Three-year outcomes of patients with non-valvular atrial fibrillation: the COOL-AF registry.

BACKGROUND: Clinical outcomes of patients with non-valvular atrial fibrillation (AF) in Asian populations may be different from non-Asians. In this study, we aimed to determine the incidence of ischemic stroke/systemic embolism (SSE), major bleeding, and death, and the predictors for clinical outcomes in a contemporary Asian cohort of newly diagnosed AF patients. METHODS: This is a prospective multicenter nationwide registry of patients with AF from 27 hospitals in Thailand. Baseline data and follow-up data were collected every 6 months until 3 years. Data collections included demographic, medical history, laboratory, and medication details. Clinical outcomes were SSE, major bleeding, and all-cause mortality. Incidence rates for each clinical outcome were calculated and presented as rate per 100 person-years. Univariate and multivariate analysis was performed to determine the independent predictors for clinical outcomes. RESULTS: There was a total of 3405 patients: mean age was 67.8 ± 11.3 years, 1981 (58.2%) were male. During 30.8 ± 9.7 months follow-up, there was a total of 132 SSE (3.9%), 191 major bleeding (5.6%), and 357 all-cause deaths (10.5%). The incidence rates of SSE, major bleeding, and death were 1.56 (1.30-1.84), 2.26 (1.96-2.61), and 4.17 (3.33-4.25), per 100 person-years respectively. Independent predictors for clinical outcomes were age, type of AF, and the presence of comorbid conditions. CONCLUSION: The incidence rate of SSE, major bleeding, and death remains high reflecting the unmet needs in AF management.

Soluble ST2 in the prediction of heart failure and death in patients with atrial fibrillation.

BACKGROUND: Biomarkers may be a useful marker for predicting heart failure (HF) or death in patients with atrial fibrillation (AF). HYPOTHESIS: Soluble ST2 (sST2) may be a good biomarker for the prediction of HF or death in patients with AF. METHODS: This is a prospective study of patients with nonvalvular AF. Clinical outcomes were HF or death. Clinical and laboratory data were compared between those with and without clinical outcomes. Univariate and multivariate analysis was performed to determine whether sST2 is an independent predictor for heart failure or death in patients with nonvalvular AF. RESULTS: A total of 185 patients (mean age: 68.9 ± 11.0 years) were included, 116 (62.7%) were male. The average sST2 and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were 31.3 ± 19.7 ng/ml and 2399.5 ± 6853.0 pg/ml, respectively. Best receiver operating characteristic (ROC) cut off of sST2 for predicting HF or death was 30.14 ng/ml. Seventy-three (39.5%) patients had an sST2 level ≥30.14 ng/ml, and 112 (60.5%) had an sST2 level <30.14 ng/dl. The average follow-up was 33.1 ± 6.6 months. Twenty-nine (15.7%) patients died, and 33 (17.8%) developed HF during follow-up. Multivariate analysis revealed that high sST2 to be an independent risk factor for death or HF with a HR and 95% CI of 2.60 (1.41-4.78). The predictive value of sST2 is better than NT-proBNP, and it remained significant in AF patients irrespective of history of HF, and NT-proBNP levels. CONCLUSIONS: sST2 is an independent predictor of death or HF in patients with AF irrespective of history of HF or NT-proBNP levels.

Average Systolic Blood Pressure and Clinical Outcomes in Patients with Atrial Fibrillation: Prospective Data from COOL-AF Registry.

PURPOSE: Hypertension is associated with incident atrial fibrillation (AF) and AF-related complications. We investigated the associations between average systolic blood pressure (SBP) and outcomes in a nationwide cohort of Asian patients with non-valvular atrial fibrillation (NVAF). PATIENTS AND METHODS: A multicenter nationwide registry of patients with NVAF in Thailand was conducted during 2014-2017. Clinical data, including blood pressure, were recorded at baseline and then every 6 months. Average SBP was calculated from the average of SBP from every visit. Cox regression models were used to calculate the rate of clinical outcomes of interest, ie ischemic stroke or transient ischemic attack (TIA), intracerebral hemorrhage (ICH), and all-cause death. Average SBP was categorized into three groups: <120, 120-140, and ≥140 mmHg. RESULTS: A total of 3402 patients were included, and the mean age was 67.4±11.3 years. The mean (±SD) baseline and average SBPs were 128.5±18.5 and 128.0±13.4 mmHg, respectively. The mean follow-up duration was 25.7±10.6 months. The median rate of ischemic stroke/TIA, ICH, and all-cause death was 1.43 (1.17-1.74), 0.70 (0.52-0.92), and 3.77 (3.33-4.24) per 100 person-years, respectively. The rate of ischemic stroke/TIA and ICH was lowest in patients with average SBP <120 mmHg, and highest among those with average SBP ≥140 mmHg. The death rates were consistent with a J-curve effect, being lowest in patients with an average SBP 120-140 mmHg. Sustained SBP control is more important than the SBP from a single visit. CONCLUSION: Sustained control of SBP was significantly associated with a reduction in adverse clinical outcomes in patients with NVAF.

Impact of anemia on clinical outcomes of patients with atrial fibrillation: The COOL-AF registry.

BACKGROUND: To determine whether anemia is an independent risk factor for ischemic stroke and major bleeding in patients with non-valvular atrial fibrillation (NVAF). HYPOTHESIS: Anemia in patients with NVAF increase risk of clinical complications related to atrial fibrillation. METHODS: We conducted a prospective multicenter registry of patients with NVAF in Thailand. Demographic data, medical history, comorbid conditions, laboratory data, and medications were collected and recorded, and patients were followed-up every 6 months. The outcome measurements were ischemic stroke or transient ischemic attack (TIA), major bleeding, heart failure (HF), and death. All events were adjudicated by the study team. We analyzed whether anemia is a risk factor for clinical outcomes with and without adjusting for confounders. RESULTS: There were a total of 1562 patients. The average age of subjects was 68.3 ± 11.5 years, and 57.7% were male. The mean hemoglobin level was 13.2 ± 1.8 g/dL. Anemia was demonstrated in 518 (33.16%) patients. The average follow-up duration was 25.8 ± 10.5 months. The rate of ischemic stroke/TIA, major bleeding, HF, and death was 2.9%, 4.9%, 1.8%, 8.6%, and 9.2%, respectively. Anemia significantly increased the risk of these outcomes with a hazard ratio of 2.2, 3.2, 2.9, 1.9, and 2.8, respectively. Oral anticoagulants (OAC) was prescribed in 74.8%; warfarin accounts for 89.9% of OAC. After adjusting for potential confounders, anemia remained a significant predictor of major bleeding, heart failure, and death, but not for ischemic stroke/TIA. CONCLUSION: Anemia was found to be an independent risk factor for major bleeding, heart failure, and death in patients with NVAF.

Clinical safety and performance of a MRI conditional pacing system in patients undergoing cardiac MRI.

BACKGROUND: Utilization of cardiac magnetic resonance imaging (cMRI) as an imaging modality in clinical practice is rapidly increasing. More evidence from randomized studies establishing clinical safety and performance of pacing systems in patients undergoing a cMRI scan is needed. OBJECTIVES: The purpose of this prospective, multicenter, randomized study was to demonstrate safety and efficacy of the Accent MRI™ conditional pacing systems (St. Jude Medical, St. Paul, MN, USA) in patients undergoing cMRI scan. METHODS: Patients (n  =  283) indicated for dual-chamber pacemaker implant were randomized to either the MRI Group (MG) (n  =  140) or the Control Group (CG) (n  =  143) after successful device implantation of the Accent MRI™ system. Clinical evaluation and device interrogation were performed at pre- and post-MRI scan, and 1 month post-MRI for all patients. At 9-12 weeks postimplant, patients in MG underwent a nondiagnostic cMRI scan at 1.5 Tesla (T), while patients in CG underwent device interrogation and clinical evaluation twice with a 45-minute waiting period in between. The safety endpoint was freedom from MRI scan-related complications and that for efficacy was significant changes in right atrial/ventricular capture threshold and sensing amplitude between right before MRI, immediately after MRI, and 1 month post-MRI. RESULTS: Results showed 100% freedom from MRI scan-related complications. There were no significant changes in device performance between pre-MRI scan and 1 month post-MRI scan time points in both study groups. CONCLUSIONS: cMRI scanning with 1.5 T scanners is safe in patients implanted with the Accent MRI™ conditional pacing system and has no significant effect on the electrical parameters of the device and leads.

Characteristics and Outcomes of Treatment for Non-ST-Segment Elevation Acute Coronary Syndrome: Results from a Single Center Registry.

BACKGROUND: Acute coronary syndrome (A CS) is a leading health burden worldwide. The Siriraj non-ST-segment elevation acute coronary syndrome (NST E-A CS) registry was established in 2012. Here, we report in-hospital outcomes and one-year outcomes from patients in the registry. OBJECTIVE: To investigate and report characteristics and outcomes of treatment for NSTE-ACS at one year from a single center MATERIAL AND METHOD: All patients admitted to Siriraj Hospital with diagnosis of NSTE-ACS were enrolled. Baseline demographic information, presenting signs and symptoms, electrocardiogram, and blood chemistry were recorded. In-hospital complications and outcomes of treatment were also collected and recorded. After being discharged from the hospital, patients were followed-up for one year. RESULTS: Two-hundred patients were evaluated between January 2012 and August 2013. A majority of patients (65.5%) presented with angina. Median TIMI risk score was 4. Thirty-two percent of patients had GR ACE risk score greater than 140. In-hospital mortality was 3.5% (95% CI 2.0-7.0). The most common complication was heart failure (36.5%). Three patients had CVA during admission. At one year the mortality rate was 5% (95% CI 3.0-9.0). Unplanned readmission rate was 9.5%. CONCLUSION: Most patients in the registry were high-risk ACS patients. In-hospital mortality and one-year mortality rates were 3.5% and 5%, respectively. Results from this study were comparable to results reported by previous studies from the Western world

Determining the Site of Accessory Pathways in Orthodromic Reciprocating Tachycardia by Using the Response to Right Ventricular Pacing.

BACKGROUND: Postpacing interval (PPI) after right ventricular (RV) pacing entrainment minus tachycardia cycle length (TCL) with a correction for atrioventricular (AV) node delay (corrected PPI-TCL) was useful to differentiate atrioventricular node reentrant tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT). However, the value of corrected PPI-TCL in determining the site of the accessory pathway (AP) in ORT has not been investigated. The purpose of this study was to assess whether the corrected PPI-TCL is useful in differentiating ORT using a left-sided AP from a right-sided AP. METHODS: We studied 52 patients with ORT using a left-sided AP and 13 patients with a right-sided AP. The PPI was measured upon cessation of the RV pacing at a cycle length 10-40 ms shorter than the TCL. The corrected PPI-TCL was calculated from the subtraction of the increment in AV nodal conduction time of the first PPI from the PPI-TCL. RESULTS: The mean corrected PPI-TCL was 83 ± 20 ms in patients with ORT using a left-sided AP and 27 ± 19 ms in patients with a right-sided AP (P ≤ 0.001). All patients with ORT using a left-sided AP except three patients with left septal AP and none of the patients with ORT using a right-sided AP had a corrected PPI-TCL > 55 ms. CONCLUSIONS: The corrected PPI-TCL after the RV pacing entrainment is useful to guide differentiating ORT using a left-sided AP from a right-sided AP.

Identifying factors that influence the length of stay in patients with Non-ST segment elevation acute coronary syndrome in Siriraj Hospital.

OBJECTIVE: Acute coronary syndrome is a leading cause of hospitalization from cardiac disease. The Siriraj NSTE-ACS registry was developed in 2012 as a single center registry. This study purpose is to identify factors affecting the length of stay of the patients in the registry. MATERIAL AND METHOD: From January 2012 to March 2013, 130 patients were enrolled consecutively. The patients were classified into two groups; patients with length of stay > 5 days, and a group of patients with length of stay ≤ 5 days. Comparison of variables of interest among the patient groups was performed using appropriate statistic RESULTS: There were 130 patients in the study. Males were predominate (56.9%). More than 80% of the patients were classified as high-risk based on TIMI risk score ≥ 3. Most patients (64.6%) had LOS > 5 days. Among various variables, coronary angiogram during admission, heart failure at presentation, and GRACE risk score > 130 were associated with LOS > 5 days with the odds ratio of 4.05, 4.34, and 3.23, respectively. Reimbursement policy also had impact on LOS. Using universal coverage as a reference, odds ratio for LOS > 5 days for government paid policy and selfpaid/private insurance policy were 0.28 and 0.05, respectively. CONCLUSION: Factors affecting LOS include CAG during admission, reimbursement policy, heart failure at presentation, and the GRACE risk score > 130. Heart failure at presentation had highest impact on length of stay with an adjusted odds ratio of 4.34.

Recent onset atrial fibrillation: baseline data from Thai subset of RECORD AF study.

BACKGROUND: The RECORD AF study is the first worldwide, prospective, observational 1-year longitudinal survey of real-life management of patients with recently diagnosed atrial fibrillation (AF). The authors present here the baseline data of Thai subset of the study. MATERIAL AND METHOD: The study enrolled consecutive patients of age > or = 18 years, presenting with and treated for AF (< or = 1 year from diagnosis), visiting office- or hospital-based cardiologists. The main primary objectives were to assess therapeutic success and clinical outcomes in rhythm- and rate-control strategies. RESULTS: Of 209 patients recruited between July and December 2007, 200 were eligible for evaluation (mean age: 62.8 years, SD 12.4; 51% males). Hypertension (49%) and dyslipidemia (36%) were the most common underlying cardiovascular diseases (CVDs). Thirty-six point nine percent of patients were at high risk of stroke (CHADS, score > or = 2). In the previous year 93 (52%) patients were diagnosed with paroxysmal AF and 86 (48%) patients with persistent AF. Rate-control was the main treatment strategy used in 151 (75.50%) of the patients, and was more frequently used in persistent AF (94.20%) than paroxysmal AF (61.3%). The most frequent medication used for rhythm-control strategy was amiodarone (83.7%) and, for rate-control strategy, it was beta-blockers (57%). For antithrombotic medication, antiplatelet agents were used in 92 (46%) patients and oral anticoagulation in 86 (43%) patients. CONCLUSION: For Thai patients with AF, hypertension and dyslipidemia were the most common underlying CVDs, and rate control was the preferred treatment strategy. The prospective 1-year data will provide insights on current AF treatment strategies.

The relationship between plasma NT-proBNP level and pacing mode in the patient with implanted permanent pacemaker.

BACKGROUND AND OBJECTIVE: Plasma BNP is current one of the prognostic markers for cardiovascular disease including congestive heart failure. The objective of the present study was to evaluate the level of plasma NT-proBNP in patients who have had permanent pacemaker implantation. MATERIAL AND METHOD: The clinical characteristics and the plasma NT-proBNP level were recorded and obtained from 284 patients with implanted permanent pacemaker followed-up at the Pacemaker Clinic, Siriraj Hospital. The factors associated with abnormal NT-proBNP level were analyzed. RESULTS: Among 284 patients who participated in the present study, 140 patients had NT-proBNP in normal range (level of < 300 pg/ml). 68 patients had NT-proBNP level between 300 to 900 pg/m/ and 76 patients had NT-proBNP level > 900 pg/ml. There were significant correlations between log NT-proBNP with patient's age, left ventricular ejection fraction and serum creatinine level with age and serum creatinine showing positive correlation and left ventricular ejection fraction having a negative correlation. From multiple regression analysis, three factors were associated with high NT-proBNP level: older age, serum creatinine level and ventricular based pacing. The patients with ventricular based pacing mode had higher NT-proBNP level than patients with atrial based pacing mode even after being adjusted for age and serum creatinine adjusted CONCLUSION: In the patient with permanent pacemaker three factors are associated with high NT-proBNP level. These are older age, serum creatinine level, and ventricular based pacemaker.

Inadvertent electrical isolation of the left atrial appendage during catheter ablation of persistent atrial fibrillation.

BACKGROUND: Left atrial appendage (LAA) isolation is rare and may be associated with impaired transport function and thromboembolism. OBJECTIVE: The purpose of this study was to determine the mechanisms of inadvertent isolation of the LAA during atrial fibrillation (AF) ablation. METHODS: This study consisted of 11 patients (ejection fraction 0.43 +/- 0.18, left atrial diameter 51 +/- 8 mm) with persistent AF who had LAA conduction block during a procedure for AF (n = 8) or atrial tachycardia (AT) (n = 3). RESULTS: LAA conduction block occurred during ablation at the Bachmann bundle region in 6 patients, mitral isthmus in 3, LAA base in 2, and coronary sinus in 1. The mean distance from the ablation site to the LAA base was 5.0 +/- 1.9 cm. LAA isolation was transient in all 6 patients in whom LAA conduction was monitored and was permanent in the 4 patients in whom conduction was not monitored during energy delivery. The remaining patient was noted to have LAA isolation during a redo procedure before any ablation. Nine of (82%) the 11 patients have remained arrhythmia-free without antiarrhythmic drugs at mean follow-up of 6 +/- 7 months, and all have continued taking warfarin. CONCLUSION: Electrical isolation of the LAA may occur during ablation of persistent AF and AT even when the ablation site is remote from the LAA. This likely is due to disruption of the Bachmann bundle and its leftward extension, which courses along the anterior left atrium and bifurcates to surround the LAA. Monitoring of LAA conduction during ablation of persistent AF or AT is important in avoiding permanent LAA isolation.

Utility of tachycardia cycle length variability in discriminating atrial tachycardia from ventricular tachycardia.

BACKGROUND: Inappropriate implantable cardioverter-defibrillator (ICD) therapy of atrial tachycardia (AT) with 1:1 atrioventricular (AV) conduction is common because it is difficult to discriminate from ventricular tachycardia (VT) with 1:1 retrograde conduction. Tachycardia cycle length (CL) variability and the relationship between atrial and ventricular CLs may be useful in discriminating AT from VT with 1:1 retrograde conduction. OBJECTIVE: The purpose of this study was to evaluate the usefulness of the relationship between the atrial and ventricular CLs in differentiating AT with 1:1 conduction from VT with 1:1 retrograde conduction. METHODS: We studied 71 patients who had a tachycardia with a 1:1 AV relationship and significant CL variability. Thirty-nine patients had AT (21 inducible and 18 simulated), and 32 patients had VT (11 inducible and 21 simulated). The relationship between atrial and ventricular CLs was examined. RESULTS: A change in atrial CL predicted the change in subsequent ventricular CL in 37 (95%) of 39 patients with AT and in none of the patients with VT. A change in preceding ventricular CL predicted the change in atrial CL in 31 (97%) of 32 patients with VT and in only one (3%) of 39 patients with AT. The sensitivity, specificity, and positive and negative predictive values of a change in atrial CL predicting the change in ventricular CL for AT with significant CL variability were 95%, 100%, 100%, and 94%, respectively. The corresponding values for the change in preceding ventricular CL predicting the change in atrial CL for AT with significant CL variability were 97%. CONCLUSION: The relationship between atrial and ventricular CL is useful in differentiating AT from VT with retrograde conduction. A change in atrial CL that predicts the change in subsequent ventricular CL rules in AT and excludes VT.

Roseomonas gilardii subsp rosea, a pink bacterium associated with bacteremia: the first case in Thailand.

Roseomonas is a pink-pigmented, non-fermentative, gram-negative coccobacillus bacterium. Human infections caused by Roseomonas are very rare. We report the first case of bacteremia associated with Roseomonas gilardii subsp rosea in Thailand. The bacterium was isolated from blood culture and identified by cellular morphology, characteristics of colonies on blood agar, extensive biochemical tests and 16S ribosomal DNA sequencing.

Primary percutaneous coronary intervention in acute myocardial infarction at Siriraj Hospital: the improvement over time.

OBJECTIVE: To evaluate the efficacy of the acute ST segment elevation treatment guidelines in reducing the door-to-balloon time at Siriraj Hospital. MATERIAL AND METHOD: Retrospective analysis of the data and records obtained from one hundred and twenty eight patients who underwent primary percutaneous intervention for acute ST segment elevation myocardial infarction at Siriraj Hospital between June 2002 and February 2006. Control chart analysis was applied to evaluate the efficacy of the guidelines. RESULTS: The mean door-to-balloon time was consistently reduced from 243.23 minutes before to 137.13 minutes after the guidelines implementation. Control chart analysis showed that this reduction in door-to-balloon time reached statistical significance. CONCLUSION: The guidelines developed by a multidisciplinary approach could effectively reduce the door-to-balloon time.