Patient characteristics from a regional multicenter database of acute decompensated heart failure in Asia Pacific (ADHERE International-Asia Pacific).

BACKGROUND: Heart failure (HF) is a leading cause of hospitalization. Although a number of multicenter international HF hospital registries have been published, there are limited data for the Asia Pacific region. METHODS: ADHERE (ie, Acute Decompensated Heart Failure Registry) International-Asia Pacific is an electronic web-based observational database of 10,171 patients hospitalized with a principal diagnosis of HF from 8 Asia-Pacific countries between January 2006 and December 2008. RESULTS: The median age (67 years) varied by more than 2 decades across the region. Fifty-seven percent of patients were male. Ninety percent of patients were Asian and 8.4% were white. Dyspnea was the presenting symptom in 95%, with 80% having documented rales. During the index hospitalization, left ventricular function was assessed in 50%, and intravenous therapies included diuretics (85%), vasodilators (14%), and positive inotropes (15%). In-hospital mortality was 4.8%. Discharge medications included angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (63%), ß-blockers (41%), and aldosterone antagonists (31%). CONCLUSIONS: Compared with other multicenter registries, patients hospitalized with acute HF in the Asia Pacific region tend to present with more severe clinical symptoms and signs and are younger, especially in countries at an earlier stage in their epidemiological transition. Echocardiography and disease-modifying medications are used less often, highlighting potential opportunities to improve outcomes.

Consensus Recommendations by the Asian Pacific Society of Cardiology: Optimising Cardiovascular Outcomes in Patients with Type 2 Diabetes.

The Asian Pacific Society of Cardiology convened a consensus statement panel for optimising cardiovascular (CV) outcomes in type 2 diabetes, and reviewed the current literature. Relevant articles were appraised using the Grading of Recommendations, Assessment, Development and Evaluation system, and consensus statements were developed in two meetings and were confirmed through online voting. The consensus statements indicated that lifestyle interventions must be emphasised for patients with prediabetes, and optimal glucose control should be encouraged when possible. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are recommended for patients with chronic kidney disease with adequate renal function, and for patients with heart failure with reduced ejection fraction. In addition to SGLT2i, glucagon-like peptide-1 receptor agonists are recommended for patients at high risk of CV events. A blood pressure target below 140/90 mmHg is generally recommended for patients with type 2 diabetes. Antiplatelet therapy is recommended for secondary prevention in patients with atherosclerotic CV disease.

The Singapore Heart Failure Risk Score: Prediction of Survival in Southeast Asian Patients.

INTRODUCTION: Numerous heart failure risk scores have been developed but there is none for Asians. We aimed to develop a risk calculator, the Singapore Heart Failure Risk Score, to predict 1- and 2-year survival in Southeast Asian patients hospitalised for heart failure. MATERIALS AND METHODS: Consecutive patients admitted for heart failure were identified from the Singapore Cardiac Databank Heart Failure registry. The follow-up was 2 to 4 years and mortality was obtained from national registries. RESULTS: The derivation (2008-2009) and 2 validation cohorts (2008-2009, 2013) included 1392, 729 and 804 patients, respectively. Ten variables were ultimately included in the risk model: age, prior myocardial infarction, prior stroke, atrial fibrillation, peripheral vascular disease, systolic blood pressure, QRS duration, ejection fraction and creatinine and sodium levels. In the derivation cohort, predicted 1- and 2-year survival was 79.1% and 68.1% compared to actual 1- and 2-year survival of 78.2% and 67.9%. There was good agreement between the predicted and observed mortality rates (Hosmer-Lemeshow statistic = 14.36, P = 0.073). C-statistics for 2-year mortality in the derivation and validation cohorts were 0.73 (95% CI, 0.70-0.75) and 0.68 (95% CI, 0.64-0.72), respectively. CONCLUSION: We provided a risk score based on readily available clinical characteristics to predict 1- and 2-year survival in Southeast Asian patients hospitalised for heart failure via a simple online risk calculator, the Singapore Heart Failure Risk Score.

Improving access to outpatient cardiac care at the national heart centre--a partnership between specialists and primary care.

Ensuring timely access to specialist care is an important indicator of the quality of a health service. Demand for cardiology outpatient appointments has grown considerably in the last decade, leading to increased waiting time for cardiology appointments at public hospitals. This paper examines the effectiveness of past and ongoing strategies initiated by the National Heart Centre, many of which were in collaboration with SingHealth Polyclinics, documents the lessons learnt, and provides a framework for approaching this problem. Instead of a simplistic approach where institutions react to long waiting times by growing capacity to meet demand, this paper emphasises the need to focus on the final intended outcome (timely diagnosis and treatment) rather than on a single performance indicator, such as waiting time. A broad systems approach at the national level is advocated, rather than piecemeal, uncoordinated actions by individual hospitals.

Pattern and outcome of subsidised referrals to cardiology specialist outpatient clinics.

INTRODUCTION: Increasing demand for public healthcare and access to specialist care has become a major concern. Characterising the referral pattern to a national centre's cardiology specialist outpatient clinics (SOCs) and the diagnostic outcomes may be useful in formulating referral guidelines to contain rising demand. MATERIALS AND METHODS: A prospective observational followup study was conducted of all consecutive new patient referrals to the cardiology SOCs of the National Heart Centre over a 1-month period. The records of these 1224 patients were reviewed following their first visit and again after 3 months of evaluation and investigation. Patients' demographics, referral sources, indications of referral, risk factors, provisional and final diagnoses were collected. Referrals from the top 2 volume sources (government polyclinics and hospital Emergency Department) accounted for 600 referrals. These subsidised referrals formed the study group for analysis. RESULTS: The mean age of referred patients was 56 +/- 15.2 years, with equal proportion of males and females. Most patients had known cardiac risk factors of hypertension (53.2%) and hyperlipidaemia (42.3%). Only 23% of referrals had significant cardiac abnormalities. Referrals for typical chest pain derived the highest yield whereas referrals for atypical chest pain, non-cardiac chest pain derived the lowest yield. Referrals for asymptomatic electrocardiogram (ECG) changes (except for atrial flutter/fibrillation) did not yield cardiac abnormalities. Multivariate analysis of chest pain referrals showed typical chest pain and hyperlipidaemia to be statistically significant predictors for coronary artery disease. CONCLUSION: Referrals to cardiology outpatient specialist clinics should be based on the presence of patient symptoms, particularly that of typical chest pain. In asymptomatic patients, routine ECG screening did not appear to yield significant cardiac abnormalities.

Improving door-to-balloon times in primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: the value of an audit-driven quality initiative.

INTRODUCTION: The study was designed to reduce door-to-balloon times in primary percutaneous coronary intervention for patients presenting to the Emergency Department with acute ST-elevation myocardial infarction, using an audit as a quality initiative. MATERIALS AND METHODS: A multidisciplinary work group performed a pilot study over 3 months, then implemented various process and work-flow strategies to improve overall door-to-balloon times. RESULTS AND CONCLUSION: We developed a guideline-based, institution-specific written protocol for triaging and managing patients who present to the Emergency Department with symptoms suggestive of STEMI, resulting in shortened median door-to-balloon times from 130.5 to 109.5 minutes (P<0.001).

Heart failure mortality in Southeast Asian patients with left ventricular systolic dysfunction.

BACKGROUND: Prognostic indicators and mortality in multiethnic Southeast Asian patients with heart failure (HF) may be different. METHODS AND RESULTS: The study population comprised 225 inpatients with HF with a left ventricular ejection fraction of 40% or less who were discharged alive. Five years later, survival and causes of death were determined. Proportionally, more Malay and Indian patients were admitted compared with Chinese patients (P < .001). There were 55.6% in New York Heart Association (NYHA) class III or IV. Ischemic heart disease was the most common cause (85.8%). At 5 years, 152 patients (67.5%) had died. Angiotensin-converting enzyme inhibitors were prescribed to 79.1% of patients on discharge. Cardiovascular causes accounted for 69.7% of deaths. Predictors of mortality include female gender (P = .046), age 70 years or more (P = .017), renal impairment (P = .008), NYHA class III or IV (P = .03), and non-use of angiotensin-converting enzyme inhibitors (P = .005). On multivariate analysis, increasing age (P = .001) and renal impairment (P = .019) were independent predictors of all-cause mortality. Cardiovascular death was more likely with NYHA class III or IV (P = .004) and renal impairment (P = .012). CONCLUSION: Mortality is unusually high in this group of patients despite treatment. Greater use of evidence-based therapies in HF-management programs may arrest this trend.

An unusual case of spinal cord compression from concomitant spinal epidural lipomatosis and Hodgkin's lymphoma.

Spinal epidural lipomatosis (SEL) results from an abnormal accumulation of unencapsulated fat within the epidural space and is a rare cause of spinal cord compression, which needs to be considered with a high index of suspicion. It most commonly occurs secondary to chronic corticosteroid use and endocrinopathies. Idiopathic cases are highly associated with obesity. We report an unusual case of idiopathic thoracic SEL in a 69-year-old male, with an adjacent infiltrative Hodgkin's lymphoma and associated vertebral crush fracture, which resulted in ataxia and sensory loss. Magnetic resonance imaging scans displayed extensive SEL and an infiltrative disease process causing thoracic cord compression. Surgical decompression confirmed the presence of extensive epidural lipomatosis and Hodgkin's lymphoma and subsequently led to improvement in neurological symptoms. To our knowledge, this is the first reported case of concomitant SEL with an adjacent Hodgkin's lymphoma resulting in cord compression.

Prevalence, Presentation, and Outcome of Heart Failure with Preserved Ejection Fraction among Patients Presenting with Undifferentiated Dyspnoea to the Emergency Room: A 10-year Analysis from a Tertiary Centre.

INTRODUCTION: We assessed the local prevalence, characteristics and 10-year outcomes in a heart failure (HF) cohort from the emergency room (ER). MATERIALS AND METHODS: Patients presenting with acute dyspnoea to ER were prospectively enrolled from December 2003 to December 2004. HF was diagnosed by physicians' adjudication based on clinical assessment and echocardiogram within 12 hours, blinded to N-terminal-pro brain natriuretic peptide (NT-proBNP) results. They were stratified into heart failure with preserved (HFPEF) and reduced ejection fraction (HFREF) by left ventricular ejection fraction (LVEF). RESULTS: At different cutoffs of LVEF of ≥50%, ≥45%, ≥40%, and >50% plus excluding LVEF 40% to 50%, HFPEF prevalence ranged from 38% to 51%. Using LVEF ≥50% as the final cutoff point, at baseline, HFPEF (n = 35), compared to HFREF (n = 55), had lower admission NT- proBNP (1502 vs 5953 pg/mL, P <0.001), heart rate (86 ± 22 vs 98 ± 22 bpm, P = 0.014), and diastolic blood pressure (DBP) (75 ± 14 vs 84 ± 20 mmHg, P = 0.024). On echocardiogram, compared to HFREF, HFPEF had more LV concentric remodelling (20% vs 2%, P = 0.003), less eccentric hypertrophy (11% vs 53%, P <0.001) and less mitral regurgitation from functional mitral regurgitation (60% vs 95%, P = 0.027). At 10 years, compared to HFREF, HFPEF had similar primary endpoints of a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and rehospitalisation for congestive heart failure (CHF) (HR 0.886; 95% CI, 0.561 to 1.399; P = 0.605), all-cause mortality (HR 0.663; 95% CI, 0.400 to 1.100; P = 0.112), but lower cardiovascular mortality (HR 0.307; 95% CI, 0.111 to 0.850; P = 0.023). CONCLUSION: In the long term, HFPEF had higher non-cardiovascular mortality, but lower cardiovascular mortality compared to HFREF.

Heart Failure Clinical Trials in East and Southeast Asia: Understanding the Importance and Defining the Next Steps.

Heart failure (HF) is a major and increasing global public health problem. In Asia, aging populations and recent increases in cardiovascular risk factors have contributed to a particularly high burden of HF, with outcomes that are poorer than those in the rest of the world. Representation of Asians in landmark HF trials has been variable. In addition, HF patients from Asia demonstrate clinical differences from patients in other geographic regions. Thus, the generalizability of some clinical trial results to the Asian population remains uncertain. In this article, we review differences in HF phenotype, HF management, and outcomes in patients from East and Southeast Asia. We describe lessons learned in Asia from recent HF registries and clinical trial databases and outline strategies to improve the potential for success in future trials. This review is based on discussions among scientists, clinical trialists, industry representatives, and regulatory representatives at the CardioVascular Clinical Trialist Asia Forum in Singapore on July 4, 2014.

Experience with mucosal melanoma of the nose and paranasal sinuses.

PURPOSE: Sinonasal mucosal melanoma is a rare and aggressive disease and its incidence does not mimic that of its cutaneous counterpart in the Australian population. The present study examines one unit's experience with the disease and proposes a treatment strategy. The significance of macroscopic widespread mucosal melanosis and histological melanoma in situ is considered in the present study to be crucial in overall survival and the main cause of local failure and is specifically addressed. METHODS: The present study represents the retrospective experience of the multidisciplinary Head and Neck Clinic at the Prince of Wales Hospital over a 30-years period (from 1970 to end 1999) in the management of the disease, including both primary and salvage treatment approaches. The study includes 27 patients treated with surgery with or without postoperative radiation therapy. Management of recurrence was also considered. RESULTS: The mean time to local recurrence was 14.7 months and the mean time to distant metastases was 23.2 months. Mean survival time was 52 months and mean time from local recurrence to death was 75 months. Overall, disease free and disease specific survival and survival post-recurrence were analysed by the Kaplan-Meir method. A cancer specific 5 years survival of 46% was achieved, which compares favourably with recent international series. CONCLUSION: Sinonasal mucosal melanoma remains an aggressive disease with the possibility of local recurrence years after initial treatment, however, initial radical surgery encompassing the primary lesion and distant in situ or satellite disease and postoperative radiotherapy can offer long-term control, as can reoperation for local recurrence where appropriate.

The impact of brain death on survival after heart transplantation: time is of the essence.

BACKGROUND: It has been suggested that the modality of brain death and time from brain death until harvest impact survival and rejection after heart transplantation. METHODS: Donor files from 475 adult heart-transplant recipients were examined. From these files, a total management time (time from incident leading to brain death until aortic cross clamp) was determined, and the cause of brain death was noted. Recipient characteristics, details of postoperative course, as well as survival were obtained from the Stanford University Medical Center Heart Transplantation Database. RESULTS: Two hundred and thirty (48.4%) donors sustained traumatic injuries, 112 (23.6%) suffered a subarachnoid hemorrhage, and 102 (21.4%) died of a gunshot wound to the head. The modality of brain death did not influence medium and long-term survival. A management time longer than 72 hours was associated with poorer outcome of the heart-transplant recipients. There were significantly more treated rejection episodes in recipients whose donor sustained traumatic injuries. CONCLUSION: Modality of brain death does not impact survival but appears to influence rejection. Increased management time is associated with adverse survival trends in heart-transplant recipients.

Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience.

BACKGROUND: Truly long term survival post heart transplantation has become increasingly frequent over the past two decades. METHODS: We analyzed multiple clinical outcomes in the cohort of 140 patients in the Stanford database who underwent heart transplantation after the introduction of cyclosporine-based immunosuppression in 1980 and survived >10 years after transplantation. RESULTS: We found generally excellent functional status in these patients, but a high incidence of hypertension, renal dysfunction, and graft CAD as well as malignancy. CONCLUSION: With continued improvement in post-transplant survival rates, providing complex care for such long-term recipients as these will assume increasing clinical importance in the everyday practice of transplant medicine and these data highlight the problems to be anticipated.

Post-operative conversion from cyclosporine to tacrolimus in heart transplantation: a single-center experience.

BACKGROUND: Tacrolimus is a potent calcineurin inhibitor that was introduced to heart transplantation in the early 1990s. The side-effect profile of tacrolimus is more favorable than that of cyclosporine and some reports have suggested an advantage of tacrolimus in the treatment of rejection. The present study was undertaken to determine whether a late conversion to tacrolimus affords these benefits to heart transplant recipients. METHODS: Charts from 109 patients who underwent conversion from cyclosporine to tacrolimus for recurrent rejection or adverse effects were retrospectively reviewed. RESULTS: During the year after conversion to tacrolimus, there was a significant decrease in treated rejection episodes. Conversion to tacrolimus rapidly resulted in an improved lipid profile. Two years after conversion blood pressure was significantly reduced. Apart from rejection, these benefits were found mainly among individuals converted to tacrolimus within 1 year of heart transplantation. CONCLUSIONS: Conversion from cyclosporine to tacrolimus is safe and results in a more favorable risk factor profile. However, most of the benefits are seen in individuals converted within 1 year of transplantation.

Predictors of mortality in acute heart failure: interaction between diabetes and impaired left ventricular ejection fraction.

AIM: The aim of this study was to test the hypothesis that diabetes modifies the risk of mortality in acute heart failure patients, especially in patients with impaired LVEF, and that impaired LVEF in turn modifies the risk of mortality in diabetic patients. METHODS AND RESULTS: We studied 2121 patients with acute heart failure admitted at two centres in Singapore from 1 January 2008 to 31 December 2009. The date of the last follow-up was 31 December 2011, with a median follow-up time (interquartile range) of 914 (442-1190) days. Cox regression was used to estimate hazard ratios for all-cause mortality in patients with LVEF ≥50%, LVEF 30-49%, and LVEF <30% relative to diabetic status. Impaired LVEF (<50%) in the presence of diabetes substantially increased the risk of mortality compared with non-diabetics with LVEF <50%. The adjusted hazard ratio (aHR) and 95% confidence interval (CI) for diabetic patients with an LVEF of 30-49% (1.46, 95% 1.18-1.81) was not statistically different from the aHR in non-diabetic patients with severely impaired LVEF of <30% (1.38, 95% CI 1.09-1.75) (P = 0.644). The deleterious effects of diabetes seemed to be confined to acute heart failure patients with impaired LVEF, as the mortality rate in patients with LVEF >50% was not increased. Other clinical predictors of mortality were ageing, prior myocardial infarction, systolic blood pressure >140 mmHg, creatinine ≥250 µmol/L, haemoglobin <9.0 g/dL, and prior stroke/transient ischaemic attack. CONCLUSION: The interaction of diabetes and impaired LVEF in acute heart failure patients significantly amplifies the deleterious effects of each as distinct disease entities.

Impact Of Sex On Clinical Characteristics And In-Hospital Outcomes In A Multi-Ethnic Southeast Asian Population Of Patients Hospitalized For Acute Heart Failure.

OBJECTIVES: To study sex differences in clinical characteristics and outcomes among multi-ethnic Southeast Asian patients with hospitalized heart failure (HHF). BACKGROUND: HHF is an important public health problem affecting man and women globally. Reports from Western populations suggest striking sex differences in risk factors and outcomes in HHF. However, this has not been studied in a multi-ethnic Asian population. METHODS: Using the population-based resources of the Singapore Cardiac Data Bank, we studied 5,703 consecutive cases of HHF admitted across hospitals in the Southeast Asian nation of Singapore from 1st January, 2008 through 31st December, 2009. RESULTS: Women accounted for 46% of total admissions and were characterized by older age (73 vs. 67 years; p<0.001), higher prevalence of hypertension (78.6 vs. 72.1%; p<0.001) or atrial fibrillation (22.2 vs. 18.1%; p<0.001), and lower prevalence of coronary artery disease (33.8 vs. 41.0%; p<0.001) or prior myocardial infarction (14.9 vs. 19.8%; p<0.001). Women were more likely than men to have HHF with preserved ejection fraction (42.5% versus 20.8%, p < 0.001). Women were less likely than men to receive evidencebased therapies at discharge, both in the overall group and in the sub-group with reduced ejection fraction. Women had longer lengths of stay (5.6 vs. 5.1 days; p<0.001) but similar in-hospital mortality and one-year rehospitalization rates compared to men. Independent predictors of mortality or rehospitalization in both men and women included prior myocardial infarction and reduced ejection fraction. Among women alone, additional independent predictors were renal impairment, atrial fibrillation, and diabetes. Prescription of beta-blockers and ACE-inhibitors at discharge was associated with better outcomes. CONCLUSION: Among multi-ethnic Asian patients with HHF, there are important sex differences in clinical characteristics and prognostic factors. These data may inform sex-specific strategies to improve outcomes of HHF in Southeast Asians.

Myocardial contractile dysfunction associated with increased 3-month and 1-year mortality in hospitalized patients with heart failure and preserved ejection fraction.

BACKGROUND: There is a clinical need for a contractility index that reflects myocardial contractile dysfunction even when ejection fraction (EF) is preserved. We used novel relative load-independent global and regional contractility indices to compare left ventricular (LV) contractile function in three groups: heart failure (HF) with preserved ejection fraction (HFPEF), HF with reduced ejection fraction (HFREF) and normal subjects. Also, we determined the associations of these parameters with 3-month and 1-year mortality in HFPEF patients. METHODS: 199 HFPEF patients [median age (IQR): 75 (67-80) years] and 327 HFREF patients [69 (59-76) years] were recruited following hospitalization for HF; 22 normal control subjects [65 (54-71) years] were recruited for comparison. All patients underwent standard two-dimensional Doppler and tissue Doppler echocardiography to characterize LV dimension, structure, global and regional contractile function. RESULTS: The median (IQR) global LV contractility index, dσ*/dtmax was 4.30s(-1) (3.51-4.57s(-1)) in normal subjects but reduced in HFPEF [2.57 (2.08-3.64)] and HFREF patients [1.77 (1.34-2.30)]. Similarly, median (IQR) regional LV contractility index was 99% (88-104%) in normal subjects and reduced in HFPEF [81% (66-96%)] and HFREF [56% (41-71%)] patients. Multi-variable logistic regression analysis on HFPEF identified sc-mFS <76% as the most consistent predictor of both 3-month (OR=7.15, p<0.05) and 1-year (OR=2.57, p<0.05) mortality after adjusting for medical conditions and other echocardiographic measurements. CONCLUSION: Patients with HFPEF exhibited decreased LV global and regional contractility. This population-based study demonstrated that depressed regional contractility index was associated with higher 3-month and 1-year mortality in HFPEF patients.

Modern radiotherapy approaches in the management of craniopharyngiomas.

An audit of treatment regimens at presentation, recurrence and survival rates spanning 37 years were reviewed for children and adults with craniopharyngioma treated at The Prince of Wales or the Sydney Children's hospitals. Eligibility criteria stipulated all patients (n=41) received radiotherapy as part of their treatment course. The primary end point for evaluation was the incidence of radiological progression post-radiotherapy, and secondary end-points were the symptomatic and hormonal status post-radiotherapy. There were 12 paediatric patients (age, <16 years) and 29 adults (age range, 16-80 years). Of the 41 patients, 39 had a suprasellar tumour component, and 38 had radiologically persistent disease post-surgery. Four patients were treated by radiosurgery (median volume treated, 3.5 cm(3)); four patients progressed post-radiotherapy, of whom two were salvaged by further radiotherapy, one succumbed to progressive local disease, and one had a small intrasellar recurrence surgically resected. Progression-free survival (95.12%) was followed for up to 23 years. Thus, subtotal resection and the modern radiotherapy approach is likely to provide excellent patient and disease outcomes.

Treatment of a pontine neuroepithelial cyst by placement of a cystocisternal grommet.

We describe an 8-year-old girl who presented with cranial nerve compression due to a brainstem cyst adjacent to the fourth ventricle and describe the first documented insertion of a grommet to form a conduit between a neuroepithelial cyst and ventricle. The patient presented with diplopia and headaches and was found to have the cystic lesion in the right pons. The patient underwent craniotomy, aspiration and fenestration with subsequent recurrence 8 months later. Definitive treatment involved insertion of a grommet. Surgical treatment of symptomatic neuroepithelial cysts can achieve full resolution of neurological deficits. Insertion of a grommet, as distinct from a shunt or fenestration procedure, has the potential to provide long-term resolution of these symptoms without recurrence.