Chronic Medication Use and Factors Associated With Polypharmacy Among Outpatient Pediatric Patients.

OBJECTIVE: This study aimed to determine the prevalence and predictors of chronic polypharmacy among pediatric patients in an outpatient setting. METHODS: We conducted a review of medications dispensed to patients from an outpatient pediatric facility during a 12-month period. Patients who received chronic medications (≥30 days' supply), which contained at least 1 active pharmaceutical ingredient were included in the study. Descriptive analysis was used to determine prevalence of polypharmacy while predictive factors for polypharmacy were evaluated using logistic regression. RESULTS: Our study included 3920 patients (median age, 9.9 years; IQR, 9.4) and 16,401 medications. The median number of chronic medications used among our study cohort was 2.0 (IQR, 1) with polypharmacy identified in 309 (7.9%) patients. Predictors for polypharmacy were age and the use of certain therapeutic class of medications. Patients 12 to <19 years old (OR, 6.95; 95% CI, 4.1-10.1) were more likely to require ≥5 concurrent medications compared with patients younger than 2 years of age. Use of calcium supplements (OR, 21.2; 95% CI, 11.3-39.6), Vitamin D analogues (OR, 14.3; 95% CI, 8.0-25.8), and systemic glucocorticoids (OR, 18.8; 95% CI, 10.7-33.2) were also highly associated with polypharmacy. CONCLUSIONS: Adolescents and children with chronic medical conditions who require prolonged systemic glucocorticoids, calcium, and Vitamin D supplements are at higher risk of incurring long-term polypharmacy. This subgroup of pediatric patients may be more vulnerable to the occurrence of negative outcomes resulting from the use of multiple chronic medications.

Guideline-Based Critical Care Pathway Improves Long-Term Clinical Outcomes in Patients with Acute Coronary Syndrome.

Implementation of a critical care pathway (CCP) for acute coronary syndrome (ACS) has been shown to improve early compliance to guideline-directed therapies and reduce early mortality. Nevertheless its long-term impact on the compliance with medications or clinical outcomes remains unknown. Between 2004 and 2015, 2023 consecutive patients were admitted to our coronary care unit with ACS. We retrospectively compared the outcomes of 628 versus 1059 patients (mean age 66.1 ± 13.3 years, 74% male) managed before and after full implementation of a CCP. Compared with standard care, implementation of the CCP significantly increased coronary revascularization and long-term compliance with guideline-directed medical therapy (both P < 0.01). After a mean follow-up of 66.5 ± 44.0 months, 46.7% and 22.2% patients admitted before and after implementation of the CCP, respectively, died. Kaplan-Meier analyses showed that patients managed by CCP had better overall survival (P = 0.03) than those managed with standard care. After adjustment for clinical covariates and coronary anatomy, CCP remained independently predictive of better survival from all-cause mortality [hazard ratio (HR): 0.75, 95%confidence intervals (CI): 0.62-0.92, P < 0.01]. Stepwise multivariate cox regression model showed that both revascularization (HR: 0.55, 95%CI: 0.45-0.68, P < 0.01) and compliance to statin (HR: 0.70, 95%CI: 0.58-0.85, P < 0.01) were accountable for the improved outcome.

Risk of venous thromboembolism in Chinese pregnant women: Hong Kong venous thromboembolism study.

BACKGROUND: Previous Caucasian studies have described venous thromboembolism in pregnancy; however, little is known about its incidence during pregnancy and early postpartum period in the Chinese population. We investigated the risk of venous thromboembolism in a "real-world" cohort of pregnant Chinese women with no prior history of venous thromboembolism. METHODS: In this observational study, 15,325 pregnancies were identified in 14,162 Chinese women at Queen Mary Hospital, Hong Kong between January 2004 and September 2016. Demographic data, obstetric information, and laboratory and imaging data were retrieved and reviewed. RESULTS: The mean age at pregnancy was 32.4±5.3 years, and the median age was 33 years (interquartile range, 29-36 yr). Pre-existing or newly diagnosed diabetes mellitus was present in 627 women (4.1%); 359 (0.7%) women had pre-existing or newly detected hypertension. There was a small number of women with pre-existing heart disease and/or rheumatic conditions. Most deliveries (86.0%) were normal vaginal; the remaining were Cesarean section 2,146 (14.0%). The incidence of venous thromboembolism was 0.4 per 1,000 pregnancies, of which 83.3% were deep vein thrombosis and 16.7% were pulmonary embolism. In contrast to previous studies, 66.7% of venous thrombosis occurred in the first trimester. CONCLUSION: Chinese women had a substantially lower risk of venous thromboembolism during pregnancy and the postpartum period compared to that of Caucasians. The occurrence of pregnancy-related venous thromboembolism was largely confined to the early pregnancy period, probably related to the adoption of thromboprophylaxis, a lower rate of Cesarean section, and early mobilization.

Screening Of Pulmonary Hypertension in Methamphetamine Abusers (SOPHMA): rationale and design of a multicentre, cross-sectional study.

INTRODUCTION: Methamphetamine misuse is classified as a 'likely' risk factor for pulmonary arterial hypertension (PAH). Nevertheless, the actual prevalence of and a screening strategy for PAH in methamphetamine users have not been established. We plan to study the prevalence of PAH and identify its independent risk factors among methamphetamine users. METHODS AND ANALYSIS: The Screening Of Pulmonary Hypertension in Methamphetamine Abusers (SOPHMA) study will be a multicentre, cross-sectional screening study that will involve substance abuse clinics, hospitals and rehabilitation facilities in Hong Kong that cater to more than 20 methamphetamine users. A total of 400 patients who (1) are ≥18 years at enrolment; (2) report methamphetamine use in the last 2 years; (3) are diagnosed with methamphetamine use disorder; and (4) voluntarily agree to participate by providing written informed consent will be included. Patients will undergo standard echocardiography-based PAH screening procedures recommended for those with systemic sclerosis. Right heart catheterisation will be offered to participants with intermediate or high echocardiographic probability of PAH. For participants with a low echocardiographic probability of PAH, rescreening will be performed within 1 year. The primary measure will be the prevalence of PAH in methamphetamine users. The secondary measures will be the risk factors and a prediction model for PAH in methamphetamine users. ETHICS AND DISSEMINATION: The SOPHMA study has been approved by the institutional review board. The findings of this study will provide the necessary evidence to establish universal guidelines for screening of PAH in methamphetamine users. Our results will be disseminated through immediate feedback to study participants, press release to the general public, as well as presentation in medical conferences and publications in peer-reviewed journals to healthcare providers and academia worldwide.

Prognostic implications of statin intolerance in stable coronary artery disease patients with different levels of high-sensitive troponin.

BACKGROUND: The prognostic implication of statin in tolerance (SI) in those with stable CAD remains unclear. We hypothesized that SI is of higher prognostic significance in stable CAD patients with elevated high-sensitive cardiac troponin I (hs-cTnI). METHODS: A total of 952 stable CAD patients from the prospective Hong Kong CAD study who had complete clinical data, biomarker measurements and who were prescribed statin therapy were studied. RESULTS: We identified 13 (1.4%) and 125 (13.1%) patients with complete and partial SI, respectively. At baseline, patients with SI were more likely to have diabetes mellitus and a higher hs-cTnI level, but no difference in LDL-C level compared with those without SI. After 51 months of follow-up, patients with SI had a higher mean LDL-C level than those without SI. A total of 148 (15.5%) patients developed major adverse cardiovascular events (MACEs). Both SI (HR 1.52, 95% CI 1.06-2.19, P = 0.02) and elevated hs-cTnI (HR 3.18, 95% CI 2.07-4.89, P < 0.01) were independent predictors of a MACE in patients with stable CAD. When stratified by hs-cTnI level, SI independently predicted MACE-free survival only in those with elevated hs-cTnI (HR 1.51, 95% CI 1.01-2.24, P = 0.04). CONCLUSIONS: SI independently predicted MACE in patients with stable CAD and high hs-cTnI, but not in those with low hs-cTnI. Hs-cTnI may be used to stratify stable CAD patients who have SI for intensive lipid-lowering therapy using non-statin agents.

TIMI risk score for secondary prevention of recurrent cardiovascular events in a real-world cohort of post-non-ST-elevation myocardial infarction patients.

BACKGROUND: Patients who survive non-ST-elevation myocardial infarction (NSTEMI) are at heightened risk of recurrent cardiovascular events. Data on long-term secondary atherothrombotic risk stratification are limited. OBJECTIVES: To stratify post-NSTEMI patients for risk of recurrent cardiovascular events to maximise benefit from aggressive secondary prevention strategies using the TIMI Risk Score for Secondary Prevention (TRS 2°P) score in a real-world cohort of NSTEMI patients. METHODS AND RESULTS: This was a single-centre observational study of 891 post-NSTEMI patients (73.7 ± 12.7 years; male: 54.2%). The TRS 2°P is a nine-point risk stratification tool to predict cardiovascular events in patients with established cardiovascular disease. The primary outcome was a composite endpoint of cardiovascular death, non-fatal MI and non-fatal ischaemic stroke. After a median follow-up of 31 months (IQR: 11.4 - 60.2), 281 patients (31.5%) had developed a primary outcome (13.3%/year) including 196 cardiovascular deaths, 94 non-fatal MIs and 22 non-fatal strokes. The TRS 2°P score was strongly associated with the primary outcome. The annual incidence of primary composite endpoint for patients with TRS 2°P score =0 was 1.6%, and increased progressively to 47.4% for those with a TRS 2°P score ≥6 (HR: 20.18, 95% CI: 4.85 to 84.05, p<0.001). Similar associations were also observed between the TRS 2°P score and cardiovascular death and MI (fatal and non-fatal), but not non-fatal ischaemic stroke. CONCLUSION: The TRS 2°P score stratified post-NSTEMI patients for risk of future cardiovascular events and potentially help guide the selection of more aggressive secondary prevention therapy.

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention of Recurrent Cardiovascular Events in a Real-World Cohort of Post-Acute Myocardial Infarction Patients.

BACKGROUND: Patients who survive myocardial infarction (MI) are at risk of recurrent cardiovascular (CV) events. This study stratified post-MI patients for risk of recurrent CV events using the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS 2°P). Methods and Results: This was an observational study that applied TRS 2°P to a consecutive cohort of post-MI patients. The primary outcome was a composite endpoint of CV death, non-fatal MI, and non-fatal ischemic stroke. A total of 1,688 post-MI patients (70.3±13.6 years; male, 63.1%) were enrolled. After a mean follow-up of 41.5±34.4 months, 405 patients (24.0%) had developed a primary outcome (9.3%/year) consisting of 278 CV deaths, 134 non-fatal MI, and 33 non-fatal strokes. TRS 2°P was strongly associated with the primary outcome. The annual incidence of primary composite endpoint for patients with TRS 2°P 0 was 1.0%, and increased progressively to 39.9% for those with TRS 2°P ≥6 (HR, 27.6; 95% CI: 9.87-77.39, P<0.001). The diagnostic sensitivity of TRS 2°P for the primary composite endpoint was 76.3% (95% CI: 72.1-80.5%). Similar associations were also observed between TRS 2°P and CV death and non-fatal MI, but not non-fatal ischemic stroke. CONCLUSIONS: TRS 2°P reliably stratified post-MI patients for risk of future CV events.

Diagnostic assessment of a deep learning system for detecting atrial fibrillation in pulse waveforms.

OBJECTIVE: To evaluate the diagnostic performance of a deep learning system for automated detection of atrial fibrillation (AF) in photoplethysmographic (PPG) pulse waveforms. METHODS: We trained a deep convolutional neural network (DCNN) to detect AF in 17 s PPG waveforms using a training data set of 149 048 PPG waveforms constructed from several publicly available PPG databases. The DCNN was validated using an independent test data set of 3039 smartphone-acquired PPG waveforms from adults at high risk of AF at a general outpatient clinic against ECG tracings reviewed by two cardiologists. Six established AF detectors based on handcrafted features were evaluated on the same test data set for performance comparison. RESULTS: In the validation data set (3039 PPG waveforms) consisting of three sequential PPG waveforms from 1013 participants (mean (SD) age, 68.4 (12.2) years; 46.8% men), the prevalence of AF was 2.8%. The area under the receiver operating characteristic curve (AUC) of the DCNN for AF detection was 0.997 (95% CI 0.996 to 0.999) and was significantly higher than all the other AF detectors (AUC range: 0.924-0.985). The sensitivity of the DCNN was 95.2% (95% CI 88.3% to 98.7%), specificity was 99.0% (95% CI 98.6% to 99.3%), positive predictive value (PPV) was 72.7% (95% CI 65.1% to 79.3%) and negative predictive value (NPV) was 99.9% (95% CI 99.7% to 100%) using a single 17 s PPG waveform. Using the three sequential PPG waveforms in combination (<1 min in total), the sensitivity was 100.0% (95% CI 87.7% to 100%), specificity was 99.6% (95% CI 99.0% to 99.9%), PPV was 87.5% (95% CI 72.5% to 94.9%) and NPV was 100% (95% CI 99.4% to 100%). CONCLUSIONS: In this evaluation of PPG waveforms from adults screened for AF in a real-world primary care setting, the DCNN had high sensitivity, specificity, PPV and NPV for detecting AF, outperforming other state-of-the-art methods based on handcrafted features.

Secular trends and etiologies of venous thromboembolism in Chinese from 2004 to 2016.

INTRODUCTION: Current epidemiological data for venous thromboembolism (VTE) are derived primarily from Caucasian populations from North America. Little is known for other ethnic groups. This study aimed to describe the incidence, etiologies, and the secular trends of VTE in a Chinese population. MATERIALS AND METHODS: This was an observational study using a hospital VTE registry. RESULTS AND CONCLUSIONS: Between 2004 and 2016, 2214 patients (mean age 66.2 ±â€¯17.4 years, 57.2% female) were hospitalized for a novel occurrence of venous thromboembolism. Of these, 1444 patients (65.2%) had deep venous thrombosis and 770 patients (34.8%) had pulmonary embolism. Over the 13-year period, there was an increasing trend in the incidence of VTE from 28.1 per 100,000 population per year in 2004 to 48.3 per 100,000 population per year in 2016. There has been a disproportional increase in the incidence of VTE among those aged 75 years or above. Etiologically, the most common cause of VTE was active malignancy with an incidence that increased from 34.8% in 2005 to 60.9% in 2014. In conclusion, the incidence of venous thromboembolism in Hong Kong appears to be lower than that in previous Caucasian series. Nonetheless there has been an increasing incidence of VTE over the past decade, primarily related to aging and malignancy.

Rationale and design of the screening of pulmonary hypertension in systemic lupus erythematosus (SOPHIE) study.

Current guideline-recommended screening for pulmonary hypertension in patients with systemic sclerosis has not been evaluated in systemic lupus erythematosus (SLE), which is disproportionately prevalent in Asians. This multicentre, cross-sectional screening study aims to study the prevalence of pulmonary hypertension among SLE patients using these guidelines, and identify independent predictors and develop a prediction model for pulmonary hypertension in SLE patients. SLE patients from participating centres will undergo an echocardiography- and biomarker-based pulmonary hypertension screening procedure as in the DETECT study. Standard right heart catheterisation will be provided to patients with intermediate or high echocardiographic probability of pulmonary hypertension. Those with low echocardiographic probability will rescreen within 1 year. The primary measure will be the diagnosis and types of pulmonary hypertension and prevalence of pulmonary hypertension in SLE patients. The secondary measures will be the predictors and prediction models for pulmonary hypertension in SLE patients. The estimated sample size is approximately 895 participants. The results of the SOPHIE study will be an important contribution to the literature of SLE-related pulmonary hypertension and may be immediately translatable to real clinical practice. Ultimately, this study will provide the necessary evidence for establishing universal guidelines for screening of pulmonary hypertension in SLE patients.

Prognostic implications of early monomorphic and non-monomorphic tachyarrhythmias in patients discharged with acute coronary syndrome.

BACKGROUND: The prognostic implication of early ventricular tachyarrhythmias (VTs) after acute coronary syndrome (ACS) remains unclear. OBJECTIVE: We sought to investigate the clinical outcomes of early monomorphic and non-monomorphic VTs that occur within 48 hours in patients after ACS. METHODS: We retrospectively reviewed the clinical outcomes of 2033 [mean age 67.0 ± 13.4 years; 1486 (73.1%) men] consecutive patients who presented with ACS from 2004 to 2015. RESULTS: A total of 67 (3.3%) and 90 (4.4%) patients developed early monomorphic or non-monomorphic VT, respectively. Killip class IV (odds ratio [OR] 3.05; 95% confidence interval [CI] 1.47-6.36; P < .01), creatine kinase level (OR 1.01; 95% CI 1.00-1.02 per 100 IU/L; P = .01), and left ventricular ejection fraction (OR 0.96; 95% CI 0.94-0.99; P < .01) were independently associated with early monomorphic VT, whereas age (OR 0.98; 95% CI 0.97-0.99; P = .04), ST elevated myocardial infarction (OR 3.53; 95% CI 1.71-7.27; P < .01), Killip class IV (OR 4.91; 95% CI 2.76-8.74; P < .01), diabetes mellitus (OR 0.48; 95% CI 0.28-0.81; P < .01), and left ventricular ejection fraction (OR 0.97; 95% CI 0.95-0.99; P < .01) were independently associated with early non-monomorphic VT. More patients with early monomorphic VT (n = 22 [32.8%]) died in hospital than those with non-monomorphic VT (n = 16 [17.8%]) or without early VT (n = 133 [7.1%]; P < .01). After a mean follow-up of 67.8 ± 43.2 months, 21 patients with early monomorphic VT (46.7%), 22 patients with early non-monomorphic VT (29.7%), and 552 patients without early VT (31.7%) died. Both early monomorphic and non-monomorphic VTs were associated with a long-term increase in sudden arrhythmic deaths and recurrent VTs. Nevertheless, only early monomorphic VT was shown to independently predict overall survival (hazard ratio 1.62; 95% CI 1.03-2.55; P = .04). CONCLUSION: Early monomorphic VT, but not early non-monomorphic VT, independently predicted all-cause mortality in patients with ACS who survived to hospital discharge.

Impact of provision of time in therapeutic range value on anticoagulation management in atrial fibrillation patients on warfarin.

INTRODUCTION: The importance of time in therapeutic range (TTR) in patients prescribed warfarin therapy for stroke prevention in atrial fibrillation (AF) cannot be overemphasised. AIM: To evaluate the impact of provision of TTR results during clinic visits on anticoagulation management. DESIGN: Single-centred, randomised controlled study. SETTING: Fifteen arrhythmia clinics in Hong Kong. PATIENTS: AF patients prescribed warfarin. INTERVENTIONS: Provision of TTR or no provision of TTR. MAIN OUTCOME MEASURES: A documented discussion between doctors and patients about switching warfarin to a non-vitamin K oral anticoagulant (NOAC). RESULTS: Four hundred and eighty one patients with AF prescribed warfarin were randomly assigned to (1) a TTR provision group or (2) control. Their mean age was 73.6±12.0 years and 60.7% were men. The mean CHA2DS2-VASc score was 3.2±1.6 and the mean HASBLED score was 1.7±1.2. The mean TTR was 63.9%±29.9%. At the index clinic visit, 71 of 481 patients (14.8%) had a documented discussion about switching warfarin to a NOAC. Patients with provision of TTR results were more likely to discuss switching warfarin to a NOAC than controls (19.1% vs 10.6%, P=0.03), especially those with a TTR <65% (35.2% vs 10.6%, P<0.001). A higher proportion of patients with provision of TTR results switched to a NOAC (5.9% vs 4.1%, P=0.49). CONCLUSIONS: The provision of TTR among patients on warfarin was associated with a discussion about switching from warfarin to a NOAC in those with TTR <65%, but did not result in actual switching to a NOAC, suggesting additional barriers.

Genetically deprived vitamin D exposure predisposes to atrial fibrillation.

AIMS: Low vitamin D level is associated with atrial fibrillation (AF) and may be implicated in its pathogenesis. METHODS AND RESULTS: We studied single nucleotide polymorphisms (SNPs) of vitamin D mechanistic pathways and serum 25-hydroxyvitamin D [25(OH)D] levels in an age- and gender-matched case-control study (controls without AF: mean age 68.6 ± 8.7 years, female 25%; n = 1019; with AF: mean age 69.7 ± 9.5 years, female 30%; n = 156) recruited from a Chinese clinical cohort of patients with stable coronary artery disease. Twelve SNPs involved in the vitamin D mechanistic pathways were studied [biosynthetic: rs4646536, rs10877012, rs3829251, rs1790349; activation: rs2060793, rs1993116; vitamin D-binding protein (VBP)/group-specific component (GC): rs4588, rs7041, rs2282679, rs1155563; and vitamin D receptor: rs1544410, rs10735810]. A genetic risk score (GRS) (0-8) was constructed from SNPs associated with serum 25(OH)D as a proxy to lifelong vitamin D-deficient state. All 4 SNPs involved in the VBP/GC were significantly associated with serum 25(OH)D (rs4588, P < 0.001; rs2282679, P < 0.001; rs7041, P = 0.011; rs1155563, P < 0.001; all other SNPs, P > 0.05). Vitamin D GRS (points 0-8) generated from these 4 SNPs was independently predictive of serum 25(OH)D [B = 0.54, 95% confidence interval (CI) 0.30-0.79; P < 0.001]. Genetically deprived vitamin D status as denoted by a low GRS (0-3) independently predicted an increased risk of AF, compared to a high GRS (4-8) (odds ratio = 1.848, 95% CI 1.217-2.805; P = 0.004). CONCLUSION: Genetically deprived vitamin D exposure predisposes to increased AF among patients with coronary artery disease. Whether VBP/GC may alter the risk of AF via alternative mechanisms warrants further studies.

Extrinsic pulmonary artery compression mimicking acute pulmonary embolism.

Right ventricular strain patterns on electrocardiogram such as right axis derivation and S1Q3T3 are well known for their diagnostic value in cases of acute pulmonary embolism. Nonetheless, these changes are not pathognomonic. We report a patient with electrocardiographic evidence of right ventricular strain secondary to an unusual etiology.

Diagnostic performance of an automatic blood pressure measurement device, Microlife WatchBP Home A, for atrial fibrillation screening in a real-world primary care setting.

OBJECTIVE: To evaluate the diagnostic performance of a UK National Institute for Health and Care Excellence-recommended automatic oscillometric blood pressure (BP) measurement device incorporated with an atrial fibrillation (AF) detection algorithm (Microlife WatchBP Home A) for real-world AF screening in a primary healthcare setting. SETTING: Primary healthcare setting in Hong Kong. INTERVENTIONS: This was a prospective AF screening study carried out between 1 September 2014 and 14 January 2015. The Microlife device was evaluated for AF detection and compared with a reference standard of lead-I ECG. PRIMARY OUTCOME MEASURES: Diagnostic performance of Microlife for AF detection. RESULTS: 5969 patients (mean age: 67.2±11.0 years; 53.9% female) were recruited. The mean CHA2DS2-VASc ( C : congestive heart failure [1 point]; H : hypertension [1 point]; A2 : age 65-74 years [1 point] and age ≥75 years [2 points]; D : diabetes mellitus [1 point]; S : prior stroke or transient ischemic attack [2 points]; VA : vascular disease [1 point]; and Sc : sex category [female] [1 point])score was 2.8±1.3. AF was diagnosed in 72 patients (1.21%) and confirmed by a 12-lead ECG. The Microlife device correctly identified AF in 58 patients and produced 79 false-positives. The corresponding sensitivity and specificity for AF detection were 80.6% (95% CI 69.5 to 88.9) and 98.7% (95% CI 98.3 to 98.9), respectively. Among patients with a false-positive by the Microlife device, 30.4% had sinus rhythm, 35.4% had sinus arrhythmia and 29.1% exhibited premature atrial complexes. With the low prevalence of AF in this population, the positive and negative predictive values of Microlife device for AF detection were 42.4% (95% CI 34.0 to 51.2) and 99.8% (95% CI 99.6 to 99.9), respectively. The overall diagnostic performance of Microlife device to detect AF as determined by area under the curves was 0.90 (95% CI 0.89 to 0.90). CONCLUSIONS: In the primary care setting, Microlife WatchBP Home was an effective means to screen for AF, with a reasonable sensitivity of 80.6% and a high negative predictive value of 99.8%, in addition to its routine function of BP measurement. In a younger patient population aged <65 years with a lower prevalence of AF, Microlife WatchBP Home A demonstrated a similar diagnostic accuracy.

Androgen deprivation therapy and fracture risk in Chinese patients with prostate carcinoma.

OBJECTIVE: Androgen deprivation therapy (ADT) increases fracture risk in men with carcinoma of the prostate, but little is known about the fracture risk for different types of ADT. We studied the fracture risk amongst Chinese patients with carcinoma of the prostate prescribed different ADT regimens. SUBJECTS AND METHODS: This was a single-centered observational study that involved 741 patients with carcinoma of the prostate from January 2001 to December 2011. RESULTS: After a median follow-up of 5 years, 71.7% of the study cohort received ADT and the incidence rate of fracture was 8.1%. Multivariable Cox regression analysis revealed that use of ADT was significantly associated with risk of incident fracture (Hazard Ratio [HR] 3.60; 95% Confidence Interval [95% CI] 1.41-9.23; p = 0.008), together with aged >75 years and type 2 diabetes. Compared with no ADT, all three types of ADT were independently associated with the risk of incident fracture: anti-androgen monotherapy (HR 4.47; 95% CI 1.47-13.7; p = 0.009), bilateral orchiectomy ± anti-androgens (HR 4.01; 95% CI 1.46-11.1; p = 0.007) and luteinizing hormone-releasing hormone agonists ± anti-androgens (HR 3.16; 95% CI 1.18-8.43; p = 0.022). However, there was no significant difference in the relative risks among the three types of ADT. CONCLUSIONS: Fracture risk increases among all types of ADT. Clinicians should take into account the risk-benefit ratio when prescribing ADT, especially in elderly patients with type 2 diabetes.

Efficacy and safety of dabigatran, rivaroxaban, and warfarin for stroke prevention in Chinese patients with atrial fibrillation: the Hong Kong Atrial Fibrillation Project.

BACKGROUND: Little is known about the comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin in Chinese atrial fibrillation (AF) patients. Our aim was to compare the ischemic stroke risk reduction and incidence of intracranial hemorrhage (ICH) of warfarin in relation to quality of anticoagulation control (as reflected by time in therapeutic range [TTR]), and to dabigatran and rivaroxaban in a real-world cohort of Chinese AF patients. HYPOTHESIS: NOAC, rather than warfarin, is preferred in Chinese AF patients. METHODS: Of 2099 patients studied (73.1 ± 12.3 years, female: 44.6%, CHA2 DS2 -VASc 3.7 ± 1.9 and HAS-BLED 2.0 ± 1.0) with nonvalvular AF, 963 patients (45.9%) were on warfarin (only 16.3% had TTR ≥65%), 669 patients were on rivaroxaban, and 467 patients were on dabigatran. RESULTS: After a mean follow-up of 21.7 ± 13.4 months, there were 156 ischemic strokes (annual incidence of 4.10%/year), with the incidence of ischemic stroke being highest in patients on warfarin with TTR <65% (5.24%/year), followed by those on rivaroxaban (3.74%/year), and those on warfarin with TTR ≥65% (3.35%/year), whereas patients on dabigatran had the lowest incidence of ischemic stroke (1.89%/year). The incidence of ICH was lowest in patients on dabigatran (0.39%/year) compared with those on rivaroxaban (0.52%/year) and warfarin, with TTR <65% (0.95%/year) and TTR ≥65% (0.58%/year). Patients on rivaroxaban 20 mg daily had similar ischemic stroke risk (1.93%/year) and ICH risk (0.21%/year) compared to dabigatran. CONCLUSIONS: In Chinese AF patients, the benefits of warfarin therapy for stroke prevention and ICH reduction depend on TTR. Of the treatments compared, dabigatran, as well as rivaroxaban 20 mg daily, was associated with lowest ischemic stroke and ICH rates.

Incidence and predictors of sudden arrhythmic death or ventricular tachyarrhythmias after acute coronary syndrome: An asian perspective.

BACKGROUND: Current data on the risk of sudden arrhythmic death (SAD) and ventricular tachyarrhythmias (VTs) after acute coronary syndrome (ACS) in the Asian population are limited. OBJECTIVE: The purpose of this study was to investigate the incidence and predictors of SAD or VT after ACS in a contemporary cohort of Chinese patients in the era of early revascularization. METHODS: Consecutive patients admitted to our unit for ACS from 2010 to 2015 were retrospectively reviewed. RESULTS: A total of 918 patients (74.8% male, mean age 65.9 ± 13.4 years) were included in the study. Of these patients, 864 (94.1%) survived to discharge. After a mean of 34.1 ± 21.8 months, 42 (4.9%) had SAD or VT. The event rate was 0.46% in month 1, 0.26% per month in the months 2 to 6, 0.15% per month in months 6 to 12, and 1.23% per year from the second year onward. In multivariate analysis, early VT (hazard ratio [HR] 5.78, 95% confidence interval [CI] 2.63-12.72, P < .01), left ventricular ejection fraction ≤35% (HR 1.96, 95% CI 1.03-3.73, P = .04), prior coronary artery disease (HR 2.50, 95% CI 1.29-4.82, P < .01), triple-vessel disease (HR 3.69, 95% CI 1.81-7.54, P < .01), and chronic kidney disease (HR 2.43, 95% CI 1.21-4.92, P = .01) independently predicted SAD or VT. CONCLUSION: This study reports the rate of SAD or VT among Asian patients after ACS in the era of early revascularization and optimal medical therapy. Aggressive preventive measures should be considered for patients with multiple risk factors for SAD or VT, especially in the initial period after ACS.