Summary Background Atrial fibrillation is an important cause of morbidity and mortality worldwide, but scant data are available for long-term outcomes in individuals outside North America or Europe, ...especially in primary care settings. Methods We did a cohort study using a prospective registry of patients in 47 countries who presented to a hospital emergency department with atrial fibrillation or atrial flutter as a primary or secondary diagnosis. 15 400 individuals were enrolled to determine the occurrence of death and strokes (the primary outcomes) in this cohort over eight geographical regions (North America, western Europe, and Australia; South America; eastern Europe; the Middle East and Mediterranean crescent; sub-Saharan Africa; India; China; and southeast Asia) 1 year after attending the emergency department. Patients from North America, western Europe, and Australia were used as the reference population, and compared with patients from the other seven regions Findings Between Dec 24, 2007, and Oct 21, 2011, we enrolled 15 400 individuals to the registry. Follow-up was complete for 15 361 (99·7%), of whom 1758 (11%) died within 1 year. Fewer deaths occurred among patients presenting to the emergency department with a primary diagnosis of atrial fibrillation compared with patients who had atrial fibrillation as a secondary diagnosis (377 6% of 6825 patients vs 1381 16% of 8536, p<0·0001). Twice as many patients had died by 1 year in South America (192 17% of 1132) and Africa (225 20% of 1137) compared with North America, western Europe, and Australia (366 10% of 3800, p<0·0001). Heart failure was the most common cause of death (519 30% of 1758); stroke caused 148 (8%) deaths. 604 (4%) of 15361 patients had had a stroke by 1 year; 170 (3%) of 6825 for whom atrial fibrillation was a primary diagnosis and 434 (5%) of 8536 for whom it was a secondary diagnosis (p<0·0001). The highest number of strokes occurred in patients in Africa (89 8% of 1137), China (143 7% of 2023), and southeast Asia (88 7% of 1331) and the lowest occurred in India (20 <1% of 2536). 94 (3%) of 3800 patients in North America, western Europe, and Australia had a stroke. Interpretation Marked unexplained inter-regional variations in the occurrence of stroke and mortality suggest that factors other than clinical variables might be important. Prevention of death from heart failure should be a major priority in the treatment of atrial fibrillation. Funding Boehringer Ingelheim.
Psychosocial factors have been reported to be independently associated with coronary heart disease. However, previous studies have been in mainly North American or European populations. The aim of ...the present analysis was to investigate the relation of psychosocial factors to risk of myocardial infarction in 24767 people from 52 countries.
We used a case-control design with 11119 patients with a first myocardial infarction and 13648 age-matched (up to 5 years older or younger) and sex-matched controls from 262 centres in Asia, Europe, the Middle East, Africa, Australia, and North and South America. Data for demographic factors, education, income, and cardiovascular risk factors were obtained by standardised approaches. Psychosocial stress was assessed by four simple questions about stress at work and at home, financial stress, and major life events in the past year. Additional questions assessed locus of control and presence of depression.
People with myocardial infarction (cases) reported higher prevalence of all four stress factors (p<0·0001). Of those cases still working, 23·0% (n=1249) experienced several periods of work stress compared with 17·9% (1324) of controls, and 10·0% (540) experienced permanent work stress during the previous year versus 5·0% (372) of controls. Odds ratios were 1·38 (99% CI 1·19–1·61) for several periods of work stress and 2·14 (1·73–2·64) for permanent stress at work, adjusted for age, sex, geographic region, and smoking. 11·6% (1288) of cases had several periods of stress at home compared with 8·6% (1179) of controls (odds ratio 1·52 99% CI 1·34–1·72), and 3·5% (384) of cases reported permanent stress at home versus 1·9% (253) of controls (2·12 1·68–2·65). General stress (work, home, or both) was associated with an odds ratio of 1·45 (99% CI 1·30–1·61) for several periods and 2·17 (1·84–2·55) for permanent stress. Severe financial stress was more typical in cases than controls (14·6% 1622
vs 12·2% 1659; odds ratio 1·33 99% CI 1·19–1·48). Stressful life events in the past year were also more frequent in cases than controls (16·1% 1790 vs 13·0% 1771; 1·48 1·33–1·64), as was depression (24·0% 2673
vs 17·6% 2404; odds ratio 1·55 1·42–1·69). These differences were consistent across regions, in different ethnic groups, and in men and women.
Presence of psychosocial stressors is associated with increased risk of acute myocardial infarction, suggesting that approaches aimed at modifying these factors should be developed.
Published online September 3, 2004
http://image.thelancet.com/extras/04art8002web.pdf
According to the "obesity paradox", adults with obesity have a survival advantage following acute coronary syndrome, compared with those without obesity. Previous studies focused on peripheral ...obesity and whether this advantage is conferred by central obesity is unknown. The objective of this study was to describe the association of peripheral and central obesity indices with risk of in-hospital and 1-year mortality following acute coronary syndrome (ACS).
Gulf COAST is a prospective ACS registry that enrolled 4044 patients age ≥18 years from January 2012 through January 2013, across 29 hospitals in four Middle Eastern countries. Associations of indices of peripheral obesity (body-mass index, BMI) and central obesity (waist circumference WC and waist-to-height ratio WHtR) with mortality following ACS were analyzed in logistic regression models (odds ratio, 95% CI) with and without adjustment for Global Registry of Acute Coronary Events risk score.
Of 3882 patients analyzed (mean age: 60 years; 33.3% women n = 1294), the prevalence of obesity was 34.5% (BMI ≥ 30.0 kg/m
), 72.2% (WC ≥ 94.0 cm men or ≥80.0 cm women) and 90.0% (WHtR ≥ 0.5). In adjusted models, deciles of obesity indices showed higher risk of mortality at extreme versus intermediate deciles (U-shaped). When defined by conventional cut-offs, peripheral obesity (BMI ≥ 30.0 versus 18.5-29.9 kg/m
) showed inverse association with risk of in-hospital mortality (0.64; 95% CI, 0.42-0.99; P = 0.04; central obesity showed trend toward reduced mortality). In contrast, for risk of 1-year mortality, all indices showed inverse association. Obesity, defined by presence of all three indices, versus nonobesity showed inverse association with risk of 1-year mortality (0.52; 95% CI, 0.35-0.75; P = 0.001). Results were similar among men and women.
The degree of obesity paradox following ACS depends on the obesity index and follow-up time. Obesity indices may aid in risk stratification of mortality following ACS.
Evidence regarding the performance of cardiovascular disease (CVD) risk assessment tools is limited in the United Arab Emirates (UAE). Therefore, we assessed the agreement between various externally ...validated CVD risk assessment tools in the UAE.
A secondary analysis of the Abu Dhabi Screening Program for Cardiovascular Risk Markers (AD-SALAMA) data, a large population-based cross-sectional survey conducted in Abu Dhabi, UAE during the period 2009 until 2015, was performed in July 2019. The analysis included 2,621 participants without type 2 Diabetes and without history of cardiovascular diseases. The CVD risk assessment tools included in the analysis were the World Health Organization for Middle East and North Africa Region (WHO-MENA), the systematic coronary risk evaluation for high risk countries (SCORE-H), the pooled cohort risk equations for white (PCRE-W) and African Americans (PCRE-AA), the national cholesterol education program Framingham risk score (FRAM-ATP), and the laboratory Framingham risk score (FRAM-LAB).
The overall concordance coefficient was 0.50. The agreement between SCORE-H and PCRE-W, PCRE-AA, FRAM-LAB, FRAM-ATP and WHO-MENA, were 0.47, 0.39, 0.0.25, 0.42 and 0.18, respectively. PCRE-AA classified the highest proportion of participants into high-risk category of CVD (16.4%), followed by PCRE-W (13.6%), FRAM-LAB (6.9%), SCORE-H (4.5%), FRAM-ATP (2.7%), and WHO-MENA (0.4%).
We found a poor agreement between various externally validated CVD risk assessment tools when applied to a large data collected in the UAE. This poses a challenge to choose any of these tools for clinical decision-making regarding the primary prevention of CVD in the country.
The characteristics of young adults with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndrome (ACS) has not been well described. The mean age of gulf citizens in ACS registries is ...10-15 years younger than their western counterparts, which provided us with a unique opportunity to investigate the characteristics and predictors of OHCA in young adults presenting with ACS.
This was a retrospective cohort study using data from 7 prospective ACS registries in the Gulf region. In brief, all registries included consecutive adults who were admitted with ACS. OHCA was defined as cardiac arrest upon presentation (i.e., before admission to the hospital). We described the characteristics of young adults (< 50 years) who had OHCA and performed multivariate logistic regression analysis to assess independent predictors of OHCA.
A total of 31,620 ACS patients were included in the study. There were 611 (1.93%) OHCA cases in the whole cohort 188/10,848 (1.73%) in young adults vs 423/20,772 (2.04%) in older adults, p = 0.06. Young adults were predominantly males presenting with ST-elevation myocardial infarction (STEMI) 182/188 (96.8%) and 172/188 (91.49%), respectively. OHCA was the sentinel event of coronary artery disease (CAD) in 70% of young adults. STEMI, male sex, and non-smoking status were found to be independent predictors of OHCA OR = 5.862 (95% CI 2.623-13.096), OR: 4.515 (95% CI 1.085-18.786), and OR = 2.27 (95% CI 1.335-3.86), respectively.
We observed a lower prevalence of OHCA in ACS patients in our region as compared to previous literature from other regions. Moreover, OHCA was the sentinel event of CAD in the majority of young adults, who were predominantly males with STEMIs. These findings should help risk-stratify patients with ACS and inform further research into the characteristics of OHCA in young adults.
Introduction
This systematic review and meta-analysis focuses on PCSK9 changes in obese patients following bariatric surgery.
Material and methods
A systematic literature search in four databases was ...performed.
Results
The results of meta-analysis on 4 trials including 260 individuals demonstrated a remarkable decline of PCSK9 after bariatric surgery (WMD: -57.34 ng/ml, 95% CI: -87.97, -26.71, p<0.001; I2:96.25%). Consistently, a significant decrease of LDL-C after bariatric surgery (WMD: -22.57 mg/dl, 95% CI: -27.5, -17.574, p<0.001; I2: 86.35%) was observed.
Conclusions
PCSK9 is reduced significantly after bariatric surgery. The decrease of PCSK9 might be utilized as an independent surrogate marker of improvement of ASCVD risk after bariatric surgery.
Background
Little is known about the achievement of low density lipoprotein cholesterol (LDL-C) targets in patients at cardiovascular risk receiving stable lipid-lowering therapy (LLT) in countries ...outside Western Europe.
Methods
This cross-sectional observational study was conducted in 452 centres (August 2015−August 2016) in 18 countries in Eastern Europe, Asia, Africa, the Middle East and Latin America. Patients (n = 9049) treated for ≥3 months with any LLT and in whom an LDL-C measurement on stable LLT was available within the previous 12 months were included.
Results
The mean±SD age was 60.2 ± 11.7 years, 55.0% of patients were men and the mean ± SD LDL-C value on LLT was 2.6 ± 1.3 mmol/L (101.0 ± 49.2 mg/dL). At enrolment, 97.9% of patients were receiving a statin (25.3% on high intensity treatment). Only 32.1% of the very high risk patients versus 51.9% of the high risk and 55.7% of the moderate risk patients achieved their LDL-C goals. On multivariable analysis, factors independently associated with not achieving LDL-C goals were no (versus lower dose) statin therapy, a higher (versus lower) dose of statin, statin intolerance, overweight and obesity, female sex, neurocognitive disorders, level of cardiovascular risk, LDL-C value unknown at diagnosis, high blood pressure and current smoking. Diabetes was associated with a lower risk of not achieving LDL-C goals.
Conclusions
These observational data suggest that the achievement of LDL-C goals is suboptimal in selected countries outside Western Europe. Efforts are needed to improve the management of patients using combination therapy and/or more intensive LLTs.
Introduction
Limited data on atrial fibrillation (AF) are available from the Middle East and North Africa region (MENA). The aim of the FLOW-AF registry was to evaluate the characteristics, treatment ...patterns, and clinical and economic outcomes of patients with newly diagnosed non-valvular atrial fibrillation (NVAF) in MENA.
Methods
This multi-center, prospective, observational study (the FLOW-AF registry) enrolled patients newly diagnosed with NVAF across Egypt, Lebanon, Kingdom of Saudi Arabia, and United Arab Emirates. The data collection occurred at enrollment (baseline) and after 6- and 12-months (follow-up). Baseline data included demographics, AF characteristics, medical history, and anti-thrombotic treatment patterns. Clinical events, healthcare resource utilization, and direct costs were collected at follow-up.
Results
The study enrolled a total of 1418 patients (52.7% males and 47.3% females). The mean age of the patients was 64.5 years and 90.6% were white. The mean (standard deviation) CHA
2
DS
2
-VASc and HAS-BLED risk scores were 2.7 (1.6) and 1.6 (1.2), respectively. Non-vitamin K antagonist oral anticoagulants, antiplatelet therapy, and vitamin K antagonists were prescribed to 65.8%, 16.4%, and 12.9% patients, respectively. During follow-up, the following rates of clinical outcomes were observed: bleeding events (1.7%), transient ischemic attack (1.7%), all-cause mortality (1.7%), stroke (0.6%), myocardial infarction (0.2%), and systemic embolism (0.08%).
Conclusions
This MENA patient population was younger and had lower mean baseline CHA
2
DS
2
-VASc and HAS-BLED scores. The rates of clinical outcomes over 1-year in this study were low. Longer follow-up is required to comprehensively assess clinical outcomes in this patient population.
The degradation of low-density lipoprotein receptor (LDLR) is induced by proprotein convertase subtilisin/kexin type 9 (PCSK9), resulting in elevated plasma concentrations of LDL cholesterol. ...Therefore, inhibiting the interactions between PCSK9 and LDLR is a desirable therapeutic goal for managing hypercholesterolemia. Aptamers, which are RNA or single-stranded DNA sequences, can recognize their targets based on their secondary structure. Aptamers exhibit high selectivity and affinity for binding to target molecules. The systematic evolution of ligands by exponential enrichment (SELEX), a combination of biological approaches, is used to screen most aptamers in vitro. Due to their unique advantages, aptamers have garnered significant interest since their discovery and have found extensive applications in various fields. Aptamers have been increasingly utilized in the development of biosensors for sensitive detection of pathogens, analytes, toxins, drug residues, and malignant cells. Furthermore, similar to monoclonal antibodies, aptamers can serve as therapeutic tools. Unlike certain protein therapeutics, aptamers do not elicit antibody responses, and their modified sugars at the 2'-positions generally prevent toll-like receptor-mediated innate immune responses. The focus of this review is on aptamer-based targeting of PCSK9 and the application of aptamers both as biosensors and therapeutic agents.
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