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.