Ahmed Aljizeeri

Background/Objectives: The use of direct oral anticoagulants (DOACs) in obese patients is scarcely studied despite having many advantages over warfarin. Consequently, this study aims to assess the real-world safety and effectiveness of apixaban compared to warfarin in treating atrial fibrillation (AF) in obese patients. Methods: A retrospective cohort study examined consecutive AF patients with a BMI of ≥ 30 kg/m² treated with apixaban or warfarin. Patients were started on these medications between January 2015 and December 2021. Efficacy outcomes included ischemic stroke and venous thromboembolism (VTE) occurrences, while safety outcomes encompassed bleeding incidents and mortality rates. Outcomes were assessed following propensity score matching. Results: We identified 876 patients treated with either apixaban (414) or warfarin (462). Their mean age was 76.9, with a mean CHA₂DS₂VASc score of 4.9 ± 1.97. After matching and compared to warfarin, apixaban was correlated with a lower incidence of all-cause mortality (19.7% vs. 33.7%, p < 0.001). The incidences of stroke, venous thromboembolism (VTE), and bleeding events were (4.7% vs. 4.7%, p = 1.000), (1.0% vs. 2.6%, p = 0.107), and (3.9% vs. 6.2%, p = 0.139), respectively. Using Cox-regression model, apixaban was associated with lower mortality risk (HR = 0.728, 95% CI: 0.55–0.97; p = 0.030) which remained significant after adjusting for the conventional cardiovascular risk factors and BMI values. Conclusions: Apixaban is associated with a trend of reduced incidence of thromboembolism among obese patients with atrial fibrillation and significantly lowers all-cause mortality. Despite earlier concerns, the use of apixaban is an effective and safe alternative to warfarin among obese patients with AF.

Myocarditis is an inflammatory condition affecting the myocardium and may have different etiologies. Patients usually present with chest pain and elevated levels of cardiac enzymes, mainly troponin. Cardiac magnetic resonance (CMR) imaging has emerged as the cornerstone test in the diagnosis of myocarditis. In this article, we present different CMR findings in cases of myocarditis.

Introduction: Hypercholesterolemia, mainly low-density lipoprotein cholesterol (LDL-C) and triglycerides (TGs), is a major risk factor for coronary artery disease (CAD). The prognostic value of lowering LDL-C and TG in patients with CAD is well studied. We sought to examine the prognostic value of TG among patients presenting with acute coronary syndrome (ACS) and target LDL-C level. Methods: This is a retrospective study of patients admitted with first-presentation ACS. We included patients with first-presentation ACS who had lipid profiles measured within 3 months before the presentation. Patients with prior ACS, congenital heart disease, and those without baseline lipid profiles were excluded. Target LDL-C level was defined as LDL-C <1.8 mmol/L, and normal TG level was defined as <1.7 mmol/L. The study subjects were followed up for major adverse cardiac events (MACE) (cardiac death and nonfatal myocardial infarction [MI]). Results: Among the 7020 patients admitted with ACS, 393 met the inclusion criteria. Of whom, 106 (mean age: 70.3 ± 10.7 years, 76% of males) had target LDL-C level and were included. CAD risk factors were prevalent among the cohort. The mean total cholesterol, LDL-C, and TG were 3.6 ± 0.9, 1.4 ± 0.3, and 1.7 ± 1.5 mmol/L, respectively. Most patients presented with non-ST-elevation MI (54.7%), followed by unstable angina (36.8%). Over a median follow-up of 5.6 years, 17 (16%) patients had MACE, of which 14.2% were nonfatal MI and 1.9% of patients had cardiac death. There was no statistically significant difference in MACE between those with normal and high levels of TG. Conclusions: In this retrospective cohort of patients presenting with first-presentation ACS, TG level did not confer an increased risk of MACE among patients with target LDL-C level.

Background: Coronary artery disease (CAD) poses a significant global health burden, necessitating optimal diagnostic strategies for risk assessment and management. This study systematically reviews randomized controlled trials (RCTs) comparing different noninvasive imaging modalities for CAD evaluation, focusing on their subsequent invasive outcomes and major adverse cardiac events (MACEs). Methods: A comprehensive electronic search was conducted across multiple databases, identifying 24 relevant RCTs published between 2010 and 2023. Key outcomes assessed included downstream referral to invasive testing, MACE rates, cost-effectiveness, and hospitalization outcomes. Results: The majority of included RCTs focused on comparing coronary computed tomography angiography (CCTA) with alternative imaging techniques. While CCTA is often associated with increased invasiveness, it demonstrates slightly better MACE rates, cost-effectiveness, and hospitalization outcomes compared to other imaging modalities. Conclusion: Continued investigation into alternative noninvasive diagnostic methods for CAD is essential to advance clinical practice and optimize patient care. By exploring new strategies beyond CCTA and leveraging technological innovations, health-care providers can improve diagnostic precision, mitigate procedural risks, and ultimately enhance outcomes for individuals with CAD.

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a complex and serious form of heart failure caused by the accumulation of transthyretin amyloid protein in the heart muscle. Variable symptoms of ATTR-CM can lead to a delayed diagnosis. Recognizing the diagnostic indicators is crucial to promptly detect this condition. A targeted literature review was conducted to examine the latest international consensus recommendations on a comprehensive diagnosis of ATTR-CM. Additionally, a panel consisting of nuclear medicine expert consultants (n = 10) and nuclear imaging technicians (n = 2) convened virtually from the Kingdom of Saudi Arabia (KSA) to formulate best practices for ATTR-CM diagnosis. The panel reached a consensus on a standard diagnostic pathway for ATTR-CM, which commences by evaluating the presence of clinical red flags and initiating a cardiac workup to assess the patient’s echocardiogram. Cardiac magnetic resonance imaging may be needed, in uncertain cases. When there is a high suspicion of ATTR-CM, patients undergo nuclear scintigraphy and hematologic tests to rule out primary or light-chain amyloidosis. The expert panel emphasized that implementing best practices will support healthcare professionals in KSA to improve their ability to detect and diagnose ATTR-CM more accurately and promptly. Diagnosing ATTR-CM accurately and early can reduce morbidity and mortality rates through appropriate treatment.

Introduction: Telemedicine is a desirable option for healthcare in Saudi Arabia. The challenges of telemedicine in cardiovascular care in Saudi Arabia are not known. The COVID-19 pandemic offered an unprecedented opportunity to identify real-life challenges of telemedicine in Saudi Arabia. We sought to identify the challenges of telemedicine among patients with cardiovascular diseases using the experience of the COVID-19 pandemic. Methods: This is a cross-sectional survey-based study through a self-filled questionnaire. The questionnaire included demographic data, type of cardiovascular disease, and difficulties faced by the patients during the COVID-19 lockdown. Results: 394 (60% male, mean age 51.4 ± 19.3 years) participated in the study. 30.3% had valve diseases, 26.4% had heart failure, and 24.1% had coronary artery disease. 45.6% reported difficulty with telemedicine during COVID-19 lockdown. Among those who have difficulties, almost half of the participants had difficulty with the cancellation of telemedicine appointments, and 15.5% had difficulty in getting medications. Conclusion: Cancellation of telemedicine appointments and getting the medications were cardiovascular patients’ main challenges during the COVID-19 lockdown. Telemedicine is a feasible option for the follow-up of chronic cardiovascular diseases. Therefore, it should be implemented to increase the availability of specialized cardiovascular care over a wide geographical area.

Mechanical heart valves are associated with high risk of thrombosis and thromboembolic complications. Vitamin K antagonist is the only approved oral medication for the anticoagulation in cases of mechanical heart valves. This poses a challenge in cases where vitamin K antagonists are contraindicated. Although temporary anticoagulation with low molecular weight heparin is common among pregnant patients with mechanical heart valves, data about long term anticoagulation with low molecular weight heparin is limited. We report a successful long-term anticoagulation with low molecular weight heparin in a patient with mechanical mitral valve and atrial flutter.

The prevalence of extrapulmonary tuberculosis (TB) is very common in the Middle East; however, myocardial involvement is among the most infrequent manifestations of extrapulmonary TB. We present an asymptomatic young adult who was incidentally found to have a large right atrial tuberculoma, diagnosed by non-invasive cardiac imaging and effectively treated with standard first-line anti-TB treatment, steroids, and anticoagulation. This case is a classical presentation of nodular myocardial involvement of TB, highlighting advantages of advanced imaging, e.g., cardiac magnetic resonance (CMR) and multidisciplinary treatment.

COVID-19 pandemic has led to major changes in the delivery of medical care around the globe. Many investigations and elective procedures had to be rescheduled to decrease the risk of spreading the infection. Non-invasive cardiac imaging studies are requested to guide appropriate cardiac care in a variety of urgent, semi-urgent, and elective procedures. This position statement of the Cardiac Imaging Working Group of the Saudi Heart Association provides guidance into the protection of healthcare personnel, assessment of the indications of the imaging studies, and highlights consideration before, during, and after the study.