European Journal of Heart Failure (2009) 11, 1135–1142 doi:10.1093/eurjhf/hfp151
Heart failure in patients hospitalized with acute coronary syndromes: observations from the Gulf Registry of Acute Coronary Events (Gulf RACE) Alawi A. Alsheikh-Ali1,2*, Mouaz H. Al-Mallah 3, Wael Al-Mahmeed 1, Nazar Albustani 1, Jassim Al Suwaidi 4, Kadhim Sulaiman 5, and Mohammad Zubaid 6 for the Gulf RACE Investigators 1 Division of Cardiology, Institute of Cardiac Sciences, Sheikh Khalifa Medical City, PO Box 51900, Abu Dhabi, United Arab Emirates; 2Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA; 3Department of Cardiology, Henry Ford Hospital, Detroit, MI, USA; 4Cardiology Department, Hamad Medical Corporation, Doha, Qatar; 5Royal Hospital, Muscat, Oman; and 6Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait
Received 21 May 2009; revised 31 August 2009; accepted 22 September 2009; online publish-ahead-of-print 4 November 2009
See page 1116 for the editorial comment on this article (doi:10.1093/eurjhf/hfp159)
Aims
We describe the prevalence and prognostic significance of heart failure (HF) complicating acute coronary syndromes (ACS) in patients enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE). ..................................................................................................................................................................................... Methods Gulf RACE is a prospective, multi-national study of all patients hospitalized with ACS in 65 centres in six Arab countries. Data were analysed based on HF on presentation (Killip class II/III) or during hospital stay. The study endpoint was alland results cause in-hospital mortality. Of 8000 patients with ACS, 2009 (25%) had HF on presentation or during the hospital stay. Patients with HF were older, more often with co-morbid conditions, and less often treated with evidence-based therapies. Heart failure was associated with higher in-hospital mortality (7.9 vs. 0.9%, P , 0.001), which persisted after adjusting for age, gender, and presentation and treatment characteristics [adjusted odds ratio 4.1 (1.8–9.4)]. There was a significant interaction between age and the prognostic effect of HF on in-hospitality mortality, such that younger patients had a significantly higher increase in mortality related to HF (P for interaction ¼ 0.002). ..................................................................................................................................................................................... Conclusion Heart failure complicates a substantial proportion of ACS admissions in the Arab Middle East and is associated with higher in-hospital death. Younger patients with ACS have a higher relative increase in mortality related to HF.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Heart failure † Acute coronary syndrome † Mortality † Middle East
Introduction A common cause of heart failure (HF) is coronary artery disease (CAD) including its acute manifestations of ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA), collectively referred to as acute coronary syndromes (ACS).1 Several studies have demonstrated a significant association between HF and mortality in patients hospitalized with ACS.2 – 7 Thus far, all studies of HF complicating ACS have focused on predominantly ‘white’ and ‘western’ populations, where the genetic pool, risk factor profile, and treatment patterns differ from patients in other parts of the world. Despite the recognition that developing regions of the world, predominantly non-western and nonwhite populations, share an increasingly larger portion of the
global burden of cardiovascular disease, relatively few studies have focused on these populations.8 – 10 Although recent estimates suggest that populations in the Arab Middle East have among the highest rates of diabetes and hypertension worldwide, which would increase their risk of both ACS and HF, the epidemiology of HF in that part of the world remains unknown.11 – 17 Characterizing such epidemiology will provide pertinent insights into the implications of HF in an ACS population that is rarely studied and identify opportunities for improving the care of these high-risk patients. Intriguingly, patients with ACS in the Arab Middle East are typically younger than their counterparts from developed countries.18 The impact of age on the prevalence and prognostic significance of HF in patients with ACS is not well understood, and one prior analysis has suggested
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[email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email:
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Table 1 Baseline characteristics of patients with or without heart failure complicating acute coronary syndromes ACS with HF (n 5 2009)
ACS without HF (n 5 5991)
P-value
............................................................................................................................................................................... Age (years)
62 (53– 70)
53 (45– 61)
,0.001
Male (%)
68
79
,0.001
Past medical history (%) Diabetes mellitus
50
37
,0.001
Hypertension
62
45
,0.001
Dyslipidaemia Myocardial infarction
39 34
29 21
,0.001 ,0.001
Smoker
28
39
,0.001
Peripheral vascular disease Stroke
5 8
2 3
,0.001 ,0.001
PCI
14
11
8
5
Ischaemic type chest pain
58
88
Atypical chest pain Dyspnoea
5 33
7 1
Other
4
4
Symptom onset .12 h (%)a Systolic blood pressure
40 140 (120–165)
27 138 (120–156)
CABG Presenting symptom (%)
0.003 ,0.001 ,0.001
,0.001 ,0.001
83 (70– 100)
80 (70– 92)
,0.001
95 (80– 110)
80 (70– 91)
,0.001 ,0.001
Anterior/anterolateral
70
55
Inferior/infero-posterior Other
25 5
39 6
STEMI NSTEMI
36 36
38 31
UA
25
30
3
1
Peak CPK
480 (195–1469)
557 (214– 1567)
0.03
Peak CPK-MB Peak troponin
65 (26– 144) 1.5 (0.3–9.5)
66 (27– 151) 2.1 (0.4–11.9)
0.37 0.001
Total cholesterol
179 (135–222)
181 (140–216)
0.59
Low-density lipoprotein cholesterol High-density lipoprotein cholesterol
123 (95– 160) 39 (31– 49)
121 (94–153) 37 (31– 46)
0.02 ,0.001
Diastolic blood pressure Heart rate Site of ST-segment deviation on ECG (%)b
,0.001
ACS diagnosis (%)
LBBB MI Laboratory investigations
Triglycerides
127 (89– 196)
142 (98–208)
,0.001
Creatinine
1.1 (0.8–1.4)
0.9 (0.7–1.1)
,0.001
PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft surgery; ECG, electrocardiogram; STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction; UA, unstable angina; LBBB, left bundle branch block; CPK, creatinine phosphokinase. Units for lab investigations are U/L for CPK and CPK-MB, mg/L for troponin I or T (depending on recruiting centre), and mg/dL for other values. a Time from symptom onset to presentation in patients with STEMI and LBBB MI. b Among patients with ST deviation on ECG (74% of patients with HF and 71% of patients without HF).
a more marked relative effect of HF on mortality in younger patients with ACS.6 In the present study, we describe the prevalence, patient characteristics, treatment patterns, and in-hospital outcomes of HF complicating ACS in patients enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE).18,19 We also examine the association of age with the prognostic effect of HF on in-hospitality mortality in patients with ACS.
Methods Study population Gulf RACE is a prospective, multi-national study of all consecutive patients hospitalized with the final diagnosis of ACS in 65 centres in six Arab countries (Kuwait, Oman, United Arab Emirates, Yemen, Qatar, and Bahrain).18,19 Patients were enrolled in a pilot phase that
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lasted for 1 month in May 2006 and a subsequent study phase from January 2007 to June 2007. All patients were included in the present analysis. Details of study organization have been previously described.18,19 All patients with ACS were eligible with no upper age cap or other restrictions on study sample. Patients were managed according to the discretion of the treating physician. An institutional review board or equivalent at each participating hospital approved the protocol. All hospitals that care for patients with ACS in Kuwait, Bahrain, and Qatar participated, as did the majority of such hospitals (serving 85% of the population) in Yemen, United Arab Emirates, and Oman.
Definitions Diagnosis of the different types of ACS and definitions of data variables were based on the American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with ACS.20 Briefly, for NSTEMI, STEMI, or left bundle branch block (LBBB) MI, the definition required the typical rise and fall of biochemical markers of myocardial necrosis (troponin or CK-MB) with at least one of the following: ischaemic symptoms, pathological Q waves on an electrocardiogram (ECG), ECG changes indicative of ischaemia, or coronary artery intervention. For UA, the definition required biochemical cardiac markers to be within normal range, along with ischaemic symptoms that were prolonged, of new-onset, or accelerating, and ECG changes indicative of ischaemia. All patients were assigned to one of the following categories: STEMI, NSTEMI, UA, or LBBB MI, taking into account the clinical presentation, ECG findings, and serum biochemical markers of myocardial necrosis. Data on baseline characteristics, admission profile, and in-hospital treatments and outcomes were prospectively collected. For this analysis, patients were categorized into two cohorts: those who had ACS complicated by HF and those who did not have HF. The ACS with HF cohort included patients with HF at the time of hospital presentation according to the Killip classification (class II: findings consistent with mild to moderate HF including a third heart sound (S3), lung rales less than one-half way up the posterior lung fields or jugular venous distension or class III: overt pulmonary oedema) or HF that developed in-hospital during the hospital stay, as coded by the site investigator. Patients with cardiogenic shock on presentation (Killip class IV) represented a small group of patients (2% of the entire cohort) with very high in-hospital mortality (44%), and were excluded from the present analysis. The study endpoint was all-cause in-hospital mortality.
Statistical analysis Continuous variables are summarized as median and inter-quartile ranges and compared using the Wilcoxon rank sum test. Categorical variables are summarized as percentages and compared using x2 tests. Step-wise, multivariable logistic regression was used to identify independent predictors of in-hospital HF adjusted for the following baseline covariates: age, gender, heart rate, systolic and diastolic blood pressure on presentation, site of ST-segment deviation on presenting ECG, history of myocardial infarction, peripheral vascular disease, stroke, diabetes mellitus, hypertension, dyslipidaemia, prior revascularization (coronary artery bypass graft surgery or percutaneous coronary intervention), smoking, and serum creatinine. Similarly, the association between HF and in-hospital mortality was examined using step-wise logistic regression models adjusting for the following covariates: age, gender, heart rate, systolic and diastolic blood pressure on presentation, site of ST-segment deviation on presenting ECG, history of myocardial infarction, peripheral vascular disease, stroke, diabetes mellitus, hypertension, or dyslipidaemia, prior
Table 2 Presentation characteristics associated with in-hospital heart failure in patients with acute coronary syndromes Wald x2
Odds ratio
95% confidence limits
Heart rate (10-beat increase)
322.6
1.27
1.24– 1.31
Age (10-year increase) History of myocardial infarction Anterior ST-segment deviation Creatinine (1 mg/dL increase) Hypertension
272.9 60.0
1.55 1.77
1.47– 1.63 1.53– 2.05
27.5
1.32
1.19– 1.47
26.9
1.14
1.09– 1.20
................................................................................
11.4
1.26
1.10– 1.44
10.5
1.23
1.08– 1.39
Diastolic blood pressurea
7.9
1.08
1.02– 1.13
Peripheral vascular disease
5.5
1.49
1.07– 2.08
Systolic blood pressurea
5.0
0.96
0.94– 0.99
Diabetes mellitus
All odds ratios are adjusted for baseline covariates (see Statistical analysis). a Per 10 mmHg increase.
revascularization (coronary artery bypass graft surgery or percutaneous coronary intervention), smoking, serum creatinine, reperfusion therapy with thrombolytics or primary angioplasty, and initiation of aspirin, clopidogrel, beta-blocker, and statin therapy within 24 h of admission, and type of acute coronary syndrome. To assess the relationship between age and the prognostic effect of HF on in-hospitality mortality, we introduced an interaction term of age HF in the logistic regression model and graphically displayed the estimated odds ratio (OR) against age as a continuous variable. All associations from the logistic regression models are quantified as OR with 95% confidence intervals. Analyses were performed with SAS 9.1 statistical package (SAS Institute, Cary, NC, USA).
Results Study population Gulf RACE enrolled 8176 consecutive patients with ACS, of whom 176 were in cardiogenic shock on presentation. The remainder (n ¼ 8000) comprised the present study sample (Table 1). Heart failure complicated ACS in 2009 patients, of whom 80% had HF on presentation (Killip class II in 53% and class III in 27%) and 20% developed HF during the hospital stay. In both genders, the proportion of ACS patients with HF increased with age from about 10% in patients younger than 40 years, to almost 50% of patients older than 70 years. Among patients within an age group similar to the average age of ACS patients in other registries (typically from 55 to 65 years), the prevalence of HF was 33%. Compared with patients with ACS not complicated by HF (n ¼ 5991), those with HF were significantly older by nearly a decade (62 vs. 53 years, P , 0.001) and more likely to be female (32 vs.
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Table 3 Treatment patterns and in-hospital outcomes of patients with or without heart failure complicating acute coronary syndromes ACS with HF (n 5 2009)
ACS without HF (n 5 5991)
P-value
Thrombolytic therapy Door to needle time (min)
80 45 (30–80)
84 44 (27–75)
0.03 0.28
Primary angioplasty
6
8
0.06
Door to balloon time (min) Shortfall
81 (60–120) 14
72 (52–110) 8
0.67 ,0.001
96 48
99 55
,0.001 ,0.001
............................................................................................................................................................................... Coronary reperfusion therapy in STEMI/LBBB MI
Medications within 24 h of admission (%) Aspirin Clopidogrel Beta-blocker
40
75
,0.001
ACE-I/ARB Statin
77 85
66 91
,0.001 ,0.001
Intravenous heparin
43
49
,0.001
Low molecular weight heparin Nitrates
48 85
46 81
,0.001 ,0.001
Diuretics
70
10
,0.001
Echocardiogram done (%) Left ventricular ejection fraction
68 40 (30–48)
59 52 (45–60)
,0.001 ,0.001
Percent with LVEF 40%
57
19
,0.001
Medications on discharge (%) Aspirin
89
96
,0.001
Clopidogrel
44
52
,0.001
Beta-blocker ACE-I/ARB
56 78
83 74
,0.001 ,0.001
Statin
78
82
,0.001
Spironolactone Nitrates
17 70
2 70
,0.001 0.66
67
10
,0.001
11
1
,0.001
Death
7.9
0.9
,0.001
Recurrent ischaemia Cardiogenic shock
12.6 11.6
8.4 1.1
,0.001 ,0.001
Diuretics Digoxin In-hospital outcomes (%)
Stroke
1.3
0.4
,0.001
Major bleeding
1.5
0.4
,0.001
ACE-I/ARB, angiotensin-converting enzyme-inhibitor or angiotensin receptor blocker. Major bleeding was defined as overt clinical bleeding associated with a drop in haemoglobin of greater than 5 g/dL or bleeding causing haemodynamic instability or requiring blood transfusion.
21%, P , 0.001). Except for a smaller proportion of smokers, risk factors for cardiovascular disease were more prevalent in patients with HF including a larger proportion with diabetes mellitus, hypertension, and dyslipidaemia (Table 1). Similarly, a history of documented cardiovascular disease was more common in patients with HF, including a significantly higher proportion of patients with prior myocardial infarction, stroke, peripheral vascular disease, or percutaneous/surgical coronary revascularization (Table 1).
Presentation characteristics While most patients with ACS and HF presented with ischaemic type chest pain (58%), they were significantly more likely to have
dyspnoea as their primary symptom, which occurred in about one third of patients with HF compared to only 1% of patients without HF (P , 0.001, Table 1). Patients with HF were significantly more likely to have anterior ST-segment deviation on their presenting ECG compared with patients without HF (70 and 55%, P , 0.001). The distribution of ACS type was significantly different between the two groups, with HF patients significantly more likely to have a LBBB MI (3 vs. 1%) and less likely to have UA (25 vs. 30%, P , 0.001). Patients with HF had a higher heart rate and slightly higher blood pressure on presentation (Table 1). Among patients with STEMI or LBBB MI, those who had HF were significantly more likely to have presented to the hospital more than 12 h
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Table 4 Association of heart failure during admission with in-hospital outcomes in patients with acute coronary syndromes Odds ratio
95% confidence limits
Death
4.10
1.80–9.36
Recurrent ischaemia
2.08
1.38–3.14
Cardiogenic shock Stroke
9.36 8.70
5.43–16.15 1.31–57.63
Major bleeding
4.51
1.45–13.96
................................................................................
All odds ratios are adjusted for baseline covariates and treatment patterns (see Statistical analysis). Major bleeding was defined as overt clinical bleeding associated with a drop in haemoglobin of greater than 5 g/dL or bleeding causing haemodynamic instability or requiring blood transfusion.
after symptom onset (40 vs. 27%, P , 0.001). Baseline serum creatinine, fasting levels of low-density lipoprotein cholesterol and high-density lipoprotein cholesterol were higher in patients with HF, whereas fasting serum triglycerides were lower (Table 1). Several presentation characteristics were independently associated with an increased risk of HF including older age, higher heart rate on presentation, anterior ST-segment deviation on ECG, history of myocardial infarction, diabetes mellitus, hypertension, or peripheral vascular disease, higher creatinine or diastolic blood pressure, and lower systolic blood pressure (Table 2).
Treatment patterns Among patients with STEMI or LBBB MI who presented within 12 h of symptom onset, those with HF were significantly less likely to receive coronary reperfusion therapy (reperfusion short fall 14 vs. 8%, P , 0.001, Table 3). Reperfusion was predominantly pharmacologic with thrombolytic therapy in both groups. Compared with patients without HF, patients with HF were less likely to receive aspirin, clopidogrel, beta-blockers, or statins in the first 24 h of admission, but more likely to receive diuretics and angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers. Beta-blockers, statins, and clopidogrel were also less often prescribed to patients with HF at discharge, whereas digoxin and diuretics were more likely to be prescribed. An echocardiogram was performed in about two-thirds of patients with HF, who had significantly lower left ventricular ejection fraction (LVEF) relative to patients without HF (Table 3). Notably, 57% of patients with HF had decreased systolic function, defined as LVEF 40%, compared with only 19% without HF. Among patients with LVEF 40% and HF, 81% were discharged on an angiotensinconverting enzyme-inhibitor or an angiotensin receptor blocker and only 57% were discharged on a beta-blocker.
In-hospital outcomes Patients with HF were significantly more likely to die in the hospital compared with patients without HF (7.9 vs. 0.9%, P , 0.001). The significant adverse effect of HF on in-hospital survival was similar across all types of ACS (P for interaction of ACS type and HF ¼ 0.67). The association of HF with in-hospital mortality persisted after adjusting for age, gender, past medical history, presentation
Figure 1 In-hospital mortality in patients with or without heart failure complicating acute coronary syndrome across different age groups: by quartile of age.
characteristics, treatment patterns, and type of ACS (adjusted OR 4.10, 95% confidence limits 1.80– 9.36). Heart failure was also associated with a significant adverse effect on in-hospital recurrent ischaemia, cardiogenic shock, stroke, and major bleeding (Table 4).
Age, heart failure, and in-hospital mortality The significant impact of HF on in-hospital mortality was evident across all age groups (Figure 1). The odds ratios of in-hospital mortality in a 40-year-old patient with ACS complicated by HF were equivalent to the odds ratios of in-hospital mortality in an 85-year-old patient with ACS but without HF. There was a significant interaction between age and the prognostic effect of HF on in-hospitality mortality, such that the relative effect of HF on mortality was significantly more pronounced in younger patients with ACS (P for interaction of age and HF ¼ 0.002). Since data on prior history of HF were not captured in Gulf RACE, we repeated the above analyses after excluding patients with prior MI (n ¼ 1922, assuming that patients with prior MI are more likely to have a prior history of HF). The prevalence of HF complicating ACS after excluding patients with prior MI was 22%. Similar findings were obtained when we examined the association of baseline characteristics with HF, and the relationship between HF and in-hospital outcomes (data not shown). The interaction between HF and age described above persisted after exclusion of patients with prior MI (P for interaction ¼ 0.0039).
Discussion This is the first systematic description of the characteristics and the prognostic impact of HF complicating ACS in the Arab Middle East. We observed that one in every four patients with ACS also had HF during admission. In both men and women, the prevalence of HF complicating ACS increased considerably with age such that ACS was complicated by acute HF in nearly half of the patients older than 70 years. Patients with ACS complicated by HF were much more likely to die in the hospital or experience other in-hospital complications such as recurrent ischaemia, stroke, cardiogenic shock, or major bleeding, an association that persisted after
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Table 5 Characteristics of patients with heart failure complicating acute coronary syndromes from different parts of the world Gulf RACE (n 5 2009)
Canadian Registry7 (n 5 559)
NRMI2 (n 5 176, 158)
GRACE6 (n 5 2647)
Euro Heart Survey5 (n 5 2529)
............................................................................................................................................................................................................................................. Prevalence (%) Age (years)
25 62 (53– 70)
12 72
29 74
19 73
26 69
Male (%)
68
63
52
61
64
Diabetes mellitus Hypertension
50 62
32 58
34 58
29 60
31 62
Myocardial infarction
34
39
27
29
36
Years of enrolment ACS type
2006–2007 All ACS
1999– 2003 NSTEMI or UA
1994–2000 STEMI or NSTEMI
1999– 2001 All ACS
2000–2001 All ACS
Definition
Killip II and III on admission or HF in hospital
Killip II and III on admission
Killip II and III on admission or HF in hospital
Killip II and III at admission or HF in hospital
Killip II and III on admission or HF in hospital
Exclusion
Killip IV
Killip IV, prior HF
Killip IV, prior HF
Killip IV, prior HF
Killip IV
In-hospital mortality (%) Adjusted OR
7.9 4.1 (1.8–9.4)
3.6 1.9 (1.1– 3.3)
24 3.8 (3.7–3.9)
14 2.2 (1.8– 2.7)
5 3.9 (2.7–5.6)
n refers to the number of patients with HF. Gulf RACE, Gulf Registry of Acute Coronary Events; NRMI (USA), National Registry of Myocardial Infarction (NRMI); GRACE, Global Registry of Acute Coronary Events; Euro Heart Survey, European Heart Survey of Acute Coronary Syndromes; adjusted OR, adjusted odds ratio for in-hospital death related to HF.
A.A. Alsheikh-Ali et al.
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adjusting for age, gender, presentation characteristics, treatment patterns and ACS type. The present analysis contributes pertinent information about the epidemiology of HF in ACS from a geographically distinct population that is rarely studied. The most striking feature is the relatively younger age of the Gulf RACE cohort, which is nearly a decade or two younger than ACS cohorts from other parts of the world.21,22 Their younger age, however, did not seem to offer protection against developing HF in the setting of ACS; the rate of HF observed in Gulf RACE (25%) is higher than that reported in the Canadian ACS registries or the Global Registry of Acute Coronary Events (GRACE) (12 and 19%, respectively), and within the range observed in the European registry and the US National Registry of Myocardial Infarction (NRMI-2) (26 and 29%, respectively, Table 5).2,5 – 7 Among Gulf RACE patients within an age group similar to the average age of ACS patients in the other registries (generally around 65 years), the prevalence of HF was even higher (33%). The higher rate of HF in patients with ACS in Gulf RACE may be due to a higher prevalence of diabetes mellitus in our population.23,24 The Arab Gulf states included in this registry have some of the highest estimates of prevalence of diabetes mellitus in the world, approaching one in four adults in some reports.11,25 – 27 Other potential explanations include differences in genetic predisposition, severity of CAD, delay in seeking care, or design/inclusion criteria among the different registries (Table 5). The younger age of the present cohort is particularly relevant given the interaction of age with the prognostic effect of HF on mortality. We observed a significantly more pronounced relative effect of HF on mortality in younger patients with ACS. This interaction was first reported by the GRACE investigators, and the present analysis is the first to independently validate the observation in a separate cohort.6 The reason for such an interaction is uncertain. The play of chance cannot be excluded, but is less likely given the highly significant finding in two independent datasets. It is conceivable that the clinical diagnosis of HF is a more specific marker of ACS severity in younger patients, and therefore has a more marked effect on mortality during the index admission. Several of our findings are consistent with previous reports characterizing HF in patients with ACS. In a post hoc analysis of four large STEMI/fibrinolytic therapy trials, the presence of HF was associated with more than twice the risk of dying or re-infarction at 30 days.4 Similar findings were observed in nonclinical trial settings in NRMI-2, the Canadian ACS registries, the European Heart Survey of ACS (Euro Heart Survey ACS), and GRACE, where HF was one of the strongest predictors of in-hospital death in patients with ACS.2,3,5 – 7 Consistent with these prior reports, we also observed that several presentation characteristics were significantly associated with HF, most notably a higher heart rate on admission, older age, a history of myocardial infarction, and anterior ST-segment deviation on the presenting ECG. As in other parts of the world, and despite their higher risk, patients with HF in the Arab Middle East were less likely to receive evidence-based therapies in the first 24 h of their ACS admission and at the time of discharge. Among those with HF and reduced LVEF, nearly one in five were not discharged on an angiotensin-converting enzyme-inhibitor or angiotensin
receptor blocker and more than 40% were not discharged on a beta-blocker. The implications of our findings should be viewed within the constraints of observational studies. Registry data may be subject to selection bias when only certain centres participate, and hence their findings may not be generalizable. This is less likely to be the case here, since the vast majority of hospitals that care for patients with ACS in the participating countries were included.18,19 The clinical exam tools used to define HF may have limited or non-uniform sensitivity or specificity, and hence our estimates may not reflect the true rate of HF in patients with ACS. However, such tools represent ‘real-life’ practice and do not invalidate the conclusion that when a physician labels an ACS patient as having ‘HF’ based on these tools, such a patient is at an increased risk of dying in the hospital. Our analysis may also be limited by the absence of information about prior history of HF and outcomes post-hospital discharge. It is also conceivable that some patients may have been admitted with a primary exacerbation of HF but were misclassified as ACS due to a slight elevation in biochemical markers of myocardial necrosis. Finally, the observational nature of the study precludes us from inferring cause-and-effect associations between treatment patterns and in-hospital outcomes. In conclusion, HF complicates a substantial proportion of ACS admissions in the Arab Middle East and is associated with higher in-hospital death and complications. Younger patients with ACS have a higher relative increase in mortality related to HF. The seemingly higher rate of HF with ACS in this population compared with other parts of the world requires further investigation.
Funding Gulf RACE is a Gulf Heart Association project and was financially supported by Sanofi Aventis and Qatar Telecommunications Company. The sponsors had no role in study design, data collection or analysis, writing of the report, or the decision to submit the manuscript. Conflict of interest: A.A.A. was a recipient of a faculty development award from Pfizer/Tufts Medical Center.
Appendix Gulf RACE National Coordinators and Investigators Bahrain: Haitham Amin (National Coordinator), Husam Noor, Rashid Albannai; Kuwait: Bassam Bulbanat (National Coordinator), Shahid Zubair, Mustafa M.Ridha, Marwan Abu Rezq, Hesham Saad, Mousa Akbar, Rashed Al-Hamdan, Fahad Al-Enizi; Oman: Jawad Al-Lawati (National Coordinator), Kadhim Sulaiman (National Coordinator), B. Kamath, P. P. Singh, Marei Aysha, Ali Yousif, Faisal Tamimi, Kurain Mathew, Ahmed Mosad, A. Narayan, Adel BadrEldin, Qassim Shimal, S. K. Samantray, Kamiran Dabagh, Zakaria Boghdady, K. J. Sulaiman, Sulieman Al-Sheraiqi; Qatar: Nidal A. Asaad (National Coordinator), Amar Mohammad Salam; UAE: Nazar Albustani (National Coordinator), Srinath Kidambi, Vipin Thomas, Afzal Y.Ali, Nayan Rao, V.J.Sebastian, Wael El-Abbassi, Mohamed Ibrahim, M Taiseer El-Massri, Adel A.S.
1142 Wassef, Amrish Agrawal, Joseph Kurein, Anthony Thomas, Ismail Jalian; Yemen: Ahmed Al-Motarreb (National Coordinator), Nora Al-Sagheer, Abdu hamood,Mohammed Abu Ghanem,Abd Al-Jalil AL wazeer, Abdullah AL-Shameeri, Majed AL-Showbaki, Elham AL-Qudari, Araf Ahamed Saleh, Hanan Mojamal, Abd AL-Raheem ba Khashwen, Faiz Khoba, Abd AL-Hakim Al-Hammadi, Munir AL-Absi, Mohammad Tantawi, Khalad Al-zanan, Ahmed AlRubaidi, Faud Ali, Abd ARakeeb Al-GHobari, Madian Shehab, Motee AL- Awlagi.
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