Characteristics and Pattern of Calcified Nodule and/or Nodular Calcification Detected by Intravascular Ultrasound on the Device-Oriented Composite Endpoint (DoCE) in Patients with Heavily Calcified Lesions Who Underwent Rotational Atherectomy-Assisted Percutaneous Coronary Intervention.

Objectives: This study aimed to determine characteristics and pattern of a calcified nodule (CN) and/or nodular calcification (NC) detected by intravascular ultrasound (IVUS) on the device-oriented composite endpoint (DoCE) in patients with calcified lesions who underwent rotational atherectomy (RA)-assisted percutaneous coronary intervention (PCI). Background: The characteristics and pattern of a CN and/or NC on clinical outcome remain unknown. Methods: We retrospectively enrolled patients who underwent RA-assisted PCI at Siriraj Hospital during August 2016 to April 2020. Preprocedural IVUS imaging was mandatory. CN/NC was defined as convex shape of luminal surface and luminal side of calcium with protrusion into the coronary artery lumen as assessed by IVUS. The primary outcome was cumulative of DoCE, defined as the composite of cardiovascular death, myocardial infarction, and clinically-driven target lesion revascularization. Results: Two hundred patients were included. Primary outcome occurred in 14%. The cumulative DoCE was significantly higher in the CN/NC group than that in the non-CN/NC group (20.7% vs. 8.8%, p = 0.022). CN/NC (p = 0.023) and MSA ≤ 5.5 mm2 (p = 0.047) were correlated with a significantly higher cumulative DoCE. CN/NC was the independent predictor for the cumulative DoCE (HR = 2.96, 95% CI 1.08-8.11, p = 0.035). Pattern and characteristic of CN/NC have a prognostic value. Patients with an eccentric CN/NC had a significantly higher cumulative DoCE compared to those CN/NC with concentric calcification (p = 0.014). Conclusion: The presence of a CN/NC in patients with heavily calcified lesions who underwent RA-assisted PCI was found to be associated with increased cumulative 5 year DoCE, especially in patients with an eccentric CN/NC. The clinical trial is registered with TCTR20210616001.

Preprocedural and procedural variables that predict new-onset conduction disturbances after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances are a common complication after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the preprocedural and procedural variables that predict new-onset conduction disturbances post-TAVR (hereafter CD/CDs). METHODS: Consecutive patients who underwent TAVR during December 2009-March 2021 at the Faculty of Medicine Siriraj Hospital, Mahidol University-Thailand's largest national tertiary referral center-were enrolled. Patients with prior implantation of a cardiac device, periprocedural death, or unsuccessful procedure were excluded. Clinical and electrocardiographic data, preprocedural imaging, including membranous septum (MS) length, and procedural variables, including implantation depth (ID), were analyzed. CD was defined as new left or right bundle branch block, significant intraventricular conduction disturbance with QRS interval ≥ 120 ms, new high-grade atrioventricular block, or complete heart block. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal ∆MSID (difference between the MS length and ID) cutoff value, respectively. RESULTS: A total of 124 TAVR patients (mean age: 84.3 ± 6.3 years, 62.1% female) were included. The mean Society of Thoracic Surgeons score was 7.3%, and 85% of patients received a balloon expandable transcatheter heart valve. Thirty-five patients (28.2%) experienced a CD, and one-third of those required pacemaker implantation. The significant preprocedural and procedural factors identified from univariate analysis included intraventricular conduction delay, mitral annular calcification, MS length ≤ 6.43 mm, self-expanding device, small left ventricular cavity, and ID ≥ 6 mm. Multivariate analysis revealed MS length ≤ 6.43 mm (adjusted odds ratio [aOR] 9.54; 95% CI 2.56-35.47; p = 0.001) and ∆MSID < 0 mm (adjusted odds ratio [aOR] 10.77; 95% CI 2.86-40.62; p = < 0.001) to be independent predictors of CD. The optimal ∆MSID cutoff value for predicting conduction disturbances was less than 0 mm (area under the receiver operating characteristic curve [AuROC]: 0.896). CONCLUSION: This study identified MS length ≤ 6.43 mm and ∆MSID < 0 mm as independent predictors of CDs. ∆MSID < 0 was the strongest and only modifiable predictor. Importantly, we expanded the CD criteria to cover all spectrum of TAVR-related conduction injury to lower the threshold of this sole modifiable risk. The optimal ∆MSID cutoff value was < 0 mm. TRIAL REGISTRATION: TCTR, TCTR20210818002. Registered 17 August 2021-Retrospectively registered, http://www.thaiclinicaltrials.org/show/TCTR 20210818002.

Long-term outcome of percutaneous transluminal renal angioplasty (PTRA) versus PTRA with stenting (PTRAS) in transplant renal artery stenosis.

BACKGROUND: Endovascular treatment is standard of care for transplant renal artery stenosis (TRAS). No study has evaluated long-term outcomes compared between percutaneous transluminal renal angioplasty (PTRA) and PTRA with stenting (PTRAS). Accordingly, this study aimed to investigate the 1-year clinical success, and short- and long-term event-free survival between PTRA and PTRAS in patients diagnosed with TRAS at Thailand's largest national tertiary referral center. METHODS: This single-center retrospective study included kidney transplant patients treated for TRAS during January 2001 to June 2019. Clinical success was defined as (1) increase in estimated glomerular filtration rate (eGFR) > 15%, or (2) reduction in mean arterial pressure (MAP) > 15% with no decrease in antihypertensive medication, or no reduction in MAP or reduction in MAP < 15% with decrease in antihypertensive medication. Incidence of kidney transplant graft failure and transplant renal artery stenosis were also collected. RESULTS: Sixty-five cases of TRAS were identified from 1072 patients who underwent kidney transplantation. The majority (98.5%) had end-to-side anastomosis technique. Thirty-four patients had PTRA, while 31 patients had PTRAS. One-year clinical success according to renal outcome and BP reduction was 78.5% and 49.2%, respectively. Both renal outcome (79.4% vs. 77.4%, p = 0.845) and BP reduction (40.6% vs. 58.1%, p = 0.166) at 1 year were similar between the PTRA and PTRAS groups. Compared between PTRA and PTRAS, event-free survival for composite of kidney transplant graft failure or transplant renal artery restenosis was significantly higher for PTRAS at 1 year (82.4% vs. 100%, p = 0.025), but not significantly different at 10 years (73.5% vs. 71%, p = 0.818). CONCLUSIONS: We demonstrated the 1-year clinical success, and short- and long-term event-free survival between PTRA and PTRAS in TRAS patients. One-year clinical success was found to be similar between groups. Event-free survival for composite of kidney transplant graft failure or transplant renal artery restenosis was significantly higher in PTRAS at 1 year, but similar between groups at 10 years. Trial registration Thai Clinical Trials Registry, TCTR20200626002. Registered 26 June 2020-Retrospectively registered, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trial search&smenu = fulltext&task = search&task2 = view1&id = 6441.

Indoleamine 2,3 dioxygenase (IDO) level as a marker for significant coronary artery disease.

BACKGROUND: Indoleamine 2,3 dioxygenase (IDO), the rate-limiting enzyme in the kynurenine (Kyn) pathway of tryptophan (Trp) degradation, is modulated by inflammation, and is regarded as a key molecule driving immunotolerance and immunosuppressive mechanisms. Little is known about IDO activity in patients with active coronary artery disease (CAD). METHODS: We prospectively enrolled patients who were scheduled to undergo coronary angiography. Measurement of IDO, high-sensitivity troponin T (hs-TnT), and high-sensitivity C-reactive protein (hs-CRP) levels was performed at baseline, and IDO activity was monitored at the 6-month follow-up. RESULTS: Three hundred and five patients were enrolled. Ninety-eight patients (32.1%) presented with recent acute coronary syndrome (ACS). Significant difference in IDO, kynurenine, and hs-TnT between patients with and without significant CAD was observed. Baseline IDO activity, kynurenine level, and hs-TnT level were all significantly higher in significant CAD patients with 3-vessel, 2-vessel, and 1-vessel involvement than in those with insignificant CAD [(0.17, 0.13, and 0.16 vs. 0.03, respectively; p = 0.003), (5.89, 4.58, and 5.24 vs. 2.74 µM/g, respectively; p = 0.011), and (18.27, 12.22, and 12.86 vs. 10.89 mg/dL, respectively; p < 0.001)]. One-year mortality was 3.9%. When we compared between patients who survived and patients who died, we found a significantly lower prevalence of left main (LM) disease by coronary angiogram (6.1% vs. 33.3%, p = 0.007), and also a trend toward higher baseline kynurenine (5.07 vs. 0.79 µM/g, p = 0.082) and higher IDO (0.15 vs. 0.02, p = 0.081) in patients who survived. CONCLUSION: Immunometabolic response mediated via IDO function was enhanced in patients with CAD, and correlated with the extent and severity of disease. Patients with LM disease had higher 1-year mortality. Lower level of IDO, as suggested by inadequate IDO response, demonstrated a trend toward predicting 1-year mortality. Trial registration TCTR Trial registration number TCTR20200626001. Date of registration 26 June 2020. "Retrospectively registered".

Impact of guideline-recommended versus non-guideline-recommended ß-blocker and Doppler echocardiographic parameters on 1-year mortality in Thai ischemic cardiomyopathy patients: A prospective multicenter registry.

BACKGROUND: Ischemic cardiomyopathy is a high-cost, resource-intensive public health burden that is associated with a 1-year mortality rate of about 16% in western population. Different in patient ethnicity and pattern of practice may impact the clinical outcome. We aim to determine 1-year mortality and to identify factors that significantly predicts 1-year mortality of Thai patients with ischemic cardiomyopathy. METHODS: This prospective multicenter registry enrolled consecutive Thai patients that were diagnosed with ischemic cardiomyopathy at 9 institutions located across Thailand. Patients with left ventricular function < 40% and one of the following criteria were included: 1) presence of epicardial coronary stenoses > 75% in the left main or proximal left anterior descending artery or coronary angiography, and/or two major epicardial coronary stenoses; 2) prior myocardial infarction; 3) prior revascularization by coronary artery bypass graft or percutaneous coronary intervention; or, 4) magnetic resonance imaging pattern compatible with ischemic cardiomyopathy. Baseline clinical characteristics, coronary and echocardiographic data were recorded. The 1-year clinical outcome was pre-specified. RESULTS: Four hundred and nineteen patients were enrolled. Thirty-nine patients (9.9%) had died at 1 year, with 27 experiencing cardiovascular death, and 12 experiencing non-cardiovascular death. A comparison between patients who were alive and patients who were dead at 1 year revealed lower baseline left ventricular ejection fraction (LVEF) (26.7 ± 7.6% vs 30.2 ± 7.8%; p = 0.021), higher left ventricular end-diastolic volume (LVEDV) (185.8 ± 73.2 ml vs 155.6 ± 64.2 ml; p = 0.014), shorter mitral valve deceleration time (142.9 ± 57.5 ml vs 182.4 ± 85.7 ml; p = 0.041), and lower use of statins (94.7% vs 99.7%; p = 0.029) among deceased patients. Patients receiving guideline-recommended ß-blockers had lower mortality than patients receiving non-guideline-recommended ß-blockers (8.1% vs 18.2%; p = 0.05). CONCLUSIONS: The results of this study revealed a 9.9% 1-year mortality rate among Thai ischemic cardiomyopathy patients. Doppler echocardiographic parameters significantly associated with 1-year mortality were LVEF, LVEDV, mitral E velocity, and mitral valve deceleration time. The use of non-guideline-recommended ß-blockers rather than guideline recommended ß-blockers were associated with increased with 1-year mortality. Guidelines recommended ß-blockers should be preferred. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20190722002. Registered 22 July 2019. "Retrospectively registered".

In-Hospital Outcomes after Rescue Percutaneous Coronary Intervention in Patients with ST Segment Elevation Myocardial Infarction.

Objective: To investigate the outcomes of patients who underwent rescue percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) after failed thrombolytic therapy. Material and Method: This observational cohort study was conducted between June 1, 2008 and May 31, 2013. Consecutive STEMI patients who underwent either emergency rescue PCI or primary PCI were included. Rescue PCI patients were compared with primary PCI patients. Clinical data including baseline characteristics, angiographic results, periprocedural details, and in-hospital adverse events were reviewed. Results: Three hundred sixteen patients were enrolled, of which 72.5% were male. Mean age of participants was 59.5 years. Rescue PCI and primary PCI was performed in 24 and 292 patients, respectively. Median time from symptom onset to emergency room (ER) arrival was 175 minutes and not statistically different between groups. Thirteen percent of patients were critically ill and in cardiogenic shock upon arrival. Radial artery access was significantly more frequently used in the rescue PCI group. The rescue PCI group had a significantly higher proportion of initial TIMI grade 3 flow than the primary PCI group (rescue PCI 33.3% vs. primary PCI 13.4%, p = 0.042). No significant differences were observed in final TIMI grade 3 between the two groups (rescue PCI 87.5% vs. primary PCI 89.7%, p = 0.77). Rate of platelet glycoprotein IIb/IIIa receptor blocker use was significantly higher in the primary PCI group (41.4% vs. 4.2%, p<0.001). Left ventricular ejection fraction was significantly higher in the rescue PCI group (rescue PCI 57.7% vs. primary PCI 50%, p = 0.013). There were no significant differences between groups for angiographic success rate (rescue PCI 83.3% vs. primary PCI 88.7%, p = 0.229) or procedural success rate (rescue PCI 79.2% vs. primary PCI 85.6%, p = 0.164). Forty-one patients (14%) in primary PCI group and two patients (8.3%) in rescue PCI group died during hospitalization (p = 0.75). Stroke and reinfarction were rare events in this study. Hemorrhagic stroke occurred in one patient in each group. There were no significant differences in major bleeding or major vascular complications between groups. Conclusion: The angiographic outcome and procedural success rates in patients who underwent rescue PCI were not significantly different from rates in patients who underwent primary PCI. Rescue PCI in STEMI can be performed with favorable success rates and in-hospital outcomes and should be considered in patients that experience failure after thrombolytic therapy.

Differentiation of Takotsubo Cardiomyopathy from ST Elevation Myocardial Infarction in Patients Activated for Fast-Track Coronary Angiography.

Objective: To compare clinical and electrocardiographic (ECG) features between Takotsubo cardiomyopathy (TC) and ST-elevation myocardial infarction (STEMI). Material and Method: We retrospectively reviewed clinical, electrocardiographic, and laboratory features of 20 consecutive TC patients and 155 consecutive STEMI patients who were activated for fast-track coronary angiography and were ultimately diagnosed with either TC or STEMI and compared these data between the two groups. Results: Patients with TC were older (p = 0.001), more often female (p = 0.001), had more often been triggered by intense emotional or physical stress (p = 0.001) or illness (p = 0.001), and had a lower rate of smoking (p = 0.005) than STEMI patients. Compared with patients who presented with anterior wall STEMI, those with TC less commonly had Q waves (30.0% vs. 62.9%, p = 0.007) and reciprocal change (0.0% vs. 37.1%, p = 0.001), and had a lower rate of ST-segment elevation in lead V1 (5.0% vs. 59.8%, p = 0.001). ST-segment depression was also more common in TC in lead aVR (20.0% vs. 2.1%, p = 0.008). Previously proposed ECG criteria had low sensitivity, but high specificity in our patients. Our proposed point scoring model includes the use of both clinical and ECG findings. According to our proposed model, a score ≥4 had 90% sensitivity and 98% specificity in differentiating TC from acute anterior STEMI (AUC = 0.976, p<0.001). Conclusion: In patients activated for fast-track coronary angiography because of acute coronary ST-segment elevation syndrome, a number of clinical and ECG features differ between TC patients and patients with true STEMI. Our proposed point scoring model that uses clinical and ECG findings demonstrated improved diagnostic accuracy in differentiating TC from acute anterior STEMI.

Low-density lipoprotein cholesterol goal attainment among post myocardial infarction patients on lipid lowering therapy at Siriraj outpatient clinic.

BACKGROUND: Cardiovascular disease is leading cause of death in the world and third order in Thailand. A number of large-scale clinical trials have demonstrated that statins reduce cardiovascular morbidity and mortality. Nevertheless, in clinical practice less than 50% of these patients could achieve the LDL-C goal based on NCEP ATP III treatment goal. The objective of this study is to assess the percentages of post myocardial infarction patients who attained LDL-C goal in Siriraj Hospital. MATERIAL AND METHOD: This is a retrospective review of all adult patients diagnosed with first event myocardial infarction (STEMI and NSTEMI) at Siriraj Hospital between 2007 and 2009. Patients were included if they were 18-75 years-old, received statins therapy before discharge and followed-up regularly at least 1 year at OPD. Patients were excluded if triglyceride > 400 mg/dL. Patient demographics, type of reimbursement and discharge medication data were collected. The goal attainment was assessed and result was demonstrated in percentages of patients who achieved LDL goal compare with all patients meeting exclusion and inclusion criteria. This goal is based on NCEP ATP III 2004 for the management of dyslipidemias treatment goal of LDL-C < 100 mg/dL. RESULTS: Eight hundred and eighty eight patients were diagnosed with myocardial infarction from 2007 to 2009. One hundred seventy-nine patients meet inclusion and exclusion criteria. Seventy-three percent are male with mean age 58.64 +/- 10.21 year-old. Civil servant reimbursement is most common type of reimbursement, for about half of patients. LDL-C goal achievement based on NCEP ATP III 2004 for the management of dyslipidemia was 84.9%. The majority of prescribed lipid lowering agent was simvastatin 72.1%, and then atorvastatin 20.7% and rosuvastatin 7.3%, respectively. LDL-C goal achievement did not depend on type of statin, type of reimbursement or type of specialist follow-up at OPD. CONCLUSION: Patients who were diagnosed first event of myocardial infarction (STEMI and NSTEMI) admitted in Siriraj hospital from 2007 and 2009, 84.9% of them could achieve LDL-C goal based on NCEP ATP III 2004.

Effect of renal nerve denervation for resistant hypertension in Thai patients: a report of the first cases series in Thailand.

BACKGROUND: Hypertension is a major contributor to death. A significant portion of the patients is still in resistant hypertension with current medical treatment. Renal nerve denervation can reduce sympathetic activity, and subsequently reduce BP in western population. OBJECTIVE: To evaluate the effect of renal nerve denervation in treatment of resistant hypertension in Thai patients. MATERIAL AND METHOD: The present study is a case series of the first four Thai patients who underwent renal nerve denervation at Faculty of Medicine Siriraj Hospital. All patients had resistant hypertension. Baseline medical records, including demographic data, baseline systolic and diastolic blood pressure (BP), ambulatory BP monitoring, number and dose of anti-hypertensive medications before and after renal nerve denervation, were recorded. Patients were followed-up at 1 month, 3 month and 6 months after the procedure. RESULTS: Patients were taking antihypertensive medications ranging from 5 to 8 types of drug classes, but in all cases, their blood pressure was still not under control at baseline range from 160-190 of systolic BP and 100-120 mean BP. One of the patients had a history of hemorrhagic stroke as a consequence of un-control hypertension. All of them had blood pressure reduction immediately at the end of the first 24 hrs, and this was sustained until follow-up at 3-6 months. The mean of systolic BP reduction is 35.2 +/- 9.9 mmHg at 3-months follow-up. The mean reduction of the number of anti-hypertensive medications was 3.5 +/- 3.0 at 3-month follow-up. CONCLUSION: The authors found that the percutaneous renal nerve denervation was very effective in blood pressure reduction in these first four cases of Thai patients with resistant hypertension.

One-year clinical outcomes of ST segment elevation myocardial infarction patients treated with emergent percutaneous coronary intervention: the impact of thrombus burden.

OBJECTIVE: To investigate the impact of thrombus burden on 1-year clinical outcomes in patients who underwent emergent percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). MATERIAL AND METHOD: Angiographic evidence of intracoronary thrombus adversely affects the outcome of PCI in STEMI. Large thrombus burden (> or = 2 times vessel diameter) has been shown to be a significant predictor of major adverse cardiac events (MACE). The impact of thrombus burden in Asian patients who undergo PCI in STEMI has not been described. This is an observational cohort of patients with STEMI from June 1, 2008 through May 31, 2011, who underwent emergent PCI (primary or rescue). The patients were categorized into two groups according to the angiographic thrombus burden, large thrombus burden (> or = 2X vessel diameter size, LTB) and small thrombus burden (< 2X vessel diameter size, STB). MACE was defined as the composite of death, repeat myocardial infarction, target vessel revascularization and stent thrombosis. RESULTS: 202 patients were enrolled, 72% were male and the mean age was 60 years old. 134 patients (66%) presented with an occluded infarct related artery. Primary PCI was performed in 90.6% of the patients and the remainder underwent rescue PCI. One hundred eleven (55%) patients were categorized into the STB group and 91 patients (45%) into the LTB group. The use of aspiration thrombectomy was significant higher in the LTB group (LTB 80.2% vs. STB 60.44%, p = 0.002). A higher proportion of patients in the STB group underwent direct stenting strategy (STB 32.4% vs. LTB 18.7%, p = 0.027). There were no significant differences in final TIMI grade 3 flows and procedural success between the groups. Overall, in hospital, mortality was 13.4% and there were no significant differences among the groups. At 1-year follow-up, there was no significant difference in cumulative MACE-free survival in the LTB vs. STB group (82.4% vs. 79.3%, 95% confidence interval for the difference: -8.0% to 13.8%, p = 0.59). CONCLUSION: In the current study, large thrombus burden is not an independent predictor of 1-year cumulative MACE in STEMI patients who were treated with emergent PCI.

First medical contact to device time in the Thailand percutaneous coronary intervention (PCI) registry.

OBJECTIVE: The aim of this study is to evaluate the first medical contact (FMC) to device time in the Thai national PCI registry 2006, and its effect on the clinical outcome. MATERIAL AND METHOD: Thailand national PCI registry enrolled 4,156 patients who underwent PCI from the all catheterization laboratories in Thailand between May 1st and October 31st, 2006. RESULTS: 581 patients with acute myocardial infarction (AMI), 352 patients underwent primary angioplasty, 229 patients underwent rescue angioplasty/facilitated PCI or after successful thrombolytic. Median FMC.to device time in primary angioplasty group was 115 minutes (range 24-1335 minutes); only 29.8% of patients who able to achieve FMC to device time ≤ 90 minutes. Cardiogenic shock was significant lower if FMC to device time ≤ 90 minutes (2.1% (1/48) versus 12.4% (14/113) if FMC to device time > 90, p = 0.040). In-hospital mortality occurred for 4.8% (2/48) ifFMC to device time ≤ 90 minutes and was 8.8% (10/113) if FMC to device time > 90 minutes, p = 0.510). Death occurred in 4.2% (2/48) if FMC to device time ≤ 90 minutes, 6.3% (5/79) if FMC to device time between 91-180 minutes, 6.7% (1/15) if FMC to device time between 181-270 minutes, 42.9% (3/7) if FMC to device time between 271-360 minutes and 8.3% (1/12) if FMC to device time > 360 minutes, (p = 0.040). CONCLUSION: FMC to device time is strongly associated with the risk ofcardiogenic shock and mortality. In Thailand national PCI registry in 2006, the majority of the patients did not receive primary PCI in timely fashion.

Predictors of in-hospital adverse events after PCI for NSTEMI in the National Percutaneous Coronary Intervention (PCI) Registry.

OBJECTIVE: Evaluate the in-hospital major adverse cardiovascular events (MACE) and clinical predictors of non-ST-T Mt that undergoing percutaneous coronary interventions (PCI) in Thailand. MATERIAL AND METHOD: Thailand National PCI Registry enrolled 4156 patients that underwent PCI in Thailand between May 1 and October 31, 2006. Four hundred eighty three patients underwent PCI with indication of non-ST-T MI. Baseline demographic and angiographic characteristic were recorded. MACE included CV death, M, and stroke. RESULTS: In-hospital MACE occurred in 27 patients (5.6%), included CV death in 15 patients (3.1%), MI in 14 patients (2.9%), and stroke in 2 patients (0.4%). In-hospital MACE were higher in patients with previous history of CABG (19.2% versus 4.8%, p = 0.01), cardiogenic shock at presentation (29.3% versus 3.4%, p<0.001), significant left main disease (19.4% versus 4.6%, p = 0.005), baseline ejection fraction <30% (25% versus 4.4%, p = 0.003), and used of intra-aortic balloon counter pulsation (IABP) during PCI (26.3% versus 3.8%, p<0.001). After multiple logistic regression analysis, prior history of CABG (OR = 6.1, 95% CI: 1.1-32.4, p = 0.03), baseline ejection fraction <30% (OR = 6.5, 95% CI: 1.7-24.4, p = 0.005), and used of lABP during PCI (OR = 4.7, 95% CI: 1.3-16.8, p = 0.01) are the strongest predictors of in-hospital MACE. CONCLUSION: In the National Thai PCI Registry, patients with non-ST-T MI undergoing PCI had in-hospital major adverse events rate at 5.6%. Prior CABG, low EF <30%, unstable hemodynamic required used of lABP during PCI and procedure scheduled as an urgent or emergent were predictors of in-hospital MACE.

Resistant hypertension: diagnosis, evaluation, and treatment a clinical consensus statement from the Thai hypertension society.

Resistant hypertension (RH) includes hypertensive patients with uncontrolled blood pressure (BP) while receiving ≥3 BP-lowering medications or with controlled BP while receiving ≥4 BP-lowering medications. The exact prevalence of RH is challenging to quantify. However, a reasonable estimate of true RH is around 5% of the hypertensive population. Patients with RH have higher cardiovascular risk as compared with hypertensive patients in general. Standardized office BP measurement, confirmation of medical adherence, search for drug- or substance-induced BP elevation, and ambulatory or home BP monitoring are mandatory to exclude pseudoresistance. Appropriate further investigations, guided by clinical data, should be pursued to exclude possible secondary causes of hypertension. The management of RH includes the intensification of lifestyle interventions and the modification of antihypertensive drug regimens. The essential aspects of lifestyle modification include sodium restriction, body weight control, regular exercise, and healthy sleep. Step-by-step adjustment of the BP-lowering drugs based on the available evidence is proposed. The suitable choice of diuretics according to patients' renal function is presented. Sacubitril/valsartan can be carefully substituted for the prior renin-angiotensin system blockers, especially in those with heart failure with preserved ejection fraction. If BP remains uncontrolled, device therapy such as renal nerve denervation should be considered. Since device-based treatment is an invasive and costly procedure, it should be used only after careful and appropriate case selection. In real-world practice, the management of RH should be individualized depending on each patient's characteristics.

N-terminal pro-brain natriuretic peptide as a biomarker for a significant renal artery stenosis in medically refractory hypertensive patients.

BACKGROUND: Although RAS is a relatively uncommon cause of hypertension, it is the most common form of correctable hypertension. There are clinical clues to be gained in identifying the small subset of individuals in whom directed evaluation for RAS may be useful. But its diagnostic accuracy is still poor. OBJECTIVE: The aim of the present study is to determine the usefulness of N-terminal pro-brain natriuretic peptide (NT-pro BNP) levels in helping improved diagnostic accuracy of a significant renal artery stenosis (RAS) in medically refractory hypertensive patients. MATERIAL AND METHOD: The present study included 40 patients with medical refractory hypertension in whom RAS was suspected and who were undergoing magnetic resonance angiogram (MRA) of renal artery and/or renal angiogram. Twenty consecutive patients with a significant RAS by MRA or renal angiogram (RAS group) compared with 20 consecutive patients in whom RAS was suspected but whose MRA/renal angiogram was normal or non-significant (normal group). Baseline clinical characteristics, number of antihypertensive medications before the procedure and NT-pro BNP were obtained from both groups. RESULTS: Age, gender glomerular filtration rate (GFR) and LV function did not differ significantly between the two groups. NT-pro BNP level was significantly higher in RAS group (1,243 ng/ml, range 156-10,628 ng/ml) compared to normal group (129 ng/ml, range 61-3,457 ng/ml), p = 0.009. NT-proBNP level > or = 600 ng/ml has sensitivity and specificity of 80% and 95%, respectively, in diagnosis of significantRAS. CONCLUSION: In medical refractory hypertensive patients, NT-pro BNP level increased in patients with significant RAS and was an aid in separating a significant RAS from non-significant/normal renal artery.

High on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention.

OBJECTIVE: To determine the prevalence, clinical profile, and risk factors of high on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients undergoing coronary angiography and planned for elective percutaneous coronary intervention (PCI). Ten ml of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin and platelet count. Platelet aggregation test was performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 5 microM adenosine diphosphate (ADP). Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. High on-clopidogrel treatment platelet reactivity was defined as post treatment maximal platelet aggregation > 46% with 5 micromol/l ADP used as agonist. RESULTS: The present study consecutively enrolled two hundred four patients diagnosed with chronic stable angina planned for PCI. Seventy-nine patients demonstrated the high on-clopidogrel treatment platelet reactivity (38.7%). Among these patients, 48% were men with a mean age of 66 years. Diabetes mellitus and chronic kidney disease were detected in 34.2%. Original clopidogrel (Plavix) was prescribed in 72% of the patients and 28% received generic clopidogrel (Apolets). The prevalence of high on-clopidogrel treatment platelet reactivity increased in the older patients, patients with CKD and patients receiving angiotensin receptor blockers (ARB). However from multivariate analysis, none of the risk factors, including age, BMl, diabetes mellitus, smoking, CKD, ARB use, and type of clopidogrel (Plavix versus Apolets) had a statistically significant association with the high on-clopidogrel treatment platelet reactivity. CONCLUSION: The prevalence of high on-clopidogrel treatment platelet reactivity in the present study was 38.7%. No significant association was demonstrated between age, BMI, diabetes mellitus, smoking, CKD, ARB use, type of clopidogrel, and high on-clopidogrel treatment platelet reactivity.

Aspirin resistance in Thai patients with chronic stable angina.

OBJECTIVE: To determine the prevalence, clinical profile and risk factors of aspirin resistance in Thai patients with chronic stable angina. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients diagnosed chronic stable angina at Siriraj Hospital during March 2011 to February 2012. Ten milliliter of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin, platelet count and platelet aggregation test performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 0.5 mg/ml of arachidonic acid and 10 mM adenosine diphosphate. Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. Aspirin resistance was defined as the mean platelet aggregation of > or = 70% with 10 mM ADP and the mean platelet aggregation of > or = 20% with 0.5 mg/ml of arachidonic acid. RESULTS: One-hundred and fifty seven patients diagnosed chronic stable angina were enrolled in the present study. There were 34 patients (21.6%) demonstrating aspirin resistance. The clinical characteristic of these patients included male 58.8% with mean age of 66 years, body mass index 27.5 kg/m2, diabetes mellitus 52.9%, smoking 8.8%, hypercholesterolemia 70.6% and proton pump inhibitor use 23.5%. Multivariate analysis demonstrated none of the risk factors including age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking and proton pump inhibitor (PPI) use had a statistically significant association with aspirin resistance. CONCLUSION: Our study demonstrated that the prevalence of aspirin resistance in Thai patients with chronic stable angina was 21.6%. No significant association was demonstrated between age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking, proton pump inhibitor (PPI) use and aspirin resistance.

2022 Renal denervation therapy for the treatment of hypertension: a statement from the Thai Hypertension Society.

Hypertension remains a significant risk factor for major cardiovascular events worldwide. Poor adherence to treatment is extremely common in clinical practice, leading to uncontrolled hypertension. However, some patients with resistant hypertension still have uncontrolled blood pressure despite good medical compliance. A specific group of patients also develop adverse reactions to many blood pressure-lowering medications. These scenarios indicate that innovative strategies to lower blood pressure in challenging cases of hypertension are needed. The blood pressure-lowering efficacy of catheter-based renal denervation therapy to decrease sympathetic tone has been confirmed in many publications in recent years. Apart from both the invasiveness and the expensiveness of this technology, appropriate case selection to undergo this procedure is still developing. The utilization of renal denervation therapy for hypertension treatment in Thailand has lasted for 10 years with a good response in most cases. Currently, only certain interventionists at a few medical schools in Thailand can perform this procedure. However, more physicians are now interested in applying this technology to their patients. The Thai Hypertension Society Committee has reviewed updated information to provide principles for the appropriate utilization of renal denervation therapy. The blood pressure-lowering mechanism, efficacy, suitable patient selection, pre- and postprocedural assessment and procedural safety of renal denervation are included in this statement.

Clinical use of optical coherence tomography during percutaneous coronary intervention and coronary procedures in Southeast Asia: a survey-based expert consensus summary.

Optical coherence tomography (OCT), an established intravascular imaging technique, enables rapid acquisition of high-resolution images during invasive coronary procedures to assist physician decision-making. OCT has utility in identifying plaque/lesion morphology (e.g., thrombus, degree of calcification, and presence of lipid) and vessel geometry (lesion length and vessel diameter) and in guiding stent optimisation through identification of malapposition and underexpansion. The use of OCT guidance during percutaneous coronary interventions (PCI) has demonstrated improved procedural and clinical outcomes in longitudinal registries, although randomised controlled trial data remain pending. Despite growing data and guideline endorsement to support OCT guidance during PCI, its use in different countries is not well established. This article is based on an advisory panel meeting that included experts from Southeast Asia (SEA) and is aimed at understanding the current clinical utility of intracoronary imaging and OCT, assessing the barriers and enablers of imaging and OCT adoption, and mapping a path for the future of intravascular imaging in SEA. This is the first Southeast Asian consensus that provides insights into the use of OCT from a clinician's point of view.

Utilizing a registry for ST segment elevation myocardial infarction from a tertiary care hospital in Thailand: opportunities to improve the quality of care.

BACKGROUND: Treatment of acute coronary syndrome requires a reliable measurement of quality for ensuring evidence-based care. Clinical registries have been used to support quality improvement activities in some countries, but there are few data concerning their implementation in developing countries. In 2008, a multidisciplinary Siriraj ST segment elevation myocardial infarction (STEMI) registry team was formed with the intention to improve the process of care. This report summarizes observational data collected within the first year to characterize the clinical profile, management and in-hospital outcomes of STEMI patients at the author's institute. MATERIAL AND METHOD: The present study is a prospective, observational study. From June 2008 through June 2009, data from all consecutive patients presenting within 24 hours of STEMI at Siriraj Hospital were collected. The patient's data on demographics, procedures, medications and in-hospital outcomes were collected. RESULTS: During the 1-year period, 112 patients with STEMI were enrolled. The mean age was 59.3 years old and 81.3% were males. There was a high prevalence of diabetes, hypertension, dyslipidemia and current smoking. Median time from symptom onset to presentation was 120 minutes. 98 patients (84.8% of the patients) received reperfusion therapy in the form of thrombolytic therapy (21.4%) or primary percutaneous coronary intervention (PCI, 63.40%). For thrombolytic therapy, the median door to needle time was 68 minutes. Rescue PCI was performed in 20.8% of the thrombolytic treated patients. For primary PCI, the median door to balloon time was 118 minutes. In-hospital coronary artery bypass graft surgery was performed in 6% of the patients. In-hospital mortality rate was 9.8%. Re-infarction and stroke were rare events. CONCLUSION: Despite a high utilization rate of reperfusion therapy the time to reperfusion therapy exceeds the length of time recommended by current guidelines. The authors' findings provide important data for future benchmarking and represent a significant opportunity for quality improvement in STEMI-related care and outcomes.

Transcatheter aortic valve implantation (TAVI): first case in Thailand.

Aortic valve replacement (AVR) is the standard treatment for patients with symptomatic severe aortic stenosis (AS). However many patients are not offered surgery due to high surgical risk for open AVR. Transcatheter aortic valve implantation has been an alternative to open heart surgery in patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The first transcatheter aortic valve implantation in Thailand via the transapical route is described. An 87-year-old woman with symptomatic severe AS, calcified aorta and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at six-months follow-up.