Impact of diet intervention on visceral adipose tissue and hepatic fat in patients with obesity or type 2 diabetes: a randomized trial.

This study aimed to assess the effects of a diet intervention on visceral and hepatic fat in patients with obesity or type 2 diabetes (T2D). Participants with obesity or T2D were randomized to a diet intervention or their usual diet. The intervention comprised a "3G rice" regimen combined with a low-salt, high-fiber diet. The primary outcomes were changes in visceral adipose tissue (VAT) area and hepatic fat over 12 weeks assessed by magnetic resonance imaging. Eighty-six patients were randomized. Their mean age was 47.5 ± 11.0 years, and 82.3% were female. Eighty-one (94.2%) had obesity, and 16 (18.6%) had T2D. Baseline metrics were body weight 76.3 ± 16.1 kg, BMI 29.6 ± 4.6, VAT 12 629 ± 5819 mm2, and hepatic fat 7.9% ± 7.2%. At the 12-week follow-up, the diet group had greater VAT and hepatic fat reductions than controls (- 1468 ± 1468 vs. - 179 ± 1576 mm2, P = 0.001; and - 2.6% ± 3.4% vs. 0.4% ± 2.2%, P < 0.001). Adjusted differences remained significant for VAT (- 1093 mm2, P < 0.001) and hepatic fat (- 2.5%, P < 0.001). In conclusion, the 12-week diet intervention decreased VAT, hepatic fat, body weight, and BMI compared to a usual diet.

Components of the Atrial fibrillation Better Care pathway for holistic care of patients with atrial fibrillation: a win ratio analysis from the COOL-AF registry.

AIMS: Compliance with integrated care based on the Atrial fibrillation Better Care (ABC) pathway has been associated with improved clinical outcomes. The primary objective of this study was to compare clinical outcomes of AF patients according to the compliant status of each component of the ABC pathway in a hierarchical win ratio approach. METHODS AND RESULTS: We studied AF patients in the COOL-AF registry. Each patient was followed every 6 months until 3 years. A win ratio analysis was performed, as not all clinical outcomes are equivalent. The hierarchical outcomes were (1) all-cause death, (2) intracranial haemorrhage (ICH), (3) ischaemic stroke/systemic embolism, (4) non-ICH major bleedings, and (5) acute myocardial infarction or heart failure. We also assessed win ratio and win proportion variance over the follow-up time, and the variations over time. A total of 3405 patients (mean age 67.8 ± 11.3; 41.8% female) were studied. Win ratio of ABC-compliant (all three components) vs. ABC-not-compliant was 1.57 (1.35-1.83), P < 0.001. When adding time in therapeutic range (TTR) data for compliant criteria for those who were on warfarin, the win ratio increased to 2.28 (1.89-2.75), P < 0.001. The A-compliant group (plus TTR data), B-compliant, and C-compliant had the win ratio of 1.81 (1.51-2.12), 1.82 (1.53-2.16), and 1.39 (1.18-1.62), all P < 0.001, compared to not compliant group. CONCLUSION: Management of AF patients according to each component of the ABC pathway is associated with better clinical outcomes compared to those non-compliant to ABC pathway. This finding underscores the importance of a holistic management approach strategy for AF patients.

Warfarin Adherence and Its Associated Factors in Thai Older Adults with Atrial Fibrillation.

Introduction: Older people mostly found unable to adhere with warfarin treatment guidelines. The health service system is challenged in order to improve medication adherence in older population under limited health resources. The purpose of this study was to explore health systems factors on warfarin adherence in older population, particularly in resources constraint setting. Methods: This study was a cross-sectional predictive study that enrolled older people who experienced atrial fibrillation (AF) and treated by warfarin, aged 60 years and over, and followed up at the warfarin clinic. Results: A total of 197 participants with the mean age of 72.03 years (SD = 8.84) was recruited. Almost of them (85.8%) reported adhered to warfarin prescription. More than a half (60.5%) were able to report their targeted INR. Participants who stayed with the family had 5.54 times (95% CI 1.79-19.33), took regular daily dose warfarin had 5.07 times (95% CI 1.05-24.49), perceived targeted INR had 2.94 times (95% CI 1.04-8.29), and received family support had 1.33 times (95% CI 1.11-1.60) increased odds of warfarin adherence than those who did not. Participants who perceived a barrier to taking medication had 0.93 times decreased odds of warfarin adherence than those who did not (95% CI 0.86-0.99). Conclusion: Healthcare system should encourage family to support the older population with AF in order to increase warfarin adherence. Future research should develop intervention combining family support to promote warfarin adherence.

Cardiac Magnetic Resonance Left Atrial Strain in the Prediction of Death, Ischemic Stroke, and Heart Failure.

BACKGROUND: To determine the prognostic value of left atrial strain (LAS) using cardiac magnetic resonance for predicting death, heart failure, and ischemic stroke in patients with known or suspected coronary artery disease with preserved left ventricular systolic function and no prior history of ischemic stroke, heart failure, or atrial fibrillation. METHODS AND RESULTS: This retrospective cohort analysis included patients referred for stress cardiac magnetic resonance or myocardial viability studies between September 2017 and December 2019. Patients with impaired left ventricular systolic function (<50%) or a history of atrial fibrillation, stroke, or heart failure were excluded. A multivariable Cox model assessed the prognostic value of LAS, with the primary outcomes being the composite outcomes of all-cause death, ischemic stroke, and heart failure. A total of 2030 participants were included in the study. The average LAS was 24.1±8.5%; 928 had LAS <23%, and 1102 had LAS ≥23%. The mean follow-up duration was 39.9±13.6 months. There were 49 deaths (2.4%), 32 ischemic strokes (1.6%), and 34 heart failure events (1.7%). Patients with LAS <23% were at greater risk for composite outcome, with an adjusted hazard ratio of 2.31 (95% CI, 1.50-3.55). CONCLUSIONS: LAS by cardiac magnetic resonance has an independent and incremental prognostic value for death, ischemic stroke, and heart failure in patients with preserved left ventricular systolic function. This prognostic value is observed after adjusting for clinical and cardiac magnetic resonance parameters, including left ventricular systolic function, late gadolinium enhancement, and left atrial volume index.

Clinical outcomes of patients with atrial fibrillation in relation to multimorbidity status changes over time and the impact of ABC pathway compliance: a nationwide cohort study.

Patients with atrial fibrillation (AF) commonly have associated comorbidities. The primary aim was to determine the effect of increasing numbers of comorbidity on clinical outcomes. The secondary aims were (1) the association of comorbidities with oral anticoagulants (OAC) discontinuation, and quality control, (2) the impact of holistic care based on the ABC pathway on clinical outcomes. The primary outcome was the composite of all-cause death, ischemic stroke/systemic embolism, major bleeding, and heart failure. A total of 3405 patients were enrolled; mean age 67.8 ± 11.3 years, 41.8% female. Compared to low comorbidity group [n = 897 (26.3%)], hazard ratios (HR) and 95% confidence intervals (CI) for the composite outcome in the high [n = 929 (27.3%)] and moderate comorbidity [n = 1579 (46.4%)] groups were 5.40 (4.20-6.94) and 2.54 (1.97-3.27), respectively. ABC pathway adherence was associated with reduction of the composite outcome overall (HR 0.63; 0.54-0.74). High comorbidity adversely impacted on OAC use, OAC discontinuation, and quality of warfarin control. If quality of anticoagulation control was included as part of the ABC pathway adherence, the reduction in composite outcome risk was greater (HR 0.46; 0.36-0.58). During 3-year follow-up, 33.9% changed from low- to the moderate-high comorbidity groups and 22.3% changed from moderate- to the high comorbidity group. In conclusion, comorbidity burden in AF patients is an important determinant of clinical outcomes, and changed over time. OAC use, OAC discontinuation, and quality of OAC control were impacted by comorbidity burden. ABC pathway adherence was associated with a reduced risk of adverse clinical outcomes.

Prognostic value of global longitudinal strain in patients with preserved left ventricular systolic function: A cardiac magnetic resonance real-world study.

BACKGROUND: Myocardial strain is a more sensitive parameter for cardiac function evaluation than left ventricular ejection fraction (LVEF). This study aimed to assess the predictive value of left ventricular global longitudinal strain (LV-GLS) by feature tracking-cardiac magnetic resonance (FT-CMR) imaging in patients with known or suspected coronary artery disease (CAD) with preserved left ventricular systolic function. METHODS: This retrospective cohort analysis enrolled patients with known or suspected CAD who underwent cardiac magnetic resonance imaging from September 2017 to December 2019. LV-GLS was analyzed via feature-tracking analysis. Patients with LVEF <50% were excluded. The composite outcome comprised all-cause death, non-fatal myocardial infarction, and heart failure. RESULTS: There was a total of 2613 patients. Mean follow-up duration was 39.7 ± 13.9 months. During follow-up, 194 patients (7.4%) experienced a composite outcome. The best cutoff of LV-GLS in the prediction of composite outcome from receiver operating characteristics was -14.4%. Patients were classified into 2 groups according to the LV-GLS; 1489 (57.0%) had LV-GLS <-14.4% and 1124 (43.0%) had LV-GLS ≥-14.4%. Patients with LV-GLS ≥-14.4% had a significantly higher rate of composite outcome than LV-GLS <-14.4% patients (3.59 vs. 1.39 per 100 person-years, respectively; p < 0.001). Multivariable analysis showed that patients with LV-GLS ≥-14.4% had a significantly higher risk of experiencing a composite outcome event compared to global longitudinal strain <-14.4% patients (adjusted hazard ratio: 1.83, 95% confidence interval: 1.28-2.61; p = 0.001). CONCLUSION: LV-GLS by FT-CMR was shown to be useful for predicting the prognosis of patients with known or suspected CAD with preserved left ventricular systolic function. LV-GLS -14.4% was the identified cutoff for prognostic determination.

Reassessing heart failure therapy in Thailand: Patient insights and treatment outcomes from the Thai heart failure registry.

BACKGROUND: This research analyzed the demographics, management, and outcomes of patients with heart failure (HF) in Thailand. METHODS: The Thai Heart Failure Registry prospectively enrolled patients diagnosed with HF from 36 hospitals in Thailand. Follow-up data were recorded at 6, 12, 18, and 24 months. This study primarily focused on two outcomes: mortality and HF-related hospitalizations. RESULTS: The study included 2639 patients aged at least 18. Their mean age was 59.2 ± 14.5 years, and most were male (68.4%). Patients were classified as having HF with reduced ejection fraction (HFrEF, 80.7%), HF with preserved ejection fraction (HFpEF, 9.0%), or HF with mildly reduced ejection fraction (HFmrEF, 10.3%). Guideline-directed medical therapy utilization varied. Beta-blockers had the highest usage (93.2%), followed by mineralocorticoid receptor antagonists (65.7%), angiotensin-converting enzyme inhibitors (39.3%), angiotensin receptor blockers (28.2%), angiotensin receptor-neprilysin inhibitors (16.1%), and sodium-glucose cotransporter-2 inhibitors (8.0%). The study monitored a composite of mortality and HF incidents, revealing incidence rates of 11.74, 12.50, and 8.93 per 100 person-years for the overall, HFrEF, and HFmrEF/HFpEF populations, respectively. CONCLUSIONS: Despite high guideline-directed medical therapy adherence, the Thai Heart Failure Registry data revealed high mortality and recurrent HF rates. These findings underscore limitations in current HF treatment efficacy. The results indicate the need for further investigation and improvements of HF management to enhance patient outcomes.

Employing Real-World Evidence for the Economic Evaluation of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation in Thailand.

BACKGROUND: This study aimed to assess the cost-effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) in comparison with warfarin using data from real practice based on the perspective of the health care system in Thailand. METHODS: A four-state Markov model encompassing well-controlled atrial fibrillation (AF), stroke and systemic embolism, major bleeding and death was utilised to forecast clinical and economic outcomes. Transitional probabilities, direct medical costs and utilities were derived from the real-world data of the 'COOL-AF Thailand' registry, Thailand's largest nationwide registry spanning 27 hospitals. The cohort comprised AF patients. The primary outcomes assessed were total costs, life years, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio. All costs and outcomes were subject to an annual discount rate of 3.0%. A spectrum of sensitivity analyses was conducted. RESULTS: The mean age of the cohort was 68.8 ± 10.7 years. The NOACs group incurred a marginally lower total lifetime cost than the warfarin group (247,857 Thai baht [THB] vs 253,654 THB or 7137 USD vs 7304 USD) and experienced gains of 0.045 life years and 0.043 QALYs over the warfarin group. Given the lower cost and higher benefits associated with NOACs, this implies that NOAC treatment is a dominant strategy compared to warfarin for AF patients. At a ceiling ratio of 160,000 THB (4607 USD) per QALY, NOACs presented a 61.2% probability of being cost effective. CONCLUSIONS: Non-vitamin K antagonist oral anticoagulants represent a cost-saving alternative to warfarin in the real clinical practice. However, with a probability of being cost effective below 65%, it suggests some parameter uncertainty regarding their overall cost effectiveness compared to warfarin.

Relation of changes in ABC pathway compliance status to clinical outcomes in patients with atrial fibrillation: A report from the COOL-AF registry.

AIM: The Atrial fibrillation Better Care (ABC) pathway provides a framework for holistic care management of atrial fibrillation (AF) patients. This study aimed to determine the impact of changes in compliance to ABC pathway management on clinical outcomes. METHODS: This is a prospective multicenter AF registry. Patients with non-valvular AF were enrolled and follow-up for 3 years. Baseline and follow-up compliance to the ABC pathway was assessed. The main outcomes were all-cause death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. RESULTS: There studied 3096 patients (mean age 67.6 ± 11.1 years, 41.8% female). Patients were categorized into 4 groups: Group 1: ABC compliant at baseline and 1 year [n = 1022 (33.0%)]; Group 2: ABC non-compliant at baseline but compliant at 1 year [n = 307 (9.9%)]; Group 3: ABC compliant at baseline and non-compliant at 1 year [n = 312 (10.1%)]; and Group 4: ABC non-compliant at baseline and also at 1 year [n = 1455 (47.0%)]. The incidence rates (95% confidence intervals, CI) of the composite outcome for Group 1 to 4 were 5.56 (4.54-6.74), 7.42 (5.35-10.03), 9.74 (7.31-12.70), and 11.57 (10.28-12.97), respectively. With Group 1 as a reference, Group 2-4 had hazard ratios (95% CI) of the composite outcome of 1.32 (0.92-1.89), 1.75 (1.26-2.43), and 2.07 (1.65-2.59), respectively. CONCLUSION: Re-evaluation of compliance status of the ABC pathway management is needed to optimize integrated care management and improve clinical outcomes. AF patients who were ABC pathway compliant at baseline and also at follow-up had the best clinical outcomes.

Molnupiravir versus favipiravir in at-risk outpatients with COVID-19: A randomized controlled trial in Thailand.

OBJECTIVES: Evaluate and compare the efficacy and safety of molnupiravir and favipiravir in outpatients with mild to moderate COVID-19 and at risk of severe COVID-19. METHODS: In an open-label, parallel-group, multicenter trial in Thailand, participants with moderate COVID-19 and at least one factor associated with severe COVID-19 were randomly assigned 1:1 to receive oral molnupiravir or oral favipiravir (standard of care). Phone calls for remote symptom assessment were made on Days 6, 15, and 29. Participants with worsening symptoms were instructed to return to the hospital. The primary endpoint was pulmonary involvement by Day 29, as evidenced by ≥2 of the following: dyspnea, oxygen saturation <92% or imaging. RESULTS: Nine hundred seventy-seven participants (487 molnupiravir, 490 favipiravir) were enrolled from 8 July 2022 to 19 January 2023. 98% had received ≥1 dose of COVID-19 vaccine and 83% ≥3 doses. By Day 29, pulmonary involvement occurred in 0% (0/483) in molnupiravir arm versus 1% (5/482) in favipiravir arm (-1.0%; Newcombe 95.2% CI: -2.4% to -0.0%; P = 0.021); all-cause death in 0% (0/483) and <1% (1/482); COVID-19 related hospitalization in <1% (1/483) and 1% (3/482); treatment-related adverse event in 1% (5/483) and 1% (4/486); and serious adverse event in 1% (4/483) and 1% (4/486). CONCLUSIONS: Favipiravir and molnupiravir had a similar efficacy and safety profile. Whether either of the two reduced the risk of complications during the omicron era in this population with a low risk of pulmonary involvement and a high vaccine coverage remains unclear. There were no differences in any of the safety endpoints. THAI CLINICAL TRIALS REGISTRY ID: TCTR20230111009.

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry.

BACKGROUND: Bleeding events are often reported among patients with atrial fibrillation (AF), irrespective of antithrombotic use. This study is to determine clinical outcomes of patients with AF who survived from bleeding event. METHODS: We analyzed data from COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) Thailand registry. Outcomes of patients who experienced any bleeding were compared with patients who had never bleed. Time updated multivariate Cox-proportional hazard models were used to estimate the risk for clinical outcomes of patients with and without bleeding. RESULTS: Of total 3,405 patients (mean age: 67.8 ± 11.3 years; 41.9% female) in COOL-AF registry, 609 patients (17.9%) reported bleeding event occurs and 568 patients (93.3%) survived though hospital discharge. Patients who survived major bleeding (n = 126) were at increased risk for both death (adjusted hazard ratio [HR]: 4.44, 95% confidence interval [CI]: 2.91-6.75, p < 0.001) and stroke/systemic embolism (adjusted HR: 4.49, 95% CI: 2.19-9.24, p < 0.001). Minor bleeding also increased subsequent death (adjusted HR: 2.13, 95% CI: 1.56-2.90, p < 0.001). Up to 30% of patients who survived major bleeding and 6.3% of minor bleedings discontinued oral anticoagulation. Discontinuation was associated with very high death rate (42.1%), whereas patients who resumed oral anticoagulation after bleeding had lower mortality (10%). The most common causes of death in patients who survived a bleeding event were not related to cardiovascular causes nor bleeding. CONCLUSION: Patients with AF who have bleeding events have an increased risk for subsequent death and stroke and systemic embolism. These patients should be identified as vulnerable clinically complex patients and require a holistic approach to their AF management.

Systolic blood pressure visit-to-visit variability and outcomes in Asian patients with atrial fibrillation.

We aimed to assess the association between SBP-VVV and outcomes in Asian patients with atrial fibrillation (AF). AF patients in the COOL-AF registry with SBP measured at baseline, and at least two other visits were studied. We defined SBP-VVV using the standard deviation (SD) of average SBP. Patients were categorized according to the quartiles of SBP SD. The associations between SBP-VVV and outcomes were assessed in the adjusted Cox model. We studied 3172 patients (mean age 67.7 years; 41.8% female), with the prevalence of hypertension being 69%. Warfarin was used in 69% of patients, whereas 7% received non-vitamin K antagonist oral anticoagulants. The minimum and maximum SD of average SBP in the study population was 0.58 and 56.38 mmHg respectively. The cutoff of SD of average SBP for each quartile in our study were 9.09, 12.15, and 16.21 mmHg. The rates of all-cause mortality, ischemic stroke or systemic embolization (SSE), major bleeding, and intracranial hemorrhage (ICH) were 3.10, 1.42, 2.09, and 0.64 per 100 person-years, respectively. Compared with the first quartile, patients in the fourth quartile had a significantly higher risk of mortality (adjusted HR 1.60, 95%CI 1.13-2.25), bleeding (aHR 1.92, 95%CI 1.25-2.96) and ICH (aHR 3.51, 95%CI 1.40-8.76). The risk of SSE was not significantly different among the quartiles. SBP-VVV had a significant impact on the long-term outcomes of Asian patients with AF, particularly mortality and bleeding. Adequate SBP control and maintaining SBP stability over time may improve outcomes for AF patients.

2024 Consensus Statement on Coronary Stenosis and Plaque Evaluation in CT Angiography From the Asian Society of Cardiovascular Imaging-Practical Tutorial (ASCI-PT).

The Asian Society of Cardiovascular Imaging-Practical Tutorial (ASCI-PT) is an instructional initiative of the ASCI School designed to enhance educational standards. In 2021, the ASCI-PT was convened with the goal of formulating a consensus statement on the assessment of coronary stenosis and coronary plaque using coronary CT angiography (CCTA). Nineteen experts from four countries conducted thorough reviews of current guidelines and deliberated on eight key issues to refine the process and improve the clarity of reporting CCTA findings. The experts engaged in both online and on-site sessions to establish a unified agreement. This document presents a summary of the ASCI-PT 2021 deliberations and offers a comprehensive consensus statement on the evaluation of coronary stenosis and coronary plaque in CCTA.

Myocardial scar and left ventricular ejection fraction classification for electrocardiography image using multi-task deep learning.

Myocardial scar (MS) and left ventricular ejection fraction (LVEF) are vital cardiovascular parameters, conventionally determined using cardiac magnetic resonance (CMR). However, given the high cost and limited availability of CMR in resource-constrained settings, electrocardiograms (ECGs) are a cost-effective alternative. We developed computer vision-based multi-task deep learning models to analyze 12-lead ECG 2D images, predicting MS and LVEF < 50%. Our dataset comprises 14,052 ECGs with clinical features, utilizing ground truth labels from CMR. Our top-performing model achieved AUC values of 0.838 (95% CI 0.812-0.862) for MS and 0.939 (95% CI 0.921-0.954) for LVEF < 50% classification, outperforming cardiologists. Moreover, MS predictions in a prevalence-specific test dataset recorded an AUC of 0.812 (95% CI 0.810-0.814). Extracted 1D signals from ECG images yielded inferior performance, compared to the 2D approach. In conclusion, our results demonstrate the potential of computer-based MS and LVEF < 50% classification from ECG scan images in clinical screening offering a cost-effective alternative to CMR.

Expert recommendations for the management of iron deficiency in patients with heart failure in Asia.

BACKGROUND: Iron deficiency is a common comorbidity in heart failure (HF) and is independently associated with a worse quality-of-life and exercise capacity, as well as increased risk of hospitalization, regardless of anemia status. Although international guidelines have provided recommendations for the management of iron deficiency in patients with HF, guidelines in Asia are less established, and practical use of guidelines for management of iron deficiency is limited in the region. METHODS: A panel comprising cardiologists from China, Hong Kong, India, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, and Thailand convened to share insights and provide guidance for the optimal management of iron deficiency in patients with HF, tailored for the Asian community. RESULTS: Expert opinions were provided for the screening, diagnosis, treatment and monitoring of iron deficiency in patients with HF. It was recommended that all patients with HF with reduced ejection fraction should be screened for iron deficiency, and iron-deficient patients should be treated with intravenous iron. Monitoring of iron levels in patients with HF should be carried out once or twice yearly. Barriers to the management of iron deficiency in patients with HF in the region include low awareness of iron deficiency amongst general physicians, lack of reimbursement for screening and treatment, and lack of proper facilities for administration of intravenous iron. CONCLUSIONS: These recommendations provide a structured approach to the management of iron deficiency in patients with HF in Asia.

External Validation of COOL-AF Scores in the Asian Pacific Heart Rhythm Society Atrial Fibrillation Registry.

Background: The COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) risk scores for death, bleeding, and thromboembolic events (TEs) were derived from the COOL-AF cohort from Thailand and require external validation. Objectives: The authors sought to externally validate the COOL-AF scores in the APHRS (Asia-Pacific Heart Rhythm Society) registry and to compare their performance in the ESC-EHRA (European Society of Cardiology-European Heart Rhythm Association) EORP-AF (EURObservational Research Programme in Atrial Fibrillation) General Long-Term Registry. Methods: We studied 3,628 APHRS and 8,825 EORP-AF patients. Receiver operating characteristic (ROC) curves and Cox regression analyses were used to test the predictive value of COOL-AF scores and to compared them with the CHA2DS2-VASc and HAS-BLED scores. Results: Patients in the EORP-AF were older, had a higher prevalence of male sex, and were at higher thromboembolic and hemorrhagic risk than APHRS patients. After 1 year of follow-up in APHRS and EORP-AF, the following events were recorded: 87 (2.4%) and 435 (4.9%) death for any causes, 37 (1.0%) and 111 (1.3%) major bleeding, and 25 (0.7%) and 109 (1.2%) TEs, respectively. In APHRS, the COOL-AF scores showed moderate-to-good predictive value for all-cause mortality (area under the curve [AUC]: 0.77; 95% CI: 0.71-0.83), major bleeding (AUC: 0.68; 95% CI: 0.60-0.76), and TEs (AUC: 0.61; 95% CI: 0.51-0.71), and were similar to the CHA2DS2-VASc and HAS-BLED scores. In EORP-AF, the predictive value of COOL-AF for all-cause mortality (AUC: 0.68; 95% CI: 0.65-0.70) and major bleeding (AUC: 0.61; 95% CI: 0.60-0.62) was modest and lower than in APHRS. In EORP-AF, the COOL-AF score for TE was inferior to the CHA2DS2-VASc score. Conclusions: The COOL-AF risk scores may be an easy tool to identify Asian patients with AF at risk for death and major bleeding and performs better in Asian than in European patients with AF. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia [AF-Registry]; NCT04807049).

Time in target range of systolic blood pressure and clinical outcomes in atrial fibrillation patients: results of the COOL-AF registry.

We aimed to investigate the relationship between time in target range of systolic blood pressure (SBP-TTr) and clinical outcomes in patients with atrial fibrillation (AF). We analyzed the results from multicenter AF registry in Thailand. Blood pressure was recorded at baseline and at every 6 monthly follow-up visit. SBP-TTr were calculated using the Rosendaal method, based on a target SBP 120-140 mmHg. The outcomes were death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. A total of 3355 patients were studied (mean age 67.8 years; 41.9% female). Average follow-up time was 32.1 ± 8.3 months. SBP-TTr was classified into 3 groups according to the tertiles. The incidence rates of all-cause death, SSE, major bleeding, and heart failure were 3.90 (3.51-4.34), 1.52 (1.27-1.80), 2.2 (1.90-2.53), and 2.83 (2.49-3.21) per 100 person-years, respectively. Patients in the 3rd tertile of SBP-TTr had lower rates of death, major bleeding and heart failure with adjusted hazard ratios 0.62 (0.48-0.80), p < 0.001, 0.64 (0.44-0.92), p = 0.016, and 0.61 (0.44-0.84), p = 0.003, respectively, compared to 1st SBP-TTr tertile. In conclusion, high SBP-TTr was associated with better clinical outcomes compared to other groups with lower SBP-TTr. This underscores the importance of good blood pressure control in AF patients.

Non-vitamin K Antagonist Oral Anticoagulant, Warfarin, and ABC Pathway Adherence on Hierarchical Outcomes: Win Ratio Analysis of the COOL-AF Registry.

BACKGROUND: Atrial fibrillation (AF) Better Care (ABC) pathway adherence is associated with improved outcomes. Clinical trials have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are as least as effective as warfarin for stroke prevention in AF patients. The Win Ratio method, analyzing hierarchical composite outcomes considering event timing and severity, has limited data on its use in Asians. OBJECTIVES: We aim to apply Win Ratio in a registry to access the comparative effectiveness of NOACs versus warfarin and ABC adherence versus nonadherence in Asian patients with AF. METHODS: Our study included nonvalvular AF patients from the nationwide prospective COOL-AF registry in Thailand. The NOAC-treated group was compared with the warfarin-treated group using the Win Ratio, with the following order: all-cause death, intracranial hemorrhage (ICH), ischemic stroke/transient ischemic attack/systemic embolism, non-ICH major bleeding, and myocardial infarction or heart failure. ABC pathway adherence versus nonadherence was also compared. A Win Ratio greater than 1.00 indicating a better outcome. RESULTS: The analysis included 2,568 patients, with 228 in the NOAC group and 2,340 in the warfarin group. The NOAC group had more wins than the warfarin group, with an unmatched Win Ratio of 1.64 (95% confidence interval [CI]: 1.22-2.20; p < 0.001). When compared with nonadherence, ABC pathway adherence was associated with a Win Ratio of 1.57 (95% CI: 1.33-1.85; p < 0.001). CONCLUSION: This Win Ratio analysis demonstrates the significant benefits of NOACs over warfarin and ABC pathway adherence over nonadherence in reducing the composite outcome in patients with AF.

Direct Oral Anticoagulant Dosing in Patients With Atrial Fibrillation: An Asian Perspective.

Optimal dosing of direct oral anticoagulants (DOACs) for stroke prevention in "gray area" patients with atrial fibrillation (AF) remains a challenge for clinicians. In Asia, this is concerning in patients who are very elderly, have low body weight, and are at a high risk of bleeding. This review aims to summarize the dose reduction criteria for DOACs, discuss the evidence on dosing of DOACs across Asian regions, and collate opinions from authors across Asia. Nonrecommended dosing of DOACs is common in Asia, primarily due to the fear of bleeding, with the total clinical benefit of higher dosing being overlooked. The ELDERCARE-AF (Edoxaban Low-Dose for Elder Care-Atrial Fibrillation Patients) trial and real-world case studies provide some evidence on the use of low-dose DOACs in gray area patients. Opinions on dose adjustment guidance, concomitant medication adjustments, and therapeutic drug monitoring were collated. Research is needed to fill the evidence gaps on optimal DOAC doses for gray area patients.