Improving risk prediction for death, stroke and bleeding in Asian patients with atrial fibrillation.

BACKGROUND: The objectives of this study were to compare the GARFIELD Refitted model and CHA2 DS2 -VASc/HAS-BLED risk scores with the new model from the COOL-AF registry for all-cause death, ischaemic stroke/systemic embolism (SSE) and major bleeding in Asian patients with atrial fibrillation (AF). METHODS: Patients with non-valvular AF in the nationwide COOL-AF registry were studied. Patients were enrolled from 27 hospitals in Thailand during 2014-2017. Main outcomes were all-cause mortality, SSE and major bleeding. Predictive models of the three outcomes were developed from the variables in the multivariable Cox-proportional Hazard model. Predictive values of the models were evaluated by C-statistics, calibration plots and decision curve analysis (DCA). The new COOL-AF models were compared with the GARFIELD Refitted models and CHA2 DS2 -VASc model for all-cause mortality, SSE/HAS-BLED model for major bleeding. RESULTS: A total of 3405 patients were enrolled. The C-statistics for the COOL-AF models were 0.727 (0.712-0.742), 0.708 (0.693-0.724) and 0.706 (0.690-0.721) for all-cause mortality, SSE and major bleeding, respectively. Calibration plots showed good agreement between predicted probability the observed outcomes for the COOL-AF models with a calibration slope of 0.94-0.99. The predictive ability remains preserved after the internal validation with bootstraps and optimism (bias) correction. The COOL-AF predictive models tended to be superior to the GARFIELD Refitted, CHA2 DS2 -VASc and HAS-BLED models. CONCLUSION: The COOL-AF predictive models for all-cause mortality, SSE and major bleeding in Asian patients with AF had a good predictive ability. The COOL-AF model for all-cause mortality was superior to the GARFIELD Refitted and CHA2 DS2 -VASc model.

History of major bleeding predicts risk of clinical outcome of patients with atrial fibrillation: results from the COOL-AF registry.

OBJECTIVE: To compare clinical outcomes between patients with and without history of major bleeding according to types of antithrombotic medications in patients with non-valvular atrial fibrillation (NVAF). METHODS: We conducted a multicenter registry of patients with NVAF during 2014 to 2017 in Thailand. The following data were collected: demographic data, type of NVAF, medical illness, components of CHA2DS2-VASc and HAS-BLED scores, history of bleeding and severity, investigations, and antithrombotic medications. Clinical outcomes were death, bleeding, and ischemic stroke/transient ischemic attack (TIA). RESULTS: There were a total of 3218 patients. The average age was 67.3 ± 11.3 years, and 58.3% were men. Sixty-nine patients (2.14%) had a history of major bleeding. Antithrombotic use was, as follows: 2126 patients (75.3%) received oral anticoagulant (OAC) alone, 555 (17.2%) received antiplatelet alone, 298 (9.3%) received both, and 239 (7.4%) received neither. During follow-up, 9.9% had major adverse outcomes, including death (5.9%), ischemic stroke/TIA (2.5%), and major bleeding (4.0%). There were no significant differences in the types of antithrombotic medications between patients with and without history of major bleeding. Multivariate analysis revealed old age, low body mass index, hypertension, diabetes, heart failure, and history of major bleeding to be independently associated with major adverse outcome. Adverse events significantly increased in patients with OAC plus antiplatelet. CONCLUSIONS: History of major bleeding was identified as a factor that significantly affects clinical outcome. Inappropriate use of OAC plus antiplatelet should be avoided. Special caution should be made in this high-risk patients.

Risk profiles and pattern of antithrombotic use in patients with non-valvular atrial fibrillation in Thailand: a multicenter study.

BACKGROUND: Anticoagulation therapy is a standard treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) that have risk factors for stroke. However, anticoagulant increases the risk of bleeding, especially in Asians. We aimed to investigate the risk profiles and pattern of antithrombotic use in patients with NVAF in Thailand, and to study the reasons for not using warfarin in this patient population. METHODS: A nationwide multicenter registry of patients with NVAF was created that included data from 24 hospitals located across Thailand. Demographic data, atrial fibrillation-related data, comorbid conditions, use of antithrombotic drugs, and reasons for not using warfarin were collected. Data were recorded in a case record form and then transferred into a web-based system. RESULTS: A total of 3218 patients were included. Average age was 67.3 ± 11.3 years, and 58.2% were male. Average CHADS2, CHA2DS2-VASc, and HAS-BLED score was 1.8 ± 1.3, 3.0 ± 1.7, and 1.5 ± 1.0, respectively. Antiplatelet was used in 26.5% of patients, whereas anticoagulant was used in 75.3%. The main reasons for not using warfarin in those with CHA2DS2-VASc ≥2 included already taking antiplatelet (26.6%), patient preference (23.1%), and using non-vitamin K antagonist oral anticoagulants (NOACs) (22.7%). Anticoagulant was used in 32.3% of CHA2DS2-VASc 0, 56.8% of CHA2DS2-VASc 1, and 81.6% of CHA2DS2-VASc ≥2. The use of NOACs increased from 1.9% in 2014 to 25.6% in 2017. CONCLUSIONS: Anticoagulation therapy was prescribed in 75.3% of patients with NVAF. Among those receiving anticoagulant, 90.9% used warfarin and 9.1% used NOACs. The use of NOACs increased over time.

Fever-Induced Brugada Syndrome Is More Common Than Previously Suspected: A Cross-Sectional Study from an Endemic Area.

BACKGROUND: Brugada syndrome (BrS) is defined as presenting of type-1 Brugada pattern (BrP). BrS can also be induced by fever. This study demonstrated a highest prevalence of fever-induced BrS ever reported. METHOD: During May 2014, febrile (oral temperature ≥ 38 °C) and nonfebrile patients underwent standard and high leads (V1 and V2 at 2nd intercostal space) electrocardiogram. Risk factor and cardiac symptoms were recorded. Patients with a persistent of type-1 BrP after fever had subsided were excluded. The prevalence of BrS, type-2 BrP and early repolarization pattern (ERP) were demonstrated. RESULTS: A total of 401 patients, 152 febrile, and 249 nonfebrile, were evaluated. BrS was identified in six febrile patients (five males and one female) and two males in nonfebrile patients. The study demonstrated higher prevalence of BrS in febrile group compared to nonfebrile group (4.0% vs 0.8%, respectively, P = 0.037). Among fever-induced BrS patients, three patients (50.0%) experienced cardiac symptoms before and at the time of presentation and two patients (33.3%) had history of first-degree relative sudden death. No ventricular arrhythmia was observed. All of type-1 BrP disappeared after fever had subsided. We found no difference in prevalence of type-2 BrP in febrile and nonfebrile group (2.0% vs 2.8%, respectively, P > 0.05) as well as ERP (3.3% vs 6.4%, respectively, P > 0.05). CONCLUSIONS: Our study showed a highest prevalence of fever induced BrS ever reported. A larger study of prevalence, risk stratification, genetic test and management of fever-induced BrS should be done, especially in an endemic area.

CHA2DS2-VASc scores predict mortality after hospitalization for atrial fibrillation.

OBJECTIVE: The outcome of patients hospitalized for atrial fibrillation (AF) is relatively poor. We sought to determine the mortality rate and predictors of mortality following hospitalization for AF and to evaluate whether the CHA2DS2-VASc score was a predictor of mortality. METHODS: We examined the national database of Thailand residents who registered for government provided health insurance in 2005 and reviewed patient records from 2005 to 2010 to determine all-cause mortality. A total of 8981 patients (mean age, 65 years; 42% male) were admitted to the hospital with a diagnosis of AF. Data on demographics and comorbidities were retrieved from the database. The CHA2DS2-VASc score was calculated for each patient. RESULTS: The hospitalization rate for AF was 15.5 per 100,000 person-years. The two most common comorbidities were hypertension (N=1638, 18.2%) and diabetes (N=1349, 15.0%). The average CHA2DS2-VASc score for all patients was 1.8. By the 72-month follow-up (average 46 months), 3948 patients (44.0%) had died. The CHA2DS2-VASc score was directly related to the mortality rate (P log-rank <0.0001). Multivariate analysis showed that a CHA2DS2-VASc score ≥ 6 (hazard ratio [HR] 2.2, 95% confidence interval [CI], 1.4-3.7, P=0.002) and the presence of chronic kidney disease (HR 2.0, 95% CI 1.7-2.4, P<0.0001) were the strongest predictors of death. CONCLUSION: The outcome after hospitalization for AF is relatively poor. The CHA2DS2-VASc score is an independent prognostic marker of poor outcomes following hospitalization for AF.

Correlation between percutaneous coronary intervention volume, door-to-balloon time and mortality of patients with acute ST-segment elevation myocardial infarction.

BACKGROUND: Reperfusion therapy with percutaneous coronary intervention (PCI) is the preferred method for treatment of STEMI if it can be done in a timely manner in a high volume center. The present study aimed to evaluate the correlation between total PCI volume, emergency PCI volume, elective PCI volume, mean door-to-balloon (DTB) time and in-hospital mortality of patients with STEMI treated with emergency PCI. MATERIAL AND METHOD: Using Prince of Songkla university emergency PCI registry, the authors analyzed the study population of STEMI patients who underwent emergency PCI between January 2007 and December 2010. Pearson's Correlation Coefficient was used to determine the correlation. RESULTS: One thousand five hundred one PCI procedures including 355 emergency PCI procedures were done during the present study period. All types of PCI volume increased in each consecutive year between 2007 and 2010 while mean DTB time and in-hospital mortality continuously declined. The mean DTB time had positive correlation (r = 0.932) with in-hospital mortality. The emergency PCI volume was strongly negatively correlated with in hospital mortality (r = -0.953) and was statistically significant. There were negative correlations of elective PCI volume (r = -0.796), total PCI volume (r = -0.848), and in-hospital mortality but the correlations were not statistically significant. CONCLUSION: For emergency PCI, shorten mean DTB time in each consecutive year was associated with lower in-hospital mortality. Regarding to procedural volume, increase in each type of PCI procedure especially emergency PCI procedure was associated with a decrease in-hospital mortality.

Alcohol septal ablation without myocardial contrast echocardiography for hypertrophic obstructive cardiomyopathy.

OBJECTIVE: Review the efficacy and safety of using the anatomical characteristics of the first septal branch to select the target vessel for alcohol septal ablation (ASA) in treating patients with medically refractory symptoms hypertrophic obstructive cardiomyopathy (HOCM), ASA without guided myocardial contrast echocardiography (MCE). MATERIAL AND METHOD: Fifteen patients with HOCM and refractory to medical therapy were screened by echocardiography and coronary angiography between November 2007 and January 2010 in Songklanagarind university hospital. The procedure was abandoned in three patients due to vessel unsuitability. The clinical and hemodynamic data of 12 patients with HOCM before and after ASA were reviewed. The authors used the anatomical characteristics of vessel to identify the suitable septal perforator artery. RESULTS: ASA was done successfully in 12 patients. The averages of left ventricular outflow tract (LVOT) peak/mean pressure gradients (PPG/MPG) were 92.4 +/- 22.5/48.8 +/- 12.8 before and 21.6 +/- 11/12.8 +/- 5 mmHg immediately after ASA. The mean absolute alcohol volume was 2.5 +/- 0.64 ml. One patient had to have alcohol injection into two septal branches. Transient complete atrioventricular block occurred in two patients. All patients reported substantial symptomatic improvement. CONCLUSION: Most patients with medically refractory symptom HCOM have suitable first septal branches for ASA. ASA without MCE in those with suitable first septal branches is effective and safe.

Coronary spasm due to type A aortic dissection complicated by hemopericardium: a case report of another possible cause of coronary malperfusion.

Coronary malperfusion complicating Type A aortic dissection is relatively rare. The diagnosis of Type A aortic dissection as the cause of coronary ischemia is a challenge. The mechanism of coronary malperfusion has been proposed. We report a 45-year-old man presenting with acute inferior wall ST segment elevation myocardial infarction who was finally diagnosed to have Type A aortic dissection complicated by hemopericardium and cardiac tamponade. Coronary spasm is the most likely cause of transient myocardial ischemia in this patient and should be considered as another possible cause of coronary malperfusion in patients with Type A aortic dissection.

Alcohol septal ablation for hypertrophic obstructive cardiomyopathy, the first cases series in Thailand.

BACKGROUND: Alcohol septal ablation (ASA) is an emerging percutaneous technique to treat patients with hypertrophic obstructive cardiomyopathy (HOCM) and refractory to medical therapy. ASA in Thailand has never been reported. MATERIAL AND METHOD: The authors reviewed clinical and hemodynamic data of four patients with HOCM before and after ASA performed between November 2007 and May 2008 in Songklanagarind Hospital. RESULTS: ASA without myocardial contrast echocardiography was done successfully in all four patients with HOCM and refractory to medical therapy. The authors used the anatomical characteristics of vessel and pressure-guided technique to identify the optimal septal perforator artery. The averages of left ventricular outflow tract (LVOT) peak/mean pressure gradients (PPG/MPG) were 105/56 before and 32/18 mmHg immediately after ASA, consecutively. There were further falls in LVOT PPG and MPG to averages of 14 and 8.5 mmHg respectively at 6-12 week follow-up. The mean absolute alcohol volume was 2.5 +/- 0.41 ml. Transient complete atrioventricular block occurred in one patient. All patients reported substantial symptomatic improvement. CONCLUSION: The authors reported the first cases series of HOCM patients who underwent ASA in Thailand ASA without myocardial contrast echocardiography in carefully selected patient is feasible, effective, and safe.