Journal of the Saudi Heart Association最新文献

We report the first case of unilateral pulmonary edema (UPE) in our series of 150 patients undergoing minimally invasive mitral and tricuspid valve surgery via right thoracotomy. A 30-year-old female with rheumatic heart disease developed UPE requiring temporary extracorporeal membrane oxygenation (ECMO) support postoperatively. The patient recovered uneventfully and was discharged on postoperative day 15. This case underscores the importance of recognizing and mitigating UPE in minimally invasive cardiac surgery (MICS).

Background: Acute coronary syndrome (ACS) in young adults is uncommon. The case of a 34-year-old male, post mechanical mitral valve replacement (MVR), who developed anterior ST-elevation myocardial infarction (STEMI) despite therapeutic anticoagulation (INR 3.17), shortly after the initiation of diclofenac, highlights an important clinical scenario.

Case presentation: The patient presented with atypical upper back pain and was diagnosed with anterior STEMI. Coronary angiography revealed a 100 % thrombotic occlusion in the mid left anterior descending (LAD) artery. Percutaneous transluminal coronary angioplasty (PTCA) was successfully performed. Importantly, the patient had no history of hypercoagulable states or atherosclerosis and had been compliant with oral anticoagulation therapy. He had been initiated on diclofenac therapy nine days prior to symptom onset.

Conclusion: This case highlights the serious thrombotic risks associated with NSAID use, even in patients adequately anticoagulated with acenocoumarol. It underscores the necessity of careful NSAID prescribing and demonstrates that therapeutic INR does not offer protection from platelet-driven thrombotic events.

Background: Atherosclerosis is the leading underlying cause of cardiovascular disease (CVD), which remains the primary cause of mortality in Saudi Arabia. Saudi patients experience CVD events nearly a decade earlier than their Western counterparts. Given the limitations of traditional risk assessment tools, there is a growing need to detect subclinical atherosclerosis to refine risk stratification and improve primary prevention strategies, particularly in younger and asymptomatic individuals.

Methods: The Saudi Heart Association (SHA) developed this position statement through a structured, multistep process that included a comprehensive literature review and two expert panel meetings. Recommendations were formulated based on current evidence, expert consensus, and consideration of population-specific characteristics and healthcare infrastructure in Saudi Arabia. The final recommendations were reviewed by the expert panel to ensure scientific accuracy and relevance to local practice.

Results and conclusions: The SHA recommends systematic screening for subclinical atherosclerosis in individuals aged 35 years or older with borderline or intermediate 10-year ASCVD risk (5-20 %). Subclinical atherosclerosis can be assessed using validated non-invasive imaging modalities: coronary artery calcium (CAC) scoring, coronary computed tomography angiography (CCTA), carotid ultrasound, or ankle-brachial index (ABI). CAC scoring is the most validated modality, especially in individuals aged ≥40 years, while CCTA offers the advantage of detecting both calcified and non-calcified plaques. Carotid ultrasound can be advantageous in younger adults, and ABI is useful in older adults. Management should be tailored to disease burden: lifestyle modification is advised for individuals with minimal disease, while moderate-to high-intensity statin therapy is recommended in those with mild or moderate to severe subclinical disease. These recommendations aim to support evidence-based integration of subclinical atherosclerosis screening into routine clinical practice, facilitating earlier interventions and reducing the burden of cardiovascular disease in Saudi Arabia.

Objective: Near-infrared spectroscopy (NIRS), can be used to monitor renal tissue oxygenation (SrO₂), as well as thenar muscle oxygenation (SmO₂). In this study, we have examined the ability of SrO₂ and SmO₂ in predicting cardiac surgery related change in serum creatinine level (ΔsCr) and explored any correlation between these two parameters.

Methods: This study included 55 adult patients (18-60 years), who were scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB), having no pre-existing renal impairment, with skin-to-kidney depth of <4 cm at superior lumbar region which was detected by preoperative ultrasonography examination. NIRS sensors were applied on the superior lumber region to measure SrO₂ and on thenar eminence for SmO₂, preoperatively. ΔsCr was investigated at 24, 48 and 72 hours post-operatively. Relative thresholds of SrO₂ and SmO₂ were quantified using the area-under curve; expressed in % min.

Results: Area under the receiver-operating characteristic curve (AUROC) analyses showed SrO₂ decrease >20 % from baseline can significantly predict (AUROC 0.921; p = 0.001) post-operative ΔsCr. SmO₂ decreased 15 % from baseline (AUROC 0.843; p = 0.001) is a better predictor of ΔsCr than its fall >20 % from baseline (AUROC 0.749; p = 0.002). Correlation analysis revealed that the 15 % and >20 % decrease of SmO2 below baseline (Spearman's rho 0.593 and 0.606 respectively) had significant (p = 0.01) positive correlation with decrease of SrO₂ >20 % from baseline.

Conclusion: SrO₂ and SmO₂ have significant predictive values for post-cardiac surgery rise in serum creatinine, and there is strong positive correlation between them.

Background: Type 2 diabetes mellitus (T2DM) is a chronic disease with a rapidly increasing prevalence, posing a significant public health challenge worldwide and in Saudi Arabia. Cardiovascular disease (CVD) is the leading cause of death among patients with T2DM, necessitating early detection and intervention to prevent disease progression. Elevated natriuretic peptide levels, particularly N-terminal pro-B-type natriuretic peptide (NT-proBNP), are promising biomarkers for CVD risk stratification in individuals with T2DM. However, the integration of these biomarkers in clinical management remains limited.

Methods: Published evidence and existing guidelines/consensuses related to the use of NT-proBNP for CVD risk stratification in T2DM patients were reviewed and discussed by a multidisciplinary expert panel from Saudi Arabia. The panel also considered the unique characteristics of the local Saudi population, healthcare system, resources, and medical expertise.

Results and conclusions: NT-proBNP-based screening holds significant promise for improving CVD outcomes in T2DM patients by identifying at-risk individuals and guiding management approaches. Based on available evidence, the Saudi Heart Association (SHA) developed an evidence-based position statement on the use of NT-proBNP for CVD risk stratification in patients with T2DM who have no established CVD (asymptomatic). The proposed algorithm for NT-proBNP-based screening aims to improve the early identification of at-risk patients with T2DM, inform clinical management decisions, and enhance patient outcomes in Saudi Arabia. The algorithm includes age-adapted thresholds to reduce unnecessary referrals and medical testing. The SHA recognizes the need for further research and local data collection on NT-proBNP-based screening, in addition to clinician training to address the limitations and improve the practical implementation of NT-proBNP screening in routine clinical practice.

Background: Secondary mitral regurgitation (SMR) worsens outcomes in heart failure. Transcatheter mitral valve repair (MitraClip/TMVr) is an established alternative for patients who remain symptomatic on guideline-directed medical therapy (GDMT), but comparative efficacy versus GDMT and surgery has been debated.

Methods: We searched MEDLINE, Embase, and Cochrane through February 2025. To avoid double counting, quantitative syntheses used unique randomized controlled trials (RCTs) only; RCT substudies informed qualitative context. Pairwise random-effects meta-analyses compared MitraClip + GDMT vs GDMT and MitraClip vs surgery. Primary outcomes were all-cause mortality and heart-failure hospitalization (HFH). Secondary outcomes included quality of life (Kansas City Cardiomyopathy Questionnaire (KCCQ), MR ≤ 2+, stroke/MI, and major adverse events (MAE). Heterogeneity was explored with I²/τ², leave-one-out, and prespecified sensitivity analyses per Cochrane/JBI guidance.

Results: Nineteen studies were included, of which 5 unique Randomized Control Trials (RCTs) (n = 1912 randomized) contributed to pooling. Versus GDMT, MitraClip reduced mortality (RR 0.77, 95 % CI 0.63-0.95; I² = 73 %) and (Heart Failure Hospitalization) HFH (RR 0.76, 0.65-0.89; I² = 90 %), and improved KCCQ (MD + 13.7 points, 6.6-20.7). Including all available comparators across RCTs, mortality remained lower with MitraClip (RR 0.80, 0.65-1.00; p = 0.047; I² = 26 %). Versus surgery, MitraClip had fewer 30-day MAE (Major Adverse events) (RR 0.29, 0.21-0.40; I² = 0 %), with no difference in 1-year mortality and similar MR ≤ 2+ at ~1 year. Stroke/MI were comparable. Procedural success exceeded 96 %; partial clip detachment occurred in 1-2 %.

Conclusions: In contemporary RCTs, MitraClip on top of GDMT lowers mortality and HF hospitalizations and improves quality of life in SMR. Compared with surgery, TMVr offers a superior early safety profile with similar MR reduction at ~1 year. These results support Heart-Team use of MitraClip after optimized GDMT in anatomically suitable SMR, while reserving surgery for selected scenarios.

Cardiovascular disease complicates pregnancy and elevates maternal and fetal risks. Local data in Saudi Arabia is scarce. This study examines pregnancy outcomes in women with cardiovascular disease at a tertiary center. A retrospective cohort study of 103 cardio-obstetric patients (2015-2023) at King Khalid University Hospital. Multivariable logistic regression identified risk factors for adverse maternal and neonatal outcomes, with significance at p < 0.05. The cohort (mean age = 35.5 ± 5.03 years, mean BMI = 31.33 ± 6.32 kg/m²) had high rates of hypertension (45.6 %) and preterm delivery (<37 weeks: 37/101, 36.6 %). Maternal hypertension occurred in 14.7 % (15/102). Neonatal outcomes included NICU admission (15.7 %, 16/102) and fetal loss (6.8 %, 7/103). Multivariable analysis revealed that a history of preeclampsia increased the odds of preterm birth (OR = 7.29, 95 % CI [2.16-24.63], p = 0.001), maternal hypertension (OR = 8.38, 95 % CI [1.90-36.97], p < 0.01), and NICU admission (OR = 6.98, 95 % CI [1.78-27.40], p < 0.01). Pre-existing diabetes (Types I/II) was associated with preterm birth (OR = 7.74, 95 % CI [1.70-35.24], p < 0.01). A higher BMI independently increased the odds of maternal hypertension (OR = 1.14 per unit, 95 % CI [1.01-1.28], p < 0.05). Bivariate analysis indicated that autoimmune disease increased the risk of low APGAR scores (0-6: 57.1 % vs. 11.1 %, p = 0.008), and prior cardiac procedures increased the risk of fetal loss (18.8 % vs. 4.6 %, p = 0.039). A history of preeclampsia, diabetes, and elevated BMI is a critical risk factor. Multidisciplinary preconception counseling and stringent antenatal monitoring are essential for this high-risk.

Background: Cardiovascular diseases (CVDs) remain the leading cause of mortality worldwide. Individuals with CVD are particularly vulnerable to severe complications from vaccine-preventable infections; however, adult vaccination continues to be underutilized.

Methods: A multidisciplinary expert panel from the Saudi Heart Association (SHA) conducted a comprehensive literature review and a series of consensus meetings to develop evidence-based recommendations for adult immunization in patients with CVD.

Results and conclusions: Evidence from randomized trials, observational studies, and real-world data supports the role of vaccines in reducing the risk of major adverse cardiovascular events in individuals with CVD. The SHA recommends the implementation of age-appropriate vaccinations against influenza, COVID-19, respiratory syncytial virus (RSV), herpes zoster, pneumococcal disease and meningococcal disease as an integral component of cardiovascular care. Recommendations emphasize routine vaccine assessment, integration into cardiology practice, healthcare provider engagement, patient education, and leveraging high-risk periods such as Hajj and Umrah for vaccination outreach.

This report highlights the diagnostic challenges and successful surgical management in a symptomatic pediatric case with anomalous origin of the circumflex artery from the pulmonary artery. A 4-year-old boy presented emergently with dyspnea and substernal pain. Coronary angiography identified the circumflex artery originating anomalously from the right pulmonary artery. Emergency surgical reimplantation to the aorta was performed, with subsequent normalization of cardiac function (EF 67 % at 3-month follow-up). Although exceptionally rare, anomalous origin of the circumflex artery from the pulmonary artery requires high clinical suspicion in pediatric patients with ischemic symptoms. Early anatomical correction yields excellent outcomes, as demonstrated in this case.

Background: Early initiation of dapagliflozin, a sodium-glucose co-transporter-2 (SGLT2) inhibitor, may improve cardiovascular outcomes in acute myocardial infarction (AMI) by mitigating adverse remodeling and enhancing cardiac function.

Objectives: To assess dapagliflozin's impact on major adverse cardiovascular events (MACE) and left ventricular (LV) recovery in non-diabetic AMI patients using speckle-tracking echocardiography (STE).

Methods: This prospective, single-blinded randomized controlled trial (RCT) enrolled 200 non-diabetic patients with a first episode of AMI, including both ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), following successful percutaneous coronary intervention (PCI). Participants received guideline-directed therapy and were randomized to dapagliflozin + standard care (Group I, n = 100) or standard care alone (Group II, n = 100). Echocardiographic parameters, including left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), LV end-diastolic volume (EDV), and LV end-systolic volume (ESV), were measured at baseline (1-3 days after acute myocardial infarction [AMI]) and at 6-month follow-up. Primary endpoint: 6-month MACE; secondary endpoints: cardiac function changes.

Results: MACE rates showed no significant difference (Group I: 4 % vs. Group II: 9 %; p = 0.152). Group I demonstrated superior cardiac improvement: higher LVEF (52.24 % vs. 47.66 %; p = 0.025), greater ESV reduction (-7.41 ± 13.20 mL vs. -2.52 ± 9.17 mL; p = 0.003), and improved GLS (-14.50 ± 3.27 % vs. -13.48 ± 3.77 %; p = 0.043). GLS change was significantly greater in Group I (Δ-1.467 ± 3.023 % vs. Δ-0.475 ± 2.252%; p = 0.009). Hypertensive and chronic kidney disease (CKD) subgroups showed enhanced myocardial recovery with dapagliflozin.

Conclusion: Early dapagliflozin in non-diabetic AMI patients did not reduce 6-month MACE but significantly improved LV function and remodeling, suggesting cardioprotective benefits beyond glycemic control, especially in high-risk subgroups.