11 - 14 JUNE 2013

Thursday, 13 June 2013

Flame of Science... CardioAlexNEWSLETTER

Bibliotheca AlexandrinaAlexandria - Egypt

CardioAlex

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رية

كندكلية طب االس

ALEXANDRIA FACULTY OF MEDICIN

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Thursday, 13 June

Prof. Panos E. Vardas, MD, PhD (London, UK)Heraklion University Hospital, Crete, GreecePresident of the European Society of Cardiology08:57 - 09:09 Sudden Cardiac death 2013:

scientific, social & economic issuesPanos Vardas - Greece

Fausto Pinto FESC, PortugalPresident-Elect of the European Society of Cardiology09:30 - 09:42

Wednesday, 12 June

New ESC guidelines onvalvular heartFausto pinto - Portugal

Prof. Petr Kala S(tent For Life Co-Chairman)“I have been participating in the Stent for Life Initiative (SFL) as its Ambassador from its early phase and I am honored to accept the nomination to become the SFL Co-Chairman. I strongly believe in teamwork, collaboration and visions and I am very happy to have the opportunity to share the experience from my presidency of the Czech Working Group of Interventional Cardiology. Since 1995 I have been leading the primary PCI program

and have been involved in building the nationwide primary PCI care that serves as one of the best examples of acute myocardial infarction systems in Europe. Membership in the EAPCI Committee for Databases and Registries, EAPCI Scientific Program Committee and EuroPCR Program Committee will help me to further implement the SFL mission in Europe and other geographies.”

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Update in Antithrombotic therapy in ACSDr Ali M Elneihoum, MD, PhDMedical Faculty, Benghazi University, LibyaThe pathophysiology of acute coronary syndromes (ACS) is characterized by atherosclerotic plaque rupture or erosion, leading to acute thrombosis in a coronary vessel. Platelet activation plays a primary role in the pathogenesis of ACS, as well as in the recur-rence of events both in medically treated and in invasively-managed patients with ACS; thus, in those patients dual antiplatelet therapy with aspirin and Clopidogrel represents an evidence-based, guideline recom-mended, standard of care.Clopidogrel causes inhibition of platelet activation and aggrega-tion; maximal inhibition by this drug ranges from 40% to 60%, and this is reached 3-7 days after a standard dose of 75 mg, 6-12 hours after a 300mg load and 2 hours after a 600 mg load. Several randomized studies have shown the clinical benefit of adding clopidogrel to aspirin in patients with ACS. Although incidence of bleeding events was significantly higher in patients receiving clopidogrel there were no significant difference in the occurrence of life-threatening bleeding or hemorrhagic stroke. However, despite those favorable findings, up to 15% of patients with ACS continue to suffer from ischemic events during long-term follow up, and this may be at least in part related to the inter-individual variability in clopidogrel responsiveness.Evaluation of individual Clopido-grel response has become a contemporary issue in interven-tional cardiology.Various studies have been performed with the aim to achieve a standardized definition of low clopidogrel response as the correlation between results of laboratory assays and clinical outcome, and to demonstrate the prognostic impact of high residual platelet reactivity (i.e. low Clopidogrel response) on short- and long-term outcome after PCI. In the ARMYDA PRO (Antiplatelet therapy for Reduction of Myocar-dial damage during Angioplasty-Platelet Reactivity Predicts Outcome) study, high platelet reactivity after clopidogrel admin-istration, measured at the time of the procedure by P2Y12 assay, was associated with 6-fold higher risk of 30-day major cardiac

adverse events after PCI.New Antithrombotic DrugsNovel P2Y12 receptors antago-nists are characterized by more potent and rapid onset of antiplatelet action. However, the greater platelet inhibition and the consequent more effective prevention of ischemic events by more potent antiplatelet agents need to be weighed against an increase in bleeding complica-tions.Prasugrel, a third-generation thienopyridine, is a prodrug that requires hepatic conversion; however, this process needs only one cytochrome P450-dependent oxidative step to generate the active metabolite and this difference explains the faster onset of action than clopidogrel, the greater inhibition of platelet aggregation, the lower incidence of non responders and the lesser influence of genetic polymorphisms. The clinical efficacy of prasugrel was evalu-ated in the phase III TRITONTIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel – TIMI 38) trial. This study compared the efficacy and safety of prasugrel (60 mg loading dose, 10 mg daily mainte-nance dose) vs. clopidogrel (300 mg loading dose, 75 mg daily maintenance dose) in ACS patients undergoing PCI. Over amedian follow up of 14.5 months, patients pre-treated with prasug-rel showed significantly lowerincidence of primary end point, including cardiovascular death, MI or stroke (9.9% vs. 12.1% inthe Clopidogrel arm; P<0.001); this benefit was essentially due to prevention of non-fatal MI.However, a significant 32% excess in life-threatening and fatal bleedings was observed in the prasugrel group. Prasugrel was still associated with a signifi-cant net clinical benefit compared to clopidogrel (HR

0.87; 95% CI 0.79-0.95; P=0.004), and a further analysis suggested a markedbenefit with this drug in patients with diabetes mellitus and in those presenting with ST-segment elevation MI, whereas, the excess of bleeding was more evident in patients with previous historyof stroke or transient ischemic attack, age > 75 years or body weight < 60 kg.Ticagrelor is an oral, reversible, short-acting non-thienopyridine P2Y12 antagonist; it is not a prodrug, it has a direct action, and in platelet aggregation studies the inhibition of platelet aggregation by ticagrelor was more pronounced than clopido-grel, with lower degree of interindi-vidual response variability.The phase III PLATO [28] (PLATelet Inhibition and Patient Outcomes) trial was a double-blind, randomized study compar-ing ticagrelor (180 mg loading dose, 90 mg twice daily thereaf-ter) and clopidogrel (300-to-600 mg loading dose, 75 mg daily thereafter) for the prevention of cardiovascular events in patients with ACS. At 12 month, the incidence of the composite

endpoint, including death from vascular causes, MI or stroke, was significantly reduced in theticagrelor group (9.8% vs 11.7% in the clopidogrel arm; HR 0.84; 95% CI 0.77-0.92; P<0.001).Of note, all-cause mortality through 12 months was also reduced with ticagrelor (4.5% vs 5.9%; P<0.001). However, ticagre-lor was associated with increased rates of major bleeding not related to coronary-artery bypass graft (4.5% vs 3.8%; P=0.03), as well as more elevated incidence of intracranial fatal bleeding.Cangrelor: Intravenous reversible P2Y12 antagonist. The objective of the BRIDGE study was to evalu-ate the use of cangrelor for bridg-ing thienopyridine-treated patients to CABG. Although it included small number of patients they concluded that when iv cangrelor (at 0.75 µg/kg/min) used as a bridging strategy to CABG after thienopyri-dine discontinuation, it achieves levels of platelet inhibition known to be associated with a low risk of thrombotic events, without increased risk of bleeding before or during CABG, although with a numerical increase in minor pre-CABG bleeding

Mohammed Omar GalalM.D., PhD, MBAPrince Salman Heart Center, Riyadh, Saudi ArabiaThe risk of Infective endocarditis in patients with ventricular septal defect (VSD) is relatively rare and affects only about 2.5 per every 1000 patients per year. It seems that small VSDs have a higher risk for endocarditis than large VSDs. Also, it is apparent that Gerbode defects, or VSDs associated with aortic regurgitation, as well as post surgical VSDs are at higher risk. As the occurrence of endo-carditis shows general regression in the western world, the AHA has thus suggested, as of 2007, to abandon the previously recom-mended sub endocarditis prophy-laxis for left to right shunts.Disregarding the excellent outcome of surgical and trans-catheter closure of VSD, the expert opinion found no reason - as for patent ductus arteriosus - to close all VSDs, disregarding their size. It remained generally accepted that small VSDs with Qp/Qs < 1.5/1 and those without any sign of volume overload should not be closed.On the contrary, when endocardi-tis occurs in a VSD, even if it is a small one, there is a general agreement that it should be closed. This is done - although without any evidence- assuming that the recurrence rate after a previous endocarditis is higher than the risk of endocarditis for

Transcatheter Closure post Endocarditis VSD

the native VSD. Infective endocar-ditis, due to introduction of early surgical intervention in the 60s in its management, clearly improved the otherwise extremely poor prognosis of the disease. It is accepted that surgical intervention is recom-mended whenever a patient is in severe heart failure and/or when a valve is involved. Transcatheter closure did not find acceptance in the medical community as method for closing post endocar-ditis VSDs. Until now, only in desperate situations and when the patient is in a critical clinical status, transcatheter closure of the VSD can be occasionally indicated. There are different studies which suggest that in selected cases of post VSD IE, transcatheter closure can be used. In summary, the risk of infective endocarditis for VSDs is getting lower. AHA in 2007 did not recommend sub endocarditis prophylaxis for most left to right shunt lesions. Surgery advanced to be an integral part in the management regimen of infective endocarditis. While transcatheter closure still seeks acceptance to be included in this setup.

CardioAlex 2013

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Thursday, 13 June14:30 - 15:50

Hall: Small TheatreChairpersons

Mohamed SobhyNagwa Lachine

Wagdy Ayad14:30 - 14:50

14:50 - 14:5514:55 - 15:15

15:15 - 15:2015:20 - 15:40

15:40 - 15:50

Comprehensive Glycaemic Control,The role of Incretin based therapyIbrahim El Ibrashy CairoDiscussionManaging Patients at risk, Insightsfrom Jupiter TrialAmr Zaki - AlexandriaDiscussionARBs in Treatment of heart FailureMohamed Loutfi - AlexandriaDiscussion

Symposium

WORKSHOP01:30 - 2:30

Training Set Hall

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Editor in Cheif:Prof. Mahmoud Hassanein

Visit us and Subscribe at our stand at Level 1

Thursday, 13 June09:45 - 10:45

Hall: Small TheatreChairpersonsAhmed khattabAmr YoussefMohamed MandourPetr KalaSamir WafaTarek Helmy

09:45 - 10:45 OperatorsPetr Kala - Czech RepublicAly Zidan - AlexandriaAly Aboul Hoda - Alexandria

2nd Day National Live

INTE

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ModeratorsAmr ZakiSherif El Beltagui

It’s easy to move forward when you leave nothing behindThe dream of a bioresorbable scaffold has now become a reality. Absorb defines a new paradigm – Vascular Reparative Therapy (VRT). The goal of VRT is to restore the vessel to a more natural state, capable of natural vascular function, with the potential for long term benefits. Absorb works in three phases to deliver VRT: it Revascularizes, Restores, and Resorbs. Leaving nothing behind* heralds a bright future for interventional cardiology. Together, we can lead the revolution in patient care.

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*Small platinum markers at scaffold edges remain for fluoroscopic landmarking.

Abbott Vascular International BVBA, Park Lane, Culliganlaan 2B, B-1831 Diegem, Belgium, Tel: +32 2 714 14 11. Absorb is a trademark of the Abbott Group of Companies.Products intended for use by or under the direction of a physician. Prior to use, it is important to read the package insert thoroughly for instructions for use, warnings and potential complications associated with the use of this device. Information contained herein is for distribution for Europe, Middle East and Africa ONLY. Please check the regulatory status of the device before distribution in areas where CE marking is not the regulation in force. Photo(s) on file at Abbott Vascular. For more information, visit our web site at www.abbottvascular.com.©2013 Abbott. All rights reserved. 1-EH-2-3298-01 03/2013

AbsorbBioresorbable Vascular Scaffold System

Prof. Ghada SlimFifty years ago, patients who survived a myocardial infarction were confined to bed for two months or longer, and then urged to limit their physical activity indefinitely. Avoidance of physical activity was likewise advocated for those with angina. Eventually patients were both physically and psychologically disabled.By the 1960s , studies reported that the functional capacity of normal subjects confined to bed for three weeks decreased approximately 33%.Numerous studies demonstrated that early activity after an MI safely negates the adverse effects associated with prolonged bed restEvidence showed that both regular exercise and physical fitness are associated with a reduced risk of coronary events and coronary death.Based upon these observations and the demonstrated benefit of risk factor reduction, cardiac rehabilitation programs have been developed to provide exercise training and counseling on risk factor modification for the secondary prevention of coronary heart diseaseThe term” cardiac rehabilitation” refers to coordinated, multifac-eted interventions designed to optimize a cardiac patient’s physi-cal, psychological, and social functioning, in addition to stabiliz-ing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality.A comprehensive cardiac rehabili-tation program today consists of several phases:Phase I—Inpatient hospital phase beginning in the CCUPhase II— Outpatient hospital-based phase for 2 to 4 monthsPhase III—Maintenance phase for 4 to 6 months or even up to 12 months.Each phase has its own objective for patient care and progression. Each phase has an educational component commensurate with the patient's level of knowledge of the disability and level of

Cardiac Rehabilitation in CADactivity. Most programs today include a graded exercise test not only as a screening procedure but also as a functional evalua-tion for prescription and progres-sion.Physical activity is beneficial in reducing the risk of coronary heart disease: Improved Glucose Metabolism and Reduced Risk for Type 2 Diabetes Mellitus, improvement in the classic coronary risk factors, reduction in autonomic nervous system and endothelial dysfunction, reduced thrombosis and increased fibrino-lysis, less progression and possible modest regression of coronary atherosclerosis lesions, and a reduction in myocardial ischemia. All of this information provides evidence base for the use of exercise training as a part of comprehensive cardiac rehabili-tation.Target patients:Although traditionally most candi-dates for CR services are patients following myocardial infarction or coronary artery bypass graft surgery, contemporary use also includes patients following percu-taneous coronary interventions; heart or heart/lung transplanta-tion recipients; patients with stable angina or stable chronic heart failure; those with periph-eral arterial disease with claudica-tion; and patients following cardiac surgical procedures.Timing of Referral for enrollment in cardiac rehabilitation optimally occurs within:One to three days following elective PCI for chronic stable angina. One to three weeks follow-ing discharge from the hospital after a coronary event. Four to six weeks following hospital discharge for decompensated heart failure. Four weeks follow-ing CABG. Four weeks following PPM and ICD implantationBenefits of CR and Status in guidelines: Indeed, referral for cardiac rehabilitation is a class I indication (useful and effective) in most contemporary clinical practice guidelines, including those for ST-segment elevation MI, unstable angina/non-ST-segment elevation MI, chronic stable angina, PCI , CABG surgery. heart failure, valvular heart disease, peripheral arterial disease and cardiovascular prevention in women .Meta-analyses of randomized, controlled trials of outpatient CR demonstrate a 25% reduction in long-term, all-cause, and cardio-

CardioAlex 2013

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vascular mortality ratesPatient assessment:The risk of cardiovascular compli-cations of exercise should be assessed before initiation of exercise training, using a standardized assessment to identify patients who may have unstable symptoms or other factors that characterize them as at increased risk for adverse cardiovascular events. For most patients, clinical risk stratification based on history, examination and resting ECG combined with a functional capacity test such as a symptom limited stress testing or a six minute walking test will be sufficient. Stratifying the patient’s risk is crucial to determine exercise prescription interms of intensity and duration. Factors as age, weight, CAD, Ejection Fraction, musculoskel-etal system are considered while

prescribing exercise.The most effective exercises for physical conditioning use large muscle groups, are maintained continuously, and are rhythmic and aerobic in nature. These are commonly referred to as endur-ance exercise. Other exercise modalities often used in exercise – based primary and secondary prevention programs include calisthenics, particularly those involving sustained total body movement; flexibility and stretch-ing exercises; resistance training; and recreational games. Exercise is performed ideally twice or 3 times a week, with gradually increasing intensities and durations.In addition to lifestyle modifica-tion, diabetes management, lipid management, psychological, and sexual support.

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CardioAlexNEWS

Thursday, 13 JUNE 2013

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Ibrahim Khadragi, Mohamed NassarMany techniques have been developed to address the partial anomalous pulmonary venous drainage into the superior vena cava with or without sinus venosus atrial septal defect.The morphology of this anomaly is responsible for the possible surgical complications including sinus node dysfunction, systemic and/or pulmonary venous

The trans-caval approach for surgical correction of sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage into the superior vena cava :

Early experience in Alexandria University

MEDTRONIC SYMPLICITY™ RENAL DENERVATION THERAPY AVAILABLE IN EGYPT FOR PATIENTS SUFFERING FROM HIGH BLOOD PRESSURE

channels obstruction.Since early 2010, we started to slowly adopt the vertical trans-caval incision for the correction of this anomaly. Here, we present our early experience in Alexandria University with six patients operated using this approach.Between April 2010 and April 2011, six patients, aged between 7 and 35 years, were addressed using one patch of Gluteraldhyde prepared autologus pericardium, after vertical superior vena caval incision at the mouth of the anomalous pulmonary veins. Two patients had associated left

superior vena cava. One patient required enlargement of the caval incision site by an additional patch. Follow up ranged from 2-12 months.There was no mortality or impor-tant morbidities. Post-operative echocardiographic examination of all patients showed unob-structed caval and pulmonary venous flow. Follow up ECG confirmed the absence of any arrhythmia.In Conclusion:Vertical trans-caval approach is a highly reproducible technique for

correction of partial anomalous pulmonary venous drainage into the superior vena cava with very low incidence of complications.

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ALEXANDRIA – JUNE 11, 2013 - During the Cardio Alex 2013 Congress held at the BibliothecaAlexandrina in Alexandria from June 11th till the 14th, Medtronic, the world’s leading medical device company, is presenting the most advanced therapy available today addressing treatmentresistant hypertension. In Egypt, it is estimated that approximately 27% of its adult population are living with high blood pressure*.Hypertension is the leading attrib-utable cause of death worldwide. It is a significant, escalating global healthcare problem affect-ing approximately 1.2 billion people and is associated with anincreased risk of heart attack, stroke, heart failure, kidney disease and death. Although pharmaceutical therapy plays a primary role in hypertension management, drugs alone aresometimes not effective for all patients. As a result, despite lifestyle changes and the availabil-ity of anti-hypertensive agents, approximately 50 percent of patients with hypertension remain uncontrolled, and approxi-mately 15–20 percent of those are resistant.iTreatment-resistant hypertension

is defined as high blood pressure despite treatment with three or more anti-hypertensive medica-tions. The Medtronic Symplicity Catheter System™ is an innova-tive therapy for treatment-resistant hypertension which accomplishes renal denervation through a minimally invasive procedure that disables sympa-thetic nerves located in the renalartery walls and does not involve a permanent implant.A clinical update from Symplicity HTN-2, the first randomized clinical trial investigating renaldenervation, presented at the 62nd Annual Scientific Session of the American College ofCardiology on March 10, 2013, has demonstrated that the Symplicity™ renal denervation systemsustained a significant drop in blood pressure (-31/-11 mm Hg from baseline [p<0.01]) at 24months.In collaboration with leading clinicians, researchers and scien-tists worldwide, Medtronic offersthe broadest range of innovative medical technology for the interventional and surgicaltreatment of cardiovascular disease and cardiac arrhythmias.

Thursday, 13 June13:30 - 14:30Hall: Lecture

Thrombosis Management,Changing Practice

Alexander Turpie - Canada

Symposium

Bayer HealthCareBayer Schering Pharma

Thursday, 13 June9:30 - 11:00Hall: Lecture

The role of novel oralanticoagulants in SPAFIhab Attia Ain ShamsWhen selecting an ARB…lookdeeperRamzy El Mawardy Ain Shams

Symposium

CardioAlex 2013

7www.cardio-alex.com

BackgroundDiabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi ArabiaMethodsACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patientsResultsOf the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2±11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hyperten-sion, hyperlipidemia) prevalence and were more likely to present with non–ST-elevation myocardial infarction (40.2% vs. 31.4%, p<0.001), heart failure (25.4% vs. 13.9%, p<0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardio-genic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI:1.02–3.30, p=0.042)ConclusionsA substantial proportion of Saudi patients presenting with ACS

Impact of diabetes on hospital adverse cardiovascular outcomes in acute coronary syndrome patients:Data from the Saudi project of acute coronary eventsBackgroundDiabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi ArabiaMethodsACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patientsResultsOf the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2±11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hyperten-sion, hyperlipidemia) prevalence and were more likely to present with non–ST-elevation myocardial infarction (40.2% vs. 31.4%, p<0.001), heart failure (25.4% vs. 13.9%, p<0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardio-genic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI:1.02–3.30, p=0.042)ConclusionsA substantial proportion of Saudi patients presenting with ACS

have DM and a significantly worse prognosis. These data highlight the importance of cardio-vascular preventative interven-tions in the general population.DiscussionSPACE is the first national ACS registry in Saudi Arabia. We have found that almost two thirds of ACS patients enrolled in this registry were diabetic. To our knowledge, this is the highest DM prevalence ever reported in an ACS population and is two to three times higher than that reported in other ACS registries [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. Moreover, the preva-lence of DM in the SPACE registry seems higher than that reported in neighboring Gulf countries. The

Gulf Registry of Acute Coronary Events (Gulf RACE) has identified a prevalence of approximately 40% [16]. Although this preva-lence is considered high compared to western registries, it is significantly lower than that found in the SPACE registry. A higher proportion of expatriates in the Gulf RACE, who are usually healthier and younger, could potentially explain this observa-tion (16) Given that newly diagnosed diabetic patients were a small minority, including them under the known diabetic patients group did not change the adjusted associations between Diabetic patients status and adverse outcomes. .

SymposiumThursday, 13 June

12:00 - 13:30Hall: Main

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15:50 -16:50SymposiumThursday, 13 JuneHall: Small Theatre

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CardioAlex is caring to encourage the publicto increase their physical activities

& improve their healthJOIN US

From Gleem Parking to Bibliotheca Alexandrina,Corniche Road

Friday 14th of June08:00 AM

For more information please contact: 01277759992 - 01281696669

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CARDIOLOGY“Caring for your Heart”

for your heartCycle Walk&for your heartCycle Walk&

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