2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension

Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.

Implementing a flipped classroom model in an evidence-based medicine curriculum for pre-clinical medical students: evaluating learning effectiveness through prospective propensity score-matched cohorts

BACKGROUND

In a flipped classroom (FC) model, blended learning is used to increase student engagement and learning by having students finish their readings at home and work on problem-solving with tutors during class time. Evidence-based medicine (EBM) integrates clinical experience and patient values with the best evidence-based research to inform clinical decisions. To implement a FC and EBM, students require sufficient information acquisition and problem-solving skills. Therefore, a FC is regarded as an excellent teaching model for tutoring EBM skills. However, the effectiveness of a FC for teaching EBM competency has not been rigorously investigated in pre-clinical educational programs. In this study, we used an innovative FC model in a pre-clinical EBM teaching program.

METHODS

FC's teaching was compared with a traditional teaching model by using an assessment framework of prospective propensity score matching, which reduced the potential difference in basic characteristics between the two groups of students on 1:1 ratio. For the outcome assessments of EBM competency, we used an analysis of covariance and multivariate linear regression analysis to investigate comparative effectiveness between the two teaching models. A total of 90 students were prospectively enrolled and assigned to the experimental or control group using 1:1 propensity matching.

RESULTS

Compared with traditional teaching methods, the FC model was associated with better learning outcomes for the EBM competency categories of Ask, Acquire, Appraise, and Apply for both written and oral tests at the end of the course (all p-values< 0.001). In particular, the "appraise" skill for the written test (6.87 ± 2.20) vs. (1.47 ± 1.74), p < 0.001), and the "apply" skill for the oral test (7.34 ± 0.80 vs. 3.97 ± 1.24, p < 0.001) had the biggest difference between the two groups.

CONCLUSIONS

After adjusting for a number of potential confunding factors, our study findings support the effectiveness of applying an FC teaching model to cultivate medical students' EBM literacy.

Prognostic Role of Pulmonary Function in Patients With Heart Failure With Reduced Ejection Fraction

Background

Both ventilatory abnormalities and pulmonary hypertension (PH) are frequently observed in patients with heart failure with reduced ejection fraction. We aim to investigate the association between ventilatory abnormalities and PH in heart failure with reduced ejection fraction, as well as their prognostic impacts.

Methods and Results

A total of 440 ambulatory patients (age, 66.2±15.8 years; 77% men) with left ventricular ejection fraction ≤40% who underwent comprehensive echocardiography and spirometry were enrolled. Total lung capacity, forced vital capacity, and forced expiratory volume in the first second were obtained. Pulmonary arterial systolic pressure was estimated. PH was defined as a pulmonary arterial systolic pressure of >50 mm Hg. The primary end point was all‐cause mortality at 5 years. Patients with PH had significantly reduced total lung capacity, forced vital capacity, and forced expiratory volume in the first second. During a median follow‐up of 25.9 months, there were 111 deaths. After accounting for age, sex, body mass index, renal function, smoking, left ventricular ejection fraction, and functional capacity, total lung capacity (hazard ratio [HR] per 1 SD, 0.66; 95% CI per 1 SD, 0.46–0.96), forced vital capacity (HR per 1 SD, 0.64; 95% CI per 1 SD, 0.48–0.84), and forced expiratory volume in the first second (HR per 1 SD, 0.72; 95% CI per 1 SD, 0.53–0.98) were all significantly correlated with mortality in patients without PH. Kaplan‐Meier curve demonstrated impaired pulmonary function, defined as forced expiratory volume in the first second ≤58% of predicted or forced vital capacity ≤65% of predicted, was associated with higher mortality in patients without PH (HR, 2.85; 95% CI, 1.66–4.89), but not in patients with PH (HR, 1.05; 95% CI, 0.61–1.82).

Conclusions

Ventilatory abnormality was more prevalent in patients with heart failure with reduced ejection fraction with PH than those without. However, such ventilatory defects were related to long‐term survival only in patients without PH, regardless of their functional status.

Seven-action approaches for the management of hypertension in Asia - The HOPE Asia network

Asia is a large continent and there is significant diversity between countries and regions. Over the last 30 years, absolute blood pressure (BP) levels in Asia have increased to a greater extent than those in other regions. In diverse Asia‐Pacific populations, for choosing an Asia‐specific approach to hypertension management is important to prevent target organ damage and cardiovascular diseases. In this consensus document of HOPE Asia Network, we introduce seven action approaches for management of hypertension in Asia.

Evaluating Teaching Effectiveness of Medical Humanities in an Integrated Clerkship Program by a Novel Prospective Propensity Score Matching Framework

Background: This study aims to rigorously compare the effectiveness of the educational programs of a new integrated clinical clerkship in medicine (3 months) and surgery (3 months) at a cancer center with the conventional subspecialty-based rotations at a tertiary teaching hospital, by this prospective, pre-post comparative method. Methods: Between 2013–2016, we compared 69 students who had selected the integrated clerkship that emphasized clinical competency and medical humanities training with 138 matched peers who had completed conventional clerkships during the same period. Outcome measures for medical humanities included empathy, patient-centeredness, and other values and skills related to holistic health care professionalism by introducing prospective propensity score matching (PSM). Results: At baseline, no significant between-group differences existed. At the completion of the core clerkships, students receiving the integrative clerkship had significantly higher scores on the Patient–Practitioner Orientation Scale (PPOS) and the Professionalism Climate in Clinical Teaching Environment (PCI), and similar Jefferson Scale of Physician Empathy Student Version (JSPE) scores, as compared with the comparison group. We also found that the students in this program did not perform worse than those in the traditional internship group in the comprehensive and formative OSCE medical clinical skills test. Conclusions: Our study develops an empirical basis for rigorous evaluation to design medical education to improve the medical humanities values and skills of interns. Features of the new integrated clerkship program that we developed include substantial participation by the students in patient-centered in-hospital culture, as well as reflection, discussion, and feedback on actual clinical cases.

Associations Between Cerebral Vasoreactivity and Cognitive Function in the Middle-Aged Non-Demented Population

Background: Increasing evidence shows early vascular dysregulation in the pathophysiology of Alzheimer’s disease (AD) in elderly population. Objective: We wondered about the relationship between vascular health and cognitive performance in middle-aged adults. The present study aims to evaluate whether and which brain vascular hemodynamic parameters are associated with cognitive functions in a middle-aged, non-demented population. Methods: We recruited 490 middle-aged community-based participants (30–60 years). Transcranial color-coded sonography was used to measure cerebral vascular hemodynamics, including mean flow velocity, pulsatility index, and breath-holding index (BHI) in the middle cerebral arteries (MCAs). Cognitive functions were assessed using the Montreal Cognitive Assessment (MoCA). A multivariate linear regression model was used to determine the association between the MoCA scores and each intracranial hemodynamic parameter. Results: In 369 participants (median age 52 years [IQR 47–56], 48.8% men) with robust acoustic windows, the factors related to poorer MoCA scores were older age, less education extent, and the habitats of cigarette smoking or alcohol consumption. Multivariate analyses did not show a significant association between any intracranial hemodynamic parameters in both MCAs and MoCA scores in the total study population. Left MCA BHI was found to be significantly and independently correlated with the MoCA scores only in people aged 55–60 years (n = 111, B = 0.70, 95% confidence interval, 0.13–1.26, p = 0.017), however, not in people younger than 55 years. Conclusion: Our results emphasize the role of neurovascular abnormalities in the early pathophysiology of cognitive impairment and suggest cerebral vasoreactivity as the earliest detectable cognition-associated hemodynamic parameter.

Developing and Validating Risk Scores for Predicting Major Cardiovascular Events Using Population Surveys Linked with Electronic Health Insurance Records

A risk prediction model for major cardiovascular events was developed using population survey data linked to National Health Insurance (NHI) claim data and the death registry. Another set of population survey data were used to validate the model. The model was built using the Nutrition and Health Survey in Taiwan (NAHSIT) collected from 1993–1996 and linked with 10 years of events from NHI data. Major adverse cardiovascular events (MACEs) were identified based on hospital admission or death from coronary heart disease or stroke. The Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH), conducted in 2002 was used for external validation. The NAHSIT data consisted of 1658 men and 1652 women aged 35–70 years. The incidence rates for MACE per 1000 person-years were 13.77 for men and 7.76 for women. These incidence rates for the TwSHHH were 7.27 for men and 3.58 for women. The model had reasonable discrimination (C-indexes: 0.76 for men; 0.75 for women), thus can be used to predict MACE risks in the general population. NHI data can be used to identify disease statuses if the definition and algorithm are clearly defined. Precise preventive health services in Taiwan can be based on this model.

Cardiovascular risk assessment tools in Asia

Cardiovascular disease (CVD) is becoming the most important burden to health care systems in most part of the world, especially in Asia. Aiming at identifying high risk individuals and tailoring preventive treatment, many cardiovascular risk assessment tools have been established and most of them were developed in Western countries. However, these cardiovascular risk assessment tools cannot be used interchangeably without recalibration because of the different risk factor profiles (ie, greater absolute burden of hypertension and lower level of total‐cholesterol in Asians and higher prevalence of metabolic disorders in South Asians) and different CVD profiles (higher ratio of stroke/coronary heart disease in Asians) between Western and Asian populations. Original risk models such as Prediction for ASCVD Risk in China (China‐PAR) and Japan Arteriosclerosis Longitudinal Study (JALS) score have been developed and well validated for specific countries, while most of countries/regions in Asia are using established models. Due to higher incidence of stroke in Asians, risk factors like hypertension should weigh more in cardiovascular risk assessment comparing with Western populations, but their actual proportions should be based on CVD profiles in specific countries/regions. The authors encourage the development of new cardiovascular risk assessment tools for Asians, if possible. Still, modifying established models with native epidemiological data of risk factor as well as CVD is acceptable in regions where health care resources are insufficient.

Comparison of OSCE performance between 6- and 7-year medical school curricula in Taiwan

BACKGROUND

The year 2013 marks a watershed in the history of medical education in Taiwan. Following Taiwan's Taskforce of Medical School Curriculum Reform recommendations, the medical school curriculum was reduced from 7 to 6 years. This study aimed to analyze the impact of medical school curriculum reform on medical students' performance in objective structured clinical examinations (OSCEs).

METHODS

We retrospectively analyzed the OSCE records at Taipei Veterans General Hospital (Taipei VGH), one of Taiwan's largest tertiary medical centers, between November 2016 and July 2020. The eligibility criteria were medical students receiving a full one-year clinical sub-internship training at Taipei VGH and in their last year of medical school. All medical students received a mock OSCE-1 at the beginning of their sub-internship, a mock OSCE-2 after six months of training, and a national OSCE at the end of their sub-internship. The parameters for performance in OSCEs included "percentage of scores above the qualification standard" and "percentage of qualified stations."

RESULTS

Between November 2016 and July 2020, 361 undergraduates underwent clinical sub-internship training at Taipei VGH. Among them, 218 were taught under the 7-year curriculum, and 143 were instructed under the 6-year curriculum. Based on baseline-adjusted ANCOVA results, medical students under the 7-year curriculum had a higher percentage of scores above the qualification standard than those under the 6-year curriculum at the mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 33.8% [95% CI 32.0-35.7] vs. 28.2% [95% CI 25.9-30.4], p < 0.001), and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001). Moreover, medical students in the 7-year curriculum had a higher percentage of qualified stations in mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001) and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 91.9% [95% CI 90.1-93.8] vs. 86.1% [95% CI 83.8-88.3], p = 0.001). After clinical sub-internship training, there were no differences in the percentage of scores above the qualification standard (7-year curriculum vs. 6-year curriculum: 33.5% [95% CI 32.2-34.9] vs. 34.6 [95% CI 32.9-36.3], p = 0.328) and percentage of qualified stations (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 88.1-90.7] vs. 90.2% [95% CI 88.6-91.8], p = 0.492).

CONCLUSIONS

At the beginning of the sub-internship, medical students under the 7-year curriculum had better OSCE performance than those under the 6-year curriculum. After the clinical sub-internship training in Taipei VGH, there was no difference in the national OSCE score between the 6- and 7-year curricula. Our study suggests that clinical sub-internship is crucial for the development of clinical skills and performance in the national OSCE.

Network meta-analysis and trial sequential analysis for atrial fibrillation patients receiving PCI or with ACS

BACKGROUND

In patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), choosing the most appropriate antithrombotic treatment remains a dilemma. We aimed to compare the relative efficacy and safety outcomes of antithrombotic drugs in patients with AF after undergoing PCI or ACS.

METHODS

Randomized controlled trials were systematically searched on PubMed, EMBASE, and the Cochrane Library. Five studies (11,532 patients) were included in the network meta-analysis. Trial sequential analysis (TSA) was performed to assess the reliability and conclusiveness of the meta-analysis comparing the dual antithrombotic therapy strategies with the triple antithrombotic therapy strategy.

RESULTS

Compared with vitamin K antagonist + dual antiplatelet therapy, novel oral anticoagulant (NOAC) + P2Y12 inhibitor was associated with a significantly better trial-defined primary safety outcome (odds ratio: 0.53; 95% CI, 0.31-0.90) and the lowest probability of thrombolysis in myocardial infarction major bleeding and intracranial hemorrhage using the cumulative ranking technique. In patients omitting aspirin, TSA demonstrated conclusive evidence with significant decreases in all safety outcomes and inconclusive evidence with a nonsignificant increase in in-stent thrombosis (risk ratio: 1.32; TSA-adjusted 95% CI, 0.54-3.24) and myocardial infarction (risk ratio: 1.19; TSA-adjusted 95% CI, 0.84-1.68).

CONCLUSIONS

In patients with AF receiving PCI or with ACS, NOAC + P2Y12 inhibitor was associated with the lowest bleeding risk but resulted in a statistically nonsignificant, numerically greater risk for stent thrombosis and myocardial infarction, suggesting that triple antithrombotic therapy should still be an option for certain patients at a high risk of stent thrombosis or myocardial infarction.

Role of Heart Rate Variability in Association Between Glomerular Hyperfiltration and All-Cause Mortality

Background

Glomerular hyperfiltration (GHF) is paradoxically associated with increased cardiovascular events in healthy individuals, but the pathogenesis remains unclear. We aim to investigate whether GHF is associated with mortality and whether decreased heart rate variability (HRV) is associated with GHF.

Methods and Results

We retrospectively analyzed 1615 participants (aged 66.1±17.3 years, 61.9% men) without prior cardiovascular events. The glomerular filtration rate was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. GHF was defined as glomerular filtration rate >the 95th percentile after stratification for age and sex, whereas normal filtration was defined as the 25th to 75th percentiles. HRV indexes, including time domain, frequency domain, and sample entropy, were measured using 24‐hour ambulatory electrocardiography. Clinical outcomes were defined as all‐cause mortality at 2 years. During a mean follow‐up of 16.5±8.2 months, there were 117 deaths (7.2%). GHF was associated with a higher risk of death (hazard ratio and 95% CIs, 1.97 [1.15–3.37]). Reduced HRV indexes, including time domain, frequency domain, and sample entropy (odds ratio and 95% CIs, 0.79 [0.70–0.89]) were all independently associated with the presence of GHF after accounting for age, sex, mean heart rate, morbidities, and medications. In subgroup analysis, reduced HRV was more predictive of GHF in the young than the elderly. Mediation analysis revealed a significant mediation effect between HRV and GHF in addition to their respective detrimental effects on survival.

Conclusions

Reduced HRV was independently associated with the presence of GHF. Autonomic dysfunction may be involved in the pathogenesis of adverse outcomes of GHF in individuals without prior cardiovascular events.

The prognostic significance of the alterations of pulmonary hemodynamics in patients with pulmonary arterial hypertension: a meta-regression analysis of randomized controlled trials

BACKGROUND

Hemodynamic assessment in patients with pulmonary arterial hypertension (PAH) is essential for risk stratification and pharmacological management. However, the prognostic value of the hemodynamic changes after treatment is less well established.

OBJECTIVES

We investigated the prognostic impacts of the changes in hemodynamic indices, including mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), right atrial pressure (RAP), and cardiac output index (CI). We conducted this systematic review with meta-regression analysis on existing clinical trials.

METHODS

We searched and identified all relevant randomized controlled trials from multiple databases. An analogous R² index was used to quantify the proportion of variance explained by each predictor in the association with PAH patients' prognosis. A total of 21 trials and 3306 individuals were enrolled.

RESULTS

The changes in mPAP, PVR, RAP, and CI were all significantly associated with the change in 6MWD (∆6MWD). The change in mPAP was with the highest explanatory power for ∆6MWD (R² analog = 0.740). Additionally, the changes in mPAP, PVR, and CI were independently predictive of adverse clinical events. The change in mPAP had the highest explanatory power for the clinical events (R² analog = 0.911). Furthermore, the change in PVR was with the highest explanatory power for total mortality of PAH patients (R² analog = 0.612).

CONCLUSION

Hemodynamic changes after treatment, including mPAP, PVR, CI, and RAP, were significantly associated with adverse clinical events or mortality in treated PAH patients. It is recommended that further studies be conducted to evaluate the changes in hemodynamic indices to guide drug titration.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019125157.

Oral Anticoagulation Timing in Patients with Acute Ischaemic Stroke and Atrial Fibrillation

BACKGROUND AND PURPOSE

Oral anticoagulants (OACs) prevent stroke recurrence and vascular embolism in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF). Current guidance recommends a "1-3-6-12 day"' rule to resume OACs after AIS, based mainly on empirical consensus. This study investigated the suitability of guideline-recommended timing for OAC initiation.

METHODS

To overcome immortal time bias, we emulated a sequence of randomized placebo-controlled trials and constructed 90 propensity score-matched cohorts of 12,307 patients with AF and AIS from 2012 to 2016. We compared the risk of composite effectiveness and safety outcome in the early vs no OAC use group and in the delayed vs no OAC use. Indirect comparison between early and delayed use was conducted using a network meta-analysis.

RESULTS

Across the groups of AIS severity, the risks of composite outcome or effectiveness outcome were lower in the OAC use group than the no use group and the risks were similar between the early and delayed use groups. In patients with severe AIS, those receiving early OACs use had an increased risk of safety outcome, with HR of 2.10 (CI: 1.13-3.92) compared with those without OAC use, and HR of 1·44 (CI: 0·99-2·09) compared with those receiving delayed use.

CONCLUSIONS

In AF patients with severe AIS, early OAC use before the guideline-recommended days appeared to increase the risk of bleeding events, although the OAC initiation time seemed not to affect the risk of serious vascular events. The optimal severity-specific timing for OAC initiation after AIS requires further evaluation.

2021 Consensus Pathway of the Taiwan Society of Cardiology on Novel Therapy for Type 2 Diabetes

Type 2 diabetes is a major threat to human health in the 21st century. More than half a billion people may suffer from this pandemic disease in 2030, leading to a huge burden of cardiovascular complications. Recently, 2 novel antidiabetic agents, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, reduced cardiovascular complications in a number of randomized control trials. To integrate new information and to achieve a streamlined process for better patient care, a working group was appointed by the Taiwan Society of Cardiology to formulate a stepwise consensus pathway for these therapies to reduce cardiovascular events in patients with type 2 diabetes. This consensus pathway is complementary to clinical guidelines, acting as a reference to improve patient care.

Urinary proteomics combined with home blood pressure telemonitoring for health care reform trial: rational and protocol

BACKGROUND

Hypertension and diabetes cause chronic kidney disease (CKD) and diastolic left ventricular dysfunction (DVD) as forerunners of disability and death. Home blood pressure telemonitoring (HTM) and urinary peptidomic profiling (UPP) are technologies enabling prevention.

METHODS

UPRIGHT-HTM (Urinary Proteomics Combined with Home Blood Pressure Telemonitoring for Health Care Reform [NCT04299529]) is an investigator-initiated 5-year clinical trial with patient-centred design, which will randomise 1148 patients to be recruited in Europe, sub-Saharan Africa and South America. During the whole study, HTM data will be collected and freely accessible for patients and caregivers. The UPP, measured at enrolment only, will be communicated early during follow-up to 50% of patients and their caregivers (intervention), but only at trial closure in 50% (control). The hypothesis is that early knowledge of the UPP risk profile will lead to more rigorous risk factor management and result in benefit. Eligible patients, aged 55-75 years old, are asymptomatic, but have ≥5 CKD- or DVD-related risk factors, preferably including hypertension, type-2 diabetes, or both. The primary endpoint is a composite of new-onset intermediate and hard cardiovascular and renal outcomes. Demonstrating that combining UPP with HTM is feasible in a multicultural context and defining the molecular signatures of early CKD and DVD are secondary endpoints.

EXPECTED OUTCOMES

The expected outcome is that application of UPP on top of HTM will be superior to HTM alone in the prevention of CKD and DVD and associated complications and that UPP allows shifting emphasis from treating to preventing disease, thereby empowering patients.

Risk of work-related injury in workers with obstructive sleep apnea: A systematic review and meta-analysis

The objective of this study is to elucidate the relationship between obstructive sleep apnea (OSA) and the risk of work-related injuries (WRIs), synthesize the latest clinical evidence and conduct a systematic review and meta-analysis adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA 2020). Observational studies published before April 2020 in PubMed, Cochrane library, PsycINFO, Scopus, Google Scholar and Web of Science were included. Random-effects Mantel-Haenszel meta-analysis was performed. A total of 15 studies with 21,507 participants were included. Prespecified subgroup analyses based on study design and the characteristics of the enrollees were conducted. Overall, workers with OSA had 1.64-fold increased odds of being involved in WRIs compared to their counterparts (OR = 1.64, 95% CI = 1.24-2.16, p = 0.0005). In addition to the professional drivers that have been studied in the past, such a trend also existed in the general working population (OR = 1.68, 95% CI = 1.14-2.49, p = 0.01). We also found that workers with excessive daytime sleepiness (Epworth Sleepiness Scale score >10) had a 1.68-fold increased risk of WRIs compared to those with lower ESS scores (OR = 1.68, 95% CI = 1.22-2.30, p = 0.002). This study verified that OSA workers had a higher risk of WRIs, and such correlations do not show obvious differences in subgroups with different sample sizes, OSA diagnosis methods, job types or definitions of WRI. Based on the association between OSA and WRIs identified in our study, further studies investigating the protective effects of early identification and management of OSA on WRIs are warranted.

The early detection of immunoglobulins via optical-based lateral flow immunoassay platform in COVID-19 pandemic

The coronavirus disease (COVID-19) is the global public health challenge currently persisting at a grand scale. A method that meets the rapid quantitative detection of antibodies to assess the body's immune response from natural COVID-19 illness or vaccines' effects is urgently needed. In the present study, an attempt was made to integrate a newly designed spectrometer to the COVID-19 test strip procedure; this augmentation provides the quantitative capacity to a lateral flow immunoassay (LFIA). Optical interpretation of results by quantitative α index, rather than visual qualification, can be done quickly, in 5-10 minutes. The developed product was compared with several other serological IgM/IgG antibody reagents on the market by recruiting 111 participants suspected of having COVID-19 infection from March to May 2020 in a hospital. Taking RT-PCR as the diagnostic gold standard, the quantitative spectral LIFA platform could correctly detect all 12 COVID-19 patients. Concerning RT-PCR negative patients, all three antibody testing methods found positive cases. The optical-based platform exhibited the ability of early detection of immunoglobulins of RT-PCR negative patients. There was an apparent trend that elevation of IgM levels in the acute phase of infection; then IgG levels rose later. It exhibited the risk of a false-negative diagnosis of RT-PCR in COVID-19 testing. The significant detection ability of this new optical-based platform demonstrated clinical potential.

Optimal blood pressure for patients with end-stage renal disease following coronary interventions

Hypertension is a frequent manifestation of chronic kidney disease but the ideal blood pressure (BP) target in patients with coronary artery disease (CAD) with end-stage renal disease (ESRD) (eGFR < 15 ml/min/1.73m² ) still unclear. The authors aimed to investigate the ideal achieved BP in ESRD patients with CAD after coronary intervention. Five hundred and seventy-five ESRD patients who had undergone percutaneous coronary interventions (PCIs) were enrolled and their clinical outcomes were analyzed according to the category of systolic BP (SBP) and diastolic BP (DBP) achieved. The clinical outcomes included major cardiovascular events (MACE) and MACE plus hospitalization for congestive heart failure (total cardiovascular (CV) event).The mean systolic BP was 135.0 ± 24.7 mm Hg and the mean diastolic BP was 70.7 ± 13.1 mm Hg. Systolic BP 140-149 mm Hg and diastolic BP 80-89 mm Hg had the lowest MACE (11.0%; 13.2%) and total CV event (23.3%; 21.1%). Patients with systolic BP < 120 mm Hg had a higher risk of MACE (HR: 2.01; 95% CI: 1.17-3.46, p = .008) than those with systolic BP 140-149 mm Hg. Patients with systolic BP ≥ 160 mm Hg (HR: 1.84; 95% CI, 3.27-1.04, p = .04) and diastolic blood BP ≥ 90 mm Hg (HR: 2.19; 95% CI: 1.15-4.16, p = .02) had a higher risk of total CV event rate when compared to those with systolic BP 140-149 mm Hg and diastolic BP 80-89 mm Hg. A J-shaped association between systolic (140-149 mm Hg) and diastolic (80-89 mm Hg) BP and decreased cardiovascular events for CAD was found in patients with ESRD after undergoing PCI in non-Western population.

Vascular complications of diabetes: natural history and corresponding risks of dementia in a national cohort of adults with diabetes

AIMS

This study aimed to determine the trajectory of diabetic vascular diseases and to investigate the association between vascular diseases and dementia.

METHODS

We included adults aged ≥ 50 years with newly diagnosed type 2 diabetes (n = 173,118) from 2001 to 2005 who were followed-up until December 31, 2013 in the Taiwan's National Health Insurance Research Database. Multivariable Cox regression models were constructed to estimate hazard ratios (HRs) and confidence limits (CLs) for all-cause dementia in relation to the number, types, and occurrence patterns of vascular disease.

RESULTS

Within 1 year of diabetes diagnosis, 26.3% of adults developed their first vascular disease. During the 1,864,279 person-years of follow-up, 17,426 adults had all-cause dementia, corresponding to an incidence of 97.9 cases/10,000 person-years in 127,718 adults with at least one vascular disease and 67.5 cases/10,000 person-years in 45,400 adults without vascular diseases. Across all age groups, adults who subsequently developed a vascular disease in two one-year windows since diabetes diagnosis had the highest incidence of all-cause dementia. In comparison with adults without vascular diseases, HR for all-cause dementia was 1.99 (CL: 1.92-2.07) for those with one vascular disease only; 2.04 (CL: 1.98-2.13) for two or more vascular diseases; 3.56 (CL: 3.44-3.70) for stroke only; and 2.06 (CL: 1.99-2.14) for neuropathy alone. Similar associations were also observed with a smaller magnitude for adults with nephropathy, retinopathy, cardiovascular disease, or peripheral arterial disease.

CONCLUSIONS

Patients with diabetes-related complications, particularly stroke and neuropathy, and those with rapidly developed vascular diseases appeared to have a high risk of dementia.

Blood pressure variability and cognitive dysfunction: A systematic review and meta-analysis of longitudinal cohort studies

The variability of blood pressure (BPV) has been suggested as a clinical indicator for cognitive dysfunction, yet the results from clinical studies are variable. This study investigated the relationship between BPV and the risk of cognitive decline or dementia. Bibliographic databases, including PubMed, Scopus, and Embase, were searched systematically for longitudinal cohort studies with BPV measurements and neuropsychological examinations or dementia diagnosis. A traditional meta‐analysis with subgroup analysis, and a further dose‐response meta‐analysis were conducted. Twenty cohort studies with 7 924 168 persons were included in this review. The results showed that a higher systolic BPV (SBPV), when measured with the coefficient of variation (SBP‐CV) or standard deviation (SBP‐SD), was associated with a higher risk of all‐cause dementia diagnosis but not incidence of cognitive decline on neuropsychological examinations. In subgroup analysis, the effect was more prominent when using BPV of shorter timeframes, during shorter follow‐ups, or among the elderly aged more than 65 years. No dose‐response relationship could be found. Our study suggested possible positive associations between SBPV and the risk of dementia. Further studies are required to validate these findings.

From Genetic Mutations to Molecular Basis of Heart Failure Treatment: An Overview of the Mechanism and Implication of the Novel Modulators for Cardiac Myosin

Heart failure (HF) is a syndrome encompassing several important etiologies that lead to the imbalance between oxygen demand and supply. Despite the usage of guideline-directed medical therapy for HF has shown better outcomes, novel therapeutic strategies are desirable, especially for patients with preserved or mildly reduced left ventricular ejection fraction. In this regard, understanding the molecular basis for cardiomyopathies is expected to fill in the knowledge gap and generate new therapies to improve prognosis for HF. This review discusses an evolutionary mechanism designed to regulate cardiac contraction and relaxation through the most often genetically determined cardiomyopathies associated with HF. In addition, both the myosin inhibitor and myosin activator are promising new treatments for cardiomyopathies. A comprehensive review from genetic mutations to the molecular basis of direct sarcomere modulators will help shed light on future studies for a better characterization of HF etiologies and potential therapeutic targets.

The Comprehensive Machine Learning Analytics for Heart Failure

Background: Early detection of heart failure is the basis for better medical treatment and prognosis. Over the last decades, both prevalence and incidence rates of heart failure have increased worldwide, resulting in a significant global public health issue. However, an early diagnosis is not an easy task because symptoms of heart failure are usually non-specific. Therefore, this study aims to develop a risk prediction model for incident heart failure through a machine learning-based predictive model. Although African Americans have a higher risk of incident heart failure among all populations, few studies have developed a heart failure risk prediction model for African Americans. Methods: This research implemented the Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression, support vector machine, random forest, and Extreme Gradient Boosting (XGBoost) to establish the Jackson Heart Study's predictive model. In the analysis of real data, missing data are problematic when building a predictive model. Here, we evaluate predictors' inclusion with various missing rates and different missing imputation strategies to discover the optimal analytics. Results: According to hundreds of models that we examined, the best predictive model was the XGBoost that included variables with a missing rate of less than 30 percent, and we imputed missing values by non-parametric random forest imputation. The optimal XGBoost machine demonstrated an Area Under Curve (AUC) of 0.8409 to predict heart failure for the Jackson Heart Study. Conclusion: This research identifies variations of diabetes medication as the most crucial risk factor for heart failure compared to the complete cases approach that failed to discover this phenomenon.

Low central blood pressure and sympathetic activity predispose for the development of intradialytic hypotension

Intradialytic hypotension (IDH) may lead to a poor life quality and was associated with cardiovascular mortality in patients under hemodialysis. This study investigated the autonomic nerve and cardiovascular function in the IDH episodes.In this case-control study, 70 end stage renal disease patients (198 visits) were recruited. Pulse wave analysis and heart rate variability were evaluated before hemodialysis. Two definitions of IDH were confirmed by medical records. IDH-f indicated a drop of systolic blood pressure or mean arterial pressure, accompanied with symptoms; IDH-n indicated a low nadir systolic pressure during the hemodialysis. All parameters were evaluated for the possible predisposing factors under each definition.A total of 24 IDH-f and 37 IDH-n were noted in 177 visits. For both definitions, central pulse pressure seemed to be a consistent predisposing factor. Furthermore, lower sympathetic activity (odds ratio [OR] 0.55; 95% confidence interval [CI] 0.35-0.87), lower pulse pressure (OR 0.95; 95% CI 0.92-0.98), and higher augmentation index (OR 17.36; 95% CI 1.48-204.10) were the possible predisposing factors for IDH-f. On the contrary, lower mean arterial pressure (OR 0.87; 95% CI 0.78-0.98) was identified as the possible factor for IDH-n.It was suggested that the lower central pulse pressure and sympathetic activity might be involved in the development of IDH.

Non-pharmacological management of hypertension

Hypertension is an insidious disease which predisposes to cardiovascular complications and if not treated properly can lead to various serious complications. Economic limitations, having additional benefits with few or almost no side effects have made non-pharmacological management of hypertension an attractive approach for dealing with hypertension, in developed and developing countries alike. A MEDLINE search was done for relevant references with emphasis on original studies, randomized controlled trials, and meta-analyses for this review paper. Lifestyle modifications including changes in the dietary pattern, adopting special diets with low sodium, saturated fat and high calcium, magnesium and potassium and trying the new methods like time restricted meal intake which work in tandem with the circadian rhythm are opening new vistas in the field of non-pharmacological management of hypertension. Lifestyle modifications that effectively lower blood pressure are increased physical activity, weight loss, limited alcohol consumption, relaxation techniques of Yoga, Acupuncture, Tai chi, mindfulness-based stress-reduction program, and Transcendental Meditation. Air pollution of the surrounding air is linked with poor health outcomes and is a major contributor to the global burden of disease. Fine particulate matter <2.5 μm in diameter (PM2.5) is strongly associated with cardiovascular morbidity and mortality. Short-term PM exposure (hours to weeks) increases the likelihood of adverse cardiovascular events including myocardial infarction, stroke, and heart failure, and longer-term exposure multiplies that risk. Non-pharmacological methods should be initiated early phase of disease and should be continued with medication.

Characteristics of hypertension in obstructive sleep apnea: An Asian experience

Obstructive sleep apnea (OSA) is a risk of hypertension and is associated with cardiovascular disease (CVD) incidence. In Asian countries, the prevalence of OSA is high, as in Western countries. When blood pressure (BP) is evaluated in OSA individuals using ambulatory BP monitoring (ABPM), the BP phenotype often indicates abnormal BP variability, such as increased nighttime BP or abnormal diurnal BP variation, that is, non‐dipper pattern, riser pattern, and morning BP surge, and all these conditions have been associated with increased CVD events. Asians have a higher prevalence of increased nighttime BP or morning BP surge than Westerners. Therefore, this review paper focused on OSA and hypertension from an Asian perspective to investigate the importance of the association between OSA and hypertension in the Asian population. Such abnormal BP variability has been shown to be associated with progression of arterial stiffness, and this association could provoke a vicious cycle between abnormal BP phenotypes and arterial stiffness, a phenomenon recognized as systemic hemodynamic atherothrombotic syndrome (SHATS). OSA may be one of the background factors that augment SHATS. An oxygen‐triggered nocturnal oscillometric BP measurement device combined with a pulse oximeter for continuous SpO₂ monitoring could detect BP variability caused by OSA. In addition to treating the OSA, accurate and reliable detection and treatment of any residual BP elevation and BP variability caused by OSA would be necessary to prevent CVD events. However, more detailed detection of BP variability, such as beat‐by‐beat BP monitoring, would further help to reduce CV events.

Applications of artificial intelligence for hypertension management

The prevalence of hypertension is increasing along with an aging population, causing millions of premature deaths annually worldwide. Low awareness of blood pressure (BP) elevation and suboptimal hypertension diagnosis serve as the major hurdles in effective hypertension management. The advent of artificial intelligence (AI), however, sheds the light of new strategies for hypertension management, such as remote supports from telemedicine and big data-derived prediction. There is considerable evidence demonstrating the feasibility of AI applications in hypertension management. A foreseeable trend was observed in integrating BP measurements with various wearable sensors and smartphones, so as to permit continuous and convenient monitoring. In the meantime, further investigations are advised to validate the novel prediction and prognostic tools. These revolutionary developments have made a stride toward the future model for digital management of chronic diseases.

Comparison of guidelines for the management of hypertension: Similarities and differences between international and Asian countries; perspectives from HOPE-Asia Network

Guidelines on the management of hypertension have been developed by various professional bodies and institutions to primarily address the issues of diagnosis, treatment, and control in order to rationalize and improve the management of hypertension. Hypertension guidelines across the world have recently been updated following the new and controversial lower blood pressure threshold of ≥130/80 mmHg for the diagnosis of hypertension adopted by the Americans. While there are differences between the major as well as between the Asian national guidelines, there were also many similarities. This paper discusses and highlights the differences and similarities between the major international guidelines of the American College of Cardiology/American Heart Association, of the European Society of Cardiology/European Society of Hypertension, and of the International Society of Hypertension and also compares them with the Asian guidelines.

Characteristics and control of the 24-hour ambulatory blood pressure in patients with metabolic syndrome

Asian countries are facing an increasing prevalence of metabolic syndrome (MetS), which may aggravate the burden of cardiovascular diseases in this region. MetS is closely associated with ambulatory blood pressure (BP). Patients with MetS, compared to those without, had a twofold higher risk of new-onset office, home, or ambulatory hypertension. Furthermore, the risk of new-onset MetS in patients with white-coat, masked and sustained hypertension was also doubled compared to normotensives. High-risk masked hypertension and blunted nighttime BP dipping are common in patients with MetS, suggesting perfect 24-hour BP control with long-acting antihypertensive drugs and early initiation of combination therapy might be especially important for patients with MetS.

Disaster hypertension and cardiovascular events in disaster and COVID-19 pandemic

The incidence of large disasters has been increasing worldwide. This has led to a growing interest in disaster medicine. In this review, we report current evidence related to disasters and coronavirus disease‐2019 (COVID‐19) pandemic, such as cardiovascular diseases during disasters, management of disaster hypertension, and cardiovascular diseases associated with COVID‐19. This review summarizes the time course and mechanisms of disaster‐related diseases. It also discusses the use of information and communication technology (ICT) as a cardiovascular risk management strategy to prevent cardiovascular events. During the 2011 Great East Japan Earthquake, we used the “Disaster Cardiovascular Prevention” system that was employed for blood pressure (BP) monitoring and risk management using ICT. We introduced an ICT‐based BP monitoring device at evacuation centers and shared patients’ BP values in the database to support BP management by remote monitoring, which led to improved BP control. Effective use of telemedicine using ICT is important for risk management of cardiovascular diseases during disasters and pandemics in the future.

Telemedicine in the management of hypertension: Evolving technological platforms for blood pressure telemonitoring

The prevalence of hypertension is high and still increasing in almost all communities regardless of high, middle, or low income. The control rate remains low in most countries. Telemedicine offers possibilities to improve blood pressure control. The past two decades witnessed the fast evolving telecommunication from telephone transmission to smart mobile phone technology for telemedicine. There is some evidence from randomized controlled trials that telemonitoring improves blood pressure control. However, it requires co‐interventions. The emerging new technology may offer even more possibilities in telemonitoring and co‐interventions, for instance, an interactive platform between patients and health professionals for the management of hypertension. Telemedicine might ultimately change the situation of the unsatisfactory management of hypertension in many communities. It helps fully utilize antihypertensive treatment, the most effective cardiovascular prevention, to achieve the goal of ending atherosclerosis and arteriosclerosis in humans.

Office blood pressure measurement: A comprehensive review

The conventional auscultatory methods for measuring blood pressure have been used to screen, diagnose, and manage hypertension since long. However, these have been found to be prone to errors especially the white coat phenomena which cause falsely high blood pressure readings. The Mercury sphygmomanometer and the Aneroid variety are no longer recommended by WHO for varying reasons. The Oscillometric devices are now recommended with preference for the Automated Office Blood Pressure measurement device which was found to have readings nearest to the Awake Ambulatory Blood Pressure readings. The downside for this device is the cost barrier. The alternative is to use the simple oscillometric device, which is much cheaper, with the rest and isolation criteria of the SPRINT study. This too may be difficult due to space constraints and the post‐clinic blood measurement is a new concept worth further exploration.

Identifying Isolated Systolic Hypertension From Upper-Arm Cuff Blood Pressure Compared With Invasive Measurements

Isolated systolic hypertension (ISH) is the most common form of hypertension and is highly prevalent in older people. We recently showed differences between upper-arm cuff and invasive blood pressure (BP) become greater with increasing age, which could influence correct identification of ISH. This study sought to determine the difference between identification of ISH by cuff BP compared with invasive BP. Cuff BP and invasive aortic BP were measured in 1695 subjects (median 64 years, interquartile range [55-72], 68% male) from the INSPECT (Invasive Blood Pressure Consortium) database. Data were recorded during coronary angiography among 29 studies, using 21 different cuff BP devices. ISH was defined as ≥130/<80 mm Hg using cuff BP compared with invasive aortic BP as the reference. The prevalence of ISH was 24% (n=407) according to cuff BP but 38% (n=642) according to invasive aortic BP. There was fair agreement (Cohen κ, 0.36) and 72% concordance between cuff and invasive aortic BP for identifying ISH. Among the 28% of subjects (n=471) with misclassification of ISH status by cuff BP, 20% (n=96) of the difference was due to lower cuff systolic BP compared with invasive aortic systolic BP (mean, -16.4 mm Hg [95% CI, -18.7 to -14.1]), whereas 49% (n=231) was from higher cuff diastolic BP compared with invasive aortic diastolic BP (+14.2 mm Hg [95% CI, 11.5-16.9]). In conclusion, compared with invasive BP, cuff BP fails to identify ISH in a sizeable portion of older people and demonstrates the need to improve cuff BP measurements.

Virtual reality informative aids increase residents' atrial fibrillation ablation procedures-related knowledge and patients' satisfaction

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and increasing numbers of patients receive AF ablation nowadays. Therefore, in the cardiology division, residents need to be familiar with the AF ablation procedure-related knowledge for primary care. This study evaluated the baseline residents and patients' self-efficacy to the AF ablation procedure-related knowledge, developed the specific virtual reality (VR) informative aids, and evaluated the effects of VR training and resident-led VR aids-based patient education on their self-efficacy, in the aspects of familiarity, confidence and anxiety, and satisfaction.

METHODS

From 2019, April to 2020, April, this 1-year prospective prestudy and poststudy was undergone in the cardiology division. Between 2019, April and 2019, December, the experienced physicians were invited to develop VR informative aids for AF ablation procedure-related knowledge. Between January 2020 and April 2020, newly developed VR informative aids were implemented in the educational program of training rotated residents for giving patient education.

RESULT

A total of 20 residents and 32 patients were enrolled. The baseline self-reported self-efficacy and knowledge scores were relatively low among rotated residents and their patients. In addition to the high level of satisfaction, self-efficacy and knowledge scores of residents and their patients were increased after VR aids-based training and resident-led patient education. Higher degree of improvement in self-efficacy was noted among patients with depression/anxiety history than those without history. The follow-up assessments among residents showed that the positive effects of VR aids were sustained until 2 weeks later.

CONCLUSION

Overall, residents and patients reported that the VR aids increase the effectiveness of patient education, achieve the purpose of a paperless environment, and motivate them to recommend it to others. The implementation of resident-to-patient education has a positive impact on trainees and patients understanding about AF ablation procedures-related knowledge.

Long sleep duration and cardiovascular disease: Associations with arterial stiffness and blood pressure variability

Although short and long sleep duration are both risk factors of cardiovascular disease (CVD), the recent meta‐analyses have been shown that long sleep duration was closely associated with CVD mortality. While the specific mechanism underlying the association between long sleep duration and CVD remains unclear, long sleep duration was shown to be associated with arterial stiffness and blood pressure variability (BPV) in many Asian populations. This review article will focus on the pathophysiology of long sleep duration, arterial stiffness, BPV and their effects on CVD. To set the stage for this review, we first summarize the current insights for the relationship between long sleep duration and CVD in relation to arterial stiffness and BPV.

Isolated systolic hypertension and central blood pressure: Implications from the national nutrition and health survey in Taiwan

We aimed to investigate the association between isolated systolic hypertension (ISH) and central blood pressure (BP) in a nationally representative population, with a focus on the young and middle‐aged adults (<50 years old). A total of 2029 adults without taking antihypertensive medications, aged ≥ 19 years old, participated in the 2013–2016 National Nutrition and Health Survey in Taiwan. Central and brachial BP were simultaneously measured using a cuff‐based stand‐alone central blood pressure monitor purporting to measure invasive central BP (type II device). Central hypertension was defined by central systolic (SBP)/diastolic BP (DBP) ≥130 or 90 mm Hg, and ISH was defined by brachial SBP ≥ 140 and DBP < 90 mm Hg. Overall, the prevalence rates of ISH, isolated diastolic hypertension (IDH, brachial SBP < 140 and DBP ≥ 90 mmHg), and systolic/diastolic hypertension (SDH, brachial SBP ≥ 140 and DBP ≥ 90 mmHg) were 6.51%, 1.92%, and 4.34%, respectively. ISH subjects had significantly higher central pulse pressure (PP) (62.8 ± 9.7 mm Hg for age < 50 years and 72.4 ± 13.5 mmHg for age ≥ 50 years) than those subjects with either IDH (44.7 ± 10.7 and 44.9 ± 10.6 mmHg) or SDH (55.2 ± 14.0 and 62.6 ± 17.1 mmHg). All ISH adults had central hypertension, and a higher prevalence of central obesity than the normotensives (80.95% vs. 26.15%, for age < 50 years; and 63.96% vs. 43.37% for age ≥ 50 years). All untreated subjects with ISH, whether younger or older, had central hypertension and had significantly higher central PP than those with IDH or SDH. Central obesity was one of the major characteristics of ISH, especially in the young‐ and middle‐aged adults.

Hypertension and erectile dysfunction: The role of endovascular therapy in Asia

The prevalence of erectile dysfunction (ED) is above 40% in both Asian and non-Asian male populations after the age of 40 years. The prevalence of ED among hypertensive patients is approximately double than that in normotensive population. Pelvic arterial insufficiency is the predominant cause of ED in men aged over 50 years. Stenosis in any segment of the iliac-pudendal-penile arterial system, which is considered an erectile-related arterial axis, could lead to ED. Pharmacotherapy with lifestyle modification is effective in alleviating sexual dysfunction, yet a substantial number of patients still develop ED. Given the established applicability of angioplasty for the entire iliac-pudendal-penile arterial system, penile duplex ultrasound, and pelvic computed tomography angiography could be considered as the routine screening tools in ED patients with poor response to phosphodiesterase-5 inhibitors. Endovascular therapy for pelvic arterial insufficiency-related ED has been shown to be a safe and effective treatment option in patients who have anatomically suitable vessels and functionally significant stenoses. Clinical improvement was achieved in over 60% of patients at one year following pelvic angioplasty in the PERFECT registry from Taiwan. A 30%-40% restenosis rate in distal internal pudendal and penile arteries remains a hurdle. Angioplasty for pelvic arterial occlusive disease could be considered as a viable approach to arteriogenic ED.

Dietary intervention for the management of hypertension in Asia

Hypertension is among the leading global risks for premature death. As the risks substantially increase along with the elevated blood pressure, a small reduction of blood pressure could have prevented numerous cardiovascular events in general population. Evidence has shown that dietary intervention is a cost-effective strategy that has been broadly advocated in the published guidelines. However, the implementation could be limited by different food cultures. This review details the mechanisms of each dietary intervention approach, evidence, and the implications in Asian populations, and the perspective of future research.

Isolated systolic hypertension in Asia

Isolated systolic hypertension (ISH) is the most common type of essential hypertension in the elderly and young adults. With rapid industrialization and population aging, the prevalence of ISH in Asia will rise substantially. Asian populations have distinct epidemiological features, risk factors and are especially vulnerable to ISH. There is a pressing need for Asian countries to formulate their unique strategies for control of ISH. In this review, we focus on the (1) epidemiology and pathophysiology, (2) risk factors and impact on outcomes, and (3) treatment goal and strategy for ISH in Asia.

A statistical predictive model consistent within a 5-year follow-up period for patients with acute heart failure

BACKGROUND

Acute heart failure (AHF) is a major and rapidly growing health problem responsible for millions of hospitalizations annually. Due to a high proportion of in-hospital mortality and postdischarge rehospitalization and mortality, a prompt strategy for risk stratification and subsequently tailored therapy is desirable to help improve clinical outcomes. The AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) and AHEAD-U (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus, U: uric acid) are popular prognostic scoring systems. However, only a specific follow-up period is considered in these systems, and whether their predictive capability is still accurate in a significantly shorter or longer follow-up period is not known.

METHODS

In this research, we adapted extensive statistical approaches based on the Cox model to explore consistent risk factors in various follow-up durations. Results showed that six factors, namely, hemoglobin level, age, sodium level, blood urea nitrogen level, atrial fibrillation, and high-density lipoprotein level could be used to establish a new prognostic model, which was referred to as HANBAH. For a simple clinical application, the HANBAH scoring system, with scores from 0 to 6, was developed using several statistical models.

RESULTS

Based on an evaluation using the conventional statistical approaches, such as the Akaike information criterion, concordance statistic, and Cox area under the curve, the HANBAH scoring system consistently outperformed other strategies in predicting short- and long-term mortality. Notably, an independent replication study also revealed similar results. In addition, a modern machine learning technique using the support vector machine confirmed its superior performance.

CONCLUSION

The use of the HANBAH scoring system, which is a clinically friendly tool, was proposed, and its efficacy in predicting the mortality rates of patients with AHF regardless of the follow-up duration was independently validated.

Abiraterone and enzalutamide had different adverse effects on the cardiovascular system: a systematic review with pairwise and network meta-analyses

BACKGROUND

Abiraterone and enzalutamide may increase the risk of cardiovascular events in patients with castration-resistant prostate cancer (CRPC).

METHODS

A comprehensive literature search was performed using a combination of keywords related to "abiraterone," "enzalutamide," "prostate cancer," and "adverse events." Phase II-IV randomized controlled trials (RCTs) on abiraterone or enzalutamide for patients with nonmetastatic or metastatic CRPC were included. Outcome measures included (1) any grade cardiac disorder, (2) severe grade cardiac disorder, (3) any grade hypertension, and (4) severe grade hypertension, as defined by the Common Terminology Criteria for Adverse Events. Pairwise meta-analysis and Bayesian network meta-analyses were performed to investigate the risk ratios (RRs) of abiraterone and enzalutamide. Surface under cumulative ranking curves (SUCRAs) and cumulative ranking probability plots based on the probability of developing cardiac disorders or hypertension were presented.

RESULTS

A total of 7103 patients from seven RCTs were included. Upon pairwise meta-analysis, abiraterone was associated with increased risks of any grade (RR = 1.34, 95% confidence interval (CI) = 1.05-1.73) and severe grade cardiac disorders (RR = 1.71, 95% CI = 1.16-2.53); enzalutamide was associated with increased risks of any grade (RR = 2.66, 95% CI = 1.93-3.66) and severe grade hypertension (RR = 2.79, 95% CI = 1.86-4.18). Based on the SUCRA rankings, abiraterone had a higher probability of cardiac disorders (84.84% for any grade and 85.12% for severe grade) than enzalutamide (62.83% for any grade and 50.76% for severe grade); whereas enzalutamide had a higher probability of hypertension (99.43% for any grade and 89.71% for severe grade) than abiraterone (49.08% for any grade and 49.37% for severe grade).

CONCLUSIONS

Abiraterone and enzalutamide had different adverse effects on the cardiovascular system. We should take this into consideration when we are deciding on the choice of novel hormonal agents for patients with CRPC.

Nocturnal thoracic volume overload and post-discharge outcomes in patients hospitalized for acute heart failure

Aims

Volume overload and perturbations of pulsatile haemodynamics may precipitate acute heart failure (AHF). Nocturnal thoracic volume overload due to rostral fluid shift during recumbency undetected by daytime measures may impact nighttime haemodynamics and post‐discharge outcomes.

Methods and results

A total of 63 patients (median 60 years, 79.4% men, and left ventricular ejection fraction 29.4%) hospitalized for AHF were enrolled. Once clinical euvolaemia was achieved, noninvasive pulsatile haemodynamics were assessed during daytime followed by circadian monitoring (6 p.m. to 5 a.m.) of thoracic fluid content and thoracic fluid content index (TFCi) using impedance cardiography, normalized electromechanical activation time ratio (EMAT%) using acoustic cardiography, and mean blood pressure using ambulatory blood pressure monitoring before discharge. The primary endpoints were composited of the first hospitalization for heart failure and death from any cause. Patients were also followed for the repeated heart failure hospitalizations. During a median follow‐up duration of 16 months, 33 patients encountered primary composite endpoints (52.4%), and there were 42 hospitalizations developed among 25 patients. An overnight increase in TFCi along with persistently prolonged EMAT% and low mean blood pressure was observed in the eventful group. Overnight increase in TFCi (ΔTFCi, the difference between the measures at 4 a.m. and 6 p.m.) was an independent predictor of primary composite events (hazard ratio and 95% confidence interval: 1.58, 1.07–2.33; P = 0.022) and recurrent composite events (2.22, 1.51–3.26; P < 0.001), after adjusting for potential confounding factors. A high ΔTFCi (≥0.5/kΩ/m²) significantly correlated with higher post‐discharge events (hazard ratio 6.25; 95% confidence interval 2.30–16.96; P < 0.001) in comparison with a low ΔTFCi (<0.5/kΩ/m²). ΔTFCi was significantly associated with EMAT%, estimated glomerular filtration rate, and left ventricular ejection fraction, but not with parameters of pulsatile haemodynamics.

Conclusions

Nocturnal thoracic volume overload in AHF before discharge, indicating the presence of residual volume overload unidentified by daytime measures, may predict post‐discharge outcomes.

2020 Consensus of Taiwan Society of Cardiology on the pharmacological management of patients with type 2 diabetes and cardiovascular diseases

The global incidence and prevalence of type 2 diabetes have been escalating in recent decades. The total diabetic population is expected to increase from 415 million in 2015 to 642 million by 2040. Patients with type 2 diabetes have an increased risk of atherosclerotic cardiovascular disease (ASCVD). About two-thirds of patients with type 2 diabetes died of ASCVD. The association between hyperglycemia and elevated cardiovascular (CV) risk has been demonstrated in multiple cohort studies. However, clinical trials of intensive glucose reduction by conventional antidiabetic agents did not significantly reduce macrovascular outcomes.In December 2008, U.S. Food and Drug Administration issued a mandate that every new antidiabetic agent requires rigorous assessments of its CV safety. Thereafter, more than 200,000 patients have been enrolled in a number of randomized controlled trials (RCTs). These trials were initially designed to prove noninferiority. It turned out that some of these trials demonstrated superiority of some new antidiabetic agents versus placebo in reducing CV endpoints, including macrovascular events, renal events, and heart failure. These results are important in clinical practice and also provide an opportunity for academic society to formulate treatment guidelines or consensus to provide specific recommendations for glucose control in various CV diseases.In 2018, the Taiwan Society of Cardiology (TSOC) and the Diabetes Association of Republic of China (DAROC) published the first joint consensus on the "Pharmacological Management of Patients with Type 2 Diabetes and Cardiovascular Diseases." In 2020, TSOC appointed a new consensus group to revise the previous version. The updated 2020 consensus was comprised of 5 major parts: (1) treatment of diabetes in patients with multiple risk factors, (2) treatment of diabetes in patients with coronary heart disease, (3) treatment of diabetes in patients with stage 3 chronic kidney disease, (4) treatment of diabetes in patients with a history of stroke, and (5) treatment of diabetes in patients with heart failure. The members of the consensus group thoroughly reviewed all the evidence, mainly RCTs, and also included meta-analyses and real-world evidence. The treatment targets of HbA1c were finalized. The antidiabetic agents were ranked according to their clinical evidence. The consensus is not mandatory. The final decision may need to be individualized and based on clinicians' discretion.

The ventilatory abnormalities and prognostic values of H2 FPEF score in dyspnoeic patients with preserved left ventricle systolic function

AIMS

Heart failure with preserved ejection fraction (HFpEF) is one of the major diagnoses in dyspnoeic subjects, and H₂ FPEF score enables robust differentiation of HFpEF. Given ventilatory abnormalities prevail in subjects with HFpEF, the associations between H₂ FPEF score and pulmonary function remain to be elucidated.

METHODS AND RESULTS

Subjects who presented with exertional dyspnoea and had left ventricular ejection fraction of >50% were eligible for this study. Total lung capacity, forced expiratory volume in the 1 s, and forced vital capacity (FVC) were obtained by pulmonary function tests. Pulmonary artery systolic pressure (PASP), the ratio of early ventricular filling flow velocity to the septal mitral annulus tissue velocity (E/e'), and left ventricular mass (LVM) were measured by echocardiogram. Among a total of 5849 participants (65.6 ± 6.4 years, 54% men), 2453 (41.9%) had low H₂ FPEF score (0 ~ 1) and 160 (2.7%) had high H₂ FPEF score,^6~9 respectively. Subjects with high H₂ FPEF score were older and had higher proportion of restrictive and obstructive defect, more morbidities, poorer renal function, lower haemoglobin, higher LVM, E/e' ratio, and PASP. During a mean follow-up duration of 30.0 ± 20.5 months, the H₂ FPEF score was significantly associated with mortality [hazard ratio and 95% confidence intervals, 1.063(1.010-1.18)], independent of sex, haemoglobin, renal function, LVM, and comorbidities.

CONCLUSIONS

Either obstructive or restrictive ventilation defects prevail in subjects with high H₂ FPEF score, indicating chronic obstructive pulmonary disease (COPD) is commonly associated with HFpEF. In addition, H₂ FPEF score was correlated with long-term survival in dyspnoeic subjects with or without concomitant diseases of HFpEF and COPD.