; Middle East; mortality; reteplase; STEMI; streptokinase; tenecteplase; thrombolytic therapy
11.  Coronary artery disease in Africa and the Middle East 
Countries in Africa and the Middle East bear a heavy burden from cardiovascular disease. The prevalence of coronary heart disease is promoted in turn by a high prevalence of cardiovascular risk factors, particularly smoking, hypertension, dyslipidemia, diabetes, and sedentary lifestyles. Patients in Africa and the Middle East present with myocardial infarction at a younger age, on average, compared with patients elsewhere. The projected future burden of mortality from coronary heart disease in Africa and the Middle East is set to outstrip that observed in other geographical regions. Recent detailed nationally representative epidemiological data are lacking for many countries, and high proportions of transient expatriate workers in countries such as Saudi Arabia and the United Arab Emirates complicate the construction of such datasets. However, the development of national registries in some countries is beginning to reveal the nature of coronary heart disease. Improving lifestyles (reducing calorie intake and increasing physical activity) in patients in the region will be essential, although cultural and environmental barriers will render this difficult. Appropriate prescribing of pharmacologic treatments is essential in the prevention and management of cardiovascular disease. In particular, recent controversies relating to the therapeutic profile of beta-blockers may have reduced their use. The current evidence base suggests that beta-blockers are as effective as other therapies in preventing cardiovascular disease and that concerns relating to their use in hypertension and cardiovascular disease have been overstated.
PMCID: PMC3284217  PMID: 22368447
coronary heart disease; beta-blockers; cardiovascular risk factors; cardiovascular disease; heart failure
12.  Polyvascular Disease in Patients Presenting with Acute Coronary Syndrome: Its Predictors and Outcomes 
The Scientific World Journal  2012;2012:284851.
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.
PMCID: PMC3259691  PMID: 22272171
13.  Prevalence, Characteristics, and In-Hospital Outcomes of Metabolic Syndrome among Patients with Acute Coronary Syndrome in the United Arab Emirates 
To evaluate clinical profiles, management and in-hospital outcomes of acute coronary syndrome (ACS) patients with metabolic syndrome (MetS) in the United Arab Emirates (UAE).
MetS was defined according to the criteria for its diagnosis by the International Diabetes Federation (IDF) and the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI). Participants were admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 as part of the Gulf Registry of Acute Coronary Events (Gulf RACE) project. We compared baseline characteristics, treatment patterns, and in-hospital outcomes stratified by MetS status.
Of 1259 patients with ACS in the UAE (mean age: 52 ± 11 years, 88.8% males), the majority (n = 851, 67.6%) had MetS. MetS patients were more frequently males (86.4 vs 13.6%; P < 0.001). They were more obese (waist circumference and BMI, P < 0.001) as compared with non-MetS patients. MetS was more frequently associated with hypertension (51.1 vs 37.7%; P < 0.001) and diabetes mellitus (45.6 vs 24.3%; P < 0.001). After multivariate adjustment, certain MetS criteria rather than MetS itself were associated with higher in-hospital mortality and heart failure. Paradoxically, hypertension was associated with lower in-hospital mortality.
Prevalence of MetS among patients with ACS in our study population was high. Certain MetS criteria were associated with higher in-hospital mortality and heart failure.
PMCID: PMC3414714  PMID: 22888374
acute coronary syndrome; Gulf Registry of Acute Coronary Events; metabolic syndrome; Middle East; obesity; United Arab Emirates.
14.  Weekend Versus Weekday, Morning Versus Evening Admission in Relationship to Mortality in Acute Coronary Syndrome Patients in 6 Middle Eastern Countries: Results from Gulf Race 2 Registry 
We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their management on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.
PMCID: PMC3447162  PMID: 23002404
Acute coronary syndrome; Weekend; Weekday; Mortality; Admission.
15.  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.
PMCID: PMC3246760  PMID: 22220279

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