Publications by authors named "Mirvat Alasnag"

51 Publications

Artificial intelligence and machine learning: the resurgence of the industrial revolution by robots.

Open Heart 2022 Jan;9(1)

Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

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http://dx.doi.org/10.1136/openhrt-2021-001883DOI Listing
January 2022

One year outcomes for patients undergoing transcatheter aortic valve replacement: The Gulf TAVR registry.

Cardiovasc Revasc Med 2021 Dec 31. Epub 2021 Dec 31.

Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia. Electronic address:

Background: The use of transcatheter aortic valve replacement (TAVR) is steadily increasing with TAVR procedures offered to patients across the entire spectrum of surgical risks. The Gulf TAVR registry captures the demographics of patients undergoing TAVR in the Gulf region, comorbidities that drive outcomes, procedural success, complications, and one-year outcomes of death or rehospitalization.

Methods: This is a retrospective cohort study for adult patients aged at least 18 years undergoing TAVR at eight centers in the Gulf region. The primary outcome was a composite of death or re-hospitalization at one-year. Secondary outcomes included the individual components of the composite, stroke, and myocardial infarction (MI). We used multivariable Cox regression to determine factors associated with the composite endpoint.

Results: A total of 795 patients (56% male) were included in the final analysis with a mean age of 74.6 (standard deviation (SD) 8.9) years, Society of Thoracic Surgeons Score (STS) Score 4.9 (4.2), ejection fraction of 53% (12.7%). Transfemoral approach was employed in over 95% (762/795). The primary outcomes rate was 12.8% (95% confidence interval [CI]: 10.6-15.4); secondary endpoints were death 5.4% (95% CI 4.0-7.2); stroke 0.8% (95% CI 0.3, 1.7), MI 0.8% (95% CI 0.4-1.9), rehospitalization: 9.3% (95% CI 7.5-11.5) of whom 71.6% were related to cardiovascular causes. 77% of the cardiovascular admissions were attributable to heart failure or the need for pacemaker implantation. Stage IV or V chronic kidney disease was significantly associated with the primary composite endpoint (Hazard Ratio: 2.49, [95% CI: 1.31, 4.73], p = 0.005). Although not significant, paravalvular leak and severe left ventricular dysfunction showed a 2-fold and 3-fold increased risk for the composite endpoint, respectively.

Conclusions: The Gulf TAVR registry is the first of its kind in the region. It profiles an elderly population with a high procedural success rate and a low rate of complications. One-year outcomes were primarily driven by repeat hospitalization for heart failure and pacemaker implantation indicating a need to optimize heart failure management and improve algorithms for the detection of conduction abnormalities.
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http://dx.doi.org/10.1016/j.carrev.2021.12.024DOI Listing
December 2021

Women making waves Editorial: Impact of sex in the functional assessment of intermediate coronary lesions by instantaneous wave-free ratio.

Cardiovasc Revasc Med 2022 Jan 7. Epub 2022 Jan 7.

Department of Cardiology, Lariboisière Hospital APHP, Paris University, Paris, France.

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http://dx.doi.org/10.1016/j.carrev.2021.12.034DOI Listing
January 2022

Timing of coronary angiography in patients following out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and Meta-analysis of randomized trials.

Cardiovasc Revasc Med 2021 Nov 26. Epub 2021 Nov 26.

Department of Medical Education, University of Tennessee at Nashville, Nashville, TN, USA. Electronic address:

Introduction: Out-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear.

Objective: We performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation.

Methods: We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG.

Results: A total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94-1.20; P = 0.32; I = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90-1.13; P = 0.85, I = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84-1.39; P = 0.56; I = 49%).

Conclusion: In patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.
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http://dx.doi.org/10.1016/j.carrev.2021.11.026DOI Listing
November 2021

Intracoronary Imaging to Guide and Optimize: From Seeing Is Believing to Imaging Is Knowing.

Circ Cardiovasc Interv 2021 10 19;14(10):e011373. Epub 2021 Oct 19.

Columbia University Irving Medical Center, NY (G.W.).

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.011373DOI Listing
October 2021

Case Report: Transcatheter Aortic Valve Replacement in a Patient With Severe Aortic Stenosis, Left Ventricular Dysfunction, and an Anomalous Left Circumflex Artery.

Front Cardiovasc Med 2021 18;8:721363. Epub 2021 Aug 18.

Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

The role of cardiac computed tomography in the evaluation of patients for transcatheter aortic valve implantation is well-established. However, its role in the evaluation of anomalous vessels in the pre-procedure planning, intra-procedural fusion imaging and post-procedure assessment of vessel patency is not yet defined. This case report illustrates the utility of cardiac CT throughout the management of complex structural interventions. Here, we describe an anomalous left coronary artery where the course of the anomalous vessel and its proximity to the aortic valve annulus is defined allowing the selection of the most appropriate balloon expandable valve with a planned deployment. Upon follow up, patency of this anomalous vessel is ascertained using CT as well as the transcatheter valve function and leaflet thickening.
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http://dx.doi.org/10.3389/fcvm.2021.721363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416351PMC
August 2021

Abbreviated Antiplatelet Therapy in Patients at High Bleeding Risk With or Without Oral Anticoagulant Therapy After Coronary Stenting: An Open-Label, Randomized, Controlled Trial.

Circulation 2021 10 29;144(15):1196-1211. Epub 2021 Aug 29.

Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland (M.V.).

Background: The optimal duration of antiplatelet therapy (APT) in patients at high bleeding risk with or without oral anticoagulation (OAC) after coronary stenting remains unclear.

Methods: In the investigator-initiated, randomize, open-label MASTER DAPT trial (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT Regimen), 4579 patients at high bleeding risk were randomized after 1-month dual APT to abbreviated or nonabbreviated APT strategies. Randomization was stratified by concomitant OAC indication. In this subgroup analysis, we report outcomes of populations with or without an OAC indication. In the population with an OAC indication, patients changed immediately to single APT for 5 months (abbreviated regimen) or continued ≥2 months of dual APT and single APT thereafter (nonabbreviated regimen). Patients without an OAC indication changed to single APT for 11 months (abbreviated regimen) or continued ≥5 months of dual APT and single APT thereafter (nonabbreviated regimen). Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes (composite of all-cause death, myocardial infarction, stroke, and Bleeding Academic Research Consortium 3 or 5 bleeding events); major adverse cardiac and cerebral events (all-cause death, myocardial infarction, and stroke); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding.

Results: Net adverse clinical outcomes or major adverse cardiac and cerebral events did not differ with abbreviated versus nonabbreviated APT regimens in patients with OAC indication (n=1666; hazard ratio [HR], 0.83 [95% CI, 0.60-1.15]; and HR, 0.88 [95% CI, 0.60-1.30], respectively) or without OAC indication (n=2913; HR, 1.01 [95% CI, 0.77-1.33]; or HR, 1.06 [95% CI, 0.79-1.44]; =0.35 and 0.45, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding did not significantly differ in patients with OAC indication (HR, 0.83 [95% CI, 0.62-1.12]) but was lower with abbreviated APT in patients without OAC indication (HR, 0.55 [95% CI, 0.41-0.74]; =0.057). The difference in bleeding in patients without OAC indication was driven mainly by a reduction in Bleeding Academic Research Consortium 2 bleedings (HR, 0.48 [95% CI, 0.33-0.69]; =0.021).

Conclusions: Rates of net adverse clinical outcomes and major adverse cardiac and cerebral events did not differ with abbreviated APT in patients with high bleeding risk with or without an OAC indication and resulted in lower bleeding rates in patients without an OAC indication. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03023020.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.121.056680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500374PMC
October 2021

Dual Antiplatelet Therapy after PCI in Patients at High Bleeding Risk.

N Engl J Med 2021 10 28;385(18):1643-1655. Epub 2021 Aug 28.

From the Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano (M.V.), CTU Bern, University of Bern (E.F., D.H.), and the Department of Cardiology, Bern University Hospital (S.W.), Bern, the Division of Cardiology, Geneva University Hospitals, Geneva (M.R.), and HerzZentrum Hirslanden Zürich, Zurich (A.M.) - all in Switzerland; the Department of Cardiology, Amsterdam University Medical Centers, Amsterdam (J.T.), European Cardiovascular Research Institute (J.T.), and the Department of Cardiology, Maasstad Hospital (P.C.S.), Rotterdam, and the Department of Cardiology, Catharina Hospital, Eindhoven (P.A.L.T.) - all in the Netherlands; the University of Toronto, Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (P.J.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, and the Faculty of Medicine and Life Sciences, Hasselt University, Hasselt (P.V.), and the Cardiovascular Center, OLV Hospital, Aalst (J.B.) - all in Belgium; the Department of Cardiology, School of Medicine, Fujita Health University, Toyoake, Japan (Y. Ozaki); the Cardiovascular European Research Center (M.-C.M.), and Ramsay Générale de Santé, Interventional Cardiology Department, Institut Cardiovasculaire Paris Sud (B.C.) - both in Massy, France; the National University of Ireland, Galway (Y. Onuma); the First Department of Cardiology, University of Medical Sciences, Poznan, Poland (M.L.); the Department of Internal Medicine III-Cardiology, Angiology, and Intensive Care Medicine, Saarland University, Homburg, Germany (F.M.); Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom (D.H.-S.); the Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan (A.C.), the Interventional Cardiology Unit, Policlinico Casilino, Rome (M.D.), and the University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia (S.L.) - all in Italy; the Department of Cardiology, Clinical Center of Serbia, and the Faculty of Medicine, University of Belgrade, Belgrade, Serbia (G.S.); Hospital Alvaro Cunqueiro, Vigo, Spain (A.I.); the Department of Cardiology, Royal Perth Hospital Campus, University of Western Australia, Perth, Australia (C.S.); Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (R.K.); Tan Tock Seng Hospital, Singapore, Singapore (P.J.L.O.); the Department of Cardiology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia (M.A.); Cardiac Unit Otamendi Hospital, Buenos Aires School of Medicine Cardiovascular Research Center (A.E.R.); and North Estonia Medical Center Foundation, Tallinn, Estonia (P.L.).

Background: The appropriate duration of dual antiplatelet therapy in patients at high risk for bleeding after the implantation of a drug-eluting coronary stent remains unclear.

Methods: One month after they had undergone implantation of a biodegradable-polymer sirolimus-eluting coronary stent, we randomly assigned patients at high bleeding risk to discontinue dual antiplatelet therapy immediately (abbreviated therapy) or to continue it for at least 2 additional months (standard therapy). The three ranked primary outcomes were net adverse clinical events (a composite of death from any cause, myocardial infarction, stroke, or major bleeding), major adverse cardiac or cerebral events (a composite of death from any cause, myocardial infarction, or stroke), and major or clinically relevant nonmajor bleeding; cumulative incidences were assessed at 335 days. The first two outcomes were assessed for noninferiority in the per-protocol population, and the third outcome for superiority in the intention-to-treat population.

Results: Among the 4434 patients in the per-protocol population, net adverse clinical events occurred in 165 patients (7.5%) in the abbreviated-therapy group and in 172 (7.7%) in the standard-therapy group (difference, -0.23 percentage points; 95% confidence interval [CI], -1.80 to 1.33; P<0.001 for noninferiority). A total of 133 patients (6.1%) in the abbreviated-therapy group and 132 patients (5.9%) in the standard-therapy group had a major adverse cardiac or cerebral event (difference, 0.11 percentage points; 95% CI, -1.29 to 1.51; P = 0.001 for noninferiority). Among the 4579 patients in the intention-to-treat population, major or clinically relevant nonmajor bleeding occurred in 148 patients (6.5%) in the abbreviated-therapy group and in 211 (9.4%) in the standard-therapy group (difference, -2.82 percentage points; 95% CI, -4.40 to -1.24; P<0.001 for superiority).

Conclusions: One month of dual antiplatelet therapy was noninferior to the continuation of therapy for at least 2 additional months with regard to the occurrence of net adverse clinical events and major adverse cardiac or cerebral events; abbreviated therapy also resulted in a lower incidence of major or clinically relevant nonmajor bleeding. (Funded by Terumo; MASTER DAPT ClinicalTrials.gov number, NCT03023020.).
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http://dx.doi.org/10.1056/NEJMoa2108749DOI Listing
October 2021

Sex-based outcomes in contemporary antiplatelet therapy trials.

Open Heart 2021 07;8(2)

Cardiology, Aberdeen Royal Infirmary, Aberdeen, UK.

Balancing ischaemic and bleeding risks in high-risk populations undergoing percutaneous coronary interventions has become an everyday dilemma for clinicians. It is particularly difficult to make decisions concerning combinations and duration of antiplatelet regimens in women given the poor representation of women in trials that have shaped current practice. Several contemporary landmark trials have recently been presented at the American College of Cardiology. The trials included the Harmonising Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy, Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention and the TicAgrelor versus CLOpidogrel in Stabilised Patients With Acute Myocardial Infarction. In this article, we summarise the main findings of these trials and include the The Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk (LEADERS FREE) in search for evidence based best practices for women patients. Although some of these trials had prespecified a subanalysis of sex differences, women constituted only 17%-30% of participants making sex-specific analyses challenging. Data suggest that women benefit from de-escalation to both ticagrelor and clopidogrel monotherapy. However, given the increased bleeding risks observed in women further randomised controlled trials are necessary to determine the most appropriate combination and duration of dual antiplatelet therapy as well as maintenance single antiplatelet therapy.
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http://dx.doi.org/10.1136/openhrt-2021-001761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320246PMC
July 2021

Sealing the leaky pipeline: attracting and retaining women in cardiology.

Open Heart 2021 07;8(2)

Cardiology, Surrey and Sussex Healthcare NHS Trust, Redhill, UK

Multiple publications have addressed the under-representation of women in the cardiology workforce, and indeed in leadership positions and procedural subspecialities, despite gender parity among medical school graduates. The work-life balance does not appear to be the only determining factor since other specialties such as obstetrics have a adequate representation of women. Vlachadis Castles report the results from their online survey of 452 female doctors (both trainees and specialists) from Australia and New Zealand, 13% of whom were women in cardiology. Female cardiologists reported working longer hours and more on-call commitments; significantly fewer women in cardiology reported a balanced life, or that cardiology was family friendly or female friendly, despite a greater earning capacity and an overwhelming majority agreeing that they were professionally challenged whilst intellectually stimulated in their jobs. Our editorial addresses the deterrents to women in cardiology seeking leadership opportunities in all areas including academic, administrative and research positions.
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http://dx.doi.org/10.1136/openhrt-2021-001751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320255PMC
July 2021

Social Media for Cardiovascular Medicine: Real Reflections from Virtual Medium.

Curr Cardiol Rev 2021 ;17(2):116-117

Keele Cardiovascular Research Group Keele University, United Kingdom.

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http://dx.doi.org/10.2174/1573403X1702210311093359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226198PMC
July 2021

Sex-based inequalities in contemporary UK hospital management of stable chest pain.

Open Heart 2021 06;8(1)

Cardiac Sciences Department, King Saud University, Riyadh, Riyadh Province, Saudi Arabia.

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http://dx.doi.org/10.1136/openhrt-2021-001705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174504PMC
June 2021

Role of Cardiovascular Computed Tomography in Acute Coronary Syndromes During the COVID-19 Pandemic-Single Center Snapshot Study.

Front Cardiovasc Med 2021 11;8:665735. Epub 2021 May 11.

Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

In clinical practice, cardiac computed tomography (CCT) has a limited role in acute coronary syndromes (ACS). Several trials evaluated CCT in low and intermediate risk patients presenting to the emergency room (ER) and noted that it was both safe and feasible. During the COVID19 pandemic, it is imperative to adopt a pathway for the evaluation of ACS that permits early discharge, reduces invasive coronary angiography and limits exposure of healthcare workers. Here, we present a single center experience by which CCT was incorporated in the clinical pathway of patients presenting to the ER with chest pain and ACS. This is a snapshot study of the first 27 patients who underwent CCT immediately after the lockdown in the city of Jeddah. ST elevation myocardial infarctions and hemodynamically unstable patients were excluded. Those with unstable angina or a Non-ST elevation myocardial infarction were screened for COVID19. The patients' COVID19 status and the results of the CCT were then used to determine the treatment strategy. Patient predisposition, hospital stay and exposure of staff are collected and reported. All CCT images were interpretable with no limitations or significant artifact. CCT identified critical disease in 7 patients (26%), normal epicardial coronary arteries in 11 (41%) and mild to moderate disease in 9 (33%). All patients with normal or mild to moderate disease were assigned to a conservative strategy and discharged within 24 h. Those with a NSTEMI and critical anatomy were assigned to an additional invasive evaluation with subsequent revascularization. During the course of this study, no transmission to healthcare workers occurred. CCT enabled 80% of patients to be discharged within the first 24 h, the majority of whom were discharged from the emergency room. It was able to identify critical anatomy facilitating appropriate revascularization. This snapshot study warrants exploration of the role of CCT in ACS further particularly since the latest European Society of Cardiology's Non-STEACS guidelines suggest a role for CCT in the evaluation of low risk ACS.
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http://dx.doi.org/10.3389/fcvm.2021.665735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144287PMC
May 2021

Results of an international crowdsourcing survey on the treatment of non-ST segment elevation ACS patients at high-bleeding risk undergoing percutaneous intervention.

Int J Cardiol 2021 08 15;337:1-8. Epub 2021 May 15.

Inselspital, University Hospital Bern, Bern, Switzerland. Electronic address:

Aims: Choosing an antiplatelet strategy in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) at high bleeding risk (HBR), undergoing post-percutaneous coronary intervention (PCI), is complex. We used a unique open-source approach (crowdsourcing) to document if practices varied across a small, global cross-section of antiplatelet prescribers in the post-PCI setting.

Methods And Results: Five-hundred and fifty-nine professionals from 70 countries (the 'crowd') completed questionnaires containing single- or multi-option and free form questions regarding antiplatelet clinical practice in post-PCI NSTE-ACS patients at HBR. A threshold of 75% defined 'agreement'. There was strong agreement favouring monotherapy with either aspirin or a P2Y inhibitor following initial DAPT, within the first year (94%). No agreement was reached on the optimal duration of DAPT or choice of monotherapy: responses were in equipoise for shorter (≤3 months, 51%) or longer (≥6 months, 46%) duration, and monotherapy choice (45% aspirin; 53% P2Y inhibitor). Most respondents stated use of guideline-directed tools to assess risk, although clinical judgement was preferred by 32% for assessing bleeding risk and by 46% for thrombotic risk.

Conclusion: The crowdsourcing methodology showed potential as a tool to assess current practice and variation on a global scale and to achieve a broad demographic representation. These preliminary results indicate a high degree of variation with respect to duration of DAPT, monotherapy drug of choice following DAPT and how thrombotic and bleeding risk are assessed. Further investigations should concentrate on interrogating practice variation between key demographic groups.
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http://dx.doi.org/10.1016/j.ijcard.2021.05.012DOI Listing
August 2021

Leaps and Gaps in Transcatheter Aortic Valve Replacement Management.

Circ Cardiovasc Interv 2021 04 20;14(4):e010719. Epub 2021 Apr 20.

Penn State University College of Medicine, Milton S. Hershey Medical Center, Heart and Vascular Institute, PA (G.V.N.).

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.010719DOI Listing
April 2021

Non-invasive Cardiac Imaging During the Coronavirus Disease 2019 (COVID-19) Pandemic: A Statement from the Cardiac Imaging Working Group of the Saudi Heart Association.

J Saudi Heart Assoc 2020 18;32(5):6-10. Epub 2020 May 18.

King Abdulaziz Cardiac Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.

COVID-19 pandemic has led to major changes in the delivery of medical care around the globe. Many investigations and elective procedures had to be rescheduled to decrease the risk of spreading the infection. Non-invasive cardiac imaging studies are requested to guide appropriate cardiac care in a variety of urgent, semi-urgent, and elective procedures. This position statement of the Cardiac Imaging Working Group of the Saudi Heart Association provides guidance into the protection of healthcare personnel, assessment of the indications of the imaging studies, and highlights consideration before, during, and after the study.
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http://dx.doi.org/10.37616/2212-5043.1029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735958PMC
May 2020

Acute Myocardial Infarction in Autoimmune Rheumatologic Disease: A Nationwide Analysis of Clinical Outcomes and Predictors of Management Strategy.

Mayo Clin Proc 2021 02 26;96(2):388-399. Epub 2020 Nov 26.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK; Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, PA. Electronic address:

Objectives: To examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014.

Methods: All AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD.

Results: Of 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography-0.87; 0.84 to 0.91; PCI-0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication.

Conclusion: In a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.
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http://dx.doi.org/10.1016/j.mayocp.2020.04.044DOI Listing
February 2021

The Middle East: Names from Underneath the Rubble.

Authors:
Mirvat Alasnag

Eur Heart J 2021 02;42(7):726-727

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http://dx.doi.org/10.1093/eurheartj/ehaa809DOI Listing
February 2021

Improvement initiative in LDL-C management in Saudi Arabia: A call to action.

Int J Cardiol Heart Vasc 2020 Dec 27;31:100667. Epub 2020 Oct 27.

Cardiac Science, College of Medicine, King Saud University, Saudi Arabia.

Purpose: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the Saudi Arabia (KSA). Over the last decade dyslipidemia has been the predominant risk factor in KSA. The linear relationship between low density lipoprotein cholesterol (LDL-C) levels, a marker for dyslipidemia, and progression of ASCVD is well established. The objective of this paper is to to provide an overview of the burden of disease, outline current clinical practice guidelines (CPG), examine gaps in care, and provide actionable recommendations to prevent, diagnose, and treat dyslipidemia in KSA.

Results: Saudi Arabia has the highest prevalence of ASCVD in the Gulf region. Several gaps in the implementation of CPGs, including the underdiagnosis and undertreatment of dyslipidemia, inadequate primary and secondary prevention efforts, complicated by a fragmented health system have been identified. Compelling evidence indicates that target LDL-C levels are not achieved throughout the Middle East region. In addition, high-risk patients are often left unidentified with adequate treatment.

Conclusion: This statement recommends specific multilevel interventions to optimize the prevention, diagnosis, and treatment of ASCVD. These recommendations focus on strengthening primary and secondary prevention through education initiatives, establishment of specialized prevention and treatment centers, and development of local and regional CPGs.
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http://dx.doi.org/10.1016/j.ijcha.2020.100667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7596183PMC
December 2020

Social media in the era of COVID-19.

Open Heart 2020 09;7(2)

Keele Cardiovascular Research Group, Keele University, Staffordshire, United Kingdom.

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http://dx.doi.org/10.1136/openhrt-2020-001352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526301PMC
September 2020

3-Dimensional modeling to plan tricuspid valve in valve in a patient with a permanent dual-chamber pacemaker.

HeartRhythm Case Rep 2020 Sep 5;6(9):588-590. Epub 2020 Jun 5.

Cardiac Center-King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

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http://dx.doi.org/10.1016/j.hrcr.2020.05.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498512PMC
September 2020

Management of Acute Coronary Syndrome During the MERS-CoV Outbreak - Single-Center Experience.

Cardiovasc Revasc Med 2021 03 10;24:20-23. Epub 2020 Sep 10.

Cardiac Center-King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

Background: During the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) outbreak of 2014, tertiary care cardiac centers shouldered the responsibility of caring for patients presenting with Acute Coronary Syndromes (ACS). This entailed designing algorithms that ensured timely management of patients with ACS in the setting of an emerging novel viral infection that was rapidly spreading within the community with a high infectivity and case fatality rate. The objective of this study is to describe a single center experience and the adopted pathway for the management of ACS.

Methods: This is a single center retrospective observational study of all patients who were admitted between March 1, 2014 and May 31, 2014 with an ACS. Total ACS admissions, bed turnover, procedures and healthcare personnels' infection rates were obtained from the annual statistics database and employee health records. All baseline characteristics, therapy received, outcomes and MERS-CoV status were obtained from the chart review.

Results: A total of 148 patients with a diagnosis of ACS were admitted during that period of time. Of those, 59 had STEMI, 42 had NSTEMI and 47 had unstable angina. PCI was performed in 74, coronary artery bypass grafting (CABG) in 28 and conservative therapy was prescribed for 46 patients. The bed turnover was no higher than the previous or subsequent two months suggesting no change in practice. The infection rate of MERS-CoV was zero for healthcare workers.

Conclusions: In times of a national health crisis it is imperative that best practices are upheld to sustain existing resources, reduce bed occupancy and preserve medical personnel. A key component of such a strategy depends on assigning centers dedicated to isolating and treating the highly infectious disease outbreak while allowing other centers to provide expeditious cardiac care.
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http://dx.doi.org/10.1016/j.carrev.2020.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482588PMC
March 2021

Women and Cardiology: The Value of Diversity.

Heart Lung Circ 2021 Jan 27;30(1):3-5. Epub 2020 Aug 27.

Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia; Monash Heart, Monash Medical Centre, Melbourne, Vic, Australia.

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http://dx.doi.org/10.1016/j.hlc.2020.06.027DOI Listing
January 2021

STEMI and COVID-19 Pandemic in Saudi Arabia.

Curr Probl Cardiol 2021 Mar 22;46(3):100656. Epub 2020 Jul 22.

The COVID-19 pandemic had significant impact on health care worldwide which has led to a reduction in all elective admissions and management of patients through virtual care. The purpose of this study is to assess changes in STEMI volumes, door to reperfusion, and the time from the onset of symptoms until reperfusion therapy, and in-hospital events between the pre-COVID-19 (PC) and after COVID-19 (AC) period. All acute ST-segment elevation myocardial infarction (STEMI) cases were retrospectively identified from 16 centers in the Kingdom of Saudi Arabia during the COVID-19 period from January 01 to April 30, 2020. These cases were compared to a pre-COVID period from January 01 to April 30, 2018 and 2019. One thousand seven hundred and eighty-five patients with a mean age 56.3 (SD ± 12.4) years, 88.3% were male. During COVID-19 Pandemic the total STEMI volumes was reduced (28%, n = 500), STEMI volumes for those treated with reperfusion therapy was reduced too (27.6%, n= 450). Door to balloon time < 90 minutes was achieved in (73.1%, no = 307) during 2020. Timing from the onset of symptoms to the balloon of more than 12 hours was higher during 2020 comparing to pre-COVID 19 years (17.2% vs <3%, respectively). There were no differences between the AC and PC period with respect to in-hospital events and the length of hospital stay. There was a reduction in the STEMI volumes during 2020. Our data reflected the standard of care for STEMI patients continued during the COVID-19 pandemic while demonstrating patients delayed presenting to the hospital.
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http://dx.doi.org/10.1016/j.cpcardiol.2020.100656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374127PMC
March 2021

Identification of Genetic Variants Associated With Myocardial Infarction in Saudi Arabia.

Heart Surg Forum 2020 Jul 23;23(4):E517-E523. Epub 2020 Jul 23.

Department of Biological Sciences, Science and Arts College, Rabigh Campus, King Abdulaziz University (KAU), Jeddah, Saudi Arabia.

The genetic variants associated with various genetic disorders have not been identified decisively in Saudi Arabia. Among these variants, six known for their association with coronary artery disease or myocardial infarction (MI) were studied on Saudi patients. Reference single nucleotide polymorphisms (SNPs) of these variants are rs5174, rs11591147, rs2259816, rs111245230, rs3782886 and rs2259820, referring to genes LRP8, PCSK9, HNF1A, SVEP1, BRAP and HNF1A, respectively. The analysis employed polymerase chain reaction panel coupled with mini-sequencing (SNapShot multiplex system) in order to identify these variants. A total of 100 MI patients and 103 healthy control individuals participated in this study. The six variants (SNPs) were evaluated for the risk of developing MI in the Saudi patients. Analysis of allele frequencies indicated that A allele of rs11591147 variant can be a protective allele, thus, is associated with the decreased risk of MI in Saudi individuals. Rare allele of rs111245230 variant (e.g., C allele) was extremely reduced, while rare allele of rs3782886 variant (e.g., G allele) does not exist in the ethnic signature of the Saudi population. This study elucidates the possible prediction of risk factors associated with severe diseases in Saudi population utilizing SNapShot multiplex system.
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http://dx.doi.org/10.1532/hsf.2955DOI Listing
July 2020

Understanding the Analytics of Twitter in Cardiovascular Medicine.

JACC Case Rep 2020 May 6;2(5):837-839. Epub 2020 May 6.

Division of Nephrology and Hypertension at the Department of Veterans Affairs, Salisbury, North Carolina.

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http://dx.doi.org/10.1016/j.jaccas.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301679PMC
May 2020

Mechanical Circulatory Support: a Comprehensive Review With a Focus on Women.

Curr Atheroscler Rep 2020 04 23;22(3):11. Epub 2020 Apr 23.

Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

Purpose Of The Review: The purpose of this review is to analyze the evidence for use of mechanical circulatory support (MCS) with a focus on women, namely, intra-aortic balloon pump (IABP), Impella, ventricular assist devices (VAD), and extracorporeal membrane oxygenation (ECMO).

Recent Findings: There is paucity of data examining management options for cardiogenic shock (CS) in women specifically. In published data, although only a minority of MCS recipients (33%) were women, there is a trend toward even lower use in women relative to men over time. Women presenting with CS tend to have a higher risk profile including older age, greater comorbidities, higher Society of Cardiothoracic Surgery (STS) mortality scores, more hypotension and index vasopressor requirements, and longer duration of CS. Overall, women receiving mechanical support suffer increased bleeding and vascular complications and have higher 30-day readmission rates. The incidence of cardiogenic shock (CS) has been rising at a higher rate in women compared to men. Women in CS tend to present with an overall higher risk profile including older age, greater burden of medical comorbidities, more hypotension and index vasopressor requirements, higher STS mortality scores, and more out-of-hospital cardiac arrest. After adjusting for comorbidities and traditional cardiovascular risk factors, mortality remained higher in younger women compared to men of similar age. In spite of these facts, evidence points to the underutilization of support devices in eligible female patients. Higher complication rates, such as vascular complications requiring surgery and bleeding requiring transfusion, may be deterring factors that limit the use of MCS and hinderoperator confidence and experience with devices in women. This suggests that future research should address the sex disparities in outcomes of contemporary MCS practices.
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http://dx.doi.org/10.1007/s11883-020-0828-0DOI Listing
April 2020

3D Model Guiding Transcatheter Aortic Valve Replacement in a Patient With Aortic Coarctation.

JACC Case Rep 2020 Mar 18;2(3):352-357. Epub 2020 Mar 18.

Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

We demonstrate the utility of a printed 3-dimensional model to assist in the vascular access planning for a transcatheter aortic valve replacement in an elderly woman with complicated vascular anatomy including aortic coarctation, severe iliofemoral disease, and a small and tortuous left subclavian artery. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311682PMC
March 2020
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