The Intersection of Atrial Fibrillation and Coronary Artery Disease in Middle Eastern Patients. Analysis from the Jordan Atrial Fibrillation Study

Background

There is a scarcity of clinical studies which evaluate the association of atrial fibrillation (AF) and coronary artery disease (CAD) in the Middle East. The aim of this study was to evaluate the impact of CAD on baseline clinical profiles and one-year outcomes in a Middle Eastern cohort with AF.

Methods

Consecutive AF patients evaluated in 29 hospitals and cardiology clinics were enrolled in the Jordan AF Study (May 2019-December 2020). Clinical and echocardiographic features, use of medications and one-year outcomes in patients with AF/CAD were compared to AF/no CAD patients.

Results

Of 2020 AF patients enrolled, 216 (10.7%) had CAD. Patients with AF/CAD were more likely to be men and had significantly higher prevalence of hypertension, diabetes, dyslipidemia, heart failure and chronic kidney disease compared to the AF/no CAD patients. They also had lower mean left ventricular ejection fraction and larger left atrial size. Mean CHA2DS2 VASc and HAS-BLED scores were higher in AF/CAD patients than those with AF/no CAD (4.3 ± 1.7 vs. 3.6 ± 1.8, p < 0.0001) and (2.0 ± 1.1 vs. 1.6 ± 1.1, p < 0.0001), respectively. Oral anticoagulant agents were used in similar rates in the two groups (83.8% vs. 82.9%, p = 0.81), but more patients with AF/CAD were prescribed additional antiplatelet agents compared to patients with AF/no CAD (73.7% vs. 41.5%, p < 0.0001). At one year, AF/CAD patients, compared to AF/no CAD patients had significantly higher hospitalization rate (39.4% vs. 29.2%, p = 0.003), more acute coronary syndrome and coronary revascularization (6.9% vs. 2.4%, p = 0.004), and higher all-cause mortality (18.5% vs. 10.9%, p = 0.002).

Conclusions

In this cohort of Middle Eastern patients with AF, one in 10 patients had CAD. The coexistence of AF and CAD was associated with a worse baseline clinical profile and one-year outcomes. Clinical study registration: the study is registered on clinicaltrials.gov (unique identifier number NCT03917992).

Expert Recommendations to Bridge Gaps in Heart Failure Patient Support in the Middle East and Africa Region

Heart failure (HF) remains a serious health and socioeconomic problem in the Middle East and Africa (MEA). The age-standardized prevalence rate for HF in the MEA region is higher compared to countries in Eastern Europe, Latin America, and Southeast Asia. Also cardiovascular-related deaths remain high compared to their global counterparts. Moreover, in MEA, 66% of HF readmissions are elicited by potentially preventable factors, including delay in seeking medical attention, nonadherence to HF medication, suboptimal discharge planning, inadequate follow-up, and poor social support. Patient support in the form of activation, counseling, and caregiver education has been shown to improve outcomes in patients with HF. A multidisciplinary meeting with experts from different countries across the MEA region was convened to identify the current gaps and unmet needs for patient support for HF in the region. The panel provided insights into the real-world challenges in HF patient support and contributed strategic recommendations for optimizing HF care.

Protocolized Natriuresis-Guided Decongestion Improves Diuretic Response: The Multicenter ENACT-HF Study

BACKGROUND

The use of urinary sodium to guide diuretics in acute heart failure is recommended by experts and the most recent European Society of Cardiology guidelines. However, there are limited data to support this recommendation. The ENACT-HF study (Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure) investigated the feasibility and efficacy of a standardized natriuresis-guided diuretic protocol in patients with acute heart failure and signs of volume overload.

METHODS

ENACT-HF was an international, multicenter, open-label, pragmatic, 2-phase study, comparing the current standard of care of each center with a standardized diuretic protocol, including urinary sodium to guide therapy. The primary end point was natriuresis after 1 day. Secondary end points included cumulative natriuresis and diuresis after 2 days of treatment, length of stay, and in-hospital mortality. All end points were adjusted for baseline differences between both treatment arms.

RESULTS

Four hundred one patients from 29 centers in 18 countries worldwide were included in the study. The natriuresis after 1 day was significantly higher in the protocol arm compared with the standard of care arm (282 versus 174 mmol; adjusted mean ratio, 1.64; P<0.001). After 2 days, the natriuresis remained higher in the protocol arm (538 versus 365 mmol; adjusted mean ratio, 1.52; P<0.001), with a significantly higher diuresis (5776 versus 4381 mL; adjusted mean ratio, 1.33; P<0.001). The protocol arm had a shorter length of stay (5.8 versus 7.0 days; adjusted mean ratio, 0.87; P=0.036). In-hospital mortality was low and did not significantly differ between the 2 arms (1.4% versus 2.0%; P=0.852).

CONCLUSIONS

A standardized natriuresis-guided diuretic protocol to guide decongestion in acute heart failure was feasible, safe, and resulted in higher natriuresis and diuresis, as well as a shorter length of stay.

Strategic Recommendations to Bridge the Gaps in Awareness, Diagnosis and Prevention of Heart Failure in the Middle East Region and Africa

Objective

Method

Results

Conclusion

Surviving a Decade or More after Coronary Revascularization in a Middle Eastern Population: The Impact of Diabetes Mellitus

Introduction

Studies that evaluate Middle Eastern patients who have long-term survival after coronary artery revascularization are scarce. The prevalence of diabetes mellitus (DM) is high and rapidly increasing in our region.

Methods

The study enrolled consecutive ambulatory or in-patients who had percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery at least 10 years earlier. Collected data included cardiovascular risk factors at the time of the index revascularization and evolution of risk factors since then, the occurrence of cardiovascular events, and the need for coronary revascularization after the index procedure. Events were compared between patients with DM and no DM at baseline.

Results

The study population consisted of 891 consecutive patients with 351 patients (39.4%) had DM and 540 patients (60.6%) had no DM. The mean age at baseline was 53.9 ± 8.8 years for DM patients and 53.0 ± 9.8 years for no DM patients (P = 0.16). At baseline, the DM group had more hypertension (70.9% vs. 27.6%, P < 0.0001), more dyslipidemias (12% vs. 5.2%, P = 0.001) but less smokers compared to no DM group (44.4% vs. 58.3%, P < 0.001). DM and no DM groups had similar proportion of PCI (65.5% vs. 68.3%, P = 0.42) and CABG (34.5% vs. 31.7%, P = 0.43) at baseline. Following the index revascularization procedure, acute coronary events, heart failure, and stroke developed in similar proportions in the two groups. Repeat revascularization after the index procedure showed that the DM group had more PCI compared to no DM group (52.7% vs. 45.4%, P = 0.04) but similar proportions of CABG (7.1% vs. 9.8%, P = 0.20).

Conclusions

In this retrospective observation of Middle Eastern patients who survived at least a decade after coronary revascularization, the DM group had more hypertension and dyslipidemias but fewer smokers compared to no DM at baseline. During follow-up, the DM group required more PCI revascularization compared with no DM group.

Acute cardiovascular events triggered by the COVID-19 pandemic-related stress in non-infected individuals. The Jordan COVID-19 Acute Cardiovascular Events (JoCORE) study

The Corona Virus Disease 2019 (COVID-19) has become an unprecedented global public health crisis and a pandemic associated with vicarious psychosocial and economic stresses. Such stresses were reported to lead to behavioral and emotional disturbances in individuals not infected with the COVID-19 virus. It is largely unknown if these stresses can trigger acute cardiovascular events (CVE) in such individuals. Covid-19-neagtive adults presenting with acute myocardial infarction (AMI), cerebrovascular accident (CVA), or out-of-hospital cardiac arrest (OHCA) during the COVID-19 pandemic in Jordan from March 15, 2020 through March 14, 2021 were enrolled in the study if they reported exposure to psychosocial or economic stresses related to the pandemic lockdown. Of 300 patients enrolled (mean age 58.7 ± 12.9 years), AMI was diagnosed in 269 (89.7%) patients, CVA in 15 (5.0%) patients, and OHCA in 16 (5.3%) patients. Triggering events were psychosocial in 243 (81.0%) patients and economic stressors in 157 (52.3%) patients. The psychosocial stresses included loneliness, hopelessness, fear of COVID-19 infection, anger, and stress-related to death of a significant person. The economic stressors included financial hardships, job loss or insecurity, volatile or loss of income. Exposure to more than one trigger was reported in 213 (71.0%) patients. In-hospital mortality of the patients admitted for AMI or CVA was 2.1%, and none of the OHCA survived the event. The COVID-19 pandemic continues to be a source of significant psychosocial and economic hardships that can trigger life-threatening acute CVE among individuals not infected with the virus.

COVID-19 pandemic triggers acute myocardial infarction, stroke, and out-of-hospital cardiac arrest in non-infected individuals: the final results of the JoCORE study

Introduction

The relentless COVID-19 pandemic caused a devastating sickness and loss of life at a global level. The stress related to the pandemic lockdown and near total paralysis of most human activities was associated with behavioral changes. It is largely unknown if these stresses could trigger acute cardiovascular events among non-infected individuals.

Purpose

To explore the relation between COVID-19 associated stresses and acute cardiovascular events among non-infected individuals.

Methods

Adult patients presented with acute myocardial infarction (AMI), stroke or out-of-hospital cardiac arrest (OHCA) at 11 hospitals in Jordan from March 2020 through February 2021 were assessed for potential exposure to stressful life events related to the COVID-19 pandemic. None of the patients was COVID-19 infected or a health care worker.

Results

Of 297 patients enrolled (mean age 58.4±13.1 years, 18.5% females), 267 patients (89.8%) had AMI, 15 patients (5.1%) had stroke, and 15 patients (5.1%) had OHCA. Cigarette smoking was present in 59.6%, hypertension in 50.5%, dyslipidemia in 42.8%, diabetes in 37.4%, and 35% had prior diagnosis of cardiovascular disease. Coronary revascularization was performed in 228 (85.4%) of AMI patients. In-hospital mortality among the AMI and stroke patients was 4.3% and none of the OHCA patients survived. The most common stresses preceded these events included financial hardships (50.8%), lockdown stress (25.9%), fears from the pandemic (24.9%), anger (22.6%), loneliness (19.2%), smoking binges (19.9%), death of a significant person (6.4%), and food binges (3.4%).

Conclusions

The COVID-19 pandemic and lockdown caused immense psychosocial and financial stresses that triggered life threatening acute cardiovascular events in non-infected individuals. Early recognition of stress-related symptoms during this unremitting pandemic warrants proper referral and evaluation.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): ABDEL HAMEED SHOMAN FOUNDATION (AHSF) RESEARCH FUND

Clinical profiles of atrial fibrillation patients with or without malignancy: analysis from the Jordan Atrial Fibrillation study

Introduction

Atrial Fibrillation (AF) is the most prevalent arrhythmia and is associated with high morbidity and mortality. Malignancy can predispose to AF directly or through adverse effects of certain chemotherapeutic agents. Moreover, AF in the presence of malignancy is a special subgroup with high risk of both thromboembolism and bleeding.

Purpose

To study the clinical characteristics of AF in patients with malignancy compared to those without malignancy in a Middle Eastern population.

Methods

A total of 2015 Consecutive adult patients with previously or newly diagnosed AF in 19 hospitals and 30 out-patient cardiology clinics were enrolled in the Jordan AF study from May 2019 to October 2020. Clinical and epidemiological characteristics of patients with coexisting malignancy were compared to those without malignancy.

Results

Of the 2015 patients enrolled in the study, 136 (6.7%) had a coexisting malignancy; with breast cancer being the most common type of cancer (19.8%). Patients with malignancy were older than patients without malignancy (71±10 vs 67.5±13.3 years, p=0.005) with no gender difference between the two groups.

Patients with malignancy were less symptomatic compared to those without malignancy; fatigue (6.6% vs. 21.9%, p=0.ehab724.28492), dizziness (2.9% vs. 11.8%, p=0.0006) and shortness of breath (8.1% vs. 35.2%, p&lt;0.0001). Patients with AF and malignancy were more likely to have permanent AF at presentation compared to patients without malignancy (42.6% vs. 29.4%, P=0.0005).

While mean CHA2DS2-VASc in patients with malignancy was similar to those without malignancy (3.8±2.0 vs 3.5±2.0 p=0.269), the malignancy group had a higher proportion of patients with CHA2DS2-VASc score &gt;2.0 compared to those without malignancy (91.9% vs. 84.8%, p=0.023). On the contrary, patients without malignancy had higher proportions with HAS-BLED score &gt;3 compared to patients with malignancy (19.6% vs. 11.0%, p=0.014).

Left ventricular hypertrophy (LVH) and pulmonary hypertension (PAH) were diagnosed more frequently on echocardiography in patients with compared to those without malignancy (55.9% vs. 34.2%, p&lt;0.0001) and (43.4 vs. 26.2%, p&lt;0.ehab724.28498) respectively.

While patients with malignancy had a lower rate of direct oral anticoagulants (DOACs) utilization compared to patients without malignancy (34.6% vs. 48.1%, p=0.002), they had a higher rate of Low molecular weight heparin (LMWH) utilization (16.2% vs. 1.3%, p&lt;0.0001). There was no difference in the utilization of vitamin K antagonist between the two groups (29.4% vs. 31.8%. p=0.568).

Conclusion

Middle Eastern patients who have AF and coexisting malignancy were older, had less symptoms at presentation, and higher prevalence of permanent AF than patients without malignancy. These patients were more likely to be prescribed LMWH and less likely to receive DOACs compared to those without malignancy. Prospective long-term follow-up and outcomes is underway.

Funding Acknowledgement

Type of funding sources: None.

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.

COVID-19 Pandemic and Volume of Cardiac Catheterization Procedures in Jordan: Impact of Strict Lockdown

Introduction:

Global surge of COVID-19 forced most countries to impose variable measures to curb the disease. Jordan imposed one of the strictest lockdowns from mid-March through April 2020. Hospitals deferred elective cardiac catheterization procedures and most of those performed during that period were limited to urgent presentations. Our purpose is to evaluate the impact of strict lockdown on cardiac catheterization procedural volume.

Methods and Results:

We collected data about the numbers of all coronary angiography (CA) and percutaneous coronary intervention (PCI) procedures performed in 5 tertiary care hospitals in Amman, Jordan, from January through June 2020. We compared the volume of procedures performed in April 2020 (the strict lockdown month) to the corresponding period of prior year (April 2019) and to volumes performed prior to the lockdown in January–February 2020.

There was a 64% decline in CA and PCI volumes in April 2020 compared to April 2019. Comparing number of procedures performed in April 2020 to those in January–February 2020, there was 59% decline in CA and a 60% decline in PCI volumes. Following partial lifting of lockdown in May–June 2020, procedural volumes increased gradually.

Conclusion:

Strict COVID-19-related lockdown in Jordan was associated with drastic declines in cardiac catheterization procedural volumes.

Adherence to the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline on the Use of Oral Anticoagulant Agents in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

BACKGROUND

There is a scarcity of studies that evaluate adherence to the utilization of guideline-recommended oral anticoagulant agents (OACs) in patients with atrial fibrillation (AF) in the Middle East. The Jordan Atrial Fibrillation (JoFib) Study evaluated baseline clinical profiles and the utilization of OACs, including vitamin K antagonists (VKAs) and direct OACs (DOACs), in patients with valvular AF (VAF) and nonvalvular AF (NVAF) according to the 2019 focused update of the 2014 AHA/ACC/HRS guidelines.

METHODS

Consecutive patients with AF were enrolled in 29 hospitals and outpatient clinics. The use of OACs was evaluated in patients with VAF and NVAF according to the prespecified guideline.

RESULTS

Of 2000 patients, 177 (8.9%) had VAF and 1823 (91.1%) had NVAF. A VKA was prescribed for 88.1% of the VAF group. In the NVAF group, 1468 (80.5%) of patients had a high CHA2DS2-VASc score, i.e., a score of ≥3 in women and ≥2 in men; 202 (11.1%) patients had an intermediate CHA2DS2-VASc score, i.e., a score of 2 in women and 1 in men; and 153 (8.4%) patients had a low CHA2DS2-VASc score, i.e., a score of 1 in women and 0 in men. Of patients with a high CHA2DS2-VASc score, 1204 (82.0%) received OACs, including DOACs for 784 (53.4%) and VKA for 420 (28.6%) patients. Among patients with an intermediate score, OACs were prescribed for 148 (73.3%) patients, including 107 (53.0%) who received DOACs and 41 (20.3%) patients who received VKA. In patients with a low score, OACs were omitted in 94 (61.4%) patients and prescribed for 59 (38.6%) patients. Multivariate analysis showed that age between 50 and 70 years, CHA2DS2-VASc score of ≥2, a diagnosis of stroke or systemic embolization, and nonparoxysmal AF were significantly associated with increased odds of OAC prescription.

CONCLUSIONS

The current status of the utilization of OACs in Middle Eastern AF patients appears to be promising and is consistent with the 2019 focused update of the 2014 AHA/ACC/HRS guideline. This trial is registered with NCT03917992.

Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the PROspective multicenter registry on radiaTion dose Estimates of cardiac CT angIOgraphy iN daily practice in 2017 (PROTECTION VI)

Aims

Advances of cardiac computed tomography angiography (CTA) have been developed for dose reduction, but their efficacy in clinical practice is largely unknown. This study was designed to evaluate radiation dose exposure and utilization of dose-saving strategies for contrast-enhanced cardiac CTA in daily practice.

Methods and results

Sixty one hospitals from 32 countries prospectively enrolled 4502 patients undergoing cardiac CTA during one calendar month in 2017. Computed tomography angiography scan data and images were analysed in a central core lab and compared with a similar dose survey performed in 2007. Linear regression analysis was performed to identify independent predictors associated with dose. The most frequent indication for cardiac CTA was the evaluation of coronary artery disease in 89% of patients. The median dose-length product (DLP) of coronary CTA was 195 mGy*cm (interquartile range 110-338 mGy*cm). When compared with 2007, the DLP was reduced by 78% (P < 0.001) without an increase in non-diagnostic coronary CTAs (1.7% in 2007 vs. 1.9% in 2017 surveys, P = 0.55). A 37-fold variability in median DLP was observed between the hospitals with lowest and highest DLP (range of median DLP 57-2090 mGy*cm). Independent predictors for radiation dose of coronary CTA were: body weight, heart rate, sinus rhythm, tube voltage, iterative image reconstruction, and the selection of scan protocols.

Conclusion

This large international radiation dose survey demonstrates considerable reduction of radiation exposure in coronary CTA during the last decade. However, the large inter-site variability in radiation exposure underlines the need for further site-specific training and adaptation of contemporary cardiac scan protocols.

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.

Rationale and design of the worldwide prospective multicenter registry on radiation dose estimates of cardiac CT angiography in daily practice in 2017 (PROTECTION VI)

BACKGROUND

Cardiac computed tomography angiography (cardiac CTA) is an increasingly used versatile imaging method to evaluate coronary and cardiac morphology. Owing to improvements in technology, image quality has continuously improved over the last 10-20 years. At the same time, numerous non-randomized and randomized studies have been performed to reduce the associated radiation exposure. Currently, it is unclear if the advances in technology and knowledge about radiation reduction translated into reduced levels of cardiac CTA radiation dose in daily clinical practice as well as a wide utilization of dose-saving strategies.

METHODS

The PROTECTION VI study is a multicenter, prospective, worldwide registry designed to evaluate radiation dose exposure, utilization of dose-saving strategies and diagnostic image quality during cardiac CTA in current daily practice. Assessment of image quality will be addressed by the evaluation of diagnostic image quality at the local study site and the calculation of quantitative image quality parameters in an imaging core laboratory. Above 4000 patients will be enrolled from approximately 70 sites in Europe, North America, South America, Asia and Australia. The study will analyze median radiation dose levels, image quality, frequency of use and efficacy of algorithms for dose reduction, and patient and study-related predictors associated with radiation dose.

CONCLUSIONS

The PROTECTION VI study is designed to provide a reliable estimate of current radiation dose for cardiac CTA and to assess the potential for additional dose reductions.

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.

Incidence and impact on prognosis of heart failure in Middle Eastern patients undergoing percutaneous coronary interventions

Background:  Heart failure (HF) is a serious complication of percutaneous coronary intervention (PCI) that adversely impacts survival and quality of life.  Aims and Objectives: We sought to study the incidence of HF in Middle Eastern patients undergoing PCI and its impact on prognosis.Materials and Methods: The first Jordanian PCI Registry was a prospective multicenter study of PCI patients who were followed for one year. Patients who developed heart failure during hospitalization had their clinical and coronary angiographic profiles and adverse outcomes compared with those in patients who did not develop HF.  Results: Of 2425 patients who had PCI, 194 (8.0%) developed HF during the hospital stay. Compared with patients who did not develop HF, those who developed HF were more likely to have diabetes mellitus, prior history of myocardial infarction (MI), elevated levels of cardiac biomarkers, ST-segment elevation MI and multivessel or left anterior descending coronary artery disease (all p values<0.05). Cardiac mortality was significantly higher among patients who developed HF compared with those who did not (5.2% vs. 0.4%; p<0.0001) and at one year (11.2% vs. 1.2%; p<0.001). Multivariate analysis showed that HF during hospital stay was an independent predictor of one-year cardiac mortality (Odds ratio 6.1, 95% CI 3.3-11.1, p<0.001) . At one year, readmission rates for HF and ACS were higher among HF patients.  Conclusions: Certain clinical and angiographic features were associated with higher incidence of HF among Middle Eastern patients who undergo PCI. HF was associated with higher risk of death and other adverse cardiac events during hospital stay and one year of follow up.Asian Journal of Medical Sciences Vol.8(2) 2017 20-28

Outcomes of Middle Eastern Patients Undergoing Percutaneous Coronary Intervention: The Primary Analysis of the First Jordanian PCI Registry

Aim:

This is a prospective multicenter registry designed to evaluate the incidence of adverse cardiovascular events in Middle Eastern patients undergoing percutaneous coronary interventions (PCI). The registry was also designed to determine the predictors of poor outcomes in such patients.

Methods and Results:

We enrolled 2426 consecutive patients who underwent PCI at 12 tertiary care centers in Jordan between January 2013 and February 2014. A case report form was used to record data prospectively at hospital admission, discharge, and 12 months of follow-up. Mean age was 56 ± 11 years, females comprised 21% of the study patients, 62% had hypertension, 53% were diabetics, and 57% were cigarette smokers. Most patients (77%) underwent PCI for acute coronary syndrome. In-hospital and 1-year mortality rates were 0.78% and 1.94%, respectively. Definite or probable stent thrombosis occurred in 9 patients (0.37%) during hospitalization and in 47 (1.94%) at 1 year. Rates of target vessel repeat PCI and coronary artery bypass graft surgery at 1 year were 3.4% and 0.6%, respectively. The multivariate analysis revealed that cardiogenic shock, congestive heart failure, ST-segment deviation, diabetes, and major bleeding were significantly associated with higher risk of 1-year mortality.

Conclusions:

In this first large Jordanian registry of Middle Eastern patients undergoing PCI, patients treated were relatively young age population with low in-hospital and 1-year adverse cardiovascular events. Certain clinical features were associated with worse outcomes and may warrant aggressive therapeutic strategies.

Incidence and prognosis of stent thrombosis following percutaneous coronary intervention in Middle Eastern patients: The First Jordanian Percutaneous Coronary Intervention Registry (JoPCR1)

BACKGROUND

The incidence, risk factors, and outcome of stent thrombosis (ST) after percutaneous coronary intervention (PCI) in Middle Eastern patients are largely unknown.

OBJECTIVE

To determine the incidence, risk factors and outcome in our population.

DESIGN

Retrospective study of a prospective multicenter registry of consecutive patients who underwent PCI between January 2013 and February 2014 (JoPCR1).

SETTING

12 tertiary care centers in Amman and Irbid, Jordan.

PATIENTS AND METHODS

We collected clinical baseline and follow-up data.

MAIN OUTCOME MEASURES

Incidence of stent thrombosis.

RESULTS

The mean (standard deviation) age of patients (n=2426) was 59.0 (10.1) years and 20.6% were women. Stents (n=3038) were drug eluting (89.6%), bare metal (9.4%) or bioabsorbable (1.0%). After 1 year, 47 patients (1.97%) had ST, including 44 (94%) definite and 3 (6%) probable ST. Patients who had ST presented with sudden death (n=6; 12.2%) or with a nonfatal event (n=43; 87.8%). Nonfatal events included non-ST-segment elevation acute coronary syndrome (26; 53%), acute ST segment elevation myocardial infarction (n=15; 31%) or heart failure (n=2; 4.1%). ST was associated with significantly higher one-month (22.0% vs. 0.7%) and one-year (12.3% vs. 0.73%) mortality rates compared with patients who did not have ST (P < .001). ST patients were younger (mean age 52.9 years vs. 58.4 years), had heart failure (64% vs. 18%), left ventricular ejection fraction (LVEF) < 45% (36% vs. 13%), ST-segment deviation (70% vs. 48%), and elevated cardiac biomarkers blood levels (62% vs. 40%). In the multivariate analysis, the only factor that was significantly associated with ST was the heart failure (OR=3.5, 95% confidence interval: 1.8, 6.6; P < .0001).

CONCLUSIONS

The incidence of ST was not different from that in other regions and was associated with an increased one-year mortality. Younger age, heart failure, low LVEF, ST-segment deviation, and elevated blood levels of cardiac biomarkers were predictors of ST.

LIMITATIONS

Possible selection bias, recall bias, and missing or incomplete information. The majority of patients were lost to follow up after the 6th month. The registry may not fully represent PCI practice and outcome in all areas in the country or region.