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Clin Cardiol. 2010 Sep;33(9):565-71. doi: 10.1002/clc.20802.

Missed opportunities in the management of ST-segment elevation myocardial infarction in the Arab Middle East: patient and physician impediments.

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Wayne State University School of Medicine, Henry Ford Hospital, Detroit, Michigan 48202, USA.



Lack of timely reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI) has been associated with worse outcomes. The aim of this study is to identify the frequency and predictors of delayed presentation and missed reperfusion in patients with STEMI in the Gulf Register of Acute Coronary Events (Gulf RACE) registry. Delayed Presentation and missed reperfusion is associated with increased in hospital mortality in STEMI patients.


Gulf RACE is a prospective, multinational study of all consecutive patients hospitalized with the final diagnosis of acute coronary syndrome in 65 centers in 6 Arab countries. In this analysis, we included 3197 patients with STEMI. The independent predictors of delayed presentation and missed reperfusion therapy were identified using multivariate logistic regression.


In total, 929 patients presented > 12 hours after symptom onset. The independent predictors of late presentation are older age, atypical symptoms, no family history of coronary artery disease, and being in Yemen. Of the 2268 STEMI patients presenting early, a total of 205 patients (9.3%) did not receive reperfusion therapy despite no contraindications (shortfall). The independent predictors of not receiving appropriate reperfusion therapy are older age, prior stroke, being in Yemen, and atypical symptoms. Lack of reperfusion therapy due to shortfall or delayed presentation was associated with increased in-hospital mortality.


Nearly one-third of patients with STEMI in the Arab Middle East present to the hospital > 12 hours after symptom onset, and nearly 1 in 10 eligible patients do not receive any reperfusion therapy. Community and physician awareness programs are needed to increase the utilization of appropriate lifesaving therapies.

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