578585

research-article2015
TAK0010.1177/1753944715578585Therapeutic Advances in Cardiovascular DiseaseS Al-Kindi, T Al-Juhaishi

Therapeutic Advances in Cardiovascular Disease Original Research

Cardiovascular disease research activity in

Ther Adv Cardiovasc Dis

2015, Vol. 9(3) 70­–76

the Middle East: a bibliometric analysis DOI: 10.1177/

1753944715578585

© The Author(s), 2015.

Reprints and permissions:
Sadeer Al-Kindi, Taha Al-Juhaishi, Fadi Haddad, Shahrad Taheri and Charbel Abi Khalil http://www.sagepub.co.uk/
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Abstract
Objectives: The Middle East has a high prevalence of noncommunicable chronic diseases. The
objective of this article was to quantify the research activity in cardiovascular disease (CVD) in
the Middle East over the last 10 years.
Methods: A Medline search was conducted using medical subject headings and author
affiliation to retrieve research articles published from the Middle East between 2003 and 2012
(inclusive).
Results: Middle Eastern countries produced only 3% of the total number of CVD research
articles in the world. However, the overall trend showed an increase in the number of articles
over the years, mainly from Turkey and Iran. Within this region, the ratio of CVD to non-
CVD publications was highest in Qatar (0.23). Lebanon ranked first in the number of CVD
publications per million persons (PMP) averaging 194.2 publications PMP and Turkey ranked
highest in the number of CVD publications per US$1000 gross domestic product (GDP) per
capita averaging 954 CVD publications per US$1000 GDP per capita.
Conclusions: Although there has been a drive towards greater publication of CVD papers in
the last decade, research activity in the Middle East still lags behinds developed countries.
Greater productivity is anticipated to emerge to accompany the recent significant investment
in research in Gulf countries.

Keywords:  bibliometric analysis, cardiovascular disease, epidemiology, global health, Middle

East
Correspondence to:
Charbel Abi Khalil, MD,
PhD, FESC
Department of Genetic
Medicine and Department
Introduction complications [Akala and El-Saharty, 2006; of Medicine,
Cardiovascular disease (CVD) is the leading cause Almahmeed et al. 2012; Gehani et al. 2014], nota- Weill Cornell Medical
College, Doha, Qatar
of death worldwide. Globally, it is estimated that bly DM. It is already known that patients with cha2022@qatar-med.
17.3 million people died from CVD in 2008 con- DM develop more cardiovascular complications, cornell.edu

stituting 30% of all causes of mortality and the which consequently lead to a higher mortality rate Sadeer Al-Kindi, MD
Department of Internal
number of cardiovascular deaths is expected to than individuals without DM [Abi Khalil et  al. Medicine, University
increase to 23.3 million by 2030 [Myers and 2012]. In a case-control study in a coronary care Hospitals - Case Medical
Center, Case Western
Mendis, 2014]. Major drivers for increasing car- unit in Qatar, Mushlin and colleagues showed Reserve University,
diovascular deaths include smoking, hypertension, that the odds ratios associated with DM in Cleveland, OH, US

diabetes mellitus (DM) and obesity [Beaglehole patients admitted with acute myocardial infarc- Taha Al-Juhaishi, MD
Department of Medicine.
et al. 2011]. tion was estimated to be 4.01 (95% confidence Weill Cornell Medical
intervals [CIs] 2.51–6.42) compared with 1.75 College, Doha, Qatar
Fadi Haddad, MD
In the Middle East, the continued increase in (95% CIs 0.94–3.29) for North America [Mushlin Department of Medicine,
CVD burden is partially driven by accelerated et al. 2012]. Saint-Joseph University,
Faculty of Medicine,
epidemiological transition secondary to lifestyle Beirut, Lebanon
change and urbanization [Akala and El-Saharty, The Institute for Health Metrics and Evaluation Shahrad Taheri, MBBS,
2006]. In this particular area of the world, patients in 2012 reported a significant increase in ischemic PhD
Department of Medicine.
with CVD are often younger in age, have a higher heart disease, DM, and stroke-related mortality Weill Cornell Medical
prevalence of risk factors, and more CVD severe between 1990 and 2010 all over the world, and College, Doha, Qatar

70 http://tac.sagepub.com
 S Al-Kindi, T Al-Juhaishi et al.

Table 1.  Population estimates and gross domestic product per capita.

Country Population (2010) Average gross domestic

product (US$) (2003–2012)
Bahrain 1,234,571 23587.28
Egypt 78,728,000 5528.615
Iran 74,733,230 9885.981
Iraq 32,481,000 3290.406
Jordan 6,113,000 5103.34
Kuwait 3,566,437 46573.95
Lebanon 3,785,655 11648.24
Oman 2,773,479 23523.35
Qatar 1,699,435 74173.17
Saudi Arabia 27,136,977 24407.77
Syria 20,619,000 4540.784
Turkey 73,722,988 13912.46
United Arab Emirates 8,264,070 53883.34
Yemen 23,153,982 2429.388
UK 62,026,962 34359.04
USA 309,349,689 44876.32

the Middle East was not an exception [Lozano
et al. 2012].  This was also confirmed by Mokdad
and colleagues who recently showed that 7 out of
the 14 top causes of death in the Arab world in
2010 were due to CVD, whereas 20 years ago
infectious-related pathologies and other diseases
were more prevalent [Mokdad et al. 2014]. Given
the high burden of CVD in the Middle East, there
is a major need for further research. In this study,
we provide the first comparative bibliometric
analysis of CVD research publications in the
Middle East compared with the USA and UK.
Methods
We conducted a Medline search using the data-
base website PubMed (available from the National
Institutes of Health, Bethesda, MA, USA) during
the month of August 2013. We employed the
medical subject headings service (MeSH), a com-
prehensive controlled medical vocabulary that
provides indexing for articles within MEDLINE.
To search for CVD publications, we used the fol-
lowing MeSH terms: ‘cardiovascular diseases’,
‘coronary artery disease’, and ‘heart failure’.
For the purposes of this study, PubMed filters
were set to include all of the following types of
articles: case reports; clinical conference; clinical
trial; clinical trial, phase I; clinical trial, phase
II; clinical trial, phase III; comparative study;
controlled clinical trial; journal article; letter;
meta-analysis; multicenter study; randomized
controlled trial; review; systematic reviews; vali-
dation studies.
To locate the primary institution of publication, we
employed the search criteria of the first author
affiliation country. T
  he strategy included the name
of the country (or modified name in case of disam-
biguation/different names for countries as noted in
Table 1). For the purposes of this study, the Middle
East includes the following 14 countries: Bahrain,
Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman,
Qatar, Saudi Arabia, Syrian Arab Republic, Turkey,
United Arab Emirates, and Yemen.
Our search included combining the strategies using
the Boolean parameters (AND, OR). For example,
to look for CVD publications from Iraq, we used
the following search keywords: ‘cardiovascular dis-
eases’ [mesh] AND ‘Iraq’ [ad]. We used 2012 as the
end year as articles need processing time to be
indexed in Medline after being published.
After applying the filters above, we conducted a
search on CVD publications during the month of
August 2013 for each country. For correction of
the number of publications per gross domestic
product (GDP), we divided the number of publi-
cations retrieved by US$1000 GDP per capita
[World Bank, 2012a]. We also divided the number
of publications by population size [Heston et  al.
2012].

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Therapeutic Advances in Cardiovascular Disease 9(3)

Table 2.  Summary of the number of publications on cardiovascular disease in the 10-year period (2003–2012)
in the Middle East. USA and UK data are presented for comparison.

Country Cardiovascular Noncardiovascular All biomedical Ratio of cardiovascular

disease disease publications publications disease to
publications noncardiovascular
disease publications
Bahrain 58 423 481 0.14
Egypt 785 14283 15068 0.05
Iran 2366 36958 39324 0.06
Iraq 67 882 949 0.08
Jordan 200 3892 4092 0.05
Kuwait 267 2494 2761 0.11
Lebanon 735 5778 6513 0.13
Oman 164 1566 1730 0.10
Qatar 197 874 1071 0.23
Saudi 969 10641 11610 0.09
Syria 23 438 461 0.05
Turkey 13278 75158 88436 0.18
United Arab 137 1761 1898 0.08
Emirates
Yemen 17 310 327 0.05
UK 30193 347471 377664 0.09
USA 153015 1764163 1917178 0.09

Results When corrected for GDP per capita (Figure 4),

Data for GDP per capita and population size are
shown in Table 1. Over the 10-year study period,
there were a total of 641,704 CVD publications
registered in PubMed. Of those results, 19,263
(3.0 %) CVD publications were from the Middle
East (Table 2).  There was an overall upward trend
for the number of CVD publications in all Middle
Eastern countries, mainly from Turkey and Iran
(Figure 1). The ratio of CVD to non-CVD publi-
cations over the 10-year period ranged between
0.05 (Egypt, Jordan, Syria, and Yemen) to 0.23
(Qatar) compared with 0.09 (USA and UK).
Figure 2 provides visual representation of these
percentages by country.
From the Middle Eastern countries, Turkey had
the highest number of CVD publications with
13,278 reported, whereas Yemen had the smallest
number with only 17 (Table 2). To avoid the bias
of a ‘population mass effect’ on the number of
publications, we corrected our results for popula-
tion size (Figure 3). Lebanon ranked first in the
region at 194.2 publications per million persons
(PMP), but Yemen still had the lowest number of
CVD publications at 0.73 publications PMP. For
comparison, USA had 494.6 publications PMP
and UK had 486.8 PMP.
Bahrain had the lowest number of CVD publica-
tions at 2.5 publications per US$1000 GDP per
capita, whereas Turkey ranked first, averaging
954.4 CVD publications per US$1000 GDP per
capita (Figure 4). This compares with 3409.7
CVD publications per US$1000 GDP per capita
for USA and 878.7 CVD publications per
US$1000 GDP per capita for UK.
Discussion
Our results show that Middle Eastern countries
produced only 3.0 % of the total number of CVD
research articles as registered in PubMed. The
overall trend showed an increase in the number of
articles from the Middle East over the last 10
years. Our results are in line with a recent global
cardiovascular bibliometric analysis that showed a
36% increase in CVD publications during the last
10 years [Huffman et al. 2013].
The low research productivity in Middle Eastern
countries might be attributed to multiple factors.
The medical schools and hospitals in the Arab
world are patient-care oriented, with a fledgling
clinical research culture. Only in recent times has
clinical research been emphasized. In addition,

72 http://tac.sagepub.com
 S Al-Kindi, T Al-Juhaishi et al.

Figure 1.  Trend of cardiovascular disease (CVD) publications (2003–2012) by country.

0.25
Rao of CVD publicaons to non -CVD

0.20
biomedical publicaons

0.15

0.10

0.05

0.00

Figure 2.  Ratio of cardiovascular disease (CVD) publications to publications on non-CVD disease by country.

there is a general lack of research infrastructure
within hospitals and academic centers in some of
these countries. T
  here is also a general lack of fund-
ing for biomedical research, except in some Gulf
Cooperation Council (GCC) countries, and most
published studies are independent retrospective
studies. Another explanation for the low productiv-
ity could be the absence of grey literature in our
bibliometric analysis as research does not always
progress to the publication of manuscripts. Political
instability contributes to the absence of biomedical
research funding and opportunities in some Middle

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Therapeutic Advances in Cardiovascular Disease 9(3)

250

CVD publicaons per million persons

200

150

100

50

Figure 3.  Numbers of cardiovascular disease (CVD) publications per million persons by country.

Figure 4.  Numbers of cardiovascular disease (CVD) publications per US$1000 of gross domestic product
(GDP) per capita by country.

Eastern countries [Kahan et al. 1996]. T   he recog-
nition of these barriers has resulted in countries
such as Qatar developing an academic health sci-
ence program accompanied by a restructuring of
healthcare to embed research activity. Furthermore,
collaborations with established institutions have
supported a rapid expansion in research activity.
Other initiatives include research training for clini-
cians and the establishment of medical journals
[Chouchane et al. 2011].
GCC countries rank among the highest income
countries, but are only recently investing in medi-
cal research and establishing successful research
institutions. Qatar and Saudi Arabia are among the
first to allocate large funds for biomedical research
activity and attract international researchers [Giles,
2006]. Qatar, for example, has allocated 2.8% of
its annual domestic income for research support,
compared with 2.7% in USA [World Bank, 2012b].
Over the past 10 years, Qatar has produced many
CVD papers and has ranked first in terms of pub-
lications PMP in GCC countries, but ranks lower
when assessed per GDP. T   his might be attributed
to a lag between initiation of research institutions
and research activity and publication; therefore,
more time is required to reflect the number
of research publications. Initiatives, such as the

74 http://tac.sagepub.com

academic health sciences program in Qatar
[Hillhouse et  al. 2012], are likely to expedite a
greater number and better quality of CVD papers.
Saudi Arabia produced a notable number of
research papers on CVD, and this is probably due
to the longer establishment of research activity in
the field as it started its research programs earlier.
The larger population, appropriate fund allocation
towards scholarships, and citizens traveling abroad
to attain their education could also be contributing
factors. Turkey and Iran have had their research
and academic institutions for a significant time and
this is reflected in the high number of CVD publi-
cations. Countries with lower income (i.e. Syria,
Yemen, Iraq, and Jordan) still have low production
of CVD publications, probably due to their previ-
ous low gross income, which limits research
investment.
Research activity in the Middle East has been
evaluated in various biomedical specialties. Most
reports concluded that productivity is very low
and insufficient compared with surrounding and
western countries [El-Azami-El-Idrissi et  al.
2013]. Benamer and Bakoush reported earlier
that Arabic Middle Eastern countries produced
less than other non-Arabic Middle Eastern coun-
tries [Benamer and Bakoush, 2009], a finding we
are able to confirm when looking at the data from
Iran and Turkey.  The Middle East produced only
0.75% of global DM publications between 1996
and 2012 [Sweileh et  al. 2014a], and 1% of the
global obesity research output at all times [Sweileh
et al. 2014b].  The research activity related to pri-
ority interventions for noncommunicable disease
prevention in low- and middle-income countries
showed that the Middle East published fewer
research articles than the Latin America and
Caribbean region, the East Asia and Pacific
region, or Europe and Central Asia [Jones and
Geneau, 2012]. To our knowledge, no study has
analyzed CVD publications in this region despite
the increased burden of CVD. Our data are close
to those published by Jahangir and colleagues
who reported that Latin America published 4% of
CVD publications compared with 26% from the
USA with a slow upward trend over time [Jahangir
et al. 2011].
There are some limitations related to our study.
We recognize that bibliometric analysis is not a
perfect representation of research productivity.
This has been demonstrated in different areas of
medicine, particularly in cardiovascular medicine
[McAlister et  al. 2011]. Bibliometric analysis
http://tac.sagepub.com 75
S Al-Kindi, T Al-Juhaishi et al.
cannot represent the impact of a scientific work or
its quality using current standardized methods
such as impact factors of the journal, article’s
citations, or h-index.
Research in CVD, especially clinical research,
requires multicenter participation, and thus,
requires organized research groups with coordi-
nation between the different centers. With the
recent cardiovascular research initiatives, more
publications are expected to appear, especially
from the GCC countries where local and interna-
tional research institutes have recently increased
their collaborative research activity, aiming to
develop cutting-edge translational medicine
research [Chouchane et  al. 2011].   This would
also enhance patient care as it has been shown
that participating in clinical research is linked to
improvement of clinical outcomes [Krzyzanowska
et  al. 2011]. A correlation has also been shown
between disease epidemiology and volume of
research activity [Somogyi and Schubert, 2005].
Conclusion
Currently, most Middle Eastern countries are
lagging behind in biomedical and cardiovascular
research activity. Given the high burden of CVD
in the Middle East, and given the different genetic
backgrounds and composition of these popula-
tions, more high-quality research is essential. We
expect that several Gulf countries will see signifi-
cant research productivity in the next decade.
This will, in turn, improve healthcare outcomes in
very high-risk populations.
Conflict of interest statement
The authors declare no conflicts of interest in
preparing this article
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
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