In this interview, EP Lab Digest speaks with Mohammad Zubaid, MB, ChB, FRCPC, FACC, Professor of Medicine at Kuwait University and Head of the Division of Cardiology at Mubarak Alkabeer Hospital in Kuwait, about patients with atrial fibrillation (AF) in the Arab Middle East.
What is known about patient demographics and cardiovascular conditions in the Arab Middle East and the Gulf states? Why is there so few data on AF from these regions?
The Arab Middle East in general, and the Gulf states in particular, are known for their young population age structure. United Nations data (Figure 1) show that, currently in the Gulf, only about 5% of the population is over the age of 60. One might argue that this age pattern is due to the presence of a large number of working, transiently migrant population who are young. However, even when you look at more populous countries without this migrating work force — in countries like Egypt, Iran, Tunisia, and Morocco — you see the same pattern with less than 10% of the population over the age of 60. While in the western industrialized countries, those over 60 years represent more than 20% of the population. Having said that, our previous work in the field of acute coronary syndromes (ACS) has shown that, despite young age, these populations are still at high risk. A large number are diabetics and smokers, two risk factors that predispose to cardiovascular disease.1 As a matter of fact, the diabetes rate among the adult population in the Gulf countries is around 15–20%, a very alarming rate. Our local research has shown that ACS patients in the region have a mean age of 56 years, compared to a mean age of about 65 years in western industrialized countries (Figure 2). Yet, despite this relatively young age, 40% of them were diabetic and more than 40% were smokers (Figure 3). Therefore, in terms of risk factors and cardiovascular conditions, the picture is gloomy.
As far as the reason for the lack of data on atrial fibrillation, and for that matter cardiovascular conditions in general, the answer to that is more complicated. It has to do with the lack of research in general, and in particular, medical research, from the area. Many issues are involved here, including funding, lack of trained researchers, lack of institutions willing to invest heavily in the future of the society (by institutions I am referring to both governmental and pharmaceutical), and many other factors. That said, the picture is changing, and more research is coming out of the area, but it will take time to make its way to the front of the news and impact our practice.
Why was it important to launch the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE)2? Tell us about how Gulf SAFE came about.
A group of researchers in the Gulf had collaborated on several projects, including a large ACS registry with the acronym Gulf RACE (Gulf Registry of Acute Coronary Events) that was funded by sanofi-aventis. This project formed the foundation for good collaboration and data collection across these countries and the 63 hospitals that were involved in Gulf RACE. As we were thinking of a new project, we felt that we lacked a great deal of information about arrhythmias in general and atrial fibrillation in particular. In addition, the field of AF practice was anticipating important developments in the aspects of arrhythmia control and prevention of stroke and thromboembolism. We felt we needed some local data in order to know where we were at with AF in our region. If we are to assess the use of antiarrhythmic medication and oral anticoagulation in our AF population, we need to know who our patients are, what risks they have, and whether or not they are being treated appropriately. Therefore, we felt that we needed to study AF in our patient populations. Thankfully, sanofi-aventis showed the interest to fund such a project. They have been great in supporting research in the area, and have contributed funds without any restrictions or control on the type of work or analysis we do. I felt it was important to thank sanofi-aventis at this juncture.
What are the goals of the Gulf SAFE registry?
Simply put, our aim is to know who our AF patients are, how we are treating them, and what their short- and long-term outcomes are. In more details, the goals of the Gulf SAFE registry are to determine the clinical characteristics of AF patients in the Gulf region of the Middle East, analyze the practice patterns and treatments of AF in this region of the world, determine the level of adherence to published guidelines, and describe outcomes among patients with AF.
Describe the registry data being collected, including some of your findings thus far.
It is important to emphasize that Gulf SAFE is an emergency room (ER) based registry, ie., patients were enrolled when they presented to the ER and not from the outpatient department or the hospital wards. The data that were collected were extensive. They included baseline demographics of each gender, nationality, as well as past history of illnesses that predispose to AF, such as hypertension and valvular heart disease, etc. In addition, data were collected regarding hospital presentation and reason for ER visits. There is also a detailed look at how they were managed in the ER and the outcome of the ER visit. If patients were admitted to the hospital, then the reason for that admission was documented. All patients were followed up for one month, six months and twelve months to determine their outcomes.
As you can see from the published “methodology” paper, the study was carried out in general hospitals rather than specialized arrhythmia centers. The reason behind this is that we believe that general cardiologists and internists see a lot of the AF cases, at least initially, and it was important to know how they handled these cases. In addition, our countries have few electrophysiology (EP) specialists, and the “real world” practice in our region dictates that most of the AF patients are seen by physicians other than EP specialists.
What findings from the registry have been most surprising?
Perhaps most surprising so far is to know that, despite their relatively young age, this population was at high risk. Knowing that this is an AF population with a relatively young age (mean age 57 years), 30% had diabetes and more than 50% had hypertension. Another very surprising finding is that almost 80% of the patients were admitted to the hospital. One might argue that this was an ER-based population, and that led to their admission; however, our preliminary analysis indicates that even the lowest risk patients — the young with paroxysmal AF — were admitted to the hospital most of the time. This finding needs detailed analysis to determine the reason behind that, and whether it was a society issue or the way patients were managed in the ER, etc.
When will follow-up data be published?
Follow up of the last patient enrolled will finish at the end of August 2011. We hope to be able to publish the follow-up data in early 2012.
What types of treatments are currently available to AF patients in these regions?
Antiarrhythmic medications are available, including amiodarone and class IC agents. Dofetilide and Ibutilide are available mainly in centers with EP specialists. Recently, dronedarone has become available in some centers. AF ablation is not available in all six countries that were involved in the registry.
What were some of the main findings from Gulf RACE? How will Gulf SAFE differ from Gulf RACE?
Gulf RACE was an ACS registry in 63 hospitals across the same six Gulf countries. This was a registry of all comers, all consecutive ACS patients that were admitted to hospital. The findings were characterized by a young population, which had high incidence of diabetes and smoking. The majority of the ST-segment elevation patients received thrombolytic therapy, and there was a disparity in outcomes between Yemen and Oman versus the other four Gulf countries (Kuwait, United Arab Emirates, Qatar, and Bahrain).
Tell us more about the upcoming Gulf COAST registry.
The Gulf COAST registry stands for “Gulf loCals with acute cOronAry Syndrome evenTs.” It focuses on ACS in the local population (citizens of the Gulf). In Gulf RACE, we found that this population is older than the migrant population, and had a staggering 60% diabetes rate. Therefore, we decided to look at this population in a prospective fashion, enrolling all consecutive cases. We hope to be able to start at the end of this year, enroll 3,000–4,000 patients, and follow them up for a year.
The Gulf region of the Middle East is one of the highest income areas in the world (Figure 4), yet it is poorly studied. We hope to carry out research that highlights the cardiovascular health problems these societies will be facing. We hope this research will attract the attention of health policy and law makers to help us battle these diseases.
- Zubaid M, Rashed WA, Almahmeed W, et al. Management and outcomes of Middle Eastern patients admitted with acute coronary syndromes in the Gulf Registry of Acute Coronary Events (Gulf RACE). Acta Cardiol 2009;64:439–446.
- Zubaid M, Rashed WA, Alsheikh-Ali AA, et al. Gulf Survey of Atrial Fibrillation Events (Gulf SAFE): Design and Baseline Characteristics of Patients With Atrial Fibrillation in the Arab Middle East. Circ Cardiovasc Qual Outcomes 2011;4:477–482.