Left Atrial Strain Predicts Cardiovascular and All-Cause Mortality.

Background: Left atrial strain can usefully reflect left atrial function. The follow-up periods in previous studies assessing left atrial strain as a survival predictor have been relatively short, and few studies have examined the ability of left atrial strain to predict mortality in patients with borderline diastolic function. This study sought to investigate the survival predictive value of left atrial strain with a longer follow-up duration. In addition, we also evaluated the survival predictive value of left atrial strain in patients with borderline diastolic function. Methods: In total, 652 participants who received routine echocardiography underwent 2-D speckle tracking echocardiography to evaluate left atrial reservoir function by peak atrial longitudinal strain. The study endpoints were all-cause and cardiovascular mortality. Results: The mean left atrial strain was 27.6%, and the median follow-up duration was 92 months. During follow-up, 72 patients died of cardiovascular causes and 181 died of all causes. Univariable Cox regression analysis revealed that lower left atrial strain significantly predicted an increase in all-cause and cardiovascular mortality. After adjusting for common clinical and echocardiographic parameters, lower left atrial strain was still associated with a higher risk of all-cause mortality [hazard ratio (HR) = 0.942, p = 0.011] and cardiovascular mortality (HR = 0.915, p = 0.018) in multivariable Cox-regression analysis. In addition, 293 patients had borderline left ventricular diastolic function. Multivariable analysis still revealed that left atrial strain could predict cardiovascular mortality in this population. Conclusions: Our data showed that left atrial strain could predict all-cause and cardiovascular mortality, even after adjusting for general clinical and echocardiographic parameters.

CHA2DS2-VASc Score and Risk of New-Onset Peripheral Arterial Occlusive Disease in Patients without Atrial Fibrillation.

BACKGROUND: CHA2DS2-VASc score is a useful score to evaluate the risk of stroke in patients with atrial fibrillation (AF), and it has been shown to outperform CHADS2 score. Our recent cross-sectional study showed that CHA2DS2-VASc score was associated with an ankle-brachial index < 0.9. The aim of the current study was to evaluate whether CHA2DS2-VASc score is a useful predictor of new-onset peripheral artery occlusive disease (PAOD) and whether it can outperform CHADS2 and R2CHADS2 scores. METHODS: We used the National Health Insurance Research Database to survey 723750 patients from January 1, 2000 to December 31, 2001. CHADS2, R2CHADS2, and CHA2DS2-VASc scores were calculated for every patient. Finally, 280176 (score 0), 307209 (score 1), 61093 (score 2), 35594 (score 3), 18956 (score 4), 11032 (score 5), 6006 (score 6), 2696 (score 7), 843 (score 8), and 145 (score 9) patients were studied and followed to evaluate new-onset PAOD. We further divided the study patients into six groups: group 1 (score 0), group 2 (score 1-2), group 3 (score 3-4), group 4 (score 5-6), group 5 (score 7-8), and group 6 (score 9). RESULTS: Overall, 24775 (3.4%) patients experienced new-onset PAOD during 9.8 years of follow-up. The occurrence rate of PAOD increased from 1.3% (group 1) to 23.4% (group 6). Subgroup analysis by gender also showed an association between CHA2DS2-VASc score and the occurrence rate of PAOD. After multivariate analysis, groups 2-6 were significantly associated with new-onset PAOD. CHA2DS2-VASc score also outperformed CHADS2 and R2CHADS2 scores for predicting new-onset PAOD. CONCLUSIONS: CHA2DS2-VASc score was a more powerful predictor of new-onset PAOD than CHADS2 and R2CHADS2 scores in patients without AF.

Usefulness of four-limb blood pressure measurement in prediction of overall and cardiovascular mortality in acute myocardial infarction.

Four-limb blood pressure measurement could improve mortality prediction in the elderly. However, there was no study to evaluate whether such measurement was still useful in predicting overall and cardiovascular (CV) mortality in acute myocardial infarction (AMI). Two hundred AMI patients admitted to cardiac care unit were enrolled. The 4-limb blood pressures, inter-limb blood pressure differences, and ankle brachial index (ABI) were measured using an ABI-form device. The median follow-up to mortality was 64 months (25th-75th percentile: 5-174 months). There were 40 and 138 patients documented as CV and overall mortality, respectively. After multivariable adjustment, the ankle diastolic blood pressure (DBP) on the lower side, ABI value, ABI < 0.9, interarm DBP difference, interankle systolic blood pressure (SBP) and DBP differences, interankle SBP difference ≥ 15 mmHg, and interankle DBP difference ≥ 10 mmHg could predict overall mortality (P ≤ 0.025). The ankle DBP on the lower side, interankle DBP difference, and interankle DBP difference ≥ 10 mmHg could predict CV mortality (P ≤ 0.031). In addition, in the Nested Cox model, the model including the ankle DBP on the lower side and the model including interankle DBP difference had the best value for overall and CV mortality prediction, respectively (P ≤ 0.031). In AMI patients, 4-limb blood pressure measurement could generate several useful parameters in predicting overall and CV mortality. Furthermore, ankle DBP on the lower side and interankle DBP difference were the most powerful parameters in prediction of overall and CV mortality, respectively.

Cardiovascular disease management during the coronavirus disease 2019 pandemic.

Based on clinical presentation, pathophysiology, high infectivity, high cardiovascular involvement, and therapeutic agents with cardiovascular toxicity of coronavirus disease 2019 (COVID-19), regular cardiovascular treatment is being changing greatly. Despite angiotensin-converting enzyme 2 serving as the portal for infection, the continuation of clinically indicated renin-angiotensin-aldosterone blockers is recommended according to the present evidence. Fibrinolytic therapy can be considered a reasonable option for the relatively stable ST segment elevation myocardial infarction (STEMI) patient with suspected or known COVID-19. However, primary percutaneous coronary intervention is still the standard of care in patients with definite STEMI if personal protective equipment is available and cardiac catheterization laboratory has a good infection control. In patients with elevated cardiac enzymes, it is very important to differentiate patients with Type 2 myocardial infarction or myocarditis from those with true acute coronary syndromes because invasive percutaneous intervention management in the former may be unnecessary, especially if they are hemodynamically stable. Finally, patients with baseline QT prolongation or those taking QT prolonging drugs must be cautious when treating with lopinavir/ritonavir and hydroxychloroquine for COVID-19.

Association of renal systolic time intervals with brachial-ankle pulse wave velocity.

Aims: The renal systolic time intervals (STIs), including renal pre-ejection period (PEP), renal ejection time (ET), and renal PEP/renal ET measured by renal Doppler ultrasound, were associated with poor cardiac function and adverse cardiac outcomes. However, the relationship between renal hemodynamic parameters and arterial stiffness in terms of brachial-ankle pulse wave velocity (baPWV) has never been evaluated. The aim of this study was to assess the relationship between renal STIs and baPWV. Methods: This cross-sectional study enrolled 230 patients. The renal hemodynamics was measured from Doppler ultrasonography and baPWV was measured from ABI-form device by an oscillometric method. Results: Patients with baPWV ≧ 1672 cm/s had a higher value of renal resistive index (RI) and lower values of renal PEP and renal PEP/ET (all P< 0.001). In univariable analysis, baPWV was significantly associated with renal RI, renal PEP, and renal PEP/renal ET (all P< 0.001). In multivariable analysis, renal PEP (unstandardized coefficient ß = -3.185; 95% confidence interval = -5.169 to -1.201; P = 0.002) and renal PEP/renal ET (unstandardized coefficient ß = -5.605; 95% CI = -10.217 to -0.992; P = 0.018), but not renal RI, were still the independent determinants of baPWV. Conclusion: Our results found that renal PEP and renal PEP/renal ET were independently associated with baPWV. Hence, renal STIs measured from renal echo may have a significant correlation with arterial stiffness.

In-Hospital Implementation of Evidence-Based Medications is Associated with Improved Survival in Diabetic Patients with Acute Coronary Syndrome - Data from TSOC ACS-DM Registry.

BACKGROUND: Patients with acute coronary syndrome (ACS) and diabetes mellitus (DM) receive less aggressive treatment and have worse outcomes in Taiwan. We sought to explore whether the current practices of prescribing guideline-directed medical therapy (GDMT) for ACS and clinical outcomes have improved over time. METHODS: A total of 1534 consecutive diabetic patients with ACS were enrolled between 2013 and 2015 from 27 hospitals in the nationwide registry initiated by the Taiwan Society of Cardiology (the TSOC ACS-DM Registry). Baseline and clinical demographics, treatment, and clinical outcomes were compared to those of 1000 ACS patients with DM recruited in the Taiwan ACS-full spectrum (ACS-FS) Registry, which was performed between 2008 and 2010. RESULTS: Compared to the DM patients in the Taiwan ACS-FS Registry, even though reperfusion therapy was carried out in significantly fewer patients, the primary percutaneous coronary intervention (PCI) rate for ST-segment elevation myocardial infarction (STEMI) and the prescription rates of GDMT for ACS including P2Y12 inhibitors, renin-angiotensin blockers, beta-blockers, and statins were significantly higher in those in the TSOC ACS-DM Registry. Moreover, significant reductions in 1-year mortality, recurrent nonfatal MI and stroke were observed compared to those of the DM patients in the Taiwan ACS-FS Registry. Multivariate analysis identified reperfusion therapy in combination with GDMT as a strong predictor of better 1-year outcomes [hazard ratio (95% confidence interval) = 0.54 (0.33-0.89)]. CONCLUSIONS: Marked improvements in performing primary PCI for STEMI and prescribing GDMT for ACS were observed over time in Taiwan. This was associated with improved 1-year event-free survival in the diabetic patients with ACS.

One-Year Outcomes of Acute Decompensated Systolic Heart Failure in Taiwan: Lessons from TSOC-HFrEF Registry.

BACKGROUND: Heart failure (HF) is a global health problem. The Taiwan Society of Cardiology-Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry was a multicenter, observational survey of patients admitted with HFrEF in Taiwan. The aim of this study was to report the one-year outcome in this large-cohort of hospitalized patients presenting with acute decompensated HFrEF. METHODS: Patients hospitalized for acute HFrEF were recruited in 21 hospitals in Taiwan. A total of 1509 patients were enrolled into the registry by the end of October 2014. Clinical status, readmission rates and dispensed medications were collected and analyzed 1 year after patient index hospitalization. RESULTS: Our study indicated that re-hospitalization rates after HFrEF were 31.9% and 38.5% at 6 and 12 months after index hospitalization, respectively. Of these patients, 9.7% of them were readmitted more than once. At 6 and 12 months after hospital discharge, all-cause mortality rates were 9.5% and 15.9%, respectively, and cardiovascular mortality rates were 6.8% and 10.5%, respectively. Twenty-three patients (1.5%) underwent heart transplantation. During a follow-up period of 1 year, 46.4% of patients were free from mortality, HF re-hospitalization, left ventricular assist device use and heart transplantation. At the conclusion of follow-up, 57.5% of patients were prescribed either with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; also, 66.3% were prescribed with beta-blockers and 40.8% were prescribed with mineralocorticoid receptor antagonists. CONCLUSIONS: The TSOC-HFrEF registry showed evidence of suboptimal practice of guideline-directed medical therapy and high HF re-hospitalization rate in Taiwan. The one-year mortality rate of the TSOC-HFrEF registry remained high. Ultimately, our data indicated a need for further improvement in HF care.

Statin Dose and the Risk of Intracerebral Hemorrhage: A Population-Based Longitudinal Study in Taiwan.

BACKGROUND: In the last 15 years, there has been considerable interest in statin use as a means to reduce the likelihood of vascular events. Several clinical trials have shown that high-dose statin (HDS) treatment could reduce vascular events. In high-risk populations, lipid treatment guidelines have generally suggested prescribing statin up to the highest recommended dosage. However, there remains concern about the risk of intracerebral hemorrhage (ICH) with HDS treatment. METHODS: This was a national population-based cohort study from the National Health Insurance Research Database of Taiwan extending from July 2001 to December 2008. Patients with cerebrovascular or cardiovascular disease were enrolled. The HDS group was defined as those patients receiving more than 420 mg per year of atorvastatin or an equivalent potency statin. Moderate dose statin group (MDS) was defined as those patients receiving atorvastatin in amounts between 196-420 mg per year or an equivalent potency statin. Low dose statin (LDS) group was defined as those receiving less than 196 mg per year of atorvastatin or an equivalent statin. The primary endpoint is ICH. The secondary endpoints are myocardial infarction (MI), ischemic stroke (IS) and new-onset DM (NDM). RESULTS: A total of 5459 patients were enrolled in our study, with study participant ages ranging from 62.91 ± 11.85 years and a mean follow-up time of 2039 ± 6 days. After adjusting for age, gender, diabetes and hypertension, Cox regression analysis found ICH risk was lower in HDS and MDS groups compared with LDS (HR 0.49, 95% CI 0.26-0.91, p = 0.0246 and HR 0.45, 95% CI 0.24-0.86, p = 0.0157). The risk of IS is lower in patients with HDS treatment (HR 0.68, 95% CI 0.55-0.83, p < 0.01). However, the risk of MI and NDM incidence are not statistically significant between the different dose groups. CONCLUSIONS: In the real-world data provided by Taiwan's National Health Insurance research database, it was shown that patients who received a higher dose of statin had a reduced and not elevated risk of intracerebral hemorrhage. KEY WORDS: High-dose statin; Hyperlipidemia; Intracerebral hemorrhage; Ischemic stroke; New-onset DM.

The Current Status of Performing Left Ventriculography in Taiwan.

BACKGROUND: Left ventriculography (LVG) is a gold standard examination of left ventricular function, although it also involves a small but significant risk of complications. However, it was recently reported to be overused in the USA in comparison to an alternative imaging modality. In this study, our aim was to analyze the real-world use of LVG in Taiwan. METHODS: This cohort study analyzed the data in the Taiwan National Health Insurance Bureau database for patients undergoing coronary angiography from 1996-2008. The most recent imaging modalities were used to evaluate left ventricular function including echocardiography and single-photon emission computed tomography (SPECT) within 30-day. The primary outcome was the concomitant use of LVG during coronary angiography. RESULTS: Of 8653 patients who underwent coronary angiography, LVG was performed on 4634 (53.6%) of those study participants. The frequency of LVG use was lower in the groups indicating left ventricular function evaluation, including acute myocardial infarction, heart failure and shock (49.5 vs. 57.1%, p < 0.001). In the population that had undergone a recent left ventricular assessment, the use of LVG was lower (52.2% vs. 54.7%, p = 0.03). Multivariate analysis found that 30-day imaging tests are not a predictor for use of LVG. CONCLUSIONS: In Taiwan, about one half of those patients whose data we reviewed actually received coronary angiography and LVG at the same time. Ultimately, we found that there was no overuse of LVG in those patients with recent alternative imaging modality performed. KEY WORDS: Angiography; Coronary; Ventriculography.

Longitudinal Stent Deformation Caused by Retraction of the Looped Main Branch Guidewire.

A 66-year-old male was treated percutaneously for a bifurcation lesion of the left anterior descending coronary artery by provisional stenting using the jailed wire technique. After successfully stenting the main branch, retraction of the looped main branch guidewire was impossible. After using an intravascular ultrasound we discovered the guidewire was entangled with a stent strut. Thereafter, the proximal stent elongated after retraction. With the support of an over-the-wire microcatheter, we finally pulled out the entrapped guidewire. This rare complication should remind physicians that it is important to prevent the distal guidewire from being looped while retracting it through a stent, regardless of whether it is in the side branch or main vessel. If the guidewire becomes entangled with a stent, a microcatheter or low-profile balloon can be advanced to rescue it before the stent is damaged. Furthermore, the microcather should be maintained after successful retraction of the entangled guidewire to facilitate further wiring and subsequent rescue angioplasty as necessary.

TSOC-HFrEF Registry: A Registry of Hospitalized Patients with Decompensated Systolic Heart Failure: Description of Population and Management.

INTRODUCTION: Heart failure (HF) is a medical condition with a rapidly increasing incidence both in Taiwan and worldwide. The objective of the TSOC-HFrEF registry was to assess epidemiology, etiology, clinical management, and outcomes in a large sample of hospitalized patients presenting with acute decompensated systolic HF. METHODS: The TSOC-HFrEF registry was a prospective, multicenter, observational survey of patients presenting to 21 medical centers or teaching hospitals in Taiwan. Hospitalized patients with either acute new-onset HF or acute decompensation of chronic HFrEF were enrolled. Data including demographic characteristics, medical history, primary etiology of HF, precipitating factors for HF hospitalization, presenting symptoms and signs, diagnostic and treatment procedures, in-hospital mortality, length of stay, and discharge medications, were collected and analyzed. RESULTS: A total of 1509 patients were enrolled into the registry by the end of October 2014, with a mean age of 64 years (72% were male). Ischemic cardiomyopathy and dilated cardiomyopathy were diagnosed in 44% and 33% of patients, respectively. Coronary artery disease, hypertension, diabetes, and chronic renal insufficiency were the common comorbid conditions. Acute coronary syndrome, non-compliant to treatment, and concurrent infection were the major precipitating factors for acute decompensation. The median length of hospital stay was 8 days, and the in-hospital mortality rate was 2.4%. At discharge, 62% of patients were prescribed either angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers, 60% were prescribed beta-blockers, and 49% were prescribed mineralocorticoid receptor antagonists. CONCLUSIONS: The TSOC-HFrEF registry provided important insights into the current clinical characteristics and management of hospitalized decompensated systolic HF patients in Taiwan. One important observation was that adherence to guideline-directed medical therapy was suboptimal.

Anemia as an Independent Predictor of Adverse Cardiac Outcomes in Patients with Atrial Fibrillation.

BACKGROUND: Anemia and echocardiographic systolic and diastolic parameters are useful predictors of cardiovascular outcomes in patients with atrial fibrillation (AF). However, no studies have evaluated the use of anemia for predicting cardiovascular outcome in AF patients when the important echocardiographic parameters are known. Therefore, this study was designed to evaluate whether low hemoglobin is a useful parameter for predicting poor cardiac outcome after adjustment for important echocardiographic parameters in AF patients. METHODS: Index beat method was used to measure echocardiographic parameters in 166 patients with persistent AF. Cardiac events were defined as death and hospitalization for heart failure. The association of hemoglobin with adverse cardiac events was assessed by Cox proportional hazards model. RESULTS: The 49 cardiac events identified in this population included 21 deaths and 28 hospitalizations for heart failure during an average follow-up of 20 months (25th-75th percentile: 14-32 months). Multivariable analysis showed that increased left ventricular mass index (LVMI) and decreased body mass index, estimated glomerular filtration rate, and hemoglobin (hazard ratio 0.827; P = 0.015) were independently associated with increased cardiac events. Additionally, tests of a Cox model that included important clinic variables, LVMI, left ventricular ejection fraction, and the ratio of transmitral E-wave velocity to early diastolic mitral annulus velocity showed that including hemoglobin significantly increased value in predicting adverse cardiac events (P = 0.010). CONCLUSIONS: Hemoglobin is a useful parameter for predicting adverse cardiac events, and including hemoglobin may improve the prognostic prediction of conventional clinical and echocardiographic parameters in patients with AF.

Plasma High-Sensitivity C-Reactive Protein Level is Associated with Impaired Estimated Glomerular Filtration Rate in Hypertensives.

BACKGROUND: Both inflammation and chronic kidney disease (CKD) are related to cardiovascular disease. Whether inflammatory biomarkers are associated with impaired glomerular filtration rate (GFR) is unclear in hypertensives. METHODS: We recruited hypertension patients from the cardiovascular clinic of a tertiary medical center in Taiwan. GFR was calculated using the 7-item Modification of Diet in Renal Disease (MDRD) study equation and impaired GFR (IGFR) was defined as GFR less than 60 ml/min/1.73 m(2). High-sensitivity C-reactive protein (hsCRP) kits were used for the measurement of the CRP levels. RESULTS: In our study, 572 consecutive hypertensive patients were enrolled. The range of patient age was 26-91 years (mean 60.5 ± 11.7), and hsCRP and GFR ranged from 0.01 to 9.99 mg/L and 16.6 to 239.6 ml/min//1.73 m(2), respectively. HsCRP levels were correlated with GFR (p = 0.01) and the presence of IGFR (p = 0.009). Multivariate regression analysis showed hsCRP (p = 0.03), age (p < 0.001) and urinary albumin-to-creatinine ratio (UACR) (p = 0.002) are independent factors associated with GFR. Furthermore, hsCRP levels [odds ratio (OR) = 1.16, 95% CI = 1.03-1.31, p = 0.02], age (OR = 1.09, 95% CI = 1.07-1.12, p < 0.001), and UACR (OR = 1.02, 95% CI = 1.01-1.04, p < 0.001) independently predicted the presence of IGFR using binary logistic regression analysis. CONCLUSIONS: Information obtained from our study showed that hsCRP is associated with IGFR in hypertensives. KEY WORDS: Chronic kidney disease; C-reactive protein; Glomerular filtration rate; Hypertension; Inflammation.

Significant Correlation between Brachial Pulse Pressure Index and Renal Resistive Index.

BACKGROUND: The renal resistive index (RI) is calculated as (peak systolic velocity - minimum diastolic velocity)/peak systolic velocity, and has been significantly associated with renal function. Pulse pressure index (PPI) is derived from a formula similar to renal RI, i.e. (systolic blood pressure - diastolic blood pressure)/systolic blood pressure. The purpose of this study was to investigate whether brachial PPI had a significant correlation with renal RI and could be used in identifying patients with impaired renal function. METHODS: We consecutively enrolled 255 patients referred for echocardiographic examination. The renal RI was measured from Doppler ultrasonography and blood pressure was measured from an ABI-form device. RESULTS: Patients with brachial PPI ≥ 0.428 (mean value of brachial PPI) had a lower estimated glomerular filtration rate (eGFR) than those with brachial PPI < 0.428 (p < 0.001). After the multivariate analysis was completed, brachial PPI had a significant correlation with renal RI (unstandardized coefficient ß = 0.53, p < 0.001). The areas under the curve for brachial PPI and renal RI in prediction of eGFR < 45 mL/min/1.73 m(2) were 0.682 and 0.893 (both p < 0.001), respectively. CONCLUSIONS: Brachial PPI was significantly correlated with renal RI. Patients with higher brachial PPI had a more reduced renal function. Hence, brachial PPI may be able to quickly reflect the intrarenal vascular hemodynamics, and may serve as an important tool for screening and follow-up for patients with abnormal renovascular resistance. KEY WORDS: Chronic kidney disease; Pulse pressure index; Resistive index.

The hOGG1 Ser326Cys gene polymorphism and the risk of coronary ectasia in the Chinese population.

Oxidative stress (OS) is related to vascular inflammation possibly, contributing to the development of coronary ectasia (CE). Base excision repair (BER) and nucleotide excision repair are the main DNA repair pathways that can help to remove 8-hydroxydeoxyguanine (8-OHdG), a marker of OS. Human 8-oxoguanine DNA glycosylase 1 (hOGG1) is a key enzyme of the BER pathway and catalyzes the removal of 8-OHdG. The aim of our study was to investigate the association between hOGG1 Ser326Cys gene polymorphism and CE in a Chinese population. Five-hundred forty-seven patients who underwent diagnostic coronary angiography in a tertiary medical center were recruited. The angiographic definition of CE is the diameter of the ectatic segment being more than 1.5 times larger compared with an adjacent healthy reference segment. The gene polymorphisms were analyzed by polymerase chain reaction. The urine 8OHdG concentration was measured using a commercial ELISA kit. The distribution of hOGG1 Ser326Cys genotypes was significantly different between CE and non-CE groups (p = 0.033). The odds ratio of CE development for the Ser to the Cys variant was 1.55 (95% confidence interval (CI), 1.04-2.31, p = 0.033). Both univariate and logistic regression analysis showed a significant association of hOGG1 Ser326Cys polymorphism in the dominant model with CE development (p = 0.009 and 0.011, respectively). Urine 8-OHdG levels were significantly higher in subjects carrying the hOGG1 Ser variant than in those with the Cys/Cys genotype (p < 0.03). In conclusion, our study suggests that the hOGG1 Ser326Cys gene variant might play a role in susceptibility to the development of CE.

Comparison of antiplatelet and antithrombotic therapy for secondary prevention of ischemic stroke in patients with peripheral artery disease: population-based follow-up study in Taiwan.

BACKGROUND: A limited number of studies have assessed the benefit and risk among the different antiplatelet and antithrombotic therapies in patient with stroke and peripheral artery disease (PAD). We compared the efficacy and safety of clopidogrel, cilostazol, warfarin, and aspirin. METHODS AND RESULTS: A retrospective cohort study analyzing the Taiwan National Health Insurance Research Dataset identified patients with stroke and PAD from 2002 to 2008. Patients were stratified according to their use of aspirin, clopidogrel, cilostazol, warfarin or combination therapy. A total of 1,686 patients were enrolled: aspirin (n=862), clopidogrel (n=92), warfarin (n=136), cilostazol only (n=515), and cilostazol-based combination therapy (n=81). Compared with aspirin, cilostazol could reduce the risk of ischemic stroke [hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.63-0.98, P=0.0349) and no increase in hemorrhagic events (HR 0.98, 95% CI 0.74-1.32, P=0.9122). Clopidogrel decreased the risk of ischemic stroke (HR 0.47, 95% CI 0.29-0.78, P=0.0033) and hemorrhagic events (HR 0.64, 95% CI 0.31-0.96, P=0.034) more than aspirin. There was no statistical difference regarding the risk of stroke and hemorrhagic events among warfarin, cilostazol-based combination therapy and aspirin. CONCLUSIONS: Cilostazol and clopidogrel were more effective in preventing recurrent ischemic stroke without increased hemorrhagic events than aspirin in patients with PAD.

Differential effects of central and peripheral fat tissues on the delayed rectifier K(+) outward currents in cardiac myocytes.

OBJECTIVES: The amount of fat tissue is associated with an increasing incidence of cardiac arrhythmias. The purpose of this study was to investigate effects of adipocytokines from different body fat on delayed rectifier K(+) outward currents (IK). METHODS: H9c2 cells were treated with adipocytokine-free medium (the Adipo-free group) and with adipocytokines from epicardial (central fat group) and limb (peripheral fat group) rat fat tissues. IK, as well as expressions of Kv2.1 and Kv2.1 mRNA in H9c2 cells, were measured and compared between different groups. RESULTS: IK measured in H9c2 cells immediately after treatment with adipocytokines were not significantly different from those treated with adipocytokine-free medium. After H9c2 cells were treated with adipocytokines for 18 h, IK were significantly decreased in the peripheral and central fat groups in comparison with the Adipo-free group. Compared with the peripheral fat group, IK were more significantly decreased in the central fat group. Expressions of Kv2.1 and Kv2.1 mRNA in H9c2 cells were not significantly different among the three groups. CONCLUSIONS: Adipocytokines significantly decreased IK in H9c2 cells, and IK was more prominently decreased by adipocytokines from epicardial fat than from limb fat tissues. The decrease in IK by adipocytokines may partially contribute to the mechanisms of arrhythmogenesis by fat tissues.

Impact of chronic kidney disease in early invasive versus early conservative revascularization strategies in non-ST-segment elevation acute coronary syndromes: a population-based study from NHIRD of Taiwan.

BACKGROUND: Patients with chronic kidney disease (CKD) sustaining a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are considered high risk and an early invasive strategy (EIS) is often recommended. However, the impact of CKD on patients receiving an EIS or an early conservative strategy (ECS) is unclear in real-world practice. METHODS: Data were analyzed from the 2005-2008 National Health Insurance Research Database (NHIRD) in Taiwan. The diagnosis of CKD was based on the International Classification of Disease-9 codes recorded by physicians. EIS was defined as coronary angiography with intent to revascularization performed within 72 h of symptom onset. The primary endpoint was time to first major adverse cardiac event (MACE) comprising cardiovascular death, myocardial infarction (MI) and stroke. The secondary endpoints included major bleeding (MB), heart failure (HF) and dialysis during admission (DDA). RESULTS: 834 patients (466 EIS and 368 ECS) were enrolled and age was 64.3 ± 12.6 years. Mean follow-up time was 1,163.96 ± 19.99 days. In the whole population an EIS was associated with a reduction in MACE (HR 0.69; 95% CI 0.50-0.95, p = 0.024) but not in the CKD population (HR 1.08; 95% CI 0.66-1.78, p = 0.76). Kaplan-Meier curves showed CKD subjects receiving an EIS had the highest MACE, HF and DDA rate (all p < 0.019) and CKD subjects receiving an ECS had the highest MB rate (p = 0.018). Cox regression analysis showed CKD predicted higher HF and DDA in those receiving an EIS and higher DDA and MB in those receiving an ECS. CONCLUSION: An EIS reduced MACE in the overall population, and CKD was a poor outcome predictor for both revascularization strategies in NSTE-ACS.

Heart rate significantly influences the relationship between atrial fibrillation and arterial stiffness.

BACKGROUND: Atrial fibrillation (AF) and vascular disease share several risk factors and the two diseases often coexist. Heart rate (HR) is reported to be a major determinant of arterial stiffness. AF patients often have a transiently or persistently rapid HR. Hence, this study was to assess whether AF was significantly associated with arterial stiffness and HR could significantly influence the relationship between AF and arterial stiffness. Besides, we also determine the main correlates of arterial stiffness in AF patients and see whether HR was correlated with arterial stiffness in these patients. METHODS: We included 166 AF and 1336 non-AF patients from subjects arranged for echocardiographic examinations. Arterial stiffness was assessed by brachial-ankle pulse wave velocity (baPWV). RESULTS: Compared to non-AF patients, AF patients had a higher baPWV (p <0.001). In a multivariate model, including covariates of age, sex, blood pressures and so on, the presence of AF was significantly associated with baPWV (ß = 0.079, P = 0.001). However, further adjustment for HR made this association disappear (ß = 0.005, P = 0.832). In addition to age and systolic blood pressure, increased HR (ß = 0.309, p <0.001) was a major determinant of increased baPWV in our AF patients. CONCLUSIONS: This study demonstrated the presence of AF was associated with increased baPWV, but this association became insignificant after further adjustment for HR, which suggested HR could significantly influence the relationship between AF and baPWV. Besides, HR was positively correlated with arterial stiffness in our AF patients.

Association of increased arterial stiffness and p wave dispersion with left ventricular diastolic dysfunction.

BACKGROUND: The association between increased arterial stiffness and left ventricular diastolic dysfunction (LVDD) may be influenced by left ventricular performance. P wave dispersion is not only a significant determinant of left ventricular performance, but is also correlated with LVDD. This study is designed to compare left ventricular diastolic function among patients divided by brachial-ankle pulse wave velocity (baPWV) and corrected P wave dispersion (PWDC) and assess whether the combination of baPWV and PWDC can predict LVDD more accurately. METHODS: This cross-sectional study enrolled 270 patients and classified them into four groups according to the median values of baPWV and PWDC. LVDD was defined as impaired relaxation and pseudonormal/restrictive mitral inflow patterns. RESULTS: The ratio of transmitral E wave velocity to early diastolic mitral annulus velocity (E/Ea) was higher in group with higher baPWV and PWDC than in the other groups (all p <0.001). The prevalence of LVDD was higher in group with higher baPWV and PWDC than in the two groups with lower baPWV (p ≤ 0.001). The baPWV and PWDC were correlated with E/Ea and LVDD in multivariate analysis (p ≤ 0.030). The addition of baPWV and PWDC to a clinical mode could significantly improve the R square in prediction of E/Ea and C statistic and integrated discrimination index in prediction of LVDD (p ≤ 0.010). CONCLUSIONS: This study showed increased baPWV and PWDC were correlated with high E/Ea and LVDD. The addition of baPWV and PWDC to a clinical model improved the prediction of high E/Ea and LVDD. Screening patients by means of baPWV and PWDC might help identify the high risk group of elevated left ventricular filling pressure and LVDD.