[The research of liver failure in Banna miniature pigs caused by amanita exitialis]

Objective: To explore the characteristics of Banna miniature pig liver failure induced by amanita exitialis. Methods: From September to October 2020, a reverse high performance liquid chromatography (RP-HPLC) method was used to determine the toxin content of amanita exitialis solution, and 2.0 mg/kg amanita exitialis solution (α-amanitins+β-amanitins) was administered orally to Banna miniature pigs. Toxic symptoms, blood biochemical indexes and histopathological changes of liver, heart and kidney were observed at each time point. Results: All Banna miniature pigs died within 76 h of exposure, and different degrees of digestive tract symptoms such as nausea, vomiting and diarrhea appeared between 6 and 36 h. The biochemical indexes of alanine aminotransferase, aspartate aminotransferase, total bilirubin, lactate dehydrogenase, myoglobin, creatine kinase isoenzyme, blood urea nitrogen and creatinine increased significantly at 52 h after exposure, and the differences were statistically significant compared with 0 h (P<0.05). The bleeding of liver and heart was obvious under macroscopic and microscopic observation, hepatocyte necrosis, renal tubule epithelial cell swelling. Conclusion: Large dose of amanita exitialis can cause acute liver failure of Banna miniature pigs, which is in line with the pathophysiological characteristics of acute liver failure, and lays a foundation for further research on the toxic mechanism and detoxification drugs of amanita exitialis induced liver failure.

[Investigation on a case of Amanita neoovoidea poisoning]

This paper reported a case of poisoning caused by ingestion of Amanita neoovoidea. The patient experienced nausea, vomiting, oliguria, acute renal function injury, and was discharged after symptomatic support treatment and blood purification treatment. Given the different toxicity of different mushrooms, species identification of poisonous mushrooms can help clinicians in diagnosis and treatment.

Passive Prescription of Secondary Prevention Medical Therapy during Index Hospitalization for Acute Myocardial Infarction Is Prevalent and Associated with Adverse Clinical Outcomes

Secondary prevention therapy reduces death and reinfarction after acute myocardial infarction (AMI), but it is underutilized in clinical practice. Mechanisms for this therapeutic gap are not well established. In this study, we have explored and evaluated the impact of passive continuation compared to active initiation of secondary prevention therapy for AMI during the index hospitalization. For this purpose, we have analyzed 1083 consecutive patients with AMI to a tertiary referral hospital in Hong Kong and assessed discharge prescription rates of secondary prevention therapies (aspirin, beta-blockers, statins, and ACEI/ARBs). Multivariate analysis was used to identify independent predictors of discharge medication, and Kaplan-Meier survival curve was used to evaluate 12-month survival. Overall, prescription rates of aspirin, beta-blocker, statin, and ACEI/ARBs on discharge were 94.8%, 64.5%, 83.5%, and 61.4%, respectively. Multivariate analysis showed that prior use of each therapy was an independent predictor of prescription of the same therapy on discharge: aspirin (odds ratio (OR) = 4.8, 95% CI = 1.9-12.3, P < 0.01), beta-blocker (OR = 2.5, 95% CI = 1.8-3.4, P < 0.01); statin (OR = 8.3, 95% CI = 0.4-15.7, P < 0.01), and ACEI/ARBs (OR = 2.9, 95% CI = 2.0-4.3, P < 0.01). Passive continuation of prior medication was associated with higher 1-year mortality rates than active initiation in treatment-naïve patients (aspirin (13.7% vs. 5.7%), beta-blockers (12.9% vs. 5.6%), and statins (11.0% vs. 4.6%); all P < 0.01). Overall, the use of secondary prevention medication for AMI was suboptimal. Our findings suggested that the practice of passive continuation of prior medication was prevalent and associated with adverse clinical outcomes compared to active initiation of secondary preventive therapies for acute myocardial infarction during the index hospitalization.

[Three cases of mushroom poisoning caused by lethal Amanita species]

Mushroom poisoning with amatoxins can cause liver dysfunction in patients, and death in severe cases. The amatoxins detection by enzyme-linked immunosorbent assay (ELISA) can help early clinical diagnosis. Three patients were identified as α-amatoxin containing mushroom poisoning by ELISA. The first symptoms of patients was gastrointestinal symptoms, and liver function damage occured later. One patient gave up treatment and died. After received supportive treatments such as adsorption of toxins, catharsis, fluid supplementation to promote toxin metabolism and liver protection, 2 patients were recovered and discharged.

Intersection Between Diabetes and Heart Failure: Is SGLT2i the "One Stone for Two Birds" Approach?

Purpose of Review

Diabetes mellitus (DM) is a major comorbidity of heart failure (HF). Comparing the similarities and differences in disease characteristics and treatment between the HF patients with and without DM, this review was to investigate whether and how the novel class of sodium-glucose transport protein 2 inhibitors (SGLT2i) would benefit both populations.

Recent Findings

Despite the obviously different clinical profiles, patients of HF with reduced ejection fraction (HFrEF) should be treated the same with guideline directed medical therapy, irrespective of DM status. Upon the mounting evidence that supported its use in diabetic patients at high risk of HF, recent large clinical trials demonstrated that SGLT2i could further reduce HF hospitalization or cardiovascular mortality and improve quality of life in diabetic and non-diabetic HFrEF patients who were optimally managed.

Summary

SGLT2i expands the foundation of HFrEF therapy. Whether it is equally effective in HF with preserved ejection fraction awaits more evidence.

Discrepancy of Aortic Valve Area Measurements by Doppler vs. Biplane Stroke Volume Measurements and Utility of Combining the Different Areas in Aortic Valve Stenosis - The Asian Valve Registry

BACKGROUND

The aortic valve area index (AVAI) in aortic stenosis (AS) is measured by echocardiography with a continuity equation using the stroke volume index by Doppler (SVI_Doppler) or biplane Simpson (SVI_Biplane) method. AVAI_Dopplerand AVAI_Biplaneoften show discrepancy due to differences between SVI_Dopplerand SVI_Biplane. The degree of discrepancy and utility of combined AVAIs have not been investigated in a large population of AS patients, and the characteristics of subjects with larger discrepancies are unknown.Methods and Results:We studied 820 patients with significant AS (AVA_Doppler<1.5 cm²) enrolled in the Asian Valve Registry, a prospective multicenter registry at 12 Asian centers. All-cause death and aortic valve replacement were defined as events. SVI_Dopplerwas significantly larger than SVI_Biplane(49±11 vs. 39±11 mL/m², P<0.01) and AVAI_Dopplerwas larger than AVAI_Biplane(0.51±0.15 vs. 0.41±0.14 cm²/m², P<0.01). An increase in (AVAI_Doppler- AVAI_Biplane) correlated with shorter height, lower weight, older age, smaller left ventricular (LV) diameter and increased velocity of ejection flow at the LV outflow tract. Severe AS by AVAI_Doppleror AVAI_Biplaneenabled prediction of events, and combining these AVAIs improved the predictive value of each.

CONCLUSIONS

Discrepancy in AVAI by Doppler vs. biplane method was significantly more pronounced with increased LV outflow tract flow velocity, shorter height, lower weight, older age and smaller LV cavity dimensions. Combining the AVAIs enabled mutual and incremental value in predicting events.

P914 Changes of echocardiographic parameters in primary mitral regurgitation and determinants of symptom: an assessment from the Asian valve registry data

[Background]Clinicians often have a difficulty in determining the presence of mitral regurgitation (MR)-relatedsymptoms because of subjectivity.However, there are few actual measurement data for echocardiographic left ventricular (LV) and left atrial (LA) size related to the severity of MR and the relationship between MR-related symptoms and these echocardiographic parameters.

[Purpose] The purpose of this study was to clarify actual values for echocardiographic parameters related to severity of MR and determinant factors of MR-related symptoms.

[Methods] Among patients enrolled in the Asian Valve Registry, we investigated 778 consecutive patients with primary MR showing sinus rhythm. Symptoms were determined by NYHA (≤ II or ≥ III).

[Results]MR severity was mild in 106, moderate in 285, and severe in 387 patients. LA volume index, LV end-diastolic diameter, and LV mass index increased with increasing MR grade [LA volume index: 47.9 (mild), 56.2 (moderate), and 64.9 ml/m2(severe) (p &lt; 0.001), LV end-diastolic diameter: 51.2, 54.5, 58.1 mm (p &lt; 0.001), and LV mass index: 101, 109, 123 g/m2(p &lt; 0.001)]. Regarding moderate and severe MR, 70 patients (10.4%) were symptomatic. Table shows multivariable analysis for being symptomatic in moderate and severe MR patients. LV mass index (p = 0.040), ejection fraction (p &lt; 0.001), female gender (p = 0.004), and heart rate (p = 0.007) were independent factors for MR-related symptoms.

[Conclusions] LV and LA parameters on echocardiography worsened as MR severity progressed. Larger LV mass index and lower ejection fraction were independent determinant factors for MR-related symptoms. We should also pay attention to LV hypertrophy in patients with primary MR.

Determinant factors for mitral regurgita Model 1 Model 2 OR (95% CI) P-value OR (95% CI) P-value Age, per 1-y increment 1.03 (1.00-1.05) 0.035 1.02 (0.99-1.05) 0.053 Sex (female) 2.23 (1.20-4.16) 0.011 2.28 (1.31-3.98) 0.004 Hear rate, per 1 bpm increment 1.03 (1.00-1.05) 0.025 1.03 (1.01-1.05) 0.007 LVDs index, per 1 mm increment 0.99 (0.90-1.09) 0.90 EF, per 1% increment 0.95 (0.92-0.99) 0.019 0.96 (0.93-0.98) &lt;0.001 LV mass index, per 10 g/m2increment 1.12 (1.01-1.25) 0.033 1.09 (1.005-1.18) 0.040 LA volume index, per 10 mL/m2increment 0.96 (0.90-1.03) 0.23 E wave, per 1cm/s increment 1.81 (0.70-4.66) 0.23 TR pressure gradient &gt;40 mmHg 2.11 (0.97-4.57) 0.057 Hypertention 1.40 (0.75-2.63) 0.29

Impact of diabetes and sex in heart failure with reduced ejection fraction patients from the ASIAN-HF registry

AIMS

To examine sex differences in clinical characteristics, echocardiographic features, quality of life and 1-year death or heart failure (HF) hospitalization outcomes in patients with/without diabetes mellitus (DM).

METHODS AND RESULTS

Utilizing the Asian Sudden Cardiac Death in HF (ASIAN-HF) registry, 5255 patients (mean age 59.6 ± 13.1, 78% men) with symptomatic HF with reduced ejection fraction (HFrEF) were stratified by DM status to address the research aims. Despite similar prevalence of DM between Asian men (43%) and women (42%), the odds of DM increased at lower body mass index in women vs. men (≥ 23 vs. ≥ 27.5 kg/m² , P_interaction  = 0.014). DM was more strongly related to chronic kidney disease in women vs. men [adjusted odds ratio (OR) 1.85, 95% confidence interval (CI) 1.33-2.57 vs. OR 1.32, 95% CI 1.11-1.56, P_interaction  = 0.009]. Sex also modified the relationship between DM and left ventricular geometry (P_interaction  = 0.003), whereby DM was associated with a more concentric left ventricular geometry in women than men. Women had lower quality of life than men (P < 0.001), in both DM and non-DM groups. DM was associated with worse composite outcomes at 1 year in women vs. men [hazard ratio (HR) 1.79, 95% CI 1.24-2.60 vs. HR 1.32, 95% CI 1.12-1.56; P_interaction  = 0.005).

CONCLUSIONS

Asian women with HFrEF were more likely to have DM despite a lean body mass index, a greater burden of chronic kidney disease and more concentric left ventricular geometry, compared to men. Furthermore, DM confers worse quality of life, irrespective of sex, and a greater risk of adverse outcomes in women than men. These data underscore the need for sex-specific approaches to diabetes in patients with HF.

Heart failure with preserved ejection fraction in Asia

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a global public health problem. Unfortunately, little is known about HFpEF across Asia.

METHODS AND RESULTS

We prospectively studied clinical characteristics, echocardiographic parameters and outcomes in 1204 patients with HFpEF (left ventricular ejection fraction ≥50%) from 11 Asian regions, grouped as Northeast Asia (Hong Kong, Taiwan, China, Japan, Korea, n = 543), South Asia (India, n = 252), and Southeast Asia (Malaysia, Thailand, Singapore, Indonesia, Philippines, n = 409). Mean age was 68 ±12 years (37% were < 65 years) and 50% were women. Seventy per cent of patients had ≥2 co-morbidities, most commonly hypertension (71%), followed by anaemia (57%), chronic kidney disease (50%), diabetes (45%), coronary artery disease (29%), atrial fibrillation (29%) and obesity (26%). Southeast Asian patients had the highest prevalence of all co-morbidities except atrial fibrillation, South Asians had the lowest prevalence of all co-morbidities except anaemia and obesity, and Northeast Asians had more atrial fibrillation. Left ventricular hypertrophy and concentric remodelling were most prominent among Southeast and South Asians, respectively (P < 0.001). Overall, 12.1% of patients died or were hospitalized for heart failure within 1 year. Southeast Asians were at higher risk for adverse outcomes, independent of co-morbidity burden and cardiac geometry.

CONCLUSION

These first prospective multinational data from Asia show that HFpEF affects relatively young patients with a high burden of co-morbidities. Regional differences in types of co-morbidities, cardiac remodelling and outcomes of HFpEF across Asia have important implications for public health measures and global HFpEF trial design.

Disparity Between Indications for and Utilization of Implantable Cardioverter Defibrillators in Asian Patients With Heart Failure

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are lifesaving devices for patients with heart failure (HF) and reduced ejection fraction. However, utilization and determinants of ICD insertion in Asia are poorly defined. We determined the utilization, associations of ICD uptake, patient-perceived barriers to device therapy and, impact of ICDs on mortality in Asian patients with HF.

METHODS AND RESULTS

Using the prospective ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) registry, 5276 patients with symptomatic HF and reduced ejection fraction (HFrEF) from 11 Asian regions and across 3 income regions (high: Hong Kong, Japan, Korea, Singapore, and Taiwan; middle: China, Malaysia, and Thailand; and low: India, Indonesia, and Philippines) were studied. ICD utilization, clinical characteristics, as well as device perception and knowledge, were assessed at baseline among ICD-eligible patients (EF ≤35% and New York Heart Association Class II-III). Patients were followed for the primary outcome of all-cause mortality. Among 3240 ICD-eligible patients (mean age 58.9±12.9 years, 79.1% men), 389 (12%) were ICD recipients. Utilization varied across Asia (from 1.5% in Indonesia to 52.5% in Japan) with a trend toward greater uptake in regions with government reimbursement for ICDs and lower out-of-pocket healthcare expenditure. ICD (versus non-ICD) recipients were more likely to be older (63±11 versus 58±13 year; P<0.001), have tertiary (versus ≤primary) education (34.9% versus 18.1%; P<0.001) and be residing in a high (versus low) income region (64.5% versus 36.5%; P<0.001). Among 2000 ICD nonrecipients surveyed, 55% were either unaware of the benefits of, or needed more information on, device therapy. ICD implantation reduced risks of all-cause mortality (hazard ratio, 0.71; 95% confidence interval, 0.52-0.97) and sudden cardiac deaths (hazard ratio, 0.33; 95% confidence interval, 0.14-0.79) over a median follow-up of 417 days.

CONCLUSIONS

ICDs reduce mortality risk, yet utilization in Asia is low; with disparity across geographic regions and socioeconomic status. Better patient education and targeted healthcare reforms in extending ICD reimbursement may improve access.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov/ct2/show/NCT01633398. Unique identifier: NCT01633398.

Sustained 3-Year Benefits in Quality of Life After Percutaneous Coronary Interventions in the Elderly: A Prospective Cohort Study

BACKGROUND

Impact of percutaneous coronary interventions (PCI) on health-related quality of life (HRQOL) is important but under-reported in elderly patients.

OBJECTIVES

To evaluate long-term health status in elderly patients who underwent PCI.

METHODS

Consecutive patients who underwent PCI at a university-affiliated hospital from September 2009 to June 2012 were prospectively enrolled with HRQOL assessment at baseline (up to 2 weeks before PCI) and at 6-, 12-, and 36-month follow-up using the EuroQol five-dimensional questionnaire descriptive profile and visual analogue scale (VAS). Minimally important benefit (MIB) in HRQOL was defined as greater than half an SD improvement in the baseline VAS score.

RESULTS

Of 1957 patients, 49.9%, 29.1%, and 21.0% were aged younger than 65 years, 65 to 74 years, and 75 years and older, respectively. Mean VAS scores at baseline (50.1 ± 20.5 vs. 51.6 ± 20.5 vs. 52.6 ± 21.8; P = 0.09) and at 36 months (72.9 ± 14.0 vs. 72.8 ± 16.1 vs. 72.0 ± 14.8; P = 0.77) were similar between the three age groups, respectively. MIB at 36 months was observed in 65.7%, 61.9%, and 61.2% of patients in each age group, respectively. Proportion of patients aged 75 years and older reporting problems in pain/discomfort and self-care reduced from 91.2% and 24.8% at baseline to 41.4% and 10.1% at 36 months, respectively (both P < 0.01). Independent predictors of MIB in HRQOL at 36 months in patients 75 years and older included poor baseline HRQOL, MIB at 6 months, and presentation with myocardial infarction (all P < 0.01).

CONCLUSIONS

Elderly patients experienced sustained long-term improvement in quality of life comparable with younger patients after PCI. Our findings suggest that age per se should not deter against revascularization because of sustained benefit in HRQOL.

Incremental prognostic value of multichamber deformation imaging and renal function status to predict adverse outcome in heart failure with reduced ejection fraction

AIMS

Deformation imaging, particularly of left-sided heart, is fast becoming an essential tool in clinical cardiology. However, data are scant regarding the value of biventricular and bi-atrial deformation in association with comorbidities in heart failure with reduced left ventricular ejection fraction (HFREF).

METHODS AND RESULTS

Forty-nine subjects (72 ± 13 years; 28 male) with HFREF and 14 age-matched controls underwent deformation imaging including LV global longitudinal strain (LVGLS%), right ventricular strain (RVS%), and left atrial reservoir strain (LARS%). Standard echo parameters included LVEF%, E/E' ratio, and pulmonary artery systolic pressure (PASP). Mean ± SD of LVEF, LVGLS%, and RVS% were 31% ± 8%, 7% ± 3%, and 17% ± 7%, respectively, and were significantly lower compared with controls (all P < .0001). Over a follow-up period of 4.2 years, 24% of patients died and 48% had a composite outcome of death and heart failure hospitalization. In the logistic regression model, taking the composite of death and heart failure hospitalization as a dichotomous variable, RVS%, E/E' ratio, and PASP were the only significant univariate predictors of adverse outcome (R²  = .68, all P < .05). In the multivariate model, however, only PASP predicted adverse outcome. PASP also had the largest AUC (0.8) in the ROC analysis. A creatinine level of >88 μmol/L (SCREAT) and a cutoff value of LA reservoir strain (LARS %) at <16.7% provided the best sensitivity (86%) and specificity (40%) with an odds ratio of 3.8. In the Kaplan-Meier survival estimate, LARS%-SCREAT predicted all-cause mortality and HF hospitalization.

CONCLUSION

Multichamber deformation imaging along with renal function and PASP could best predict adverse outcome in HFREF.

Comparison between characteristics of severe and very severe aortic stenosis

OBJECTIVES

Patients with very severe aortic stenosis (AS) have extremely poor clinical outcomes even if they are asymptomatic compared to those with severe AS, but the clinical and echocardiographic characteristics of patients with very severe AS remain unclear.

METHODS

The Asian Valve Registry is a prospective, multicenter, multinational registry for the study and identification of the incidence, natural course, clinical outcomes, and prognostic factors for patients with significant AS at 9 centers in Asian countries. Severe AS was observed in 367 of 1066 patients with AS, and 212 were classified as very severe AS, defined as a peak aortic valve velocity ≥5.0 m/s or a mean aortic valve gradient ≥60 mm Hg.

RESULTS

The prevalence of NYHA functional class II-IV among patients with very severe AS was significantly higher than that among patients with severe AS (67.9% vs 51.5%, P < .001). As for echocardiographic parameters, it was noteworthy that left ventricular mass index (LVMI) and left atrial volume index (LAVI) for patients with very severe AS were significantly larger than those for patients with severe AS (LVMI: 145.1 ± 36.4 g/m² vs 119.2 ± 32.1 g/m² , P < .0001; LAVI: 56.1 ± 24.6 mL/m² vs 49.8 ± 22.6 mL/m² , P = .002). Moreover, multivariate logistic regression analysis showed that LVMI was the only independently associated with NYHA functional class II-IV in patients with very severe AS.

CONCLUSIONS

Our findings may well have clinical implications for better management of patients with AS and lead to better understanding of poor outcomes for patients with very severe AS.

Tetramethylpyrazine suppresses angiotensin II-induced soluble epoxide hydrolase expression in coronary endothelium via anti-ER stress mechanism

Activation of soluble epoxide hydrolase (sEH) is associated with endothelial dysfunction in hypertension, though the underlying mechanisms are inadequately understood and the role of endoplasmic reticulum (ER) stress is yet to be studied in detail. Tetramethylpyrazine (TMP), a major bioactive ingredient of Chinese herb Chuanxiong, is well-known for its cardiovascular benefits. Nevertheless, whether TMP may protect vascular endothelium from ER stress and whether regulation of sEH is involved remain unknown. This study aimed at investigating the role of ER stress in angiotensin-II (Ang-II)-induced sEH dysregulation and elucidating the significance of ER stress regulation in the vasoprotective effect of TMP. Porcine primary coronary artery endothelial cells (PCECs) were used for western blot, ELISA, and reverse-transcription PCR analysis. Porcine coronary arteries were assessed in a myograph for endothelial dilator function. Ang-II induced expression of ER stress molecules in PCECs meanwhile enhanced sEH expression and decreased 11,12-EET. Exposure of PCECs to the chemical ER stress inducer tunicamycin also increased sEH expression. Inhibition of ER stress suppressed sEH upregulation, resulting in an increase of 11,12-EET. The impairment of endothelium-dependent vasorelaxation induced by Ang-II or tunicamycin was ameliorated by inhibitors of ER stress or sEH. TMP showed comparable inhibitory effect to ER stress inhibitors on the expression of ER stress molecules, the dysregulation of sEH/EET, and the impairment of endothelial dilator function. We demonstrated that ER stress mediates Ang-II-induced sEH upregulation in coronary endothelium. TMP has potent anti-ER stress capacity through which TMP normalizes sEH expression and confers protective effect against Ang-II on endothelial function of coronary arteries.

Efficacy and safety of instantaneous wave-free ratio in patients undergoing coronary revascularisation: protocol for a systematic review

INTRODUCTION

Effective selection of coronary lesions for revascularisation is pivotal in the management of symptoms and adverse outcomes in patients with coronary artery disease. Recently, instantaneous 'wave-free' ratio (iFR) has been proposed as a new diagnostic index for assessing the severity of coronary stenoses without the need of pharmacological vasodilation. Evidence of the effectiveness of iFR-guided revascularisation is emerging and a systematic review is warranted.

METHODS AND ANALYSIS

This is a protocol for a systematic review of randomised controlled trials and controlled observational studies. Electronic sources including MEDLINE via Ovid, Embase, Cochrane databases and ClinicalTrials.gov will be searched for potentially eligible studies investigating the effects of iFR-guided strategy in patients undergoing coronary revascularisation. Studies will be selected against transparent eligibility criteria and data will be extracted using a prestandardised data collection form by two independent authors. Risk of bias in included studies and overall quality of evidence will be assessed using validated methodological tools. Meta-analysis will be performed using the Review Manager software. Our systematic review will be performed according to the guidance from the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

ETHICS AND DISSEMINATION

Ethics approval is not required. Results of the systematic review will be disseminated as conference proceedings and peer-reviewed journal publication.

TRIAL REGISTRATION NUMBER

This protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42017065460.

Challenges and opportunity in the era of quantitative echocardiography

The advancement of echocardiography in the past two decades is more than downsizing of the machines and improvement of image quality, but introduction of new imaging modalities leading to the ability of performing quantitative analysis. This function is greatly facilitated by the integration of echo machines with high performance computers, software programming and establishment of workstation for offline analysis. Today, echo examination is more than estimation of ejection fraction (EF) and patterns of left ventricular (LV) diastolic dysfunction. Echosonographers are facing a large number of quantitative parameters for interpretation. In newer imaging modalities such as tissue Doppler imaging, speckle tracking, 3-dimensional echocardiography and 3D-transoesophageal echocardiography, quantitative echocardiographic assessment has important roles. These have brought many opportunities but also challenges in our echo practice.

Risk of aortic aneurysm and dissection in patients with autosomal-dominant polycystic kidney disease: a nationwide population-based cohort study

Although cardiovascular complications are the most common cause of death in patients with autosomal-dominant polycystic kidney disease (ADPKD), the incidence and risk of aortic aneurysm and dissection (AAD) in ADPKD remains unclear due to limited data and insufficient cases. We utilized the data from Taiwan National Health Insurance Research Database (NHIRD) to do a population-based cohort study (1997-2008). After excluding those patients with age <18 years old and initially concomitant diagnoses of end-stage renal disease and AAD, a total of 2076 ADPKD patients were selected from 1,000,000 of general population. Additionally, the non-ADPKD group was set up as comparison group in 1:10 ratio after matching with age, gender, income and urbanization (n=20760). The result showed that ADPKD group had higher frequency of comorbidities than non-ADPKD group. The frequency of AAD in ADPKD was significantly higher than in general population (0.92% v.s. 0.11%, p<0.0001). Of them, 58% of AAD were acute aortic dissection. In addition, Kaplan-Meier analysis demonstrated that cumulative incidence of AAD was remarkably higher in the ADPKD than non-ADPKD group (p<0.001). The mean time period from ADPKD diagnosis to AAD occurrence was 4.02±3.16 years. After adjusting for age, gender and comorbidities, the ADPKD patients had up to 5.49-fold greater risk for AAD occurrence as compared to non-ADPKD counterparts (95% CI 2.86-10.52, p<0.0001). Particularly, those patients with co-existing ADPKD and hypertension had very high risk for future development of AAD. In conclusion, the risk of AAD significantly increases in patients with ADPKD as compared with those of general population.

Regional and ethnic differences among patients with heart failure in Asia: the Asian sudden cardiac death in heart failure registry

AIMS

To characterize regional and ethnic differences in heart failure (HF) across Asia.

METHODS AND RESULTS

We prospectively studied 5276 patients with stable HF and reduced ejection fraction (≤40%) from 11 Asian regions (China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, and Thailand). Mean age was 59.6 ± 13.1 years, 78.2% were men, and mean body mass index was 24.9 ± 5.1 kg/m². Majority (64%) of patients had two or more comorbid conditions such as hypertension (51.9%), coronary artery disease (CAD, 50.2%), or diabetes (40.4%). The prevalence of CAD was highest in Southeast Asians (58.8 vs. 38.2% in Northeast Asians). Compared with Chinese ethnicity, Malays (adjusted odds ratio [OR] 1.97, 95% CI 1.63-2.38) and Indians (OR 1.44, 95% CI 1.24-1.68) had higher odds of CAD, whereas Koreans (OR 0.38, 95% CI 0.29-0.50) and Japanese (OR 0.44, 95% CI 0.36-0.55) had lower odds. The prevalence of hypertension and diabetes was highest in Southeast Asians (64.2 and 49.3%, respectively) and high-income regions (59.7 and 46.2%, respectively). There was significant interaction between ethnicity and region, where the adjusted odds were 3.95 (95% CI 2.51-6.21) for hypertension and 4.91 (95% CI 3.07-7.87) for diabetes among Indians from high- vs. low-income regions; and 2.60 (95% CI 1.66-4.06) for hypertension and 2.62 (95% CI 1.73-3.97) for diabetes among Malays from high- vs. low-income regions.

CONCLUSIONS

These first prospective multi-national data from Asia highlight the significant heterogeneity among Asian patients with stable HF, and the important influence of both ethnicity and regional income level on patient characteristics.

CLINICALTRIALSGOV IDENTIFIER

NCT01633398.

Uncontrolled blood pressure as an independent risk factor of early impaired left ventricular systolic function in treated hypertension

BACKGROUND

Uncontrolled blood pressure (BP) is commonly observed in patients receiving antihypertensive agents. However, its relationship with early left ventricular (LV) dysfunction has not been elucidated.

METHODS

This study enrolled 276 patients with treated hypertension and 85 healthy controls. The 140/90 mm Hg was used to define controlled (HT1 group, n=145) or uncontrolled BP (HT2 group, n=131) according to the concurrent guidelines. LV myocardial function was assessed by two-dimensional speckle tracking imaging, and the circumferential end-systolic wall stress (cESS)-corrected mid-wall fraction shortening (MWFS), systolic longitudinal (εLs-18), circumferential (εCs-18), and radial (εRs-18) strain were measured.

RESULTS

Despite similar ejection fraction, the HT1 and HT2 groups displayed an overall reduction in the cESS-corrected MWFS (13.4±2.7 vs 11.7±1.7 vs 15.5±1.2), εLs-18 (15.6±2.8 vs 13.0±2.2 vs 17.4±2.8), εCs-18 (17.3±3.4 vs 14.1±2.7 vs 18.9±3.3), and εRs-18 (18.4±4.0 vs 14.8±3.1 vs 20.5±4.5) %·cm² /kdyne·10^-2 when compared with the control group (all P<.001). The changes were more obvious in the HT2 group, regardless of LV hypertrophy. Reductions in the cESS-corrected MWFS and εLs-18 were seen in 68 (25%) and 52 (19%) patients, respectively. Uncontrolled BP were 4.365 times (95% CI 2.203-8.648, P<.001) and 3.928 times (1.851-8.337, P<.001) more likely to be associated with the changes.

CONCLUSIONS

Uncontrolled BP in hypertensive patients is associated with further reduction in LV myocardial function detected by advanced echocardiographic techniques, which cannot be explained by the increase in afterload. It might be regarded as a composite risk factor for earlier and faster development of clinical heart failure, therefore, a simplified treatment target.

Feasibility Study of Transthoracic Echocardiography for Coronary Slow Flow Phenomenon Evaluation: Validation by Coronary Angiography

OBJECTIVE

This study aimed to assess echocardiography parameters in CSFP evaluation.

METHODS

This study enrolled 79 consecutive patients with CSFP validated by coronary angiography and control individuals with normal coronary flow. Coronary flow rates were determined by corrected CTFC. Clinical and coronary angiography data and coronary parameters assessed by echocardiography using the CFI were recorded.

RESULTS

Baseline characteristics were similar between the two groups. Patients with CSFP were predominantly males, with higher BMI values, weights and triglyceride levels (p < 0.05), but lower platelet counts (p < 0.05). Conventional echocardiography parameters were similar in the two groups. However, echocardiographic measurements of the LAD, including PDV, MDV, PDP, MDP and VTI, in the CSFP group were lower compared with control values (p < 0.05). BMI was positively correlated with CSFP. LAD's CTFC showed strong inverse correlations with PDV, MDV, PDP, and MDP in CSFP groups. ROC curve analysis revealed that coronary artery flow-related parameters occupied more than half of the AUC.

CONCLUSIONS

CSFP could be identified with the help of echocardiography.

Long-term clinical outcomes after fatty liver screening in patients undergoing coronary angiogram: A prospective cohort study

There is ongoing debate on whether screening for nonalcoholic fatty liver disease (NAFLD) is worthwhile in high-risk groups. Because of shared risk factors, NAFLD is highly prevalent in patients with coronary artery disease. We aimed to test the hypothesis that NAFLD screening in patients requiring coronary angiogram would identify high-risk patients and predict long-term clinical outcomes. This was a prospective cohort study. NAFLD screening was performed by abdominal ultrasonography before coronary angiogram in 612 consecutive patients. At baseline, 356 (58.2%) patients had NAFLD. NAFLD patients, compared with those without, were more likely to have >50% stenosis in one or more coronary arteries (84.6% vs. 64.1%; P < 0.001) and therefore require percutaneous coronary intervention (68.3% vs. 43.4%; P < 0.001). During 3,679 patient-years of follow-up, 47 (13.2%) NAFLD patients and 59 (23.0%) patients without NAFLD died (age- and sex-adjusted hazard ratio [aHR]: 0.36; 95% confidence interval [CI]: 0.18-0.70; P = 0.003). Composite cardiovascular outcomes (cardiovascular deaths, nonfatal myocardial infarction, heart failure, or secondary interventions) were similar between groups (36.5% vs. 37.1%; aHR, 0.90; 95% CI: 0.69-1.18). Older age and diabetes were the only independent factors associated with cardiovascular events. Only 2 patients, both in the NAFLD group, died of primary liver cancer. No other patients developed liver-related complications.

CONCLUSION

In patients with clinical indications for coronary angiogram, the presence of NAFLD is associated with coronary artery stenosis and need for coronary intervention, but not increased mortality or cardiovascular complications. Liver cancer and cirrhotic complications are rare. Our data do not support NAFLD screening in this patient group at present, but studies with a longer duration of follow-up are needed.

Cellular and molecular mechanisms of endothelial ischemia/reperfusion injury: perspectives and implications for postischemic myocardial protection

Ischemia/reperfusion (I/R) injury is a major cause of myocardial damage. Despite continuous efforts, minimizing I/R injury still represents a great challenge in standard medical treatments of ischemic heart disease, i.e., thrombolytic therapy, primary percutaneous coronary intervention, and coronary arterial bypass grafting. Development of effective interventions and strategies to prevent or reduce myocardial I/R injury is therefore of great clinical significance. Endothelial dysfunction plays a significant role in myocardial I/R injury, which renders endothelial cells an attractive target for postischemic myocardial protection. The rapidly evolving knowledge of the mechanisms of endothelial I/R injury helps broaden perspective for future development of novel strategies targeting endothelium for alleviating myocardial I/R damage. This review provides a comprehensive summary of the cellular and molecular mechanisms of endothelial I/R injury. Current perspectives and future directions for developing endothelium targeting therapeutics for postischemic myocardial protection are further discussed.

Deterioration of left ventricular systolic function in extended Pacing to Avoid Cardiac Enlargement (PACE) trial: the predictive value of early systolic dyssynchrony

AIMS

Biventricular (BiV) pacing was superior to right ventricular apical (RVA) pacing at extended follow-up in the Pacing to Avoid Cardiac Enlargement (PACE) trial. Early pacing-induced systolic dyssynchrony (DYS) might be related to mid-term result. However, it remains unknown whether early pacing-induced DYS can predict long-term reduction of left ventricular (LV) systolic function.

METHODS AND RESULTS

Patients with standard pacing indications and normal LV ejection fraction (LVEF) were randomized either to BiV (n = 89) or RVA (n = 88) pacing. Seventy-four patients in the RVA group and 72 in the BiV pacing group completed follow-up longer than 2 years. Serial echocardiography was performed with DYS assessed by tissue Doppler imaging, and the early pacing-induced DYS was defined as >33 ms by using standard deviation of the time to peak systolic velocity (Dyssynchrony Index) in a 12-segment model of LV at 1 month. There were 46 (32%) patients having early pacing-induced DYS that was more prevalent in the RVA pacing group than that in the BiV pacing group (50.7 vs. 12.3%, χ(2) = 25.1, P < 0.001) despite the similar DYS between the two groups at baseline (30 ± 13 vs. 26 ± 11 ms, P = 0.051). At a median follow-up of 4.8 years, patients developing early DYS had lower LVEF (53.2 ± 9.4 vs. 60.9 ± 8.0%, P < 0.001) and larger LV end-systolic volume (40.3 ± 23.7 vs. 29.3 ± 13.4 mL, P < 0.001) than those without DYS. Significant EF reduction (defined as ≥5%) occurred in 71.7% (33 in 46) of patients with DYS, but only in 30% (30 in 100) in those without DYS (χ(2) = 22.4, P < 0.001). Further analysis showed that both DYS at 1 month [odds ratio (OR): 3.113, P = 0.013] and RVA pacing (OR: 7.873, P < 0.001) independently predicted the deterioration of LV systolic function with pacing period of 4.8 years.

CONCLUSION

Early pacing-induced DYS is a significant predictor of reduction of LV systolic function for long-term pacing, which could be prevented by BiV pacing at relatively long-period follow-up.

CLINICAL TRIAL REGISTRATION

Centre for Clinical Trials number, CUHK_CCT00037 (URL: http://www.cct.cuhk.edu.hk/Registry/publictrialrecord.aspx?trialid=CUHK_CCT00037).

Improvement of long-term survival by cardiac contractility modulation in heart failure patients: A case-control study

INTRODUCTION

Cardiac contractility modulation (CCM) has been shown to be effective in improving symptoms and cardiac function in heart failure (HF). However, there is limited data on the role of CCM on long-term survival, which was explored in the present study.

METHODOLOGY

Forty-one consecutive HF patients with left ventricular ejection fraction (EF) <40% received CCM and were followed for approximately 6 years. They were compared with another 41 HF patients who were enrolled into the HF registry in the same period, and had similar age, gender, EF and etiology of HF. The primary end-point was all cause-mortality. This was stratified by EF. Secondary end-points included HF hospitalization, cardiovascular death, and the composite outcome of death or heart failure hospitalization.

RESULTS

The CCM and control groups were well balanced for demographic data, medications and baseline left ventricular EF (27 ± 6 vs 27 ± 7%, p=NS). The mean follow-up duration was 75 ± 19 months in the CCM group and 69 ± 17 months in the control group. All-cause mortality was lower in the CCM group than the control group (39% vs. 71%, respectively; Log-rank χ(2)=11.23, p=0.001). Of note, the improvement of all-cause mortality is more dramatic in patients with EF ≥ 25-40% (36% vs. 80%, Log-rank χ(2)=15.8, p<0.001) than those with EF<25% (50% vs. 56%, p=NS), CCM vs. control respectively. Similar results were shown for the benefit of CCM in the secondary endpoints of cardiovascular death, and the composite outcome of death or heart failure hospitalization. The occurrence of HF hospitalization showed no significant difference between CCM and control groups in the whole cohort (41% vs. 49%, p=NS), but was significantly lower with CCM in subjects with EF ≥ 25-40% at baseline (36% vs. 64%, Log-rank χ(2)=7.79, p=0.005).

CONCLUSION

CCM resulted in significant improvement of long-term survival, in particular in those with EF ≥ 25-40%. A reduction in heart failure hospitalizations was also seen in this group of patients with less severely reduced EF.

Effect of Nurse-Implemented Transitional Care for Chinese Individuals with Chronic Heart Failure in Hong Kong: A Randomized Controlled Trial

OBJECTIVES

To determine the effect of nurse-implemented transitional care (TC) on readmission and mortality rates in Chinese individuals with chronic heart failure (CHF) in Hong Kong.

DESIGN

Single-center randomized controlled trial of TC versus usual care (UC).

SETTING

University-affiliated hospital in Hong Kong.

PARTICIPANTS

Hospitalized Chinese individuals with CHF (N = 178; aged 78.6 ± 6.9, 45% male).

MEASUREMENTS

The TC group received a predischarge visit, two home visits, and then regular telephone calls over 9 months to provide self-care education and support, optimized health surveillance, and facilitation in use of community services. Primary endpoints were event-free survival, all-cause hospital readmission, and mortality during the 9-month follow-up. Secondary endpoints were length of hospital stay, self-care, and health-related quality of life (HRQL). Data were analyzed using survival analysis and generalized estimating equations, following an intention-to-treat principle.

RESULTS

Survival analysis indicated no significant differences in event-free survival, hospital readmission, or mortality between the TC and UC groups, although the TC group had a lower hospital readmission rate at 6 weeks (8.1% vs 16.3%, P = .048) and lower mortality at 9 months (4.1% vs 13.8%, P = .03). The TC group also had a shorter hospital stay (P = .006) and significantly better self-care and HRQL. Because of attrition, sensitivity analyses were conducted to examine whether the intention-to-treat assumption affected the results. Per-protocol population analyses (hazard ratio (HR) = 0.40, 95% confidence interval (CI) = 0.17-0.93) and worst-case-scenario analysis (HR = 0.44, 95% CI = 0.25-0.77) suggested a lower mortality risk in the TC group.

CONCLUSION

The translation of individual-centered nurse-implemented TC to the Chinese culture and healthcare context of Hong Kong appears beneficial.

Wearable cuff-less PTT-based system for overnight blood pressure monitoring

A wearable cuff-less pulse transit time (PTT) based monitoring device is developed for ambulatory blood pressure (BP) monitoring. Ten healthy subjects (aged 27 ± 4 years old) underwent 24-hour ambulatory BP monitoring using 1) a standard brachial cuff-based oscillometric device as reference and 2) the proposed cuff-less PTT measuring system. Raw PTT and BP measurements were linearly interpolated and then smoothed by a low-pass filter to remove aliasing effect caused by the low sampling rate and synchronized. Resampled PTT and BP were assessed for correlation using correlation coefficients and Bland-Altman plots. Our study showed that PTT estimated systolic BP most accurately within 4.8 ± 4.3 mmHg on healthy young subjects during sleep time. We conclude from this study that the proposed cuff-less PTT-based BP monitoring system has potential to be a less intrusive alternative to standard oscillometric method for long-term overnight BP monitoring.

Micro-RNA and mRNA myocardial tissue expression in biopsy specimen from patients with heart failure

AIMS

There is increasing evidence that changes in microRNA (miRNA) expression occur in chronic heart failure and these may be involved in the pathogenesis. In this study we have explored the expression of selected myocyte and fibroblast-related microRNAs and messenger RNAs (mRNAs) that are associated with hypertrophy, apoptosis and fibrosis in biopsy specimens from patients with relatively new onset heart failure compared to a group of patients without heart failure.

METHODS AND RESULTS

Myocardial biopsy specimens taken from Chinese patients presenting with recent heart failure were compared with a group of patients without heart failure undergoing routine cardiac surgery (n=34). miRNAs (miR-1, -21, -23, -29, -30, -130, -133, -195, -199, -208, and -320) and corresponding mRNA expression were measured by real-time quantitative-PCR method. miR-1, -21, -23, -29, -130, -195 and -199 were significantly up-regulated in the heart failure group when compared to those without heart failure (all p<0.01). However, miR-30, -133, -208 and -320 were not significantly different. Related mRNAs (casp3, coll I, coll III and TGF) were also significantly up-regulated (all p<0.05) in the heart failure group.

CONCLUSION

Certain selected microRNAs involved in apoptosis, hypertrophy and fibrosis are up-regulated in the myocardium of patients with a clinical history of heart failure compared to those without. These specific miRNAs may be the most suitable for circulating biomarkers in the early stages of chronic heart failure and possibly future therapeutic targets.