Document Detail

Acute coronary syndrome in the Middle East: The importance of registries for quality assessment and plans for improvement.
Jump to Full Text
MedLine Citation:
PMID:  24688996     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Acute coronary syndrome (ACS) represents one of the most common causes of death worldwide. Several practice guidelines have been developed in Europe and North America to improve outcome of ACS patients through implementation of the recommendations into clinical practice. It is well know that there is wide gap between guidelines and implementation in real practice as was demonstrated in registry findings mainly conducted in the developed world. Here in we review main gaps in the management of ACS patients observed from two recent registries conducted in the Middle East.
Authors:
Jassim Al Suwaidi
Related Documents :
11892106 - Don't blame the iceberg.
17245086 - Prenatal management and postnatal separation of omphalopagus and craniopagus conjoined ...
21154366 - Sound therapy (masking) in the management of tinnitus in adults.
23332496 - From guidelines to practice: how reporting templates promote the use of radiology pract...
14753646 - Managing a subsidized predator population: reducing common raven predation on desert to...
16236056 - Sexual medicine in the medical curriculum.
Publication Detail:
Type:  Journal Article; Review     Date:  2013-11-01
Journal Detail:
Title:  Global cardiology science & practice     Volume:  2013     ISSN:  2305-7823     ISO Abbreviation:  Glob Cardiol Sci Pract     Publication Date:  2013  
Date Detail:
Created Date:  2014-04-01     Completed Date:  2014-06-24     Revised Date:  2014-06-24    
Medline Journal Info:
Nlm Unique ID:  101613130     Medline TA:  Glob Cardiol Sci Pract     Country:  Qatar    
Other Details:
Languages:  eng     Pagination:  2-4     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Glob Cardiol Sci Pract
Journal ID (iso-abbrev): Glob Cardiol Sci Pract
Journal ID (pmc): GCSP
ISSN: 2305-7823
Publisher: Bloomsbury Qatar Foundation Journals, Qatar
Article Information
Download PDF
© 2013 Al Suwaidi, licensee Bloomsbury Qatar Foundation Journals.
open-access:
Received Day: 16 Month: 12 Year: 2012
Accepted Day: 09 Month: 2 Year: 2013
collection publication date: Year: 2013
Electronic publication date: Day: 1 Month: 11 Year: 2013
Volume: 2013 Issue: 1
First Page: 2 Last Page: 4
PubMed Id: 24688996
ID: 3963729
Publisher Id: gcsp.2013.2
DOI: 10.5339/gcsp.2013.2

Acute coronary syndrome in the Middle East: The importance of registries for quality assessment and plans for improvement Alternate Title:Global Cardiology Science and Practice Alternate Title:Al Suwaidi
Jassim Al Suwaidi*
Department of Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
Correspondence: *Email: jalsuwaidi@hotmail.com

ACS in the Middle East

Heart disease is the major cause of death worldwide. Many individuals with heart disease present with acute coronary syndrome (ACS); this puts them at significant risk of morbidity and mortality. This significant burden necessitates ongoing improvements in patient management to minimize these complications. These improvements in outcome are promoted by an evidence-based approach shaped by comprehensive clinical guidelines.

The Gulf Heart Association (GHA) has launched two multicenter multinational registries of ACS: The Gulf Registry of Acute Coronary Events (Gulf RACE),1 which was conducted in 2007 and included 8,169 patients with ACS from six adjacent Middle eastern countries (Bahrain, Kuwait, Qatar, Oman, the United Arab Emirates, and Yemen), and the Gulf-RACE-2, which was conducted in 2009 and included 7,939 patients with ACS from Middle eastern countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates and Yemen) with one-year follow-up.2 These two registries provided valuable information to health care officials. Whereas some aspects of the care provided were comparable to that of the developed countries, other aspects where clearly suboptimal. These main suboptimal practices are summarized in this commentary.

One of the most striking findings was the under-utilization of emergency medical services (EMS). Only 17% of patients in Gulf RACE were presented to the emergency department by EMS,3 with the remaining patients arriving by private cars. When compared to reports in the developed world this is extremely low rate. Canto et al.4 reported 53.4% use of EMS in the 2nd National Registry of Myocardial Infarction, which was conducted between June 1994 and March 1998 in the United States; this rate increased only to 60% a decade later as was documented in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines (2007–2009).5 Nevertheless it is much higher than that demonstrated in our two registries. We also observed that the frequency of EMS utilization was similarly low in patients presenting with ST-segment elevation myocardial infarction (18%) and non-ST elevation ACS (17%). Moreover, the utilization of EMS was low among patients presenting with typical chest pain (16%), pulmonary edema (32%), cardiogenic shock (30%), or cardiac arrest (29%).3

However, when patients with ST-elevation myocardial infarction (STEMI) were transported by EMS, they were significantly less likely to exhibit major delay in presentation and were significantly more likely to receive favorable processes of care, including shorter door-to-ECG time and more frequent reperfusion therapy emphasizing the importance of using EMS services.3

These findings have significant implications for improving care and outcome of ACS patients for Gulf countries and may suggest redirecting emphasis in improvement of pre-hospital care. The improvement in inpatient care is reflected in relatively low in-hospital mortality rates among patients with ACS in the region, as was documented in the 2 registries.2,3

The second issue is the reperfusion therapy used for STEMI patients in the Gulf countries. In many randomized clinical trials, primary percutaneous coronary intervention (PCI) has been shown to be superior to thrombolytic therapy (TT).6 This benefit is related to a much higher early mechanical reperfusion rate in comparison to TT. Indeed, the vast majority of acute cardiac centers in North America and Europe use primary PCI as the main modality of reperfusion therapy.6 In a recent analysis of 30 European countries, primary PCI was the main modality of treatment.7 The striking finding in Gulf RACE registries was the use of TT as the primary reperfusion modality. Among 2,155 STEMI patients in Gulf RACE, 84% underwent thrombolytic therapy and only 8% underwent primary PCI. This low overall use was present in small as well as larger countries, and in poor as well as well rich countries.8

Thirdly, there is an overall under-utilization of cardiac catheterization for patients admitted with acute coronary syndrome. The overall rate of in-hospital cardiac catheterization for ACS patients was only 20% with some variability among the various Gulf countries,9 which is considerably low when compared to previous studies. In the multinational GRACE (Global Registry of Acute Coronary Events) registry,10 catheterization use was about 60%, as was the case in in the CRUSADE (Can Rapid Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) registry11 for Non-STE-ACS. Sixty-five percent of patients with ACS in the Canadian registry underwent cardiac catheterization.12

Furthermore, we observed that low-risk patients were more likely to undergo cardiac catheterization when compared with intermediate and high-risk patients. This is consistent with many studies reported from Western countries, suggesting the urgent need to implement guidelines that risk-stratify patients more appropriately. Moreover, there is lack of cardiac catheterization facilities in significant number of hospitals involved in the region, which undoubtedly contributes to this overall low use. These two ACS registries suggested the need for current and future expansion of cardiac catheterization laboratories in many hospitals in the Gulf. This need obviously varies among the different countries involved. Finally, there is urgent need to implement ways to target patients for catheterization who would benefit most from this procedure.

The current review suggests three major gaps in the management of ACS in the Gulf; which are underuse of EMS, primary PCI and in-hospital cardiac catheterization. In Qatar, plans are underway to launch a nationwide primary PCI program which will require educating the public of the need to use EMS, close and coordinated work between EMS personal, emergency room and cardiology staff for expedited process of ECG evaluation and transfer for cardiac catheterization laboratory at the Heart Hospital for primary PCI or early invasive therapies, with the hope of further improvement of outcome in these high risk patients.


References
[1]. Zubaid M,Rashed WA,Almahmeed W,Al-Lawati J,Sulaiman K,Al-Motarreb A,Amin H,Al Suwaidi J,Alhabib K. Management and outcomes of middle Eastern patients admitted with acute coronary syndromes in the Gulf Registry of Acute Coronary Events (Gulf RACE)Acta CardiolYear: 200964443944619725435
[2]. AlHabib K,Sulaiman K,Al-Motarreb A,Almahmeed W,Asaad N,Amin H,Hersi A,Al-Saif S,AlNemer K,Al-Lawati J,Al-Sagheer NQ,AlBustani N,Al Suwaidi J,Gulf RACE-2 investigators. Baseline characteristics, management practices, and long-term outcomes of middle Eastern patients in the second Gulf Registry of Acute Coronary Events (Gulf RACE-2)Ann Saud MedYear: 2012321918
[3]. Fares S,Zubaid M,Al-Mahmeed W,Ciottone G,Sayah A,Al Suwaidi J,Amin H,Al-Atawna F,Ridha M,Sulaiman K,Alsheikh-Ali AA. Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf statesJ Emerg MedYear: 201141331031620580517
[4]. Canto JG,Zalenski RJ,Ornato JP,Rogers WJ,Kiefe CI,Magid D,Shlipak MG,Frederick PD,Lambrew CG,Littrell KA,Barron HV,National Registry of Myocardial Infarction 2 Investigators. Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2CirculationYear: 2002106243018302312473545
[5]. Mathews R,Peterson ED,Li S,Roe MT,Glickman SW,Wiviott SD,Saucedo JF,Antman EM,Jacobs AK,Wang TY. Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the national cardiovascular data registry acute coronary treatment intervention outcomes network registry-get with the guidelinesCirculationYear: 201112415416321690494
[6]. Keeley EC,Boura JA,Grines CL. Comparison of primary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trialsLancetYear: 2003361132012517460
[7]. Widimsky P,Wijns W,Fajadet J,de Belder M,Knot J,Aaberge L,Andrikopoulos G,Baz JA,Betriu A,Claeys M,Danchin N,Djambazov S,Erne P,Hartikainen J,Huber K,Kala P,Klinceva M,Kristensen SD,Ludman P,Ferre JM,Merkely B,Milicic D,Morais J,Noc M,Opolski G,Ostojic M,Radovanovic D,De Servi S,Stenestrand U,Studencan M,Tubaro M,Vasiljevic Z,Weidinger F,Witkowski A,Zeymer U European association for percutaneous cardiovascular interventions. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countriesEur Heart JYear: 201031894395719933242
[8]. Zakwani I,Zubaid M,Al-Riyami A,Alanbaie M,Suliman K,Almahmeed W,Al-Motarreb A,Al Suwaidi J,Amin H. Primary coronary intervention versus thrombolytic therapy in ST-segment elevation myocardial infarction patients in six Middle Eastern countries: data from Gulf Registry of Acute Coronary EventsInt J Clin PharmYear: 2012506418425
[9]. Panduranga P,Sulaiman K,Al-Zakwani I,Zubaid M,Rashed W,Al-Mahmeed W,Al-Lawati J,Al-Motarreb A,Haitham A,Suwaidi J,Al-Habib K. Utilization and determinants of in-hospital cardiac catheterization in patients with acute coronary syndrome from the middle eastAngiologyYear: 201061874475020498144
[10]. Fox KA,Goodman SG,Anderson FA,Granger CB,Moscucci M,Flather MD,Spencer F,Budaj A,Dabbous OH,Gore JM,GRACE Investigators. From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE)Eur Heart JYear: 200324151414142412909070
[11]. Bhatt DL,Roe MT,Peterson ED,Li Y,Chen AY,Harrington RA,Greenbaum AB,Berger PB,Cannon CP,Cohen DJ,Gibson CM,Saucedo JF,Kleiman NS,Hochman JS,Boden WE,Brindis RG,Peacock WF,Smith SC Jr,Pollack CV Jr,Gibler WB,Ohman EM,CRUSADE Investigators. Utilization of early invasive management strategies for high-risk patients with non-ST- segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement InitiativeJAMAYear: 2004292172096210415523070
[12]. Lee CH,Tan M,Yan AT,Yan RT,Fitchett D,Grima EA,Langer A,Goodman SG,Canadian Acute Coronary Syndromes (ACS) Registry II Investigators. Use of cardiac catheterization for non-ST-segment elevation acute coronary syndromes according to initial risk: reasons why physicians choose not to refer their patientsArch Intern MedYear: 2008168329129618268170

Article Categories:
  • Review Article

Keywords: Keywords: acute coronary syndrome, ST-elevation myocardial infarction, Non-ST-elevation acute coronary syndrome, thrombolytic therapy, primary percutaneous coronary intervention.

Previous Document:  Robotic excision of aortic valve papillary fibroelastoma and concomitant maze procedure.
Next Document:  Bioengineering and the cardiovascular system.