Acute heart failure with mildly reduced ejection fraction and myocardial infarction: a multi-institutional cohort study.

BACKGROUND: Little research has been done on ischemic outcomes related to left ventricular ejection fraction (EF) in acute decompensated heart failure (ADHF). METHODS: A retrospective cohort study was conducted between 2001 and 2021 using the Chang Gung Research Database. ADHF Patients discharged from hospitals between January 1, 2005, and December 31, 2019. Cardiovascular (CV) mortality and heart failure (HF) rehospitalization are the primary outcome components, along with all-cause mortality, acute myocardial infarction (AMI) and stroke. RESULTS: A total of 12,852 ADHF patients were identified, of whom 2,222 (17.3%) had HFmrEF, the mean (SD) age was 68.5 (14.6) years, and 1,327 (59.7%) were males. In comparison with HFrEF and HFpEF patients, HFmrEF patients had a significant phenotype comorbid with diabetes, dyslipidemia, and ischemic heart disease. Patients with HFmrEF were more likely to experience renal failure, dialysis, and replacement. Both HFmrEF and HFrEF had similar rates of cardioversion and coronary interventions. There was an intermediate clinical outcome between HFpEF and HFrEF, but HFmrEF had the highest rate of AMI (HFpEF, 9.3%; HFmrEF, 13.6%; HFrEF, 9.9%). The AMI rates in HFmrEF were higher than those in HFpEF (AHR, 1.15; 95% Confidence Interval, 0.99 to 1.32) but not in HFrEF (AHR, 0.99; 95% Confidence Interval, 0.87 to 1.13). CONCLUSION: Acute decompression in patients with HFmrEF increases the risk of myocardial infarction. The relationship between HFmrEF and ischemic cardiomyopathy, as well as optimal anti-ischemic treatment, requires further research on a large scale.

Ivabradine in heart failure patients with reduced ejection fraction and history of paroxysmal atrial fibrillation.

AIMS: Ivabradine is indicated for heart failure (HF) patients with reduced ejection fraction (HFrEF), but limited data are available with regards to the use of ivabradine in those with a history of paroxysmal atrial fibrillation (AF). To assess the effect of ivabradine in HFrEF patients with paroxysmal AF, we analysed heart failure (HF) hospitalization and mortality from multiple-centre registry database. METHODS AND RESULTS: We conducted a multicentre observational matched cohort study, and this study enrolled patient with symptomatic HFrEF from 1 January 2015 to 31 December 2018 who had a history of paroxysmal AF in Chang Gung Memorial Hospital medical database in Taiwan. A total of 2042 patients were eligible for the study, of whom 887 were prescribed with ivabradine and 1115 were not. The primary outcome, including HF hospitalization and cardiovascular death, and individual outcome during the 12 month observation period were analysed after inverse probability of treatment weighting. The ivabradine group had significantly lower mean heart rate after 12 months follow-up than the non-ivabradine group (P < 0.05). The primary outcome was significantly higher in the ivabradine group than the non-ivabradine group after 12 months follow-up (hazard ratio [HR] = 1.58; 95% confidence interval [CI], 1.26-2.00, P < 0.001). Moreover, the ivabradine group had a significantly higher event rate of HF hospitalization (HR = 1.56; 95% CI, 1.40-1.75, P < 0.001) and HF death (HR = 1.67; 95% CI, 1.14-2.44, P = 0.009) than the non-ivabradine group. CONCLUSIONS: Ivabradine treatment was associated with an increased risk of HF hospitalization in symptomatic HFrEF patients with a history of paroxysmal AF. Further prospective randomized studies are warranted.

The Impact of Hepatitis C Virus, Metabolic Disturbance, and Unhealthy Behavior on Chronic Kidney Disease: A Secondary Cross-Sectional Analysis.

BACKGROUND: Hepatitis C virus (HCV) infection is associated with a higher risk of chronic kidney disease (CKD). This study investigates the relationship among HCV, CKD, and understudied confounders, such as unhealthy behaviors and metabolic disturbances. METHODS: This cross-sectional study was conducted as part of a community health promotion program in an HCV endemic area of Taiwan from June to December 2019. Multivariable logistic regression analyses adjusted for demographic and clinical characteristics were performed to investigate the association between CKD and HCV seropositivity. RESULTS: Of 2387 participants who underwent health check-ups, the mean age was 64.1 years old; females predominated (63.2%), and 306 (12.8%) subjects were seropositive for HCV. CKD, defined as a lower estimated glomerular filtration rate (eGFR) was associated with unhealthy dietary habits, metabolic syndrome, and HCV. Less frequent exercise, higher waist circumference (WC) and HbA1c all affected risk of CKD; HCV increased risk of CKD by 44% compared to non-HCV (OR 1.44, 95% confidence interval (CI) 1.05-1.98) in the multivariable analysis. In the HCV group, lower eGFR was also significantly associated with the severity of metabolic syndrome (MetS) (median eGFR was 86.4, 77.1, and 64.5 mL/min/1.73 m2 for individuals with three and five MetS components, respectively). CONCLUSIONS: Beyond metabolic disturbance and irregular exercise, HCV seropositivity is independently associated with CKD in a community survey. Healthy lifestyle promotion might protect against renal function decline in HCV; however, the mechanisms underlying the association need further large-scale investigation.

Cardioselective Versus Nonselective ß-Blockers After Myocardial Infarction in Adults With Chronic Obstructive Pulmonary Disease.

OBJECTIVE: To investigate which types of ß-blockers have better efficacy and safety profiles in patients with concomitant chronic obstructive pulmonary disease (COPD) and myocardial infarction (MI) to address concerns about use of ß-blockers in COPD. METHODS: We identified 65,699 patients with COPD prescribed ß-blockers after first MI in the Taiwan National Health Insurance Research Database between January 1, 2001, and December 31, 2013. Comparisons were performed using the inverse probability of treatment weighting method. The primary outcome was all-cause mortality; secondary outcomes were heart failure hospitalization, major adverse cardiac and cerebrovascular event (MACCE), and major adverse pulmonary event (MAPE). RESULTS: A total of 14,789 patients prescribed ß-blockers were enrolled, of whom 7247 (49.0%) used cardioselective ß-blockers and 7542 (51.0%) used nonselective ß-blockers. The cardioselective group had lower incidence rates of mortality (hazard ratio [HR], 0.93; 95% CI, 0.89 to 0.96), MACCE (HR, 0.96; 95% CI, 0.93 to 0.998), heart failure hospitalization (subdistribution HR, 0.84; 95% CI, 0.78 to 0.91), and MAPE (HR, 0.94; 95% CI, 0.90 to 0.98) at the end of follow-up after weighting. Similar results were also found in subgroup analysis between those prescribed bisoprolol and those prescribed carvedilol. CONCLUSION: Patients prescribed a cardioselective ß-blocker may have a lower incidence of all-cause mortality, MACCE, heart failure hospitalization, and MAPE than those prescribed a nonselective ß-blocker. Cardioselective ß-blocker treatment during hospitalization and continuing after discharge appears to be superior to nonselective ß-blocker treatment in patients with COPD after MI.

The effect of deep vein thrombosis on major adverse limb events in diabetic patients: a nationwide retrospective cohort study.

Little is known about the association between deep vein thrombosis (DVT) and arterial complications in patients with type 2 diabetes (T2DM). The aim of this retrospective cohort study was to assess the influence of prior DVT on major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) in T2DM. A total of 1,628,675 patients with T2DM with or without a history of DVT from 2001 to 2013 were identified in the National Health Insurance Research Database of Taiwan. Before matching, the patients in the DVT group (n = 2020) were older than the control group (66.3 vs. 58.3 years). Patients in the DVT group were more likely to be female than the control group (54.3% vs. 47.5%). Before matching, the DVT group had higher prevalence of most comorbidities, more prescription of antiplatelet, antihypertensive agents and insulins, but less prescription of metformin and sulfonylurea. During a mean follow-up of 5.2 years (standard deviation: 3.9 years), the matched DVT group (n = 2017) have a significantly increased risk of MALE (8.4% vs. 5.2%; subdistribution hazard ratio [SHR] 1.60, 95% CI 1.34-1.90), foot ulcer (5.2% vs. 2.6%, SHR 1.96, 95% CI 1.57-2.45), gangrene (3.4% vs. 2.3%, SHR 1.44, 95% CI 1.10-1.90) and amputation (2.5% vs. 1.7%; SHR 1.42, 95% CI 1.03-1.95) than the 10,085 matched controls without DVT. They also tended to have a greater risk of all-cause mortality (38.1% vs. 33.1%; hazard ratio [HR] 1.18, 95% CI 1.09-1.27) and systemic thromboembolism (4.2% vs. 2.6%; SHR 1.56, 95% CI 1.22-1.99), respectively. We showed the presence of DVT may be associated with an increased risk of MALEs, major amputation, and thromboembolism, contributing to a higher mortality rate in T2DM.

The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study.

BACKGROUND: Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients. METHODS: This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths. RESULTS: After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients' completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86-0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45-0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson's Comorbidity Index scores and infection-related hospitalization in the previous 3 years. CONCLUSIONS: The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients.

Effect of initiating statin therapy on long-term outcomes of patients with dyslipidemia after intracerebral hemorrhage.

BACKGROUND AND AIMS: Intracerebral hemorrhage (ICH) has a higher mortality than ischemic stroke. Statin is beneficial for stroke, but high potency statin treatment has been associated with the risk of hemorrhagic stroke. The aim of this study was to assess the impact of initiating statin therapy after ICH on cardiovascular outcomes. METHODS: Dyslipidemic patients were retrieved from the ICH population from the National Health Insurance Research Database in Taiwan. We retrospectively compared patients prescribed with and without statin treatment after ICH. Outcomes of interest were mortality, myocardial infarction, ischemic stroke, and hemorrhagic stroke during 5 years of follow-up. RESULTS: Of 17,980 adult patients with ICH and dyslipidemia, 8927 were eligible for analysis over the study period, including 1613 patients receiving statin therapy and 7314 patients not taking statins. After propensity score matching, the mean age was 61.2 ±â€¯12.2 years in the statin group and 61.6 ±â€¯13.0 years in the non-statin group. Hypertension was dominant, followed by diabetes mellitus, and the mean estimated NIHSS score was 12.9. The patients who received statin therapy were associated with lower risks of all-cause mortality (12.7% vs. 21.3%; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.45-0.65), cardiovascular death (4.0% vs. 7.1%; HR, 0.54; 95% CI, 0.39-0.75) and ICH (5.4% vs. 8.5%; HR, 0.62; 95% CI, 0.46-0.83) compared to those who did not receive statins. CONCLUSIONS: Initiating statin therapy after ICH was associated with a decreased risk of recurrent ICH and mortality for dyslipidemia patients.

Association between hepatitis C virus infection and osteoporotic fracture risk among postmenopausal women: a cross-sectional investigation in Taiwan.

PURPOSE: Early low bone mass is a risk factor for osteoporotic fractures associated with multiple factors, including menopause and chronic liver diseases. Hepatitis C virus (HCV) also plays a major role in chronic liver disease and has many extrahepatic consequences, such as decreased bone mineral density (BMD). This study aimed to examine the hypothesis that HCV seropositivity is independently associated with menopausal BMD loss. METHODS: This community-based, cross-sectional study was based in two rural townships in Yunlin County, Taiwan. A total of 636 menopausal women aged 45-80 years who underwent annual health checks were included. Viral markers of HCV, dual-energy X-ray absorptiometry and fracture risk assessment tool (FRAX) scores were measured. Logistic regression analysis was performed to assess the association between various predictors and the presence of low BMD. RESULTS: The participants (median age: 65 years) had a HCV seropositivity rate of 32.2%. BMD was significantly lower in the HCV-seropositive participants in different anatomic locations than in the seronegative individuals (lumbar spine: -1.5 vs -1.1; total hip: -0.9 vs -0.6; femoral neck: -1.2 vs -1.0; p<0.05). HCV-seropositive subjects had higher rates of major osteoporotic fractures (11.3%±7.6%vs 9.0±6.8%; p<0.001) and hip fractures (3.4%±4.7%vs 2.3±4.9%; p=0.006) and a higher risk of lower BMD (osteopenia and osteoporosis) based on a multivariable regression analysis (adjusted OR: 1.8; 95% CI 1.16 to 2.81; p=0.009). CONCLUSIONS: HCV infection may be an independent risk factor for menopausal BMD loss and fractures predicted by FRAX.

In-hospital and post-discharge outcomes of pediatric acute myocarditis underwent after high-dose steroid or intravenous immunoglobulin therapy.

BACKGROUND: High-dose steroids and intravenous immunoglobulin (IVIG) are controversial treatments for pediatric patients with acute myocarditis. This study aimed to investigate their efficacies in the Taiwanese pediatric population. METHODS: This study evaluated 5563 acute myocarditis patients from the Taiwan's National Health Insurance Research Database and identified 1542 pediatric patients hospitalized for acute myocarditis between January 1, 2001 and December 31, 2011. The exclusion criteria were age of > 11 years, associated cardiovascular comorbidities, autoimmune disease, malignancy before the index hospitalization, extracorporeal membrane oxygenation, intra-aortic balloon pumping, and dual therapy using IVIG and high-dose steroids. RESULTS: After 2:1 propensity score matching, we identified 208 subjects without steroid therapy and 104 subjects who received high-dose steroids. The mean age in that cohort was 2.6 ± 2.9 years, and high-dose steroid therapy had no significant effects on major in-hospital complications and post-discharge outcomes. After 2:1 propensity score matching, we identified 178 subjects without IVIG therapy and 89 subjects who received IVIG. The mean age in that cohort was 2.0 ± 2.1 years, and IVIG had no significant effects on the major outcomes. CONCLUSIONS: The present study revealed that high-dose steroid or IVIG therapy had no significant effects on major in-hospital complications, late heart failure hospitalization, and long-term mortality.

Gender Differences and Work-Family Conflicts among Emergency Physicians with Intention to Leave.

BACKGROUNDS: The objective of this study was to investigate the relationships among intention to leave, emergency physician clinical activities, work-family conflicts, and gender differences in emergency physicians (EPs). METHODS: The survey instrument was a self-administered questionnaire containing basic demographic information and characteristics of clinical activities. The work-family conflicts were assessed by the Chinese version of the work-family conflict (WIF) scale. The questionnaires were mailed to board-certified EPs between January 2014 and August 2014. Student's t-test, Chi-square test, and one-way analysis of variance (ANOVA) were used to test the difference between subgroups. Logistic regression analysis was performed to determine the factors associated with intention to leave and gender differences. RESULTS: The study included 222 respondents for analysis after exclusions. Compared with physicians not planning to leave, those planning to leave ED practice showed higher dissatisfaction with their clinical work hours (50.0% versus 31.4%, p = 0.035) and night/day shift ratio (52.9% versus 31.0%, p = 0.013) and tended to work with night/day shift ratio exceeding 40% (67.6% versus 45.7%, p = 0.019). Female physicians were more likely to leave ED practice (females versus males, 26.5% versus 10.1%, p = 0.008). A significantly higher level of WIF scale was noted in the group with intention to leave ED practice (3.7 ± 0.6 versus 3.3 ± 0.7, p = 0.001). CONCLUSIONS: Females and EPs with higher level of WIF scale were more likely to leave emergency clinical practice. Instead of the number of clinical practice hours, the satisfaction with the clinical work hours and night shift frequency were significantly associated with the intention to leave.

Heart Failure and Mortality of Adult Survivors from Acute Myocarditis Requiring Intensive Care Treatment - A Nationwide Cohort Study.

Background The correlation between severity and long-term outcomes of pediatric myocarditis have been reported, however this correlation in adults has rarely been studied. Materials and Methods This nationwide population-based cohort study used data from the National Health Insurance Research Database in Taiwan. Patients aged < 75 and > 18 years admitted to an intensive care unit due to acute myocarditis were enrolled and divided into three groups according to mechanical circulatory support (MCS) after excluding major comorbidities. All-cause mortality, cardiovascular death, and heart failure hospitalization were evaluated from January 1, 2001 to December 31, 2011. Results There were 1145 patients with acute myocarditis (mean age 40.2 years, SD: 14.8 years), of which 851 did not require MCS, 99 underwent intra-aortic balloon pump (IABP) support, and 195 extracorporeal membrane oxygenation (ECMO) support. There was no significant difference in heart failure hospitalization between the three groups after index admission. The incidence of cardiovascular death after discharge ranged from 10 % to 22%, which was highest in the ECMO group, and was also significantly different between the three groups within 3 months (p<0.001) but it disappeared after 3 months (p=0.458). The trend was also noted in incidence of all-cause mortality. Conclusions The severity of acute myocarditis did not affect long-term outcomes, however, it was associated with cardiovascular/all-cause death within 3 months after discharge.

Moderate to high intensity statin in dialysis patients after acute myocardial infarction: A national cohort study in Asia.

BACKGROUND AND AIMS: Statin is not beneficial for dialysis patients but moderate to high intensity statin is beneficial for patients after acute myocardial infarction (MI). The aim of this study was to evaluate the effect of moderate to high intensity statin on mortality, cardiovascular outcomes in dialysis patients after acute MI. METHODS: Data on dialysis patients were retrieved from the National Health Insurance Research Database in Taiwan. Dialysis patients admitted for MI were selected and divided into two groups according to statin prescription or not after MI. All-cause mortality and cardiovascular outcomes after a 4-year follow-up were analyzed after propensity score matching (PSM). RESULTS: We identified 790 patients who received moderate to high intensity statin therapy and 1788 patients who did not receive any statins after acute MI and clinical outcomes were analyzed after 1:1 PSM. The benefit of statin on mortality therapy appeared from 1 year to the end of the 4-year follow-up period after hospitalization (statin group versus non-statin group: 22.9% vs. 31.1% at 1 year (HR: 0.70; 95% CI: 0.58-0.85); 48.0% vs. 55.1% at the end of the 4 years (HR: 0.76; 95% CI: 0.67-0.88)). In addition, the impact of statin therapy was stronger in patients with shock at admission (p = 0.035). There were no differences in any individual cardiovascular outcome or adverse event. CONCLUSIONS: Moderate to high intensity statin therapy might lower all-cause mortality in dialysis patients after acute MI, especially those with shock, but not influence cardiovascular outcomes and any adverse events.

Predictors of Left Ventricle Remodeling: Combined Plasma B-type Natriuretic Peptide Decreasing Ratio and Peak Creatine Kinase-MB.

Background: Previous studies reported that patients who had an acute myocardial infarction (AMI) have found that measuring B-type natriuretic peptide (BNP) during the subacute phase of left ventricular (LV) remodeling can predict the possible course of LV remodeling. This study assessed the use of serial BNP serum levels combined with early creatine kinase-MB (CK-MB) to predict the development of significant LV remodeling in AMI patients. Methods: Nighty-seven patients with new onset AMI were assessed using serial echocardiographic studies and serial measurements of BNP levels, both performed on day-2 (BNP1), day-7 (BNP2), day-90 (BNP3), and day-180 (BNP4) after admission. LV remodeling was defined as >20% increase in biplane LV end-diastolic volume on day-180 compared to baseline (day-2). Results: Patients were divided into LV remodeling [LVR(+)] and non LV remodeling [LVR(-)] groups. No first-week BNP level was found to predict remodeling. However, the two groups had significantly different day-90 BNP level (208.1 ± 263.7 pg/ml vs. 82.4 ± 153.7 pg/ml, P = 0.039) and significantly different 3-month BNP decrease ratios ( R BNP13) (14.4 ± 92.2% vs. 69.4 ± 25.9%, P < 0.001). The appropriate cut-off value for R BNP13 was 53.2% (AUC = 0.764, P < 0.001). Early peak CK-MB (cut-off 48.2 ng/ml; AUC = 0.672; P = 0.014) was another independent predictor of remodeling. Additionally, combining peak CK-MB and R BNP13 offered an excellent discrimination for half-year remodeling when assessed by ROC curve (AUC = 0.818, P < 0.001). Conclusion: R BNP13 is a significant independent predictor of 6-month LV remodeling. The early peak CK-MB additionally offered an incremental power to the predictions derived from serial BNP examinations.

Association of brachial-ankle pulse wave velocity with atherosclerosis and presence of coronary artery disease in older patients.

OBJECTIVE: Brachial-ankle pulse wave velocity (baPWV) is a simple and reproducible measure of arterial stiffness and is extensively used to assess risk of cardiovascular disease in Asia. We examined whether baPWV was associated with coronary atherosclerosis and presence and extent of coronary artery disease (CAD) in older patients with chest pain. METHODS: This cross-sectional study enrolled 370 consecutive patients >65 years old who underwent baPWV measurement and elective coronary angiogram for suspected CAD at a single cardiovascular center, between June 2013 and July 2014. RESULTS: In addition to diabetes mellitus and body mass index, baPWV was one of the statistically meaningful predictors of significant CAD (diameter of stenosis >50%) in a multivariate analysis. When the extent of CAD was classified as nonsignificant or significant CAD (ie, one-, two-, and three-vessel disease), there was a significant difference in baPWV between the significant and nonsignificant CAD groups, but not between the three significant CAD groups. Multivariate linear regression analyses showed that the number of diseased vessels and baPWV were both significantly associated with the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score. The cutoff value of baPWV at 1,874 cm/s had a sensitivity of 60.1%, specificity of 70.8%, and area under receiver operating characteristic curve of 0.639 in predicting CAD. CONCLUSION: Arterial stiffness determined by baPWV was associated independently with CAD severity, as assessed by angiography and the SYNTAX score in older patients with chest pain. As a result, increased arterial stiffness assessed by baPWV is associated with the severity and presence of CAD in older patients.

Differences in prevalence and severity of coronary artery disease by three metabolic syndrome definitions.

BACKGROUND: People with metabolic syndrome (MS) are at increased risk for cardiovascular disease-associated morbidity and all-cause mortality. However, predicting the severity of coronary artery disease (CAD) according to different MS definitions is controversial. This study explores the prevalence and severity of CAD according to different MS definitions, focusing on their predictive value. METHODS: We enrolled 690 Taiwanese adults with CAD in this study. Coronary artery lesions were classified by the modified American Heart Association-American College of Cardiology grading system. MS was diagnosed in 3 groups of randomly assigned subjects according to World Health Organization (WHO), International Diabetes Federation (IDF), and revised Adult Treatment Panel III (rATP III) criteria. RESULTS: More MS components and more severe CAD were identified in the WHO group. Prevalence of MS in the WHO, IDF, and rATP III groups was 33.9%, 47.4%, and 52.8%, respectively (P < 0.001). Mean lesion and culprit vessel numbers were slightly higher in WHO-group patients. The WHO group had more complex stenoses with type C classification than did the IDF and rATP III groups (32.7%, 26.3%, and 28.1%; P = 0.041) and significantly more calcified stenoses (21.5%, 16.2%, and 16.4%; P = 0.027). In a comparison of CAD severity by complex morphology lesions, the area under the receiver operating characteristic curve was higher in the WHO group (0.552; 95% confidence interval, 0.509-0.595; P = 0.019). CONCLUSION: Compared with IDF and rATP III definitions, the WHO definition of MS has superior predictive value of CAD severity in Taiwanese patients.