120 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 Original Outcomes of Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction in Kurdistan Region of Iraq Ameen M Mohammad1*, Schivan U Mohammed2, Saad Y Saeed3 1Department of Internal Medicine, College of Medicine, University of Duhok, Iraq. 2Department of Biomedicine, College of Medicine, University of Zakho, Duhok, Iraq. 3Department of Community Medicine, College of Medicine, University of Duhok, Iraq. *Correspondence to: Ameen M Mohammad (E-mail: doctoramb@yahoo.com) (Submitted: 16 December 2021 – Revised version received: 10 January 2022 – Accepted: 27 January 2022 – Published online: 26 April 2022) Abstract Objectives: This registry aims to clarify the characteristics and 6-weeks outcomes of patients with STEMI after PPCI in the region. Methods: Data from a total of 151 STEMI patients undergoing PPCI at Duhok heart center, Iraq from 2020 to 2021 was collected. Patient’s demographic, clinical and PPCI profiles were recorded. The major adverse cardiac events (MACE) and left ventricle ejection fraction (LVEF%) outcomes for 6 weeks period was registered. Results: Of the 151 consecutive patients with STEMI who underwent PPCI, 46 (30.4%) were <50 years old. Majority of patients were males and have clusters of cardiometabolic risk factors. 64% of cases attained Cath lab within first hour of initial chest pain. Almost 90% of STEMI cases were treated with stenting with TIMI3 in (94%). 80% of PPCI cases discharged home within 24 hours uneventfully. 6-weeks LVEF was preserved within normal range in 55% of cases. 36% had MACEs including impaired LVEF. All cause-mortality happened in 5%. 4% were Censored from follow up. The predictors of 6-weeks outcomes were depend on type/location of myocardial infarction, the culprit artery, TIMI flow post PCI and length of hospital stay. Conclusion: This registry has shown feasibility in doing PPCI with reasonable outcomes in the Region. Networking of capable centers of PPCI in the country is essential for augmenting the cardiac services and sharing the knowledge among cardiologists and people for better STEMI outcomes. Keywords: STEMI, primary PCI, Iraq ISSN 2413-0516 Introduction The cardiovascular diseases coming at the top of the list of the disease-related death in Iraq.1 The incidence of STEMI in the area is rapidly over happening particularly in young people.2 According to international medical guidelines the best approach to STEMI patient is the PPCI.3 The PPCI services are generally new in our area. Since long time the main modality of reperfusion in STEMI was thrombolytics. In the last decade the interventional cardiology services and Cath lab facilities entered to the field in our area, nevertheless, the systematic PPCI per 24 hours/7 days per 365 days was relatively a new approach in our area. Given the fact that the services of PPCI are relatively recent in the area and the data about STEMI and the feasibility of PPCI are sparse. Hence, this study was con- ducted in order to clarify the characters and 6-weeks outcomes of patients with STEMI after primary percutaneous coronary intervention (PPCI) in the region. Methods Belongs to Azadi teaching tertiary hospital Duhok heart center is a specialized center with a history of than 15 years. In regards to STEMI, the center provided PPCI services 24 hours/7 days per week in the last 4 years. The center has three equipped Cath Lab with continuous back up surgery and intensive care unit. The center has more than 12 interventional cardiologists with a group of cardiac surgeons and intensives, besides a large group of paramedics and staffs in the Cath lab. In this prospective follow up study patients who pre- sented with diagnosis of STEMI from Duhok and its districts and referred to Duhok heart center inside Azadi hospital for potential primary percutaneous coronary intervention were enrolled during the period of 2020 to 2021. The patients were given guideline directed medical therapy in from of loading doses of dual antiplatelets and anti-ischemic drugs. Eligible patients after their acceptance and consent from patients were referred to Cath lab for PPCI. Patients with established STEMI or late presentations (> 12 hours) were excluded and admitted to coronary care unit for optimal medical therapy/ thrombolytics. During the procedure, the interventional cardiologists perform the procedure through either femoral or radial approach. All the procedural data including angiographic findings with culprit artery lesion and type of PCI (whether stents, ballooning or medical therapy) were documented. Plat- forms of stents were mentioned. Successfulness of PCI and procedure was based on the TIMI flow scores. After the procedure all patients were admitted for 24 hours monitoring in the intensive care unit of the center. All complications including mortality, if happened were regis- tered. The estimation of LVEF was performed. Post discharge advices for regular complaint to medications, life style modifi- cations and follow up schedule were given. Then after patients were followed for a period of 6 weeks. The LVEF (%) were performed for coming cases. In addition to registration of the rates of patient’s readmissions to hospital for major acute ischemic events (MACE) like acute stent thrombosis, myocardial infarction and stroke. The cardiac death rate and censored cases for follow up during this period was documented. A detailed demographic, clinical, angio- graphic profile of all cases were recorded and stored on a file of excel. 121J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 A.M. Mohammad et al. Original Outcomes of PPCI in Iraq Ethical Approval and Patients Consent The study was approved by the appropriate ethical committee at the Kurdistan board of medical specialization (Erbil, Iraq. The number of order;) and an informed written consent was obtained from all participants, or legal guardians (either parent) as appropriate. Statistical Analysis Data from the original Excel file were transferred and analyzed by using Microsoft Office Excel 2007 and SPSS for Windows, version 16.0, Chicago. Continuous variables were calculated as mean ± (SD), and categorical variables were presented as counts and percentages. A chi-square test and fisher exact were used to compare the variables. P-value < 0.05 was regarded as significant. Results The main findings of patients by age groups are summarized in Table 1. The patients were predominately males. 30% were young (<50 years). The fast majority of PPCI was performed within first 6 hours of onset of chest pain. Risk factors were clustered among both young and old. Anterior (49%) then inferior (40) STEMI was the presentation. Normal coronary lumen angiogram seen in (1.3%). Drug eluting stents deployed in 92% of cases. Successful result (TIMI3) obtained in 94%. 80% of PPCI discharged home uneventfully with first 24 hours. 6-weeks LVEF preserved in 64%. 36% of cases survived but with MACEs. All-cause mortality was 4.6%. No major dif- ferences were seen between different age groups. In Table 2 the clinical, angiographic and outcomes find- ings of cases by the sex were summarized. However, the STEMI equivalent presentations were more common among women, Table 1. The main findings of patients (n = 151), by age groups Clinical finding 21–49 years (n = 46) 50–90 years (n = 105) Total (n = 151) P-value* No. % No. % No. % Sex Male 41 89.1 84 80.0 125 82.8 0.171 Female 5 10.9 21 20.0 26 17.2 Chief complaint Chest pain 41 89.1 86 81.9 127 84.1 0.626SOB 2 4.3 8 7.6 10 6.6 Other 3 6.5 11 10.5 14 9.3 Duration 0.5 hour 8 17.4 27 25.7 35 23.2 0.535 1 hour 18 39.1 45 42.9 63 41.7 2 hours 12 26.1 22 21.0 34 22.5 3–6 hours 3 6.5 3 2.9 6 4.0 > 6 hours 5 10.9 8 7.6 13 8.6 DM Positive 8 17.4 38 36.2 46 30.5 0.021 Negative 38 82.6 67 63.8 105 69.5 Smoking Positive 34 73.9 65 61.9 99 65.6 0.257Ex-smoker 1 2.2 2 1.9 3 2.0 Negative 11 23.9 38 36.2 49 32.5 Hypertension Positive 17 37.0 62 59.0 79 52.3 0.012 Negative 29 63.0 43 41.0 72 47.7 Dyslipidemia Positive 39 84.8 86 81.9 125 82.8 0.666 Negative 7 15.2 19 18.1 26 17.2 Family history Positive 9 19.6 25 23.8 34 22.5 0.565 Negative 37 80.4 80 76.2 117 77.5 Past medical history IHD 5 10.9 22 21.0 27 17.9 0.303Previous stents 1 2.2 3 2.9 4 2.6 Negative 40 87.0 80 76.2 120 79.5 Drugs Category 1 35 76.1 74 72.5 109 73.6 0.651 Category 2 11 23.9 28 27.5 39 26.4 BMI (kg/m2) 18–24.9 7 15.2 18 17.1 25 16.6 0.37825–29.9 34 73.9 82 78.1 116 76.8 30–35 5 10.9 5 4.8 10 6.6 (Continued) 122 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 Outcomes of PPCI in Iraq Original A.M. Mohammad et al. Table 1. The main findings of patients (n = 151), by age groups—Continued Clinical finding 21–49 years (n = 46) 50–90 years (n = 105) Total (n = 151) P-value* No. % No. % No. % Diagnosis Anterior STEMI 29 63.0 45 42.9 74 49.0 0.205 Inferior STEMI 15 32.6 46 43.8 61 40.4 Posterior STEMI 1 2.2 8 7.6 9 6.0 Lateral STEMI 1 2.2 4 3.8 5 3.3 STEMI equivalent 0 0.0 2 1.9 2 1.3 Angiogr. findings Normal CAG 1 2.2 1 1.0 2 1.3 0.575 Single v. disease 32 69.6 68 64.8 100 66.2 Two v. disease 6 13.0 22 21.0 28 18.5 Triple v. disease 7 15.2 14 13.3 21 13.9 Culprit artery LAD 28 60.9 47 44.8 75 49.7 0.169 RCA 11 23.9 45 42.9 56 37.1 LCX 4 8.7 9 8.6 13 8.6 LMS 2 4.3 3 2.9 5 3.3 Normal 1 2.2 1 1.0 2 1.3 Procedure Stenting 41 89.1 98 93.3 139 92.1 0.231 Ballooning 3 6.5 1 1.0 4 2.6 Graft stent 0 0.0 1 1.0 1 0.7 Surgery 0 0.0 2 1.9 2 1.3 Medical Rx 2 4.3 3 2.9 5 3.3 Result of PCI TIMI 0 flow 0 0.0 1 1.0 1 0.7 1.000 TIMI II flow 1 2.2 4 3.8 5 3.3 TIMI III flow 45 97.8 98 93.3 143 94.7 Surgery 0 0.0 2 1.9 2 1.3 Length of hospital stay 24 hours 39 84.8 82 78.1 121 80.1 0.343 > 24 hours 7 15.2 23 21.9 30 19.9 EF after 6 weeks 50–60 26 56.5 71 67.6 97 64.2 0.190 20–49 20 43.5 34 32.4 54 35.8 Six-weeks outcome Died 0 0.0 7 6.7% 7 4.6 0.137Survived with complication** 20 43.5 35 33.3 55 36.4 Survived without complications** 25 54.3 58 55.2 83 55.0 Censored*** 1 2.2 5 4.8 6 4.0 *Based on Chi-square or Fisher’s Exact test. **Stent thrombosis, readmission or EF < 50. ***Not included in the statistical test (missing data). N.B. All the percentages are vertical; therefore, comparisons are to made horizontally, between the two age groups. the males had more anterior STEMI. We notably not found a statistically significant difference between both gender in other parameters except of some expected risk factors like smoking among males. The Table 3 showed the relation of cases’s characteris- tics to 6 weeks (EF). The predictors of 6-weeks outcomes and LVEF were depend on type/location of STEMI, the cul- prit artery, TIMI flow post PCI and length of hospital stay. The impaired EF was observed among anterior STEMI (P < 0.001), LAD culprit (P < 0.001), less than TIMI3 PCI result (P < 0.039). The overall mortality and morbidity (MACEs) and longer length of in-hospitalization time were registered in lower LVEF. Discussion This registry showed the feasibility of PPCI with reasonable outcomes in STEMI patients. There were generally no clear differences in characteristics outcomes of STEMI with respect to gender and ages of patients. In the developed countries the CAD is typically aged related with low inci- dence of the disease among young compared to our area. Almost 30% of cases of STEMI in this study were among young.5 Another striking point is the predominate male gender affection by the disease in the current study. The potential explanation of this phenomena is that the males constitute the 123J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 A.M. Mohammad et al. Original Outcomes of PPCI in Iraq Table 2. Clinical findings of the patients (n = 151), by sex Clinical finding Males (n = 125) Females (n = 26) Total P-value No. % No. % No. % Chief complaint Chest pain 107 85.6 20 76.9 127 84.1 0.449SOB 8 6.4 2 7.7 10 6.6 Other 10 8.0 4 15.4 14 9.3 Duration 0.5 hour 27 21.6 8 30.8 35 23.2 0.080 1 hour 58 46.4 5 19.2 63 41.7 2 hours 25 20.0 9 34.6 34 22.5 3–6 hours 5 4.0 1 3.8 6 4.0 > 6 hours 10 8.0 3 11.5 13 8.6 DM Positive 32 25.6 14 53.8 46 30.5 0.004 Negative 93 74.4 12 46.2 105 69.5 Smoking Positive 97 77.6 2 7.7 99 65.6 <0.001Ex-smoker 3 2.4 0 0.0 3 2.0 Negative 25 20.0 24 92.3 49 32.5 Hypertension Positive 61 48.8 18 69.2 79 52.3 0.058 Negative 64 51.2 8 30.8 72 47.7 Dyslipidemia Positive 104 83.2 21 80.8 125 82.8 0.777 Negative 21 16.8 5 19.2 26 17.2 Family history Negative 95 76.0 22 84.6 117 77.5 0.339 Positive 30 24.0 4 15.4 34 22.5 Past medical history Negative 98 78.4 22 84.6 120 79.5 0.900IHD 23 18.4 4 15.4 27 17.9 Previous stents 4 3.2 0 0.0 4 2.6 Drugs Category 1 92 74.8 17 68.0 109 73.6 0.482 Category 2 31 25.2 8 32.0 39 26.4 BMI (kg/m2) 18–24.9 22 17.6 3 11.5 25 16.6 0.73125–29.9 95 76.0 21 80.8 116 76.8 30–35 8 6.4 2 7.7 10 6.6 Diagnosis Anterior STEMI 65 52.0 9 34.6 74 49.0 0.006 Inferior STEMI 50 40.0 11 42.3 61 40.4 Posterior STEMI 8 6.4 1 3.8 9 6.0 Lateral STEMI 2 1.6 3 11.5 5 3.3 STEMI equivalent 0 0.0 2 7.7 2 1.3 Angiogr. findings Normal CAG 1 .8 1 3.8 2 1.3 0.266 Single v. disease 85 68.0 15 57.7 100 66.2 Two v. disease 21 16.8 7 26.9 28 18.5 Triple v. disease 18 14.4 3 11.5 21 13.9 Culprit artery LAD 65 52.0 10 38.5 75 49.7 0.051 RCA 45 36.0 11 42.3 56 37.1 LCX 12 9.6 1 3.8 13 8.6 LMS 2 1.6 3 11.5 5 3.3 Normal 1 .8 1 3.8 2 1.3 Procedure Stenting 114 91.2 25 96.2 139 92.1 Ballooning 4 3.2 0 0.0 4 2.6 Graft stent 1 0.8 0 0.0 1 0.7 1.000 (Continued) 124 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 Outcomes of PPCI in Iraq Original A.M. Mohammad et al. Table 2. Clinical findings of the patients (n = 151), by sex—Continued Clinical finding Males (n = 125) Females (n = 26) Total P-value No. % No. % No. % Surgery 2 1.6 0 0.0 2 1.3 Medical Rx 4 3.2 1 3.8 5 3.3 Result of PCI TIMI 0 flow 0 0.0 1 3.8 1 0.7 0.265 TIMI II flow 4 3.2 1 3.8 5 3.3 TIMI III flow 119 95.2 24 92.3 143 94.7 Surgery 2 1.6 0 0.0 2 1.3 Length of hospital stay 24 hours 98 78.4 23 88.5 121 80.1 0.242 > 24 hours 27 21.6 3 11.5 30 19.9 EF after 6 weeks 50–60 77 61.6 20 76.9 97 64.2 0.138 20–49 48 38.4 6 23.1 54 35.8 Six-weeks outcome Died 5 4.0 2 7.7 7 4.6 0.114Survived with complication* 50 40.0 5 19.2 55 36.4 Survived (EF ≥50) without compl 65 52.0 18 69.2 83 55.0 Censored** 5 4.0 1 3.8 6 4.0 *Stent thrombosis, readmission or EF < 50. **Not included in the statistical test (missing data). N.B. All the percentages are vertical; therefore, comparisons are to made horizontally, between the two sexes. Table 3. Relation clinical findings of the patients (n = 151), with their outcome, in terms of Ejection Fraction (EF), after 6 weeks Clinical finding Six-weeks outcome (EF) P-value 50–60 (n = 97) 20–49 (n = 54) Total No. % No. % No. % Age 21–49 years 26 26.8 20 37.0 46 30.5 0.190 50–90 years 71 73.2 34 63.0 105 69.5 Sex Male 77 79.4 48 88.9 125 82.8 0.138 Female 20 20.6 6 11.1 26 17.2 Chief complaint Chest pain 85 87.6 42 77.8 127 84.1 0.064SOB 3 3.1 7 13.0 10 6.6 Other 9 9.3 5 9.3 14 9.3 Duration 0.5 hour 25 25.8 10 18.5 35 23.2 0.128 1 hour 41 42.3 22 40.7 63 41.7 2 hours 23 23.7 11 20.4 34 22.5 3–6 hours 1 1.0 5 9.3 6 4.0 > 6 hours 7 7.2 6 11.1 13 8.6 DM Positive 31 32.0 15 27.8 46 30.5 0.593 Negative 66 68.0 39 72.2 105 69.5 Smoking Positive 60 61.9 39 72.2 99 65.6 0.137Ex-smoker 1 1.0 2 3.7 3 2.0 Negative 36 37.1 13 24.1 49 32.5 Hypertension Positive 50 51.5 29 53.7 79 52.3 0.799 Negative 47 48.5 25 46.3 72 47.7 Dyslipidemia Positive 81 83.5 44 81.5 125 82.8 0.752 Negative 16 16.5 10 18.5 26 17.2 (Continued) 125J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 A.M. Mohammad et al. Original Outcomes of PPCI in Iraq Table 3. Relation clinical findings of the patients (n = 151), with their outcome, in terms of Ejection Fraction (EF), after 6 weeks—Continued Clinical finding Six-weeks outcome (EF) P-value 50–60 (n = 97) 20–49 (n = 54) Total No. % No. % No. % Family history Negative 77 79.4 40 74.1 117 77.5 0.454 Positive 20 20.6 14 25.9 34 22.5 Past medical history Negative 78 80.4 42 77.8 120 79.5 0.869IHD 16 16.5 11 20.4 27 17.9 Previous stents 3 3.1 1 1.9 4 2.6 Drugs Category 1 71 75.5 38 70.4 109 73.6 0.493 Category 2 23 24.5 16 29.6 39 26.4 BMI (kg/m2) 18–24.9 15 15.5 10 18.5 25 16.6 0.83725–29.9 76 78.4 40 74.1 116 76.8 30–35 6 6.2 4 7.4 10 6.6 Diagnosis Anterior STEMI 31 32.0 43 79.6 74 49.0 <0.001 Inferior STEMI 57 58.8 4 7.4 61 40.4 Posterior STEMI 4 4.1 5 9.3 9 6.0 Lateral STEMI 3 3.1 2 3.7 5 3.3 STEMI equivalent 2 2.1 0 0.0 2 1.3 Angiogr. findings Normal CAG 2 2.1 0 0.0 2 1.3 0.369 Single v. disease 68 70.1 32 59.3 100 66.2 Two v. disease 15 15.5 13 24.1 28 18.5 Triple v. disease 12 12.4 9 16.7 21 13.9 Culprit artery LAD 33 34.0 42 77.8 75 49.7 <0.001 RCA 50 51.5 6 11.1 56 37.1 LCX 9 9.3 4 7.4 13 8.6 LMS 3 3.1 2 3.7 5 3.3 Normal 2 2.1 0 0.0 2 1.3 Procedure Stenting 91 93.8 48 88.9 139 92.1 0.130 Ballooning 2 2.1 2 3.7 4 2.6 Graft stent 0 0.0 1 1.9 1 0.7 Surgery 0 0.0 2 3.7 2 1.3 Medical Rx 4 4.1 1 1.9 5 3.3 Result of PCI TIMI 0 flow 0 0.0 1 1.9 1 0.7 0.039 TIMI II flow 2 2.1 3 5.6 5 3.3 TIMI III flow 95 97.9 48 88.9 143 94.7 Surgery 0 0.0 2 3.7 2 1.3 Length of hospital stay 24 hours 86 88.7 35 64.8 121 80.1 <0.001 > 24 hours 11 11.3 19 35.2 30 19.9 Six-weeks outcome Died 1 1.0 6 11.1 7 4.6 <0.001 Survived with complication** 7 7.2 48 88.9 55 36.4 Survived (EF ≥50) without compl. 83 85.6 0 0.0 83 55.0 Censored*** 6 6.2 0 0.0 6 4.0 *Stent thrombosis, readmission or EF < 50. **Not included in the statistical test (missing data). N.B. All the percentages are vertical; therefore, comparisons are to made horizontally, between the two EF groups. 126 J Contemp Med Sci | Vol. 8, No. 2, March-April 2022: 120–127 Outcomes of PPCI in Iraq Original A.M. Mohammad et al. bulk of the young premature CAD and the second is the well- known protective effect of estrogen in premenopausal age in females.6,7 In term of cardiometabolic risk factors there was clear trend of clustering of risk factors in our patients. And this clustering was the main attributable to STEMI in our region. Hence, the control of such risk factors should be the priority in health agenda as soon as possible. It is recognizable that the traditional risk is more important the genetic polymor- phisms in this group of patients according to available data from the area.5,8 The fast majority of our cases were presented for first time with CAD with negative past history of coronary dis- ease. Only one fifth of cases had past history of CAD regard- less of the original presentation. This highlight the significant increase in the new cases and incidence of the disease in this area.9 Compared to previous report from our area the time of presentation of STEMI cases to hospital and emergency department is mildly improved.10 Since several years ago more than 50% of acute coronary syndrome cases were lately coming to hospital. In this registry the time of presentation was shorter than the time determined by previous report.10 This reflect some improvement in facilities and health educa- tion in the area. The angiographic profile of patient reflects another fact; the nature of coronary involvement in this study was extensive lesions. More than 30% of cases had more than one vessel dis- eased. And this point should raise the awareness about the silent CAD before the STEMI presentation.11 Depend on some national reports the nature of coronary lesion among our patients has two characters: more extensive lesions and more calcification. This point needs a particular attention by the community of cardiology in the area.12 The feasibility of the primary PCI procedure was achiev- able. Almost more than 90% cases underwent successful stenting with drug eluting platforms of the culprit artery with TIMI 3 flow in the culprit artery. The adopted policy for dis- charging cases post successful PPCI was within first 24 hours in 80% of cases and only 20% were stayed hospitalized for longer duration. This early discharge of stable cases after PPCI will preserve the economic and health facilities for those with critical cases.13 In terms of 6 weeks follow up, the LVEF were preserved in 65%. The remaining percent were presented with different level of impaired LVEF especially among the more vulnerable patients. Probably the stunning and particularly the hiberna- tion of the myocardium is one of the expected causalities beyond the impaired LVEF.14 In addition to different degree of heart failure and LV dysfunction there was higher rate OF MACE in this study compared to others.15 The predictors of 6-weeks adverse outcomes were depending mainly on type/ location of myocardial infarction, the culprit artery, TIMI flow post PPCI and length of hospital stay. Conclusion This study indicated that the 24 hours/7 days of week/ 365 days of year’s PPCI is feasible procedure in our area with acceptable outcomes. Within the accumulation of experi- ences in treating STEMI and PPCI among our health per- sonnel and staff we do expect better outcomes in the near future particularly if these experiences come in line with the health awareness of STEMI and chest pain among people. The implementation of recent STEMI management protocols like CODESTEMI or STEMI Alert in our area will add an additional step toward improving the STEMI outcomes and cathlab services.16,17 Conflicts of Interest None.  References 1. Mohammad, A.M., Jehangeer, H.I. & Shaikhow, S.K. Prevalence and risk factors of premature coronary artery disease in patients undergoing coronary angiography in Kurdistan, Iraq. BMC Cardiovasc Disord 15, 155 (2015). https://doi.org/10.1186/s12872-015-0145-7 2. Steg G, James S, Atar D, Badano L, Bldmstrom-Lundqvist C, Di Mario C, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2012;33:2569–2619. 3. Mohammad AM, Rashad HH, Habeeb QS, Rashad BH, Saeed SY. Demographic, clinical and angiographic profile of coronary artery disease in kurdistan region of Iraq. 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