2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary.

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.

2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation.

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.

Multiparameter diagnostic sensor measurements during clinically stable periods and worsening heart failure in ambulatory patients.

AIMS: This study aims to characterize the range of implantable device-based sensor values including heart sounds, markers of ventilation, thoracic impedance, activity, and heart rate for patients with heart failure (HF) when patients were deemed to be in clinically stable periods against the time course of acute decompensation and recovery from HF events. METHODS AND RESULTS: The MultiSENSE trial followed 900 patients implanted with a COGNIS CRT-D for up to 1 year. Chronic, ambulatory diagnostic sensor data were collected and evaluated during clinically stable periods (CSP: unchanged NYHA classification, no adverse events, and weight change ≤2.27 kg), and in the timeframe leading up to and following HF events (HF admissions or unscheduled visits with intravenous HF treatment). Physiologic sensor data from 1667 CSPs occurring in 676 patients were compared with those data leading up to and following 192 HF events in 106 patients. Overall, the mean age was 66.6 years, and the population were predominantly male (73%). Patients were primarily in NYHA II (67%), with a mean LVEF of 29.6% and median NT-proBNP of 754.5 pg/mL. Sensor values during CSP were poorer in patients who had HF events during the study period than those without HF events, including first heart sound (S1: 2.18 ± 0.84 mG vs. 2.62 ± 0.95 mG, P = 0.002), third heart sound (S3: 1.13 ± 0.36 mG vs. 0.91 ± 0.30 mG, P < 0.001), thoracic impedance (45.66 ± 8.78 Ohm vs. 50.33 ± 8.43 Ohm, P < 0.001), respiratory rate (19.09 ± 3.10 br/min vs. 17.66 ± 2.39 br/min, P = 0.002), night time heart rate (73.39 ± 8.36 b.p.m. vs. 69.56 ± 8.09 b.p.m., P = 0.001), patient activity (1.69 ± 1.84 h vs. 2.56 ± 2.20 h, P = 0.006), and HeartLogic index (11.07 ± 12.14 vs. 5.31 ± 5.13, P = 0.001). Sensor parameters measured worsening status leading up to HF events with recovery of values following treatment. CONCLUSIONS: Device-based physiologic sensors not only revealed progressive worsening leading up to HF events but also differentiated patients at increased risk of HF events when presumed to be clinically stable.

Low-Density Lipoprotein Cholesterol Target Attainment in Patients Surviving an Acute Coronary Syndrome in Thailand: Results From the Dyslipidaemia International Study (DYSIS) II.

BACKGROUND: Patients suffering an acute coronary syndrome (ACS) are at increased risk for future cardiovascular events. Effective management of hyperlipidaemia in such patients is essential. We aimed to document the use of lipid-lowering therapy (LLT) and low-density lipoprotein cholesterol (LDL-C) target achievement in patients hospitalised with an ACS in Thailand. METHODS: The Dyslipidemia International Study (DYSIS) II was a multinational, observational study that enrolled patients over 18 years of age who were hospitalised with an ACS in 2013-2014 and survived until discharge. Patients were analysed according to whether or not they were treated with LLT prior to hospital admission. A lipid profile was carried forward from blood taken within the first 24 hours after admission, and attainment of the LDL-C target of <70 mg/dL (1.8 mmol/L) for very high-risk subjects was reported. Details of LLTs were collected. Lipid levels, LLT use and cardiovascular events since discharge were collected at a follow-up interview 4 months later. RESULTS: A total of 320 ACS patients were enrolled from seven sites across Thailand, 188 (58.8%) of whom were being treated with LLT prior to the acute event. The mean LDL-C levels of the LLT and no LLT patients were 106.2 ± 39.4 mg/dL (2.75 ± 1.02 mmol/L) and 139.8 ± 46.6 mg/dL (3.62 ± 1.21), respectively, with 15.4% and 4.5% having an LDL-C level below 70 mg/dL (1.8 mmol/L). Lipid-lowering therapy consisted mainly of statins, with an atorvastatin-equivalent daily dosage of 17 ± 13 mg/day. At the 4-month follow-up, LDL-C target attainment remained low at 26.7% for the initial LLT group and 24.1% for the no LLT group. Although most patients were being treated with LLT at this point, the dosage was still low (28 ± 16 mg/day) and there was little use of combination therapy. CONCLUSION: In this cohort of Thai ACS patients, LDL-C levels were highly elevated, placing them at extreme risk of recurrent adverse cardiovascular events. Lipid-lowering therapy was widely used after the ACS; however, treatment was rarely optimised. Huge improvements are required in the management of hyperlipidaemia in Thailand.

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.

An International Observational Prospective Survey Assessing the Control of Atrial Fibrillation in Asia-Pacific: Results of the Record-AFAP Registry.

A prospective 1-year observational survey was designed to assess the management and control of atrial fibrillation (AF) in eight countries within the Asia-Pacific region. Patients (N = 2,604) with recently diagnosed AF or a history of AF ≤1 year were included. Clinicians chose the treatment strategy (rhythm or rate control) according to their standard practice and medical discretion. The primary endpoint was therapeutic success. At baseline, rhythm- and rate-control strategies were applied to 35.7% and 64.3% of patients, respectively. At 12 months, therapeutic success was 43.2% overall. Being assigned to rhythm-control strategy at baseline was associated with a higher therapeutic success (46.5% vs 41.4%; P = 0.0214) and a lower incidence of clinical outcomes (10.4% vs 17.1% P < 0.0001). Patients assigned to rate-control strategies at baseline had higher cardiovascular morbidities (history of heart failure or valvular heart disease). Cardiovascular outcomes may be less dependent on the choice of treatment strategy than cardiovascular comorbidities.

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.

Prospective randomized study to assess the efficacy of site and rate of atrial pacing on long-term progression of atrial fibrillation in sick sinus syndrome: Septal Pacing for Atrial Fibrillation Suppression Evaluation (SAFE) Study.

BACKGROUND: Atrial-based pacing is associated with lower risk of atrial fibrillation (AF) in sick sinus syndrome compared with ventricular pacing; nevertheless, the impact of site and rate of atrial pacing on progression of AF remains unclear. We evaluated whether long-term atrial pacing at the right atrial (RA) appendage versus the low RA septum with (ON) or without (OFF) a continuous atrial overdrive pacing algorithm can prevent the development of persistent AF. METHODS AND RESULTS: We randomized 385 patients with paroxysmal AF and sick sinus syndrome in whom a pacemaker was indicated to pacing at RA appendage ON (n=98), RA appendage OFF (n=99), RA septum ON (n=92), or RA septum OFF (n=96). The primary outcome was the occurrence of persistent AF (AF documented at least 7 days apart or need for cardioversion). Demographic data were homogeneous across both pacing site (RA appendage/RA septum) and atrial overdrive pacing (ON/OFF). After a mean follow-up of 3.1 years, persistent AF occurred in 99 patients (25.8%; annual rate of persistent AF, 8.3%). Alternative site pacing at the RA septum versus conventional RA appendage (hazard ratio=1.18; 95% confidence interval, 0.79-1.75; P=0.65) or continuous atrial overdrive pacing ON versus OFF (hazard ratio=1.17; 95% confidence interval, 0.79-1.74; P=0.69) did not prevent the development of persistent AF. CONCLUSIONS: In patients with paroxysmal AF and sick sinus syndrome requiring pacemaker implantation, an alternative atrial pacing site at the RA septum or continuous atrial overdrive pacing did not prevent the development of persistent AF. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00419640.

Association of statin therapy with ventricular arrhythmias among patients with acute coronary syndrome.

BACKGROUND: In addition to lowering cholesterol, statins stabilise atherosclerotic plaques and can potentially reduce the incidence of ventricular arrhythmias. We tested the hypothesis that prior statin therapy is associated with a lower incidence of inhospital ventricular arrhythmias among patients with acute coronary syndrome (ACS). METHODS: The study population consisted of 2007 patients (mean age 64 years, 67.5% male) enrolled in the Thai Registry of Acute Coronary Syndrome, a prospective, multicentre, nationwide, observational study of patients with ACS. Patients were categorised as either statin users or non-users according to their reports of statin use before enrolment at their initial presentation. The primary endpoint was inhospital ventricular arrhythmias. The secondary endpoint was a composite endpoint of inhospital ventricular arrhythmias or inhospital cardiac death. A propensity-adjusted multivariate model was developed to assess the effects of statin use on the primary and secondary endpoints. RESULTS: During a mean hospital stay of 7 days, a total of 96 patients (4.8%) died; 82 (4.1%) of the deaths were due to cardiac causes. The primary and secondary endpoints were reached in 163 patients (8.1%) and 194 patients (9.7%), respectively. A total of 525 patients (26.2%) had used statins prior to hospitalisation. After adjusting for the propensity scores and other relevant covariates, statin use was associated with lower risks of the primary (adjusted OR 0.505, 95% CI 0.276 to 0.923) and secondary endpoints (adjusted OR 0.498, 95% CI 0.276 to 0.897). CONCLUSIONS: The use of statins is associated with a reduced incidence of ventricular arrhythmias among patients with ACS.

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.

Atrial fibrillation management in Asia: from the Asian expert forum on atrial fibrillation.

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with increased morbidity and mortality. AF has a slightly lower incidence and prevalence in Asian populations than in Western populations, but the associated relative risk of stroke and mortality is similar. Patients with AF in Asia have similar disease profiles and CHADS2 score distributions compared to those in the West, with the exception of a slightly higher prevalence of valvular heart diseases in Asia. Acute ventricular rate control should be the initial consideration in patients with AF and rapid ventricular rate. Anti-arrhythmic drugs have only a modest long-term effect on maintenance of sinus rhythm, and clinical trials in both the West and the East show that chronic rhythm control is not superior to chronic rate control in terms of cardiovascular outcomes, most likely because the benefit of anti-arrhythmic drugs in these trials was often offset by proarrhythmic effects. ECG-driven trials for AF should be replaced by outcome-driven ones. ATHENA is the largest outcome trial to confirm the superiority of a new anti-arrhythmic drug in improving cardiovascular outcomes. The choice of anti-arrhythmic drugs for AF should be based on both safety and efficacy in improving cardiovascular outcomes. For long-term rate control, a lenient strategy with a ventricular rate of less than 110bpm may be adequate, but more strict rate control may be required if patients continue to complain of symptoms. Catheter ablation should be reserved for patients who remain symptomatic despite optimal medical therapy.

Apolipoprotein E gene polymorphism: effects on plasma lipids and risk of type 2 diabetes and coronary artery disease.

BACKGROUND: The most common apolipoprotein E (apoE) gene polymorphism has been found to influence plasma lipid concentration and its correlation with coronary artery disease (CAD) has been extensively investigated in the last decade. It is, however, unclear whether apoE gene polymorphism is also associated with increased risk of type 2 diabetes mellitus (T2DM). The knowledge of this study may provide the primary prevention for T2DM and CAD development before its initiation and progression. Therefore, this study was carried out to determine the association between apoE gene polymorphism and T2DM with and without CAD and its role in lipid metabolism. METHODS: The case-control study was carried out on a total of 451 samples including 149 normal control subjects, 155 subjects with T2DM, and 147 subjects with T2DM complicated with CAD. The apoE gene polymorphism was tested by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Univariable and multivariable logistic regression analyses were used to identify the possible risks of T2DM and CAD. RESULTS: A significantly increased frequency of E3/E4 genotype was observed only in T2DM with CAD group (p = 0.0004), whereas the ε4 allele was significantly higher in both T2DM (p = 0.047) and T2DM with CAD (p = 0.009) as compared with controls. E3/E4 genotype was also the independent risk in developing CAD after adjusting with established risk factors with adjusted odds ratio (OR) 2.52 (95%CI 1.28-4.97, p = 0.008). The independent predictor of individuals carrying ε4 allele still remained significantly associated with both CAD (adjusted OR 2.32, 95%CI 1.17-4.61, p = 0.016) and T2DM (adjusted OR 2.04, 95%CI 1.07-3.86, p = 0.029). After simultaneously examining the joint association of E3/E4 genotype combined with either obesity or smoking the risk increased to approximately 5-fold in T2DM (adjusted OR 4.93, 95%CI 1.74-13.98, p = 0.003) and 10-fold in CAD (adjusted OR 10.48, 95%CI 3.56-30.79, p < 0.0001). The association between apoE genotypes on plasma lipid levels was compared between E3/E3 as a reference and E4-bearing genotypes. E4-bearing genotypes showed lower HDL-C and higher VLDL-C and TG, whereas other values of plasma lipid concentrations showed no significant difference. CONCLUSIONS: These results indicate that ε4 allele has influence on lipid profiles and is associated with the development of both T2DM with and without CAD, and furthermore, it increased the risk among the subjects with obesity and/or smoking, the conditions associated with high oxidative stress.

Insights into management of atrial fibrillation in Asia Pacific gained from baseline data from REgistry on cardiac rhythm disORDers (RecordAF-Asia Pacific [AP]) registry.

The burden of atrial fibrillation (AF) and the lack of data on AF and its management in the Asia Pacific highlight the need for a comprehensive prospective study of AF management in this region. To address this need, the REgistry on Cardiac rhythm disORDers (RecordAF-Asia Pacific [AP]) has been initiated to assess the management of AF in 8 countries across the Asia Pacific. RecordAF-AP is a prospective, observational survey of the management of recently diagnosed AF with 1 year of follow-up. Eligible patients with AF, treated or not, were included in the registry; with data recorded prospectively during the follow-up visits at 6 and 12 months. A total of 2,721 patients with AF were recruited, of whom 2,629 were eligible for evaluation (intent-to-treat population). At study inclusion, rhythm- and rate-control strategies were applied to 37% (n = 959) and 62% (n = 1,610) of the patients, respectively. At baseline, the rhythm-control patients were mainly prescribed class III agents (49%), class Ic agents (39%), or ß blockers (except for sotalol; 35%). The rate-control patients were mainly prescribed ß blockers (except for sotalol; 57%) or cardiac glycosides (32%). Patients receiving rate-control strategies were more likely to have a history of heart failure or valvular heart disease and persistent AF. In contrast, those receiving rhythm-control strategies were more likely to have recently diagnosed or paroxysmal AF. In conclusion, RecordAF-AP will provide much needed insight into the real-life management of patients with AF in the Asia Pacific region.

An Observational, Prospective Survey Assessing the Control of Atrial Fibrillation in Asia Pacific: Rationale and Design of the RecordAF-AP Registry.

BACKGROUND: The literature suggests that the prevalence of atrial fibrillation (AF) may be lower in Asian countries than in Western countries. Nevertheless, AF remains a significant public health problem in the region. The burden of AF, the experiences of previous trials and the lack of data on AF and its management in Asia Pacific highlight the need for a comprehensive prospective study of AF management. METHODS: The REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation Asia Pacific (RecordAF-AP) is a prospective, observational survey of the management of recently diagnosed AF patients with 1-year follow-up in 8 countries across Asia Pacific. Eligible patients presenting with AF, treated or not, will be included in the registry and data will be recorded prospectively during follow-up visits at 6 and 12 months. RESULTS: RecordAF-AP will recruit more than 3000 patients. Study recruitment commenced in April 2009 and the final results anticipated at the end of 2011. CONCLUSIONS: RecordAF-AP will assess the real-life management of AF patients in Asia Pacific, including a comparison of clinical outcomes in rhythm versus rate control strategies, providing much needed insight into the costs, treatment choices and clinical outcomes of AF patients in this region.

Lipid-lowering therapy using statins in patients with cardiovascular risk in clinical practice in Thailand.

BACKGROUND: Since the release in Thailand in 2001 of the Third Guidelines by the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults or the Adult Treatment Panel (ATP III), there have been no nationwide studies on the proportion of dyslipidaemic patients who have achieved the low-density lipoprotein cholesterol (LDL-C) goals. The authors therefore aimed to estimate the percentage achievement of LDL-C goals based on the modified NCEP ATP III guidelines in intermediate- to high-risk patients. METHODS: The authors conducted a hospital-based, cross-sectional, epidemiological survey. Patients (1240) were selected consecutively from 50 hospitals across Thailand. Patients were included if they had been treated with statins for at least 3 months. RESULTS: Two-thirds were female, and the mean age was 61.7±9.5 years. The median duration of statin treatment was 21 months. Half (633/ 1240) of the patients achieved the LDL-C goal levels as defined by the NCEP guidelines (51.1%, 95% CI 48.3% to 53.8%). The very-high-risk group had the lowest percentage achievement (11.6%; 95% CI 1.6% to 21.6%), compared with 54.2% (95% CI 50.9% to 57.4%) for the high-risk group and 47.0% (95% CI 41.1% to 52.8%) for the moderate-risk group. More males achieved the LDL-C goals than females (55.6% vs 48.9%; p=0.029). CONCLUSIONS: Overall, 51.1% of the patients with cardiovascular risk, on statins treatment, achieved the NCEP ATP III LDL-C goal levels.

Lipid peroxidation and antioxidant enzyme activities in erythrocytes of type 2 diabetic patients.

BACKGROUND AND OBJECTIVE: Although diabetes mellitus (DM) patients are claimed to be under oxidative stress because of prolonged exposure to hyperglycemia, the influence of glycemic control and cardiovascular complication in diabetes on oxidative stress parameters has not been fully studied. The present study aimed to investigate lipid peroxidation end product (malondialdehyde, MDA) and antioxidant enzymes in fairly controlled type 2 DM (fasting plasma glucose [FPG] < or = 180 mg/dl) or type 2 DM complicated with coronary heart disease (CHD) and poorly controlled type 2 DM (FPG > 180 mg/dl) in comparison to a normal healthy group (FPG < 110 mg/dl). MATERIAL AND METHOD: MDA and antioxidant enzymes such as superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) were determined in the red cell of 19 subjects with poorly controlled type 2 DM, 26 subjects with fairly controlled type 2 DM and 20 subjects with type 2 DM complicated with CHD who were matched for age and gender. Twenty healthy subjects with normal plasma glucose level and matched for age and gender were served as a control group. In all groups of DM these oxidative stress parameters were compared to a control group by one-way ANOVA test. Pearson rank correlation coefficient was used to compare the relationship between FPG and oxidative stress status in type 2 DM and normal controls. RESULTS: The red cell MDA levels were significantly higher in all types of diabetes compared to age-matched normal controls. The mean of red cell MDA level was highest in type 2 DM complicated with CHD. Red cell antioxidant enzyme activities were also significantly increased except for SOD and GPx activities in fairly controlled type 2 DM. The significant positive correlation between oxidative stress status (as MDA and CAT) and FPG was found in poorly controlled type 2 DM and type 2 DM complicated with CHD whereas in fairly controlled type 2 DM the significant positive correlation between CAT and FPG was only observed. CONCLUSION: These findings strongly confirmed the evidence that diabetic patients were susceptible to oxidative stress and higher blood glucose level had an association with free radical-mediated lipid peroxidation. The highest level of MDA in type 2 DM complicated with CHD suggested that oxidative stress played an important role in the pathogenesis of cardiovascular complication. The results also showed the increase in antioxidant enzymes. These could probably be due to adaptive response to pro-oxidant in diabetic state. Hence, there seems to be imbalance between oxidant and antioxidant systems in type 2 diabetic patients.

Paraoxonase 1 polymorphisms as the risk factor of coronary heart disease in a Thai population.

OBJECTIVE: Two common polymorphisms of the paraoxonase (PON1) gene, L55M and Q192R, were proven to mitigate atherosclerosis pathogenesis by protecting lipoproteins against peroxidation. This study was to evaluate the associations between both PON1 gene polymorphisms in Thai hyperlipidaemia with and without coronary heart disease (CHD). METHODS: Both PON1 genotypes were determined using PCR-RFLP in 103 healthy control subjects, 103 primary hyperlipidaemia without history of such diseases and 106 angiographically documented CHD patients. RESULTS: The frequencies of PON1 192R allele and 192RR genotype were significantly higher in CHD patients than in normal control subjects (P = 0.009 and 0.037, respectively). The significantly higher frequencies of 55M allele and 55LM genotype were also observed in CHD patients (P = 0.037 and P = 0.034, respectively). The frequencies of both PON1 polymorphisms were not different in primary hyperlipidaemia as compared to the normal control subjects. The odds ratio (OR) of 192RR genotype and 192R allele for CHD were 2.84 (1.17-6.99, P = 0.011) and 1.70 (1.11-2.61, P = 0.009), respectively. The age-adjusted OR for CHD was 2.72 (1.25-5.94, P = 0.012). These frequencies of both PON1 alleles were similar to those seen in other Asian populations. CONCLUSIONS: The association between PON1 polymorphisms and CHD risk was demonstrated in aThai population. These new data underscore the essence of ethnic variations in the interpretation of CHD associated with PON1 polymorphism.

A prospective randomized study to assess the efficacy of rate and site of atrial pacing on long-term development of atrial fibrillation.

The Septal Pacing for Atrial Fibrillation Suppression Evaluation (SAFE) study is a single-blinded, parallel randomized designed multicenter study in pacemaker indicated patients with paroxysmal atrial fibrillation (AF). The objective is to evaluate whether the site of atrial pacing--conventional right atrial appendage versus low atrial septal--with or without atrial overdrive pacing will influence the development of persistent AF. The study will provide a definitive answer to whether a different atrial pacing site or the use of AF suppression pacing or both can give incremental antiarrhythmic benefit when one is implanting a device for a patient with a history of paroxysmal AF.

A randomised study comparing the efficacy and safety of rosuvastatin with atorvastatin for achieving lipid goals in clinical practice in Asian patients at high risk of cardiovascular disease (DISCOVERY-Asia study).

BACKGROUND: Most studies investigating the benefits of statins have focused on North American and European populations. This study focuses on evaluating the lipid-lowering effects of rosuvastatin and atorvastatin in Asian patients. OBJECTIVES: The DIrect Statin COmparison of LDL-C Values: an Evaluation of Rosuvastatin therapY (DISCOVERY)-Asia study is one of nine independently powered studies assessing the efficacy of starting doses of statins in achieving target lipid levels in different countries worldwide. DISCOVERY-Asia was a 12-week, randomised, open-label, parallel-group study conducted in China, Hong Kong, Korea, Malaysia, Taiwan, and Thailand. RESULTS: A total of 1482 adults with primary hypercholesterolaemia and high cardiovascular risk (> 20%/10 years, type 2 diabetes, or a history of coronary heart disease) were randomised in a 2 : 1 ratio to receive rosuvastatin 10 mg once daily (o.d.) or atorvastatin 10 mg o.d. The percentage of patients achieving the 1998 European Joint Task Force low-density lipoprotein cholesterol (LDL-C) goal of < 3.0 mmol/L at 12 weeks was significantly higher in the rosuvastatin group (n = 950) compared with the atorvastatin group (n = 471) (79.5 vs. 69.4%, respectively; p < 0.0001). Similar results were observed for 1998 European goals for total cholesterol (TC), and the 2003 European goals for LDL-C and TC. LDL-C and TC levels were reduced significantly more with rosuvastatin compared with atorvastatin. Both drugs were well-tolerated and the incidence and type of adverse events were similar in each group. TRIALS REGISTRATION: The trial registry summary is available at http://www.clinicaltrials.gov/; ClinicalTrials.gov Identifier: NCT00241488 CONCLUSIONS: This 12-week study showed that the starting dose of rosuvastatin 10 mg o.d. was significantly more effective than the starting dose of natorvastatin 10 mg o.d. at enabling patients with primary hypercholesterolaemia to achieve European goals for LDL-C and TC in a largely Asian population in real-life clinical practice. The safety profile of rosuvastatin 10 mg is similar to that of atorvastatin 10 mg in the Asian population studied here, and is consistent with the known safety profile of rosuvastatin in the white population.

Electrocardiographic predictors of long-term outcomes after radiofrequency ablation in patients with right-ventricular outflow tract tachycardia.

AIMS: The objectives of this study were to identify electrocardiographic (ECG) predictors of long-term outcomes after radiofrequency (RF) ablation in patients with right-ventricular outflow tract (RVOT) tachycardia. METHODS AND RESULTS: We correlated ECG characteristics with RF ablation outcomes in 144 patients with RVOT tachycardia who underwent RF ablation for >1 year. Unfavourable RF ablation outcomes were predefined as unsuccessful RF ablation or recurrence of tachycardia requiring repeated ablation. RF ablation was not successful in 11 (7.6%) patients and 16 (12%) patients had arrhythmia recurrence requiring repeated ablation. Average follow-up time was 72.2+/-28.4 months. Selected parameters from univariate analysis included number of RF applications, pacemapping, application of bonus burn, procedure time, monophasic R-wave in lead I, QS pattern in leads I and aVL, QRS duration in leads II and V(2), and right axis deviation, in ventricular tachycardia. From logistic regression analysis, only monophasic R-wave in lead I remained in the final equation (P=0.004, odds ratio 12.9). CONCLUSION: Monophasic R-wave in lead I during RVOT tachycardia is associated with unfavourable outcomes after RF ablation. This finding may help clinicians in the selection of patients for RF ablation and for the prediction of RF ablation outcome.