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.

Comparative cardiovascular benefits of individual SGLT2 inhibitors in type 2 diabetes and heart failure: a systematic review and network meta-analysis of randomized controlled trials.

Background: In patients with type 2 diabetes (T2D) and a history of heart failure (HF), sodium-glucose cotransporter-2 inhibitors (SGLT2is) have demonstrated cardiovascular (CV) benefits. However, the comparative efficacy of individual SGLT2is remains uncertain. This network meta-analysis (NMA) compared the efficacy and safety of five SGLT2is (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and sotagliflozin) on CV outcomes in these patients. Materials and methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to September 23, 2022, to identify all randomized controlled trials (RCTs) comparing SGLT2is to placebo in T2D patients with HF. The main outcomes included composite CV death/heart failure hospitalization (HFH), HFH, CV death, all-cause mortality, and adverse events. Pairwise and NMA approaches were applied. Results: Our analysis included 11 RCTs with a total of 20,438 patients with T2D and HF. All SGLT2is significantly reduced HFH compared to standard of care (SoC) alone. "Add-on" SGLT2is, except ertugliflozin, significantly reduced composite CV death/HFH relative to SoC alone. Moreover, canagliflozin had lower composite CV death/HFH compared to dapagliflozin. Based on the surface under the cumulative ranking curve (SUCRA), the top-ranked SGLT2is for reducing HFH were canagliflozin (95.5%), sotagliflozin (66.0%), and empagliflozin (57.2%). Head-to-head comparisons found no significant differences between individual SGLT2is in reducing CV death. "Add-on" SGLT2is reduced all-cause mortality compared with SoC alone, although only dapagliflozin was statistically significant. No SGLT2is were significantly associated with serious adverse events. A sensitivity analysis focusing on HF-specific trials found that dapagliflozin, empagliflozin, and sotagliflozin significantly reduced composite CV death/HFH, consistent with the main analysis. However, no significant differences were identified from their head-to-head comparisons in the NMA. The SUCRA indicated that sotagliflozin had the highest probability of reducing composite CV death/HFH (97.6%), followed by empagliflozin (58.4%) and dapagliflozin (44.0%). Conclusion: SGLT2is significantly reduce the composite CV death/HFH outcome. Among them, canagliflozin may be considered the preferred treatment for patients with diabetes and a history of heart failure, but it may also be associated with an increased risk of any adverse events compared to other SGLT2is. However, a sensitivity analysis focusing on HF-specific trials identified sotagliflozin as the most likely agent to reduce CV death/HFH, followed by empagliflozin and dapagliflozin. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022353754.

Effects of Buddhist walking meditation on exercise capacity and quality of life of patients with chronic heart failure: A randomized controlled trial.

BACKGROUND: Buddhist walking meditation (BWM) is widely practiced in many countries. However, there is a lack of evidence relating to its effectiveness for patients with heart failure (HF). PURPOSE: To determine the effects of a six-week BWM program on exercise capacity, quality of life, and hemodynamic response in patients with chronic HF. METHODS: Patients with HF were randomly assigned to a BWM program or an aerobic exercise program. Each group trained at least three times a week during the six-week study period. The outcome measures included exercise capacity (six-minute walk test), disease-specific quality of life (Minnesota Living with Heart Failure Questionnaire), and hemodynamic response (blood pressure and heart rate) immediately after the six weeks of training. RESULTS: The study enrolled 48 patients with a mean age of 65 years and a New York Heart Association functional class of II and III. At baseline, there were no significant differences in their clinical and demographic characteristics or the outcome measures. Although six patients withdrew, all participants were included in the intention-to-treat analysis. There was no statistically significant increase in the functional capacity of the BWM group; however, there was a significant improvement for the aerobic group. With both groups, there was no significant improvement in quality of life or most hemodynamic responses. CONCLUSIONS: The six-week BWM program did not improve the functional capacity, quality of life, or hemodynamic characteristics of the HF patients, compared with the values of the patients in the aerobic exercise program.

Cardiovascular impact in patients undergoing maintenance hemodialysis: Clinical management considerations.

Patients undergoing maintenance hemodialysis develop both structural and functional cardiovascular abnormalities. Despite improvement of dialysis technology, cardiovascular mortality of this population remains high. The pathophysiological mechanisms of these changes are complex and not well understood. It has been postulated that several non-traditional, uremic-related risk factors, especially the long-term uremic state, which may affect the cardiovascular system. There are many cardiovascular changes that occur in chronic kidney disease including left ventricular hypertrophy, myocardial fibrosis, microvascular disease, accelerated atherosclerosis and arteriosclerosis. These structural and functional changes in patients receiving chronic dialysis make them more susceptible to myocardial ischemia. Hemodialysis itself may adversely affect the cardiovascular system due to non-physiologic fluid removal, leading to hemodynamic instability and initiation of systemic inflammation. In the past decade there has been growing awareness that pathophysiological mechanisms cause cardiovascular dysfunction in patients on chronic dialysis, and there are now pharmacological and non-pharmacological therapies that may improve the poor quality of life and high mortality rate that these patients experience.

Pericardiectomy is Associated with Improvement in Longitudinal Displacement of Left Ventricular Free Wall Due to Increased Counterclockwise Septal-to-Lateral Rotational Displacement.

BACKGROUND: Pericardiectomy is an effective intervention for constrictive pericarditis. Speckle-tracking echocardiography can provide quantitative information not only about longitudinal strain (LS) but about longitudinal displacement (LD) and septal-to-lateral rotational displacement (SLRD). The aim of this study was to investigate whether pericardiectomy improves myocardial mechanics using speckle-tracking analysis. METHODS: Eighty-three patients with constrictive pericarditis who underwent echocardiography were retrospectively assessed (mean age, 58 ± 12 years; 72 men; 50 idiopathic, 20 postoperative, four viral, three radiation, and six others) and compared with 20 healthy volunteers. LD and SLRD were measured from the apical four-chamber view and global LS from three apical views. RESULTS: LD was less in the constrictive pericarditis group compared with control subjects (P < .001). Only lateral LS was significantly less than that of control subjects (P < .001), but septal LS was similar (P = .48). In pre- and post-pericardial surgery comparisons (n = 27), values of septal and lateral LD were almost identical (mean, 13.6 ± 4.7 vs 13.3 ± 5.4 mm; P = .70) before pericardiectomy, but septal LD decreased (mean, 9.3 ± 3.5 mm; P < .001) and lateral LD increased (mean, 16.8 ± 4.7 mm; P = .0106) after the surgery, even though the difference in LS between the septal and lateral walls decreased (from 5.6 ± 5.3% to 2.5 ± 4.2%, P = .008). Systolic whole-heart swinging motion significantly increased to a counterclockwise direction after surgery (mean SLRD, -0.8 ± 3.3° vs 2.1 ± 3.0°; P = .001). Although the change in SLRD after pericardiectomy was not different between patients with decreases and increases in New York Heart Association class, SLRD change was significantly greater in patients who received fewer diuretics after surgery (mean, 4.00 ± 0.91 vs 0.27 ± 1.47; P = .027). CONCLUSIONS: After surgical removal of the pericardium, LD of the septal and lateral walls became significantly different, and counterclockwise SLRD increased, reflecting loss of pericardial support.

Impact of long-axis function on cardiac surgical outcomes in patients with radiation-associated heart disease.

BACKGROUND: Malignancy-associated thoracic radiation leads to radiation-associated cardiac disease (RACD) that often necessitates cardiac surgery. Myocardial dysfunction is common in patients with RACD. We sought to determine the predictive value of global left ventricular ejection fraction and long-axis function left ventricular global longitudinal strain (LV-GLS) in such patients. METHODS: We studied 163 patients (age, 63 ± 14 years; 74% women) who had RACD and underwent cardiac surgery (20% had reoperations) between 2000 and 2003. In addition to standard echocardiography, LV-GLS (%) was derived from the average of 18 segments in 3 apical views of the left ventricle, using velocity vector imaging. Standard clinical and demographic parameters were recorded. All-cause mortality was recorded. RESULTS: The mean duration between cardiac surgery and the last chest radiation was 18 ± 12 years. The median European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8, and 88 patients died over 6.6 ± 4 years. A total of 52% of patients had ≥ II+ mitral regurgitation; 23% of patients had severe aortic stenosis; and 39% of patients had ≥ II+ tricuspid regurgitation. The mean left ventricular ejection fraction was 54% ± 13%, and the mean LV-GLS was -12.9% ± 4%. In a Cox proportional survival analysis, lower LV-GLS was predictive of mortality in univariable analysis (hazard ratio, 1.07 (95% confidence interval, 1.01-1.14); P = .006); however, after adjustment for other variables, the association became nonsignificant. In patients with a EuroSCORE

Dobutamine stress echocardiography during follow-up surveillance in heart transplant patients: Diagnostic accuracy and predictors of outcomes.

BACKGROUND: Cardiac allograft vasculopathy (CAV), a major cause of graft failure and mortality at >3 years after orthotopic heart transplantation (OHT), is commonly evaluated using dobutamine stress echocardiography (DSE). We sought to study: (a) the incidence of positive results and diagnostic accuracy of DSE; and (b) the predictors of adverse outcomes in OHT patients. METHODS: We studied 497 consecutive patients (63 ± 10 years, 78% men) with OHT who had undergone DSE as part of routine surveillance at our center between 1998 and 2013. Every DSE and coronary angiogram performed during follow-up was reviewed. CAV was regraded according to the 2010 recommendations of the International Society for Heart and Lung Transplantation. Composite events (death, coronary revascularization, myocardial infarction and retransplantation) were recorded. RESULTS: There were 1,243 DSE studies performed during a median of 8.7 (6.2 to 11.9) years after transplantation. Only 22 studies (1.8%) were positive, 978 (78.7%) were negative and 243 (19.5%) were non-diagnostic (sub-maximal heart rate response) for ischemia. Among 497 patients, only 20 (4%) had at least one positive DSE study. There were 310 diagnostic DSEs with coronary angiograms performed within 1 year of one another other. In this subgroup, the sensitivity, specificity, positive predictive value and negative predictive value of DSE were 7%, 98%, 82% and 41%, respectively, to detect any CAV, and 28%, 98%, 71% and 89% to detect CAV Grades 2 or 3, respectively. There were no deaths during DSE. At 5.6 ± 3.6 years after DSE, there were 201 (40%) events. Degree of CAV (and not DSE-based ischemia, p = 0.3) independently predicted outcomes (p < 0.001). CONCLUSIONS: The incidence of a positive result is very low in OHT patients undergoing surveillance DSE. DSE is insufficiently sensitive for detection of early CAV. Degree of CAV and not DSE-based ischemia independently predicted outcomes.

Left atrial volume as an independent predictor of exercise capacity in patients with isolated diastolic dysfunction presented with exertional dyspnea.

BACKGROUND: Left atrial volume (LAV) and exercise capacity are important prognostic determinants of cardiovascular risk. Exercise intolerance and increased LAV are expected in patients with diastolic dysfunction. While dyspnea is the symptom reported by the patient and considered subjective, exercise capacity obtained by exercise testing provides an objective measure of cardiovascular fitness. The objective of this study is to determine the relationship between LAV index and exercise capacity in patients with isolated diastolic dysfunction who presented with exertional dyspnea. METHODS: We studied consecutive patients with dyspnea who underwent treadmill exercise testing and transthoracic echocardiography on the same day. LAV was assessed using the biplane area-length method. Symptom-limited exercise testing was performed immediately after echocardiography. Patients with coronary artery disease, valvular or congenital heart disease, left ventricular systolic dysfunction, pulmonary hypertension or positive exercise test were excluded. RESULTS: The study consisted of 111 patients (58.1 ± 9.2 years of age, 54.1% male, 64% hypertension, 57.7% dyslipidemia and 20.7% diabetes). The exercise duration and capacity were 6.8 ± 2.1 minutes and 7.7 ± 1.9 METs, respectively. Left ventricular ejection fraction and LAV index was 71.0 ± 5.8% and 31.4 ± 10.5 ml/m2, respectively. In multivariate analysis, age [odds ratios (OR) 0.94; 95% confidence interval (CI) 0.89-0.99], body mass index (OR 0.82, 95% CI 0.72-0.93), and LAV index (OR 0.92, 95% CI 0.87-0.97) were associated with good exercise capacity. CONCLUSION: In patients with isolated diastolic dysfunction and exertional dyspnea, an increased LAV index, a marker of chronic diastolic dysfunction, is associated with poor exercise capacity.

Quantitative measurement of mitral regurgitation: comparison between echocardiography and cardiac magnetic resonance imaging.

BACKGROUND AND OBJECTIVE: Echocardiography is usually performed to quantify the severity of regurgitation. Magnetic resonance imaging (MRI) can also quantify mitral regurgitation. This study was performed to determine whether MRI can reliably quantify the severity of mitral regurgitation when compared with echocardiography MATERIAL AND METHOD: The authors retrospectively studied patients who underwent cardiac MRI between January 2008 and January 2011. Echocardiography was performed within 3 months of MRI. Mitral regurgitation was quantified by 3 methods of MRI; 1) difference of left ventricular stroke volume and right ventricular stroke volume, 2) difference of left ventricular stroke volume and forward flow volume in ascending aorta and 3) calculation of regurgitation fraction from the ratio of area of regurgitantjet and area of the left atrium. Proximal isovelocity surface area was the echocardiography parameter for mitral regurgitation. RESULTS: Forty-three subjects (24 women and 19 men; 47 to 85 years of age) were enrolled. Mitral regurgitation grading by MRI (2nd method) was mild (n = 28) moderate (n = 11) and severe (n = 4). There was moderate correlation between echocardiography and MRI assessments of regurgitation volume as follows; (1) difference between left ventricular stroke volume and right ventricular stroke volume (r = 0.48, p = 0.016), (2) subtracting forward flow volume of ascending aorta from left ventricular stroke volume (r = 0.48, p = 0.012). There was also correlation between regurgitation volume by echocardiography and fraction of maximal area of regurgitant jet divided by the area of the left atrium (r = 0.72, p < 0.001). CONCLUSION: Cardiac MRI compares favorably with echocardiography for quantifying mitral regurgitation severity.

Patients with non-sT-segment elevation myocardial infarction present with more severe systolic and diastolic dysfunction than patients with unstable angina.

BACKGROUND: Patients with non ST-segment elevation acute coronary syndrome (NSTEACS) present with diverse clinical, electrocardiographic, cardiac biomarker, echocardiographic and angiographic characteristics. We sought to determine whether there was any difference in the indices of left ventricular systolic and diastolic function among subgroups of patients with NSTEACS. MATERIAL AND METHOD: We studied 121 consecutive patients (mean age 68.6 +/- 11.3 years, 45% male) with NSTEACS who underwent comprehensive echocardiography within 48 hours of admission. Two-dimensional and Doppler echocardiography was performed for the evaluation of left ventricular systolic and diastolic function. RESULTS: Non ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) were reported in 59% and 41% of patients, respectively. Clinical characteristics (such as age, gender, cardiovascular risk factors, prior myocardial infarction and revascularization, medication) were not significantly different between patients with NSTEMI and UA. Patients with NSTEMI were more likely to have wall motion abnormalities and lower left ventricular ejection fraction (p < 0.05) as compared to those with UA. Diastolic dysfunction was significantly more frequent and more severe in patients with NSTEMI than in those with UA. CONCLUSION: Among patients with NSTEACS, left ventricular systolic and diastolic dysfunction was more frequent and more severe in patients with NSTEMI that in those with UA. These findings may be used to characterize the sicker group among patients with NSTEACS.

Comparison of aortic diameter in normal subjects and patients with systemic hypertension.

BACKGROUND: Standard aortic root dimensional measurement by the two dimensional echocardiography should be routinely performed in all patients. There is limited data on the normal reference on Thai population. OBJECTIVE: Aims of this study were (1) to determine the normal reference of aortic root dimension in Thai population and (2) to determine the difference in the aortic root size in patients with hypertension comparing with normal population. MATERIAL AND METHOD: We retrospectively reviewed 81 patients who had the transthoracic echocardiographic examinations in our echocardiographic lab and had the aortic root measurement data. The patients with ascending aortic aneurysm, aortic dissection, aortic stenosis and/or regurgitation more than mild in degree, Marfan's syndrome and annuloaortic ectasia were excluded. The echocardiographic data of were collected; the aortic root dimensions at four levels; aortic valve annulus, sinus of Valsava, sinotubular junction and tubular parts. Hypertension was indentified if the patient had the prior diagnosis of hypertension and on antihypertensive medications, or who had blood pressure more than 140/90 mmHg for two or more occasions. RESULTS: Eighty-one patients were enrolled. Sixty patients (74.1%) were diagnosed hypertension. Mean age was 66.9 +/- 11.2 years in hypertensive patients and 49.1 +/- 16.4 years in normotensive patients. Normal reference values based on 95% upper normal limit of aortic valve annulus, sinus of Valsava, sinotubular junction and tubular part were 2.30 (2.21-2.38), 3.56 (3.35-3.77), 2.79 (2.61-2.97), and 3.36 (3.13-3.59), respectively. Patients with hypertension had significant larger sinus of Valsava and tubular part of aortic root than patients with normotension. CONCLUSION: We reported a normal reference value for aortic root size in Thai population. The aortic root sizes are influenced by hypertensive status, age and gender.