SHA24/036005

Abdulhalim J. Kinsara, FRCP Adel M. Hasanin*, MRCP King Saud bin Abdulaziz University for Health Sciences, COM King Abdul Aziz Medical City, King Faisal Cardiac Center,Jeddah & Department of Cardiology Arrayan Hospital, Dr Sulaiman Al Habib Medical Group, Riyadh*

 Multicenter International Diabetes – Acute

Coronary Syndromes (MIDAS) study aimed to: Monitor the adherence to evidence-based therapy among diabetic patients with UA/NSTEMI- ACS

 How socioeconomic growth in KSA affects lifestyle of the people?  Prevalence of DM in KSA

(23.7%; Saudi Med J 2004)

 DM as risk factor for coronary artery disease (56%; SPACE)

changes in dietary habits that occurred in 20 years in KSA is and independent predictor of mortality in NSTEMI- ACS &  DM The took 137 years in Japan and 200 years in UK

worse outcomes following PCI & CABG

Khan M, Al‐ Kanhal M. Dietary energy and protein requirements for Saudi Arabia: a methodological approach. E Medit Health J1998; 4: 68–76

 Do DM patients receive more aggressive therapy in the setting of ACS (early invasive strategy and GP IIb/IIIa inhibitors) ?

(CRUSADE & NRMI 4)

 TIMI & GRACE scores remain to be validated in DM population

 Data of DM patients with ACS who presented at the time of admission to the emergency/coronary care units .

 A total of 3624 patients were enrolled in several

countries in Europe and the Middle East and India.

 142 DM patients were enrolled in 5 hospitals in KSA  The following variables were extracted: ST deviation ≥ 0.5 mm, positive troponin and , TIMI risk score

 The Z test for two proportions was used to compare the KSA values with the international figures. Analysis was done by stata 10. Level of significance was set at 5%.

 Unstable angina = ischemic chest pain occurring either at rest (or with minimal exertion), in a crescendo pattern, or severe and of new onset.  NSTEMI = these symptoms accompanied by a release of cardiac biomarkers of necrosis (CK-MB or troponin).  Primary clinical outcome measure was in-hospital death or ST elevation myocardial infarction (STEMI).  Variables extracted : • • • • •

Utilization of GP IIb/IIIa inhibitors Utilization of clopidogrel/Ticlopidine Percentage of early coronary angiography Percentage of PCI procedures Percentage of patients who had CABG.

Figure 1: Percentage distribution of risk factors prevalence

The high risk factors were less prevalent in KSA

Figure 2: GP IIb/IIIa utilization based on risk factors

GP IIb/IIIa inhibitors utilization in the international data was significantly higher than in KSA (p=0.046)

Figure 3: Clopedogril utilization based on risk factors

Utilization of clopidogril/Ticlopidine was higher in KSA exceeding the international figure (p <0.0001)

Figure 4: percentage of early coronary angiography approach based on risk factors

The overall percentage of early coronary angiography in Saudi Arabia was lower than the international (p=0.292)

Figure 5: percentage of PCI based on risk factors

The percentage of PCI procedures was less in KSA in comparison to the international (p=0.001)

Figure 6: percentage of CABG based on risk factors

Percentage of patients who had CABG was higher in KSA in comparison to the international percentage (p=0.864)

Figure 7: percentage of CABG + PCI based on risk factors

The overall percentage of patients who had revascularization (PCI and/or CABG) was lower in KSA in comparison to the international (p=0.005)

Results Summary  The utilization of GP IIb/IIIa was 18.3% in KSA vs. 37.4% internationally (p=0.046).

 On the contrary, the utilization of clopidogril/Ticlopidine

was 96.8% in KSA vs. 74.7% internationally (p<0.0001) .

 The percentage of early coronary angiography was 38.9% in KSA vs. 46.1% internationally (p=0.292).

 Among patients who had early coronary angiography,

The percentage of revascularization (PCI and/or CABG) was 34.9% in KSA in comparison to 54.8% in the international figures (p=0.199).

 The main goal of the MIDAS registry was to improve the awareness of this potentially deadly and progressively growing combination of DM and ACS.

 Diabetic patients who present with ACS are at high risk

for developing subsequent cardiovascular events and they derive greater benefit from aggressive antithrombotic therapy, early coronary angiography, and percutaneous coronary intervention*.

 In general The data from MIDAS showed a satisfactory

use of EBM and acceptable rates of in-hospital death or MI in DM patients who present with ACS; however,……. *Roffi M and Topol EJ. Eur Heart J. 2004;25(3):190-198

 Reviewing the data from KSA, we can easily notice that utilization of GP IIb/IIIa inhibitors, particularly in the elderly population, was significantly less than the international figures.

 recent reports and guidelines showed more concern about the increased risk of bleeding in this setting, particularly upon using double or triple antiplatelet therapy in combination with heparin*.

 On the contrary, the utilization of Clopidogril/Ticlopidine

was higher in KSA in comparison to the international figures. This might be related to financial issues or the greater interest in use of Clopedogril in patients who are not receiving GP IIb/IIIa inhibitors. *2011 ACCF/AHA Focused Update of the Guidelines for the Management of UA/NSTEMI

ď&#x201A;§ The overall percentage of early coronary angiography and the percentage of revascularization (PCI and/or CABG) were lower in KSA in comparison to the international figures showing relative tendency towards the conservative management in our region.

ď&#x201A;§ This is probably related to concerns about complications of intervention and lower number of centers that had catheterization laboratories.

ď&#x201A;§ MIDAS is a registry and accordingly it has some

limitations that are common to most registries where no additional diagnostic, monitoring, or therapeutic procedures applied to the patients.

CONCLUSIONS

CONCLUSIONS  MIDAS aimed to increase the awareness of the use of evidence based treatment in the deadly combination of DM and ACS.

 There was a satisfactory use of evidence based

medicine in KSA in such group but did not reach target.

 Further studies and clinical trials are required to

identify the clinical significance of the differences in the Saudi practice in comparison to the international one.