Patient Characteristics, Procedural Details, and Outcomes of Contemporary Percutaneous Coronary Intervention in Real-World Practice: Insights from Nationwide Thai PCI Registry.

Background: Percutaneous coronary intervention (PCI) practice and outcomes vary substantially in different parts of the world. The contemporary data of PCI in Asia are limited and only available from developed Asian countries. Objectives: To explore the pattern of practice and results of PCI procedures in Thailand as well as a temporal change of PCI practice over time compared with the registry from other countries. Methods: Thai PCI Registry is a prospective nationwide registry that was an initiative of the Cardiac Intervention Association of Thailand (CIAT). All cardiac catheterization laboratories in Thailand were invited to participate during 2018-2019, and consecutive PCI patients were enrolled and followed up for 1 year. Patient baseline characteristics, procedural details, equipment and medication use, outcomes, and complications were recorded. Results: Among the 39 hospitals participated, there were 22,741 patients included in this registry. Their mean age (standard deviation) was 64.2 (11.7) years and about 70% were males. The most common presentation was acute coronary syndrome (57%) with a high proportion of ST-elevation myocardial infarction (28%). Nearly two-thirds of patients had multivessel disease and significant left main stenosis was reported in 11%. The transradial approach was used in 44.2%. The procedural success rate was very high (95.2%) despite the high complexity of the lesions (56.9% type C lesion). The incidence of procedural complications was 5.3% and in-hospital mortality was 2.8%. Conclusion: Thai PCI Registry provides further insights into the current practice and outcomes of PCI in Southeast Asia. The success rate was very high, and the complications were very low despite the high complexity of the treated lesions.

Optimal INR level in elderly and non-elderly patients with atrial fibrillation receiving warfarin: a report from the COOL-AF nationwide registry in Thailand.

BACKGROUND: Asian population are at increased risk of bleeding during the warfarin treatment, so the recommended optimal international normalized ratio (INR) level may be lower in Asians than in Westerners. The aim of this prospective multicenter study was to determine the optimal INR level in Thai patients with non-valvular atrial fibrillation (NVAF). METHODS: Patients with NVAF who were on warfarin for stroke prevention were recruited from 27 hospitals in the nationwide COOL-AF registry in Thailand. We collected demographic data, medical history, risk factors for stroke and bleeding, concomitant disease, electrocardiogram and laboratory data including INR and antithrombotic medications. Outcome measurements included ischemic stroke/transient ischemic attack (TIA) and major bleeding. Optimal INR level was assessed by the calculation of incidence density for six INR ranges (< 1.5, 1.5-1.99, 2-2.49, 2.5-2.99, 3-3.49, and ≥ 3.5). RESULTS: A total of 2, 232 patients were included. The mean age of patients was 68.5 ± 10.6 years. The mean follow-up duration was 25.7 ± 10.6 months. There were 63 ischemic stroke/TIA and 112 major bleeding events. The lowest prevalence of ischemic stroke/TIA and major bleeding events occurred within the INR range of 2.0-2.99 for patients < 70 years and 1.5-2.99 for patients ≥ 70 years. CONCLUSIONS: The INR range associated with the lowest risk of ischemic stroke/TIA and bleeding in the Thai population was 2.0-2.99 for patients < 70 years and 1.5-2.99 for patients ≥ 70 years. The rates of major bleeding and ischemic stroke/TIA were both higher than the rates reported in Western population.

Adherence to Anticoagulant Guideline for Atrial Fibrillation Improves Outcomes in Asian Population: The COOL-AF Registry.

Background and Purpose- Guideline adherent oral anticoagulant (OAC) management of patients with nonvalvular atrial fibrillation has been associated with improved outcomes, but limited data are available from Asia. We aimed to investigate outcomes in patients who received guideline compliant management compared with those who were OAC undertreated or overtreated, in a large nationwide multicenter cohort of patients with nonvalvular atrial fibrillation in Thailand. Methods- Patients with nonvalvular atrial fibrillation were prospectively enrolled from 27 hospitals-all of which are data contributors to the COOL-AF Registry (Cohort of Antithrombotic Use and Optimal INR Level in Patients With Non-Valvular Atrial Fibrillation in Thailand). Patients were categorized as follows: (1) guideline adherence group when OAC was given in high-risk or intermediate-risk, but not in low-risk patients; (2) undertreatment group when OAC was not given in the high-risk or intermediate-risk groups; and (3) overtreatment group when OAC was given in the low-risk group or when OAC was given in combination with antiplatelets without indication. Results- A total of 3327 patients who had follow-up clinical outcome data were included. The mean age of patients was 67.4 years and 58.1% were male. The numbers of patients in the guideline adherence group, undertreatment group, and overtreatment group were 2267 (68.1%), 624 (18.8%), and 436 (13.1%) patients, respectively. The overall rate of ischemic stroke, major bleeding, all bleeding, and death was 3.0%, 4.4%, 15.1%, and 7.8%, respectively. Undertreated patients had a higher risk of ischemic stroke and death compared with guideline adherent patients, and overtreated patients had a higher risk of bleeding and death compared with OAC guideline-managed patients. Conclusions- Adherence to OAC management guidelines is associated with improved clinical outcomes in Asian nonvalvular atrial fibrillation patients. Undertreatment or overtreatment was found to be associated with increased risk of adverse outcomes compared with guideline-adherent management.

History of major bleeding predicts risk of clinical outcome of patients with atrial fibrillation: results from the COOL-AF registry.

OBJECTIVE: To compare clinical outcomes between patients with and without history of major bleeding according to types of antithrombotic medications in patients with non-valvular atrial fibrillation (NVAF). METHODS: We conducted a multicenter registry of patients with NVAF during 2014 to 2017 in Thailand. The following data were collected: demographic data, type of NVAF, medical illness, components of CHA2DS2-VASc and HAS-BLED scores, history of bleeding and severity, investigations, and antithrombotic medications. Clinical outcomes were death, bleeding, and ischemic stroke/transient ischemic attack (TIA). RESULTS: There were a total of 3218 patients. The average age was 67.3 ± 11.3 years, and 58.3% were men. Sixty-nine patients (2.14%) had a history of major bleeding. Antithrombotic use was, as follows: 2126 patients (75.3%) received oral anticoagulant (OAC) alone, 555 (17.2%) received antiplatelet alone, 298 (9.3%) received both, and 239 (7.4%) received neither. During follow-up, 9.9% had major adverse outcomes, including death (5.9%), ischemic stroke/TIA (2.5%), and major bleeding (4.0%). There were no significant differences in the types of antithrombotic medications between patients with and without history of major bleeding. Multivariate analysis revealed old age, low body mass index, hypertension, diabetes, heart failure, and history of major bleeding to be independently associated with major adverse outcome. Adverse events significantly increased in patients with OAC plus antiplatelet. CONCLUSIONS: History of major bleeding was identified as a factor that significantly affects clinical outcome. Inappropriate use of OAC plus antiplatelet should be avoided. Special caution should be made in this high-risk patients.

Ten-year survival and factors associated with increased mortality in patients admitted for acute decompensated heart failure in Thailand.

INTRODUCTION: Data on the long-term outcomes of Asian patients admitted for acute decompensated heart failure is scarce. The objectives of this study were to determine short-term, intermediate-term and long-term survival among patients admitted for acute decompensated heart failure in Thailand, and to identify factors independently associated with increased mortality. METHODS: Patients who were admitted with a primary diagnosis of heart failure were enrolled in the Thai Acute Decompensated Heart Failure Registry (ADHERE) from 18 hospitals located across Thailand during 2006. Medical record data was collected according to ADHERE protocol. Mortality data was collected from death certificates on file at the Thailand Bureau of Registration Administration. RESULTS: A total of 1,451 patients were included. The mean age of the patients was 63.7 ± 14.4 years, and 49.7% were male. One-year, five-year and ten-year mortality rates in Thai patients admitted for acute decompensated heart failure were 28.0%, 58.2% and 73.3%, respectively. Independent predictors of increased mortality were identified. There were more cardiovascular-related deaths than non-cardiovascular-related deaths (54.6% vs. 45.4%, respectively). CONCLUSIONS: The ten-year mortality rate in Thai patients admitted for acute decompensated heart failure was 73.3%. Many factors were found to be independently associated with increased mortality, including left ventricular ejection fraction.

Risk profiles and pattern of antithrombotic use in patients with non-valvular atrial fibrillation in Thailand: a multicenter study.

BACKGROUND: Anticoagulation therapy is a standard treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) that have risk factors for stroke. However, anticoagulant increases the risk of bleeding, especially in Asians. We aimed to investigate the risk profiles and pattern of antithrombotic use in patients with NVAF in Thailand, and to study the reasons for not using warfarin in this patient population. METHODS: A nationwide multicenter registry of patients with NVAF was created that included data from 24 hospitals located across Thailand. Demographic data, atrial fibrillation-related data, comorbid conditions, use of antithrombotic drugs, and reasons for not using warfarin were collected. Data were recorded in a case record form and then transferred into a web-based system. RESULTS: A total of 3218 patients were included. Average age was 67.3 ± 11.3 years, and 58.2% were male. Average CHADS2, CHA2DS2-VASc, and HAS-BLED score was 1.8 ± 1.3, 3.0 ± 1.7, and 1.5 ± 1.0, respectively. Antiplatelet was used in 26.5% of patients, whereas anticoagulant was used in 75.3%. The main reasons for not using warfarin in those with CHA2DS2-VASc ≥2 included already taking antiplatelet (26.6%), patient preference (23.1%), and using non-vitamin K antagonist oral anticoagulants (NOACs) (22.7%). Anticoagulant was used in 32.3% of CHA2DS2-VASc 0, 56.8% of CHA2DS2-VASc 1, and 81.6% of CHA2DS2-VASc ≥2. The use of NOACs increased from 1.9% in 2014 to 25.6% in 2017. CONCLUSIONS: Anticoagulation therapy was prescribed in 75.3% of patients with NVAF. Among those receiving anticoagulant, 90.9% used warfarin and 9.1% used NOACs. The use of NOACs increased over time.

Management of atherosclerosis risk factors for patients at high cardiovascular risk in real-world practice: a multicentre study.

INTRODUCTION: Atherosclerotic cardiovascular disease is a global health burden. However, there are heterogeneities among countries or regions in the risk factors and clinical manifestations of atherosclerotic diseases as well as management patterns. METHODS: We collected data from 25 centres in Thailand. Patients with documented coronary artery disease, cerebrovascular disease or peripheral arterial disease, or with at least three atherosclerosis risk factors were enrolled between April 2011 and March 2014. Data on demographics, atherosclerosis risk factors and the management pattern of risk factors, including laboratory findings, were recorded. RESULTS: In total, 9,390 patients, including 4,861 patients with established atherosclerotic disease and 4,529 patients with multiple risk factors, were enrolled. The modifiable risk factors, other than current smoking habit (5.3%), were common: hypertension (83.8%), dyslipidaemia (85.9%) and diabetes mellitus (57.4%). A majority of patients with hypertension (96.3%), dyslipidaemia (93.8%) and diabetes mellitus (78.5%) received medications for their conditions. Antiplatelet agents were given to 73.9% of patients. The undertreatment rate of cardiovascular risk factors, such as blood pressure, low-density lipoprotein cholesterol, haemoglobin A1c and smoking status, was 35.8%, 59.0%, 45.3% and 5.3%, respectively. CONCLUSION: Conventional atherosclerosis risk factors were common among Thai patients with established atherosclerotic disease. Even though most of the patients received recommended treatments according to established guidelines, a significant proportion of them were undertreated for atherosclerosis risk factors.

Demographics and Outcomes of Percutaneous Coronary Intervention in Thailand: Data from Thai Percutaneous Coronary Intervention Registry.

Background: Percutaneous coronary intervention (PCI) has been and continues to be standard treatment in patients with coronary artery disease. The data for demographic and outcomes in Thailand are limited. Objective: To study data and characteristics relating to patients, the procedure, and outcomes of percutaneous coronary intervention in the Thai population. Material and Method: The Thai Percutaneous Coronary Intervention Registry (TPCIR) was established in 2006, consisting of 27 hospitals in Thailand that perform the PCI procedure. All patients who underwent PCI between May 2006 and October 2006 in participating hospitals were asked to participate in this registry. Data was recorded in case record form and then entered into the web-based registry. Key variables include demographic data, risk factors, indications for PCI, outcomes, and complications. Results: Four thousand one hundred fifty six patients were enrolled; 69.2% were male. Average age of PCI patients was 62.7 years. Indications for PCI were ST segment elevation myocardial infarction (14%), Non-ST segment elevation acute coronary syndrome (37.3%), and stable coronary artery disease (48.7%). PCI was successfully performed in 92.5% of lesions or 89.6% of cases with in-hospital complications reported in 12% of cases. Conclusion: This was the first nationwide multi-center study of PCI in Thailand. The overall PCI procedure success rate was 92.5%.

Management and risk factor control of coronary artery disease in elderly versus nonelderly: a multicenter registry.

BACKGROUND: Coronary artery disease (CAD) is a leading cause of death in elderly because aging is the important non-modifiable risk factors of atherosclerosis and also a predictor of poor outcomes. Underuse of guideline directed therapy may contribute to suboptimal risk factor control and worse outcomes in the elderly. We aimed to explore the management of CAD, risk factors control as well as goal attainment in elderly compared to nonelderly CAD patients. METHODS: The CORE-Thailand is an ongoing multicenter, prospective, observational registry of patients with high atherosclerotic risk in Thailand. The data of 4120 CAD patients enrolled in this cohort was analyzed comparing between the elderly (age ≥ 65 years) vs. nonelderly (age < 65 years). RESULTS: There were 2172 elderly and 1948 nonelderly patients. The elderly CAD patients had higher prevalence of hypertension, dyslipidemia, atrial fibrillation and chronic kidney disease. The proportion of patients who received coronary revascularization was not different between the elderly and nonelderly CAD patients. Antiplatelets were prescribed less in the elderly while statin was prescribed in the similar proportion. Goal attainments of risk factor control of glycemic control, low density lipoprotein cholesterol, and smoking cessation except the blood pressure goal were higher in the elderly CAD patients. CONCLUSIONS: The CORE-Thailand registry showed the equity in the treatment of CAD between elderly and non-elderly. Elderly CAD patients had higher rate of goal attainment in risk factor control except blood pressure goal. The effects of goal attainment on cardiovascular outcomes will be demonstrated from ongoing cohort.

Predictors of in-hospital mortality in acute decompensated heart failure (Thai ADHERE).

BACKGROUND: Heart failure had emerged as a major public health problem and became the leading cause of hospitalization. The Acute Decompensated Heart Failure National Registry (ADHERE) of US patients hospitalized with a primary diagnosis of acute decompensated heart Failure (ADHF) had been reported worldwide for the risk stratification and predicting In-hospital mortality. OBJECTIVE: Identify clinical risk factors or treatment procedures that could predict In-hospital mortality in Thai patients with ADHF. MATERIAL AND METHOD: Thai ADHERE is a multicenter, observational, prospective study. The data were collected via web-based electronic data capture and analyzed. Two thousand forty one hospitalization episodes involving 1,671 patients in the 18 participating hospitals between March 2006 and September 2007 were analyzed. All clinical factors associated with In-hospital mortality identified by univariated analysis were further analyzed by Logistic regression model. RESULTS: One hundred thirteen patients died during the hospitalization period with overall mortality rate of 5.5%. Systolic blood pressure < 90 mmHg, creatinine > 2.0 mg/dL, history of stroke/TIA, and NYHA class IV were independent risk factors for In-hospital mortality with adjusted OR (95% CI) = 3.45 (1.77-6.79), 1.99 (1.30-3.05), 1.85 (1.11-3.08) and 1.69 (1.08-2.64) respectively. Hypertensive cause of CHF, prior use of lipid lowering drug, and hemoglobin level were associated with lower risk, adjusted OR (95% CI) = 0.35 (0.15-0.81), 0.51 (0.34-0.78) and 0.90 (0.82-0.98) respectively. CONCLUSION: The clinical predictors for In-hospital mortality of Thai ADHERE that associated with worse outcome were systolic blood pressure < 90 mmHg, creatinine > 2.0 mg/dL, history of stroke/TIA, and NYHA class IV. Hypertensive cause of CHF, prior use of lipid lowering drug, and hemoglobin were associated favorable outcome.

Thai Registry in Acute Coronary Syndrome (TRACS)--an extension of Thai Acute Coronary Syndrome registry (TACS) group: lower in-hospital but still high mortality at one-year.

BACKGROUND: The Thai Registry of Acute Coronary Syndrome (TRACS) registry was conducted five years after the first Thai Acute Coronary Syndrome (ACS) registry. OBJECTIVE: To describe demographics, management practices, and in-hospital outcomes of current Thai ACS patients and to seek for any significant changes in this registry from the earlier first Thai ACS registry. MATERIAL AND METHOD: The TRACS is a multi-centers, prospective, nation-wide registration with 39 participating medical centers. Web-based data entry was used and the data were centrally managed and analyzed. RESULTS: Between October 007 and December 2008, 2,007 patients were enrolled. Fifty-five percent had ST elevation myocardial infarction (STEMI), 33% had non-ST-elevation myocardial infarction (NSTEMI), and 12% had unstable angina (UA). Overall prevalence of diabetes was 50.7%. The STEMI group was younger predominantly male, with less diabetes than NSTEMI. At presentation, lower percent of cardiogenic shock (7.9%) and cardiac arrest (2.8%) were noted. Sixty seven percent of the STEMI received reperfusion therapy. Thrombolysis was given in 42.6% and primary percutaneous coronary intervention (PCI) was performed in 24.7% of all STEMl patients. Median door-to-needle and door-to-balloon time were 65 and 127 minutes. The median time-to-treatment was 285 min in the thrombolysis group and 324 min in the primary PCI group. Regarding NSTE-ACS, coronary angiography was performed in 38.4% and about one-fourth received revascularization either by PCI or bypass surgery during index admission. In-hospital mortality was 5.3% for STEMI, 5.1% for NSTEMI, and 1.7% for UA. When following the patients up to 12 months, the mortality was 14.1%, 25.0%, and 13.8% respectively. CONCLUSION: The TRACS registry showed differences in demographic, management practices and in-hospital outcomes of the Thai ACS patients. Although mortality rate in this registry decreased significantly as compared to the first Thai ACS registry, the results had to be interpreted with caution because of the difference in characteristics and severity of the enrolled patients. At 12-month follow-up, the mortality rate was significantly higher in NSTEMI than STEMI or UA patients. Practice management should be considered particularly for the invasive strategy for these groups of patients.