Characteristics, treatment, and outcome of patients with acute ...

European Heart Journal Supplements (2014) 16 (Supplement B), B102–B105 The Heart of the Matter doi:10.1093/eurheartj/suu003

Characteristics, treatment, and outcome of patients with acute coronary syndrome presenting at King Abdulaziz Cardiac Center compared with the European patients Waqas Khan*, Zeinelabdien Elsherif, Yousri Daoud, Abdelmagid Mukhtar, Hafiz Omer, Basil Saeed, and Murtada Halim Division of Adult Cardiology, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, PO BOX 22490, Riyadh 11426, Kingdom of Saudi Arabia

KEYWORDS Cardiac risk factors; Acute coronary syndrome; Saudi population

The aim of this study was to examine the management of acute coronary syndrome (ACS) at King Abdul Aziz Cardiac Center (KACC) and to compare our practice with that of the European population of Euro Heart Survey—2009 (EHS 2009). This is a study of 3233 consecutive ACS patients who presented to KACC from January 2010 to December 2013. The data describing baseline characteristics, treatment, and outcome were collected and compared with that of EHS-2009 population. The diagnosis of STelevation myocardial infarction (STEMI) and non-STEMI at KACC compared with EHS 2009 was 30 vs. 70% and 60.5 vs. 39.5%, respectively. Our population was younger with more male patients. Smoking, obesity, hypertension, hyperlipidaemia, diabetes, and renal failure were more common in the KACC population. More echocardiograms were performed at KACC, while the diagnostic angiograms performed were comparable in the two populations. More PCI procedures were performed for non-STEMI at KACC, while similar number of primary PCI was performed in two populations of STEMI. The adherence to the recommended medical therapy was more frequent in KACC population. Despite high burden of risk factors, the in-hospital mortality trend was lower at KACC compared with EHS-2009 population. KACC population was younger, with more risk factors for coronary artery disease and better adherence to guidelines recommended medical treatment. More PCI were performed at KACC for non-STEMI patients. The in-hospital mortality was lower at KACC compared with EHS-2009 population.

Introduction Different areas of the Middle East have undergone a fast and major socio-economic transition which has increased the burden of coronary artery disease (CAD).1 The Kingdom of Saudi Arabia is a typical example. Previous studies have shown a much higher burden of cardiovascular

* Corresponding author. Tel: +966 118011111, Email: waqascardio@ gmail.com

risk factors in the Saudi population.2 Previous studies have identified significant differences in the outcome of ACS patients treated in different regions of Middle East.3 It is, therefore, likely that such regional differences also exist within Saudi Arabia which is geographically a large country with important socio-economic and health care implications. If so, the SPACE registry may not be the representative of the outcome of ACS patients treated in the most advanced cardiac center. To explore this hypothesis, we conducted a study to compare the baseline

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Characteristics, treatment, and outcome of patients with ACS

characteristics, treatment, and the outcome of ACS patients treated in a state of art tertiary cardiac center [King Abdul Aziz Cardiac Center (KACC)] with those reported for European population in the Euro Heart Survey (EHS) ACS-2009.4

Methods This is an analysis of 3233 consecutive adult (.18 years old) male and female patients who presented to KACC from January 2010 to December 2013 with ACS. All those eligible fulfilled the criteria of ACS occurring either spontaneously or after non-cardiac procedures. The diagnosis was based on positive cardiac troponin with classical symptoms or ECG changes suggestive of ischaemia. Those patients who suffered ACS after a cardiovascular procedure were excluded. Based on ECG findings, a diagnosis of either STelevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (non-STEMI) was made. All patients were admitted through ER to a 19-bedded CCU or a medical care intensive care unit either directly or via the catheter laboratory if a diagnosis of either STEMI or a high-risk non-STEMI was made. The treatment of STEMI was primary percutaneous coronary intervention in all those eligible for reperfusion therapy. The ethical committee approval was granted after submission of a formal research proposal to the research ethics committee. The data were routinely collected by the admitting physician on an electronic data base ‘Apollo Advance’. Three hundred and fiftyseven patients (11%) with missing data were excluded from the cohort of renal failure and diabetes.

Statistical methods Primary analysis (frequency, mean, and standard deviation) was done for KACC data using IBM SPSS Statistics version 21. Each categorical value of EHS 2009 was recalculated. Online 2 by 2 tables were used with application of the Chi-square test for categorical data. Direct comparisons of the mean of numerical data for two groups were done by using an online unpaired t-test. A P-value of ,0.05 was considered statistically significant.

Results Of 3233 patients at KACC compared with EHS-2009 population, a diagnosis of STEMI and non-STEMI was 30 vs. 70% and 60.5 vs. 39.5%, respectively. The baseline characteristics of KACC (n ¼ 3233) and EHS-2009 (n ¼ 4236) populations subdivided into STEMI and non-STEMI are shown in Tables 1 and 2, respectively. There were less STEMI and more non-STEMI in Saudi compared with the European patients (P , 0.0001). KACC STEMI and non-STEMI populations were significantly younger (P , 0.0001) than the European population. Male gender was prevalent in Saudi when compared with European patients. The burden of risk factors was higher in KACC patients such as smoking, BMI, dyslipidemia and diabetes independent of the diagnosis of STEMI or NSTEMI. However, hypertension was more common in the European STEMI population while renal failure was comparable in both STEMI groups. The adherence to guideline-recommended medical therapy was higher for all classes of drugs in KACC compared with the European population. More Saudi patients had an

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echocardiogram, while diagnostic angiograms were performed equally in both populations. Significantly more PCI procedures were performed in Saudi non-STEMI patients (P , 0.0001), more primary PCI procedures were performed in Europe (P ¼ 0.2) (Table 3). The mortality was lower in KACC compared with European population in both non-STEMI (P , 0.01) and STEMI (P , 0.03) patients.

Discussion The presentation of patients with ACS in Saudi Arabia differs in terms of age, prevalence of risk factors, and timely access to hospital with consequent delay in receiving reperfusion therapy compared with the developed countries.2 The early manifestation of CAD in Arab population is mainly due to a high burden of risk factors.5 We would first acknowledge the major limitations of this analysis. We compared the results of a single center in Saudi Arabia with those of a multi-centric registry in Europe. Second, our data refer to the years 2010–13, while the European registry is a snapshot, conducted in 2009. The European Society of Cardiology is just starting a new registry on ACS and the first results are expected in 2015. Despite these limitations, we considered EHS-2009 population for comparison to have at least a point of reference to discuss and ameliorate our daily operations. From the data reported, it is clear that the Saudi ACS population is younger than the European, suggesting an early onset and quicker progression of coronary atherosclerosis in this population. This is not at all surprising considering the higher prevalence of important risk factors for CAD, such as diabetes, hyperlipidaemia, and renal failure in the Saudi population. The reasons for this are multiple and not fully understood. The most likely one is the abrupt and rapid change of life style of the Saudi population. The socio-economic conditions have drastically changed in the last years due to the discovery of oil in the Kingdom and the consequent wealth. This has resulted in a ‘specific culture’ consisting in rapid urbanization, availability of abundant western-type of food, and dramatic changes in lifestyle of the population which are not necessarily favourable for the coronary arteries. The prevalence of diabetes in Saudi Arabia, for example, is indeed one of the highest in the world as 60% of patients presenting to KACC with an ACS were diabetic, almost more than double compared with the ESC 2009 population. The in-hospital mortality at KACC among diabetic patients was almost double compared with non-diabetics (4.4 vs. 2.4%) and, of interest, there were more diabetic female than male, resulting in higher risk of adverse outcome in female gender (Table 4). Urbanization, sedentary lifestyle, and abundance of (wrong) food are the likely explanation for the high percentage of diabetes which is equivalent to CAD. This is very worrying because it is easier to change the lifestyle of a population for the worse than for the better, Saudi Arabia being a typical example. Such an epidemic of diabetes has to be tackled through educational program at a national level by the government, schools, and social networks, including the Saudi Heart Association.


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Table 1 Baseline characteristics of KACC vs. EHS 2009 STEMI population ST-elevation

Age (years) mean Age ≥75 years (%) Male gender (%) BMI (mean) Smoker (%) Hypertension (%) Dyslipidaemia (%) Diabetes (%) Renal failure (%) Echo (%) Angiogram (%) PCI (%)

KACC (n ¼ 969)

EHS 2009 AMI (n ¼ 2563)

P-value

57.48 + 13.51 12.6 84.4 28.08 + 4.83 46.33 44.7 49.2 53 4.7 94 76.4 47.6

64.3 + 13.2 24 71 27.5 + 4.5 37 58 40 22 6 83.1 71 50

,0.0001 ,0.0001 ,0.0001 ,0.001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 0.165 ,0.0001 ,0.01 0.2

Table 2 Baseline characteristics of KACC vs. EHS 2009 non-STEMI population Non-ST elevation

Age (years) mean Age ≥75 years (%) Male gender (%) BMI (mean) Smoker (%) Hypertension (%) Dyslipidaemia (%) Diabetes (%) Renal failure (%) Echo (%) Angiogram (%) PCI (%)

KACC (n ¼ 2264)

EHS 2009 AMI (n ¼ 1673)

P-value

63 + 12.16 16.8 73.9 28.95 + 5.41 29.3 70.7 66.4 65.2 12.2 93.5 69.6 53.2

68.4 + 12.8 25 67 27.6 + 4.9 24.5 65 46.5 27 8 72.2 66 47

,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.001 ,0.0001 ,0.0001 ,0.0001 ,0.0001 0.017 ,0.0001

KACC being a tertiary center can only play a very limited role in prevention and ends up mostly dealing with to limit damages induced by diabetes and the other risk factors. Therefore, an important question is whether we are fulfilling this goal? The answer is partially ‘yes’ because the outcome for ACS without STEMI was significantly better compared with that of central, eastern, and Mediterranean European countries and similar to that of the more advanced northern and western European countries. However, the outcome for STEMI at KACC is significantly worse than that of non-STEMI and higher than that of northern European countries. This is likely due to a longer time from chest pain to presentation of the Saudi population vs. the European one. It is well recognized that the outcome of primary PCI is timedependent. In our population, the delay from chest pain to the hospital was ,6, 6–24, and .24 h in 57, 19.8, and 22.8%, respectively. Primary PCI was offered in 69.8, 37.8, and 2.8% and the mortality was 5.2, 8.3, and 5.3%, respectively. Of interest in those patients with STEMI who

died, only 28.6% had primary PCI because of too late presentation or too many co-morbidities. The reasons for this are: (i) lack of patient knowledge who traditionally prefer to wait at home instead of rushing to the hospital; (ii) lack of proper educational campaigns to educate the general public and alert on symptoms and signs of ACS in order to call for help in time; (iii) lack of dedicated infrastructure of emergency medical services; (iv) last not the least, the heavy traffic congestions which sometimes makes it difficult even for ambulances to reach the hospital. The adherence to guideline-recommended medical treatment seems to be better at KACC than elsewhere. This is due to an excellent in-patient care and discharge planning service provided under the guidance of our clinical cardiology teams and also an excellent follow-up service in the out-patient clinics run under the supervision of very experienced nurses and doctors to ensure the continuity and compliance to medical treatment. Unfortunately, however, at present there is no predictable or well-organized


Characteristics, treatment, and outcome of patients with ACS

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solved on urgent basis to prevent epidemic of cardiac risk factors in Saudi population.

Table 3 In-hospital medical therapy Medical treatment

KACC (n ¼ 3233)

EHS-2009 (n ¼ 4236)

P-value

Aspirin (%) Clopidogrel (%) Beta-blocker (%) ACE/agiotensin II receptor blocker (%) Statin (%)

94 81.6 87 87

93 83 84 82

0.08 0.06 ,0.001 ,0.001

Acknowledgement I would like to thank Dr Amjad Ahmed for his valuable assistance with the statistical analysis. Conflict of interest: none declared.

94

91

,0.001

References Table 4 Total in-hospital mortality Total died

KACC (n ¼ 3233)

EHS-2009 (n ¼ 4236)

P-value

Total mortality (%) Non-STEMI (%) STEMI (%)

3.7 2.51 6.5

6.3 3.9 7.9

,0.001 ,0.01 ,0.03

referral system to take care of the patients from different areas of the Kingdom. In conclusion, like anywhere else in the developing world, the management of ACS is a major challenge in the Middle East and at KACC. Our center is able to provide treatments comparable with European standards. There is, however, room for improvement in terms of organized public campaigns to minimize pain-to-balloon times for primary angioplasty and a reliable referral and transport system to allow timely presentation. In addition, the problem of an unhealthy lifestyle of the general population remains. However, this is a problem which needs to be

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