SQU Med J, August 2011, Vol. 11, Iss. 3, pp. 338-342, Epub. 15th Aug 11
Submitted 12th Jan 11
Accepted 5th Apr 11

Acute coronary syndrome (ACS) is a clinical syndrome characterised by unstable angina (UA), ST-segment 
elevation myocardial infarction (STEMI) and 
non–STEMI. In the majority of cases, the primary 
mechanism of ACS is either erosion or rupture of 
an atherosclerotic plaque resulting in intracoronary 
thrombus formation leading to either subtotal or 
total occlusion of a major coronary artery. ACS 
is the most common cause of cardiovascular 
mortality and morbidity in Western countries. 
International guidelines with recommendations 
for diagnosis and treatment have been developed 
based on randomised clinical trials.1,2 However, 
data from international registries like the National 
Registry of Myocardial Infarction from the USA3 

and the Global Registry of Acute Coronary Events 

(GRACE),4 report a lack of association between 
guideline recommendations and actual clinical 
practice. Similar to these registries, the Gulf Heart 
Association initiated a registry called Gulf Registry 
of Acute Coronary Events (Gulf RACE). This registry 
was developed to determine the characteristics and 
management of ACS in the Gulf countries including 
Oman.5 Registry data is extremely important 
because the information is derived from unselected 
populations of patients reflecting "real-life" practice 
as well as including patients who are frequently 
left out of clinical trials, such as the elderly or 
female patients. Additionally, registries allow an 
assessment of the acceptance and practice of new 
treatments by the medical community.

Gulf RACE is the largest multinational 
prospective ACS registry from the Middle East with 

1Department of Cardiology, Royal Hospital, Muscat, Oman; 2Department of Pharmacology & Clinical Pharmacy, College of Medicine 
& Health Sciences, Sultan Qaboos University, Muscat, Oman, and 3Gulf Health Research, Muscat, Oman.
*Corresponding Author email: prashanthp_69@yahoo.co.in 

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aBstract: Acute coronary syndrome (ACS) is the most common cause of cardiovascular mortality and 
morbidity in Western countries. International guidelines for diagnosis and treatment have been developed based 
on randomised clinical trials. However, data from international registries report a lack of association between 
guideline recommendations and actual clinical practice. Similarly, the Gulf Heart Association initiated a registry 
called Gulf Registry of Acute Coronary Events (Gulf RACE). This registry was developed to determine the 
characteristics and management of ACS in the Gulf countries including Oman. Here, we report on the results of 
the various Gulf RACE registry studies from Oman and compare our results with the main Gulf RACE data as 
well as other international registries.

Keywords: Acute coronary syndrome; Oman

SOUNDING BOARD

Acute Coronary Syndrome in Oman
Results from the Gulf Registry of Acute Coronary Events

*Prashanth Panduranga,1Kadhim Sulaiman,1 Ibrahim Al-Zakwani2,3



Sounding Board | 339

Prashanth Panduranga, Kadhim Sulaiman, Ibrahim Al-Zakwani

more than 8,000 patients with a final diagnosis of 
ACS admitted in the periods 8 May to 6 June 2006 
and 29 January to 29 June 2007. It provides a unique 
opportunity to study ACS management in this part 
of the world. As part of the Gulf RACE study, the 
data from Oman on 1,579 patients from 14 hospitals 
(including two hospitals with catheterisation 
facilities) have thrown light on the characteristics, 

management, and in-hospital outcomes of ACS 
patients in Oman. This registry determined the 
epidemiology of ACS including risk factors, clinical 
presentation, accuracy of ECG (electrocardiogram) 
interpretation, validation of risk models like the 
GRACE risk score, and in-hospital management, 
including utilisation of medications and invasive 
procedures. This registry also determined whether 
the evidence-based guideline recommendations are 
being applied, along with in-hospital outcomes and 
mortality in patients with ACS.

Table 1 shows the baseline characteristics of 
ACS patients from Oman. With a mean age of 
59 years, ACS patients from Oman are younger 
than those in Western countries whose mean age 
is about 65 years.4 The majority of patients were 
Omani citizens (84%) and were male (61%). In the 
GRACE registry, women consisted of 34% of the 
patients whereas in Oman they formed 39% of ACS 
patients.4 Among the risk factors, hypertension 
was the commonest risk factor (53%) followed by 
diabetes (37%) and hyperlipidaemia (35%). Smoking 
(17%), a family history of coronary artery disease 
(CAD) and obesity were not found to be high in 
ACS patients from Oman. In the GRACE UK-
Belgian study, hypertension was recorded in 46% of 
patients, diabetes in 16% and smoking in 30% of the 
patients.6 In the main Gulf RACE registry, diabetes 
and smoking prevalence were high at 40% and 38%, 
respectively.5 This high prevalence of diabetes among 
ACS patients from Oman and other Gulf countries 
is an alarming trend as it is well known that diabetic 
ACS patients have poor hospital outcomes. This 
was reported in a recent Gulf RACE analysis from 
Oman.7 When adjusted for age and gender, diabetes 
status was an independent risk factor of in-hospital 
mortality in ACS patients (adjusted odds ratio [OR] 
1.68; 95% confidence interval [CI] 1.02–2.77; P = 
0.042).7 Moreover, the burden of diabetes mellitus 
in Gulf countries is the highest among all world 
regions (13–18% versus the 6–7% global prevalence) 
and according to the International Diabetic 
Federation it will double by 2030.8 Furthermore, in 
another analysis of Gulf RACE data from Oman, it 
was seen that non-diabetic ACS patients presenting 
with hyperglycaemia of >11 mmol/L were found 
to have a higher mortality rate when compared 
to euglycaemic patients (13.1% versus 1.52%;  
P <0.001).9 This indicates that diabetes mellitus 
remains undiagnosed in many patients in Oman. 

Table 1: Baseline clinical characteristics of patients with 
acute coronary syndrome from Oman

Characteristic N = 1,579

Age + SD

Age, mean ± SD, years 58 ± 13

Body mass index, mean ± SD, kg/m2 27 ± 5

(n, %)

Male gender 971 (61)

Omani citizen 1326 (84)

Diabetes mellitus 581 (37)

Hypertension 838 (53)

Hyperlipidaemia 550 (35)

Current smoker 278 (17)

Family history of CAD 121 (7.6)

Prior Angina 757 (48)

Past MI 285 (18)

Past PCI 118 (7.5)

Past CABG 108 (6.8)

Aspirin use 751 (47)

COPD 77 (4.8)

Stroke 55 (3.4)

Dialysis 26 (1.6)

PVD 34 (2.1)

Ischemic chest pain 1154 (73)

Atypical chest pain 109 (6.9)

Dyspnoea 216 (14)

Unstable angina 795 (50)

Non-STEMI 381 (24)

STEMI 393 (25)

LBBB MI 10 (0.6)

Legend: NS = non-significant; SD = standard deviation; CAD = coronary 
artery disease; MI = myocardial infarction; PCI = percutaneous 
coronary intervention; CABG = coronary artery bypass surgery; COPD 
= chronic obstructive pulmonary disease; PVD = peripheral vascular 
disease; STEMI = ST-elevation myocardial infarction; LBBB = left 
bundle branch block. All values are n (%) unless specified otherwise.



340 | SQU Medical Journal, August 2011, Volume 11, Issue 3

Acute Coronary Syndrome in Oman 
Results from the Gulf Registry of Acute Coronary Events

Hence, measures to prevent and control diabetes 
as well as diagnose it early are very important in 
Oman. Even though hyperlipidaemia was found 
in 34% of ACS patients in a recent analysis of Gulf 
RACE patients from Oman, metabolic syndrome 
was found to be present in 66% of patients who had 
higher rates of heart failure (odds ratio (OR): 1.37; 
95% confidence interval (CI): 1.03–1.81; P = 0 .028) 
and mortality (OR: 4.42; 95% CI: 1.25–15.5; P = 
0.020) when compared to non-metabolic syndrome 
patients.10 

Among ACS patients from Oman, prior angina 
was seen in 48% of patients, with prior myocardial 
infarction (MI) in 18%, prior percutaneous coronary 
intervention (PCI), or coronary artery bypass graft 
surgery (CABG) in 7.5% and 6.8%, respectively, and 
prior stroke in 3.4% of patients. The prevalence of 
prior angina is similar to the GRACE UK-Belgian 

study where it was found in 47% of the patients, 
but prior MI, prior PCI, prior CABG, and previous 
stroke were higher in Oman than in the GRACE 
population at 28%, 17%, 11% and 8% respectively.6 

Of the 1,579 ACS patients from Oman, 50% had a 
final diagnosis of UA, 25% had STEMI, and 24% had 
non-STEMI. Among the types of ACS, investigators 
of the GRACE registry reported that UA was the 
most frequent cause of hospital admission (38%), 
followed by 30% STEMI, and 25% non-STEMI 
patients.4 The occurrence of UA is higher in patients 
in Oman, which indicates that picking up these 
patients for an early invasive strategy will prevent 
future cardiac events. 

Figures 1 and 2 show the in-hospital management 
of ACS patients in Oman. The frequent use of in-
hospital evidence-based pharmacologic therapies, 
such as aspirin (98%), anticoagulation (84%), statins 

0

10

20

30

40

50

60

70

80

90

100

ASA 

98 

25 

84 

0.5 

62 
68 

85 

11 

CLO HEP
In-hospital management

GP BB ACE/ARB STA CAG

Per
cen

tag
e o

f pa
tien

ts

Figure 1: In-hospital management of patients with acute coronary syndrome from Oman. 
Legend: ASA = aspirin; CLO = clopidogrel; HEP = heparin (includes low molecular weight heparin); GP = glycoprotein IIb/IIIa inhibitors; BB = beta-
blockers; ACE = angiotensin-converting enzyme inhibitors; ARB = angiotensin II receptor blockers; STA = statins; CAG = coronary angiography.

Figure 2: Missed opportunities for thrombolysis in patients with acute coronary syndrome from Oman. 



Sounding Board | 341

Prashanth Panduranga, Kadhim Sulaiman, Ibrahim Al-Zakwani

(85%), and thrombolytic therapy (91%) is similar 
to the GRACE and CRUSADE (Can Rapid Risk 
Stratification of Unstable Angina Patients Suppress 
Adverse Outcomes With Early Implementation of 
the ACC/AHA Guidelines) registries.4,11,12 The use 
of beta-blockers (62%) is low in Oman compared 
to nearly 80% use in these registries as well as in 
the main Gulf RACE registry, but angiotensin-
converting enzyme inhibitors (ACEI)/angiotensin 
II receptor blockers (ARB) (68%) use is similar to 
these registry reports. This variation in the use 
of guideline-recommended medications may be 
related to patient or physician characteristics, as well 
as hospital type and national variations.11,12 In one of 
the GRACE analyses, which may be true for Oman 
as well, high-risk features (e.g. heart failure, older 
age) were related to failure to use beta-blockers, but 
being at a teaching hospital and care by a cardiologist 
were associated with better use of these drugs.13 
Some drugs with proven benefits were used less 
often, such as clopidogrel (25%) and glycoprotein 
IIb/IIIa receptor inhibitors (0.25%), probably due 
to the non-availability of these medications in most 
of the hospitals in Oman. Among STEMI patients, 
26% had delayed presentation of >12 hours which 
is similar to the GRACE study;11 however, 91% of 
the eligible patients were thrombolysed which is 
consistent with guideline recommendations. 

Coronary angiography was utilised in only 11% 
of the patients which is mostly due to the existence 
of only two invasive catheterisation facility 
hospitals in Oman. However, in a recent Gulf RACE 
analysis14 overall utilisation of catheterisation in 
ACS patients from all Gulf countries was very low 
(20%) when compared to 66% usage rate in the 
GRACE registry.11 Other than the unavailability of 

catheterisation facilities, a second important reason 
for the low rate was the avoidance of catheterisation 
in high risk ACS patients among Gulf cardiologists. 
Low risk ACS patients were more often catheterised 
than intermediate or high risk patients.11 This 
"treatment-risk paradox" has been proposed as one 
of the reasons why less or no mortality benefit was 
seen in some ACS registries when compared with 
randomised trials.

Table 2 shows the in-hospital outcomes of ACS 
patients from Oman. Most of the outcomes were 
comparable to the GRACE registry except for 
the high prevalence of heart failure (25%) among 
Omani ACS patients which is nearly twice that 
of the GRACE registry. The reason could be the 
high prevalence of diabetic ACS patients in Oman. 
In-hospital mortality of 4.3% is low compared to 
10.8% in the GRACE registry. In another analysis 
of ACS patients from Oman, women experienced 
more recurrent ischaemia and heart failure, but 
had similar in-hospital mortality (4.6% versus 4.3%) 
even after adjusting for age (P = 0.500).15

In conclusion, ACS patients in Oman, 
compared to other countries, are younger with 
higher rates of diabetes and heart failure, but lower 
overall in-hospital mortality. There is evidence 
of good adherence to most of the evidence-based 
medications, except for the use of catheterisation. 
There is a need to explore ways to increase the 
overall rate of in-hospital cardiac catheterisation as 
well as to provide other evidence-based medications 
in Oman and prescribe them to patients who would 
benefit most. In addition, there is a need to diagnose 
and control diabetes effectively. Awareness of 
these findings from Oman may help the medical 
community adhere more strictly to the national and 
international guidelines.

References
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3. Rogers WJ, Canto JG, Lambrew CT, Tiefenbrunn 
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Table 2: In-hospital outcome in patients (n,[%]) 
presenting with acute coronary syndrome from Oman

Characteristic N = 1,579

Recurrent ischaemia 150 (9.4)

Re-infarction 38 (2.4)

Congestive heart failure 403 (25)

Ventilation 82 (5)

Cardiogenic shock 89 (5.6)

Major bleed 16 (1)

Stroke 16 (1)

Mortality 69(4.3)



342 | SQU Medical Journal, August 2011, Volume 11, Issue 3

Acute Coronary Syndrome in Oman 
Results from the Gulf Registry of Acute Coronary Events

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