|I will discuss these
diseases under the following headings:
of Peripheral arterial vessels of
discuss these, I would first like to analyse the
common symptoms of heart disease seen in Arab
on exertion ("Taab Tanafass
Baadein Aimshey") is one
of the most common symptoms heard of in Arab
population, especially if you elicit it by asking
a leading question. If an Arab patient says
"no" to your question, ask him if off
and on, ("Saa aad"
or "Aao Kaat")
he gets dyspnoea on climbing steps ("Tatla
Daaraj"). The answer will
invariably be "yes". The following is
the etiology of this symptom
population is very conscious of dyspnoea
and takes it very seriously.
Yemenis, most of the Arabs are
Anaemiais a common
"associated"cause, mainly in
Bahraini female population. Of course
severe anaemia is commonly picked up in
many males and females when they do
complain of dyspnoea on exertion. So
often with severe anaemia (sickle cell or
the dyspnoea complained of is very
little. They get so adapted that they can
do their normal activities at this lower
level of haemoglobin at which a Westerner
would be confined to his house only.
bronchitis is an additional factor
responsible for dyspnoea on exertion and
is noted off and on.
disease is an uncommon cause of this
symptom and that too if seen, it is more
often either rheumatic heart disease or a
cardiomyopathy rather than ischaemic
Hiduk" or "Dakka"
is a very common symptom in majority of Arabs and
one of the most common symptoms complained of by
Bahrainis. This symptom is also complained of, in
decreasing order of frequency, by Yemenis,
Saudis, Qataris, Omanis and other patients from
U. A. E. who point at the epigastrium. These
patients place their hand on the precordium
unlike those complaining of "Fooaat".
Often they explain that this symptom occurs after
climbing steps ("Daaraj")
or excessive walking ("Aimshey").
in majority of females it is a symptom of fear,
anxiety, nervousness and consciousness of heart
beat. It is the same in the males as well, except
in a few, where ventricular ectopic heart beats
are the cause. These patients consume excessive
or coffee ("Qahwah").
amusing part of the symptom is the
associated "gestures" with
which they demonstrate this symptom. The
gesture consists of a closed hand, with
pronated wrist, and the shaking of it
forwards and backwards in front of the
precordium (see fig alongside).
While looking out for the
other causes of this symptom, the following are
heart disease is seen off and on in Arabs
and definitely more frequently than in
Western countries. Incidentally innocent
murmurs are not so common in Arabs (and
if they were, the amount of 'neurosis'
which would increase in Arab population
is unimaginable). I do not know the cause
for this, but probably, most of the
haemic murmurs we hear in majority of
Indian female population, are not present
in these patients.
valve prolapse syndrome is rare in this
population. Some of my colleagues in
echocardiography department have come
across a few Arabs suffering from this
Rarely this entity can be present without
physical signs, even when midsystolic
click or late systolic murmur at the
mitral area are absent in Iying, sitting
and standing positions. I sent many of
these young women with chest pains and
palpitations for routine echocardiography
to rule out this disorder. Out of one
group of hundred young female patients of
mine, there was not a single patient
whose M-mode or 2 D-echocardiography
showed a prolapse of mitral valve
in practice although I see so many
elderly Arab patients, sick sinus
syndrome is rare.
hypertension is a very common disease,
severe diastolic hypertension is rare as
a cause of this symptom. More often it is
the anxiety of suffering from
hypertension which is responsible for the
symptom of palpitations.
rare, should be excluded Incidentally,
examination of thyroid gland is one of
the most difficult part of the physical
check up to perform in a female Arab, not
only because of the "Veil"
which many middle aged and elderly
Bahrainis, Saudis and Qataris wear, but
also the heaps of cloth tied round the
neck like a bandage in Yemeni women! And
then, to raise their chin up, to stretch
the neck, in order to bring out a thyroid
swelling from behind the upper sternum,
is often very time consuming. It is also
a problem to tell them to swallow ("Iblaa")
during the examination for thyroid
feetOedema of feet as a symptom of
congestive cardiac failure is very rare in Arab
of the feet even otherwise is a
"symptom" rarely heard from an Arab
patient, though on examination a slight pitting
is often found in obese patients having possibly
additional venous insufficiency. And, if present,
the patient is usualiv a Bahraini or less
commonly a patient from Saudi, Qatar, Oman, U. A.
E.in this order of diminishing frequency.
It is a very rare symptom in Yemenis. Whenever
present, unilateral or even bilateral, deep
venous thrombosis is the underlying cause
(incidentally many Bahraini women use oral
causes of oedema of feet like severe anaemia,
nephrotic syndrome, cirrhosis of liver are rare
in this population.
PainThis is such a common complaint in
Arab population and yet ischaemic chest pain i.e.
Angina Pectoris is rare except in Bahrainis. It
is also seen in Arabs from Saudi Arabia and
Qatar. And of course, when present, Angina can be
easily missed because retrosternal discomfort is
complained of by majority of the Arab patients.
However, it is important to note that these
patients keep on moving their hands up and down
in the retrosternal area (like a cardiac
ischaemic patient). But if questioned, majority
of them are sure that the symptom is
which is due to hyperacidity (often related to
intake of Chillies in food) and has no relation
causes of chest pain seen in Arab population are
Teitz's syndrome is a very common cause
if not the most common cause of chest
pain. It is very common in Bahrainis and
FugaxThis type of shooting,
momentary pain felt in one of the costal
cartilages, is best heard in Yemenis who
describe this symptom very vividly with
associated facial gestures.
Tip SyndromeThis syndrome is very
common in Arabs especially Yemenis. The
patient pin-points one of the anterior
ends of the floating ribs and presses it
with a finger to demonstrate tenderness.
' pseudo mammary" neuralgia and a frank
D'Costa's syndrome is very rare in Arab patients.
In fact the moment these patients complaining of
chest pain, are told that the heart, the
electrocardiogram and the fluoroscopy or the
Chest X-ray are normal, they seem to be satisfied
easily! Severe cardiac neurosis is a rarity in an
Arab and even in a Yemeni!
Heart DiseaseAlthough in many Arabs,
multiple risk factors are present, and
retrosternal symptoms are complained of,
ischaemic heart disease is less common. Thus an
Arab who is obese, leads a sedentary life,
suffers from diabetes mellitus, has mild
hypertension, smokes cigarettes and consumes
alcohol, yet he is found to have chest pains of
But if you
see a Bahraini, not only is ischaemic heart
disease seen frequently but precocious coronary
artery disease also manifests in this population.
So many Bahrainis are seen, often below the age
of forty five (sometimes even females), in whom
coronary by-pass surgery has already been done!
Some of the gross ischaemic patterns are seen in
the electrocardiograms of Bahrainis. Similarly
gross ischaemic heart disease is often seen in
Bahrainis with minimal evidence of diabetes,
hypertension, smoking (as in women, who are
non-smokers) and obesity. Often their blood
lipids are elevated. There are families in
Bahrain with extremely elevated lipid levels.
But, frequently, family history ("Fi
Ailitik") of ischaemic heart
disease cannot be elicited because the patient's
father, mother may never have undergone a medical
check up, but the fact that they are alive and
healthy and are more than 60 or 70 years old is
against their having suffered from ischaemic
heart disease is also seen in patients coming
from Saudi, Qatar and Oman. But one Arab
community where this disease is very very rare is
Yemenis. Here I must hasten to add that there are
a few Yemenis whose constitution is like Saudis.
In fact they have been doing business or are
living in Saudi for years together. The health
problems e.g. hypertension, diabetes, ischaemic
heart disease in these Yemenis are like Saudis.
cardiomyopathy is more likely to be the cause if
an Arab is diagnosed as 'ischaemic heart disease'
and has a gross cardiomegaly and chronic
congestive cardiac failure.
following heart diseases which may
"appear" to be common, are very rare in
- Pickwickian syndrome
is a common disorder amongst Arab patients. The
incidence of this disease is highest in Bahrain,
followed in decreasing order by Saudi, Qatar,
Oman and U.A.E. (in U.A.E. highest in Abu
Dhabi). It is rare in Yemenis (except
"Saudi" type of Yemenis as described
is at its worst with Arab population. They just
do not believe in any "long-term"
therapy. Many of my patients come for a yearly
check-up. Yet at the next examination they have
been "off" their tablets for at least
few months! They do not comply with low salt
diet. They do not lose weight. They continue
smoking though fewer cigarettes. But curiously
enough, I often do not find their condition
population tolerates hypertension much better
than many others in the world. Hypertensive
retinopathy, nephropathy and cardiopathy are
rarities. Strokes do occur, but less frequently
in spite of the high incidence of hypertension in
patients enjoy getting investigated, it is
interesting to note that renal and renovascular
causes of hypertension are rare in this
population, leave alone the other rare causes
like phaeochromocytoma etc. The incidence of
kidney stones on l.V.P. is same as in
sometimes, when I do see chronic renal failure in
a patient having hypertension, I find that it is
a complication of renal stones with superadded
chronic pyelonephritis or bladder neck
obstruction, often due to prostatic enlargement.
conclude with the subject of hypertension, I must
hasten to add that Arab patients are very
"afraid" of hypertension ("Dakht").
The moment you start recording the blood
pressure, they are curious to hear the reading.
Especially those who have headache, giddiness,
weakness etc. are "so relieved" to hear
from you that their blood pressure is normal,
that they immediately thank.... not
the consciousness of the pulsations of a normal
abdominal aorta felt by the patient in the
epigastrium, I have already discussed this
subject elsewhere. This symptom is complained of
as "Fooaat Gulb"
especially by Omanis
of aorta is common in Arab patients. I
have seen even middle aged women with
extensive linear calcification of
abdominal aorta. This stands out
prominently in the lateral view (X-ray)
of lumbar spine. It is one of the X-rays
which invariably has to be asked for
nearly in every alternate Arab patient
because of the universal complaint of
backache. Although rarely these patients
may suffer from associated Angina
Pectoris and hypertension, most of the
times, aortic atheroma is symptomless and
harmless to the patient (see fig.
Symptoms of aortic arch
syndrome, renal artery or mesenteric artery
stenosis (intestinal angina) are hardly ever
seen. off and on, in elderly Arabs, Lehriche's
syndrome is discovered. But symptoms have hardly
been severe enough to coax the patient for
vascular diseaseis rare in Arabs. The
symptoms of ischaemia are very uncommon even when
peripheral pulsations are not palpable. Calf
pains, when present are more due to tension and
In spite of
heavy smoking the entity of thrombo-angiitis
obliterans is relatively rare.
vein thrombosisI am surprised to find a
low incidence of deep vein thrombosis in Arab
ladies who undergo, on an average, half to one
dozen deliveries!! As mentioned earlier, this
condition is more common in Bahraini females. In
Arabs, the veins (and their valves) behave
definitely better than those of Indian or western
population ! !
phenomenonMany Arab patients,
especially females, complain that their hands and
become cold ("Baraad")
when they are in air-conditioned rooms. Now ask
the patient if she also feels the limbs hot
and on. The answer is always "yes".
Also the limbs do not become blue. The burning
complained of does not follow immediately the
feeling of cold. Thus, you can exclude Raynaud's
collagen disorders like Scleroderma or S.L.E.
which are etiological factors of this symptom,
are very rare in Arabs.