Frequency of Cardiac Events in Patients with or without Diabetes Admitted to a Cardiac Unit of Dubai Hospital before, during, and after Ramadan

Abstract

Objective To understand the impact of Ramadan fasting on people with diabetes and cardiovascular diseases (CVDs). Many people with diabetes have a range of CVD conditions, such as coronary artery disease, heart failure, and/or diabetic cardiomyopathy. This is of particular importance as there is no benchmark to compare the incidence for cardiac events during fasting in Ramadan in people with diabetes due to lack of adequate studies.

Methods We observed the frequency of admission with cardiac events such as congestive cardiac failure, unstable angina, acute coronary syndrome, non-ST elevation myocardial infarction, and ST elevation myocardial infarction in people with and without diabetes across the 3 months of Sha'ban (the month pre-Ramadan), Ramadan, and Shawwal (the month post-Ramadan) in the year 2018. The detailed history and biophysical and biochemical data are presented as frequency and percentages.

Result The majority of admissions were from people with Muslim background (87.1%). People with diabetes constituted 45.5% of total admissions. Nondiabetic patients were younger (53.50 ± 11.91 vs. 63.56 ± 13.17 years, p = 0.05) and have significantly higher low-density lipoprotein-cholesterol value compared to those with diabetes (129.70 ± 45.47 vs. 97.00 ± 29.56 mg/dL, p = 0.05). In Muslim patients, hospitalization in the month of Ramadan was much lower compared to the months of Sha'ban and Shawwal (24.1, 40.4, and 35.5%, respectively). Admissions in those with no previous history of diabetes was lower during Ramadan (57.1%) compared to Shaaban (64.6%) and Shawwal (72.2%). In people with diabetes, the hospitalization rate during Ramadan with ischemic heart disease (IHD) was higher (88.91%) compared to the months of Shaaban (63.6%) and Shawwal (62.9.%). However, during the same period, admissions with congestive heart failure (CHF) were much lower (11.1, 36.4, and 36.1%, respectively).

Conclusion The overall admission with CVD during Ramadan is lower than the month before or after. The rate of reduction in admissions during Ramadan was marginal in those with previous history of CVD and diabetes mellitus; however, this was much more obvious in those with no history of CVD. During the month of Ramadan, there were lower rates of admission with CHF while admissions with IHD were higher compared to the previous or following month in diabetic patients.

Keywords

diabetes - cardiovascular events - Ramadan - congestive heart failure - Ischemic heart disease

Introduction

Ramadan fasting has great importance from a religious perspective among Muslims. During fasting hours, Muslims are prohibited from drinking, eating, smoking, or engaging in sexual activity. While Islam exempt people with illness from fasting, many Muslims with diabetes prefer to fast.[1] [2] [3]

Recent interest has increased in the medical emergencies during Ramadan fasting.[4] [5] As Ramadan is usually a month of high spiritual and social impact, many Muslims try to avoid elective admissions and postpone it until after Ramadan unless there is a serious health need. It is not clear whether acute cardiac emergencies are linked to diabetes and indeed, the impact of fasting on the cardiac events in people with or without diabetes is not well studied.

Ramadan fasting in people with diabetes and cardiovascular disease (CVD) can increase risk of hypoglycemia.[6] Previous studies showed that when a person fasts for long duration, has missed their medications, and consumed diet rich in sugar and/or carbohydrate and fat, this can lead to detrimental plasma coagulation and hemostatic factors.[7] These changes lead to higher risk of coronary plaque rupture, vascular thrombosis, and aggravation of underlying coronary heart disease (CHD).[7] Few retrospective surveys with inconsistent findings have looked into how Ramadan fasting affects cardiovascular (CV) outcomes in people with underlying CHD.[7] [8] [9] Other research found that during Ramadan fasting, cardiac risk factors such lipid profile, body weight, and their metabolic management had a favorable or impartial outcome.[8] [9] [10] The population-based nature of all these investigations precluded a detailed examination of the type and incidence of cardiac events in the diabetes population.[11]

Type 2 diabetes (T2D) is a prevalent disease globally, particularly in the Gulf region, impacting primarily aging and middle age population who are mostly at higher risk of CV problem.[12] The Cardiology Unit of Dubai Hospital, Dubai Health Authority is one of the main referral centers for cardiac patients in Dubai, where Islam is the religion of the overwhelming majority of patients, which presents a unique opportunity to understand the notional risk of increased CVD by Ramadan fasting in real life scenario.

The primary aim of the study is to observe the hospitalization rate with CV events in patients with diabetes and those without diabetes during Ramadan, and to compare it with the months before and after Ramadan. The secondary aim of the study is to observe the characteristics of the patients hospitalized with acute cardiac events during Ramadan, compared to before and after Ramadan. Also, to understand the differences in CVD events and interventions in patients with or without diabetes during Ramadan compared to before and after Ramadan.

Subjects and Methods

Subjects

This is an observational study assessing the rate of hospitalization with acute CV events in the months of Ramadan, Sha'ban, and Shawwal in Dubai Hospital, a tertiary care center in United Arab Emirates in 2018. We included all patients above 18 years of age who were admitted through emergency department of Dubai Hospital and attended by cardiologists with a diagnosis of acute coronary syndrome (ACS) including ST elevation myocardial infarction, non-ST elevation myocardial infarction, and congestive cardiac failure. We excluded patients younger than 18 years of age or those who refused to sign a consent form.

Methods

After obtaining an informed written consent, the history was taken, which included gender, religion, age, state of fasting, history of diabetes, previous history of any CVD, and all the medication details. Patients' weight and systolic and diastolic blood pressures were recorded. The biochemical data collected included hemoglobin A1c (HbA1c), renal function, and lipid profile. Patients were prospectively followed during the period of hospitalization for cardiac management and data for cardiac intervention were recorded. Patients were admitted by a cardiologist with a diagnosis of acute coronary syndrome including ST elevation myocardial infarction, non-ST elevation myocardial infarction and congestive cardiac failure.[12] A patient was considered to have diabetes if the American Diabetes Association criteria for the diagnosis of diabetes mellitus (fasting blood glucose ≥ 126 mg/dL, random blood glucose ≥ 200 mg/dL, or HbA1c ≥ 6.5%) were met.

Data Collection and Statistical Analysis

All the data were entered in an Excel sheet and were prepared for analysis. The Shapiro–Wilk test was used to test the normality of numerical variables. Normally distributed numerical variables were presented as mean ± standard deviation (SD) and skewed numerical variables were presented as median (first quartile, third quartile). Categorical data were presented as count and percent. To compare a numerical variable between groups, T- test or ANOVA (analysis of variance) was used if the numerical variable is bell-shaped in all the groups, and the Mann–Whitney test or Kruskal–Wallis test was used if the numerical variable is skewed in at least one of the groups. The chi-squared test was used to compare the percent of diabetes mellitus patients during the 3 months of the study. All tests are two-tailed tests and a p-value <0.05 indicates a statistically significant result. SPSS 28 was used for the statistical analysis (IBM Corp, Released 2021, IBM SPSS Statistics for Windows, Version 28.0. Armonk, New York, United States).

Results

Characteristics of the Study Population

The total number of patients who were admitted with different acute CV problems during the three months of the study period was 233. Out of them, 197 (84.5%) were males and 36 (15.5%) were females, and 33% were known to have previous history of CVD. Of the total patients, 203 were Muslim patients (87.5%) and 106 (45.5%) were people with diabetes ([Table 1]). Further data analyzed in Muslim patients showed that there are lesser number of hospitalizations in the month of Ramadan with any CV event compared to Sha'ban and Shawwal (24, 40, and 36%, respectively). Out of those who were admitted during Ramadan, 51% of them had existing diabetes and 42.9% of them had a history of previous CHD ([Table 2]).

Table 1 Characteristics of patients

Parameters	Number	%	Age (y)
Sex:
All	233	100.0%	54 (47, 65)
Male	197	84.5%	52 (46, 62)
Female	36	15.5%	66.9 ± 13.7
History of diabetes
Yes	106	45.5%	60.4 ± 12.0
No	127	54.5%	50 (45, 62)
History of cardiovascular disease
Yes	77	33%	63.2 ± 12.8
No	156	67%	51 (46, 58.75)
Religion
Muslim	203	87.1%	55 (48, 68)
Non-Muslim	30	12.9%	50.2 ± 9.0

Table 2 Distribution of Muslim patients (with and without diabetes (DM)) across the 3 months of the study

Month	Muslim patients	Diabetes	No diabetes	p-Value	Known CVD
Sha'ban	82 (40.4%)	40 (48.8%)	42 (51.2%)	0.92	29 (35.4%)
Ramadan	49 (24.1%)	25 (51%)	24 (49%)		21 (42.9%)
Shawwal	72 (35.5%)	34 (47.2%)	38 (52.8%)		20 (27.8%)

Abbreviation: CVD, cardiovascular disease.

Data of Ramadan

During Ramadan, there were 49 Muslims admitted to the Dubai Hospital Cardiology Department, out of the total number of admissions in the study. Of these, 31 (63.3%) persons were fasting. Out of these 49 cases, there were 25 patients with diabetes and 24 cases without diabetes. In Muslim patients with diabetes, 14 (56%) observed fast during Ramadan, while 11 (44%) patients did not. People with diabetes fasted lesser number of days compared to those with no diabetes (10 vs. 14, p = 0.053).

Preexisting CVD was noted in 56% of patients with diabetes, compared to 29% without diabetes.

Muslim patients with and without diabetes showed a body mass index (mean ± SD) of 27.7 ± 4.7 versus 28.9 ± 4.54, p = 0.33, the mean systolic blood pressure in patients with diabetes was 146.4 ± 24.9 versus 129.9 ± 31.5 mmHg, p = 0.1, while the mean diastolic blood pressure was 76.7 ± 15.4 versus 84.5 ± 17.0 mmHg, p = 0.1, respectively, with no statistically significant difference ([Table 3]).

Table 3 Comparison of risk factors in patients with diabetes versus without diabetes in the months of Sha'ban (8th), Ramadan (9th), and Shawwal (10th)

Risk factor	Group	n	Shaaban, N = 82	n	Ramadan, N = 49	n	Shawwal, N = 72	p-Value
Age (y)	DM	40	62 ± 12.2	25	63 ± 13.2	34	57.3 ± 10.9	0.109[a] 0.612[b]
	No DM	42	51 (47, 62.5)	24	52 (47.25, 60)	38	48.5 (42, 68)
	p-Value		0.005[c]		0.01[c]		0.09[c]
Body mass index (kg/m2)	DM	40	29.3 ± 4.5	25	27.7 ± 4.7	34	27.9 (24.2, 32.9)	0.256[b] 0.556[b]
	No DM	42	27.5 (24.3, 30.3)	24	28.9 ± 4.5	38	27.2 (23.4, 31)
	p-Value		0.116[c]		0.331[d]		0.37[c]
HbA1c (%)	DM	39	7.0 (6, 8.9)	24	8.6 ± 2.1	32	8.1 ± 1.6	0.177[b] 0.093[b]
	No DM	42	5.5 (5.1, 5.7)	22	5.8 (5.4, 6.4)	35	5.5 (5.3, 6)
	p-Value		<0.001[c]		<0.001[c]		<0.001[c]
SBP (mmHg)	DM	40	131.5 (112.8, 131.5)	25	146.4 ± 24.9	34	140.3 ± 24.6	0.120[b] 0.545[b]
	No DM	42	136 ± 23.1[c]	24	129 (111.5, 143.3)	38	138.6 ± 2.1
	p-Value		0.358		0.105[c]		0.988[d]
DBP (mmHg)	DM	40	68.5 (59.3, 80.8)	25	76.7 ± 15.4	34	82.1 ± 17.5	0.015[b] 0.676[a]
	No DM	42	85 ± 17.3	24	84.5 ± 17	38	82 ± 17.2
	p-Value		<0.001[c]		0.101[d]		0.774[d]
LDL (mg/dl)	DM	37	87.7 ± 38.8	25	97 ± 29.5	31	84 (70, 120)	0.475[b] 0.04[a]
	No DM	41	107.1 ± 48.7	23	129.7 ± 45.5	35	101 ± 29.8
	p-Value		0.057		0.006[d]		0.128[c]
HDL (mg/dl)	DM	38	36.2 ± 9.5	25	39 (32.5, 50)	31	37.2 ± 11	0.079[b] 0.268[b]
	No DM	42	38 ± 9.8	23	37.4 ± 7	36	33 (29, 42.5)
	p-Value		0.412		0.207[c]		0.323[c]
Creatinine (mcg/L)	DM	40	1.1 (0.8, 1.48)	25	0.8 (0.7, 0.95)	34	0.95 (0.7, 1.43)	0.081[b] 0.571[b]
	No DM	42	0.8 (0.7, 1.13)	24	0.9 (0.73, 1.18)	38	0.8 (0.7, 0.93)
	p-Value		0.079[c]		0.17[c]		0.169[c]

Abbreviations: DBP, diastolic blood pressure; HDL, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol; SBP, systolic blood pressure.

^a ANOVA test.

^b Kruskal–Wallis test.

^c Mann–Whitney test.

^d T-test.

Comparative Data across the 3 Months

HbA1c was higher in people with diabetes; however, it is important to note that nondiabetics admitted with acute cardiac events had the mean HbA1c% in the pre-diabetic range (5.8 ± 1.63%). Muslim patients without diabetes were generally younger than diabetics across the 3 months and have significantly higher low-density lipoprotein-cholesterol value in Ramadan (129.7 ± 45.5 vs. 97 ± 29.5 mg/dL, p = 0.006) and a higher diastolic blood pressure in Sha'ban (85.38 ± 17.3 vs. 68.5 ± 21.5, p < 0.001). Full details of the various biochemical and biometric parameters across the study duration are reported in [Table 3].

Type of Cardiac Events

We recorded a high rate of hospitalization with CHF in people with diabetes compared to nondiabetics across the study duration ([Figs. 1] and [2]). During Ramadan, rates of admissions with CHF were reduced from 36% pre-Ramadan to 11.1%, while admissions with ischemic heart disease (IHD) were increased from 64 to 88%. These changes were not noted in nondiabetics across the 3 months.

Fig. 1 Type of cardiac diagnosis in nondiabetics during study periods.

Fig. 2 Type of cardiac diagnosis in diabetics during study periods.

Discussion

The current study aimed to understand the rate of admission with different types of acute cardiac events in the months of Ramadan, Sha'ban, and Shawwal in patients with diabetes and without diabetes.

The recognition of the growing importance of Ramadan fasting in different subsets of medical illnesses has led to an increased number of guidelines on the subject.[14] [15] [16] However, upon literature review, we found that many studies have looked into different cardiac events, symptoms, hospitalizations, and mortality associated with Ramadan fasting in patients with pre-existing cardiac illnesses or assessed change in CV risk factors. Findings were inconsistent but mostly showed that fasting favored a reduction in glycemic parameters and systolic blood pressure.[17]

A prospective study (Gulf Acute Heart Failure Registry) was conducted in many centers in the Gulf region on all the patients who were hospitalized with acute heart failure (AHF) during the study period from the month of February till November 2012. This study had 4,157 patients, of which 3,851 patients (92.6%) were admitted with AHF during the non-Ramadan period and 306 (7.4%) were admitted in the month of Ramadan. Similar to our study, their findings also showed a significant difference in hospitalization with ACS during Ramadan versus in the non-Ramadan period. Moreover, that study also showed significantly more hospitalization with symptoms of CHF outside Ramadan. It is noted that functional classification grades for New York Heart Association were significantly higher before Ramadan compared to the period of Ramadan. Also noted in that study is that either immediate or 1-year mortality was not independently related with hospitalization during Ramadan.[18]

A relatively recent prospective observational study from Saudi Arabia reported the impact of fasting in Ramadan on any cardiac symptoms in 249 patients with pre-existing heart failure, where 227 patients (91.2%) observed fasting Ramadan, and 136 (54.6%) of them had diabetes.[19] Their results showed that 209 patients out of 227 and 125 out of 136 diabetic patients had improvement in symptoms during Ramadan fasting. While the only 18 fasting patients had worsening of their symptoms, including 11 patients with diabetes.[19] This concurs with our result where diabetic patients had less incidence of CHF during the fasting month of Ramadan.

In contrast to our study, a retrospective research study of the clinical data from Qatar, including 2,160 patients having CHF in the period between 1991 and 2001, showed that the number of hospital admissions for CHF was similar between the month of Ramadan and other months, but this study did not look separately into patients with diabetes.[20] Another observational prospective analysis consisting of 465 patients with CHD from Gulf Cooperation Council countries including the United Arab Emirates from October 24 to November 24, 2003 found that among all patients, 91.2% were able to fast and only 6.7% felt deterioration in their condition while fasting in Ramadan. There was no change in cardiac status pre- and post-Ramadan. Of these 465 cardiac patients, only 37.2% (173) were diabetic.[21]

Few observational studies looking into the clinical condition of patients with stable cardiac disease and the rate of hospitalization during the Ramadan fast found no change in the clinical status.[22] One prospective study from Iran in 2014 compared 148 patients with a known CHD and found no variation in the clinical condition of fasting versus nonfasting cardiac patients.[23] A 1999 retrospective study from Turkey on 1,665 patients admitted with ACS between 1991 and 1997 in the 3 months of Ramadan, Sha'ban, and Shawwal has shown similar results to our study that the number of patients admitted during Ramadan was significantly less (p = 0.03) than non-Ramadan period.[24] However, contrary to our result, their data showed a slightly higher rate of hospitalization in patients with T2D and with decompensated AHF.[24] Our study did not show any difference in the length of hospital stay in Ramadan compared to the preceding and the following months (6 days in Shaaban, 5 days in Ramadan, and 6 days in Shawwal) but Al Mansori and Cherif looked into the duration of stay in Ramadan in two groups of patients (fasting versus nonfasting, admitted with acute myocardial infarction) and concluded that fasting is associated with a significantly shorter hospital stay on average (9.8 vs. 5.3, p = 0.015, respectively).[25] In a previous study from our center where 25 persons with T2D and stable CHD who were provided with structured education, continuous blood glucose monitoring through freestyle libre and treatment adjustment according to guidelines showed that fasting Ramadan was not associated with an increase in cardiac events or in CV risk factors. However, hypoglycemic episodes were higher during Ramadan compared to the previous month.[26]

Previous studies have indicated that patients with pre-existing hypertension, diabetes, or CVD may omit or alter the schedules of their essential medications during fasting. Additionally, it is common for many individuals to consume high-fat and high-sugar diets during the fasting month, which can exacerbate health issues. Factors such as dehydration due to harsh fasting conditions (depending on geographical location), sleep deprivation, or hypoglycemic episodes may also contribute to an increased risk of CV events in certain cases.[19] [20]

The present study has some strengths and weaknesses. One key advantage of our study lies in its design to specifically assess the impact of fasting in the month of Ramadan and its connection with CVD during periods in and around Ramadan in people with and without diabetes. Further randomized controlled research studies in individuals with diabetes are needed to be conducted for a better understanding of the risks of CVD or stroke in patient with diabetes and to measure the real effect of fasting in the month of Ramadan. This study has some noteworthy limitations. It is an observational study with a limitation of the small number of patients that may affect the significance of the results. We believe that recruiting more patients might show more accurate results especially if done as a multicenter trial.

Conclusion

The results of our study suggest that the total number of admissions with CVD during Ramadan might be lower than in other months for both people with diabetes and those without diabetes. It appears that patients with diabetes were generally older, had relatively better low-density lipoprotein levels, and lower diastolic blood pressure compared to patients without diabetes throughout the 3 months of the study. The prevalence of CHF seems higher in individuals with diabetes compared to nondiabetics across the other 2 months of the study, except during Ramadan. However, admissions with CHF in patients with diabetes appeared to decrease during Ramadan, while admissions for IHD seemed to increase. In contrast, there was no apparent change in the proportion of IHD/CHF among nondiabetics across the 3 months.

Conflict of Interest

None declared.

Author Contributions

F.R. did writing proposal for ethical committee and all correspondence, and contributed in study design, writing of the manuscript, reviewing, and submission. N.Y. and M.S.M. performed data collection. H.Z., shared in study concept, reviewed the patient history and confirmed the diagnoses and study results. M.Z. contributed in the analysis of methodology, data, and results. F.A. contributed in study design and reviewing, M.H. contributed in study concept, study design, data analysis, writing, reviewing, and submission of the manuscript. All authors approved the content of the manuscript and approved submission to International Journal of Diabetes for developing countries.

Compliance with Ethical Principles

The research complies with the guidelines for human studies in accordance with the World Medical Association Declaration of Helsinki. This study protocol was reviewed and approved by Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority on April 22, 2018 and the reference number is DSREC-03/2018_20.

Data Availability Statement

The data that support the findings of this study are not publicly available due to policy of Dubai Scientific Research Ethics Committee (DSREC) for the privacy of the participants, but are available from the corresponding author upon the request of the Journal.

Anonymized data may be available by reasonable requests to the corresponding author.

• References

• 1 Hassanein M, Hussein Z, Shaltout I. et al. The DAR 2020 Global survey: Ramadan fasting during COVID 19 pandemic and the impact of older age on fasting among adults with Type 2 diabetes. Diabetes Res Clin Pract 2021; 173: 108674
• 2 Jabbar A, Hassanein M, Beshyah SA, Boye KS, Yu M, Babineaux SM. CREED study: hypoglycaemia during Ramadan in individuals with Type 2 diabetes mellitus from three continents. Diabetes Res Clin Pract 2017; 132: 19-26
• 3 Hassanein M, Al Awadi FF, El Hadidy KES. et al. The characteristics and pattern of care for the type 2 diabetes mellitus population in the MENA region during Ramadan: an international prospective study (DAR-MENA T2DM). Diabetes Res Clin Pract 2019; 151: 275-284
• 4 Beshyah AS, Elamouri JS, Almagdub I. et al. Burden and patterns of medical emergencies during Ramadan fasting: a narrative review. J Med Biomed Sci 2023; 15 (01) 5-19
• 5 Beshyah SA. High-risk patients observing Ramadan fasting: more data and more insights!. Ibnosina J Med Biomed Sci 2020; 12: 147-150
• 6 Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and cardiovascular events. Diabetes Care 2010; 33 (06) 1389-1394
• 7 Siegel AJ, Bhatti NA, Wasfy JH. Reprising Ramadan-related angina pectoris: a potential strategy for risk reduction. Am J Case Rep 2016; 17: 841-844
• 8 Nematy M, Alinezhad-Namaghi M, Rashed MM. et al. Effects of Ramadan fasting on cardiovascular risk factors: a prospective observational study. Nutr J 2012; 11 (01) 69
• 9 Khatib FA, Shafagoj YA. Metabolic alterations as a result of Ramadan fasting in non-insulin-dependent diabetes mellitus patients in relation to food intake. Saudi Med J 2004; 25 (12) 1858-1863
• 10 Lamine F, Bouguerra R, Jabrane J. et al. Food intake and high density lipoprotein cholesterol levels changes during ramadan fasting in healthy young subjects. Tunis Med 2006; 84 (10) 647-650
• 11 Almulhem M, Susarla R, Alabdulaali L. et al. The effect of Ramadan fasting on cardiovascular events and risk factors in patients with type 2 diabetes: a systematic review. Diabetes Res Clin Pract 2020; 159: 107918
• 12 IDF diabetes atlas - 2019 Atlas [Internet]. 2015 [cited 2019 Apr 27]. Accessed February 7, 2025 at: http://www.diabetesatlas.org/resources/2019-atlas.html
• 13 Ye S. Cardiac events. In: Gellman MD, Turner JR. eds. Encyclopedia of Behavioral Medicine. New York, NY: Springer New York; 2013: 331-332
• 14 Al-Arouj M, Assaad-Khalil S, Buse J. et al. Recommendations for management of diabetes during Ramadan: update 2010. Diabetes Care 2010; 33 (08) 1895-1902
• 15 Hassanein M, Al-Arouj M, Hamdy O. et al; International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract 2017; 126: 303-316
• 16 Hassanein M, Afandi B, Yakoob Ahmedani M. et al. Diabetes and Ramadan: practical guidelines 2021. Diabetes Res Clin Pract 2022; 185: 109185
• 17 Bener A, AAl-Hamaq AOA, Öztürk M. et al. Effect of ramadan fasting on glycemic control and other essential variables in diabetic patients. Ann Afr Med 2018; 17 (04) 196-202
• 18 Salam AM, Sulaiman K, Alsheikh-Ali AA. et al. Acute heart failure presentations and outcomes during the fasting month of Ramadan: an observational report from seven Middle Eastern countries. Curr Med Res Opin 2018; 34 (02) 237-245
• 19 Abazid RM, Khalaf HH, Sakr HI. et al. Effects of Ramadan fasting on the symptoms of chronic heart failure. Saudi Med J 2018; 39 (04) 395-400
• 20 Al Suwaidi J, Bener A, Suliman A. et al. A population based study of Ramadan fasting and acute coronary syndromes. Heart 2004; 90 (06) 695-696
• 21 Al Suwaidi J, Zubaid M, Al-Mahmeed WA. et al. Impact of fasting in Ramadan in patients with cardiac disease. Saudi Med J 2005; 26 (10) 1579-1583
• 22 Chamsi-Pasha M, Chamsi-Pasha H. The cardiac patient in Ramadan. Avicenna J Med 2016; 6 (02) 33-38
• 23 Mousavi M, Mirkarimi S, Rahmani G, Hosseinzadeh E, Salahi N. Ramadan fast in patients with coronary artery disease. Iran Red Crescent Med J 2014; 16 (12) e7887
• 24 Temizhan A, Dönderici O, Ouz D, Demirbas B. Is there any effect of Ramadan fasting on acute coronary heart disease events?. Int J Cardiol 1999; 70 (02) 149-153
• 25 Almansori M, Cherif E. Impact of fasting on the presentation and outcome of myocardial infarction during the month of Ramadan. Italian J Med 2013; 8 (01) 35-38
• 26 Hassanein M, Rashid F, Elsayed M. et al. Assessment of risk of fasting during Ramadan under optimal diabetes care, in high-risk patients with diabetes and coronary heart disease through the use of FreeStyle Libre flash continuous glucose monitor (FSL-CGMS). Diabetes Res Clin Pract 2019; 150: 308-314

Publication History

Article published online:
01 April 2025