Klebsiella-induced acute infectious purpura fulminans in a Thai woman: Case report and review of literature.

Purpura fulminans (PF) is an uncommon syndrome of acute purplish skin eruption characterized by coagulation of the microvasculature, which leads to purplish lesions and skin necrosis. There are three subtypes; idiopathic PF, neonatal PF and, the most common subtype, acute infectious PF (AIPF). Acute infectious PF is related to the thrombotic subtype of disseminated intravascular coagulation (DIC) and usually is superimposed on sepsis. This can rapidly lead to multi-organ failure from thrombotic occlusion of small and medium-sized blood vessels. We report a case of Klebsiella-induced AIPF in a 78-year-old Thai woman and also review other published cases.

Clinical effectiveness of second-line antihyperglycemic drugs on major adverse cardiovascular events: An emulation of a target trial.

Introduction: The cardiovascular benefits of multiple antihyperglycemic drugs as add-on therapies to metformin in the real-practice are unclear. This study aimed to directly compare major adverse cardiovascular events (CVE) associated with these multiple drugs. Methods: An emulation of a target trial was conducted using a retrospective-cohort data of type 2 diabetes mellitus (T2DM) prescribed with second-line drugs on top of metformin, including sodium-glucose cotransporter 2 inhibitors (SGLT2i), dipeptidyl peptidase-4 inhibitors (DPP4i), thiazolidinediones (TZD) and sulfonylureas (SUs). We applied inverse probability weighting and regression adjustment using intention-to-treat (ITT), per-protocol analysis (PPA) and modified ITT. Average treatment effects (ATE) were estimated using SUs as the reference. Results and Discussion: Among 25,498 patients with T2DM, 17,586 (69.0%), 3,261 (12.8%), 4,399 (17.3%), and 252 (1.0%) received SUs, TZD, DPP4i, and SGLT2i. Median follow-up time was 3.56 (1.36-7.00) years. CVE was identified in 963 patients. The ITT and modified ITT approaches showed similar results; the ATE (i.e., the difference of CVE risks) for SGLT2i, TZD, and DPP4i compared to SUs were -0.020(-0.040, -0.0002), -0.010(-0.017, -0.003), and -0.004(-0.010, 0.002), respectively, indicating 2% and 1% significant absolute risk reduction in CVE in SGLT2i and TZD compared to SUs. These corresponding effects were also significant in the PPA with ATEs of -0.045(-0.060, -0.031), -0.015(-0.026, -0.004), and -0.012(-0.020, -0.004). In addition, SGLT2i had 3.3% significant absolute risk reduction in CVE relative to DPP4i. Our study demonstrated benefits of SGLT2i and TZD in reducing CVE in T2DM patients compared to SUs when added to metformin.

External Validation of the ACUITY/HORIZON Bleeding Risk Score among Acute Coronary Syndrome Patients in Thai PCI Registry.

BACKGROUND: External validation is essential before implementing a predictive model in clinical practice. This analysis validated the performance of the ACUITY/HORIZON risk score in the most contemporary Thai PCI registry. METHODS: The ACUITY/HORIZON model was applied and validated externally in 12,268 ACS (acute coronary syndrome) patients. For revision and updating models, the regression coefficientd of all predictors were re-estimated and then additional predictors were stepwise selected from multivariate analysis. RESULTS: In-hospital bleeding defined by the BARC (Bleeding Academic Research Consortium) criteria was 1.3% (161 patients) and 2.3% (285 patients) by the ACUITY criteria. The calibration of both scales demonstrated overestimation of the original model with C-statistic values of 0.704 for ACUITY major bleeding and 0.793 for BARC 3 or 5 bleeding. For ACUITY major bleeding, the discriminatory power of the update model improved substantially when congestive heart failure (CHF), prior vascular disease as well as body mass index were considered. The update model demonstrated good calibration and C-statistic of 0.747 and 0.745 with no white blood cell (WBC) count. For BARC 3 or 5 bleeding, good calibration and discriminatory capacity could be observed when CHF and prior vascular disease were added in the update models, with an excellent C-statistic of 0.838, and a lower C-statistic value of 0.835 was obtained in the absence of WBC count. CONCLUSION: The ACUITY/HORIZON score was successfully validated in contemporary predictive and risk-adjustment models for PCI-related bleeding. The update models had good operating characteristics in patients from a real-world ACS population irrespective of bleeding definitions.

A challenging case of rheumatoid arthritis-associated aortitis presenting with erythema nodosum after ST-segment elevation myocardial infarction: A case report.

Rheumatoid arthritis is a systemic inflammatory disease that has many extra-articular manifestations. Cardiovascular involvement, including coronary vasculitis and aortitis and skin lesion of erythema nodosum are uncommon findings of patients with rheumatoid arthritis, and thus, it is challenging for diagnosis of this case from those unusual extra-articular presentation.

Medical students' confidence and competence with prescribing in ST-elevation myocardial infarction: a mixed-methods study.

Objectives: To explore factors associated with prescribing confidence and competence of final-year medical students for prescribing antiplatelet and fibrinolytic agents in ST-segment elevation myocardial infarction (STEMI). Methods: The study was conducted among final-year medical students with a triangular convergent mixed-methods approach. First, an online survey was conducted using a voluntary sampling method with concurrent in-depth interviews performed. The survey data was analysed using descriptive statistics and paired t-tests, while survey factors were compared using the chi-squared or Fisher's exact test. The interview data were coded and analysed thematically. The relations between the qualitative and quantitative findings were finally described. Results: Totally 92 validly replied to the questionnaire, and 20 participated in the interviews. The quantitative analysis indicated that they had high competence in the diagnosis of STEMI and prescribing antiplatelet and fibrinolytic agents. The mean confidence score of prescribing for both was medium and was significantly lower in fibrinolytic agents. (M=3.3, SD=1.1 vs. M=2.8, SD=1.0, t(91)=5.39, p<0.01). Their experience, knowledge, and mentoring were accounted for, considering the prescribing confidence factors in both approaches. Besides, providing guidelines and standing orders were derived from the interview data. Conclusions: This study has demonstrated that final-year medical students have a high ability to diagnose and prescribe essential medications in STEMI but tend to have low confidence in prescribing fibrinolytic agents. Experiential learning, mentorship and providing guidelines can help them, especially in emergency settings to prescribe confidently and safely. Further multicenter studies on undergraduate and graduate medical students' confidence and perspective of prescribing are required, especially for high-alert medications.

Comparison of efficacy and safety of intracoronary nicardipine and adenosine for fractional flow reserve assessment of coronary stenosis.

BACKGROUND: Administration of intracoronary (IC) adenosine allows an easily feasible, inexpensive, and more rapid alternative method for fractional flow reserve (FFR). It is common practice in many centers worldwide. Nicardipine is a strong coronary vasodilator but its efficacy and safety for assessing FFR is not established. The purpose of present study was to compare the efficacy and safety of IC nicardipine and adenosine for assessing FFR. METHODS: One hundred and fifty-nine patients with a total of 193 vessels undergoing clinically indicated FFR assessment of intermediate coronary stenoses were included. For the initial assessment of FFR, hyperemia was induced by an IC adenosine. After a washout period of 3 min, FFR was reassessed using 200 µg of IC nicardipine. RESULTS: Hyperemic efficacy among two different stimuli was compared. The mean FFR with IC adenosine was 0.83 ± 0.09 and that with an IC nicardipine was 0.84 ± 0.09. The median FFR with an IC adenosine was 0.83 (0.78-0.91) and that with an IC nicardipine was 0.85 (0.79-0.91) (p-value 0.246). Both FFR values showed an excellent correlation (R2 = 0.982, p < 0.001). Nicardipine produced fewer changes in heart rate, less chest pain and less flushing than adenosine. Transient atrioventricular block occurred in 29 patients with IC adenosine and none with IC nicardipine. CONCLUSIONS: IC bolus injection of nicardipine could be introduced as a safe and practical alternative method of inducing hyperemia during FFR measurements. Compared to IC adenosine, IC nicardipine has a similar hyperemic efficacy and excellent side-effect profile.

Alice in Wonderland Syndrome-Like Seizure and Refractory Supraventricular Tachycardia.

Alice in Wonderland syndrome (AIWS) is a rarely curious visual perceptual disorder which has been associated with diverse neurologic and psychiatric problems. It may be a manifestation in migraine, epileptic seizures, encephalitis, other brain lesions, medication-related side effects, schizophrenia, and depressive disorders. Principal character of AIWS is the disproportion between the external world and the self-image in which micropsia (objects appear smaller), macropsia (objects appear larger), and teleopsia (objects appear further away) are frequently reported. The cases of temporal lobe epilepsy may present with complex visual auras of visual distortions (e.g., micropsia and macropsia) like AIWS. We report an unusual case of an elderly man who presented with AIWS, focal impaired awareness seizures, ictal tachyarrhythmia, multiple episodes of transient visual disturbances of macropsia and transient loss of consciousness. During those symptoms, telemetry showed self-limited supraventricular tachycardia several times which could not be regulated with heart rate-controlled medication. The electroencephalography was later tested and showed rhythmic theta activity over the right cerebral hemisphere. He was treated with levetiracetam, and all his symptoms and tachyarrhythmias were gradually resolved thereafter. Refractory response to treatment would remind the physicians to reassess for the correct diagnosis.

The Predictive role of Neutrophil-to-Lymphocyte Ratio (NLR) and Mean Platelet Volume-to-Lymphocyte Ratio (MPVLR) for Cardiovascular Events in Adult Patients with Acute Heart Failure.

INTRODUCTION: The inflammatory response plays a potential role for the pathogenesis and adverse outcomes of heart failure (HF). We aimed to explore the predictive role of baseline neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume-to-lymphocyte ratio (MPVLR) on cardiovascular events (CVEs) in patients hospitalized with acute HF. MATERIALS AND METHODS: A retrospective cohort study was conducted in 321 patients with HF between January 2017 and December 2019. The association between their NLR, MPVLR, and combined NLR and MPVLR and CVEs, rehospitalization for HF, in-hospital death, and a composite outcome was explored by survival analysis using a Cox proportional hazard model. They were separately investigated and compared with the area under the receiver operating characteristics curve (AUC). RESULTS: Up to the end of the 3-year follow-up, 96 (29.9%) had CVEs, 106 (33.0%) died, 62 (19.3%) were rehospitalized with HF, and 21 (6.5%) died during admission. The NLR and MPVLR were significantly associated with CVEs (adjusted HR for NLR ≥ 3.29, 3.11; 95% CI, 1.98-4.89; MPVLR ≥ 8.57, 2.86; 95% CI, 1.87-4.39), readmissions for HF (adjusted HR for NLR ≥ 3.58, 2.70; 95% CI, 1.58-4.61; MPVLR ≥ 6.43, 2.84; 95% CI,1.59-5.07), in-hospital mortality (adjusted HR for NLR ≥ 3.29, 9.54; 95% CI, 2.19-41.40; MPVLR ≥ 8.57, 7.87; 95% CI, 2.56-24.19), and composite outcome (adjusted HR for NLR ≥ 3.32, 4.76; 95% CI, 3.29-6.89; MPVLR ≥ 7.07, 3.64; 95% CI, 2.58-5.15). The AUC of NLR and MPVLR for CVEs were 0.67 (95% CI, 0.61-0.72) and 0.63 (95% CI, 0.58-0.69). Combined NLR and MPVLR increased the AUC to 0.77 (95% CI, 0.72-0.83) with statistical significance. CONCLUSION: The elevated NLR and MPVLR on admission in patients with acute HF were independently associated with worse CVEs, rehospitalization for HF, in-hospital death, and composite outcomes. These economical biomarkers should be considered in the management and follow-up care of patients with acute HF.

Associations of left ventricular systolic dysfunction with the factors among Thai patients on peritoneal dialysis: a cross-sectional study.

BACKGROUND: Factors associated with left ventricular systolic dysfunction (LVSD) of peritoneal dialysis (PD) patients are limited. We aim to explore and quantify the associated factors of LVSD among PD patients. METHODS: Participants from a PD clinic treated between 2012 and 2014 at the HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand were recruited and divided into 2 groups according to their left ventricular ejection fraction (LVEF) (< 50% vs. ≥ 50%) with LVEF < 50% considered as LVSD. Correlations among the clinical, laboratory and echocardiographic variables were analyzed. The factors associated with LVSD were explored with univariate and multivariate logistic regression analyses. Beta coefficient along with odds ratio and 95% confidence interval (CI) were calculated and the P value < 0.05 was considered significant. RESULTS: Among 103 subjects stratified as LVSD (n = 18, 17.5%). The mean (SD) age was 59.3 (12.7) years, and nearly halves were males. Preexisting CAD, diabetes (DM) and current smoking were 20 (19.4%), 63 (61.2%) and 23 (22.3%) patients, respectively. The median time of dialysis vintage was 12 (3, 24) months. Factors associated with LVSD and corresponding ORs with 95% CI by multivariate analysis were prior coronary artery disease (CAD) [5.08 (1.16, 22.19)], DM [6.36 (1.29, 31.49)], smoking [10.62 (2.17, 51.99)], neutrophil to lymphocyte ratio (NLR) > 3.6 [6.77 (1.41, 32.52)], and high serum phosphate [9.39 (2.16, 40.92)] were significantly associated with LVSD. CONCLUSIONS: Prior history of CAD, DM, smoking, high NLR and serum phosphate levels were found to be associated with LVSD for our PD patients. The evidence from prospective study is needed to confirm the predictive value of these variables.

Mediation Effect of Neutrophil Lymphocyte Ratio on Cardiometabolic Risk Factors and Cardiovascular Events.

Neutrophil to lymphocyte ratio (NLR), an inflammatory biomarker, is associated with cardiovascular events (CVEs), but its causal pathway is unknown. We aimed to explore the extent to which NLR is directly associated with CVEs or mediated through diabetes mellitus (DM), hypertension (HT) and creatinine (Cr). The study used data on 2,501 subjects from the Electricity Generating Authority of Thailand cohort 2002-2012. Two causal pathways A: NLR→(DM→Cr→HT)→CVEs and B: NLR→(DM → HT→Cr)→CVEs were constructed. A generalized structural equation model and 1,000-replication bootstrapping were applied. The incidence rate of CVE was 8.8/1000/year. Prevalence rates of HT, DM, and chronic kidney disease were 45.1%, 23.6%, and 16.5%, respectively. The total effect of NLR on CVEs was explained partly (44%) by a direct effect and partly (56%) by an indirect effect through DM, HT and Cr. For pathway A, the direct OR of NLR on CVE was 1.25 (95% CI: 1.13, 1.39); the ORs for the indirect effects of NLR on CVEs mediated through DM, Cr, and poor-controlled HT were 1.06 (95% CI: 1.01, 1.11), 1.01 (95% CI: 1.00, 1.02), and 1.07 (95% CI: 1.01, 1.14) respectively. Results were similar for pathway B. Our findings demonstrate that roughly half of the relationship between NLR and CVEs may be mediated through DM, HT and Cr.

Neutrophil Lymphocyte Ratio and Cardiovascular Disease Risk: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review aimed to measure the association between neutrophil lymphocyte ratio (NLR) and cardiovascular disease (CVD) risk. METHODS: Relevant studies were identified from Medline and Scopus databases. Observational studies with NLR as a study factor were eligible for review. The outcomes of interest were any type of CVD including acute coronary syndrome, coronary artery disease, stroke, or a composite of these cardiovascular events. Mean differences in NLR between CVD and non-CVD patients were pooled using unstandardized mean difference (USMD). Odds ratios of CVD between high and low NLR groups were pooled using a random effects model. RESULTS: Thirty-eight studies (n=76,002) were included. High NLR was significantly associated with the risks of CAD, ACS, stroke, and composite cardiovascular events with pooled ORs of 1.62 (95% CI: 1.38-1.91), 1.64 (95% CI: 1.30, 2.05), 2.36 (95% CI: 1.44, 2.89), and 3.86 (95% CI: 1.73, 8.64), respectively. In addition, mean NLRs in CAD, ACS, and stroke patients were significantly higher than in control groups. CONCLUSION: High NLR was associated with CAD, ACS, stroke, and composite cardiovascular events. Therefore, NLR may be a useful CVD biomarker.

The Reversal of Bleeding Caused by New Oral Anticoagulants (NOACs): A Systematic Review and Meta-Analysis.

New oral anticoagulants (NOACs; ie, direct thrombin inhibitor [DTI] and factor Xa [FXa] inhibitors) were used as alternatives to warfarin. Specific antidotes (idarucizumab for dabigatran and andexanet alfa for FXa inhibitors) and hemostatic reversal agents were used for lowering bleeding, but their efficacies were still uncertain. The objectives of this study were to estimate and compare the efficacy of NOAC antidotes on bleeding reversal and death. Studies were identified from MEDLINE and Scopus databases until May 2018. Case reports/series and cohorts were selected if they assessed reversal or death rates. Data were independently extracted by 2 reviewers. Individual patient data and aggregated data of outcomes were extracted from case reports/series and cohorts. Binary regression was used to estimate outcome rates, risk ratio (RR) along with 95% confidence interval (CI). Interventions were NOACs and reversal agents (ie, DTI-specific, DTI-standard, FXa-specific, and FXa-standard). Among 220 patients of 93 case reports/series, reversal rates were 95.9%, 77.6%, and 71.5% for DTI-specific, FXa-standard, and DTI-standard. Pooled RRs for DTI-specific and FXa-standard versus DTI-standard, respectively, were 1.34 (CI: 1.13-1.60) and 1.09 (CI: 0.84-1.40). Death rate was 0.18 (CI: 0.06-0.57) times lower in DTI-specific versus DTI-standard. For pooling 10 subcohorts, pooled RRs were 1.08 (CI: 1.00-1.16), 1.29 (CI: 1.20-1.39), and 1.13 (CI: 1.01-1.25) for DTI-specific, FXa-specific, and FXa-standard versus DTI-standard. In conclusion, specific reversal agents might be useful for reversal of bleeding and lowering the risk of death than standard reversal agents. Our findings were based on case reports/series and selected cohorts, further comparative studies are thus needed.

The association of serum magnesium and mortality outcomes in heart failure patients: A systematic review and meta-analysis.

BACKGROUND: Low serum magnesium (Mg) has been independently shown to increase risk of heart failure (HF), but data on the association between serum Mg concentration and the outcome of patients with HF are conflicting. The purpose of this systematic review and meta-analysis was to estimate the prognostic effects of hypermagnesemia and hypomagnesemia on cardiovascular (CV) mortality and all-cause mortality (ACM) of patients with HF. METHODS: Relevant studies were identified from Medline and Scopus databases. Included and excluded criteria were defined. Effects (i.e., log [risk ratio [RR]]) of hypomagnesemia and hypermagnesemia versus normomagnesemia were estimated using Poisson regression, and then a multivariate meta-analysis was applied for pooling RRs across studies. Heterogeneity was explored using a meta-regression and subgroup analysis. RESULTS: On analysis, 7 eligible prospective studies yielded a total of 5172 chronic HF patients with 913 and 1438 deaths from CV and ACM, respectively. Most participants were elderly men with left ventricular (LV) ejection fraction ≤40%. Those patients with baseline hypermagnesemia had a significantly higher risk of CV mortality (RR, 1.38; 95% confidence interval [CI], 1.07-1.78) or ACM (RR, 1.35; 95% CI, 1.18-1.54) than those with baseline normomagnesemia. However, baseline hypomagnesemia was not associated with the risk of CV mortality (RR, 1.11; 95% CI, 0.79-1.57) and ACM (RR, 1.11; 95% CI, 0.87-1.41). A subgroup analysis by Mg cutoff suggested a dose-response trend for hypermagnesemia effects, that is, the pooled RRs for CV mortality were 1.28 (95% CI, 1.05-1.55) and 1.92 (95% CI, 1.00-3.68) for the cutoff of 0.89 to 1.00 and 1.05 to 1.70 mmol/L, respectively. CONCLUSION: The present systematic review and meta-analysis suggested that, in HF patients, hypermagnesemia with serum Mg ≥ 1.05 mmol/L was associated with an increased risk of CV mortality and ACM but this was not observed for hypomagnesemia. This finding was limited to the elderly patients with chronic HF who had reduced LV systolic function.

Demographics, Management Practices and In-Hospital Outcomes: Results from the HRH Princess Maha Chakri Sirindhorn Medical Center Acute Coronary Syndrome Registry.

OBJECTIVE: To determine the demographics and in-hospital outcomes of patients with acute coronary syndrome. It provides a real-life data to assess treatment strategies for acute coronary syndrome (ACS) patients. MATERIAL AND METHOD: The prospective study included patients who were hospitalized with the diagnosis of ACS during January to December, 2013. The data were analyzed in terms of characteristics, clinical presentation, treatment, and in-hospital outcomes. RESULTS: A total of 105 patients were enrolled. Mean age of all patients was 73.8 years and half of the patients were older than 70 years old. Twenty patients were classified as ST-segment elevation myocardial infarction (STEMI) and 85 as unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI). Overall prevalence of diabetes was 52.4%. The STEMI group was predominantly male, with a fewer number of diabetes than in UA/NSTEMI group. Eighty percent of the STEMI patients received reperfusion therapy. Primary percutaneous coronary intervention (PCI) was performed in 70% of STEMI patients. The median door-to-needle and door-to-balloon time were 60 and 74 minutes, respectively. Six of fourteen primary PCI patients received it after 90 minutes. Nearly half of UA/NSTEMI patients went to coronary angiography and about one-third of them received revascularization with either PCI or coronary artery bypass grafting. The total mortality rate was 15% in both the STEMI patients and the UA/NSTEMI patients. CONCLUSION: This registry provided a detail of demographics, management practices, and in hospital outcomes of ACS patients. Door-to-needle time and door-to-balloon time were considered as suboptimal. In-hospital mortality was higher than the latest national average. Patient delay should be improved by giving more education to the general public and concerted effort to improve in-hospital time delay is warranted. These data have an impact on our patient care system and alert our team to improve patient care.

Echocardiographic and Clinical Characteristics Cross-Sectional Study in Association with Thai Peritoneal Dialysis Patients: Data from a Single Center Study.

BACKGROUND: The dialysis patients have a lot of changes in cardiac structure and function detected by echocardiography and they have been recognized as key outcome predictors. However, the available data regarding echocardiographic alterations in Thai Continuous Ambulatory Peritoneal Dialysis (CAPD) patients is limited. This study aimed to determine the correlation between baseline clinical and echocardiographic characteristics of Thai CAPD patients. MATERIAL AND METHOD: This study was a single center and cross-sectional observational study, which enrolled all CAPD outpatients (104 patients), treated at Srinakharinwirot Medical University between 1 September 2012 and 31 June, 2014. Their demographic and echocardiographic data were collected one time and the latest laboratory data to the patient's echocardiographic study date were analyzed. RESULTS: One hundred and four patients (50 men and 54 women) whose mean age was 59.4 ± 12.7 years and median duration of CAPD was 12 months were recruited. An extremely high prevalence of elevated left ventricular mass index (LVMI), 82.7% was found which mean LVMI was higher in male than female (166.2 ± 55.6 vs. 131 ± 47.6 g/m2). All patients had diastolic dysfunction and most ofthem had diastolic dysfunction grade I. The studyfactors of male gender, history of hypertension, high serum phosphate, low hemoglobin level, corrected QT interval, and duration of CAPD longer than 24 months can predict the variation of LVMI. Interestingly, the study found that a duration of CAPD of longer than 42 months might reduce right ventricular systolic pressure. CONCLUSION: This study revealed a higher prevalence of left ventricular hypertrophy (LVH) in Thai CAPD patients when compared with previous studies and anemia still be an important independentfactor for developing LVH. Longer period of CAPD may regress LVH and lower RVSP that should be proven by longer well-designed prospective studies.

Unexpected causes of pulmonary hypertension in a previously healthy Thai rural man with right-sided heart failure.

UNLABELLED: Male, 52 FINAL DIAGNOSIS: Pulmonary hypertension Symptoms: Diarrhea • dyspnea • jaundice MEDICATION: - Clinical Procedure: - Specialty: Endocrinology and Metabolic. OBJECTIVE: Unusual clinical course. BACKGROUND: Hyperthyroidism is one of the important causes of high-output failure and reversible pulmonary artery hypertension. Severe pulmonary artery hypertension is rarely found in associated with hyperthyroidism due to the small number of cases reported. We present an interesting case with multiple unexpected findings of the possible causes of severe pulmonary artery hypertension: hyperthyroidism, pulmonary embolism, and ostium secundum atrial septal defect. CASE REPORT: We present the case of a previously healthy rural Thai man who progressively developed dyspnea on exertion, chronic diarrhea, and jaundice for the previous 3 months. Physical examination revealed right-sided predominate chronic heart failure with signs of pulmonary hypertension. The investigation demonstrated autoimmune hyperthyroidism, cholestatic jaundice, moderate tricuspid regurgitation, ostium secundum atrial septal defect, and severe pulmonary artery hypertension. After treatment with an anti-thyroid drug and closure of the ostium secundum atrial septal defect, his symptoms of jaundice and pulmonary artery pressure were completely resolved. CONCLUSIONS: Severe pulmonary artery hypertension may not solely be a result of hyperthyroidism. Further investigation for other causes is recommended.

Fractional flow reserve guided coronary revascularization in drug-eluting era in Thai patients with borderline multi-vessel coronary stenoses.

BACKGROUND: Previous studies have shown the cost benefit of fractional flow reserve (FFR)--guided coronary revascularization in the patient with multivessel borderline coronary artery stenoses. However; they have been performed in the Bare-metal stent era. It is a challenge to demonstrate the benefit of the FFR-guided coronary revascularization in the patient with multivessel coronary disease (MVD) in the drug-eluting era in Thai patients. MATERIAL AND METHOD: Forty-nine patients with MVD (71 stenotic vessels) underwent FFR-guided revascularization (FFR group) compared with forty-nine patients with MVD (79 stenotic vessels) underwent traditional PCI (Traditional group) on the basis of visual estimation of the stenotic lesion. PCI has been performed in the FFR group patient with FFR value < or =0.75, whereas those with FFR value > or = 0.75 continued on medical treatment. The event rates of chest pain, repeat revascularization, hospitalization, myocardial infarction and death were compared between both groups. Total costs incurred in the catheterization laboratory, including the cost of stent, balloon, pressure guide wire, contrast media and other supplies, were computed between both groups. RESULTS: In FFR group: in 46 vessels, FFR was 0.87 +/- 0.06 and PCI was avoided, the other 25 vessels, baseline FFR was 0.65 +/- 0.09 and were underwent PCI. Two patients proceed CABG In the traditional PCI group: 79 vessels were underwent PCI. In comparison of event free survival between the FFR and the traditional PCI groups during follow-up (mean follow-up 8.27 +/- 5.45 vs. 9.49 + 5.39 months), they were not different in MACE, chest pain, repeat revascularization, hospitalization, myocardial infarction and death (8.2% vs. 13.3%, p = 0.33). The average total cost saving per patient was 63,290 Baht (p < 0.001). CONCLUSION: For patients with borderline MVD, FFR-guided coronary revascularization with drug eluting stent placement could save a total cost per patient at 63,290 Bath without compromising safety.