acs inacs in yemeni yemeni khakhat chewers & cardiac … · acs inacs in yemeni yemeni khakhat...

ACS InACS In Yemeni Yemeni KhatKhat Chewers Chewers & Cardiac Bio& Cardiac Bio--markers markers

TrendsTrends FactsFacts FromFromTrends,Trends, FactsFacts From From Gulf RACEGulf RACE-- II

Mohammed AlMohammed Al--Kebsi, MD, PhD, FGHAKebsi, MD, PhD, FGHAAA--Nasser Munibari MD, FACC & A. AlNasser Munibari MD, FACC & A. Al--Motarreb MD, PhD,FGHAMotarreb MD, PhD,FGHA

Medical Department- Faculty of medicine-Sanaa university

Cardiac Center- Al-thawrah Modern General teaching Hospital

GHA:GHA:20022002. GHA was born and it became a landmark accomplishment for the GCC states.. GHA was born and it became a landmark accomplishment for the GCC states.

Member countriesMember countries :: Bahrain , Kuwait , Qatar , KSA , Oman , UAE & Yemen Bahrain , Kuwait , Qatar , KSA , Oman , UAE & Yemen

Aims :Aims : The main aim of GHA is to improve the quality of cardiac care in the GCC states The main aim of GHA is to improve the quality of cardiac care in the GCC states

through its various activities.through its various activities.

Achievements :Achievements :GHA organizes annual symposium & conferences : e g : Doha Manama Sanaa and DubaiGHA organizes annual symposium & conferences : e g : Doha Manama Sanaa and DubaiGHA organizes annual symposium & conferences : e.g. : Doha, Manama, Sanaa and Dubai, GHA organizes annual symposium & conferences : e.g. : Doha, Manama, Sanaa and Dubai,

Muscat, and Riyadh. Muscat, and Riyadh.

GHA develops & update guidelines for the treatment of various CVD: e.g: ACS , STEMI & GHA develops & update guidelines for the treatment of various CVD: e.g: ACS , STEMI &

anticoagulants, HTN, Soon HF. anticoagulants, HTN, Soon HF.

GHA established a peerGHA established a peer--reviewed journal called 'Heart Views' which is published quarterly. reviewed journal called 'Heart Views' which is published quarterly.

GHA organizes teams with expertise to perform invasive cardiac procedures and GHA organizes teams with expertise to perform invasive cardiac procedures and

cardiovascular operations within the GCC countries. cardiovascular operations within the GCC countries.

GHA and GCC Heart Disease Registry [ (Gulf RACEGHA and GCC Heart Disease Registry [ (Gulf RACE--I) I) –– GulfRACE IIGulfRACE II-- Gulf SAFE]Gulf SAFE]

What is KhatWhat is Khat

What is KhatWhat is Khat

KhatKhat (Catha(Catha edulis)edulis) isis aa largelarge greengreen shrubshrub thatthatKhatKhat (Catha(Catha edulis)edulis) isis aa largelarge greengreen shrubshrub thatthatgrowsgrows atat highhigh altitudesaltitudes inin thethe regionregion extendingextending fromfromeasterneastern toto southernsouthern Africa,Africa, asas wellwell asas onon thethe ArabianArabianpeninsulapeninsula (Yemen(Yemen))..

TheThe impactimpact ofof khatkhat chewingchewing inin YemenYemen isisTheThe impactimpact ofof khatkhat chewingchewing inin YemenYemen isisconsiderableconsiderable.. ItIt isis deepdeep--rootedrooted inin thethe YemeniteYemenitesocietysociety wherewhere khatkhat isis consumedconsumed inin socialsocial gatheringsgatheringssocietysociety wherewhere khatkhat isis consumedconsumed inin socialsocial gatheringsgatheringswithwith familyfamily andand friendsfriends whilewhile holdingholding conversations,conversations,smokingsmoking cigarettescigarettes andand drinkingdrinking teatea andand softsoft drinksdrinks..

What is KhatWhat is Khat

AboutAbout 4444 differentdifferent typestypes ofof khatkhat existexist originatingoriginatingfromfrom differentdifferent geographicgeographic areasareas ofof thethe countrycountry..

UsersUsers chewchew KhatKhat habituallyhabitually forfor itsits euphoriceuphoric effectseffectsyyandand asas aa recreationalrecreational drugdrug thatthat alsoalso improvesimprovesperformanceperformance..

What is KhatWhat is Khat

Integrated into the social life of the societies.It is rapidly distributed around theIt is rapidly distributed around the day

Pharmacology

• Main Constituents:Cathinone and Cathine. Varies from 77 7 toVaries from 77.7 to 342.8 mg/100g

•• Natural Amphetamine:Natural Amphetamine:pp

O

CH3

NH2

Cathinone

OH

CH3

OH

CH3

Cathinone

NH

CH3

CH3

NH2

CH3

Ephedrine Norpseudoephedrine(Cathine)

Pharmacological effect

• Central Peripheral• Increases the levels of

Dopaminergic and Noradrenergic

• indirect sympathomimetic actions

Noradrenergic transmission in the brain

“The average maximal plasma concentration of

• Serotonin levels are increased in response to Cathinone

Cathinone (Tmax) occurred at 2.3 hours and 2.6 hours for Cathine”to Cathinone

administration• Uptake-1 inhibition

2.6 hours for CathineToennes, SW et al. (2003) Pharmacokinetics of cathinone, cathine and norephedrine after the chewing of khat leaves. British Journal of Clinical Pharmacology, 56:125-130

K li P & Kh I (1984) Kh t h t i lik l t t i lp

Kalix, P & Khan, I. (1984) Khat: an amphetamine-like plant material. Bulletin of the World Health Organization, 62, 681–686.

CV Effect of Khat

•• IncreasesIncreases HRHR andand BPBP•• IncreasesIncreases HRHR andand BPBP..•• RiskRisk factorfactor forfor acuteacute MIMI..•• CausesCauses coronarycoronary vasospasmvasospasm..yy pp•• IncreasesIncreases activeactive smokingsmoking andand leadsleads toto passivepassive

smokingsmoking..S th tiS th ti titi (( l tl t•• SympathomemticSympathomemtic actionaction (vasospasm,(vasospasm, platplataggregation)aggregation)

•• AssociatedAssociated withwith increaseincrease riskrisk ofof strokestroke inin ACSACSpatientspatients (GulfRace(GulfRace I)I)..

A Al M t b t l HEART VIEWS VOLUME 5 NO 3 SEPTEMBER NOVEMBER 2004 54 57A. Al-Motarreb et al. HEART VIEWS VOLUME 5 NO. 3 SEPTEMBER - NOVEMBER 2004 : 54 – 57J R Soc Med 2006;99:316–318A. Al-Motarreb et al. British Journal of Clinical PharmacologyZubaid et al. Mayo Clin Proc. 2010;85(11):974-980

• This is a prospective registry of all consecutivepatients admitted to all general hospitals inpatients admitted to all general hospitals in participating countries, over a period of six months with the discharge diagnosis of acute coronarywith the discharge diagnosis of acute coronary syndrome (ACS) including:

1. ST-segment elevation myocardial infarction (STEMI)2 Non ST-segment elevation myocardial infarction2. Non ST segment elevation myocardial infarction

(NSTEMI)1. Unstable angina (UA)U stab e a g a (U )

• Diagnosis of the different types of ACS and definitions of data variables were based on thedefinitions of data variables were based on the (ACC) clinical data standards, published in 2001.

• These definitions are based on clinical• These definitions are based on clinical presentations, (ECG) findings and cardiac biomarkers.

Biochemical marker

• The biomarkers were measured locally at each• The biomarkers were measured locally at each hospital’s laboratory using its own assays and reference ranges.

1. Troponin0 01 f b th

g

• 0.01 for both sex2. CK-MB/ CK-MB mass

• 7-25 for both sex7 25 for both sex3. Total CK:

• Male 38-174F l 26 140• Female 26- 140

RESULTSRESULTSRESULTSRESULTS

KUWAIT QATAR230BAHRAIN

214432%

KUWAIT

UAE

3595%

QATAR2303%

32%133620%

UAE

YEMEN

1054

1583

OMAN

105416%

YEMEN 16%24%16%

1054

NonNon--Khat ChewerKhat Chewer297 (22%)

NonNon--Khat ChewerKhat Chewer297 (22%)

Khat Chewer757 (78%)

Khat Chewer757 (78%)

STEMISTEMI551 (73%)

STEMISTEMI551 (73%)

NSTEMINSTEMI138 (18%)NSTEMINSTEMI

138 (18%)UAUA

68 (9%)UAUA

68 (9%)STEMISTEMI

201 (68%)STEMISTEMI

201 (68%)NSTEMINSTEMI84 (28%)NSTEMINSTEMI84 (28%)

UAUA12 (4%)

UAUA12 (4%)

Baseline CharacteristicsKhat

757 (78%)Non-Khat 297 (22%)

P value( ) ( )

Mean age (years)Mean age (years) 5858±±1111 6262±±1313 <0.001<0.001Sex Male (%)Sex Male (%) 8585 6464

Female (%)Female (%) 1515 3636

Smoker (%)Smoker (%) 6060 1515

ECG (%)ECG (%)NormalNormal 0.30.3 0.40.4

New LBBBNew LBBB 1.91.9 0.40.4

Old LBBBOld LBBB 1.01.0 0.130.13

STST--DepDep 1616 1414STST DepDep 1616 1414STEMISTEMI 7373 6868OthersOthers 0505 0909

Baseline CharacteristicsKhat

757 (78%)Non-Khat 297 (22%)

P value( ) ( )

Mean age (years)Mean age (years) 5858±±1111 6262±±1313 <0.001<0.001Sex Male (%)Sex Male (%) 8585 6464

Female (%)Female (%) 1515 3636

Smoker (%)Smoker (%) 6060 1515

ECG (%)ECG (%)NormalNormal 0.30.3 0.40.4

New LBBBNew LBBB 1.91.9 0.40.4

Old LBBBOld LBBB 1.01.0 0.130.13

STST--DepDep 1616 1414STST DepDep 1616 1414STEMISTEMI 7373 6868OthersOthers 0505 0909

Baseline CharacteristicsKhat

757 (78%)Non-Khat 297 (22%)

P value( ) ( )

Mean age (years)Mean age (years) 5858±±1111 6262±±1313 <0.001<0.001Sex Male (%)Sex Male (%) 8585 6464

Female (%)Female (%) 1515 3636

Smoker (%)Smoker (%) 6060 1515

ECG (%)ECG (%)NormalNormal 0.30.3 0.40.4

New LBBBNew LBBB 1.91.9 0.40.4

Old LBBBOld LBBB 1.01.0 0.130.13

STST--DepDep 1616 1414STST DepDep 1616 1414STEMISTEMI 7373 6868OthersOthers 0505 0909

Khat & BiomarkersKhat & BiomarkersKhat & BiomarkersKhat & Biomarkers

Cardiac enzymes utilization

1200

87146

800

1000

967908

742600

908

200

400

CKMBCK

3120

TREPONIN

Done Missed

Khat and Biomarkers

Khat and Biomarkers

TROPONIN

22%

KHAT

78%

KHAT

NON

78%

Khat and Biomarkers

Khat757 (78%)

Non-Khat297 (22%)

P value

CK +ve733

542 171 <0.001

CK-MB +ve836

604 232 <0.001836

Troponin +ve310

243 67 0.004310

Khat & MortalityKhat & MortalityKhat & MortalityKhat & Mortality

Khat & Mortality %Khat & Mortality %

90.00%

100.00%

60.00%

70.00%

80.00%

Khat

20 00%

30.00%

40.00%

50.00% Non-Khat

0.00%

10.00%

20.00%

Khat 8 20% 91 80%

DEAD ALIVE

Khat 8.20% 91.80%

Non-Khat 8% 92%

Courtesy of Zubaid, Regional Comparisons: Findings and Implications of Gulf RACE

Khat & MorbidityKhat & MorbidityKhat & MorbidityKhat & Morbidity

KILLIP Class.

500

600

300

400

Khat

200

Non-Khat

0

100

Khat 554 125 47 31

I II III IV

Khat 554 125 47 31

Non-Khat 218 44 21 14

Khat & EF

40 00%

45.00%

50.00%

25 00%

30.00%

35.00%

40.00%

Khat

10 00%

15.00%

20.00%

25.00%Non-Khat

0.00%

5.00%

10.00%

Khat 8 20% 45 90% 45 90%

<35% 35-50% >50%

Khat 8.20% 45.90% 45.90%

Non-Khat 13% 44% 43%

Khat & Stroke

800

500600700

200300400500

NO STROKESSTROKE

0100200

NON KHAT KHAT

Hospital stay (day)

700

800

500

600

no. of pt.

200

300

400 mean

0

100

no of pt 755 295

khat no

no. of pt. 755 295

mean 7.1 6.1

Received Thrombolytic

180

T t l

120

140

160

thromblytic

Total218

60

80

100thromblytic

0

20

40

khat no

thromblytic 163 55

Door to needle time (min)

160

180

100

120

140

no. of pt.

40

60

80mean

0

20

40

no of pt 163 55

khat no

no. of pt. 163 55

mean 48.337 62.527

Arrhythmias

100

70

80

90

50

60

KhatNon-Khat

20

30

40

0

10

Khat 93 3 2 0 07 0 03 0 06

Sinus 2/3block AF SVT VT Others

Khat 93 3 2 0.07 0.03 0.06

Non-Khat 92 4 3 0.7 0.7 0.1

ConclusionConclusion Khat is a significant socio-economic and Khat is a significant socio economic and

health problem in Yemen.

A f t ti i Kh t h Age of presentation in Khat chewers was significantly younger in comparison to N Kh t h i ACSNon-Khat chewers in ACS.

Associated habits like smoking was ssoc a ed ab s e s o g asprevalent among Khat chewers and hence the risk of CAD was much higher.g

ConclusionConclusion

Hospital stay was longer among Khat chewers which indicates a big economic burden in the form of the health expenses in the country.

Morbidity in the form of HF & stroke were higher among Khat chewers patients withhigher among Khat chewers patients with ACS which alter the sequels of the diseasedisease.

RecommendationsRecommendations

Involvement of health authorities in further phases of registry which emphasize an improvement of quality of work.

Awareness program about the hazards of Awareness program about the hazards of Khat chewing in Yemeni people health should be established in all levels ofshould be established in all levels of society.