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2010 61: 456 originally published online 23 December 2009ANGIOLOGYMahmoud and Jassim Al Suwaidi

Abdulrahman Al-Nabti, Nidal Assad, Kadhim Sulaiman, Mouaz H. Al-Mallah, Haitham Amin, Ahmed Al-Motarreb, Hisham Hadi A. R. Hadi, Mohammad Zubaid, Wael Al Mahmeed, Ayman A. El-Menyar, Alawi A. Alsheikh-Ali, Rajivir Singh,

Acute Coronary SyndromeThe Prevalence and Outcome of Excess Body Weight Among Middle Eastern Patients Presenting With

  

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The Prevalence and Outcome of Excess BodyWeight Among Middle Eastern PatientsPresenting With Acute Coronary Syndrome

Hadi A. R. Hadi, FRCP,1 Mohammad Zubaid, FRCPC, FESC,2

Wael Al Mahmeed, FRCPC, FESC,1 Ayman A. El-Menyar, MBchB, MSc, FRCP (Glasg),3

Alawi A. Alsheikh-Ali, MD, MS, FACC,1 Rajivir Singh, PhD,4

Abdulrahman Al-Nabti, FRCPC, FACC,3 Nidal Assad, FRCPC,3 Kadhim Sulaiman, FRCPI,5

Mouaz H. Al-Mallah, MD, MS,6,7 Haitham Amin, FRCPC,8

Ahmed Al-Motarreb, MB, ChB, PhD,9 Hisham Mahmoud, MD,10 andJassim Al Suwaidi, MB, ChB, FACC, FSCAI, FESC3

AbstractWe evaluated the effect of body weight on the outcome of Middle Eastern patients presenting with acute coronary syndrome(ACS). Analysis of the Gulf Registry of Acute Coronary Events (Gulf RACE) survey that included 7843 consecutive patients hos-pitalized with ACS was made. Patients were categorized as normal weight, overweight, or obese based on their body mass index(BMI). Overall, 67% of patients were overweight or obese; obese and overweight patients were more likely to be female and havediabetes mellitus, hypertension, dyslipidemia, and less likely to be smokers. In-hospital mortality, congestive heart failure, cardio-genic shock, and strokes were comparable between the groups, although patients with obesity were more likely to have recurrentischemia and major bleeding complication in the ST-elevation myocardial infarction group. Excess body weight with ACS is asso-ciated with higher risk profile characteristics without an increase in hospital mortality or cardiovascular events.

Keywordsbody mass index, obesity, acute coronary syndrome, ST-elevation myocardial infarction, non-ST elevation myocardial infarction

Introduction

The prevalence of overweight and obesity is increasing in most

industrialized countries. One in 5 Europeans and more than half

of US adults are overweight or obese.1-3 Annual health care

costs attributable to obesity have been estimated to be approx-

imately $68 billion, with an additional $30 billion being spent

on weight-reduction programs and special diets.3 Obesity is

associated with higher levels of insulin resistance, as well as

hyperinsulinaemia, higher triglyceride and cholesterol levels,

and increased sympathetic nervous system activity.4 A high

risk of coronary heart disease is among the well-established

adverse health effects associated with excess weight.5

Hypertension, hypercholesterolemia, and diabetes are among

the clinical conditions that are important mediators of this

association.6-11

We have previously shown that obesity is independently

associated with coronary endothelial dysfunction in patients

with normal or mildly diseased coronary arteries, and we have

also shown that compared with normal weight patients, over-

weight and obese patients presenting with myocardial

1 Department of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United

Arab Emirates2 Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait3 Department of Cardiology, Hamad Medical Corporation (HMC), Qatar and

Weill Cornell Medical College, Qatar4 Department of Research, Hamad Medical Corporation (HMC), Qatar and

Weill Cornell Medical College, Qatar5 Department of Cardiology, Royal Hospital, Muscat, Oman6 Department of Internal Medicine, Henry Ford Health System, Detroit,

Michigan7 Wayne State University School of Medicine, Detroit, Michigan8 Mohammed Bin Khalifa Cardiac Centre, Manama, Bahrain9 Department of Medicine, Faculty of Medicine, Sana’a University, Sana’a,

Yemen10 Medical Department in Sanofi-Aventis Gulf Office, Dubai, United Arab

Emirates

Corresponding Author:

Jassim Al Suwaidi, Weill Cornell Medical School, and Department of

Cardiology and Cardiovascular Surgery, Hamad General Hospital (HMC),

PO Box 3050, Doha, Qatar.

Email: Jha01@hmc.org.qa

Angiology61(5) 456-464ª The Author(s) 2010Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0003319709355801http://ang.sagepub.com

456

infarction in Olmsted County, Minnesota, United States, were

3.6 to 8.2 years younger.12,13 We aimed in the current study

through retrospective analyses of prospectively collected data

to evaluate the effect of body weight on clinical charactertics,

treatment regimen, and prognosis in Middle Eastern patients

presenting with acute coronary syndrome (ACS).

Methods

The Gulf Registry of Acute Coronary Events (Gulf RACE) is

the largest multinational registry of acute coronary events in

the Middle East. It prospectively enrolled 8716 (of which

height and weight were recorded in 7843) consecutive patients

with ACS from 65 centers in 6 adjacent Middle Eastern Gulf

Countries (Bahrain, Kuwait, Qatar, Oman, United Arab Emi-

rates, and Yemen) over a 6-month period. All patients had a

final diagnosis of ACS including unstable angina (UA), and

non-ST-myocardial infarction (NSTEMI) collectively referred

to here as non-ST-segment elevation acute coronary syndrome

(NSTEACS) or ST-elevation myocardial infarction (STEMI).

The study received ethical approval from the institutional ethi-

cal bodies in all participating countries. There were no exclu-

sion criteria, and all the prospective patients were enrolled.

Full details of the methods have been published.14 Diagnosis

of the different types of ACS and definitions of data variables

were based on the American College of Cardiology (ACC)

clinical data standards.15 Recruitment in the pilot phase started

on May 8, 2006, for 30 days. Enrolment in the next phase of

the registry started on January 29, 2007, and continued for

5 months.

Body mass index (BMI) was calculated as weight in

kilograms divided by the square of height in meters. Of the

commonly used measures of obesity, BMI is the body size

measurement that correlates best with body fat content.16 As

recommended by the World Health Organization, a BMI below

25 was classified as normal, between 25 and 29.9 as over-

weight, and �30 as obese.17 Abdominal obesity for Middle

Eastern patients was defined as waist abdominal circumference

of �94 cm for men and �80 cm for women.4

Statistical Analysis

Baseline and clinical characteristics of patients are presented as

median and 25th and 75th percentiles for continuous variables,

whereas frequency distribution and percentages are presented

for categorical variables. Independent t tests were used for

comparing continuous variables, and w2 tests for categorical

variables have been used for comparing obese versus nonobese

cases. A univariate logistic regression was performed for all

important variables and a P � .05 was considered in multivari-

ate logistic regression analysis to assess the importance of obe-

sity in hospital mortality A P < .05 was considered significant.

All data analyses were carried out using the Statistical Package

for Social Sciences version 14 (SPSS Inc, Chicago, Illinois).

Results

Study Population Characteristics

Of the 7843 patients studied, 2575 (32.8%) had BMI < 25, 3173

(40.4%) had BMI 25 to <30, and 2095 (26.7%) had BMI �30.

Three thousand and sixty-eight patients were diagnosed with

STEMI of which 1245 (40.5%) had BMI 25 to <30 and 634

(22.6%) had BMI �30. Three thousand seven hundred

eighty-three patients were diagnosed with non-ST-segment ele-

vation acute coronary syndrome (NSTEACS) of which 1928

(50.9%) had BMI 25 <30 and 1459 (38.5%) had BMI �30

(Table 1). Overall, 49.2% of male patients and 74.3% of female

patients had abdominal obesity.

Presenting Symptoms and Baseline ClinicalCharacteristics

Overall, overweight patients with ACS were 1 year younger

than normal weight and obese patients (P ¼ .002; Table 1).

The same observation was noted in the subanalysis of

STEMI-ACS (P ¼ .01; Table 3) and NSTEACS (P ¼ .003;

Table 2). Patients with obesity were more likely to have dia-

betes, hypertension, and dyslipidemia and less likely to be

current smokers. Patients with obesity were more likely to

have history of previous coronary artery disease (CAD) and

prior coronary revascularization. The admission heart rate,

systolic, and diastolic blood pressures were significantly

higher in patients with obesity. Patients with obesity were

more likely to have Killip class >1 on admission. Although

patients with obesity were more likely to present with atypical

presentations (atypical chest pain or dyspnea), they were more

likely to present earlier (less than 12 hours from symptoms

onset) than normal weight patients (P ¼ .003). Patients with

obesity had higher first blood sugar level at admission when

compared to the other 2 groups (P ¼ .01). Subset analysis

of patients into STMI and NSTEMI-ACS demonstrated simi-

lar clinical characteristics and risk factor findings regardless

of the admission diagnosis (Tables 1-3).

TreatmentIn-Hospital. Overall, heparin and b-blockers were more

frequently prescribed and GPIIb/IIIa inhibitors were less

frequently prescribed on admission (in addition, the statin

on discharge) in obese patients than normal weight patients

(Table 1). Although the overall use of coronary angiography

was low, patients with obesity were more likely to undergo

coronary angiography when compared to the other 2 groups

(P ¼ .000; Table 1). In NSTEACS, overweight and obese

patients were more likely to receive b-blockers and

angiotensin-converting enzyme (ACE) inhibitors when com-

pared to normal weight patients (Table 2). In STEMI patients,

b-blocker use was more frequent among patients with obesity

(P ¼ .000) than in normal weight patients, although no signif-

icant differences in the use of other medications including

Hadi et al 457

457

thrombolytics were noted. Despite earlier presentation of

obese and overweight patients (P ¼ .005), they had signifi-

cantly prolonged door-to-needle time when compared to nor-

mal weight patients (median 80, range 25-950 minutes vs 53

range 15-740 minutes; P ¼ .05). The overall use of primary

percutaneous revascularization was low in our registry, and

no significant differences among the 3 weight groups were

noted (Table 3).

At Discharge

In the overall group and NSTEACS patients, patients with obe-

sity were more likely to receive statins and b-blockers with no

significant differences in the use of other medications (Tables 1

and 2). In the STEMI group, patients with obesity were more

likely to receive b-blockers and clopidogrel when compared

to the normal weight group (Table 3).

Table 1. Clinical Characteristics and Risk Factors in Patients With Acute Coronary Syndrome According to the Body Mass Index (BMI)

BMI <25 (N 2575) 25 to <30 (N 3173) �30 (N 2095) P Value

Age (mean, years) 56 + 13 55 + 12 56 + 12 .002Female, % 19 20 37 .000Diabetes mellitus, % 34 39 50 .000Hypertension, % 38 49 63 .000Dyslipidemia, % 25 32 41 .000Smoking, % 41 40 32 .000Prior aspirin use,% 34 40 27 .000Family history CAD, % 12 14 15 .07Prior CAD, % 40 45 52 .000Prior revascularization, % 12 16 20 .000Renal impairment, % 16 15 15 .27Heart rate, beat/minute 85 + 22 86 + 22 87 + 23 .002SBP, mm Hg 137 + 30 140 + 29 144 + 31 .000DBP, mm Hg 83 + 18 84 + 18 85 + 18 .01Killip class >1% 20 20 25 .000Presented >12 hours, % 34 29 27 .003Typical chest pain, % 80 82 77 .000Low GRACE scoring, % 39 42 38 .01High GRACE scoring, % 32 29 35Peak troponina, mg/L 18 + 1.5 19 + 3 11 + 0.8 .05Total cholesterol, mmol/L 4.7 + 2 4.7 + 3 4.6 + 3 .83Serum Triglyceridea, mmol/L 2.5 + 0.2 2.7 + 0.2 2.4 + 0.1 .34First blood sugara, mmol/L 10 + 0.2 10 + 0.2 11 + 0.2 .01On admission medications

Aspirin, % 98 98 98 .15Clopidogrel, % 55 53 52 .18Heparin, % 47 46 55 .000GPIIb-IIIa inhibitors, % 12 11 9 .000ACEI, % 64 64 65 .64b-blockers, % 61 69 67 .000Coronary angiography 17 19 23 .000

Discharge medicationsAspirin, % 94 95 94 .17Clopidogrel, % 49 49 51 .28Statins, % 81 80 83 .007b-blockers, % 73 79 75 .000ACEI,% 70 70 68 .21

In-hospital outcomesRecurrent ischemia, % 8 10 11 .007Infarction, % 2.4 2.6 2.2 .59Heart failure, % 17 15 15 .17Cardiogenic shock, % 5 3.6 4.7 .02Major bleeding, % 0.7 0.5 0.9 .12Stroke, % 0.5 0.7 0.7 .56Mortality, % 3 2.4 2.5 .32Hospital stay (mean, days) 5.6 + 5 5.4 + 4 5.8 + 5 .002

NOTES: ACEI ¼ angiotensin-converting enzyme inhibitors; BMI ¼ body mass index; CAD ¼ coronary artery disease; DBP ¼ diastolic blood pressure; SBP ¼systolic blood pressure, GPIIb-IIIa ¼glycoprotein IIb/IIIa inhibitors.a Standard error.

458 Angiology 61(5)

458

In-Hospital Outcome

In all patients with ACS, patient with obesity had longer hospi-

tal stay and more recurrent ischemia than normal weight

patients (Table 1). In NSTEACS, patients with obesity had less

heart failure than normal weight patients and no differences in

the incidence of other complications between the groups

(Table 2). In the STEMI group, there were no differences in

in-hospital mortality, heart failure, or stroke although patients

with obesity had significantly higher incidence of recurrent

ischemia and were more likely to develop major bleeding com-

plications (P ¼ .007) resulting in prolonged hospitalization

(7 range 3-23 days vs 6 range 3-18 days, P ¼ .002; Table 3).

Multivariate Predictors of Outcome

Multivariate regression of in-hospital mortality for all patients

with ACS demonstrated age, female gender, cardiogenic shock,

diabetes mellitus, ST-segment elevation myocardial infarction,

and atypical chest pain presentation to be independent

Table 2. Clinical Characteristics and Risk Factors in Patients With NSTEACS According to the Body Mass Index (BMI)

BMI <25 (N 1396) 25 to <30 (N 1928) �30 (N 1459) P value

Age (mean, years) 58 + 13 56 + 12 57 + 11 .003Female, % 26 26 42 .000Diabetes mellitus, % 38 44 55 .000Hypertension, % 50 59 70 .000Dyslipidemia, % 35 42 46 .000Smoking, % 30 32 42 .000Prior aspirin use, % 49 55 56 .000Family history CAD, % 11 14 15 .02Prior CAD, % 40 45 52 .002Prior revascularization, % 19 21 24 .003Renal impairment, % 18 14 14 .002Heart rate, beat /minute 86 + 23 85 + 23 87 + 23 .01Systolic BP, mm Hg 141 + 31 143 + 29 147 + 31 .000Diastolic BP, mm Hg 83 + 17 84 + 17 84 + 17 .007Killip class >1% 23 21 24 .07Presented >12 hours, % 42 41 28 .53Typical chest pain, % 73 76 73 .03Low GRACE scoring, % 36 38 36 .11High GRACE scoring, % 37 32 36 .11Peak troponin, mg/L 5 + 0.7 3 + 0.3 4 + 0.5 .09Total cholesterol, mmol/L 4.4 + 2 4.5 + 3 4.5 + 4 .60Serum triglycerides, mmol/L 2.1 + 0.1 2.8 + 0.3 2.3 + 0.1 .12First blood sugar, mmol/L 9.5 + 0.2 10 + 0.3 11 + 0.3 .005On admission medications

Aspirin, % 98 98 98 .1Clopidogrel, % 50 49 50 .91Heparin, % 93 93 93 .64GP inhibitors, % 15 13 10 .000ACEI, % 65 68 73 .000b-blockers, % 64 70 68 .001Coronary angiography 19 19 22 .03

Discharge medicationsAspirin, % 95 96 95 .1Clopidogrel, % 46 47 47 .55Statins, % 79 80 83 .009b-blockers, % 72 78 75 .000ACEI, % 64 66 64 .17

In-hospital outcomesRecurrent ischemia, % 8.5 10 10 .38Infarction, % 2.3 2.3 1.4 .10Heart failure, % 18 15 13 .002Cardiogenic shock, % 2.4 1.5 2.2 .09Major bleeding, % 0.3 0.5 0.4 .59Stroke, % 0.4 0.4 0.3 .92Mortality, % 1.6 1.1 1.0 .22Hospital stay (mean, days) 5.3 + 5 5.0 + 4 5.5 + 6 .007

NOTES: ACEI ¼ angiotensin-converting enzyme inhibitors; BP ¼ blood pressure; CAD ¼ coronary artery disease; GP IIb/IIIa inhibitors ¼ glycoprotein IIb/IIIainhibitors; NSTEACS ¼ non-ST-elevation acute coronary syndrome.

Hadi et al 459

459

predictors of increased mortality. Thrombolytic therapy use,

ACE inhibitors, statins, and coronary angiography perfor-

mance before discharge were independent predictors of

reduced mortality outcome. Body mass index was not an

independent predictor of improved outcome (Table 4).

Discussion

The current study demonstrates high prevalence of excess body

weight among Middle Eastern patients presenting with ACS

(67%), with very high prevalence of diabetes mellitus in

Table 3. Clinical Characteristics and Risk Factors in Patients With STEMI According to the Body Mass Index (BMI)

BMI <25 (N 1179) 25 to <30 (N 1245) �30 (N 634) P Value

Age (mean, years) 54 + 13 53 + 11 55 + 12 .01Female, % 11 10 25 .000Diabetes mellitus, % 28 31 39 .000Hypertension, % 25 34 46 .000Dyslipidemia, % 12 17 28 .000Smoking, % 54 53 50 .36Prior aspirin use, % 16 20 28 .000Family history CAD, % 13 13 14 .9Prior CAD, % 22 26 29 .003Prior revascularization, % 4 7 10 .000Renal impairment, % 13 15 16 .29Prior COPD, % 3 4 8 .000Heart rate, beat/minute 84 + 22 86 + 22 86 + 24 .01SBP, mm Hg 132 + 29 136 + 30 137 + 32 .002DBP, mm Hg 83 + 19 84 + 19 84 + 21 .08Killip class >1, % 17 18 28 .000Presented >12 hours, % 33 28 27 .005Typical chest pain, % 88 90 86 .03Low GRACE scoring, % 42 46 41 .01High GRACE scoring, % 28 24 32Peak troponin, mmol/L 35 + 3 45 + 8 29 + 2 .25Total cholesterol, mmol/L 5 + 2 5 + 2 5 + 2 .53Serum Triglyceride, mmol/L 3 + 0.3 2.5 + 0.1 3 + 0.1 .26First blood sugar, mmol 11 + 0.4 10 + 0.2 11 + 0.3 .19On admission medications

Aspirin, % 99 98 99 .11Clopidogrel, % 60 58 58 .49Heparin, % 91 92 94 .08GP inhibitors, % 8 9 6 .11ACEI, % 68 68 71 .23b-blockers, % 58 68 63 .000Thrombolytics, % 56 60 60 .14Coronary angiography 14 18 25 .000Primary PCI 25 (2.1) 38 (3.0) 14 (2.3) .38Door to needle (minutes) 74.4 + 183.5 66.9 + 151 91.9 + 224 .05

Discharge medicationsAspirin, % 93 94 91 .14Clopidogrel, % 54 52 60 .004Statins, % 83 80 83 .14b-blockers, % 73 81 76 .000ACEI, % 77 76 77 .49

In-hospital outcomesRecurrent ischemia, % 8 9.5 13 .00Infarction, % 2.5 3 4 .25Heart failure, % 15 16 19 .16Cardiogenic shock, % 8 7 10 .03Major bleeding, % 1.1 0.5 2.0 .007Stroke, % 0.5 1.0 1.4 .14Mortality, % 4.7 4.4 6.0 .31Hospital stay (mean, days) 6 + 4 6 + 4 7 + 5 .002

NOTES: ACE ¼ angiotensin-converting enzyme inhibitors; BMI ¼ body mass index; CAD ¼ coronary artery disease; SBP ¼ systolic blood pressure; DBP ¼ dia-stolic blood pressure; GP2b3a ¼ glycoprotein IIb/IIIa inhibitors; STEMI ¼ ST-elevation myocardial infarction.

460 Angiology 61(5)

460

patients with obesity (50%) and reports for the first time the

prevalence of abdominal obesity among Middle Eastern

patients with ACS. Abdominal obesity was very high among

female patients with ACS. Patients with excess body weight

had higher risk profile including diabetes, hyperlipidemia, and

hypertension and similar to studies in different ethnicities

excess body weight was not independent predictor of increased

in-hospital mortality. The current study reports for the first time

that excess body weight was associated with more atypical pre-

sentations and despite the fact that obese STEMI patients were

more likely to present earlier, they had significant delay in

thrombolytic therapy administration and higher bleeding

complications.

The world is in the midst of an obesity pandemic. Overall,

the incidence rates of overweight have increased 2-fold and

obesity more than 3-fold over the past 50 years. Obesity, par-

ticularly in those with excess intra-abdominal adipose tissue,

has been postulated to be a cardiovascular risk state mediated

through a variety of pathways, and obesity has been well

established as a risk factor for the development of CAD in the

Framingham Heart study.18 More recently in a joint scientific

statement of the International Diabetes Federation Task Force,

the World Heart Federation, and the American Heart Associa-

tion,4 the criteria for the diagnosis of abdominal obesity

according to ethnicity was proposed (for Middle Eastern

patients waist circumference threshold �94 cm for men and

�80 cm for women), and the current study reports for the first

time high prevalence of abdominal obesity among Middle East-

ern patients presenting with ACS, and this was even much

higher in women when compared to men using these criteria.

Although the association of obesity with the development of

CAD has been well known, the effect of obesity on the

morbidity and mortality of patients with ACS has not been as

well defined.18-29 Moreover, the impact of obesity on the initial

management and outcome of patients with NSTEACS has been

incompletely characterized.30

The current study was carried in this part of the developing

world, the Middle East, which has witnessed the discovery of

oil and associated improvement in income of the population

together with change in the dietary habit and associated

increase in the incidence of obesity (38.8% are overweight,

25.6% are obese, see Table 5 to compare with other registries).

Our study clearly shows that excess body weight is highly pre-

valent among patients with ACS and is associated with higher

risk profile characteristics such as diabetes mellitus, hyperten-

sion, and dyslipidemia than that reported in other ethnicities

without effect on age at presentation (see Table 5), with no

effect on in-hospital, short-term mortality.12,35,38 Of note, other

investigators reported lower mortality rate among patients with

obesity despite worse clinical characteristics and they attrib-

uted that to their younger age what is now known as the obesity

paradox.32-34,37,40

The findings in our study have shown very low use of cor-

onary angiography and percutaneous coronary revasculariza-

tion when compared to published studies and no difference in

thrombolytic and angioplasty use in obese ACS patients when

compared to normal weight group. However, overall, patient

with obesity underwent more coronary angiography compared

to the normal weight group. We reported higher incidence of

major bleeding complications among obese patients with

STEMI, despite the fact that they did not receive more

thrombolytic, anticoagulant, or antiplatelet therapy with the

exception of marginal increase in clopidogrel use, and this

finding is discordant with previous reports of higher incidence

of bleeding complications among patients with very low rather

than high BMI.41,42 Mak et al42 reported ethnic variations in

bleeding complications among blacks and Asians when com-

pared to Caucasians with cardiovascular disease, and hence it

may be hypothesized that the variability of bleeding complica-

tions findings in our study could be related to the Arab

ethnicity. Although BMI was not independent predictor of in-

hospital outcomes, bleeding complications was independent

predictor of increased in-hospital mortality, reinfarction, con-

gestive heart failure, and stroke, which is consistent with previ-

ous reports.

Finally, although obese patients with STEMI were more

likely to present earlier than normal weight patients, they had

significantly longer door-to-needle time in STEMI; this in part

may be explained by the fact they were more likely to present

with atypical chest pain and dyspnea compared with the normal

weight group, a finding that was not reported previously. Over-

all, the younger age study group, higher prevalence of diabetes

mellitus when compared to western studies, the delay in admin-

istration of reperfusion therapy, longer door-to-balloon time,

and ethnicity differences could explain the lack of lower mor-

tality among patients with obesity; absence of obesity paradox

in our study group. Finally, the age difference between obese

and normal weight was only 1 year compared with other

Table 4. Multivariate Regression Analysis for the Predictors ofMortality in Patients With Acute Coronary Syndromea

OR 95% CI P Value

Female gender 1.76 1.1-2.8 <.01Age (per year) 1.05 1.03-1.07 <.01Cardiogenic shock 58.9 39.0-88.6 .00STEMI 3.8 2.7-5.5 <.0001Atypical chest pain 1.27 1.14-1.4 <.0001Diabetes mellitus 2.0 1.22-3.28 .006Hypertension 1.4 0.85-2.39 .17Dyslipidemia 1.2 0.67-2.17 .52BMI 0.91 0.31-1.19 .61Coronary angiography 0.23 0.08-0.67 .007Thrombolysis 0.49 0.23-1.05 .06Aspirin 0.25 0.12-0.70 .008b-blockers 0.63 0.38-1.04 .07ACE inhibitors 0.46 0.29-0.74 .001Statin 0.37 0.25-0.56 <.0001Major bleeding 3.4 1.4-8.1 .0063

NOTES: ACE inhibitors ¼ angiotensin-converting enzyme inhibitors; BMI ¼body mass index; COPD¼ chronic obstructive airway disease; GP¼ glycopro-tein; STEMI ¼ ST-elevation myocardial infarction.a Variables are adjusted for age, sex, and medication on admission (aspirin, clo-pidogrel, heparin, and GP inhibitors).

Hadi et al 461

461

studies, which were ranging between 5 and 10 years (see

Table 5) may again explain the absence of obesity paradox (less

mortality) in our study.

The current study demonstrates high prevalence of excess

body weight among Middle Eastern patients presenting with

ACS. Patients with excess body weight had higher risk profile

including diabetes, hyperlipidemia, and hypertension, without

increased mortality. The current study reports that although

patients with obesity were more likely to present earlier, the

administration of thrombolytic therapy was delayed when com-

pared to normal weight patients, and this in part may be attrib-

uted to higher incidence of atypical presentations. The current

study reports the absence of the obesity paradox in Middle

Eastern patients presenting with ACS.

Study Limitations

Our data were collected from an observational study, which is a

limitation. The fundamental limitations of observational stud-

ies cannot be eliminated because of the nonrandomized nature

and unmeasured confounding factors. However, well-designed

observational studies provide valid results and do not system-

atically overestimate the results compared with the results of

randomized controlled trials. The long-term follow-up is

needed in both groups to consolidate our findings.

Acknowledgment

We thank the staff in all the participating centers for their invaluable

cooperation.

Table 5. Comparison With Reported Studiesa

AuthorName of theRegistry/Study Design No of Patients

Age (Years)Obese VersusNonobese

DM % ObeseVersus Nonobese Findings

Kosuge et al31 JACSS Study/Japan 3076/AMI þPCI

57 vs 67 39% vs 29% No effect on mortality

Madala et al32 CRUSADE 111 847/NSTEMI

62.8 vs 71.2 34.4% vs 20.9% " BMI the lower the age at first MI

Zeller et al34 RICO/France 2229/AMI 72 vs 77 37.6% vs 17.2% " BMI associated with # death rate, however,BMI not independent predictor of death

Wienbergenet al35

MITRA þ/Germany 10 534/STEMI 63.4 vs 68.0 34.8% vs 21.1% Patients with obesity had the lowest in hospital(6.0%) and long-term mortality (4.8%; OR 0.81,95% CI 0.60-1.08)

Buettner et al36 European/Prospective

1676/(NSTE)ACS

62.7 vs 65.9 23% vs 17% Obese and very obese patients had lower long-term mortality (HR) 0.38, 95% (CI) 0.18-0.81,P ¼ .012

Diercks et al37 Retrospective 80 845/high-risk (NSTE)ACS

61 vs 75 38.6% vs 24.0% Lower death and death and reinfarction inoverweight and obese patients

Eisenstein et al38 SYMPHONY and 2ndSYMPHONY trials

15 071/MI 57 vs 62 23% vs 17% No effect on mortality at 30-day and 90 follow-up

Lopez-Jimenezet al39

Retrospective 2277/MI 62.8 vs 71.9 30% vs 18% 64% are overweight; lower mortality rate foroverweight; and obese patients

Wolk et al23 Prospective /UnitedStates

504/stable and(NSTE) ACS

59.7 + 10.4 —————— BMI independently associated with ACS

Suwaidi et al13 Prospectively/MayoClinic (United States)

906 62.3 vs 72.9 26.5% vs 8.8% Overweight pts 3.6 years younger and obesepatients 8.2 years younger. No significant " in in-hospital morbidity and mortality

Current study Gulf RACE registry.Retrospective

8167/ACS 57 vs 58 38% vs 55% No effect on mortality. STEMI patients higherbleeding complications

NOTES: ACS¼ acute coronary syndrome; BMI¼ body mass index; CI¼ confidence interval; DM¼ diabetes mellitus; HR¼ hazard ratio; MI¼myocardial infarc-tion; NSTEMI ¼ non-ST-myocardial infarction; OR ¼ odds ratio; STEMI ¼ ST-elevation myocardial infarction; " ¼ increase; # ¼ decrease.a Japanese ACS Study (JACSS), retrospective, observational multicenter trial, Observatoire des Infarctus de Cote d’Or (RICO) Survey (France), Maximal IndividualTherapy of Acute Myocardial Infarction PLUS (MITRA PLUS) registry; German prospective, multicenter, observational study, the SYMPHONY (Sibrafiban vsaspirin to Yield Maximum Protection from ischemic Heart events post acute cOroNary sYndromes) and 2nd SYMPHONY trials, CRUSADE (Can Rapid RiskStratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Asso-ciation Guidelines).

462 Angiology 61(5)

462

Conflict of Interest

The authors declared no conflicts of interest with respect to the author-

ship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research and/or authorship of this article: Sanofi Aventis and Qatar

Telecommunications Company, Doha, Qatar. The sponsors had no

role in study design, data collection, or data analysis. The sponsors had

no role in the writing of the report and submission of the manuscript.

Gulf RACE is a Gulf Heart Association project.

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