Prescription Pattern in Angiotensin Receptor Neprilysin Inhibitor is Associated with Heart Failure Events.

Background: Angiotensin receptor neprilysin inhibition (ARNI) is superior to enalapril in reducing the risk of cardiovascular death and heart failure hospitalization (HFH). However, whether prescription pattern is associated with heart failure outcome is unknown. Methods: This is a retrospective study of 153 patients who received ARNI in a tertiary medical center in Taiwan. We analyzed the impact of dose up-titration and prescription timing including during initial admission, within 3 months after initial HFH discharge, and at outpatient clinics without prior HFH. The primary endpoint was the composite of cardiovascular death and HFH. Results: After a mean follow-up period of 287 ± 197 days, the primary endpoint occurred in 43 (28.1%) subjects. Patients without and with a primary endpoint significantly differed in terms of history of valvular heart disease (VHD, p = 0.006), ventricular tachyarrhythmia (VT, p = 0.043), percutaneous coronary intervention (p = 0.007), coronary artery bypass grafting (p = 0.002), chronic kidney disease (p = 0.002), age (p = 0.002), diastolic blood pressure (p = 0.025), and prescription timing (p = 0.002). Kaplan-Meier analysis showed ARNI up-titration and prescription timing had a significant association with primary endpoint-free survival (Breslow test; p = 0.032, and log-rank test; p = 0.001, respectively). Cox regression analysis showed that independent predictors for the primary endpoint were ARNI up-titration [hazard ratio (HR): 0.41, p = 0.024], non-hospital ARNI versus hospital ARNI (HR: 0.41, p = 0.009), VHD (HR: 2.71, p = 0.013), VT (HR: 3.09, p = 0.02), and age (HR: 1.03, p = 0.033). Conclusions: The prescription pattern of ARNI could be associated with heart failure events.

Normal weight and waist obesity indicated by increased total body fat associated with all-cause mortality in stage 3-5 chronic kidney disease.

Patients with chronic kidney disease (CKD) demonstrate a survival benefit with a high body mass index (BMI); this is the obesity paradox. Central obesity has a higher prognostic value than BMI, even in those with normal weight. Whether total body fat percentage (TBF%) provides more information than BMI and waist circumference (WC) remains unknown. We included 3,262 Asian patients with stage 3-5 CKD and divided these patients by TBF% and waist-to-height ratio (WHtR) quartiles (Q1-Q4). TBF% was associated with BMI, WC, nutritional markers, and C-reactive protein. In all patients, BMI but not TBF% or WHtR demonstrated a survival paradox. In patients with BMI <25 kg/m2, but not in those with BMI ≥ 25 kg/m2, TBF% Q4 and WHtR Q4 were associated with all-cause mortality, with hazard ratios [HRs; 95% confidence intervals (CIs)] of 2.35 (1.31-4.22) and 1.38 (1.06-1.80), respectively. The HRs of TBF% Q4 for all-cause mortality were 2.90 (1.50-5.58) in patients with a normal WC and 3.81 (1.93-7.50) in patients with normal weight and normal WC (All P for interaction < 0.05). In conclusion, TBF% can predict all-cause mortality in patients with advanced CKD and a normal weight, normal WC, or both.

Betel-Quid Chewing, Heart Failure, and Premature Ventricular Contractions in Patients with Cardiopulmonary Symptoms.

Betel-quid (BQ) is a commonly used psychoactive substance that renders a specific cardiotoxicity. The purpose of this study was to investigate the association between BQ chewing and premature ventricular contractions (PVC) in patients with cardiopulmonary symptoms, and examine the potential influences of cardiovascular and chronic diseases on such relationship. Participants were 146 patients with cardiopulmonary symptoms who participated in 24-h Holter electrocardiogram monitoring during 2012-2018 in a hospital serving residents that lived in a BQ high prevalence area. Data on substance uses and medical histories for cardiovascular and chronic diseases were collected. Baron-Kenny method was employed to evaluate possible mediation. In patients with cardiopulmonary symptoms, 36.3% were BQ users and 63.7% were nonusers. Adjusting for covariates, BQ chewing was significantly associated with heart failure and diabetes mellitus (adjusted odds ratio (aOR) = 3.4 and 2.3, respectively), but only heart failure was significantly correlated with a low and high level of PVC. Additionally controlling for the effect of heart failure, the risk of high PVC for BQ users reduced from 3.60 to 2.88; however, the risk for BQ chewers remained significant (95% CI: 1.06-7.84). Heart failure was found to explain 27.7% of the excessive effect of BQ use on high PVC. In conclusion, BQ use is directly associated with an elevated risk of high PVC in patients with cardiopulmonary symptoms. The higher risk might be elevated among patients who suffered heart failure. Given several research limitations, the findings from this study offer future opportunities for validation.

Impact of the duration of the evidence-based medicine use in acute heart failure: A nationwide cohort study.

BACKGROUND: Several randomized control trials have established that drugs can decrease the heart failure (HF) rehospitalization in patients with HF. However, limited studies have investigated the duration of medicine use to decrease the rehospitalization period in the real world. Hence, this study aims to investigate whether the evidence-based medicine decreases the HF rehospitalization in different treatment intervals in the clinical practice. METHOD: We examined patients admitted with acute HF from the National Health Insurance Research Database in Taiwan. In addition, the major adverse cardiovascular events (MACE) were the composite endpoints of the in-hospital mortality and rehospitalization after 1 year. Furthermore, we analyzed the medicine use to decrease 14 days and 1, 6, and 12 months' HF rehospitalization. RESULTS: Overall, we examined 11,012 patients. The use of the renin-angiotensin system (RAS) blockers [hazard ratio (HR), 0.58; P < 0.01], ß-blocker (HR, 0.67; P < 0.01), spironolactone (HR, 0.63; P < 0.01), and digitalis (HR, 0.67; P < 0.01) associated with the lower in-hospital mortality rate. The Cox regression analysis revealed that RAS blocker (HR, 0.86; P < 0.01) and ß-blocker (HR, 0.71; P < 0.01) were independent predictors for MACE. Although RAS blockers declined rehospitalization to 6 months, ß-blocker decreased the rehospitalization rate after 1 month use and the benefit persisted till 12 months. Furthermore, digitalis only lowered rehospitalization to 14 days. CONCLUSION: This study suggests that the use of evidence-based medicine is associated with lower MACE for patients with HF, and these drugs could play vital roles in different periods to decrease the rehospitalization in the clinical setting.

Arteriovenous graft infection caused by Candida glabrata: A case report and literature review.

The infection rate of arteriovenous (AV) grafts is high, but fungal etiology is rare. Only five cases of graft infection due to Candida albicans (C. albicans) or C. tropicalis have been described in the literature. Herein, we report the first case of AV graft infection caused by C. glabrata. A 60-year-old woman on maintenance hemodialysis for end-stage renal disease was admitted because of intermittent fever, for 10 days. Upon physical examination, tenderness over the AV graft site was noticed. Blood culture yielded C. glabrata and her clinical symptoms improved after she was treated with micafungin for 1 month. However, C. glabrata candidemia reoccurred 5 weeks later. Cure was achieved after removal of the AV graft and anidulafungin treatment. Pus was observed in the removed graft, from which C. glabrata was isolated. The outcome of our case and patients from the literature review suggest that removal of the infected graft is important for treatment success of AV graft Candida infection.

A Case of Takotsubo Cardiomyopathy Precipitated by Thyroid Storm and Diabetic Ketoacidosis with Poor Prognosis.

UNLABELLED: Takotsubo cardiomyopathy (TCMP) is known as stress cardiomyopathy, and long-term prognosis is generally excellent if recovering from an acute stage. Both thyroid storm and diabetic ketoacidosis (DKA) are reported to be rare causes of TCMP. However, there are no studies discussing TCMP as induced by a combination of thyroid storm and DKA, and the prognosis is unknown. Herein we report an 81-year-old female with type-2 diabetes mellitus initially presenting with palpitation, chest tightness, and gastrointestinal symptoms. She was further diagnosed as TCMP after echocardiogram and coronary angiography, and DKA was confirmed later. However, the patient's general condition didn't improve under proper treatment. Thereafter, thyroid storm was discovered fortuitously. Despite appropriate treatment, the patient finally expired due to acute respiratory distress syndrome progression. This rare case reminds us that despite TCMP being a transient cardiomyopathy with good prognosis, physicians should survey the possible underlying disease cautiously to avoid catastrophic clinical outcome. KEY WORDS: Acute respiratory distress syndrome; Diabetic ketoacidosis; Stress cardiomyopathy; Takotsubo cardiomyopathy; Thyroid storm.