The burden of carbapenem resistance is not well studied in the Middle East. We aimed to describe the molecular epidemiology and outcome of carbapenem-resistant Enterobacterales (CRE) infections from ...several Saudi Arabian Centers.
This is a multicenter prospective cohort study conducted over a 28-month period. Patients older than 14 years of age with a positive CRE Escherichia coli or Klebsiella pneumoniae culture and a clinically established infection were included in this study. Univariate and multivariable logistic models were constructed to assess the relationship between the outcome of 30-day all-cause mortality and possible continuous and categorical predictor variables.
A total of 189 patients were included. The median patient age was 62.8 years and 54.0% were male. The most common CRE infections were nosocomial pneumonia (23.8%) and complicated urinary tract infection (23.8%) and 77 patients (40.7%) had CRE bacteremia. OXA-48 was the most prevalent gene (69.3%). While 100 patients (52.9%) had a clinical cure, 57 patients (30.2%) had died within 30 days and 23 patients (12.2%) relapsed. Univariate analysis to predict 30-day mortality revealed that the following variables are associated with mortality: older age, high Charlson comorbidity index, increased Pitt bacteremia score, nosocomial pneumonia, CRE bacteremia and diabetes mellitus. In multivariable analysis, CRE bacteremia remained as an independent predictor of 30 day all-cause mortality AOR and 95% CI = 2.81(1.26-6.24), p = 0.01.
These data highlight the molecular epidemiology and outcomes of CRE infection in Saudi Arabia and will inform future studies to address preventive and management interventions.
The optimal stenting strategy for unprotected left main coronary artery (ULMCA) disease remains debated. This retrospective observational study (Gulf Left Main Registry) analyzed the outcomes of 1 vs ...2 stents in patients with unprotected left main percutaneous coronary intervention (PCI). Overall, 1222 patients were evaluated; 173 had 1 stent and 1049 had 2 stents. The 2-stent group was older with more comorbidities, higher mean SYNTAX scores, and more distal bifurcation lesions. In the 1-stent group, in-hospital events were significant for major bleeding, and better mean creatinine clearance. At median follow-up of 20 months, the 1-stent group was more likely to have target lesion revascularization (TLR). Total mortality was numerically lower in the 1-stent group (.00% vs 2.10%); however, this was not statistically significant (P=.068). Our analysis demonstrates the benefits of a 2-stent approach for ULMCA patients with high SYNTAX scores and lesions in both major side branches, while the potential benefit of a 1-stent approach for less complex ULMCA was also observed. Further studies with longer follow-up are needed to definitively demonstrate the optimal approach.
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in revascularization of left main coronary artery (LMCA) disease has been evaluated in previous studies. However, ...there has been minimal study of the relationship between co-existing non-coronary atherosclerosis (NCA) and LMCA disease revascularization. We aim to examine this relationship. The Gulf-LM study is a retrospective analysis of unprotected LMCA revascularization cases undergoing PCI with second generation drug-eluting stent vs CABG across 14 centers within 3 Gulf countries between January 2015 and December 2019. A total of 2138 patients were included, 381 with coexisting NCA and 1757 without. Outcomes examined included major adverse cardiovascular and cerebrovascular events (MACCE), cardiac and non-cardiac death, and all bleeding. In patients with NCA, preexisting myocardial infarction and congestive heart failure were more common, with PCI being the most common revascularization strategy. A statistically significant reduction in in-hospital MACCE and all bleeding was noted in patients with NCA undergoing PCI as compared to CABG. At a median follow-up of 15 months, MACCE and major bleeding outcomes continued to favor the PCI group, though no such difference was identified between revascularization strategies in patients without NCA.In this multicenter retrospective study of patients with and without NCA who require revascularization (PCI and CABG) for unprotected LMCA disease, PCI demonstrated a better clinical outcome in MACCE both in-hospital and during the short-term follow-up in patients with NCA. However, no such difference was observed in patients without NCA.
Objectives: To assess frequencies of various management approaches in cardiogenic shock (CS) and their clinical outcomes. Cardiogenic shock is a state of organ hypoperfusion and hypoxia caused by ...cardiac failure. Methods: In this retrospective record review, we assessed the presentations, vital signs, laboratory readings, and treatments for 188 consecutive CS inpatients from 2010-2021. Patients were labeled as “ischemic CS” or “non-ischemic CS” based on the occurrence of myocardial infarction as the precipitating cause, and “post-operative CS” if they had undergone cardiac surgery. In-hospital mortality was the primary endpoint of the study. Results: We identified 118 (62.8%) ischemic, 64 (34%) non-ischemic, and 6 (3.2%) postoperative CS patients. The study population had a high mortality rate (85.1%). Logistic regression analysis revealed that dopamine (p=0.040) and epinephrine (p=0.001) were independent predictors of mortality, while dobutamine (p=0.004) and digoxin (p=0.044) associated with increased survival. No significant association with mortality was found between either PCI or IABP. No significant difference in mortality was observed between CS subgroups. Conclusion: Variations in outcomes occurred with different medications. Mortality was higher in patients receiving dopamine or epinephrine and lower in those receiving dobutamine or digoxin. Implementation of clinical trials for investigation of the mortality benefit observed with dobutamine can serve towards formulation of new guidelines for improvement of CS mortality rates.
To assess frequencies of various management approaches in cardiogenic shock (CS) and their clinical outcomes. Cardiogenic shock is a state of organ hypoperfusion and hypoxia caused by cardiac ...failure.
In this retrospective record review, we assessed the presentations, vital signs, laboratory readings, and treatments for 188 consecutive CS inpatients from 2010-2021. Patients were labeled as "ischemic CS" or "non-ischemic CS" based on the occurrence of myocardial infarction as the precipitating cause, and "post-operative CS" if they had undergone cardiac surgery. In-hospital mortality was the primary endpoint of the study.
We identified 118 (62.8%) ischemic, 64 (34%) non-ischemic, and 6 (3.2%) postoperative CS patients. The study population had a high mortality rate (85.1%). Logistic regression analysis revealed that dopamine (
=0.040) and epinephrine (
=0.001) were independent predictors of mortality, while dobutamine (
=0.004) and digoxin (
=0.044) associated with increased survival. No significant association with mortality was found between either PCI or IABP. No significant difference in mortality was observed between CS subgroups.
Variations in outcomes occurred with different medications. Mortality was higher in patients receiving dopamine or epinephrine and lower in those receiving dobutamine or digoxin. Implementation of clinical trials for investigation of the mortality benefit observed with dobutamine can serve towards formulation of new guidelines for improvement of CS mortality rates.
Background: Risk stratification for patients undergoing coronary artery bypass surgery (CABG) for left main coronary artery (LMCA) disease is essential for informed decision-making. This study ...explored the potential of machine learning (ML) methods to identify key risk factors associated with mortality in this patient group. Methods: This retrospective cohort study was conducted on 866 patients from the Gulf Left Main Registry who presented between 2015 and 2019. The study outcome was hospital all-cause mortality. Various machine learning models logistic regression, random forest (RF), k-nearest neighbor, support vector machine, naïve Bayes, multilayer perception, boosting were used to predict mortality, and their performance was measured using accuracy, precision, recall, F1 score, and area under the receiver operator characteristic curve (AUC). Results: Nonsurvivors had significantly greater EuroSCORE II values (1.84 (10.08-3.67) vs. 4.75 (2.54-9.53) %, P <0.001 for survivors and nonsurvivors, respectively). The EuroSCORE II score significantly predicted hospital mortality (OR: 1.13 (95% confidence interval: 1.09-1.18), P <0.001), with an AUC of 0.736. RF achieved the best ML performance (accuracy=98, precision=100, recall=97 and F1 score=98). Explainable artificial intelligence using SHAP demonstrated the most important features as follows: preoperative lactate level, emergency surgery, chronic kidney disease (CKD), NSTEMI, nonsmoking status, and sex. QLattice identified lactate and CKD as the most important factors for predicting hospital mortality this patient group. Conclusion: This study demonstrates the potential of ML, particularly the Random Forest, to accurately predict hospital mortality in patients undergoing CABG for LMCA disease and its superiority over traditional methods. The key risk factors identified, including preoperative lactate levels, emergency surgery, chronic kidney disease, NSTEMI, nonsmoking status, and sex, provide valuable insights for risk stratification and informed decision-making in this high-risk patient population. Additionally, incorporating newly identified risk factors into future risk scoring systems can further improve mortality prediction accuracy.
The impact of left ventricular dysfunction on clinical outcomes following revascularization is not well established in patients with unprotected left main coronary artery disease (ULMCA). In this ...study, we evaluated the impact of left ventricular ejection fraction (LVEF) on clinical outcomes of patients with ULMCA requiring revascularization with percutaneous coronary intervention (PCI) compared with coronary artery bypass graft (CABG).
The details of the design, methods, end points, and relevant definitions are outlined in the Gulf Left Main Registry: a retrospective, observational study conducted between January 2015 and December 2019 across 14 centres in 3 Gulf countries. In this study, the data on patients with ULMCA who underwent revascularization through PCI or CABG were stratified by LVEF into three main subgroups; low (l-LVEF <40%), mid-range (m-LVEF 40-49%), and preserved (p-LVEF ≥50%). Primary outcomes were hospital major adverse cardiovascular and cerebrovascular events (MACCE) and mortality and follow-up MACCE and mortality.
A total of 2137 patients were included; 1221 underwent PCI and 916 had CABG. During hospitalization, MACCE was significantly higher in patients with l-LVEF (10.10%), P = 0.005 and m-LVEF (10.80%), P = 0.009, whereas total mortality was higher in patients with m-LVEF (7.40%), P = 0.009 and p-LVEF (7.10%), P = 0.045 who underwent CABG. There was no mortality difference between groups in patients with l-LVEF. At a median follow-up of 15 months, there was no difference in MACCE and total mortality between patients who underwent CABG or PCI with p-LVEF and m-LVEF.
CABG was associated with higher in-hospital events. Hospital mortality in patients with l-LVEF was comparable between CABG and PCI. At 15 months' follow-up, PCI could have an advantage in decreasing MACCE in patients with l-LVEF.
Real-world data for managing patients with diabetes and left main coronary artery (LMCA) disease are scarce. We compared percutaneous coronary intervention (PCI) outcomes versus coronary artery ...bypass grafting (CABG) in diabetes and LMCA disease patients.
We retrospectively studied patients with LMCA presented to 14 centers from 2015 to 2019. The study included 2138 patients with unprotected LMCA disease; 1468 (68.7 %) had diabetes. Patients were grouped into; diabetes with PCI (n = 804) or CABG (n = 664) and non-diabetes with PCI (n = 418) or CABG (n = 252).
In diabetes, cardiac (34 (5.1 %) vs. 22 (2.7 %); P = 0.016), non-cardiac (13 (2 %) vs. 6 (0.7 %); P = 0.027) and total hospital mortality (47 (7.1 %) vs. 28 (3.5 %); P = 0.0019), myocardial infarction (45 (6.8 %) vs. 11 (1.4 %); P = 0.001), cerebrovascular events (25 (3.8 %) vs. 12 (1.5 %); P = 0.005) and minor bleeding (65 (9.8 %) vs. 50 (6.2 %); P = 0.006) were significantly higher in CABG patients compared to PCI; respectively. The median follow-up time was 20 (10–37) months. In diabetes, total mortality was higher in CABG (P = 0.001) while congestive heart failure was higher in PCI (P = 0.001). There were no differences in major adverse cerebrovascular events and target lesion revascularization between PCI and CABG. Predictors of mortality in diabetes were high anatomical SYNTAX, peripheral arterial disease, chronic kidney disease, and cardiogenic shock.
In this multicenter retrospective study, we found no significant difference in clinical outcomes during the short-term follow-up between PCI with second-generation DES and CABG except for lower total mortality and a higher rate of congestive heart failure in PCI group of patients. Randomized trials to characterize patients who could benefit from each treatment option are needed.
•The optimal revascularization strategy for left main coronary artery disease in diabetes patients is controversial•In this multicenter retrospective study, 69% of patients with unprotected LMCA disease had diabetes•There is no difference in cardiac death, TLR, TVR, and MACCE at a median of 20 months follow-up between PCI with DES and CABG•Total mortality is lower in PCI vs. CABG in diabetes. However, congestive heart failure is higher in the PCI group of patients
Background: Previous trials remain inconsistent regarding the advantages and hazards related to intracoronary (IC) compared with intravenous (IV) administration of thrombolytics. We aimed to evaluate ...the safety and effectiveness of IC versus IV tirofiban administration in diabetic patients (DM) with acute ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PCI). Methods: This trial included 95 patients who were randomised to high-dose bolus plus a maintenance dose of tirofiban administered either IV or IC. The groups were compared for the incidence of composite major adverse cardiac events (MACE) at 30 days. Levels of cardiac markers were recorded pre- and post-intervention for myocardial perfusion. Results: The MACE were not different between the groups, but post-procedure myocardial blush grade (MBG) 3 and thrombolysis in myocardial infarction (TIMI) 3 flow were significant in the IC group (p = 0.45, 0.21, respectively), favouring the IC strategy. Peak values of both creatine kinase-muscle/brain (CK-MB) and high-sensitivity troponin T (hs-TnT) were significantly lower in the IC group (155.68 ± 121, 4291 ± 334 ng/dl) versus the IV group (192.4 ± 86, 5342 ± 286 ng/dl) (p = 0.021, p = 0.035, respectively). The peak value was significantly lower in the IC group than the IV group in terms of ST-segment resolution and 30-day left ventricular ejection fraction (LVEF) (p = 0.016 and 0.023, respectively). Conclusion: Thirty days post PCI, IC tirofiban was more efficient in ameliorating blood flow in the coronary arteries and myocardial tissue perfusion in DM patients after STEMI despite bleeding events, and MACE rates showed no significant difference between the groups. The IC group showed better improvement in LVEF.
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