Reassessing heart failure therapy in Thailand: Patient insights and treatment outcomes from the Thai heart failure registry.

BACKGROUND: This research analyzed the demographics, management, and outcomes of patients with heart failure (HF) in Thailand. METHODS: The Thai Heart Failure Registry prospectively enrolled patients diagnosed with HF from 36 hospitals in Thailand. Follow-up data were recorded at 6, 12, 18, and 24 months. This study primarily focused on two outcomes: mortality and HF-related hospitalizations. RESULTS: The study included 2639 patients aged at least 18. Their mean age was 59.2 ± 14.5 years, and most were male (68.4%). Patients were classified as having HF with reduced ejection fraction (HFrEF, 80.7%), HF with preserved ejection fraction (HFpEF, 9.0%), or HF with mildly reduced ejection fraction (HFmrEF, 10.3%). Guideline-directed medical therapy utilization varied. Beta-blockers had the highest usage (93.2%), followed by mineralocorticoid receptor antagonists (65.7%), angiotensin-converting enzyme inhibitors (39.3%), angiotensin receptor blockers (28.2%), angiotensin receptor-neprilysin inhibitors (16.1%), and sodium-glucose cotransporter-2 inhibitors (8.0%). The study monitored a composite of mortality and HF incidents, revealing incidence rates of 11.74, 12.50, and 8.93 per 100 person-years for the overall, HFrEF, and HFmrEF/HFpEF populations, respectively. CONCLUSIONS: Despite high guideline-directed medical therapy adherence, the Thai Heart Failure Registry data revealed high mortality and recurrent HF rates. These findings underscore limitations in current HF treatment efficacy. The results indicate the need for further investigation and improvements of HF management to enhance patient outcomes.

Disease activity is associated with LV dysfunction in rheumatoid arthritis patients without clinical cardiovascular disease.

OBJECTIVES: The cross-sectional study aimed to assess left ventricular systolic function using global longitudinal strain (GLS) by speckle-tracking echocardiography (STE) and arterial stiffness using cardio-ankle vascular index (CAVI) in Thai adults with rheumatoid arthritis (RA) and no clinical evidence of cardiovascular disease (CVD). METHODS: Confirmed RA patients were selected from a list of outpatient attendees if they were 18 years (y) without clinical, ECG and echocardiographic evidence of CVD, diabetes mellitus, chronic kidney disease, and excess alcoholic intake. Controls were matched with age and sex to a list of healthy individuals with normal echocardiograms. All underwent STE and CAVI. RESULTS: 60 RA patients (females = 55) were analysed. Mean standard deviation of patient and control ages were 50 ± 10.2 and 51 ± 9.9 y, respectively, and mean duration of RA was 9.0 ± 6.8 y. Mean DAS28-CRP and DAS28-ESR were 2.9 ± 0.9 and 3.4 ± 0.9, respectively. There was no between-group differences in left ventricular ejection fraction (LVEF), LV sizes, LVMI, LV diastolic function and CAVI were within normal limits but all GLSs values was significantly lower in patients vs. controls: 17.6 ± 3.4 vs 20.4 ± 2.2 (p = 0.03). Multivariate regression analysis demonstrated significant correlations between GLSs and RA duration (p = 0.02), and GLSs and DAS28-CRP (p = 0.041). CONCLUSIONS: Patients with RA and no clinical CV disease have reduced LV systolic function as shown by lower GLSs. It is common and associated with disease activity and RA disease duration. 2D speckle-tracking GLSs is robust in detecting this subclinical LV systolic dysfunction.

Disease activity is associated with LV dysfunction in rheumatoid arthritis patients without clinical cardiovascular disease

Abstract Objectives: The cross-sectional study aimed to assess left ventricular systolic function using global longitudinal strain (GLS) by speckle-tracking echocardiography (STE) and arterial stiffness using cardio-ankle vascular index (CAVI) in Thai adults with rheumatoid arthritis (RA) and no clinical evidence of cardiovascular disease (CVD). Methods: Confirmed RA patients were selected from a list of outpatient attendees if they were 18 years (y) without clinical, ECG and echocardiographic evidence of CVD, diabetes mellitus, chronic kidney disease, and excess alcoholic intake. Controls were matched with age and sex to a list of healthy individuals with normal echocardiograms. All underwent STE and CAVI. Results: 60 RA patients (females = 55) were analysed. Mean standard deviation of patient and control ages were 50 ± 10.2 and 51 ±9.9 y, respectively, and mean duration of RA was 9.0 ± 6.8 y. Mean DAS28-CRP and DAS28-ESR were 2.9 ± 0.9 and 3.4 ± 0.9, respectively. There was no between-group differences in left ventricular ejection fraction (LVEF), LV sizes, LVMI, LV diastolic function and CAVI were within normal limits but all GLSs values was significantly lower in patients vs. controls: 17.6 ± 3.4 vs 20.4 ± 2.2 (p = 0.03). Multivariate regression analysis demonstrated significant correlations between GLSs and RA duration (p = 0.02), and GLSs and DAS28-CRP (p = 0.041). Conclusions: Patients with RA and no clinical CV disease have reduced LV systolic function as shown by lower GLSs. It is common and associated with disease activity and RA disease duration. 2D speckle-tracking GLSs is robust in detecting this subclinical LV systolic dysfunction.

Predictors of mitral annulus early diastolic velocity: impact of long-axis function, ventricular filling pattern, and relaxation.

AIMS: Although left ventricular (LV) relaxation is well recognized as a predictor of mitral annulus (MA) early diastolic (E') velocity, its significance relative to other predictors of E' is less well understood. METHODS AND RESULTS: We assessed 40 healthy volunteers, 43 patients with acutely decompensated chronic systolic heart failure (HF), and 36 patients with hypertrophic obstructive cardiomyopathy (HOCM) using echocardiography and right or left heart catheterization. Data were obtained at baseline. In addition, in healthy volunteers haemodynamics were varied by graded saline infusion and low body negative pressure, while in HF patients it was varied by vasoactive drug treatment. E- and A-wave velocity (E/A) ratio of the mitral valve inflow, systolic MA velocity integral (s' integral) and E' and late velocity (A') of lateral and septal MA pulsed wave velocities were assessed by echocardiography. Time constant of isovolumic pressure decay τ(0)) was calculated from isovolumic relaxation time/[ln(aortic dicrotic notch pressure) - ln(LV filling pressure)]. In all three groups, s' integral was the strongest predictor of E' (partial r= 0.53-0.79; 0.81 for three groups combined), followed by E/A ratio (partial r= 0.10-0.78; 0.26 for all groups combined) and τ(0) (partial r= -0.1 to 0.023; -0.21 for all groups combined). CONCLUSION: In healthy adults, patients with systolic HF, or patients with HOCM, E' is related to LV long-axis function and E/A ratio, a global marker of LV filling. E' appears less sensitive to LV relaxation.

Extracranial carotid stenosis and peripheral arterial disease in Thai patients with coronary artery disease.

We assessed the prevalence of carotid stenosis (CS) and peripheral arterial disease (PAD) in patients with coronary artery disease (CAD) to determine the relationship between these conditions in a Thai population. All patients with coronary angiography during June 2008 and August 2009 were studied. Carotid duplex and ankle-brachial index (ABI) were performed. One hundred and seventy-seven patients were studied (95 men, mean age of 65). Carotid stenosis and PAD were diagnosed in 16 patients (9%) and 68 patients (38.4%), respectively. The presence of carotid bruit and older age were independent predictors of CS and PAD, respectively. There was no correlation between the presence of CS/PAD and the extent of coronary artery lesions. Although CS was uncommon in patients with CAD, the patients with cervical bruit should be screened for CS. Prevalence of PAD was high, confirming the presence of diffuse atherosclerosis in many patients with CAD.

Left atrial strain measured by two-dimensional speckle tracking represents a new tool to evaluate left atrial function.

BACKGROUND: Left atrial (LA) strain (epsilon) and epsilon rate (SR) analysis by two-dimensional speckle tracking can represent a new tool to evaluate LA function. To assess its potential value, the authors addressed whether LA epsilon and SR measured in normal subjects correlates with other Doppler echocardiographic parameters that evaluate LA function and left ventricular function. METHODS: Sixty-four healthy subjects were studied. LA epsilon and SR were calculated with the reference point set at the P wave, which enabled the recognition of peak negative epsilon (epsilon(neg peak)), peak positive epsilon (epsilon(pos peak)), and the sum of those values, total LA epsilon (epsilon(tot)), corresponding to LA contractile, conduit, and reservoir function, respectively. Similarly, peak negative SR (LA SR(late neg peak)) during LA contraction, peak positive SR (LA SR(pos peak)) at the beginning of LV systole, and peak negative SR (LA SR(early neg peak)) at the beginning of LV diastole were identified. RESULTS: Global LA epsilon(pos peak), epsilon(neg peak), and epsilon(tot) were 23.2 +/- 6.7%, -14.6 +/- 3.5%, and 37.9 +/- 7.6%, respectively. Global LA SR(pos peak), SR(early neg peak) , and SR(late neg peak) were 2.0 +/- 0.6 s(-1), -2.0 +/- 0.6 s(-1), and -2.3 +/- 0.5 s(-1), respectively. The above-described variables derived from analysis of global LA epsilon and LA SR correlated significantly with Doppler echocardiographic indexes that evaluated the same phase of the cardiac cycle or the same component of the LA function, including indexes derived from mitral inflow, pulmonary vein velocities, tissue Doppler, and LA volumes. Global LA epsilon(pos peak), LA epsilon(tot), and LA SR(early neg peak) also correlated significantly with age or body mass index. Global LA SR(late neg peak) also correlated significantly with age. CONCLUSIONS: LA epsilon analysis is a new tool that can be used to evaluate LA function. Further studies are warranted to determine the utility of LA epsilon in disease states.

Impact of left ventricular size on tissue Doppler and longitudinal strain by speckle tracking for assessing wall motion and mechanical dyssynchrony in candidates for cardiac resynchronization therapy.

BACKGROUND: Myocardial dysfunction and left ventricular (LV) geometry deformation may reduce the accuracy of tissue Doppler imaging (TDI) in assessing myocardial contractility. METHODS: In 92 patients with heart failure who underwent cardiac resynchronization therapy (CRT), we assessed the impact of LV end-diastolic volume on the accuracy of peak longitudinal velocity (TDI) and strain (epsilon(L) by speckle tracking) to assess regional wall motion and LV dyssynchrony. RESULTS: Peak-epsilon correlated to normal (-13% +/- 6%, n = 259), hypokinetic (-10% +/- 5%, n = 347), and akinetic (-7% +/- 5%, n = 498, P < .0001) wall motion independent of LV size. In contrast, velocity failed to distinguish normal from dysfunctional segments in patients with severe LV dilatation (end-diastolic volume > 250 mL). The 12 standard deviation of time to peak systolic velocity and the opposing septal-lateral wall delay by strain and TDI failed to predict response to CRT, whereas the 12 segment standard deviation of time to peak epsilon correlated to end-systolic volume reduction (r = -0.39, P < .001). CONCLUSION: Accuracy of TDI in assessing LV wall regional motion is limited in severely dilated ventricles and probably affects LV dyssynchrony measurement.

Impact of left ventricular volume/mass ratio on diastolic function.

AIMS: To assess the impact of left ventricular (LV) volume/mass ratio on diastolic function parameters in subjects with dilated cardiomyopathy (DCM) or hypertrophic cardiomyopathy (HCM) and healthy controls. METHODS AND RESULTS: We performed echocardiography in 44 healthy controls, 35 HCM subjects, 29 DCM subjects with narrow QRS complex (DCM-n), and 27 DCM subjects with wide QRS complex (DCM-w). Mitral annulus velocity (E(a)) and transmitral E-wave velocity were used to estimate time constant of isovolumic pressure decay (tau). LV flow propagation velocity (V(p)) and early intraventricular pressure gradient (IVPG) were derived from colour M-mode of LV inflow. We calculated LV twist and peak untwisting rate (UntwR) by speckle tracking. Mean LV volume/mass ratio was 0.34 +/- 0.09 mL/g in healthy controls, 0.15 +/- 0.06 mL/g in HCM, 0.6 +/- 0.2 mL/g in DCM-n, and 0.8 +/- 0.3 mL/g in DCM-w patients (P < 0.001 for all groups). Resting LV ejection fractions were 63 +/- 7, 64 +/- 8, 31 +/- 8, and 26 +/- 8%, respectively (P < 0.01 vs. controls for DCM groups). In a multivariate analysis, LV volume/mass ratio remained a strong independent predictor of V(p) (P < 0.001), IVPG (P = 0.009), and UntwR (P < 0.001) but not for E(a) (P = 0.25). CONCLUSION: LV volume/mass ratio had influences on diastolic function parameters independent of intrinsic diastolic function and filling pressures. It should be considered when assessing patients suspected of LV diastolic dysfunction.

Association between regional ventricular function and myocardial fibrosis in hypertrophic cardiomyopathy assessed by speckle tracking echocardiography and delayed hyperenhancement magnetic resonance imaging.

The relationship among myocardial fibrosis, segmental strains, and hypertrophic cardiomyopathy (HCM) in patients with preserved left ventricular ejection fraction is not known. We evaluated this relationship in 39 consecutive patients with HCM with transthoracic echocardiography and delayed hyperenhancement magnetic resonance imaging 20 minutes after injection of 0.2 mmol/kg of gadolinium. Speckle tracking echocardiography was used to assess left ventricle strains. Fibrosis was determined semiautomatically with magnetic resonance imaging, using a 12-segment short-axis left ventricular model. Myocardial fibrosis was detected in 23 of 39 patients with HCM. The mean end-systolic longitudinal strain correlated with the number of fibrotic segments (r = 0.47, P =.002) and total myocardial fibrosis (r = 0.46, P =.003). Fibrosis and wall thickness were both multivariate predictors of lower segmental longitudinal strain (P <.003). Longitudinal, circumferential, and radial strains are decreased in patients with HCM even in the absence of fibrosis. Myocardial fibrosis is associated with depressed longitudinal strain in patients with HCM.

Effect of atorvastatin on LDL & hs-CRP in a selected Thai population.

BACKGROUND: LDL and hs-CRP are risk factors for vascular events and can be modified by Statin. OBJECTIVE: To evaluate the baseline hs-CRP of a certain Thai population who would need Atorvastatin, to evaluate the dose response of Atorvastatin toward LDL and hs-CRP level, and to evaluate the efficacy and safety of different types of Atorvastatin. MATERIAL AND METHOD: Subjects, who needed Statin therapy, were randomized to receive either 20 mg of Berlin(B)-Atorvastatin(R) or Pfizer(P)-Atorvastatin(R). The cross over took place after 8 weeks of therapy and continued for 16 weeks. Baseline blood tests were compared to 8 and 16 weeks. The effect of two brands of 20 mg Atorvastatin toward serum lipid, LFT, muscle enzyme and hs-CRP were compared. RESULTS: One hundred and ten subjects aged between 20-75 years enrolled in the present study. Fifty-four and 56 patients were randomized to group A and B. Baseline total cholesterol, LDL, HDL, and TG were 251, 174, 55, and 160 mg/dl respectively. There was a wide variation of baseline hs-CRP level. One hundred and seven patients completed this 16 weeks study. Atorvastatin 20 mg lowered TC by 32%, LDL 44% and hs-CRP 10% at 16 weeks for the entire study (p < 0.003). The effect of either Atorvastatin the lipid profiles and hs-CRP were different. There was no significant change in LFT or muscle enzyme. CONCLUSION: Atorvastatin 20 mg has a dramatic effect on the lipid but moderate effect on CRP. The two different types of Atorvastatin (group A and B) have similar effect on both safety and efficacy.

Longitudinal strain delay index by speckle tracking imaging: a new marker of response to cardiac resynchronization therapy.

BACKGROUND: In heart failure patients with left ventricular dyssynchrony, contractility in delayed segments does not fully contribute to end-systolic function. We quantified this reserve of contraction related to mechanical dyssynchrony to predict response to cardiac resynchronization therapy by the strain delay index, which was defined as the sum of the difference between peak and end-systolic strain across 16 segments. METHODS AND RESULTS: In 100 heart failure patients (ejection fraction=26+/-9%, QRS=154+/-29 ms, 94% in New York Heart Association class III), we studied left ventricular dyssynchrony before cardiac resynchronization therapy by the strain delay index using longitudinal strain by 2D speckle tracking and by the SD of time to peak myocardial velocity in 12 segments. The optimal cutoff value of the strain delay index to predict response to cardiac resynchronization therapy was determined in a retrospective group (n=65) and then confirmed in a validation group (n=35). Left ventricular end-systolic volume reduction at 3 months >15% (responder) occurred in 64 of 100 patients. In the retrospective group, the strain delay index but not the SD of time to peak myocardial velocity was greater in responders (n=42/65) than nonresponders (35+/-8% versus 19+/-7%, P<0.0001), and the optimal cutoff value to identify response to cardiac resynchronization therapy was 25%. In the validation group, strain delay index > or =25% identified 82% (18/22) of responders and 92% (12/13) of nonresponders. Among the entire population (n=100), strain delay index correlated with reverse remodeling in both the ischemic (r=-0.68, P<0.0001) and nonischemic (r=-0.68, P<0.0001) population. CONCLUSIONS: Use of the strain delay index with longitudinal strain by speckle tracking has a strong predictive value for predicting response to cardiac resynchronization therapy in both ischemic and nonischemic patients.

Predictors of in-hospital mortality in non-ST elevation acute coronary syndrome in Thai Acute Coronary Syndrome Registry (TACSR).

OBJECTIVE: To determine baseline prognostic factors of in-hospital mortality in Thai patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). MATERIAL AND METHOD: Among 5,537 NSTE-ACS patients enrolled in Thai Acute Coronary Syndrome Registry, a univariate analysis and multivariate analysis were used to estimate the relationship of baseline clinical variables and in-hospital mortality. Variables examined included demographics, history and presenting characteristics. RESULTS: The in-hospital mortality rate was 9.5%. The statistically significant, adjusted baseline prognostic factors of in-hospital death were older age > or =65 years) (odds ratio [OR] 2.2, 95% confidence interval [CI] = 1.54-3.09), shock at presentation (OR 4.6, 95%CI = 2.91-7.32), heart failure (OR 3.1, 95%CI = 2.15-4.38), positive cardiac marker (OR 1.7, 95%CI = 1.18-2.53), arrhythmia (OR 12.3, 95%CI = 8.71-17.35), major bleeding (OR 2.9, 95%CI = 1.84-4.51), and cerebrovascular accident (OR 4.9, 95% CI = 2.42-9.97). While dyslipidemia (OR 0.6, 95%CI = 0.45-0.87), having percutaneous coronary intervention (OR 0.6, 95% CI = 0.39-0.94), receiving aspirin (OR 0.6, 95%CI = 0.33-0.94), beta-blocker (OR 0.5, 95% CI = 0.40-0.73), angiotensin converting enzyme inhibitor (OR 0.6, 95% CI = 0.43-0.78) and nitrate (OR 0.5, 95%CI= 0.35-0.76) were associated with lower in-hospital mortality. CONCLUSION: The in-hospital mortality is higher in Thai NSTE-ACS patients compared to other populations. The present study supports and confirms the prognostics importance of several baseline characteristics reported in previous studies.

The effect of the public or private status of health care facility in acute coronary syndrome: data from Thai ACS Registry.

BACKGROUND: Few data showed the differences between public and private hospitals in management practices and outcomes of patients with acute coronary syndrome. Furthermore, no data is available in Thailand. OBJECTIVE: To determine the patients' characteristics, management practices, and in-hospital outcomes differences between public and private hospitals in Thailand for patients with acute coronary syndrome. MATERIAL AND METHOD: Data from the Thai Acute Coronary Syndrome Registry (TACSR), which was a prospective observational study on ACS in Thailand from 2003 to 2005, was used. This registry provided clinical characteristics, medical management and outcomes of patients with ACS during hospitalization. All data were then compared based on type of admitting hospitals; public and private hospitals. To determine the relationship between type of hospital and major cardiac outcomes, multivariate logistic regression analysis was performed and represented as odd ratio (OR) and 95% confidence interval (95%CI). RESULTS: Eight thousand one hundred sixty four patients were admitted to public hospitals (n = 13), and 1,209 were admitted to private hospitals (n = 4). Patients in public hospitals were older (65.4 +/- 12.1 vs. 63.4 +/- 13.3 years, p < 0.001) and more female gender (41.7% vs. 30.1%, p < 0.001). Diagnosis of acute ST-elevation myocardial infarction were lower in public hospitals compared to private hospitals (39.6% vs. 50%, p < 0.001). After adjusting for baseline patient characteristics and management, in-hospital outcomes were higher in public hospitals for total mortality (13.6% vs. 5.9%, OR 2.3, 95%CI 1.76-3.12, p < 0.001), cardiac mortality (10.6% vs. 4.8%, OR = 2.1, 95%CI 1.55-2.91, p< 0.001) and major bleeding (6.3% vs. 3.2%, OR = 2.1, 95%CI 1.48-3.23, p < 0.001). Compared with the patients in the public hospital, patients in the private hospitals were more likely to undergo coronary angiography, percutaneous coronary intervention and coronary bypass grafting. CONCLUSION: In Thailand, management of patients with acute coronary syndrome is influenced by the public or private status of the hospitals. Patients were more likely to undergo coronary angiography and coronary revascularization procedures in private hospitals. The length of hospital stays and in-hospital mortality was higher in public hospitals.