The location of our tertiary cardiac center in the holy city of Makkah near to Haram and holy sites of Mena, Arafat, and Mouzdalifa is unique as it received all AMI indicated for interventions including huge number of hajj patients increasing yearly; hence, this created and raised the idea for the current study. No prior study conducted in Saudi Arabia comparing pilgrim vs non-pilgrim AMI patients regarding clinical characteristics, management, and outcomes.
Three thousand and forty-four patients with diagnosis of acute myocardial infarction were referred and admitted to our cardiac center from 2016 till 2019 for further revascularization. During the four hajj seasons (2016–2019), one thousand and eight pilgrim AMI patients were admitted and treated in our center. Pilgrim patients presented with acute myocardial infarction were elderly compared to non-pilgrims, and this is expected, as these are people in such age category who come for the hajj pilgrimage after finishing all their essential responsibilities. This is prescribed in previous few studies, which conducted to assess pattern of CVD among pilgrims [10, 11]. Interestingly, those hajj patients in spite of being elderly, they had lower cardiovascular risk profile compared to residence in Saudi Arabia. Different genetic, racial, environmental, and cultural backgrounds of those populations who came from variable places might explain this. Also, AMI pilgrim patients had significant values of laboratory markers suggestive of their dehydration and hyper-osmolarity compared to non-pilgrims, and this is addressed by our group in a different study .
Moreover, from our interesting findings in the current study, those AMI pilgrims were less likely to receive thrombolytic therapy and showed lower rate of late presentation compared to non-pilgrims. This could be explained by during hajj, cath lab work full capacity 24 h, 12 h shift day same as night; however, residence of Makkah sometimes come from remote area that managed by drip and shift strategy while pilgrims are mostly within Makkah city. Also, those AMI hajj patients had higher prevalence of severe coronary artery disease (multi-vessel CAD and LM disease) compared to residence, and in spite of being early revascularized with PPCI, they still showed significant LV dysfunction in their echocardiogram post MI. This could be explained by many factors including genetic variation, degree of atherosclerosis, different thrombotic activity, distribution of collateral circulation, and severe physical and emotional stress they had been developed during hajj. Moreover, the utilization rate of PPCI was recorded relatively higher among pilgrim patients with higher achieved door to balloon time < 90 min. There are several factors could explain the significant improvement of the service provided to AMI hajj patients. First, the great effort and support of the government of Saudi Arabia through the ministry of health and hajj committee to implement the program of increasing hajj manpower included interventionist cardiologist working at our center during hajj seasons. Second, raise number of the working cath labs. Third, well establishment of organized network for urgent transport of the AMI hajj patients from all Al-Mashaer, primary, and secondary hospitals to our tertiary hospital; this includes air medevac transportation. Fourth, proper preparation of all Makkah hospitals with emergency situations and to provide short-term hospitalization services with immediate transfer to our center for intervention and urgent revascularization.
Surprisingly, those AMI hajj patients who were early revascularized with PPCI, they showed significant higher rates of post AMI complications and poor outcomes. With respect of the mortality, the over all in-hospital mortality rate among our studied AMI patients was recorded (3%), and it was comparable to which reported by a recent AMI registry in Saudi Arabia ; however, it is still higher among pilgrim patients compared to non-pilgrims. Moreover, it was found that being a pilgrim would double the risk of death once got AMI. These poor in-hospital outcomes among pilgrim patients could be explained by several factors: being elderly, had critical CAD anatomy (multi-vessel CAD and LM disease), were exposed to great dehydration, severe physical and emotional stress that all might lead to huge deterioration, and adverse impact LV function and hence poor outcomes. Also, in spite of having more complication, pilgrims showed shorter length of hospital stay compared to non-pilgrims, and this might be related to many factors. First, many of them signed discharge against medical advice and went to complete their hajj and then back to their own countries. Second, referring back to their primary hospitals after revascularization to complete their hospital course (due to high need of beds during hajj season to compensate more patients who need coronary angiography). Third, some of them are taken by their groups to complete their medical care under their own responsibilities.
Unlike AMI pilgrims, non-pilgrim patients who presented with myocardial infarctions were younger in age with higher prevalence of cardiovascular risk factors. Our findings consisted with a recent multi-center registry study in 50 hospitals from various health care sectors in Saudi Arabia were conducted for AMI to evaluate the clinical characteristics, management, and outcomes of a representative sample of patients with acute myocardial infarction (AMI) in Saudi Arabia. It concluded that AMI patients in Saudi Arabia presented at relatively young age and had a high prevalence of CAD risk factors . This is also similar to results from prior ACS registries in Saudi Arabia  and mentioned by several other studies [15,16,17].
Interestingly that all our AMI population had proper access to primary PCI with higher recorded rates than reported in the previous studies [13, 18,19,20]. This is explained by the unique and valuable location of our center in the region with 24/7 acute interventional facilities, receive most of MI patients with significantly improvement in the communication, and transportation of the patients from all peripheral hospitals. Moreover, the recorded rate of primary PCIs utilization is relatively higher among pilgrim patients. This is because of the above mentioned increased proper facility services provided during the hajj seasons, and actually this is considered as unique issue provided by our center for early revascularization to those hujaj who were likely in need to complete the hajj and return back to their countries. The in-hospital outcome measures including the mortality rate were better in non-hajj compared to AMI pilgrims, and this could be explained by being younger at age, had better LVEF post AMI, and less critical CAD anatomy compared to pilgrim patients.
Finally, cardiogenic shock, arrhythmias, and respiratory failure were the most common causes of death among our patients with observed less recorded arrhythmic death among pilgrims compared to non-pilgrims. This is unclear but might be explained by different genetic factors, being early revascularized with PPCI (less myocardial necrosis and scare formation which predispose to arrhythmias) and early discharged from the hospital (late arrhythmias might be not detected).
In conclusion, hajj is a major annual mass gathering of millions of people from all over the world, with different cultures, socioeconomic levels, knowledge, attitudes, and most importantly health statuses . The causes of morbidities and mortalities are varied . Current study provides detailed information about cardiovascular risk profile, clinical characteristics, hospital course, and short-term outcomes of pilgrim patients admitted with AMI.