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Background and aim Myocardial infarction is a major global health issue and the leading cause of death. Non-ST segment elevation acute coronary syndrome (NSTE-ACS) could behave like ST-segment elevation ACS in terms of causing total or near total occlusion of the coronary artery and leading to occlusive myocardial infarction (OMI). This study aims to assess OMI prevalence and associated factors in NSTE-ACS patients in Duhok, Iraq, to improve diagnosis and treatment outcomes. Materials and methods This prospective cross-sectional study, conducted at Azadi Heart Center and Zakho Teaching Hospital from March 2023 to March 2024, included 189 NSTE-ACS patients undergoing coronary angiography. Data collection encompassed demographics, clinical profiles, electrocardiographic (ECG) patterns, cardiac biomarkers, and angiographic outcomes. Patients were categorized into those with and without occlusive myocardial infarction (OMI). Results A total of 189 NSTE-ACS patients with a mean age of 58.65 (±10.38 SD) years were enrolled in the study. The overall OMI rate was 29.63%. OMI patients were older and had a higher prevalence of hypertension, dyslipidemia, and a family history of ischemic heart disease (IHD). Significant ECG changes associated with OMI included biphasic T-wave inversion and ST depression in specific leads. Marked elevation in troponin levels was also noted in OMI patients. The left anterior descending (LAD) artery was the most common culprit artery. Conclusions About one-quarter of our study cohort exhibited OMI. The condition was linked to clinical, ECG, and elevated troponin levels. The study underscores the importance of promptly recognizing occlusive myocardial infarction (OMI) in NSTE-ACS patients for better outcomes. Regular audits are imperative to augment awareness among healthcare professionals at cardiac centers regarding updated protocols and guidelines.

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Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.

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•This report is unprecedent in treating a shift in medical training, particularly cardiology, in Kurdistan and whole Iraq.•It attempts to motivate a scientific debate to advance post graduate learning process in cardiology.•It distinguishes the apprenticeship from the competency-based approach and encourages a move towards the latter.•It links this shift with the development of competencies determining cardiological advancement.

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INTRODUCTION: Thrombocytopaenia, one of the most common haematological disorders worldwide, is characterised by platelet counts <150,000/mm3. Patients with coronavirus disease (COVID-19) were found to commonly exhibit haematological abnormalities, often with mild forms of thrombocytopaenia. Absolute thrombocytopaenia tends to be rare among these patients and is believed to be secondary to immune-induced thrombocytopaenia. CASE PRESENTATION: A 53-y-old man presented with fever and generalised body ache that persisted for a few days. His polymerase chain reaction test was positive for COVID-19, for which he was treated with acetaminophen, levofloxacin, and favipiravir. On the third day of treatment, he noticed bruising and bleeding, mainly in the oral cavity, with clot formation. A complete blood picture (CBP) revealed severe thrombocytopaenia with an almost-zero count. Prednisone 1 mg/kg/d and frequent doses of intravenous platelet transfusion were administered as rescue therapy to prevent fatal bleeding. The patient was able to recover. CLINICAL DISCUSSION: Immune thrombocytopaenia should be considered in patients presenting with bleeding tendencies after severe acute respiratory syndrome coronavirus 2 infection. Serial CBP is recommended for vulnerable patients, especially during the second and third weeks of hospitalisation, for the early detection and prevention of life-threatening COVID-19 complications. CONCLUSIONS: Absolute thrombocytopaenia is a rare condition. Such a condition should be considered in patients presenting with bleeding tendencies with severe Covid-19 infection. With early diagnosis and appropriate treatment, patients' lives can be saved.

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INTRODUCTION: The characters of coronary artery disease with its risk factors and coronary angiograms studied elsewhere revealed differences in different populations. We, here, assess the regional characters of coronary artery disease with its major risk factors and coronary angiographic profile in Duhok, Kurdistan region of Iraq. METHODS: We conducted this cross sectional study at the Azadi heart center in Duhok, Iraq. A consecutive sampling procedure was used to enroll a total of 300 adult patients with coronary artery disease (145 men and 155 women) who had undergone coronary angiography. Direct interview was used with designed questionnaire to collect demographic, cardiovascular risk factors and angiographic profiles. RESULTS: The mean patient's age was 55.5 (10.4) years. The most prevalent risk factor was hypertension (55.3%), followed by dyslipidemia (42.7%), type 2 diabetes mellitus (29%), smoking (11%) and ex-smoking (9.3%). Apart from smoking all other risk factors were more frequent in women. Angiographic analysis revealed normal angiograms in (29.3%) versus single vessel disease (23.3%), double vessel disease (14.3%), triple vessel disease (21.3%) and non significant (11.7%). As to the coronary branch involved, the most frequently affected was the left anterior descending artery followed by right coronary artery, left circumflex artery, and left main stem (60.7%, 46.3%, 43.7% and 6% respectively). CONCLUSION: This study showed that the coronary artery disease tends to occur earlier in our population. Although cardiovascular risk factors were clustered among women, older men showed more aggressive coronary angiographic lesions.

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Cardiopulmonary complications are among the most important complications of thalassemia major. Pulmonary hypertension is among these complications and studies addressing its frequency and associations in the latter disorder are sparse from Iraq. For this purpose a total 100 thalassemia major patients (≥ 8 years old) were enrolled from a main thalassemia center in Kurdistan, Northern Iraq. All patients had a full history and clinical examination. Full blood count, biochemical tests and viral screen including hepatitis B surface antigen and hepatitis C virus antibody, in addition to transthoracic Doppler echocardiography for tricuspid regurgitation jet velocity (TRV). The enrolled patients had a mean (SD) age of 17.6 (5.5) years, and included 52 males and 48 females. Pulmonary hypertension as defined by TRV> 2.8 m/s coupled with both exertional dyspnea and an absence of left sided heart failure, was identified in nine patients (9%). The latter subgroup of patients had significantly higher reticulocyte counts, S. LDH, S. ferritin, and hepatitis C sero-positivity compared to those without this complication by univariate analysis. While by multivariate logistic regression only reticulocytes and hepatitis C sero-positivity remained significant. Furthermore, TRV as a continuous variable was positively correlated with reticulocytes, S. bilirubin and LDH (p<0.001, p = 0.002 and p<0.001 respectively), but not with age or S. ferritin (p = 0.77, and p = 0.93 respectively). In conclusion, pulmonary hypertension is not uncommon in Iraqi patients with thalassemia major, and it appears to be linked to chronic hemolysis rather than iron overload.

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Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/etiología , Talasemia beta/complicaciones , Adolescente , Adulto , Niño , Ecocardiografía Doppler , Femenino , Hemólisis , Humanos , Hipertensión Pulmonar/patología , Irak/epidemiología , Masculino , Adulto Joven , Talasemia beta/diagnóstico por imagen , Talasemia beta/patología

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OBJECTIVES: Early-onset myocardial infarction constitutes nearly one third of cases of myocardial infarction among Iraqis, which is rather higher than the proportions reported in many Western countries. Thus this study was initiated to investigate the role of some genetic polymorphisms, as well as acquired risk factors in this condition. RESULTS: A total of 102 Iraqi patients with first myocardial infarction aged 50 years, and 77 matched controls were enrolled. The DNAs of participants were screened for nine polymorphisms, namely: ß-Fibrinogen (- 455G > A), Factor XIII (V34L), Plasminogen Activator inhibitor-1 (PAI-1, 4G/5G), Human Platelet Antigen-1 (HPA1a/b), 5,10-Methylenetetrahydrofolate Reductase MTHFR (C677T) and MTHFR (A1298C), Angiotensin-Converting Enzyme (ACE) 287 bp insertion/deletion (I/D), Apolipoprotein-B (ApoB: R3500Q), and Apolipoprotein-E (Apo E: E2/E3/E4), using PCR and reverse hybridization technique. Among traditional risk factors, univariate analysis revealed that smoking (OR 2.86 [95%CI 1.53-5.34]), hyperlipidemia (OR 5.23 [95%CI 2.66-10.29]), and diabetes mellitus (OR 4.05 [95% CI 1.57-10.41]) were significantly higher among patients compared to controls (P<0.001, <0.001 and 0.002 respectively), while none of the nine genetic polymorphisms reached significance. Multivariate Logistic regression, however, revealed that only smoking and hyperlipidemia retained significance (P of < 0.001 each). The need to initiate further studies on larger cohorts is paramount to understand the higher than expected frequency of early-onset myocardial infarction in our population.

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Infarto del Miocardio , Polimorfismo Genético , Apolipoproteínas E/genética , Predisposición Genética a la Enfermedad , Humanos , Metilenotetrahidrofolato Reductasa (NADPH2)/genética , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/genética , Proyectos Piloto , Inhibidor 1 de Activador Plasminogénico/genética

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To determine the impact of CYP2C19 genotyping on the occurrence of major adverse cardiovascular events (MACE), in cohort of Iraqi patients on clopidogrel after percutaneous coronary intervention (PCI), a total of 201 Iraqi patients undergoing the latter procedure were enrolled. All enrollees had their CYP2C19 genotyped using polymerase chain reaction and reverse hybridization. Genotyping revealed that CYP2C19 *1, *17, *2, and *8 allele frequencies were, respectively, 0.604, 0.276, 0.117, and 0.0026. After the exclusion of those with 2 loss of function alleles, 186 patients were available for follow-up as long as they were on clopidogrel, or until MACE occurred, which was encountered in 8.6% after a median of 12 months. Among predictors associated with MACE was the carriage of one CYP2C19 loss of function allele {hazard ratio (HR) 8.6 [confidence interval (CI) 3.15-23.4]; P < 0.0005}, hypertension [HR 3.74 (CI 1.06-13.16); P = 0.04], reduced ventricular function [HR 3.88 (1.43-10.54); P = 0.008], and history of previous myocardial infarction [HR 4.9 (CI 1.48-11.33); P = 0.007] by univariate analysis, although only CYP2C19 genotype remained significant by multivariate analysis [HR 11.88 (CI 3.25-43.44); P < 0.0005]. The latter observation favors CYP2C19 genotype-guided antiplatelet therapy and extending the use of alternative antiplatelet drugs to those with single loss of function allele after percutaneous coronary intervention.

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Clopidogrel/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Citocromo P-450 CYP2C19/genética , Resistencia a Medicamentos/genética , Intervención Coronaria Percutánea/efectos adversos , Variantes Farmacogenómicas , Inhibidores de Agregación Plaquetaria/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Toma de Decisiones Clínicas , Clopidogrel/administración & dosificación , Clopidogrel/metabolismo , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Citocromo P-450 CYP2C19/metabolismo , Femenino , Frecuencia de los Genes , Genotipo , Humanos , Irak , Masculino , Persona de Mediana Edad , Selección de Paciente , Farmacogenética , Fenotipo , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/metabolismo , Medicina de Precisión , Factores de Riesgo , Resultado del Tratamiento

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BACKGROUND: The association of vitamin D deficiency with coronary artery disease (CAD) is controversial. This study seeks the association between vitamin D deficiency and acute myocardial infarction (MI) in Iraq. PATIENTS AND METHODS: A total of 104 patients with acute MI and 104 healthy controls were studied throughout 2015. Their demographic, cardiovascular risk factors, and clinical characteristics were recorded. Serum vitamin D measurement was carried out for all patients. RESULTS: Vitamin D was more deficient in cases than controls; the number of cases was 60 (57.7%) and 53 (51%), respectively. However, a statistically significant difference (P=0.6) was not obtained. In the patient group, type 2 diabetes mellitus showed a strong association with vitamin D deficiency; there were 31 (81.6%) diabetic patients and 29 (43.9%) nondiabetic patients (P<0.001). CONCLUSION: No statistical association between vitamin D deficiency and acute MI was found. Nevertheless, a strong association between vitamin D deficiency and acute MI with type 2 diabetes mellitus was seen.

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To determine the frequency, clinical and laboratory associations of pulmonary hypertension in Iraqi Kurds with sickle cell anemia, a total of ninety four such patients attending a major hemoglobinopathy center in Iraqi Kurdistan were enrolled. All patients were re-evaluated clinically and had their blood counts, HbF, serum ferritin, LDH, renal and liver function assessed. Transthoracic Doppler echocardiography with measurement of tricuspid valve regurgitant jet velocity (TRV) was performed. A TRV in excess of 2.8 m/s was considered for the purposes of this study as indicative of pulmonary hypertension (PH). The prevalence of TRV in excess of 2.8m/s was 10.6%. By univariate analysis: significantly higher reticulocyte count, more frequent blood transfusions and pain episodes were encountered in the PH group as compared to the non-PH group (p = 0.001, 0.045 and 0.02 respectively). Moreover, PH patients had significantly higher mean right atrial area, left atrial size, E wave/A wave ratio and ejection fraction by echocardiography (p = 0.027, 0.037, <0.001 and 0.008 respectively). Except for reticulocyte count none of the other parameters remained significant by multivariate analysis (p = 0.024). In conclusion the current study revealed that pulmonary hypertension is rather frequent among Iraqi Kurds with sickle cell anemia, and identified reticulocyte count as an independently associated parameter with PH in this population. Future prospective studies including right heart catheterization and appropriate medical intervention are warranted.

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Anemia de Células Falciformes/complicaciones , Ecocardiografía Doppler , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/diagnóstico por imagen , Adolescente , Adulto , Niño , Preescolar , Estudios Transversales , Femenino , Humanos , Irak , Masculino , Adulto Joven

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To investigate the molecular basis of ß -thalassemia intermedia in Northern Iraq and evaluate its management practices, a total of 74 patients from 51 families were enrolled. The patients were clinically and hematologically reevaluated, and had their ß-thalassemia mutations characterized, as well as the number of α-globin genes and Xmn I (G)γ-158 (C>T) polymorphism studied. Out of 14 ß-thalassemia mutations identified, the four most common were IVS-I-6 (T>C) [33.3%], IVS-II-I (G>A) [21.1%], codon 82/83(-G)[10.1%], and codon 8 (-AA) [8.1%]. The most common contributing factors to the less severe phenotype of thalassemia intermedia were found to be the inheritance of mild ß-thalassemia alleles and the Xmn I polymorphism, while concomitant α-thalassemia had a limited role. Several complications were documented including: pulmonary hypertension in 20.4%, diabetes mellitus in 1.4%, hypothyroidism in 2.9%, and heart failure in 2.7%, while no documented cases of venous thrombosis were found. Compared to their counterparts in several Mediterranean countries, it appears that our patients were much less frequently transfused and had a lower proportion of patients who were splenectomized, on iron chelation, or hydroxycarbamide therapy. Such practices require further scrutiny to ensure that a better level of care is provided and that growth retardation, skeletal changes, and other complications are prevented or reduced.

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Mutación , Globinas alfa/genética , Talasemia beta/genética , Adolescente , Adulto , Niño , Preescolar , Femenino , Haplotipos , Humanos , Irak , Masculino , Persona de Mediana Edad , Fenotipo , Polimorfismo Genético , Talasemia beta/patología