Analgesic and Anti-Inflammatory Effects of 1% Topical Cannabidiol Gel in Animal Models.

Introduction: Cannabidiol (CBD), a phytocannabinoid isolated from cannabis plants, is an interesting candidate for studying its anti-inflammatory effects, especially in the pre-clinical and animal models. Its anti-inflammatory effects, such as reduction of edema and arthritis, have been demonstrated in animal models. However, topical CBD administration requires further evaluation of CBD dosage and efficacy in animal models and clinical settings. Methods: This in vivo study investigated the anti-inflammatory effects of topical CBD administration in an animal model. Scientific experiments, including the formalin test, writhing test, carrageenan-induced edema, histopathological examination, and detection of various proinflammatory mediators, were performed. Results: The anti-inflammatory effects in vivo after inflammation induction, represented by decreased times of paw licking, degree of paw edema, and decreased writhing response, showed that 1% of tropical CBD use had significantly comparable or better anti-inflammatory effects when compared with tropical diclofenac, an anti-inflammatory agent. Moreover, the anti-inflammatory effects were significant compared with the placebo. In addition, the histopathological examination showed that topical CBD drastically reduced leukocyte infiltration and the degree of inflammation. This study also showed that the levels of various proinflammatory mediators in the plasma of mice treated with topical CBD did not differ from those treated with diclofenac. Conclusions: The topical administration of 1% CBD gel is a potentially effective candidate for an anti-inflammatory agent. Candidate for an anti-inflammatory agent.

Factors Predicting 150 and 200 Microgram Adenosine Requirement during Four Increasing Doses of Intracoronary Adenosine Bolus Fractional Flow Reserve Assessment.

Direct intracoronary adenosine bolus is an excellent alternative to intravenous adenosine fractional flow reserve (FFR) measurement. This study, during four increasing adenosine boluses (50, 100, 150, and 200 mcg), aimed to explore clinical and angiographic predictors of coronary stenotic lesions for which the significant ischemic FFR (FFR ≤ 0.8) occurred at 150 and 200 mcg adenosine doses. Data from 1055 coronary lesions that underwent FFR measurement at the Central Chest Institute of Thailand from August 2011 to July 2021 were included. Baseline clinical and angiographic characteristics were analyzed. The FFR ≤ 0.8 occurred at adenosine 150 and 200 mcg boluses in 47 coronary lesions, while the FFR ≤ 0.8 occurred at adenosine 50 and 100 mcg boluses in 186 coronary lesions. After univariable and multivariable logistic regression analyses, four characteristics, including male sex, younger age, non-smoking status, and FFR procedure of RCA, were predictors of the occurrence of FFR ≤ 0.8 at adenosine 150 and 200 mcg doses. Combining all four predictors as a predictive model resulted in an AuROC of 0.72 (95% CI: 0.68-0.76), an 86% negative predictive value. Comparing these four predictors, the FFR procedure of RCA gave the most predictive power, with the AuROC of 0.60 (95% CI: 0.56-0.63).

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.

Development of a Clinical Risk Score for Prediction of Life-Threatening Arrhythmia Events in Patients with ST Elevated Acute Coronary Syndrome after Primary Percutaneous Coronary Intervention.

ST-elevated acute coronary syndrome (STEACS) is a serious condition requiring timely treatment. Reperfusion with primary percutaneous coronary intervention (pPCI) is recommended and preferred over fibrinolysis. Despite its efficacy, lethal complications, such as life-threatening arrhythmia (LTA), are common in post-PCI patients. Although various risk assessment tools were developed, only a few focus on LTA prediction. This study aimed to develop a risk score to predict LTA events after pPCI. A risk score was developed using a retrospective cohort of consecutive patients with STEACS who underwent pPCI at Chiangrai Prachanukroh Hospital from January 2012 to December 2016. LTA is defined as the occurrence of malignant arrhythmia that requires advanced cardiovascular life support (ACLS) within 72 h after pPCI. Logistic regression was used for model derivation. Among 273 patients, 43 (15.8%) developed LTA events. Seven independent predictors were identified: female sex, hemoglobin < 12 gm/dL, pre- and intra-procedural events (i.e., respiratory failure and pulseless arrest), IABP insertion, intervention duration > 60 min, and desaturation after pPCI. The LTA score showed an AuROC of 0.93 (95%CI 0.90, 0.97). The score was categorized into three risk categories: low (<2.5), moderate (2.5-4), and high risk (>4) for LTA events. The LTA score demonstrated high predictive performance and potential clinical utility for predicting LTA events after pPCI.

Cost-Utility Analysis of Dapagliflozin as an Add-On to Standard Treatment for Patients with Type 2 Diabetes and High Risk of Cardiovascular Disease in Thailand.

INTRODUCTION: Diabetes treatment has incurred financial burden. We examined the cost-utility of adding dapagliflozin to the standard treatment for treating type 2 diabetes (T2DM) with cardiovascular risk in a Thai context. METHODS: A two-part model, decision tree and Markov models, was developed to capture the benefits in terms of heart failure (HF) and chronic kidney disease. The model was used to estimate the lifetime costs and outcomes from a societal perspective. Costs were based on local data while the transitional probabilities and utilities were derived from the DECLARE-TIMI 58 clinical trial and published studies. Future costs and outcomes were discounted at an annual rate of 3%. The results were reported as incremental cost-effectiveness ratios (ICER). One-way and probabilistic sensitivity analyses were performed to investigate parameter uncertainty. RESULTS: The increased cost of adding dapagliflozin from 8707 USD to 14,455 USD was associated with an increase in quality-adjusted life years (QALYs) from 9.28 to 9.58, yielding an ICER of 18,988 USD/QALY. Compared with the standard treatment, the dapagliflozin group acquired more clinical benefits in terms of fewer HF hospitalizations and macroalbuminuria. Sensitivity analyses revealed that with high prevalence of diabetic nephropathy of 29.4-43.9%, the ICER would decline to 5591-8014 USD/QALY. CONCLUSION: On the basis of the DECLARE study with low incidence of T2DM complications and 4.2 years of median follow-up duration, the add-on dapagliflozin results in an ICER of 18,988 USD/QALY, which exceeds the local threshold of 5310 USD/QALY. Dapagliflozin would show better value for money in the context of high prevalence of T2DM complications.

Clinical Predictors Influencing the Length of Stay in Emergency Department Patients Presenting with Acute Heart Failure.

Background and objectives: Acute heart failure is a common problem encountered in the emergency department (ED). More than 80% of the patients with the condition subsequently require lengthy and repeated hospitalization. In a setting with limited in-patient capacity, the patient flow is often obstructed. Appropriate disposition decisions must be made by emergency physicians to deliver effective care and alleviate ED overcrowding. This study aimed to explore clinical predictors influencing the length of stay (LOS) in patients with acute heart failure who present to the ED. Materials and Methods: We conducted prognostic factor research with a retrospective cohort design. Medical records of patients with acute heart failure who presented to the ED of Ramathibodi Hospital from January to December 2015 were assessed for eligibility. Thirteen potential clinical predictors were selected as candidates for statistical modeling based on previous reports. Multivariable Poisson regression was used to estimate the difference in LOS between patients with and without potential predictors. Results: A total of 207 patients were included in the analysis. Most patients were male with a mean age of 74.2 ± 12.5 years. The median LOS was 54.6 h (Interquartile range 17.5, 149.3 h). From the multivariable analysis, four clinical characteristics were identified as independent predictors with an increase in LOS. These were patients with New York Heart Association (NYHA) functional class III/IV (+72.9 h, 95%Confidence interval (CI) 23.9, 121.8, p = 0.004), respiratory rate >24 per minute (+80.7 h, 95%CI 28.0, 133.3, p = 0.003), hemoglobin level <10 mg/dL (+60.4 h, 95%CI 8.6, 112.3, p = 0.022), and serum albumin <3.5 g/dL (+52.8 h, 95%CI 3.6, 102.0, p = 0.035). Conclusions: Poor NYHA functional class, tachypnea, anemia, and hypoalbuminemia are significant clinical predictors of patients with acute heart failure who required longer LOS.

Comparison on the efficacy and the safety of transradial approach versus conventional transfemoral approach for cardiac catheterization procedures.

OBJECTIVE: To compare the efficacy and safety of transradial approach (TR) and conventional transfemoral approach (TF) for cardiac catheterization procedures. MATERIAL AND METHOD: The data were collected retrospectively of all patients that received cardiac catheterization at Thammasat University Cardiac Center between September 1, 2010 and August 31, 2011 (the first year ofTR approach). RESULTS: Cardiac catheterization was performed on 597 patients. TR approach was performed about one-sixth of all procedures compared to conventional TF approach, 93 (15.58%) vs. 504 (84.42%). Safety of TR approach at the beginning was similar to conventional TF approach including in-hospital complication rate 5.4% vs. 4.6%, p = 0.788, volume of contrast media used 90.63±66.83 vs. 97.89±64.52 milliliters, p = 0.323, radiation exposure defined as median/min-max estimate skin entrance radiation dose 833.35/133.15-8,913.42 vs. 910.00/76.78-13,719.88 mGy, p = 0.599, and dose-area product 63.03/7.87-494.52 vs. 70.85/5.77-829.16 Gy x cm2, p = 0.586. The efficacy defined as procedural success rate was significantly higher in the conventional TF approach 90.3% vs. 97.8%, p = 0.001, as well as the procedural time that showed insignificantly longer 54.03±39.40 vs. 47.37?39.86 minutes, p = 0.139. This statistical diference in the procedural success rate was clear only in the first 62 TR. After this learning curve period, the procedural success rate was similar 96.8% vs. 97.6%, p = 0.575. Both the procedural success rate and the procedural time in TR approach showed trend to achieve better outcomes according to the increasing number of TRprocedures; 87.1% vs. 87.1% vs. 96.8%, p = 0.331 and 64.68±51.90 vs. 52.45±31.94 vs. 44.97±29.04 minutes, p = 0.139 in the first 31 vs. the 32nd to the 62nd, and the 63rd to the 93" cases respectively. CONCLUSION: The safety of the transradial approach for cardiac catheterization procedures was similar to conventional transfemoral approach. The learning curve period was needed but its length is acceptable before the same efficacy rate as the conventional transfemoral procedure was achieved.

Urinary Neutrophil Gelatinase-Associated Lipocalin predicts the severity of contrast-induced acute kidney injury in chronic kidney disease patients undergoing elective coronary procedures.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) particularly in high risk patients with chronic kidney disease (CKD), increases morbidity and mortality. Neutrophil gelatinase-associated lipocalin (NGAL) is a protein excreted by the kidney during AKI. There are no urine (u) NGAL data as an early CI-AKI marker in CKD patients undergoing coronary procedures. METHODS: This prospective study enrolled 130 patients with estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² undergoing elective coronary procedures. Serial urine samples, obtained at baseline and 3, 6, 12, 18, and 24 h post contrast administration were analyzed by NGAL ELISA kit. AKI was defined as an increase in serum creatinine (SCr) of ≥ 0.3 mg/dl or ≥ 1.5 times baseline SCr within 48 h per 2012 KDIGO guidelines. Receiver operator characteristic curve analyses identified optimal uNGAL and delta of uNGAL values for diagnosing CI-AKI. RESULTS: The uNGAL was significantly and inverse correlated with eGFR (R = 0.25, P < 0.005). CI-AKI developed in 16/130 (12.31%) patients: 13 and 3 in CI-AKI stages I and II, respectively. uNGAL and delta of uNGAL were significantly higher in the CI-AKI group when compared with the No CI-AKI group (P < 0.05). The best uNGAL cut-off for optimal sensitivity 94%, specificity 78%, and area under the curve 0.84 for predicting CI-AKI was 117 ng/mL at 6 h, respectively. Corresponding values for predicting CI-AKI stage II were 100%, 87% and 0.9 when using an uNGAL of 264 ng/mL at 6 h. CONCLUSIONS: Monitoring of uNGAL levels not only provide the early detecting CI-AKI but also predict the severity of CI-AKI in CKD patients undergoing elective coronary procedures.

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.

New strategy of α- and γ-tocopherol to prevent contrast-induced acute kidney injury in chronic kidney disease patients undergoing elective coronary procedures.

BACKGROUND: Contrast-induced acute kidney injury (CI- AKI) increases the likelihood of patient morbidity and mortality following coronary procedures. Volume supplement with saline is the standard treatment to prevent CI-AKI. Additional antioxidant prophylaxis has often yielded conflicting results. The present study was conducted to examine the role of novel application vitamin E (tocopherol) in preventing CI-AKI. METHODS: This prospective, double-blind, randomized and placebo-controlled trial was carried out in 305 patients with chronic kidney disease (CKD) undergoing coronary procedures. All patients were randomly assigned to prophylaxis administration with 0.9% saline infusions plus daily oral medication comprised of either (i) placebo (n = 101), (ii) α-tocopherol (n = 102) or (iii) γ-tocopherol (n = 102) starting 5 days before and ending 2 days after coronary procedures. The CI-AKI risk score of each patient was calculated. All coronary procedures were performed using a low-osmolar, non-ionic contrast agent. RESULTS: CI-AKI developed in 14.9% in the placebo group, 4.9% in the α-tocopherol group (P = 0.02 versus the placebo group) and 5.9% in the γ-tocopherol group (P = 0.04 versus the placebo group). In patients with diabetes, hypertension, anaemia, aged over 55 years, male gender or with contrast agent dosages >120 mL, α-tocopherol showed a larger effect than γ-tocopherol when compared with the placebo group (P < 0.05). CONCLUSIONS: Prophylaxis administration with oral α- or γ-tocopherol in combination with 0.9% saline is effective in protecting against CI-AKI in CKD patients undergoing elective coronary procedures.

Transthoracic echocardiography in Thai patients with acute ischemic stroke.

OBJECTIVE: Transthoracic echocardiography (TTE) is routinely performed to look for the cardiac sources of emboli in many Western stroke centers. Due to a limitation of resources in Thailand, echocardiography is done in only some patients with acute ischemic stroke. The purpose of this study is to evaluate the need for cardiac investigations, especially TTE, in Thai patients with acute ischemic stroke. MATERIAL AND METHOD: Two-hundred and seven patients with acute ischemic stroke or transient ischemic attack (TIA), who had TTE results during August 2006 to November 2008, were studied. Patients were divided into 2 groups by the risk of cardioembolism: low- versus high-risk groups. All echocardiography results were reviewed and classified by the need for management change following the echocardiography. RESULTS: Abnormal TTE results indicating a need for change in management were found in 4% (4/102) and 18% (18/105) in low- and high- risk patients, respectively The results of ECG alone led to change in management in 17% (36 patients). Atrial fibrillation was the most common cause of cardioembolism, which was found in 35 patients (17%). CONCLUSION: Because of limited resources in Thailand, ECG should be routinely performed on all ischemic stroke patients and TTE in patients with high risk for cardioembolism. However larger studies are still needed to clarify the benefits of echocardiography in low-risk patients.

Extracranial carotid stenosis and peripheral arterial disease in Thai patients with coronary artery disease.

We assessed the prevalence of carotid stenosis (CS) and peripheral arterial disease (PAD) in patients with coronary artery disease (CAD) to determine the relationship between these conditions in a Thai population. All patients with coronary angiography during June 2008 and August 2009 were studied. Carotid duplex and ankle-brachial index (ABI) were performed. One hundred and seventy-seven patients were studied (95 men, mean age of 65). Carotid stenosis and PAD were diagnosed in 16 patients (9%) and 68 patients (38.4%), respectively. The presence of carotid bruit and older age were independent predictors of CS and PAD, respectively. There was no correlation between the presence of CS/PAD and the extent of coronary artery lesions. Although CS was uncommon in patients with CAD, the patients with cervical bruit should be screened for CS. Prevalence of PAD was high, confirming the presence of diffuse atherosclerosis in many patients with CAD.

Percutaneous coronary intervention in Thammasat University Hospital: the first three-year experience.

OBJECTIVE: To study the results of percutaneous coronary intervention (PCI) and in-hospital outcomes in cardiac catheterization laboratory, Thammasat University Hospital since May, 2006 until April, 2009. MATERIAL AND METHOD: This is the prospective, single-center study. The consecutive patients who underwent PCI in Thammasat University Hospital since May 2006 to April 2009 were recruited in the study. Clinical data, angiographic data, and in-hospital outcomes were analyzed and demonstrated. RESULTS: Six hundred and seventeen patients undergoing 755 PCI procedures were enrolled in the study. 62.70% were male and 37.30% were female. Mean age was 65.45 +/- 11.21 years (range 33-97 years) and 20.10% were more than 75 years old. The indications for PCI were non-ST segment-elevation acute coronary syndrome (NSTEACS) (41.72%), chronic stable angina (25.32%), acute ST segment elevation myocardial infarction (STEMI) (8.87%), staged PCI (15.76%). The other indications were heart failure, cardiomyopathy, post-cardiac arrest and etc. The procedure was single vessel PCI in 73.25% and multivessel PCI in 26.75% (double vessels PCI 24.64% and triple vessels PCI 2.11%). According to lesion locations, 45.21% were left anterior descending (LAD) artery lesions, 30.09% were right coronary artery (RCA) lesions, 23.28% were left circumflex (LCX) artery lesions, 1.19% were left main (LM) lesions and 0.24% were graft lesions. The overall angiographic success rate was 95.57%. During hospital stay the major adverse events developed as death in 0.93%, periprocedural myocardial infarction in 3.17%, emergency coronary artery bypass graft in 0.53%, and stroke in 0.26%. CONCLUSION: During the first three years of PCI experience in Thammasat University Hospital, the overall success rate was high with low in-hospital adverse outcomes.

Incidence of perioperative myocardial infarction among high risk patients who undergo preoperative evaluation for non-cardiac surgery by cardiologists.

BACKGROUND: High risk patients who undergo a non-cardiac surgery often develop a perioperative myocardial infarction (PMI). OBJECTIVE: To study the incidence of PMI among high risk patients who undergo preoperative evaluation for non-cardiac surgery by cardiologists. MATERIAL AND METHOD: This study was a cross-sectional study, performed at Thammasat Hospital for one year Eligible patients were subjects older than 40 years with pre-existing cardiovascular disease or with at least one major cardiovascular risk factor including chronic kidney disease who underwent non-cardiac surgery with preoperative cardiovascular evaluation. The primary outcome is perioperative myocardial infarction. RESULTS: Fifty-three patients (mean age 70.5 years, 54.7% female) were eligible for the study. Most of these patients underwent orthopedic surgery (24 patients, 45.3%) and general surgery (18 patients, 34%). Four female patients developed PMI, representing the incidence of 7.5 percent. Chronic kidney disease and peripheral arterial disease were statistically significant associated with PMI. CONCLUSION: The incidence of PMI in this study was slightly higher than those reported in previous studies. Therefore, physicians should be aware of the diagnosis and proper management of this condition.

Protection of radiocontrast induced nephropathy by vitamin E (alpha tocopherol): a randomized controlled pilot study.

BACKGROUND: Contrast-induced nephropathy (CIN) increases the likelihood of patient morbidity and mortality following coronary procedures. Contrast agents cause an acute deterioration in renal function via the generation of reactive oxygen species. The present study was designed to evaluate the administration of antioxidant vitamin E (alpha tocopherol) as a means of preventing CIN in these patients. MATERIAL AND METHOD: The authors conducted a prospective, double-blind, randomized and placebo-controlled trial in 103 patients with serum creatinine (SCr) levels > or = 1.2 mg/dL, baseline creatinine clearance levels < or = 60 mL/min, and who had undergone coronary procedures. Alpha tocopherol (525 IU) or a placebo compound was administered orally at 48 hr, 24 hr, and in the morning prior to coronary procedures. RESULTS: CIN developed in 3 of 51 patients (5.88%) in the alpha tocopherol group and 12 of 52 patients (23.08%) in the placebo group (odds ratio [OR], 0.21; 95% confidence interval [CI], 0.05 to 0.79; p = 0.02). The mean SCr increased significantly in the placebo group (from 1.67 +/- 0.53 to 1.9 +/- 0.87 mg/dL, p = 0.02) but not in the alpha tocopherol group (from 1.62 +/- 0.44 to 1.64 +/- 0.59 mg/dL, p = 0.74). Patients with diabetes, anemia, or with contrast agent dosages greater than 120 ml exhibited significantly lower incidences of CIN development in the alpha tocopherol group than the placebo group (p < 0.05). CONCLUSION: Prophylactic oral administration of alpha tocopherol is capable of protecting against CIN in patients with chronic kidney disease undergoing elective coronary procedures.