Project Description
(Background)

Coronary artery disease (CAD) continues to claim the lives of many people worldwide and creates enormous disability for those who survive. According to World Health Organization (WHO) estimates, cardiovascular disease will be the leading cause of morbidity and mortality by the year 2020.

Developing countries will be the major contributor to this increased death and disability1,2,3,4. These WHO estimates are expected to affect the Gulf states in a major way due to recent evidence of increased risk factors among populations of the Gulf countries. There was only few limited data concerning the prevalence and the clinical aspects of CAD in the Kingdom of Saudi Arabia till recently when Al-Nozha reported a major national study on CAD in Saudis (CADISS) 5. That was a community-based study conducted by examining subjects in the age group of 30-70 years between 1995 and 2000.

The overall prevalence of CAD was 5.5%. The prevalence in males and females were 6.6% and 4.4%, respectively. The prevalence of CAD risk factors were as follows: diabetes mellitus: 23.7%, hypertension: 26%, current smoking: 12.8%, hypercholesterolemia: 53.9%, and obesity: 35.6%. Since these data represent only the prevalence in the community setting, it is expected that the prevalence of these factors are even higher in the hospital setting when subsequent reports from the study get published.

Other studies from the Gulf States indicate a high prevalence rate of type 2 diabetes among adults population (15-18%) 6, 7. Obesity is a growing concern, with increased rates of obese people among the general population in some Gulf states 8,9. Smoking was found to be widespread among the population in Kuwait, with about 34% of men smoking10.

While considerable progress has been made in developing effective treatment and therapies for patients with CAD, significant opportunities remain to improve the quality of cardiac care. It is well known that there is an unacceptable delay between the availability of conclusive clinical trial evidence and its application to patient care. At the same time, it is challenging for clinicians to stay current due to the rapidly increasing volume of available information. Improving the quality of care increasingly rests on the ability to efficiently translate research knowledge into practice, so that patients may benefit sooner from the available scientific evidence.

There are some well-known registries of acute coronary syndromes that have contributed to our understanding of the distribution of this disease among different societies. These registries have also demonstrated the different practice patterns of the treatment of acute coronary syndromes and their influence on morbidity and mortality11,12,13. The majority of these registries represent data from the developed industrialized countries.

Phase-I of SPACE registry started in December, 2005 and showed the following results over a 1-year period:

1588 patients were enrolled from 13 hospitals in Saudi Arabia.  Average age was 58.1 years, 77% of them were males, and 84% were Saudis. 38% had prior history of ischemic heart disease, previous percutaneous coronary intervention (13%), diabetes (57%), hypertension (53%), current smoking (33%), hyperlipidemia (40%), and family history of premature CAD (14%). Median door-to-needle time for fibrinolytic therapy received by STEMI patients was 75 minutes.

In- hospital medications included: Aspirin (98%), Clopidogrel (77%), ACE-I (69%), β-blockers (79%), statin (89%), unfractionated heparin (53%), low-molecular weight heparin (41%), and GP-IIb/IIIa inhibitors (22%). In-hospital mortality was 3%.

The pilot phase of the Gulf RACE project included ACS patients who were admitted to 65 hospitals in 6 Arabian Gulf countries during the month of May 2006. A total of 1484 ACS patients were recruited. The mean age of patients was 55 years, and 76% of them were men.

The final discharge diagnosis was ST-segment elevation myocardial infarction (STEMI) in 37%, non-ST-segment elevation myocardial infarction (NSTEMI) in 32%, left bundle branch block myocardial infarction (LBBB MI) in 2% and unstable angina in 29%.

Among patients with STEMI and LBBB MI, the reperfusion rate was 65%, with use of primary percutaneous coronary intervention strategy in 7% and administration of thrombolytic therapy in 93%.

When thrombolytic therapy was used, the median door to needle time was 45 minutes, with 37% receiving it within 30 minutes of hospital presentation. During the first day of hospitalization, aspirin was administered to 94%, clopidogrel to 51%, and beta blockers to 65%. Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers and statins were used in 62% and 82%, respectively. Coronary angiography during hospitalization was performed in 21%.

In-hospital mortality rate was 3%. This project - Gulf A.C.S Registry - represents a unified program of the 2 registries; i.e: SPACE and Gulf RACE. Its aim is to assist in reducing the gap between research and practice and hence improve the quality of cardiac care for all patients with ACS in the Arabian Gulf countries.