Prognostic value of global longitudinal strain in patients with preserved left ventricular systolic function: A cardiac magnetic resonance real-world study.

BACKGROUND: Myocardial strain is a more sensitive parameter for cardiac function evaluation than left ventricular ejection fraction (LVEF). This study aimed to assess the predictive value of left ventricular global longitudinal strain (LV-GLS) by feature tracking-cardiac magnetic resonance (FT-CMR) imaging in patients with known or suspected coronary artery disease (CAD) with preserved left ventricular systolic function. METHODS: This retrospective cohort analysis enrolled patients with known or suspected CAD who underwent cardiac magnetic resonance imaging from September 2017 to December 2019. LV-GLS was analyzed via feature-tracking analysis. Patients with LVEF <50% were excluded. The composite outcome comprised all-cause death, non-fatal myocardial infarction, and heart failure. RESULTS: There was a total of 2613 patients. Mean follow-up duration was 39.7 ± 13.9 months. During follow-up, 194 patients (7.4%) experienced a composite outcome. The best cutoff of LV-GLS in the prediction of composite outcome from receiver operating characteristics was -14.4%. Patients were classified into 2 groups according to the LV-GLS; 1489 (57.0%) had LV-GLS <-14.4% and 1124 (43.0%) had LV-GLS ≥-14.4%. Patients with LV-GLS ≥-14.4% had a significantly higher rate of composite outcome than LV-GLS <-14.4% patients (3.59 vs. 1.39 per 100 person-years, respectively; p < 0.001). Multivariable analysis showed that patients with LV-GLS ≥-14.4% had a significantly higher risk of experiencing a composite outcome event compared to global longitudinal strain <-14.4% patients (adjusted hazard ratio: 1.83, 95% confidence interval: 1.28-2.61; p = 0.001). CONCLUSION: LV-GLS by FT-CMR was shown to be useful for predicting the prognosis of patients with known or suspected CAD with preserved left ventricular systolic function. LV-GLS -14.4% was the identified cutoff for prognostic determination.

Efficacy and safety outcomes of patients with atrial fibrillation compared between warfarin and non-vitamin K antagonist oral anticoagulants based on SAMe-TT2R2 score.

OBJECTIVES: This study aimed to investigate the efficacy and safety outcomes of patients with atrial fibrillation (AF) compared between those taking warfarin and non-vitamin K antagonist oral anticoagulants (NOACs) based on SAMe-TT2R2 score. METHODS: AF patients using warfarin or NOACs were enrolled from Thailand's COOL-AF registry. A low SAMe-TT2R2 score was defined as a score of 0-2. The efficacy outcomes were all-cause death, ischemic stroke (IS), transient ischemic attack (TIA), and/or systemic embolization (SE). The safety outcome was major bleeding (MB). The secondary outcome was a combination of cardiovascular (CV) death, IS/TIA/SE, or MB. Cox proportional hazards model was used to compare the event rate between the AF patients taking warfarin and NOACs according to SAMe-TT2R2 score. RESULTS: A total of 2568 AF patients taking oral anticoagulants were enrolled. Warfarin and NOACs were used in 2340 (91.1%) and 228 (8.9%) patients, respectively. Among overall patients, 305 patients taking warfarin (13.0%) and 21 patients taking NOACs (9.2%) had the efficacy outcome, while 155 patients taking warfarin (6.6%) and 11 patients taking NOACs (4.8%) had the safety outcome. After adjustment for confounders, overall patients taking warfarin had significantly more secondary outcome than those taking NOACs (11.4% vs. 7.5%, respectively; adjusted hazard ratio: 1.74, 95% confidence interval: 1.01-2.99; p = 0.045) regardless of SAMe-TT2R2 score. CONCLUSIONS: AF patients taking warfarin had a significantly higher CV death or IS/TIA/SE or MB compared to those taking NOACs regardless of SAMe-TT2R2 score. The results of this study do not support the use of SAMe-TT2R2 score to guide OAC selection.

Net clinical benefit of oral anticoagulants in Asian patients with atrial fibrillation based on a CHA2DS2-VASc score.

BACKGROUND: This study was conducted to assess the net clinical benefit (NCB) for oral anticoagulant (OAC) in atrial fibrillation (AF) patients according to the CHA2DS2-VASc score. METHODS: Patients with AF were prospectively recruited in the COOL AF Thailand registry from 2014 to 2017. The incidence rate of thromboembolic (TE) events and major bleeding (MB) was calculated. Cox proportional hazards model was used to compare the TE and MB rate in patients with and without OACs in CHA2DS2-VASc score of 0-1 and ≥ 2, respectively. The survival analysis was performed based on CHA2DS2-VASc score. The NCB of OACs was defined as the TE rate prevented minus the MB rate increased multiplied by a weighting factor. RESULTS: A total of 3,402 AF patients were recruited. An average age of patients was 67.38 ± 11.27 years. Compared to non-anticoagulated patients, the Kaplan Meier curve showed anticoagulated patients with CHA2DS2-VASc score of 2 or more had the lower thromboembolic events with statistical significance (p = 0.043) and the higher MB events with statistical significance (p = 0.018). In overall AF patients, there were positive NCB in warfarin patients with CHA2DS2-VASc score of 3 or more while there were positive NCB in DOACs patients regardless of CHA2DS2-VASc score. Females with CHA2DS2-VASc score of 3 or more had a positive NCB regardless of OACs type. Good anticoagulation control (TTR ≥65%) improved an NCB in males with CHA2DS2-VASc score of 3 or more. CONCLUSIONS: AF patients with CHA2DS2-VASc score of 3 or more regardless warfarin or DOACs had a positive NCB. The NCB of OACs was more positive for DOACs compared to warfarin and for females compared to males.

Characteristics and antithrombotic treatment patterns of patients with concomitant coronary artery disease and atrial fibrillation from Thailand's COOL-AF registry.

BACKGROUND: Concomitant coronary artery disease (CAD) and atrial fibrillation (AF) are common in clinical practice. The aim of this study was to investigate the characteristics and antithrombotic treatment patterns of patients with concomitant CAD and AF from the COhort of antithrombotic use and Optimal INR Level in patients with non-valvular atrial fibrillation in Thailand (COOL-AF Thailand) registry. METHODS: Registry enrollment criteria included patients aged ≥ 18 years who were diagnosed with AF for any duration at any of 27 public hospitals located across Thailand during 2014-2017. The That Clinical Trials Registry study registration number is TCTR20160113002. Statistical comparisons of characteristics and treatment strategies were performed between patients with and without CAD. RESULTS: Of a total of 3461 AF patients, 557 had concomitant CAD (16.1%). Patients with concomitant CAD and AF were significantly older, more likely to be male, had more comorbidities, and had more cardiovascular implantable electronic devices. History of stroke/transient ischemic attack and prior bleeding was not significantly different between groups. CHA2DS2-VASc score and HAS-BLED score were both higher in patients with CAD than in patients without CAD (4.17 vs. 2.78, p < 0.001, and 2.01 vs. 1.45, p < 0.001, respectively). Utilization of oral anticoagulant was less in patients with CAD (76.0% vs. 84.3%, p < 0.001). Concomitant use of antiplatelet was found to be a major cause of oral anticoagulant (OAC) underutilization. Specifically, the rate of OAC prescription was 95.9% in patients without antiplatelet, and 43.7% in patients with antiplatelet. Among patients with CAD who were on OAC, the rate of concomitant antiplatelet prescription was still high. In this group, 63% of patients were on triple therapy when percutaneous coronary intervention (PCI) with drug eluting stent was performed within 1 year, and 32.2% of patients without prior PCI or acute coronary syndrome were taking at least one antiplatelet with OAC. CONCLUSION: Among patients with concomitant CAD and AF, physicians were reluctant to discontinue antiplatelet. The use of antiplatelet discourages physicians from prescribing OAC. Underutilization of OAC may increase the risk of ischemic stroke, and an inappropriate combination of OAC and antiplatelet may increase the risk of bleeding. Trial registration The trial has been registered with the Thai Clinical Trials Registry (TCTR) which complied with WHO International Clinical Trials Registry Platform dataset. The Registration Number is TCTR20160113002 (05/01/2016).

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.

Prevalence and associating factors of atrial fibrillation in patients with hypertension: a nation-wide study.

BACKGROUND: Atrial fibrillation (AF) is a common cardiac arrhythmia and increases risk of ischemic stroke. Data on the prevalence of AF in Thailand is lacking especially in patients with hypertension. The objectives of this study were to determine prevalence of AF in patients with hypertension and to determine factors that are associated with increased prevalence of AF in a multicenter nationwide study. METHODS: A cross-sectional survey for the national outcome evaluation among hypertensive patients visiting 831 public hospitals in Thailand was conducted between 2011 and 2012 to evaluate status of standard care in hypertensive patients visiting public Thailand Ministry of Public Health (MoPH) hospitals. Inclusion criteria were hypertensive patients aged at least 20 years who had received medical care in the targeted hospital for at least 12 months. The main outcome measurement was AF rhythm, and was measured along with potential risk factors age, gender and cardiovascular risk factors. RESULTS: There were 13207 hypertensive patients who had ECG data recorded during the survey. AF was detected in 457 patients (3.46 %). Prevalence of AF increased with increasing age, was more common in males and in patients with chronic kidney disease (CKD). Multivariable modelling was conducted to assess which factors were most associated with increased prevalence of AF, and the results showed older age followed by male gender, low LDL-cholesterol and increased uric acid levels were the most important risk factors for AF in this population. CONCLUSIONS: Prevalence of AF in hypertensive patients was 3.46 %. Factors associated with increased risk of AF are old age, male gender, low LDL-cholesterol and elevated uric acid level.

Association between Aortic Arch Calcification Detected on Plain Chest X-Ray and Myocardial Scarring Detected on Cardiac Magnetic Resonance Imaging in Coronary Heart Disease Patients.

Background: Coronary heart disease requires advanced investigations. However, findings of fundamental investigations are sometimes underused and/or neglected, such as plain chest X-ray (CXR) and electrocardiography (ECG). A previous study found an association between aortic calcification and coronary artery disease, but there are no studies that have investigated association between aortic arch calcification in CXR and coronary artery disease consequences, such as myocardial viability (scarring). Objective: To investigated association between aortic arch calcification detected on plain CXR and myocardial scarring detected on cardiac magnetic resonance imaging (CMRI) in coronary heart disease patients. Material and Method: one hundred eighty-seven eligible patients aged ≥18 years and diagnosed as coronary heart disease by CMRI at Siriraj Hospital between January 2008 and December 2014 study periods were enrolled. We retrospectively reviewed aortic arch calcification from plain CXR, demographic data, hospitalization data, underlying disease, medications used, and CMRI parameters. Results: There was no significant association between aortic arch calcification from CXR and myocardial scar by CMRI. Aortic arch calcification was detected in 86 (45.98%) and 78 (41.70%) of patients with and without myocardial scar by CMRI (p = 0.981). There was no significant correlation between calcium grading and calcium thickness from CXR and the presence or absence of myocardial scar by CMRI. Myocardial scar was detected in 52.2%, 47.8%, 51.4%, and 59.1% in patients with calcium grade 0, 1, 2, and 3 respectively (p = 0.751). Conclusion: There was no association found between aortic arch calcification detected on plain CXR and myocardial scarring detected on CMRI.

Prevalence and predictors of appropriate implantable cardioverter defibrillator therapy in chronic left ventricular dysfunction patients for primary prevention of sudden cardiac death in Siriraj Hospital.

OBJECTIVE: The purpose of the present study was to identify the prevalence and predictors offirst appropriate implantable cardioverter defibrillator (ICD) therapy in patients with chronic LV dysfunction after placement of lCD for primary prevention. MATERIAL AND METHOD: Retrospective design was used. Patients (n = 115) from Siriraj Hospitals with ischemic or non-ischemic cardiomyopathy who underwent ICD implantation for primary prevention were studied. Clinical data and ICD therapy data were obtained from medical records and lCD interrogation reports. RESULTS: First appropriate ICD therapy for ventricular tachycardia (VT) or ventricular fibrillation (VF) were seen in 22 patients (19%) of whom 11 (9.5%) received lCD shock and 11 patients (9.5%) received anti-tachycardic pacing. Lack of beta-blocker use and lack ofaldosterone antagonist use were identified as significant predictors of appropriate therapy. There was no difference in prevalence of appropriate ICD therapy between ischemic and non-ischemic groups. The freedom from first appropriate therapy at 1, 2 and 3 years was 88%, 80% and 78%. The freedom rate was constant after the third year CONCLUSION: Nearly one-fifth of chronic LV dysfunction patients with primary prevention ICD implantation experience appropriate ICD therapy. Most first appropriate ICD therapy occurs within 2 years after implantation. Lack ofbeta-blocker use and lack of aldosterone antagonist use were significant predictors of appropriate therapy.

Prevalence and characters of anomalous coronary artery from coronary magnetic resonance angiography.

BACKGROUND: Many types of anomalous coronary artery have been reported. Some forms of the anomaly are potentially malignant and can lead to sudden death. OBJECTIVE: To determine the prevalence and characters of anomalous coronary artery, including the associations of myocardial ischemia. MATERIAL AND METHOD: This is a retrospective study. The authors enrolled patients who were referred for cardiac magnetic resonance (CMR) and had magnetic resonance coronary angiography (MRCA) images. Imaging of the coronary arteries was acquired. The presence and patterns of anomalous coronary artery and the presence of myocardial ischemia was recorded. Myocardial perfusion study was also performed in most patients using adenosine stress test. RESULTS: Anomalous coronary artery was detected in 56 out of 3,703 patients (1.51%). There were 24 men (42.9%). Average age was 62.1 +/- 15.0 years. Most common type was right coronary artery (RCA) from left coronary cusp. Malignant form was demonstrated in 31 patients (55.4%) and myocardial ischemia was detected in 10 patients (23.3%). CONCLUSION: Prevalence of anomalous coronary artery was 1.5%. Most common types were RCA from left coronary cusp (30%) and high take-off RCA (30%).

Myocardial scar and left ventricular ejection fraction classification for electrocardiography image using multi-task deep learning.

Myocardial scar (MS) and left ventricular ejection fraction (LVEF) are vital cardiovascular parameters, conventionally determined using cardiac magnetic resonance (CMR). However, given the high cost and limited availability of CMR in resource-constrained settings, electrocardiograms (ECGs) are a cost-effective alternative. We developed computer vision-based multi-task deep learning models to analyze 12-lead ECG 2D images, predicting MS and LVEF < 50%. Our dataset comprises 14,052 ECGs with clinical features, utilizing ground truth labels from CMR. Our top-performing model achieved AUC values of 0.838 (95% CI 0.812-0.862) for MS and 0.939 (95% CI 0.921-0.954) for LVEF < 50% classification, outperforming cardiologists. Moreover, MS predictions in a prevalence-specific test dataset recorded an AUC of 0.812 (95% CI 0.810-0.814). Extracted 1D signals from ECG images yielded inferior performance, compared to the 2D approach. In conclusion, our results demonstrate the potential of computer-based MS and LVEF < 50% classification from ECG scan images in clinical screening offering a cost-effective alternative to CMR.

Time in target range of systolic blood pressure and clinical outcomes in atrial fibrillation patients: results of the COOL-AF registry.

We aimed to investigate the relationship between time in target range of systolic blood pressure (SBP-TTr) and clinical outcomes in patients with atrial fibrillation (AF). We analyzed the results from multicenter AF registry in Thailand. Blood pressure was recorded at baseline and at every 6 monthly follow-up visit. SBP-TTr were calculated using the Rosendaal method, based on a target SBP 120-140 mmHg. The outcomes were death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. A total of 3355 patients were studied (mean age 67.8 years; 41.9% female). Average follow-up time was 32.1 ± 8.3 months. SBP-TTr was classified into 3 groups according to the tertiles. The incidence rates of all-cause death, SSE, major bleeding, and heart failure were 3.90 (3.51-4.34), 1.52 (1.27-1.80), 2.2 (1.90-2.53), and 2.83 (2.49-3.21) per 100 person-years, respectively. Patients in the 3rd tertile of SBP-TTr had lower rates of death, major bleeding and heart failure with adjusted hazard ratios 0.62 (0.48-0.80), p < 0.001, 0.64 (0.44-0.92), p = 0.016, and 0.61 (0.44-0.84), p = 0.003, respectively, compared to 1st SBP-TTr tertile. In conclusion, high SBP-TTr was associated with better clinical outcomes compared to other groups with lower SBP-TTr. This underscores the importance of good blood pressure control in AF patients.

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry.

BACKGROUND: Bleeding events are often reported among patients with atrial fibrillation (AF), irrespective of antithrombotic use. This study is to determine clinical outcomes of patients with AF who survived from bleeding event. METHODS: We analyzed data from COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) Thailand registry. Outcomes of patients who experienced any bleeding were compared with patients who had never bleed. Time updated multivariate Cox-proportional hazard models were used to estimate the risk for clinical outcomes of patients with and without bleeding. RESULTS: Of total 3,405 patients (mean age: 67.8 ± 11.3 years; 41.9% female) in COOL-AF registry, 609 patients (17.9%) reported bleeding event occurs and 568 patients (93.3%) survived though hospital discharge. Patients who survived major bleeding (n = 126) were at increased risk for both death (adjusted hazard ratio [HR]: 4.44, 95% confidence interval [CI]: 2.91-6.75, p < 0.001) and stroke/systemic embolism (adjusted HR: 4.49, 95% CI: 2.19-9.24, p < 0.001). Minor bleeding also increased subsequent death (adjusted HR: 2.13, 95% CI: 1.56-2.90, p < 0.001). Up to 30% of patients who survived major bleeding and 6.3% of minor bleedings discontinued oral anticoagulation. Discontinuation was associated with very high death rate (42.1%), whereas patients who resumed oral anticoagulation after bleeding had lower mortality (10%). The most common causes of death in patients who survived a bleeding event were not related to cardiovascular causes nor bleeding. CONCLUSION: Patients with AF who have bleeding events have an increased risk for subsequent death and stroke and systemic embolism. These patients should be identified as vulnerable clinically complex patients and require a holistic approach to their AF management.

Predicting factors for a false positive treadmill exercise stress test.

BACKGROUND: The present study was conducted to determine whether the exaggerated blood pressure (BP) response as well as other factors during exercise stress test (EST) is associated with false positive treadmill EST. MATERIAL AND METHOD: This is a retrospective (case-control) study. Patient upon whom EST was performed at Her Majesty Cardiac Center (HMCC), Siriraj Hospital, Mahidol University and for whom the result revealed positive EST and underwent coronary angiogram (CAG) during October 2007-July 2011. RESULTS: 272 patients were included. 61% was male gender There were 65 false positive cases (23.9%). Most patients are female (60%). No significant difference in baseline systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) was noted between true and false positive group. Using Multiple logistic regression analysis to determining the independent predictors of false positive EST, exaggerated BP response did not result in false positive EST and factors that were associated with the occurrence of false positive EST are female (OR 2.604, 95% CI 1.109-5.952, p = 0.018), the use of statin (OR 0.402, 95% CI 0.194-0.835, p = 0.015), the difference between the peak and the baseline HR (OR 1.049, 95% CI 1.028-1.071, p < 0.001) and time from abnormal to baseline ECG (OR 0.725, 95% CI 0.641-0.820, p < 0.001). CONCLUSION: The present study did not demonstrate that the exaggerated BP response during EST is associated with false positive EST

Accuracy of ECG criteria for the diagnosis of left ventricular hypertrophy: a comparison with magnetic resonance imaging.

BACKGROUND: There are many ECG criteria for the diagnosis of left ventricular hypertrophy (LVH). There are, however limited data on the accuracy of these criteria in comparison with cardiac magnetic resonance (CMR). OBJECTIVE: To determine the accuracy of ECG criteria for the diagnosis of LVH using CMR as the gold standard and to assess gender-specific data. MATERIAL AND METHOD: Patients who were referred for CMR for clinical purposes were studied. ECG and CMR were performed on the same day. Functional CMR protocol was performed for the assessment of cardiac volume, function and mass. CMR variables were indexed by the adjustment of body surface area. The following ECG criteria were used: Romhilt-Estes criteria (score at least 4 or 5 points were used in the present study), Sokolow-Lyon and Sokolow-Lyon-Rappaport, Cornell voltage and Cornell product, and sum of QRS voltage of all 12 leads. CMR of 184 subjects (120females, 64 males) free of cardiovascular disease was used as controls. Patients with left ventricular mass index above 95 percentile of gender specific left ventricular mass in control group were considered LVH. Diagnostic yield of ECG criteria for LVH was calculated for the whole group and each gender RESULTS: There were a total of 1,882 patients, 994 males and 888 females. Average age was 64.6 +/- 11.3 years. LVH was diagnosed by CMR in 23.3% in female and 25.4% in male. ECG criteria for the diagnosis of LVH had a relatively low sensitivity (0.25-0.61), and high specificity (0.75-0.95). Female had a lower sensitivity, higher specificity, higher PPV similar NPV and higher overall accuracy than male. Cornell product, Romhilt-Estes (at least 4 points) and Sokolow-Lyon were the ECG criteria with the best accuracy, sensitivity and specificity, respectively. CONCLUSION: ECG criteria for the diagnosis of LVH had a relatively low sensitivity, and high specificity. The accuracy was in the range of 0.71-0.80. Cornell product had the highest accuracy.

Three-year outcomes of patients with non-valvular atrial fibrillation: the COOL-AF registry.

BACKGROUND: Clinical outcomes of patients with non-valvular atrial fibrillation (AF) in Asian populations may be different from non-Asians. In this study, we aimed to determine the incidence of ischemic stroke/systemic embolism (SSE), major bleeding, and death, and the predictors for clinical outcomes in a contemporary Asian cohort of newly diagnosed AF patients. METHODS: This is a prospective multicenter nationwide registry of patients with AF from 27 hospitals in Thailand. Baseline data and follow-up data were collected every 6 months until 3 years. Data collections included demographic, medical history, laboratory, and medication details. Clinical outcomes were SSE, major bleeding, and all-cause mortality. Incidence rates for each clinical outcome were calculated and presented as rate per 100 person-years. Univariate and multivariate analysis was performed to determine the independent predictors for clinical outcomes. RESULTS: There was a total of 3405 patients: mean age was 67.8 ± 11.3 years, 1981 (58.2%) were male. During 30.8 ± 9.7 months follow-up, there was a total of 132 SSE (3.9%), 191 major bleeding (5.6%), and 357 all-cause deaths (10.5%). The incidence rates of SSE, major bleeding, and death were 1.56 (1.30-1.84), 2.26 (1.96-2.61), and 4.17 (3.33-4.25), per 100 person-years respectively. Independent predictors for clinical outcomes were age, type of AF, and the presence of comorbid conditions. CONCLUSION: The incidence rate of SSE, major bleeding, and death remains high reflecting the unmet needs in AF management.

Safety and clinical impact of adenosine stress perfusion cardiac magnetic resonance in Asian patients with known or suspected coronary artery disease.

BACKGROUND: Adenosine stress cardiac magnetic resonance (CMR) imaging is increasingly utilized for evaluating patients with known or suspected coronary artery disease (CAD). This study aims to assess the safety and clinical impact of adenosine stress CMR in a tertiary care setting in Thailand. METHODS: A total of 3,768 consecutive patients aged 18 years and above who underwent adenosine stress CMR between 2017 and 2020 were included in the study. Patient records were reviewed to collect data on clinical characteristics, hemodynamic measurements, complications during or immediately after CMR, and the rates of clinical changes resulting from CMR. RESULTS: Among the included patients, the primary indications for adenosine stress CMR were risk stratification in suspected CAD (70.8%) and the assessment of myocardial ischemia/viability in patients with known CAD (26.5%). There were no reported deaths or acute myocardial infarctions during the procedure. Major complications, specifically acute pulmonary edema requiring hospital observation or admission for further management, occurred in four patients (0.11%), all of whom were elderly (ranging from 75 to 91 years) with a history of heart failure. Non-major complications were observed in 13.7% of patients, with dyspnea (9.8%) and mild chest pain (5.6%) being the most common. CMR provided a completely new diagnosis in 26.2% of patients. Overall, stress CMR resulted in a change in diagnosis or management for 48% of patients. CONCLUSION: Adenosine stress CMR was found to be safe and to have a significant impact on clinical management in Asian patients with known or suspected CAD. These findings support the use of adenosine stress CMR as a valuable tool for evaluating and guiding treatment decisions in this patient population.

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.

Extracellular volume and left ventricular hypertrophy by cardiac magnetic resonance are independent predictors of cardiovascular outcome in obesity.

This retrospective cohort study investigated for association between increased extracellular volume (ECV) and left ventricular hypertrophy (LVH) by cardiac magnetic resonance (CMR) and cardiovascular composite outcomes in obesity. Native T1 was measured at the ventricular septum. ECV was calculated from native and post-contrast T1 and hematocrit. Cardiovascular (CV) composite outcomes included acute myocardial infarction, unstable angina requiring hospitalization, myocardial revascularization (excluding early revascularization), heart failure, and CV death. A total of 456 patients with a mean follow-up of 2.1 ± 0.4 years were enrolled. LGE and LVH was detected in 30.5% and 9.2%. 107 patients (23.5%) had the composite outcomes. Multivariable analysis revealed that LGE, LVH, and high ECV as independent predictors for cardiovascular composite outcomes The event rate in the LVH and high ECV, the LVH alone, the high ECV alone, and the no-LVH with lower ECV group was 57.1%, 38.1%, 32.6%, and 17.7%, respectively. Assessment of incremental prognostic value by comparing global chi-square showed that high ECV had additional prognostic value on top of LGE, and LVH. LVH and high ECV are independent predictors of CV composite outcomes in obesity. This is the first study that demonstrate the prognostic value of ECV in obese population.

Myocardial Extracellular Volume Fraction and T1 Mapping by Cardiac Magnetic Resonance Compared Between Patients With and Without Type 2 Diabetes, and the Effect of ECV and T2D on Cardiovascular Outcomes.

Background: To investigate the difference in myocardial extracellular volume fraction (ECV) by cardiac magnetic resonance (CMR) T1 mapping between patients with and without type 2 diabetes (T2D), and the effect of ECV and T2D on cardiovascular (CV) outcomes. Methods: All patients aged > 18 years with known or suspected coronary artery disease who underwent CMR for assessment of myocardial ischemia or myocardial viability at the Department of Cardiology of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from September 2017 to December 2018 were screened for inclusion eligibility. Left ventricular ejection fraction (LVEF), late gadolinium enhancement, and T1 mapping were performed. ECV values were derived from myocardial native T1 and contrast-enhanced T1 values that were obtained using modified Look-Locker inversion recovery at the septum of the mid-cavity short-axis map. Demographic data, clinical characteristics, and CV outcomes were collected by retrospective chart review. Composite CV outcomes included CV death, acute coronary syndrome, heart failure hospitalization, or ventricular tachycardia (VT)/ventricular fibrillation. Results: A total of 739 subjects (mean age: 69.5 ± 14.0 years, 49.3% men) were included. Of those, 188 subjects had T2D (25.4%). ECV was significantly higher in T2D than in non-T2D (30.0 ± 5.9% vs. 28.8 ± 4.7%, p = 0.004). During the mean follow-up duration of 26.2 ± 8.5 months, 43 patients (5.8%) had a clinical composite outcome, as follows: three CV death (0.4%), seven acute coronary syndrome (0.9%), 33 heart failure hospitalization (4.5%), and one VT (0.1%). T2D, low LVEF, and high ECV were all identified as independent predictors of CV events. Patients with T2D and high ECV had the highest risk of CV events. Conclusion: Among patients with known or suspected coronary artery disease, patients with T2D had a higher ECV. T2D and high ECV were both found to be independent risk factors for adverse CV outcomes.

Impact of anemia on clinical outcomes of patients with atrial fibrillation: The COOL-AF registry.

BACKGROUND: To determine whether anemia is an independent risk factor for ischemic stroke and major bleeding in patients with non-valvular atrial fibrillation (NVAF). HYPOTHESIS: Anemia in patients with NVAF increase risk of clinical complications related to atrial fibrillation. METHODS: We conducted a prospective multicenter registry of patients with NVAF in Thailand. Demographic data, medical history, comorbid conditions, laboratory data, and medications were collected and recorded, and patients were followed-up every 6 months. The outcome measurements were ischemic stroke or transient ischemic attack (TIA), major bleeding, heart failure (HF), and death. All events were adjudicated by the study team. We analyzed whether anemia is a risk factor for clinical outcomes with and without adjusting for confounders. RESULTS: There were a total of 1562 patients. The average age of subjects was 68.3 ± 11.5 years, and 57.7% were male. The mean hemoglobin level was 13.2 ± 1.8 g/dL. Anemia was demonstrated in 518 (33.16%) patients. The average follow-up duration was 25.8 ± 10.5 months. The rate of ischemic stroke/TIA, major bleeding, HF, and death was 2.9%, 4.9%, 1.8%, 8.6%, and 9.2%, respectively. Anemia significantly increased the risk of these outcomes with a hazard ratio of 2.2, 3.2, 2.9, 1.9, and 2.8, respectively. Oral anticoagulants (OAC) was prescribed in 74.8%; warfarin accounts for 89.9% of OAC. After adjusting for potential confounders, anemia remained a significant predictor of major bleeding, heart failure, and death, but not for ischemic stroke/TIA. CONCLUSION: Anemia was found to be an independent risk factor for major bleeding, heart failure, and death in patients with NVAF.