Background— The khat plant is a stimulant similar to amphetamine and is thought to induce coronary artery spasm. Khat is widely chewed by individuals originating from the Horn of Africa and the Arabian Peninsula. The aim of this study was to evaluate the clinical characteristics and outcome of khat chewers presenting with acute coronary syndrome. Methods and Results— From October 1, 2008, through June, 30, 2009, 7399 consecutive patients with acute coronary syndrome were enrolled in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Nineteen percent of patients were khat chewers; 81% were not. Khat chewers were older, more often male, and less likely to have cardiovascular risk factors. Khat chewers were less likely to have a history of coronary artery disease and more likely to present late and to have higher heart rate and advanced Killip class on admission. Khat chewers were more likely to present with ST-segment–elevation myocardial infarction. Overall, khat chewers had higher risk of death, recurrent myocardial ischemia, cardiogenic shock, ventricular arrhythmia, and stroke compared with non–khat chewers. After adjustment for baseline variability, khat chewing was found to be an independent risk factor of death and for recurrent ischemia, heart failure, and stroke. Conclusions— Our data confirm earlier observations of worse in-hospital outcome among acute coronary syndrome patients who chew khat. This worse outcome persists up to 1 year from the index event. This observational report underscores the importance of improving education concerning the cardiovascular risks of khat chewing.

BackgroundGender-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 FindingsBaseline characteristics, treatment patterns, and 1-year mortality of 7390 ACS patients in 65 hospitals in 6 Arabian Gulf countries were evaluated during 2008–2009, as part of the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). Women were older (61.3±11.8 vs. 55.6±12.4; P<0.001), more overweight (BMI: 28.1±6.6 vs. 26.7±5.1; P<0.001), and more likely to have a history of hypertension, hyperlipidemia or diabetes. Fewer women than men received angiotensin-converting enzyme inhibitors (ACE), aspirin, clopidogrel, beta blockers or statins at discharge. They also underwent fewer invasive procedures including angiography (27.0% vs. 34.0%; P<0.001), percutaneous coronary intervention (PCI) (10.5% vs. 15.6%; P<0.001) and reperfusion therapy (6.9% vs. 20.2%; P<0.001) than men. Women were at higher unadjusted risk for in-hospital death (6.8% vs. 4.0%, P<0.001) and heart failure (HF) (18% vs. 11.8%, P<0.001). Both 1-month and 1-year mortality rates were higher in women than men (11% vs. 7.4% and 17.3% vs. 11.4%, respectively, P<0.001). Both baseline and management differences contributed to a worse outcome in women. Together these variables explained almost all mortality disparities.Conclusions/SignificanceDifferences 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.

Background & hypothesis:Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear.Methods:A total of 5334 patients presenting with ACS in 65 hospitals in 6 Middle East countries in the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE‐2) were studied according to their marital status (5024 married, 100 single, and 210 widowed patients).Result:When compared to married patients, widowed patients were older and more likely to be female. Widowed patients were more likely to have diabetes mellitus, hypertension, history of heart failure, and peripheral vascular disease and were less likely to be tobacco users when compared to the other groups. Widowed patients were also more likely to present with atypical symptoms and have advanced Killip class. Widowed patients were more likely to present with non‐ST‐elevation myocardial infarction (NSTEMI) when compared to the other 2 groups. Widowed patients were more likely to have heart failure (P = 0.001), cardiogenic shock (P = 0.001), and major bleeding (P = 0.002) when compared to the other groups. No statistically significant difference was observed in regard to duration of hospital stay, door to needle time in STEMI patients, or cardiac arrhythmias between the various groups. Widowed patients had higher in‐hospital, 30‐day, and 1‐year mortality rates (P = 0.001). Marital status was an independent predictor for in‐hospital mortality.Conclusion:Widowed marital status was associated with worse cardiovascular risk profile, and worse in‐hospital and 1‐year outcome. Future work should be focused on whether the provision of psychosocial support will result in improved outcomes among this high‐risk group. Clin. Cardiol. 2011 DOI: 10.1002/clc.22034Gulf RACE is a Gulf Heart Association (GHA) project and was financially supported by the GHA, Sanofi Aventis, and the College of Medicine Research Center at King Khalid University Hospital, King Saud University, and Riyadh, Saudi Arabia.The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Clinical characteristics and outcomes of ACS patients depend on the tobacco modality used. Further studies are required to evaluate the impact of emerging tobacco use modalities on patients with coronary artery disease.

a b s t r a c tContext: Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients. Aims: 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, 51e70 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 (X 2 ) test for categorical variables and multivariate logistic regression analysis for predictors were performed. Results: Among 7930 consecutive ACS patients; 2755 (35%) were 50 years, 4110 (52%) were 51e70 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 1.03e1.60), heart failure (OR 2.8; 95% CI 2.17e3.52) and major bleeding (OR 4.02; 95% CI 1.37 e11.77) and in-hospital mortality (age 51e70: OR 2.67; 95% CI 1.86e3.85, and age >70: OR 4.71; 95% CI 3.11e7.14). Conclusion: 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.

Data are scarce regarding emergency medical service (EMS) usage by patients with acute coronary syndrome (ACS) in the Arabian Gulf region. This 9-month in-hospital prospective ACS registry was conducted in Arabian Gulf countries, with 30-day and 1-year follow-up mortality rates. Of 5184 patients with ACS, 1293 (25%) arrived at the hospital by EMS. The EMS group (vs non-EMS) was more likely to be male, have cardiac arrest on presentation, be current or exsmokers, and have moderate or severe left ventricular dysfunction and ST-segment elevation myocardial infarction (STEMI). The EMS group had higher crude mortality rates during hospitalization and after hospital discharge but not after adjustment for clinical factors and treatments. The EMSs are underused in the Arabian Gulf region. Short- and long-term mortality rates in patients with ACS are similar between those who used and did not use EMS. Quality improvement in the EMS infrastructure and establishment of integrated STEMI networks are urgently needed.

No abstract

BackgroundStroke 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.MethodsFor a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries.ResultsThe 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%).ConclusionThere 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.