The obesity-mortality paradox in elderly patients with angiographic coronary artery disease: a report from the ET-CHD registry.

BACKGROUND: The body mass index (BMI)-mortality paradox has been well known in patients with obstructive coronary artery disease (CAD). However, this phenomenon has rarely been described among elderly patients over a 5-year follow-up. METHODS: We studied a cohort of 722 elderly patients (age 65 years) with angiographic CAD from the ET-CH D registry during 1997-2003 in eastern Taiwan. To evaluate the BMI effect on mortality, the elderly subjects were categorized into 5 groups by BMI (kg/m2): underweight and normal-low weight (< 21), normal-high weight (21-23.9) overweight (24-26.9), mild obesity (27-29.9) and moderate/severe obesity (30). At a maximal 10-year follow-up, cardiac and all-cause deaths were the primary end points. RESULTS: After multivariate analysis, patients from the category of under weight and normal-low weight in reference to those from the normal-high weight category had a significantly higher risk of cardiac and all-cause mortality (hazard ratio (HR): 1.68 (95% CI: 1.04-2.70) and 2.02 (95% CI: 1.42-2.87), respectively) following a median of 5.4 years. Obese elderly patients tended to have the lowest risk of all-cause death across all the study BMI categories in the early stage. However, after 5 years, mortality increased in the obese patients surviving beyond 5 years, and was higher than that in overweight patients. CONCLUSIONS: The obesity-mortality paradox was present in elderly patients with angiographic CAD in Taiwan and the risk of death was significantly higher in those with a BMI < 21 kg/n2. However, a J-shaped relationship between mortality and BMI developed after 5 years of follow-up.

Factors influencing the long-term effects of supervised cardiac rehabilitation on the exercise capacity of patients with acute myocardial infarction.

BACKGROUND AND PURPOSE: Cardiac rehabilitation (CR) programs can effectively increase exercise capacity after an acute myocardial infarction (AMI). The purpose of this study was to investigate the changes in exercise capacity at the end of a supervised CR program and to determine the factors influencing exercise capacity 6 months after the end of a supervised CR program. METHODS: One hundred and four AMI patients who completed an 8-week supervised CR program were included in the study. Those who had an increased exercise capacity at the end of the 8-week supervised CR program were followed for 6 months to determine the possible factors influencing exercise capacity. Student's-t, chi-square, and ANOVA tests were used to make comparisons between groups and among stages of the program. RESULTS: All participants had a significant increase in exercise capacity and high-density lipoprotein cholesterol (HDL-C) at the end of the 8-week supervised CR program. The anaerobic threshold increased from 0.94 +/- 0.19 to 1.11 +/- 0.19 W/kg (p < 0.05) and serum HDL-C increased from 36.0 +/- 8.7 to 41.1 +/- 10.7 mg/dL (p < 0.05). Follow-up results demonstrated that smoking cessation, decrease in body mass index, and participation in leisure time physical activities were positively associated with increased exercise capacity. CONCLUSION: This study demonstrated that a supervised CR program improves exercise capacity and serum lipid profile in patients after AMI. Status of smoking, body mass index, and leisure time physical activities affect the long-term results of exercise training.

Serum uric acid as an independent predictor of mortality in high-risk patients with obstructive coronary artery disease: a prospective observational cohort study from the ET-CHD registry, 1997-2003.

BACKGROUND: Serum uric acid (SUA) has been observed to be highly associated with the development of cardiovascular disease for more than 50 years. Several studies have reported elevated SUA as an independent predictor of mortality in patients with coronary artery disease (CAD) after adjustment for classic risk factors but some studies did not find similar results. METHODS: Between January 1997 and December 2003, a prospective cohort study was performed in 1054 patients with angiographically defined CAD, and their classic risk factors and SUA levels were determined at enrollment. The study cohort was followed for an average of 3.2 years, with a median of 3.1 years. The main outcome measure was death from cardiac disease and any cause. RESULTS: Of all study patients, 789 (74.9%) were men and 265 (25.1%) were women. The mean age of the male and female patients was 64.8 and 66.9 years, respectively. The mean SUA level of all patients was 410.4 µmol/L. There were grading effects of SUA quartiles on cardiac and all-cause mortality in univariate and multivariate Cox regression analyses. After adjustment, the multivariate analyses revealed that patients in the highest SUA quartile (>487 µmol/L) had 2.08 (95% CI=1.19-3.62, p=0.01) fold increased risk of cardiac death, and 1.68 (95% CI=1.10-2.57, p=0.017) fold increase risk of overall mortality compared with the lowest quartile (<315 µmol/L). CONCLUSIONS: SUA may be a significant predictor of cardiac and overall mortality, independent of classic risk factors in high-risk patients with obstructive CAD.

Clinical characteristics and treatment of constrictive pericarditis in Taiwan.

BACKGROUND: Constrictive pericarditis is an uncommon disease that prevents the normal diastolic filling of the heart and pericardiectomy is the only satisfactory treatment. METHODS AND RESULTS: The clinical characteristics and treatment of patients who underwent pericardiectomy for constrictive pericarditis (n = 23) were reviewed. Surgery was performed via left anterolateral thoracotomy plus transsternal extension in 3 patients, and median sternotomy in 20 patients. There were 2 deaths, resulting in an overall mortality rate of 8.7%. Of the 23 patients, 8 had Mycobacterium tuberculosis (Tb) infection, 2 had streptococcus infection, 1 had strongyloidiasis (Strongyloides stercoralis) and 1 developed the condition after a myocardial infarction; 2 patients underwent pericardial substitute insertion as post-heart surgery, and 3 patients had connective tissue disorders; 6 patients had idiopathic disease. CONCLUSION: These results show that bacterial infection, especially Tb, is a major etiology of constrictive pericarditis in Taiwan and that median sternotomy is an excellent approach for exposing the heart for pericardiectomy.

Strongyloides stercoralis infection with bloody pericardial effusion in a non-immunosuppressed patient.

A 63-year-old Taiwan aboriginal male was admitted with exertional dyspnea, appetite loss and general fatigue. Echocardiography revealed moderate pericardial effusion and histological examination of the pericardiocentesis sample revealed an eosinophil-dominated bloody exudate. The larvae of Strongyloides stercoralis were detected in the pericardial specimen. After treatment with anti-nematodal agents, the eosinophilia decreased from 26% to 1% and the patient's symptoms improved. This is a rare case of Strongyloides-induced bloody pericardial effusion in a non-immunosuppressed patient.

Cardiac myxoma originating from the anterior mitral leaflet.

Cardiac myxoma arising from the anterior mitral leaflet is extremely rare. A 47-year-old Taiwanese male was found to have a 5 x 4 x 3 cm myxoma originating from the atrial side of the anterior mitral leaflet using transesophageal echocardiography. The tumor was successfully treated by surgical excision. The resected tumor was a well-defined encapsulated mass with a broad-base stalk arising from the anterior mitral leaflet. To detect the early recurrence, a semiannual follow-up examination using transesophageal echocardiography is needed.