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Association between education and major adverse cardiac events among patients with acute coronary syndrome in the Arabian Gulf
  1. Ibrahim Al-Zakwani1,
  2. Ruth M Mabry2,
  3. Mohammad Zubaid3,
  4. Alawi A Alsheikh-Ali4,
  5. Wael Almahmeed5,
  6. Abdullah Shehab6,
  7. Wafa Rashed7
  1. 1 Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
  2. 2 Office of the Regional Director, WHO Regional Office for the Eastern Mediterranean Region, Cairo, Egypt
  3. 3 Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
  4. 4 College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
  5. 5 Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
  6. 6 Internal Medicine Department, College of Medicine and Health Sciences (CMHS), UAE University, Al Ain, UAE
  7. 7 Department of Medicine, Mubarak Al-Kabeer Hospital, Ministry of Health, Safat, Kuwait
  1. Correspondence to Dr Ibrahim Al-Zakwani; ial_zakwani{at}


Introduction The objective of this study was to evaluate the association between education and major adverse cardiac events in patients with acute coronary syndrome (ACS) in the Arabian Gulf.

Methods Data were analysed from 3874 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013. Education was defined as any type of formal training from primary school and above. MACE included stroke/transient ischaemic attack (TIA), myocardial infarction (MI), all-cause mortality and readmissions for cardiac reasons.

Results The overall mean age was 60±13 years and 67% (n=2579) were men. A total of 53% (n=2039) of the patients had some form of school education. Adjusting for demographic and clinical characteristics as well as socioeconomic measures (insurance type and employment), at 12-month follow-up, educated patients were significantly less likely to have had MACE (adjusted OR (aOR): 0.55; 95% CI 0.44 to 0.68; p<0.001) than those with no formal education. The lower rate of events was also consistent across all MACE components: stroke/TIA (aOR: 0.56; 95% CI 0.33 to 0.94; p=0.030), MI (aOR: 0.58; 95% CI 0.38 to 0.86; p=0.008), all-cause mortality (aOR: 0.58; 95% CI 0.39 to 0.87; p=0.009) and readmissions for cardiac reasons (aOR: 0.61; 95% CI 0.48 to 0.77; p<0.001). MACE outcomes were consistent across men and women and across countries.

Conclusions Education was associated with lower MACE events in patients with ACS in the Arabian Gulf. Interventions promoting healthy lifestyles and management of clinical risk factors for patients with low health literacy are urgently required.

  • education
  • acute coronary syndrome
  • stroke
  • transient ischemic attack
  • myocardial infarction
  • mortality
  • patient readmission
  • arabs
  • middle east

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  • Handling editor Seye Abimbola

  • Contributors IA contributed towards literature search, data analysis and interpretation, figures and tables and writing of the manuscript. RM contributed towards literature search, interpretation and writing of the manuscript. MZ and WR contributed towards data management and oversight of the Gulf COAST registry. MZ, AAA-A, WA, AS and WR contributed towards drafting of the protocol, study design of the Gulf COAST registry, data collection and critical evaluation and interpretation of the results and the manuscript.

  • Funding Gulf COAST is an investigator-initiated study that was supported by Astra Zeneca with oversight by Kuwait University (project code XX02/11).

  • Disclaimer Neither Kuwait University nor AstraZeneca had any role in the study design, data collection, data analysis or writing the manuscript. The views expressed in this manuscript are those of the authors and do not necessarily reflect those of their affiliated institutions.

  • Competing interests MZ and WA received speakers’ bureau from Sanofi, Boehringer Ingleheim, Amgen and Astra Zeneca. AAA-A has received honoraria related to consulting and speaker’s activities from Boehringer-Ingelheim, Bayer and Pfizer.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the local institutional ethics committees of participating centres in the various Arabian Gulf countries.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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