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.

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.

Female showed favorable left ventricle hypertrophy regression during post-TAVR follow-up.

Transcatheter aortic valve replacement (TAVR) is a well-established procedure using a catheter-introduced valve prosthesis for patients with severe aortic stenosis (AS). This retrospective study investigated sex-related differences in pre- and post-TAVR clinical and hemodynamic outcomes and analyzed data of the first 100 cases at Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH) between December 2013 and December 2021. Baseline characteristics, procedural outcomes, mortality rates, and echocardiographic parameters were analyzed and compared between sexes. Among the 100 patients, male (46%) and female (54%) were of similar age (mean age, male 86.0 years vs. female 84.5 years) and of the same severity of AS (mean pressure gradient, male 47.5 mmHg vs. female 45.7 mmHg) at the time receiving the TAVR procedure. Women had smaller aortic valve areas calculated by continuity equation (0.8 ± 0.3 cm2 vs. 0.7 ± 0.2 cm2, p < 0.001). In addition, women had better left ventricle ejection fraction (59.6 ± 14.0% vs. men 54.7 ± 17.2%, p < 0.01). In the post-TAVR follow-up, regression of left ventricle mass and dimension was better in women than in men. None of the patient died within 30 days after the procedure, and women tended to have a more favorable survival than men (2-year mortality and overall mortality rate in 8.3 year, women 9.1% and 22.2% vs. men 22.2% and 34.8%; p = 0.6385 and 0.1277, respectively). In conclusion, the sex-based difference in post-TAVR regression of LV remodeling suggests a need for sex-based evaluation for patients with severe AS and their post TAVR follow-up.

Circulating secreted frizzled-related protein 5 (Sfrp5) and wingless-type MMTV integration site family member 5a (Wnt5a) levels in patients with type 2 diabetes mellitus.

BACKGROUND: Secreted frizzled-related protein 5 (Sfrp5), an endogenous inhibitor of wingless-type MMTV integration site family (Wnt) signalling, is an anti-inflammatory adipokine whose expression is perturbed in models of obesity and type 2 diabetes mellitus (T2DM). Wnt member 5a (Wnt5a) is a representative ligand, and recent reports suggest that Wnt5a is involved in inflammatory diseases and metabolic disorders. The aim of this study was to investigate whether plasma Wnt5a and Sfrp5 levels are altered in patients with T2DM. METHODS: Plasma Sfrp5 and Wnt5a concentrations were measured through enzyme-linked immunosorbent assay in type 2 diabetic and nondiabetic subjects. RESULTS: A total of 82 patients with T2DM and 42 nondiabetic subjects were studied. Plasma Sfrp5 levels were found to be elevated in patients with T2DM (9.4 ± 9.0 vs 7.4 ± 10.9 ng/mL, p = 0.006). In contrast, Wnt5a levels were decreased (6.8 ± 12.6 vs 9.1 ± 4.0 ng/dL, p < 0.001). Increasing concentrations of Sfrp5 were independently and significantly associated with T2DM. Multiple logistic regression analysis revealed Sfrp5 as an independent association factor for T2DM, even after full adjustment of known biomarkers. In a multiple linear regression analysis, only the fasting glucose level was positively associated with the plasma Sfrp5 level. CONCLUSIONS: Our results indicate that Sfrp5 may play a role in the pathogenesis of T2DM.

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.

Levels of indoxyl sulfate are associated with severity of coronary atherosclerosis.

PURPOSE: Indoxyl sulfate (IS) is linked to endothelial damage, NF-κB activation and induced development of atherosclerosis. The purpose of this study was to investigate the relationship between serum IS levels and the severity of coronary artery stenosis. In addition, the relationship among IS and various cardiovascular risk factors was also explored. METHODS: Serum IS concentrations were measured using ultra performance liquid chromatography in 191 consecutive patients presenting with stable angina. The associations between serum IS levels and angiographic indexes of the number of diseased vessels, modified Gensini scores and calcium scores were determined. RESULTS: Patients with significant coronary artery stenosis were found to have higher serum IS levels than patients with normal coronary arteries. Using multivariate analysis, serum IS levels were found to be independently associated with the presence and severity of coronary artery disease (CAD). Furthermore, statistically significant correlation was observed between the serum IS levels and age, Agatston calcium score, volume calcium score, modified Gensini score, coronary lesions, coronary disease and Framingham-10 year risk score. CONCLUSION: This study indicates that serum IS levels are significantly higher in the presence of CAD and correlate with the severity of the disease and coronary atherosclerosis scores, which suggest that increased serum IS may be involved in the pathogenesis of coronary atherosclerosis.

Interpretation of elevated plasma visfatin concentrations in patients with ST-elevation myocardial infarction.

Visfatin is a cytokine that is expressed in many tissues, including the heart, and has been proposed to play a role in plaque destabilization leading to acute myocardial injury. The present study evaluates plasma levels of visfatin in acute ST-elevation myocardial infarction (STEMI) patients and examines the temporal changes in visfatin levels from the acute period to the subacute period to determine a correlation with the degree of myocardial ischemia. We evaluated 54 patients with STEMI. Circulating levels of visfatin and brain natriuretic peptide (BNP) were measured by ELISA. In addition, local expression of visfatin and BNP were detected by quantitative real-time polymerase chain reaction and immunohistochemical (IHC) analysis of left ventricular myocytes in a mouse model of myocardial infarction (MI). Plasma levels of visfatin were significantly increased in patients with STEMI on admission, relative to controls (effort angina patients and individuals without coronary artery disease). The visfatin levels reached a peak 24h after percutaneous coronary intervention (PCI) and then decreased toward the control range during the first week after PCI. The basal plasma visfatin levels were found to correlate with peak troponin-I, peak creatine kinase-MB, total white blood cell count, and BNP levels. Trend analyses confirmed that visfatin levels correlated with the number of diseased coronary arteries. Further, in MI mice, mRNA levels of visfatin and BNP were found to be higher than in sham-treated mice. IHC analysis showed that visfatin and BNP immunoreactivity was diffusely observable in left ventricular myocytes of the MI mice. This study indicates that plasma visfatin levels are significantly higher in STEMI patients and that these higher visfatin levels correlate with elevated levels of cardiac enzymes, suggesting that increased plasma visfatin may be closely related to the degree of myocardial damage.

Increased expression of visfatin in monocytes and macrophages in male acute myocardial infarction patients.

We demonstrated that visfatin expressed in monocytes and neutrophils and increased their reactivity in male acute ST-segment elevation myocardial infarction patients. Furthermore, visfatin was strongly appeared in lipid rich coronary rupture plaques and macrophages. These results suggest another explanation about leukocytes mediated visfatin that may play a pathogenesis role in coronary vulnerable plaques rupture.

Usefulness of Estimated Pulse Wave Velocity in Prediction of Cardiovascular Mortality in Patients With Acute Myocardial Infarction.

BACKGROUND: Pulse wave velocity (PWV) is an excellent index of arterial stiffness and can be used to predict long-term cardiovascular (CV) outcome. In recent years, estimated PWV (ePWV), calculated by equations using age and mean blood pressure, was also reported to be a significant predictor of CV outcomes. However, there was no literature discussing about usefulness of ePWV in patients of acute myocardial infarction (AMI) for prediction of long-term CV and overall mortality. Therefore, we conducted this study for further evaluation. METHODS: A total of 187 patients with AMI admitted to cardiac care unit were enrolled. ePWV were calculated by the equations for each patient. RESULTS: The median follow-up to mortality was 73 months (25th-75th percentile: 8-174 months). There were 35 and 125 patients documented as CV and overall mortality, respectively. Under univariable analysis, ePWV could independently predict long-term CV and overall mortality. However, after multivariable analysis, ePWV could only predict long-term CV mortality in AMI patients. CONCLUSIONS: To the best of our knowledge, our study was the first to evaluate the usefulness of ePWV in AMI patients for prediction of long-term CV and overall mortality. Our study showed ePWV was not only easy to calculate by formula, but also an independent predictor for long-term CV mortality in univariable and multivariable analyses. Therefore, ePWV was a simple and useful tool to measure arterial stiffness and to predict CV mortality outcome in AMI patients without the necessity for equipment to measure PWV.

Comparison between estimated and brachial-ankle pulse wave velocity for cardiovascular and overall mortality prediction.

Pulse wave velocity (PWV) was a good marker of arterial stiffness and could predict cardiovascular (CV) outcomes. Recently, estimated PWV (ePWV) calculated by equations using age and mean blood pressure was reported to be an independent predictor of major CV events. However, there was no study comparing ePWV with brachial-ankle PWV (baPWV) for CV and overall mortality prediction. We included 881 patients arranged for echocardiographic examination. BaPWV and blood pressures were measured by ankle-brachial index-form device. The median follow-up period to mortality was 94 months. Mortality events were documented during the follow-up period, including CV mortality (n = 66) and overall mortality (n = 184). Both of ePWV and baPWV were associated with increased CV and overall mortality after the multivariable analysis. ePWV had better predictive value than Framingham risk score (FRS) for CV and overall mortality prediction, but baPWV did not. In direct comparison of multivariable analysis using FRS as basic model, ePWV had a superior additive predictive value for CV mortality than baPWV (p = .030), but similar predictive valve for overall mortality as baPWV (p = .540). In conclusion, both ePWV and baPWV were independent predictors for long-term CV and overall mortality in univariable and multivariable analysis. Besides, ePWV had a better additive predictive value for CV mortality than baPWV and similar predictive value for overall mortality as baPWV. Therefore, ePWV obtained without equipment deserved to be calculated for overall mortality prediction and better CV survival prediction.

Circulating adiponectin level is associated with major adverse cardiovascular events in type 2 diabetic patients with coronary artery disease.

Elevated levels of circulating adiponectin (ADPN), an anti- inflammatory and anti-oxidative peptide, are associated with unfavorable cardiovascular outcomes in patients with cardiovascular diseases. The aim of this study was to investigate whether plasma ADPN levels could help predict major adverse cardiovascular events (MACE) in patients with documented coronary artery disease (CAD). We prospectively enrolled 193 CAD patients, who underwent percutaneous coronary intervention (PCI), and/or stenting and coronary artery bypass graft (CABG) surgery. ELISA was used to measure plasma ADPN concentrations. MACE--myocardial infarction, PCI, CABG, stroke, carotid revascularization, and death--was evaluated during a follow-up period of median 15.3 months (range 5-21 months). Cox regression analysis revealed that diabetes status, waist circumference, and plasma ADPN levels were significantly associated with MACE occurrence. On stratification according to diabetes status, plasma ADPN levels helped predict MACE only in patients with type 2 diabetes mellitus (T2DM). Kaplan-Meier analysis revealed higher MACE rates in diabetic patients with high-plasma ADPN levels than in those with low-plasma ADPN levels. High ADPN plasma concentrations can independently be associated with MACE in CAD with T2DM but not in those without diabetes. This indicates that plasma ADPN may have potential roles in high risk T2DM patients with ischemic heart disease.

Usefulness of ankle-brachial index calculated using diastolic blood pressure for prediction of mortality in patients with acute myocardial infarction.

A low ankle-brachial index (ABI) calculated using systolic blood pressure (SBP) (ABIsbp) is associated with poor cardiovascular outcome in patients with acute myocardial infarction (AMI). ABI is always calculated using SBP clinically. However, there was no study investigating ABI calculated using mean artery pressure (MAP)(ABImap) and diastolic blood pressure (DBP)(ABIdbp) for mortality prediction in AMI patients. Therefore, our study was aimed to investigate the issue. 199 AMI patients were enrolled. Different ABIs were measured by an ABI-form device. The median follow-up to mortality was 64 months. There were 40 cardiovascular and 137 all-cause mortality. The best cutoff values of ABImbp and ABIdbp for mortality prediction were 0.91 and 0.78, respectively. After multivariate analysis, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular mortality (P ≤ .047). However, all of six ABI parameters, including ABIsbp, ABImap, ABIdbp, ABIsbp < 0.90, ABImap < 0.91, and ABIdbp < 0.78, could predict all-cause mortality (P ≤ .048). In a direct comparison of six ABI models for prediction of all-cause mortality, basic model + ABIdbp <0.78 had the highest predictive value (P ≤ .025). In conclusion, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular and all-cause mortality after multivariate analysis in our study. Furthermore, when adding into a basic model, ABIdbp < 0.78 had the highest additively predictive value for all-cause mortality in the six ABI parameters. Hence, calculation of ABI using DBP except SBP might provide an extra benefit in prediction of cardiovascular and all-cause mortality in AMI patients.

Increased epicardial adipose tissue (EAT) volume in type 2 diabetes mellitus and association with metabolic syndrome and severity of coronary atherosclerosis.

OBJECTIVE: Epicardial adipose tissue (EAT) is a part of visceral fat deposited around the heart between the pericardium and myocardium along the distribution of coronary arteries. EAT thickness is reported to be associated with coronary atherosclerosis; however, no study has measured EAT volume in patients with type 2 diabetes or investigate its association with coronary artery disease. DESIGN: A hospital-based case control study. PATIENTS: A total of 49 patients with type 2 diabetes mellitus (T2DM) and 78 nondiabetic controls were studied. MEASUREMENTS: Cardiac multislice computed tomography was used to measure EAT volume, Gensini score, coronary artery calcium score and, coronary lesions. The relationships between EAT volume, markers of coronary atherosclerosis and anthropometric and biochemical parameters of metabolic syndrome (MetS) were investigated. RESULTS: EAT volume was significantly higher in patients with T2DM than in nondiabetic subjects (166.1 +/- 60.6 cm(3) vs. 123.4 +/- 41.8 cm(3), P < 0.0001). Logistic regression analysis revealed independent and significant associations between EAT and diabetic status. EAT volume was significantly associated with components of MetS (BMI, waist circumference, fasting serum glucose, total cholesterol, HDL-cholesterol, and triglycerides levels), Gensini score, coronary lesions, coronary disease and coronary calcium scores. Univariate, multivariate and trend analyses confirmed that EAT volume was associated with MetS component clustering and the coronary atherosclerosis index. CONCLUSIONS: The analytical results indicate that EAT volume is increased in T2DM patients and is associated with unfavourable components of MetS and coronary atherosclerosis. The close anatomical relationship between EAT and the coronary arteries, combined with other evidence indicating that EAT is a biologically active adipokine-secreting tissue, suggest that EAT participates in the pathogenesis of diabetic coronary atherosclerosis.

Brachial-ankle pulse wave velocity as an early indicator of left ventricular diastolic function among hypertensive subjects.

While increased arterial stiffness is a known risk of cardiovascular disease, pulse wave velocity (PWV) is a conventionally adopted index of arterial stiffness. However, the relationship between PWV and left ventricular functions are not thoroughly evaluated. This cross-sectional study investigated whether PWV measurement is an early indicator of left ventricular (LV) dysfunction. A noninvasive, volume-plethysmographic apparatus was used to determine blood pressure, electrocardiogram, heart sounds, and PWV in 42 consecutively diagnosed subjects with hypertension, and 42 sex- and age-matched nonhypertension subjects were studied. Arterial stiffness and aortic stiffness were evaluated by brachial-ankle (b-a) PWV, heart-carotid (h-c) PWV, heart-femoral (h-f) PWV, carotid-femoral (c-f) PWV, and femoral-ankle (f-a) PWV. Function of LV was estimated by tissue Doppler imaging (TDI) echocardiography. Hypertension subjects exhibited higher b-a PWV and late diastolic mitral flow velocity values than those of nonhypertensive subjects. Pearson correlation analysis revealed that LV diastolic function (Em(av)) negatively correlated with c-f PWV and b-a PWV. Multiple linear regression analysis indicated that b-a PWV was independently and negatively associated with LV diastolic function (Em(av)). Further analysis by stratified hypertensive status, the b-a PWV were independently and negatively associated with Em(av) in hypertensive subjects (p = 0.004) only. In conclusion, the b-a PWV, but not c-f PWV, h-c PWV, h-f PWV, or f-a PWV, is significantly correlated with LV diastolic function in hypertensive subjects, indicating that b-a PWV involving both central and peripheral components of arterial stiffness may be an early indicator of LV dysfunction.

Elevated visfatin/pre-B-cell colony-enhancing factor plasma concentration in ischemic stroke.

BACKGROUND: Visfatin/pre-B-cell colony-enhancing factor is a cytokine that is expressed as a protein in several tissues (e.g., liver, skeletal muscle, immune cells), including adipose tissue, and is reported to stimulate inflammatory cytokine expressions and promote vascular smooth cell maturation. Visfatin may act as a proinflammatory cytokine and be involved in the process of atherosclerosis. In this study, we investigated whether plasma visfatin levels were altered in patients with ischemic stroke. METHODS: Plasma visfatin concentrations were measured through enzyme immunoassays in patients with ischemic stroke and in control subjects without stroke. RESULTS: The mean plasma concentration of visfatin in the 120 patients with ischemic stroke was significantly higher than that of the 120 control subjects without stroke (51.5 +/- 48.4 v 23.0 +/- 23.9 ng/mL, P < .001). Multiple logistic regression analysis confirmed plasma visfatin to be an independent factor associated with ischemic stroke. Increasing concentrations of visfatin were independently and significantly associated with a higher risk of ischemic stroke when concentrations were analyzed as both a quartile and a continuous variable. The multiple logistic regression analysis-adjusted odds ratios and 95% confidence intervals for ischemic stroke in the second, third, and fourth quartiles were 2.3 (0.7-7.7), 6.9 (2.2-23.3), and 20.1 (4.9-97.7), respectively. Plasma visfatin concentration was positively associated with high-sensitivity C-reactive protein levels and negatively associated with low-density lipoprotein cholesterol. CONCLUSIONS: Our results indicate that higher visfatin levels are associated with ischemic stroke in the Chinese population.

Ping-Pong Guide Catheters to Facilitate Real-Time Intravascular Ultrasound-Guided Recanalization of Stumpless Chronic Total Occlusion.

Stumpless chronic total occlusion is associated with a higher failure rate of recanalization. Intravascular ultrasound (IVUS) is useful for identifying the entry point; however, 8-F guide catheters are necessary for real-time IVUS-guided wiring. This case reports the novel use of the "ping-pong" guide catheter technique to facilitate real-time IVUS-guided wiring for a stumpless chronic total occlusion. (Level of Difficulty: Advanced.).

Association of Increased Epicardial Adipose Tissue Thickness With Adverse Cardiovascular Outcomes in Patients With Atrial Fibrillation.

The thickness of epicardial adipose tissue (EAT) was reported to be highly associated with the incidence and severity of atrial fibrillation (AF). This study was conducted to analyze the ability of EAT thickness in predicting adverse cardiovascular (CV) events in AF. In 190 persistent AF patients, we performed a comprehensive transthoracic echocardiographic examination with assessment of EAT thickness. The definition of CV events included CV mortality, hospitalization for heart failure, myocardial infarction, and stroke. There were 69 CV events including 19 CV deaths, 32 hospitalizations for heart failure, 3 myocardial infarctions, and 15 strokes during a mean follow-up of 29 (25th-75th percentile: 17-36) months. The multivariable analysis demonstrates that chronic heart failure, increased left ventricular (LV) mass index and the ratio of transmitral E-wave velocity to early diastolic mitral annulus velocity, decreased body mass index, and increased EAT thickness (per 1-mm increase, odds ratio 1.224, 95% confidence interval [CI] 1.096-1.368, P < 0.001) were associated with adverse CV events. Additionally, the addition of EAT thickness to a model containing CHA2DS2-VASc score, left atrial volume index, and LV systolic and diastolic function significantly improved the values in predicting CV events (global χ increase 14.65, P < 0.001 and integrated discrimination improvement 0.10, 95% CI 0.04-0.16, P < 0.001). In AF, EAT thickness was useful in predicting adverse CV events. Additionally, EAT thickness could provide incremental value for CV outcome prediction over traditional clinical and echocardiographic parameters in AF.

CHADS2 Score and Risk of New-onset Peripheral Arterial Occlusive Disease in Patients without Atrial Fibrillation: A Nationwide Cohort Study in Taiwan.

AIM: Although our recent cross-sectional study demonstrated that the CHADS2 score is associated with an ankle-brachial index of ＜ 0.9 in patients without atrial fibrillation (AF), the true cause-effect relationship between these parameters remains to be evaluated. Hence, the aim of this study was to investigate whether the CHADS2 score is a useful predictor of new-onset PAOD in non-AF patients. METHODS: From January 1, 2000 to December 31, 2001, a total of 723,750 patients older than 18 years of age with no past history of PAOD, rheumatic heart disease or AF were surveyed from the "National Health Insurance Research Database." The CHADS2 score was calculated for each patient. Finally, 581,997 (score 0), 84,971 (score 1), 31,473 (score 2), 14,432 (score 3), 8,156 (score 4), 2,430 (score 5) and 291 (score 6) patients were studied and followed for the onset of PAOD. We further divided the study patients into four groups: group 1 (score 0), group 2 (score 1-2), group 3 (score 3-4) and group 4 (score 5-6). RESULTS: During the follow-up period of 9.83 ± 0.01 years, 24,775 (3.4%) patients experienced new-onset PAOD. The overall incidence of PAOD was 0.6 per 1,000 patient-years. The rate of PAOD increased from 1.8% (group 1) to 18.7% (group 4) (p ＜ 0.001). According to a multivariate analysis, groups 2-4 were significantly associated with new-onset PAOD (all p ＜ 0.001). In addition, the hazard ratio of each two-point increment in the CHADS2 score for predicting PAOD was 2.51 (p ＜ 0.001). CONCLUSIONS: The CHADS2 score is a useful predictor of new-onset PAOD in non-AF patients.

Myocardial performance index derived from pre-ejection period as a novel and useful predictor of cardiovascular events in atrial fibrillation.

PURPOSE: The pre-ejection period-derived myocardial performance index measured from tissue Doppler echocardiography (PEPa-derived MPI) was reported to be associated with left ventricular systolic and diastolic function in atrial fibrillation (AF). However, its relationship with cardiovascular outcomes in AF has never been evaluated. This study sought to examine the ability of PEPa-derived MPI in predicting adverse cardiovascular events in AF patients. METHODS: In 196 persistent AF patients, we performed comprehensive echocardiography with measurement of PEPa-derived MPI using index beat method. The index beat was defined as the beat following the nearly equal preceding (RR1) and pre-preceding (RR2) intervals. The cycle length of index beat and RR1 and RR2 must be >500ms and the difference between RR1 and RR2 must be <60ms. Cardiovascular events were defined as cardiovascular death, nonfatal stroke, and hospitalization for heart failure. RESULTS: In the multivariate analysis, chronic heart failure and increased ratio of transmitral E-wave velocity to early diastolic mitral annulus velocity (E/Ea) and PEPa-derived MPI (per 0.1 increase, hazard ratio, 1.104; 95% confidence interval, 1.032-1.182, p=0.004) were associated with increased cardiovascular events. The addition of PEPa-derived MPI to a Cox model containing chronic heart failure, systolic blood pressure, age, diabetes, prior stroke, left ventricular ejection fraction, and E/Ea provided an additional benefit in prediction of adverse cardiovascular events (p=0.015). CONCLUSIONS: In AF patients, the PEPa-derived MPI was a useful predictor of adverse cardiovascular events and could offer an additional prognostic benefit over conventional clinical and echocardiographic parameters.