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Wong HJ, Lin NH, Teo YN, Syn NL, Teo YH, Sia CH. Evaluation of the Lifetime Benefits of Metformin and SGLT2 Inhibitors in Type 2 Diabetes Mellitus Patients with Cardiovascular Disease: A Systematic Review and Two-Stage Meta-Analysis. Am J Cardiovasc Drugs 2024:10.1007/s40256-024-00640-w. [PMID: 38589722 DOI: 10.1007/s40256-024-00640-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Metformin and sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated cardiovascular benefits but their comparative effects on mortality in type 2 diabetes mellitus (T2DM) patients with cardiovascular disease (CVD) are unknown. Hence, we evaluated and compared lifetime benefits arising from metformin or SGLT2 inhibitors in T2DM patients with CVD. MATERIALS AND METHODS Studies published in the PubMed, EMBASE and CENTRAL databases before 28 October 2023 were retrieved. Treatment effects of metformin against US FDA-approved SGLT2 inhibitors in T2DM patients with CVD were evaluated and lifetime gains in event-free survival were estimated from our primary endpoints of all-cause and cardiovascular mortality. Risk ratios were derived to assess their impact on secondary outcomes such as major adverse cardiovascular events and hospitalizations for heart failure. RESULTS Overall, 14 studies were included. Five studies published Kaplan-Meier curves for the primary outcome of all-cause mortality. Individual participant data were reconstructed from these Kaplan-Meier curves, from which we conducted our two-stage meta-analysis. Participants receiving metformin and SGLT2 inhibitors experienced a reduction in the risk for all-cause mortality as compared with those not taking metformin and placebo. However, participants receiving SGLT2 inhibitors had a higher all-cause mortality (hazard ratio 1.308, 95% confidence interval 1.103-1.550) versus metformin. Treatment with metformin was estimated to offer an additional 23.26 months of survival free from all-cause mortality versus 23.04 months with SGLT2 inhibitors. CONCLUSIONS In patients with T2DM and CVD, metformin and SGLT2 inhibitors were associated with substantially lower all-cause mortality rates and slightly longer life expectancies than in patients without. Metformin presented an advantage over SGLT2 inhibitors in reducing all-cause mortality.
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Affiliation(s)
- Hon Jen Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Norman H Lin
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Yao Neng Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas L Syn
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Yao Hao Teo
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore.
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Wong SY, Lee ARYB, Sia AHJ, Wo YJ, Teo YH, Teo YN, Syn NL, Ong CC, Teo LL, Yeo TC, Poh KK, Kong WK, Wong RC, Sia CH. Effects of Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) on Cardiac Structure and Function: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials. Cardiovasc Drugs Ther 2024; 38:371-389. [PMID: 35819544 DOI: 10.1007/s10557-022-07360-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Recent trials suggest glucagon-like peptide-1 receptor agonists (GLP-1RAs) may have a cardioprotective role by reducing major adverse cardiac events, stroke mortality and heart failure-related hospitalisations. We examined whether and how GLP-1RAs affect cardiac function in cardiovascular and metabolic diseases including type 2 diabetes, heart failure and post-myocardial infarction. METHODS In this PRISMA-adherent systematic review and meta-analysis, three databases were searched from inception to July 2021 and registered on PROSPERO (CRD42021259661). RESULTS 20 reports of 19 randomized placebo-controlled trials including 2062 participants were meta-analyzed. Among type 2 diabetes patients, GLP-1RA resulted in improved systolic function measured by circumferential strain (mean difference [MD]= -5.48; 95% CI: -10.47 to -0.49; P= 0.03; I2= 89%) and diastolic dysfunction measured by E / A (MD= -0.15; 95% CI: -0.25 to -0.05; P= 0.003; I2= 0%). For post-myocardial infarction patients, GLP-1RA reduced infarct size (g) (MD= -5.36; 95% CI: -10.68 to -0.04; P= 0.05; I2= 78%). Liraglutide, but not exenatide, demonstrated improved systolic function, by increasing left ventricular ejection fraction (MD= 4.89; 95% CI: 3.62 to 6.16; P< 0.00001; I2= 0%) and reducing left ventricular end-systolic volume (MD= -4.15; 95% CI: -7.49 to -0.81; P = 0.01; I2= 0%). Among heart failure patients, no significant changes were noted. CONCLUSION GLP-1RA drugs may improve systolic and diastolic function in type 2 diabetes and reduce infarct size post-acute myocardial infarction with no demonstrable effect on cardiac function in heart failure. Tailored recommendations for the use of GLP-1RAs for cardioprotection should be considered for each patient's condition.
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Affiliation(s)
- Shi Yin Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Aaron Hon Jiun Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yu Jun Wo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Neng Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas L Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Ching Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Lynette L Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Kian-Keong Poh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - William K Kong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Raymond C Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore.
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Ou YH, Colpani JT, Cheong CS, Loke W, Thant AT, Shih EC, Lee F, Chan SP, Sia CH, Koo CY, Wong S, Chua A, Khoo CM, Kong W, Chin CW, Kojodjojo P, Wong PE, Chan MY, Richards AM, Cistulli PA, Lee CH. Mandibular Advancement vs CPAP for Blood Pressure Reduction in Patients with Obstructive Sleep Apnea. J Am Coll Cardiol 2024:S0735-1097(24)00906-9. [PMID: 38588926 DOI: 10.1016/j.jacc.2024.03.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypertension guidelines recommend diagnosis and treatment of obstructive sleep apnea (OSA) in patients with hypertension. The mandibular advancement device (MAD) is an oral appliance therapy for patients who decline or cannot tolerate CPAP. OBJECTIVE We compared the relative effectiveness of MAD versus CPAP in reducing 24-hour ambulatory BP. METHODS In an investigator-initiated, randomized, non-inferiority trial (pre-specified margin 1.5 mmHg), 321 participants, aged over 40, with hypertension and increased cardiovascular risk were recruited at 3 public hospitals for polysomnography. Of these, 220 participants with moderate-to-severe OSA (apnea-hypopnea index (AHI) ≥15 events/hour) were randomized to either MAD or CPAP (1:1). The primary outcome was the difference between the 24-hour mean arterial BP at baseline and 6 months. RESULTS Compared to baseline, the 24-hour mean arterial BP decreased by 2.5 mmHg (P = 0.003) at 6 months in the MAD group, whereas no change was observed in the CPAP group (P = 0.374). The between-group difference was -1.6 mmHg (95% confidence interval: -3.51 to 0.24, non-inferiority P < 0.001). The MAD group demonstrated a larger between-group reduction in all secondary ambulatory BP parameters compared to the CPAP group, with the most pronounced effects observed in the asleep BP parameters. Both the MAD and CPAP improved daytime sleepiness, with the between-group difference similar (P = 0.384). There were no between-group differences in cardiovascular biomarkers. CONCLUSION MAD is non-inferior to CPAP for reducing 24-hour mean arterial BP in participants with hypertension and increased cardiovascular risk.
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Affiliation(s)
- Yi-Hui Ou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Juliana Tereza Colpani
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore
| | - Crystal S Cheong
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore
| | - Weiqiang Loke
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore
| | - As Tar Thant
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - E Ching Shih
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore
| | - Frank Lee
- Department of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore
| | - Siew-Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore
| | - Serene Wong
- Department of Medicine, Alexandra Hospital, Singapore
| | - Aiping Chua
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Chin-Meng Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - William Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Calvin W Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Cardiovascular ACP, Duke-NUS Medical School, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore
| | | | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - A Mark Richards
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore; Department of Cardiology, National University Heart Centre, Singapore; Christchurch Heart Institute, University of Otago, New Zealand
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre & Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia; Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Chi-Hang Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore; Cardiovascular Research Institute, National University Heart Centre, Singapore; Department of Cardiology, National University Heart Centre, Singapore.
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Ho JS, Ho ES, Yeo LL, Kong WK, Li TY, Tan BY, Chan MY, Sharma VK, Poh KK, Sia CH. Use of wearable technology in cardiac monitoring after cryptogenic stroke or embolic stroke of undetermined source: a systematic review. Singapore Med J 2024:00077293-990000000-00101. [PMID: 38449074 DOI: 10.4103/singaporemedj.smj-2022-143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 05/28/2022] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Prolonged cardiac monitoring after cryptogenic stroke or embolic stroke of undetermined source (ESUS) is necessary to identify atrial fibrillation (AF) that requires anticoagulation. Wearable devices may improve AF detection compared to conventional management. We aimed to review the evidence for the use of wearable devices in post-cryptogenic stroke and post-ESUS monitoring. METHODS We performed a systematic search of PubMed, EMBASE, Scopus and clinicaltrials.gov on 21 July 2022, identifying all studies that investigated the use of wearable devices in patients with cryptogenic stroke or ESUS. The outcomes of AF detection were analysed. Literature reports on electrocardiogram (ECG)-based (external wearable, handheld, patch, mobile cardiac telemetry [MCT], smartwatch) and photoplethysmography (PPG)-based (smartwatch, smartphone) devices were summarised. RESULTS A total of 27 relevant studies were included (two randomised controlled trials, seven prospective trials, 10 cohort studies, six case series and two case reports). Only four studies compared wearable technology to Holter monitoring or implantable loop recorder, and these studies showed no significant differences on meta-analysis (odds ratio 2.35, 95% confidence interval [CI] 0.74-7.48, I 2 = 70%). External wearable devices detected AF in 20.7% (95% CI 14.9-27.2, I 2 = 76%) of patients and MCT detected new AF in 9.6% (95% CI 7.4%-11.9%, I 2 = 56%) of patients. Other devices investigated included patch sensors, handheld ECG recorders and PPG-based smartphone apps, which demonstrated feasibility in the post-cryptogenic stroke and post-ESUS setting. CONCLUSION Wearable devices that are ECG or PPG based are effective for paroxysmal AF detection after cryptogenic stroke and ESUS, but further studies are needed to establish how they compare with Holter monitors and implantable loop recorder.
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Affiliation(s)
- Jamie Sy Ho
- Department of Medicine, Alexandra Hospital, Singapore
| | - Elizabeth Sy Ho
- Department of Computer Science and Technology, University of Cambridge, Cambridge, UK
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kf Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Tony Yw Li
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Benjamin Yq Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
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5
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Lim CQE, Teo YN, Li TYW, Teo YH, Syn NLX, Leow AST, Ho JSY, Lim TW, Seow SC, Chan MYY, Wong RCC, Chai P, Chan ACY, Sharma VK, Tan BYQ, Yeo LLL, Ong JJY, Sia CH. Migraine and atrial fibrillation: a systematic review and meta-analysis. Singapore Med J 2024:00077293-990000000-00098. [PMID: 38409761 DOI: 10.4103/singaporemedj.smj-2022-114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/19/2022] [Indexed: 02/28/2024]
Abstract
BACKGROUND Patients with migraines, particularly those with auras, may present with stroke. Atrial fibrillation is a known risk factor for stroke. With common pathophysiological factors between migraines and atrial fibrillation, we aimed to clarify the association between migraine and atrial fibrillation in this systematic review and meta-analysis. METHODS A literature search was conducted in EMBASE, PubMed, Scopus and Cochrane electronic bibliographic databases from inception to 5 September 2022 with the following inclusion criteria: (a) cohort or cross-sectional studies; (b) studies that included only patients aged ≥18 years; and (c) studies that examined the association between atrial fibrillation and migraines. Exclusion criteria were case-control studies and the studies that included patients with previous diagnosis of atrial fibrillation or nonmigrainous headache. The Newcastle-Ottawa Scale was used to assess the quality of studies. RESULTS Six studies were included, demonstrating a pooled prevalence of atrial fibrillation of 1.61% (95% confidence interval [CI] 0.51, 3.29) in migraine with aura and 1.32% (95% CI 0.17, 3.41) in migraine without aura. The overall prevalence of atrial fibrillation in migraine was 1.39% (95% CI 0.24, 3.46). CONCLUSION In this systematic review and meta-analysis, the overall prevalence of atrial fibrillation in patients with migraine was low. Further studies are needed to clarify this relationship.
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Affiliation(s)
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tony Yi-Wei Li
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Li-Xun Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Aloysius Sheng-Ting Leow
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Jamie Sin-Ying Ho
- Academic Foundation Year Programme, Royal Free Hospital University Trust, London, United Kingdom
| | - Toon Wei Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Swee-Chong Seow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Mark Yan Yee Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Raymond Ching Chiew Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Amanda Chee Yun Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Vijay Kumar Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Benjamin Yong-Qiang Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Leonard Leong Litt Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jonathan Jia Yuan Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
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Ngiam JN, Chew N, Jou E, Ho JS, Pramotedham T, Liong TS, Kuntjoro I, Yeo TC, Sia CH, Kong WKF, Poh KK. Increased left ventricular remodelling index in paradoxical low-flow severe aortic stenosis with preserved left ventricular ejection fraction compared to normal-flow severe aortic stenosis. Singapore Med J 2024:00077293-990000000-00094. [PMID: 38363650 DOI: 10.4103/singaporemedj.smj-2022-107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/01/2022] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Patients with paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular ejection fraction (LVEF) appear distinct from normal-flow (NF) patients, showing worse prognosis, more concentric hypertrophy and smaller left ventricular (LV) cavities. The left ventricular remodelling index (LVRI) has been demonstrated to reliably discriminate between physiologically adapted athlete's heart and pathological LV remodelling. METHODS We studied patients with index echocardiographic diagnosis of severe AS (aortic valve area <1 cm2) with preserved LVEF (>50%). The LVRI was determined by the ratio of the LV mass to the end-diastolic volume, as previously reported, and was compared between patients with LF and NF AS. Patients were prospectively followed up for at least 3 years, and clinical outcomes were examined in association with LVRI. RESULTS Of the 450 patients studied, 112 (24.9%) had LF AS. While there were no significant differences in baseline clinical profile between LF and NF patients, LVRI was significantly higher in the LF group. Patients with high LVRI (>1.56 g/mL) had increased all-cause mortality (log-rank 9.18, P = 0.002) and were more likely to be admitted for cardiac failure (log-rank 7.61, P = 0.006) or undergo aortic valve replacement (log-rank 18.4, P < 0.001). After adjusting for the effect of age, hypertension, aortic valve area and mean pressure gradient on multivariate Cox regression, high LVRI remained independently associated with poor clinical outcomes (hazard ratio 1.64, 95% confidence interval 1.19-2.25, P = 0.002). CONCLUSION Pathological LV remodelling (increased LVRI) was more common in patients with LF AS, and increased LVRI independently predicts worse clinical outcomes.
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Affiliation(s)
| | - Nicholas Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Eric Jou
- MRC Laboratory of Molecular Biology, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Jamie Sy Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - Tze Sian Liong
- Department of Medicine, National University Health System, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kok Fai Kong
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Chin BZ, Lee P, Sia CH, Hong CC. Diabetic foot ulcer is associated with cardiovascular-related mortality and morbidity - a systematic review and meta-analysis of 8062 patients. Endocrine 2024:10.1007/s12020-024-03696-5. [PMID: 38280983 DOI: 10.1007/s12020-024-03696-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/10/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis of prevalence of cardiovascular-related morbidity and mortality in patients with diabetic foot ulcers (DFU), as well as compare risks of cardiovascular-related morbidity and mortality between diabetic patients with and without DFU. METHODS A systematic search was conducted on Medline, Embase, and Cochrane databases for randomized controlled trials and observational studies which explored the association between DFU and cardiovascular-related morbidity & mortality, or compared differences in hazard ratios of cardiovascular diseases between diabetics with and without DFU. Frequentist, pairwise meta-analysis was performed on studies with two comparator arms, whereas single-arm studies reporting pooled incidences of cardiovascular-related mortality and morbidity were calculated based on exact binomial distributions. A random-effect meta-analysis model was used with heterogenicity of studies assessed using I2, τ2, and χ2 statistics. RESULTS 10 studies were identified and included in the systematic review & meta-analysis of 8602 patients. DFU was consistently found to have significant association with cardiovascular-related morbidity and mortality, with pooled prevalences of all cause cardiovascular-related morbidity (37.1%), IHD (44.7%), CHF (25.1%), CAD (11.7%), and CVA (10.9%), and all cause cardiovascular-related mortality (14.6%), fatal IHD (6.2%), fatal CHF (3.67%), fatal CAD (7.92%), and fatal CVA (1.99%). Diabetic patients with DFU were found to have significantly increased risk of IHD (RR 1.25), CVA (RR 2.03), and all-cause cardiovascular-related mortality (RR 2.59) compared to those without DFU. CONCLUSIONS The presence of DFU is associated with major adverse cardiac events. The alarming rates of cardiovascular-related morbidity and mortality in DFU patients highlight its potential role as a marker of cardiovascular complications and should prompt early clinical investigation and management.
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Affiliation(s)
- Brian Zhaojie Chin
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Peng Lee
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore.
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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Ho AFW, Yau CE, Ho JSY, Lim SH, Ibrahim I, Kuan WS, Ooi SBS, Chan MY, Sia CH, Mosterd A, Gijsberts CM, de Hoog VC, Bank IEM, Doevendans PA, de Kleijn DPV. Predictors of major adverse cardiac events among patients with chest pain and low HEART score in the emergency department. Int J Cardiol 2024; 395:131573. [PMID: 37931658 DOI: 10.1016/j.ijcard.2023.131573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/08/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
AIM For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks. METHODS We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models. RESULTS Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score. CONCLUSION Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore; Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore, Singapore; Centre for Population Health Research and Implementation, SingHealth Regional Health System, Singapore, Singapore.
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jamie Sin-Ying Ho
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | | | - Mark Y Chan
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Crystel M Gijsberts
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vince C de Hoog
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ingrid E M Bank
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Dominique P V de Kleijn
- Department of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
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9
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Yeo JYP, Yau CE, Ong NY, Teo YH, Gopinathan A, Yang C, Jing M, Yang JJW, Sia CH, Tan BYQ, Yeo LLL. Comparing the Impact of Stenting vs. Medical Therapy for Intracranial Arterial Stenosis : A Systematic Review and One-stage and Two-stage Meta-Analysis of Randomized Clinical Trials. Clin Neuroradiol 2024:10.1007/s00062-023-01370-3. [PMID: 38172262 DOI: 10.1007/s00062-023-01370-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 11/23/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE In the treatment of intracranial arterial stenosis (ICAS), controversies remain regarding the optimal treatment strategy. Our study aims to conduct an individual patient-level data meta-analysis of existing RCTs comparing PTAS versus best medical therapy and to identify differences in outcomes such as incidence of ischemic stroke or death. METHODS Randomised controlled trials comparing the outcomes of stenting versus best medical therapy for patients who had symptomatic ICAS of >50%. Excluded studies included case reports, case series, reviews, observational studies, letters or studies evaluating isolated angioplasty techniques without stenting. Data was extracted in accordance with PRISMA guidelines. RESULTS 7 studies involving 1425 participants were included. There was an increased risk in the incidence of stroke and death within the first 30 days post-procedure for patients treated with PTAS over best medical therapy (RR = 2.22 [1.28-3.86], I² = 0%). Patients who underwent stenting also had a significantly higher risk of intracranial haemorrhage (RR = 12.66 [2.41-66.45], I² = 0%) and death (RR = 5.41 [1.20-24.28], I² = 0%).Under the shared frailty model, stenting when compared to medical therapy has a HR of 1.81 (95% CI:1.25-2.6) of stroke or death across 1 year. Under the parametric Royston-Parmar model, stenting has a significant decrease in the RMST(-0.83 months; 95% CI: -1.30-0.37). Stenting continued to show worse outcomes up to the 3 year mark with a HR of 1.60 (95% CI: 1.11-2.32). CONCLUSIONS AND RELEVANCE There is an increased risk of peri- and post-procedural stroke and death over best medical therapy in patients with symptomatic ICAS who undergo PTAS. Further work is required to refine patient selection and mitigate peri-procedural risks.
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Affiliation(s)
- Joshua Y P Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Chun En Yau
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Natasha Yixuan Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yao Hao Teo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Anil Gopinathan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Joanna J W Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore.
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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10
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Toh KZX, Koh MY, Loh EDW, Sia CH, Chong Y, Yeo LLL, Sharma VK, Lim MJR, Tan BYQ. Prevalence and Associations of Cognitive Impairment in Adult Patients with Moyamoya Disease: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2024; 97:541-552. [PMID: 38108354 DOI: 10.3233/jad-230979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
BACKGROUND Cognitive impairment, and in the long term Alzheimer's disease, vascular, or mixed dementia, are potential complications of moyamoya disease (MMD), of which the prevalence and associations are not well established. OBJECTIVE We performed a systematic review and meta-analysis to investigate the prevalence of cognitive impairment in adult patients with MMD as well as its clinical and demographic correlates. METHODS We performed a systematic search of four electronic databases: PubMed (MEDLINE), EMBASE, Scopus, and Cochrane Library, profiling studies from inception until 7 May 2023. Clinical data consisting of population characteristics, comorbidities, cognitive assessment tools used, and prevalence of cognitive impairment was extracted. RESULTS Seventeen studies were included in the meta-analysis, with a total study population of 1,190 patients. All studies assessed cognition, and the overall prevalence of cognitive impairment in MMD patients was 54.59%. A subgroup analysis identified that the prevalence of executive dysfunction in MMD patients was 31.55%. We performed a meta-regression analysis which identified that cognitive impairment was not associated with age, education level, or a history of ischemic or hemorrhagic stroke. CONCLUSIONS A substantial proportion of MMD patients have cognitive impairment, and cognitive impairment was found to have no association with a history of stroke. Further research is necessary to investigate the longitudinal relationship of MMD and cognitive impairment, and the impact of bypass surgery on cognitive impairment.
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Affiliation(s)
- Keith Z X Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Enver D W Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Yaofeng Chong
- Department of Medicine, Division of Neurology, National University Hospital, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Neurology, National University Hospital, Singapore
| | - Vijay K Sharma
- Department of Medicine, Division of Neurology, National University Hospital, Singapore
| | - Mervyn J R Lim
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Neurology, National University Hospital, Singapore
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11
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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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12
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Laenens D, Stassen J, Galloo X, Ewe SH, Singh GK, Ammanullah MR, Hirasawa K, Sia CH, Butcher SC, Chew NWS, Kong WKF, Poh KK, Ding ZP, Ajmone Marsan N, Bax JJ. The impact of atrial fibrillation on prognosis in aortic stenosis. Eur Heart J Qual Care Clin Outcomes 2023; 9:778-784. [PMID: 36669758 PMCID: PMC10745267 DOI: 10.1093/ehjqcco/qcad004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/11/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and aortic stenosis (AS) are both highly prevalent and often coexist. Various studies have focused on the prognostic value of AF in patients with AS, but rarely considered left ventricular (LV) diastolic function as a prognostic factor. OBJECTIVE To evaluate the prognostic impact of AF in patients with AS while correcting for LV diastolic function. METHODS Patients with first diagnosis of significant AS were selected and stratified according to history of AF. The endpoint was all-cause mortality. RESULTS In total, 2849 patients with significant AS (mean age 72 ± 12 years, 54.8% men) were evaluated, and 686 (24.1%) had a history of AF. During a median follow-up of 60 (30-97) months, 1182 (41.5%) patients died. Ten-year mortality rate in patients with AF was 46.8% compared to 36.8% in patients with sinus rhythm (SR) (log-rank P < 0.001). On univariable (HR: 1.42; 95% CI: 1.25-1.62; P < 0.001) and multivariable Cox regression analysis (HR: 1.19; 95% CI: 1.02-1.38; P = 0.026), AF was independently associated with mortality. However, when correcting for indexed left atrial volume, E/e' or both, AF was no longer independently associated with all-cause mortality. CONCLUSION Patients with significant AS and AF have a reduced survival as compared to patients with SR. Nonetheless, when correcting for markers of LV diastolic function, AF was not independently associated with outcomes in patients with significant AS.
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Affiliation(s)
- Dorien Laenens
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Xavier Galloo
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - See Hooi Ewe
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore, Singapore
| | - Gurpreet K Singh
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Mohammed R Ammanullah
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore, Singapore
| | - Kensuke Hirasawa
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center Singapore, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, Royal Perth Hospital, 197 Wellington St, Perth, WA 6000, Australia
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Center Singapore, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - William K F Kong
- Department of Cardiology, National University Heart Center Singapore, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Center Singapore, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Zee P Ding
- Department of Cardiology, National Heart Center Singapore, 5 Hospital Drive, Singapore 169609, Singapore, Singapore
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, Turku Heart Center, University of Turku and Turku Unviersity Hospital, Kiinamyllynkatu 4-8, 20521 Turku, Finland
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13
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Loh EDW, Toh KZX, Kwok GYR, Teo YH, Teo YN, Goh C, Syn NL, Ho AFW, Sia CH, Sharma VK, Tan BY, Yeo LL. Endovascular therapy for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e452-e459. [PMID: 36539273 DOI: 10.1136/jnis-2022-019717] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
AIMS Endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is a potential frontier of acute ischemic stroke (AIS) treatment, but its efficacy against best medical therapy (BMT) remains unknown. We performed a systematic review and meta-analysis evaluating the efficacy and safety of EVT versus BMT in primary DMVO. METHODS We systematically searched PubMed, Cochrane Library and Embase, from inception to August 14, 2022, for studies comparing EVT with BMT in DMVO-AIS. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (90-day modified Rankin Scale (mRS) 0-2) and excellent functional outcomes (90-day mRS 0-1). Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS Fourteen observational and two randomized-controlled studies were included, with 1202 patients receiving EVT and 1267 receiving BMT. After trim-and-fill correction, EVT achieved significantly better odds of functional independence than BMT (adjusted OR 1.61, 95% CI 1.06 to 2.43). There were no significant differences in overall excellent functional outcomes (OR 1.23, 95% CI 0.88 to 1.71), sICH (OR 1.44, 95% CI 0.78 to 2.66), and mortality (OR 1.03, 95% CI 0.73 to 1.45). Stratified by EVT method, mechanical thrombectomy±intra-arterial thrombolysis achieved more excellent functional outcomes than BMT (OR 1.59, 95% CI 1.13 to 2.23). In mild strokes (National Institutes of Health Stroke Scale score <6), EVT caused significantly more sICH (OR 6.30, 95% CI 1.55 to 25.64). CONCLUSIONS EVT shows promising efficacy benefit over BMT for primary DMVO-AIS. Further randomized controlled trials are necessary to evaluate the efficacy and safety of EVT in DMVO-AIS.
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Affiliation(s)
- Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Institute of Health Sciences Education, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L Syn
- Department of Surgery, National University Health System, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Vijay Kumar Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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14
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Lim GZ, Lai JY, Seet CYH, Tham CH, Venketasubramanian N, Tan BYQ, Jing M, Yeo JYP, Myint MZ, Sia CH, Teoh HL, Sharma VK, Chan BPL, Yang C, Makmur A, Ong SJ, Yeo LLL. Revolutionizing the Management of Large-Core Ischaemic Strokes: Decoding the Success of Endovascular Therapy in the Recent Stroke Trials. J Cardiovasc Dev Dis 2023; 10:499. [PMID: 38132666 PMCID: PMC10743836 DOI: 10.3390/jcdd10120499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/02/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Endovascular therapy (EVT) has revolutionized the management of acute ischaemic strokes with large vessel occlusion, with emerging evidence suggesting its benefit also in large infarct core volume strokes. In the last two years, four randomised controlled trials have been published on this topic-RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2 and TENSION, with overall results showing that EVT improves functional and neurological outcomes compared to medical management alone. This review aims to summarise the recent evidence presented by these four trials and highlight some of the limitations in our current understanding of this topic.
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Affiliation(s)
- Gareth Zigui Lim
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jonathan Yexian Lai
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Christopher Ying Hao Seet
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Joshua Yee Peng Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
- Department of Cardiology, National University Heart Center, Singapore 119228, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Bernard Poon Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Cunli Yang
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Andrew Makmur
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Shao Jin Ong
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
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15
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Yau CE, Low CE, Ong NY, Rana S, Chew LJR, Tyebally SM, Chai P, Yeo TC, Chan MY, Lee MX, Tan LL, Koo CY, Lee ARYB, Sia CH. Non-Vitamin K Antagonist Oral Anticoagulants versus Low Molecular Weight Heparin for Cancer-Related Venous Thromboembolic Events: Individual Patient Data Meta-Analysis. Cancers (Basel) 2023; 15:5887. [PMID: 38136433 PMCID: PMC10741613 DOI: 10.3390/cancers15245887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/09/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. Low molecular weight heparin (LMWH) has been the standard of care but new guidelines have approved the use of non-vitamin K antagonist oral anticoagulants (NOAC). By conducting an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) comparing the outcomes of NOAC versus LMWH in cancer patients, we aim to determine an ideal strategy for the prophylaxis of VTE and prevention of VTE recurrence. Three databases were searched from inception until 19 October 2022. IPD was reconstructed from Kaplan-Meier curves. Shared frailty, stratified Cox and Royston-Parmar models were fit to compare the outcomes of venous thromboembolism recurrence and major bleeding. For studies without Kaplan-Meier curves, aggregate data meta-analysis was conducted using random-effects models. Eleven RCTs involving 4844 patients were included. Aggregate data meta-analysis showed that administering NOACs led to a significantly lower risk of recurrent VTE (RR = 0.65; 95%CI: 0.50-0.84) and deep vein thrombosis (DVT) (RR = 0.60; 95%CI: 0.40-0.90). In the IPD meta-analysis, NOAC when compared with LMWH has an HR of 0.65 (95%CI: 0.49-0.86) for VTE recurrence. Stratified Cox and Royston-Parmar models demonstrated similar results. In reducing risks of recurrent VTE and DVT among cancer patients, NOACs are superior to LMWHs without increased major bleeding.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Natasha Yixuan Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sounak Rana
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Lucas Jun Rong Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sara Moiz Tyebally
- Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Ping Chai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Tiong-Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Mark Y. Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore;
| | - Li-Ling Tan
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Ainsley Ryan Yan Bin Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
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16
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Loo JH, Leow AS, Jing M, Sia CH, Chan BP, Seet RC, Teoh HL, Meyer L, Fiehler J, Papanagiotou P, Kastrup A, Mpotsaris A, Maus V, Yapici F, Simonato D, Gabrieli JD, Cester G, Bhogal P, Spooner O, Nikola C, Joshi A, Lee TH, Wu J, Chen Y, Yang S, Sharma VK, Tan BY, Yeo LL. Impact of atrial fibrillation on the treatment effect of bridging thrombolysis in ischemic stroke patients undergoing endovascular thrombectomy: a multicenter international cohort study. J Neurointerv Surg 2023; 15:1274-1279. [PMID: 36609541 DOI: 10.1136/jnis-2022-019590] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/23/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The role of bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in the treatment of acute ischemic stroke (AIS) remains debatable. Atrial fibrillation (AF) associated strokes may be associated with reduced treatment effect from IVT. This study compares the effect of bridging IVT in AF and non-AF patients. METHODS This retrospective cohort study comprised anterior circulation large vessel occlusion (LVO) AIS patients receiving EVT alone or bridging IVT plus EVT within 6 hours of symptom onset. Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were successful reperfusion defined as expanded Thrombolysis In Cerebral Infarction (eTICI) grading ≥2b flow, symptomatic intracerebral hemorrhage (sICH), and in-hospital mortality. RESULTS We included 705 patients (314 AF and 391 non-AF patients). The mean age was 68.6 years and 53.9% were male. The odds of good functional outcomes with bridging IVT was higher in the non-AF (adjusted odds ratio (aOR) 2.28, 95% CI 1.06 to 4.91, P=0.035) compared with the AF subgroups (aOR 1.89, 95% CI 0.89 to 4.01, P=0.097). However, this did not constitute a significant effect modification by the presence of AF on bridging IVT (interaction aOR 0.12, 95% CI -1.94 to 2.18, P=0.455). The rate of successful reperfusion, sICH, and mortality were similar between bridging IVT and EVT for both AF and non-AF patients. CONCLUSION The presence of AF did not modify the treatment effect of bridging IVT. Further individual patient data meta-analysis of randomized trials may shed light on the comparative efficacy of bridging IVT in AF versus non-AF LVO strokes.
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Affiliation(s)
- Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Mingxue Jing
- National University Health System Singapore, Singapore
| | - Ching-Hui Sia
- National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Bernard Pl Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Raymond Cs Seet
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Neurology, National University Hospital, Singapore
| | - Hock-Luen Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | | | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
| | - Furkan Yapici
- Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
| | - Davide Simonato
- Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
| | - Joseph D Gabrieli
- Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
| | - Giacomo Cester
- Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
| | - Pervinder Bhogal
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Oliver Spooner
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Christos Nikola
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Abhishek Joshi
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiale Wu
- School of Medicine, Shaoguan University, Shaoguan, Guangdong, China
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Shuiquan Yang
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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17
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Leow R, Kong WKF, Li TYW, Poh KK, Sia CH, Yeo TC. Yeo's index: A novel index that combines anatomic and haemodynamic assessment of the severity of mitral stenosis. Int J Cardiol 2023; 392:131350. [PMID: 37689399 DOI: 10.1016/j.ijcard.2023.131350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND A mitral leaflet separation index (MLSI), measuring the anatomical separation of the mitral valve (MV) leaflet tips in diastole, was previously described as an accurate method of assessing mitral stenosis (MS). We propose a novel modification of the MLSI by including a hemodynamic assessment which we term Yeo's index that may improve its diagnostic performance. METHODS AND RESULTS We retrospectively studied 174 patients with varying severity of MS without significant mitral regurgitation, aortic valve disease or ventricular septal defect. MLSI was measured in 2 orthogonal views on transthoracic echocardiography as previously described. MV dimensionless index (DI) was calculated by dividing the left ventricular outflow tract pulsed-wave Doppler time velocity integral (TVI) by the MV continuous-wave Doppler TVI. We defined Yeo's index as the product of MLSI and DI. With linear correlation, Yeo's index demonstrated good correlation against MVA by planimetry (r = 0.728), pressure half-time (r = 0.677), and continuity equation (r = 0.829), with improved performance over the MLSI. Using ROC analysis, Yeo's index demonstrated good ability to correctly classify MS as severe (MVA ≤1.5cm2) (AUC 0.874, 95% CI 0.816-0.920). Yeo's index ≤0.260 cm correctly classified severe MS with sensitivity of 82% and specificity of 80%. Presence of AF did not affect the performance of Yeo's index. Yeo's index ≤0.147 cm also identified very severe MS (MVA ≤ 1.0 cm2) with specificity of 94% and sensitivity of 78%. CONCLUSION Yeo's index performed well in identifying severe MS and may be a useful adjunct to existing measures of MS severity.
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Affiliation(s)
- Ryan Leow
- Department of Cardiology, National University Heart Centre Singapore (NUHCS), Singapore
| | - William K F Kong
- Department of Cardiology, NUHCS, and the Department of Medicine, Yong Loo Lin School of Medicine (YLLSoM), National University of Singapore (NUS), Singapore
| | | | - Kian-Keong Poh
- Department of Cardiology, NUHCS, and the Department of Medicine, YLLSoM, NUS, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, NUHCS, and the Department of Medicine, YLLSoM, NUS, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, NUHCS, and the Department of Medicine, YLLSoM, NUS, Singapore.
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18
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Koh TJW, Tan HJH, Ravi PRJ, Sng JWZ, Yeo TC, Tan BYQ, Chai P, Yeo LLL, Chan MY, Kong WKF, Wong RCC, Teo YH, Ho JSY, Teo YN, Sia CH. Association Between Breast Arterial Calcifications and Cardiovascular Disease: A Systematic Review and Meta-analysis. Can J Cardiol 2023; 39:1941-1950. [PMID: 37506765 DOI: 10.1016/j.cjca.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Recent studies have shown that breast arterial calcification (BAC) detected on screening mammography is linked to cardiovascular diseases via medial calcification. However, its effect on cardiovascular outcomes remains unclear. Therefore, we conducted a meta-analysis to determine the effect of BAC on cardiovascular outcomes in patients. METHODS Three electronic databases (Pubmed, Embase, and Scopus) were searched on May 1, 2022, for studies examining the relationship between BAC and cardiovascular outcomes including cardiac death, acute myocardial infarction, ischemic heart disease, stroke, peripheral artery disease, and heart failure. A random-effects meta-analysis model was used to summarise the studies. RESULTS A total of 5 longitudinal studies were included with a combined cohort of 87,865 patients. Significantly, the pooled risk ratio (RR) of the association between BAC and cardiac death was 2.06 (P < 0.00001). BAC was associated with a significantly increased risk of developing other cardiovascular diseases, such as ischemic/hemorrhagic stroke (RR 1.51; P = 0.003), ischemic stroke (RR 1.82; P < 0.00001), peripheral vascular disease (RR 1.24; P = 0.003), and heart failure (RR 1.84; P < 0.00001). There was no significant relationship for developing myocardial infarction or for total cardiovascular diseases. CONCLUSIONS Our findings suggest that BAC was associated with an increased risk of cardiovascular mortality, and certain cardiovascular outcomes. There is thus a potential to use BAC as a sex-specific cardiovascular risk assessment tool. Furthermore, there is a need for more widespread reporting of BAC to better understand the pathophysiologic mechanisms behind its correlation with cardiovascular disease and to apply it in clinical practice.
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Affiliation(s)
- Tricia Jia Wen Koh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hannah Jia Hwee Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jonathan W Z Sng
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Raymond C C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jamie Sin Ying Ho
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
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19
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Tan BY, Zheng Y, Lim MJR, Koh YY, Tan YK, Goh C, Myint MZ, Sia CH, Tan J, Nor FEM, Soon B, Chan BP, Leow AS, Ho JS, Yeo LL, Sharma VK. Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease. Clin Neurol Neurosurg 2023; 235:108024. [PMID: 37922680 DOI: 10.1016/j.clineuro.2023.108024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/16/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD. METHODS From 2017-2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke). RESULTS Of 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively. CONCLUSIONS Patients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.
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Affiliation(s)
- Benjamin Yq Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ying Ying Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Kiat Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Cardiology, National University Health System, Singapore
| | - Jaclyn Tan
- Division of Neurosurgery, National University Health System, Singapore
| | | | - Betsy Soon
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Bernard Pl Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Aloysius St Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jamie Sy Ho
- Department of Medicine, National University Health System, Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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20
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Ngiam JN, Liong TS, Pramotedham T, Sia CH, Jou E, Kong WKF, Poh KK. Left ventricular vortex formation time: emerging clinical applications and limitations. Singapore Med J 2023:389617. [PMID: 38037777 DOI: 10.4103/singaporemedj.smj-2022-132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Vortex formation during left ventricular diastolic filling may provide clinically useful insights into cardiac health. In recent years, there has been growing interest in the measurement of vortex formation time (VFT), especially because it is derived noninvasively. There are important applications of VFT in valvular heart disease, athletic physiology, heart failure and hypertrophic cardiomyopathy. The formation of the vortex as fluid propagates into the left ventricle from the left atrium is important for efficient fluid transport. Quantifying VFT may thus help in evaluating and understanding disease and pathophysiological processes.
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Affiliation(s)
| | - Tze Sian Liong
- Department of Medicine, National University Health System, Singapore
| | | | - Ching-Hui Sia
- Department of Medicine; Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Eric Jou
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - William Kok-Fai Kong
- Department of Medicine; Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Kian-Keong Poh
- Department of Medicine; Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
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21
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Kanneganti A, Tan BYQ, Nik Ab Rahman NH, Leow AST, Denning M, Goh ET, Lim LJH, Sia CH, Chua YX, Kinross J, Tan M, Tan LF, Wan YM, Sharma A, Danuaji R, Komal Kumar RN, Sheng CK, Kheng CP, Abdul Karim SS, Abdul Ghani MN, Mahmud S, Chan YH, Sharma VK, Sim K, Ooi SBS. Safety attitudes, burnout and well-being among healthcare workers during the COVID-19 pandemic: an Indo-Pacific regional cross-sectional study. Singapore Med J 2023; 64:667-676. [PMID: 35139631 PMCID: PMC10754367 DOI: 10.11622/smedj.2022014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022]
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact in Asia and has placed significant burden on already stretched healthcare systems. We examined the impact of COVID-19 on the safety attitudes among healthcare workers (HCWs), as well as their associated demographic and occupational factors, and measures of burnout, depression and anxiety. Methods A cross-sectional survey study utilising snowball sampling was performed involving doctors, nurses and allied health professions from 23 hospitals in Singapore, Malaysia, India and Indonesia between 29 May 2020 and 13 July 2020. This survey collated demographic data and workplace conditions and included three validated questionnaires: the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory and Hospital Anxiety and Depression Scale. We performed multivariate mixed-model regression to assess independent associations with the SAQ total percentage agree rate (PAR). Results We obtained 3,163 responses. The SAQ total PARs were found to be 35.7%, 15.0%, 51.0% and 3.3% among the respondents from Singapore, Malaysia, India and Indonesia, respectively. Burnout scores were highest among respondents from Indonesia and lowest among respondents from India (70.9%-85.4% vs. 56.3%-63.6%, respectively). Multivariate analyses revealed that meeting burnout and depression thresholds and shifts lasting ≥12 h were significantly associated with lower SAQ total PAR. Conclusion Addressing the factors contributing to high burnout and depression and placing strict limits on work hours per shift may contribute significantly towards improving safety culture among HCWs and should remain priorities during the pandemic.
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Affiliation(s)
- Abhiram Kanneganti
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | - Benjamin Yong Qiang Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nik Hisamuddin Nik Ab Rahman
- Department of Emergency & Trauma, Hospital Universiti Sains Malaysia, Malaysia
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Ma laysia, Kota Bharu, Malaysia
| | - Aloysius Sheng-Ting Leow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Max Denning
- Department of Surgery and Cancer, Imperial College London, UK
| | - Ee Teng Goh
- Department of Surgery and Cancer, Imperial College London, UK
| | - Lucas Jun Hao Lim
- Early Psychosis Intervention Program, Institute of Mental Health, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ying Xian Chua
- National University Polyclinics – Pioneer, National University Health System, Singapore
| | - James Kinross
- Department of Surgery and Cancer, Imperial College London, UK
| | - Melanie Tan
- Department of Geriatric Medicine, Ng Teng Fong General Hospital, Singapore
| | - Li Feng Tan
- Division of Healthy Ageing, Alexandra Hospital, Singapore
| | - Yi Min Wan
- Department of Psychiatry, Ng Teng Fong General Hospital, Singapore
| | - Arvind Sharma
- Department of Neurology, Zydus Hospitals and BJ Medical College, Ahmedabad, Gujarat, India
| | - Rivan Danuaji
- Department of Neurology, Dr Moewardi Hospital, Kota Surakarta, Jawa Tengah, Indonesia
| | - RN Komal Kumar
- Cerebrovascular Unit, Yashoda Institute of Neuroscience, Secunderabad, Telangana, India
| | - Chew Keng Sheng
- Department of Surgery, Faculty of Medicine & Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Cheah Phee Kheng
- Emergency and Trauma Department, Sabah Women and Children’s Hospital, Kota Kinabalu, Sabah, Malaysia
| | | | - Mohd Najib Abdul Ghani
- Emergency and Trauma Department, Hospital Raja Perempuan Zainab (II), Bandar Kota Bharu, Kelantan, Malaysia
| | - Suhaimi Mahmud
- Emergency and Trauma Department, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vijay Kumar Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kang Sim
- West Region, Institute of Mental Health, Singapore
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shirley Beng Suat Ooi
- Emergency Medicine Department, National University Hospital, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University Singapore, Singapore
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22
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Chen KX, Lee C, Kanneganti A, Lim LJH, Tan M, Chua YX, Sia CH, Sim K, Ooi SBS, Tan BYQ, Tan LF. Impact of Safety Culture Domains on Burnout of Health Care Workers During COVID-19 in Singapore: A Multigroup Structural Equation Modeling Analysis. Asia Pac J Public Health 2023; 35:583-585. [PMID: 37694846 DOI: 10.1177/10105395231197902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Affiliation(s)
- Ken Xy Chen
- Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore
| | | | - Abhiram Kanneganti
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | | | - Melanie Tan
- Department of Geriatric Medicine, Ng Teng Fong General Hospital, Singapore
| | - Ying Xian Chua
- Pioneer Polyclinic, National University Polyclinics, National University Health System, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Kang Sim
- Institute of Mental Health, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shirley B S Ooi
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Emergency Medicine, National University Hospital, Singapore
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Li Feng Tan
- Healthy Ageing Programme, Alexandra Hospital, Singapore
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23
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Tan SML, Ong SH, Yeo TT, Nga VDW, Chew E, Tam PK, Su P, Ng MB, Lim HS, Yeo LL, Sharma VK, Sia CH, Lim MJR, Tan BYQ. Ischemic and hemorrhagic strokes in young adults: Comparison of functional outcomes and return to work after stroke. Clin Neurol Neurosurg 2023; 233:107964. [PMID: 37717357 DOI: 10.1016/j.clineuro.2023.107964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Functional recovery and return to work (RTW) after stroke are important rehabilitation goals that have significant impact on quality of life. Comparisons of functional outcomes and RTW between ischemic stroke (IS) and hemorrhagic stroke (HS), especially among young adults with stroke, have either been limited or yielded inconsistent results. We aimed to assess functional outcomes and ability to RTW in young adults with IS and HS, specifically primary spontaneous intracranial hemorrhage (SICH). METHODS Young adults with IS or SICH aged 18-50-years-old were included. Outcome measures were modified Rankins score (mRS) on discharge and 3-months and RTW at 3-months after stroke. Good functional outcome was defined as an mRS of 0-2. RESULTS We included 459 patients (71.5% male) with a mean age of 43.3 ± 5.7 years, comprising 49.2% IS and 50.8% SICH. Patients with SICH were more likely to have unfavourable shifts in ordinal mRS on discharge (OR 7.52, CI 5.18-10.87, p < 0.001) and at 3-months (OR 6.41, CI 4.17-9.80, p < 0.001). Patients with IS more likely achieved good functional outcomes (80.2% vs. 51.8%, p < 0.001) and were able to RTW at 3-months (54.4% vs. 36.3%, p = 0.004). Among all stroke patients with good functional outcomes, one-third did not RTW at 3-months. Patients with longer length of hospitalisation and higher National Institutes of Health Stroke Scale (NIHSS) score on admission, especially in the domain categories of level of consciousness, vision, motor function, language and neglect, were less likely to RTW at 3-months. CONCLUSION Patients with IS were more likely to RTW when compared to SICH patients. Many young stroke patients did not RTW despite good functional outcomes. Further research should therefore address differences in prognosis and identify predictors that influence ability to RTW after stroke in the young adult population.
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Affiliation(s)
- Sarah Ming Li Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Shi Hui Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vincent Diong Weng Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Effie Chew
- Division of Rehabilitation Medicine, Department of Medicine, National University Hospital, Singapore
| | - Pui Kit Tam
- Division of Rehabilitation Medicine, Department of Medicine, National University Hospital, Singapore
| | - Peijing Su
- Division of Rehabilitation Medicine, Department of Medicine, National University Hospital, Singapore
| | - Megan Bj Ng
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Hui Shi Lim
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mervyn Jun Rui Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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24
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Chew NWS, Wong RCC, Djohan AH, Ngiam JN, Chai P, Yeo TC, Tan HC, Sia CH. Association of face mask use with self-reported cardiovascular symptoms during the COVID-19 pandemic. Singapore Med J 2023; 64:609-615. [PMID: 34600453 PMCID: PMC10645009 DOI: 10.11622/smedj.2021140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 03/07/2021] [Indexed: 11/18/2022]
Abstract
Introduction Countries are mandating the use of face masks to stem the spread of coronavirus disease 2019 (COVID-19). Face mask use has been associated with discomfort due to its effects on thermoregulation, breathing and oxygenation. We evaluated the prevalence and severity of self-reported cardiovascular symptoms before and during face mask use. Methods This was a cross-sectional study of 1,001 participants residing in Singapore, who participated in a self-administered questionnaire between 25 April 2020 and 4 May 2020. Symptom severity before and during mask use, and health-seeking behaviour information were collected. The study outcome was self-reported worsening of cardiovascular symptoms and its association with the type of mask worn, duration of mask worn per day, and intensity of physical activities during mask use. Results The most common symptom reported during mask use was dyspnoea. Independent predictors for self-reported cardiovascular symptoms during mask use were moderate-high physical activity during mask use (odds ratio [OR] 1.634, 95% confidence interval [CI] 1.176-2.270, P = 0.003), duration of mask use for ≥3 h (OR 1.672, 95% CI 1.189-2.352, P = 0.003) and type of mask used, after adjusting for age, sex, healthcare-based worker status and presence of comorbidities. N95 mask was associated with worse symptoms when compared to surgical mask. Participants with ≥3 worsening symptoms or worsening dyspnoea, palpitations, fatigue and dizziness were more likely to seek medical help. Conclusion Face mask use has been proven to be an effective way in curbing COVID-19 transmission. However, participants in this study had concerns regarding its use and these concerns should be urgently addressed to enable mask use policies to be enacted.
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Affiliation(s)
| | - Raymond Ching Chiew Wong
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jinghao Nicholas Ngiam
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore
| | - Ping Chai
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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25
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Sim MG, Teo YN, Teo YH, Syn NL, Li TYW, Yeo LLL, Kong WKF, Tan BYQ, Yip JW, Wong RCC, Poh KK, Yeo TC, Sharma VK, Chai P, Chan MY, Sia CH. Association Between Calcium Supplementation and the Risk of Cardiovascular Disease and Stroke: A Systematic Review and Meta-Analysis. Heart Lung Circ 2023; 32:1230-1239. [PMID: 37743221 DOI: 10.1016/j.hlc.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Some observational studies and randomised controlled trials (RCTs) have reported an association between calcium supplementation and increased risk of cardiovascular disease. Previous meta-analyses on the topic, based on data from RCTs and observational studies, have contradictory findings. This meta-analysis was conducted to determine the difference in associated risks of calcium supplementation with cardiovascular disease and stroke in RCTs. METHODS Relevant studies published from database inception to 6 August 2021 were sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials. Any RCTs focusing on the relationship between calcium supplementation and incidence of cardiovascular disease or stroke were included. Articles were screened independently by two authors, according to the PICO criteria, with disagreements resolved by a third author. RESULTS Twelve RCTs were included in the meta-analysis. Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and all-cause/cardiovascular mortality. Subgroup analysis focusing on calcium monotherapy/calcium co-therapy with vitamin D, female sex, follow-up duration, and geographical region did not affect the findings. CONCLUSION Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and cardiovascular/all-cause mortality. Further studies are required to examine and understand these associations.
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Affiliation(s)
- Ming Gin Sim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. http://www.twitter.com/yaoneng_teo
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tony Y W Li
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - James W Yip
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Raymond C C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kian Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Vijay Kumar Sharma
- Department of Cardiology, National University Heart Centre Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
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26
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Lee KS, Siow I, Zhang JJ, Syn NL, Gillespie CS, Yuen LZ, Anil G, Yang C, Chan BP, Sharma VK, Teoh HL, Mingxue J, Teo KSH, Myint MZ, Bhogal P, Meyer L, Schob S, Sia CH, Mpotsaris A, Maus V, Andersson T, Arnberg F, Gontu VK, Lee TH, Tan BYQ, Yeo LL. Bridging thrombolysis improves survival rates at 90 days compared with direct mechanical thrombectomy alone in acute ischemic stroke due to basilar artery occlusion: a systematic review and meta-analysis of 1096 patients. J Neurointerv Surg 2023; 15:1039-1045. [PMID: 36175014 DOI: 10.1136/jnis-2022-019510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is an effective treatment for patients with acute ischemic stroke (AIS) from basilar artery occlusion (BAO). OBJECTIVE To compare the clinical outcomes of MT, with and without bridging intravenous thrombolysis (IVT), in acute BAO through a systematic review and meta-analysis of the current literature. METHODS Systematic searches of Medline, EMBASE, and Cochrane Central were undertaken on August 1, 2022. Good functional outcome defined as 90-day modified Rankin Scale score 0-2 was the primary outcome measure. Secondary outcome measures were 90-day mortality, successful post-thrombectomy recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracranial hemorrhage (sICH), and subarachnoid hemorrhage (SAH). RESULTS Three studies reporting 1096 patients with BAO AIS were included in the meta-analysis. No significant differences in good functional outcome were detected between the two groups (RR=1.28 (95% CI 0.86 to 1.92); p=0.117). However, specifically patients with large artery atherosclerosis (LAA) benefited from bridging IVT (OR=2.52 (95% CI 1.51 to 4.22); p<0.001) with better functional outcomes. There was a significantly lower 90-day mortality rate for patients who underwent bridging IVT compared with MT alone (RR=0.70 (95% CI 0.62 to 0.80); p=0.008). No significant differences were detected in rates of post-treatment recanalization (RR=1.01 (95% CI 0.35 to 2.91); p=0.954), sICH (RR=0.96 (95% CI 0.66 to 1.42); p=0.724), and SAH (RR=0.93 (95% CI 0.31 to 2.83); p=0.563). CONCLUSIONS In patients with AIS due to BAO, bridging IVT was associated with lower mortality rates at 90 days, compared with direct MT. There were no improved functional outcomes or increased sICH or SAH between both arms, However, patients with LAA benefited from bridging IVT, with better functional outcomes.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Isabel Siow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - John Jy Zhang
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Nicholas L Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Conor S Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Linus Zh Yuen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gopinathan Anil
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Divison of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Divison of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore
| | - Bernard Pl Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Hock-Luen Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jing Mingxue
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Kevin Soon Hwee Teo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - May Zin Myint
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, St. Bartholomew's and The Royal London Hospital, London, UK
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Schob
- Department of Neuroradiology, Clinic and Policlinic of Radiology, University Hospital Halle/Saale, Halle, Germany
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Volker Maus
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tommy Andersson
- Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Fabian Arnberg
- Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | - Vamsi Krishna Gontu
- Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | - Tsong-Hai Lee
- Department of Neruology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Leonard Ll Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
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Hausenloy DJ, Sia CH, Ko J. Unraveling the smoker's paradox: impact of smoking on outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Pol Arch Intern Med 2023; 133:16564. [PMID: 37772711 DOI: 10.20452/pamw.16564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Affiliation(s)
- Derek J Hausenloy
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore; Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore; The Hatter Cardiovascular Institute, University College London, London, United Kingdom.
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Junsuk Ko
- MD Program, Duke-National University of Singapore Medical School, Singapore
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Ho JSY, Sia CH, Ngiam JN, Loh PH, Chew NWS, Kong WKF, Poh KK. A review of COVID-19 vaccination and the reported cardiac manifestations. Singapore Med J 2023; 64:543-549. [PMID: 34808708 PMCID: PMC10564100 DOI: 10.11622/smedj.2021210] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/18/2021] [Indexed: 12/21/2022]
Abstract
In Singapore, 9.03 million doses of the mRNA COVID-19 vaccines by Pfizer-BioNTech and Moderna have been administered, and 4.46 million people are fully vaccinated. An additional 87,000 people have been vaccinated with vaccines in World Health Organization's Emergency Use Listing. The aim of this review is to explore the reported cardiac adverse events associated with different types of COVID-19 vaccines. A total of 42 studies that reported cardiac side effects after COVID-19 vaccination were included in this study. Reported COVID-19 vaccine-associated cardiac adverse events were mainly myocarditis and pericarditis, most commonly seen in adolescent and young adult male individuals after mRNA vaccination. Reports of other events such as acute myocardial infarction, arrhythmia and stress cardiomyopathy were rare. Outcomes of post-vaccine myocarditis and pericarditis were good. Given the good vaccine efficacy and the high number of cases of infection, hospitalisation and death that could potentially be prevented, COVID-19 vaccine remains of overall benefit, based on the current available data.
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Affiliation(s)
- Jamie Sin Ying Ho
- Academic Foundation Programme, Royal Free London NHS Trust, London, UK
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jinghao Nicholas Ngiam
- Division of Infectious Diseases, Department of Medicine, National University Health System, Singapore
| | - Poay Huan Loh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - William Kok-Fai Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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29
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Ngiam JN, Koh MCY, Liong TS, Sim MY, Chhabra S, Goh W, Chew NWS, Sia CH, Goon PKC, Soong JTY, Tambyah PA, Cove ME. Inflammatory phenotypes may be more important than age and comorbidities in predicting clinical outcomes in hospitalised patients with COVID-19. IJID Reg 2023; 8:84-89. [PMID: 37529630 PMCID: PMC10307670 DOI: 10.1016/j.ijregi.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/13/2023] [Accepted: 06/23/2023] [Indexed: 08/03/2023]
Abstract
Objectives In critically ill patients with COVID-19, distinct hyperinflammatory and hypoinflammatory phenotypes have been described, with different outcomes and responses to therapy. We investigated if similar phenotypes exist in non-severe illness. Methods Consecutive patients with polymerase chain reaction (PCR) confirmed SARS-CoV-2 were examined. Baseline demographics and laboratory investigations were tabulated, including serum C-reactive protein. Patients were divided into those who were hyperinflammatory (defined as C-reactive protein >17 mg/l) or hypoinflammatory. Adverse outcomes, defined as requiring oxygenation, intensive care, or death, were recorded during the hospital stay. Clinical characteristics and outcomes were compared. Results Of the 1781 patients examined, 276 (15.5%) had a hyperinflammatory phenotype. They were older (51.8 ± 17.2 vs 40.3 ± 13.8 years, P <0.001), had a lower PCR cycle threshold (PCR cycle threshold value 19.3 ± 6.3 vs 22.7 ± 15.4, P = 0.025) at presentation, and more medical comorbidities. The hyperinflammatory phenotype was independently associated with adverse clinical outcomes, even after adjusting for age, medical history and viral load on multivariable analyses (adjusted odds ratio 5.78, 95% confidence interval 2.86-11.63). Conclusion Even in non-severe COVID-19, there are distinct hyper- and hypoinflammatory phenotypes, with the hyperinflammatory phenotype strongly associated with adverse clinical outcomes, that could be distinguished with a simple biomarker.
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Affiliation(s)
| | - Matthew CY Koh
- Department of Infectious Diseases, National University Health System, Singapore
| | - Tze Sian Liong
- Department of Medicine, National University Health System, Singapore
| | - Meng Ying Sim
- Department of Infectious Diseases, National University Health System, Singapore
| | - Srishti Chhabra
- Department of Infectious Diseases, National University Health System, Singapore
| | - Wilson Goh
- Department of Medicine, National University Health System, Singapore
| | - Nicholas WS Chew
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Peter KC Goon
- Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - John TY Soong
- Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul Anantharajah Tambyah
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Matthew Edward Cove
- Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Chew NWS, Sia CH, Loh JPY. Takotsubo cardiomyopathy precipitated by election preparation-related stress. Singapore Med J 2023; 64:590-591. [PMID: 35305549 PMCID: PMC10564101 DOI: 10.11622/smedj.2022033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Nicholas Wen Sheng Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore E-mail:
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore E-mail:
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Thong EHE, Quek EJW, Loo JH, Yun CY, Teo YN, Teo YH, Leow AST, Li TYW, Sharma VK, Tan BYQ, Yeo LLL, Chong YF, Chan MY, Sia CH. Acute Myocardial Infarction and Risk of Cognitive Impairment and Dementia: A Review. Biology (Basel) 2023; 12:1154. [PMID: 37627038 PMCID: PMC10452707 DOI: 10.3390/biology12081154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/05/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
Cognitive impairment (CI) shares common cardiovascular risk factors with acute myocardial infarction (AMI), and is increasingly prevalent in our ageing population. Whilst AMI is associated with increased rates of CI, CI remains underreported and infrequently identified in patients with AMI. In this review, we discuss the evidence surrounding AMI and its links to dementia and CI, including pathophysiology, risk factors, management and interventions. Vascular dysregulation plays a major role in CI, with atherosclerosis, platelet activation, microinfarcts and perivascular inflammation resulting in neurovascular unit dysfunction, disordered homeostasis and a dysfunctional neurohormonal response. This subsequently affects perfusion pressure, resulting in enlarged periventricular spaces and hippocampal sclerosis. The increased platelet activation seen in coronary artery disease (CAD) can also result in inflammation and amyloid-β protein deposition which is associated with Alzheimer's Dementia. Post-AMI, reduced blood pressure and reduced left ventricular ejection fraction can cause chronic cerebral hypoperfusion, cerebral infarction and failure of normal circulatory autoregulatory mechanisms. Patients who undergo coronary revascularization (percutaneous coronary intervention or bypass surgery) are at increased risk for post-procedure cognitive impairment, though whether this is related to the intervention itself or underlying cardiovascular risk factors is debated. Mortality rates are higher in dementia patients with AMI, and post-AMI CI is more prevalent in the elderly and in patients with post-AMI heart failure. Medical management (antiplatelet, statin, renin-angiotensin system inhibitors, cardiac rehabilitation) can reduce the risk of post-AMI CI; however, beta-blockers may be associated with functional decline in patients with existing CI. The early identification of those with dementia or CI who present with AMI is important, as subsequent tailoring of management strategies can potentially improve outcomes as well as guide prognosis.
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Affiliation(s)
- Elizabeth Hui En Thong
- Internal Medicine Residency, National University Health System, Singapore 119074, Singapore; (E.H.E.T.); (Y.H.T.); (A.S.T.L.)
| | - Ethan J. W. Quek
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
| | - Jing Hong Loo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
| | - Choi-Ying Yun
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (C.-Y.Y.); (T.Y.W.L.)
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
| | - Yao Hao Teo
- Internal Medicine Residency, National University Health System, Singapore 119074, Singapore; (E.H.E.T.); (Y.H.T.); (A.S.T.L.)
| | - Aloysius S. T. Leow
- Internal Medicine Residency, National University Health System, Singapore 119074, Singapore; (E.H.E.T.); (Y.H.T.); (A.S.T.L.)
| | - Tony Y. W. Li
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (C.-Y.Y.); (T.Y.W.L.)
| | - Vijay K. Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Benjamin Y. Q. Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Leonard L. L. Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Yao Feng Chong
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Mark Y. Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (C.-Y.Y.); (T.Y.W.L.)
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (E.J.W.Q.); (J.H.L.); (Y.N.T.); (V.K.S.); (B.Y.Q.T.); (L.L.L.Y.); (M.Y.C.)
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (C.-Y.Y.); (T.Y.W.L.)
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Tan SM, Ho JS, Sia CH, Leow AS, Seet RC, Teoh HL, Yuen LZ, Tham CH, Chua CY, Yap ES, Chan BP, Lim MJ, Sharma VK, Yeo LL, Tu TM, Tan BY. Etiologies, mechanisms, and risk factors of ischemic stroke in a young Asian adult cohort. J Stroke Cerebrovasc Dis 2023; 32:107134. [PMID: 37172470 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 03/18/2023] [Accepted: 04/09/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVES Risk factors and causes of acute ischemic stroke (AIS) are more diverse in young adults, and traditional stroke classifications may be inadequate. Precise characterisation of AIS is important for guiding management and prognostication. We describe stroke subtypes, risk factors and etiologies for AIS in a young Asian adult population. MATERIALS AND METHODS Young AIS patients aged 18-50 years admitted to two comprehensive stroke centres from 2020-2022 were included. Stroke etiologies and risk factors were adjudicated using Trial of Org 10172 in Acute Stroke Treatment (TOAST) and International Pediatric Stroke Study (IPSS) risk factors. Potential embolic sources (PES) were identified in a subgroup with embolic stroke of undetermined source (ESUS). These were compared across sex, ethnicities and age groups (18-39 years versus 40-50 years). RESULTS A total of 276 AIS patients were included, with mean age 43±5.7 years and 70.3% male. Median duration of follow-up was 5 months (IQR: 3-10). The most common TOAST subtypes were small-vessel disease (32.6%) and undetermined etiology (24.6%). IPSS risk factors were identified in 95% of all patients and 90% with undetermined etiology. IPSS risk factors included atherosclerosis (59.5%), cardiac disorders (18.7%), prothrombotic states (12.4%) and arteriopathy (7.7%). In this cohort, 20.3% had ESUS, of which 73.2% had at least one PES, which increased to 84.2% in those <40 years old. CONCLUSIONS Young adults have diverse risk factors and causes of AIS. IPSS risk factors and ESUS-PES construct are comprehensive classification systems that may better reflect heterogeneous risk factors and etiologies in young stroke patients.
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Affiliation(s)
- Sarah Ml Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Jamie Sy Ho
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Aloysius S Leow
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Raymond Cs Seet
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Linus Zh Yuen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, SingHealth, Singapore
| | - Christopher Yk Chua
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Bernard Pl Chan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Mervyn Jr Lim
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, SingHealth, Singapore
| | - Benjamin Yq Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore.
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Wong ZY, Yuen LZ, Tan YK, Goh CX, Teo YN, Ho JS, Seow SC, Lee EC, Teoh HL, Yeo LL, Sia CH, Tan BY. Detection of Atrial Fibrillation After Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and Individual Patient Data Meta-Analysis of Randomised Clinical Trials. Cerebrovasc Dis 2023:000533265. [PMID: 37517392 DOI: 10.1159/000533265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
OBJECTIVE In ischemic stroke patients, we compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring on the incidence of atrial fibrillation (AF) detection and other clinical outcomes. BACKGROUND Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomised controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring post-stroke AF are lacking; including the optimal timing, duration, and method of electrocardiography monitoring. METHODS A systematic search was conducted on Embase and PubMed from database inception until 27 October 2022 to include randomised controlled trials that compared ICM with non-ICM methods of cardiac monitoring for post-stroke AF detection. This yielded 3 randomised controlled trials with a combined cohort of 1231 patients with a recent ischemic stroke. Individual patient data (IPD) was then reconstructed from Kaplan-Meier curves and analysed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1231 patients across all 3 studies for outcomes that could not be reconstructed using IPD. RESULTS One-stage meta-analysis demonstrated an increase in the hazard ratio (HR 6.01, 95% CI 3.40-10.60; p<0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. Aggregate data meta analysis revealed a significant increase in initiation of anticoagulation (OR 3.09, 95% CI 2.05 - 4.66; p<0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack or death were found. CONCLUSIONS In this meta-analysis, we found that the use of ICM increased the detection rate of post-stroke AF and the rate of anticoagulation initiation. However, this did not translate into a reduced incidence of recurrent ischemic stroke.
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Goh FQ, Sia CH, Chan MY, Yeo LL, Tan BY. What's the optimal duration of anticoagulation in patients with left ventricular thrombus? Expert Rev Cardiovasc Ther 2023; 21:947-961. [PMID: 37830297 DOI: 10.1080/14779072.2023.2270906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Left ventricular thrombus (LVT) occurs in acute myocardial infarction and in ischemic and non-ischemic cardiomyopathies. LVT may result in embolic stroke. Currently, the duration of anticoagulation for LVT is unclear. This is an important clinical question as prolonged anticoagulation is associated with increased bleeding risks, while premature discontinuation may result in embolic complications. AREAS COVERED There are no randomized trial data regarding anticoagulation duration for LVT. Guidelines and expert consensus recommend anticoagulation for 3-6 months with cessation of anticoagulation if interval imaging demonstrates thrombus resolution. Cardiac magnetic resonance imaging (CMR) is more sensitive and specific compared to echocardiography for LVT detection, and may be appropriate for high-risk patients. Prolonged anticoagulation may be considered in unresolved protuberant or mobile LVT, and in patients with resolved LVT but persistent depressed left ventricular ejection fraction and/or myocardial akinesia or dyskinesia. EXPERT OPINION CMR will likely be increasingly used for LVT surveillance to guide anticoagulation duration. Further research is needed to determine which patients with persistent LVT on CMR benefit from prolonged anticoagulation.
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Affiliation(s)
- Fang Qin Goh
- Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Y Chan
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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Sia CH, Ko J, Zheng H, Ho AFW, Foo D, Foo LL, Lim PZY, Liew BW, Chai P, Yeo TC, Yip JWL, Chua T, Chan MYY, Tan JWC, Bulluck H, Hausenloy DJ. Association of body mass index, metabolic health status and clinical outcomes in acute myocardial infarction patients: a national registry-based study. Front Cardiovasc Med 2023; 10:1142078. [PMID: 37435049 PMCID: PMC10331723 DOI: 10.3389/fcvm.2023.1142078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction Obesity is an important risk factor for acute myocardial infarction (AMI), but the interplay between metabolic health and obesity on AMI mortality has been controversial. In this study, we aimed to elucidate the risk of short- and long-term all-cause mortality by obesity and metabolic health in AMI patients using data from a multi-ethnic national AMI registry. Methods A total of 73,382 AMI patients from the national Singapore Myocardial Infarction Registry (SMIR) were included. These patients were classified into four groups based on the presence or absence of metabolic diseases, diabetes mellitus, hyperlipidaemia, and hypertension, and obesity: (1) metabolically-healthy-normal-weight (MHN); (2) metabolically-healthy-obese (MHO); (3) metabolically-unhealthy-normal-weight (MUN); and (4) metabolically-unhealthy-obese (MUO). Results MHO patients had reduced unadjusted risk of all-cause in-hospital, 30-day, 1-year, 2-year, and 5-year mortality following the initial MI event. However, after adjusting for potential confounders, the protective effect from MHO on post-AMI mortality was lost. Furthermore, there was no reduced risk of recurrent MI or stroke within 1-year from onset of AMI by the MHO status. However, the risk of 1-year mortality was higher in female and Malay AMI patients with MHO compared to MHN even after adjusting for confounders. Conclusion In AMI patients with or without metabolic diseases, the presence of obesity did not affect mortality. The exception to this finding were female and Malay MHO who had worse long-term AMI mortality outcomes when compared to MHN suggesting that the presence of obesity in female and Malay patients may confer worsened outcomes.
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Affiliation(s)
- Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Junsuk Ko
- MD Program, Duke-NUS Medical School, Singapore
| | - Huili Zheng
- Health Promotion Board, National Registry of Diseases Office, Singapore, Singapore
| | - Andrew Fu-Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore
- National Heart Research Institute Singapore, NationalHeart Centre Singapore, Singapore
- Pre-hospital and Emergency Care Research Centre, Health Services and Systems Research, Duke-NUS Medical School
| | - David Foo
- Tan Tock Seng Hospital, Singapore, Singapore
| | - Ling-Li Foo
- Health Promotion Board, National Registry of Diseases Office, Singapore, Singapore
| | | | | | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James W. L. Yip
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Terrance Chua
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Derek J. Hausenloy
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National Heart Research Institute Singapore, NationalHeart Centre Singapore, Singapore
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taiwan
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Li J, Lee ARYB, Tariq A, Lau G, Yau CE, Tan LL, Tyebally SM, Lee MX, Koo CY, Sia CH. Comparing Renin-Angiotensin-Aldosterone Blockade Regimens for Long-Term Chemotherapy-Related Cardiac Dysfunction: A Network Meta-Analysis. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07457-w. [PMID: 37314568 DOI: 10.1007/s10557-023-07457-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Cancer therapies including trastuzumab and anthracyclines are cardiotoxic and cause cardiac dysfunction. To prevent cardiotoxicity, pharmacological agents used in heart failure have been administered concomitantly with cardiotoxic cancer therapy, but few studies to date have performed a head-to-head comparison of these different agents. This systematic review and network meta-analysis of randomized-controlled trials aims to evaluate the efficacy of renin-angiotensin-aldosterone system (RAAS) blockers, namely angiotensin-converting enzyme inhibitors (ACE-Is), aldosterone receptor blockers (ARBs), and mineralocorticoid receptor antagonists (MRAs), in primary prevention against chemotherapy-related cardiac dysfunction in patients receiving anthracyclines and/or trastuzumab. METHODS A systematic search was performed in major web databases for studies from inception to 15 September 2022. A Bayesian network meta-analysis model was used to assess the relative effects of competing treatments on the primary outcomes of risk of significant decline in left ventricular ejection fraction (LVEF) and mean LVEF decline. Secondary outcomes included left ventricular diastolic function, global longitudinal strain, and cardiac biomarkers. This study is registered with PROSPERO, CRD42022357980. RESULTS AND CONCLUSION Nineteen studies reported the effects of 13 interventions (N = 1905 patients). Only enalapril (RR 0.05, 95% CI 0.00-0.20) was associated with reduced risk of patients developing significant decline in LVEF relative to placebo. Subgroup analysis showed that the beneficial effect of enalapril was driven by protection against anthracycline-associated toxicity. In addition, no RAAS-inhibiting agents showed efficacy in protection against treatment with both anthracycline and trastuzumab. The use of RAAS inhibition therapy did not conclusively impact on other markers of cardiac function, including left ventricular diastolic function and cardiac biomarkers.
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Affiliation(s)
- Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Areeba Tariq
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Grace Lau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Li Ling Tan
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore
| | - Sara Moiz Tyebally
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Matilda Xinwei Lee
- Department of Hematology-Oncology, National University Cancer Institute Singapore, Singapore, Singapore
| | - Chieh Yang Koo
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore.
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Toh KZX, Koh MY, Loh EDW, Kwok GYR, Teo YH, Teo YN, Goh CXY, Syn NLX, Ho AFW, Sia CH, Brouwer PA, Andersson T, Meyer L, Fiehler J, Bhogal P, Sharma VK, Tan BYQ, Yeo LLL. Distal medium vessel occlusions in acute ischaemic stroke - Stent retriever versus direct aspiration: A systematic review and meta-analysis. Eur Stroke J 2023; 8:434-447. [PMID: 37231692 PMCID: PMC10334182 DOI: 10.1177/23969873231151262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/28/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Acute ischaemic stroke due to distal medium vessel occlusion (AIS-DMVO) causes significant morbidity. Endovascular thrombectomy advancement has made treating AIS-DMVO with stent retrievers (SR) and aspiration catheters (AC) possible, however the optimal technique remains unknown. We performed a systematic review and meta-analysis to investigate the efficacy and safety of SR use compared to purely AC use in patients with AIS-DMVO. METHODS We systematically searched PubMed, Cochrane Library and EMBASE, from inception to 2nd September 2022, for studies comparing SR or primary combined (SR/PC) against AC in AIS-DMVO. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (modified Rankin Scale (mRS) 0-2 at 90 days), first pass effect (modified Thrombolysis in Cerebral Infarction scale (mTICI) 2c-3 or expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2c-3 at first pass), successful final recanalisation (mTICI or eTICI 2b-3), and excellent final recanalisation (mTICI or eTICI 2c-3). Safety outcomes were symptomatic intracranial haemorrhage (sICH) and 90-day mortality. RESULTS 12 cohort studies and 1 randomised-controlled trial were included, involving 1881 patients with 1274 receiving SR/PC and 607 receiving AC only. SR/PC achieved higher odds of functional independence (odds ratio (OR) 1.33, 95% confidence interval (CI) 1.06-1.67) and lower odds of mortality (OR 0.69, 95% CI 0.50-0.94) than AC. Odds of successful/excellent recanalisation and sICH were similar between both groups. Stratified to compare only SR and only AC, the use of only SR, achieved significantly higher odds of successful recanalisation as compared to only AC (OR 1.80, 95% CI 1.17-2.78). CONCLUSION There is potential for efficacy and safety benefits in SR/PC use as compared to AC only in AIS-DMVO. Further trials are necessary to validate the efficacy and safety of SR use in AIS-DMVO.
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Affiliation(s)
- Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Xin Yi Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Li Xun Syn
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Andrew Fu Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Program, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Patrick A Brouwer
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
| | | | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin YQ Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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Chee RCH, Lin NH, Ho JSY, Leow AST, Li TYW, Lee ECY, Chan MY, Kong WKF, Yeo TC, Chai P, Yip JWL, Poh KK, Sharma VK, Yeo LLL, Tan BYQ, Sia CH. Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis. J Cardiovasc Dev Dis 2023; 10:231. [PMID: 37367396 DOI: 10.3390/jcdd10060231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
(1) Background: Little is known about how left ventricular systolic dysfunction (LVSD) affects functional and clinical outcomes in acute ischemic stroke (AIS) patients undergoing thrombolysis; (2) Methods: A retrospective observational study conducted between 2006 and 2018 included 937 consecutive AIS patients undergoing thrombolysis. LVSD was defined as left ventricular ejection fraction (LVEF) < 50%. Univariate and multivariate binary logistic regression analysis was performed for demographic characteristics. Ordinal shift regression was used for functional modified Rankin Scale (mRS) outcome at 3 months. Survival analysis of mortality, heart failure (HF) admission, myocardial infarction (MI) and stroke/transient ischemic attack (TIA) was evaluated with a Cox-proportional hazards model; (3) Results: LVSD patients in comparison with LVEF ≥ 50% patients accounted for 190 and 747 patients, respectively. LVSD patients had more comorbidities including diabetes mellitus (100 (52.6%) vs. 280 (37.5%), p < 0.001), atrial fibrillation (69 (36.3%) vs. 212 (28.4%), p = 0.033), ischemic heart disease (130 (68.4%) vs. 145 (19.4%), p < 0.001) and HF (150 (78.9%) vs. 46 (6.2%), p < 0.001). LVSD was associated with worse functional mRS outcomes at 3 months (adjusted OR 1.41, 95% CI 1.03-1.92, p = 0.030). Survival analysis identified LVSD to significantly predict all-cause mortality (adjusted HR [aHR] 3.38, 95% CI 1.74-6.54, p < 0.001), subsequent HF admission (aHR 4.23, 95% CI 2.17-8.26, p < 0.001) and MI (aHR 2.49, 95% CI 1.44-4.32, p = 0.001). LVSD did not predict recurrent stroke/TIA (aHR 1.15, 95% CI 0.77-1.72, p = 0.496); (4) Conclusions: LVSD in AIS patients undergoing thrombolysis was associated with increased all-cause mortality, subsequent HF admission, subsequent MI and poorer functional outcomes, highlighting a need to optimize LVEF.
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Affiliation(s)
- Ryan C H Chee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Norman H Lin
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Jamie S Y Ho
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Aloysius S T Leow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Tony Y W Li
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Edward C Y Lee
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - James W L Yip
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
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Ngiam JN, Chew NWS, Sia CH, Kong WKF, Poh KK. Silent hypoxia: pulse oximetry and its relation to COVID-19 in Singapore. Singapore Med J 2023; 64:222-225. [PMID: 34581542 PMCID: PMC10144454 DOI: 10.11622/smedj.2021134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jinghao Nicholas Ngiam
- Division of Infectious Diseases, Department of Medicine, National University Health System, Singapore
| | | | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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40
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Goh FQ, Leow AST, Ho JSY, Tan BYQ, Yeo LLL, Sia CH. Effect of Anticoagulation Duration on Stroke Incidence in Asian Patients With Left Ventricular Thrombus. Am J Cardiol 2023; 191:141-143. [PMID: 36702665 DOI: 10.1016/j.amjcard.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Fang Qin Goh
- National University Hospital, National University Health System, Singapore, Singapore
| | - Aloysius S T Leow
- National University Hospital, National University Health System, Singapore, Singapore
| | - Jamie S Y Ho
- National University Hospital, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore, Singapore
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41
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Soh RYH, Evangelista LKM, Yeo TC, Sia CH. Right Ventricle Takotsubo Cardiomyopathy with Abnormal Echocardiographic Right Heart Haemodynamics. Acta Cardiol Sin 2023; 39:353-356. [PMID: 36911547 PMCID: PMC9999183 DOI: 10.6515/acs.202303_39(2).20221030a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 10/30/2022] [Indexed: 03/14/2023]
Affiliation(s)
| | | | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228
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42
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Yeo TC, Goh FQ, Teo YN, Sia CH. Approach to bradyarrhythmias: A proposed algorithm. Ann Acad Med Singap 2023. [DOI: 10.47102/annals-acadmedsg.2022411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Bradyarrhythmias are commonly encountered in clinical practice. While there are several electrocardiographic criteria and algorithms for tachyarrhythmias, there is no algorithm for bradyarrhythmias to the best of our knowledge. In this article, we propose a diagnostic algorithm that uses simple concepts: (1) the presence or absence of P waves, (2) the relationship between the number of P waves and QRS complexes, and (3) the regularity of time intervals (PP, PR and RR intervals). We believe this straightforward, stepwise method provides a structured and thorough approach to the wide differential diagnosis of bradyarrhythmias, and in doing so, reduces misdiagnosis and mismanagement.
Keywords: Arrhythmia, bradyarrhythmia, bradycardia, cardiology, electrocardiography
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Affiliation(s)
| | - Fang Qin Goh
- National University Hospital, National University Health System, Singapore
| | - Yao Neng Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- National University Heart Centre Singapore, Singapore
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43
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Ho AFW, Ting PZY, Ho JSY, Fook-Chong S, Shahidah N, Pek PP, Liu N, Teoh S, Sia CH, Lim DYZ, Lim SL, Wong TH, Ong MEH. The Effect of Building-Level Socioeconomic Status on Bystander Cardiopulmonary Resuscitation: A Retrospective Cohort Study. PREHOSP EMERG CARE 2023; 27:205-212. [PMID: 35363103 DOI: 10.1080/10903127.2022.2061094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Understanding the social determinants of bystander cardiopulmonary resuscitation (CPR) receipt can inform the design of public health interventions to increase bystander CPR. The association of socioeconomic status with bystander CPR is generally poorly understood. We evaluated the relationship between socioeconomic status and bystander CPR in cases of out-of-hospital cardiac arrest (OHCA). METHODS This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry between 2010 and 2018. We categorized patients into low, medium, and high Singapore Housing Index (SHI) levels-a building-level index of socioeconomic status. The primary outcome was receipt of bystander CPR. The secondary outcomes were prehospital return of spontaneous circulation and survival to discharge. RESULTS A total of 12,730 OHCA cases were included, the median age was 71 years, and 58.9% were male. The bystander CPR rate was 56.7%. Compared to patients in the low SHI category, those in the medium and high SHI categories were more likely to receive bystander CPR (medium SHI: adjusted odds ratio [aOR] 1.48, 95% CI 1.30-1.69; high SHI: aOR 1.93, 95% CI 1.67-2.24). High SHI patients had higher survival compared to low SHI patients on unadjusted analysis (OR 1.79, 95% CI 1.08-2.96), but not adjusted analysis (adjusted for age, sex, race, witness status, arrest time, past medical history of cancer, and first arrest rhythm). When comparing high with low SHI, females had larger increases in bystander CPR rates than males. CONCLUSIONS Lower building-level socioeconomic status was independently associated with lower rate of bystander CPR, and females were more susceptible to the effect of low socioeconomic status on lower rate of bystander CPR.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Prehospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | | | - Jamie Sin Ying Ho
- Academic Foundation Programme, Royal Free London NHS Foundation Trust, London, UK
| | - Stephanie Fook-Chong
- Prehospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Pin Pin Pek
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Nan Liu
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Seth Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Health Services Research Unit, Medical Board, Singapore General Hospital, Singapore, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ting Hway Wong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.,Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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44
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Teo YN, Sia CH, Tan BYQ, Mingxue J, Chan B, Sharma VK, Makmur A, Gopinathan A, Yang C, Loh S, Ng S, Ong SJ, Teoh HL, Rathakrishnan R, Andersson T, Arnberg F, Gontu VK, Lee TH, Maus V, Meyer L, Bhogal P, Spooner O, Li TY, Soh RY, Yeo LL. Combined balloon guide catheter, aspiration catheter, and stent retriever technique versus balloon guide catheter and stent retriever alone technique: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:127-132. [PMID: 35101960 DOI: 10.1136/neurintsurg-2021-018406] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/31/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND The use of a combination of balloon guide catheter (BGC), aspiration catheter, and stent retriever in acute ischemic stroke thrombectomy has not been shown to be better than a stent retriever and BGC alone, but this may be due to a lack of power in these studies. We therefore performed a meta-analysis on this subject. METHODS A systematic literature search was performed on PubMed, Scopus, Embase/Ovid, and the Cochrane Library from inception to October 20, 2021. Our primary outcomes were the rate of successful final reperfusion (Treatment in Cerebral Ischemia (TICI) 2c-3) and first pass effect (FPE, defined as TICI 2c-3 in a single pass). Secondary outcomes were 3 month functional independence (modified Rankin Scale score of 0-2), mortality, procedural complications, embolic complications, and symptomatic intracranial hemorrhage (SICH). A meta-analysis was performed using RevMan 5,4, and heterogeneity was assessed using the I2 test. RESULTS Of 1629 studies identified, five articles with 2091 patients were included. For the primary outcomes, FPE (44.9% vs 45.4%, OR 1.04 (95% CI 0.90 to 1.22), I2=57%) or final successful reperfusion (64.5% vs 68.6%, OR 0.98 (95% CI 0.81% to 1.20%), I2=85%) was similar between the combination technique and stent retriever only groups. However, the combination technique had significantly less rescue treatment (18.8% vs 26.9%; OR 0.70 (95% CI 0.54 to 0.91), I2=0%). This did not translate into significant differences in secondary outcomes in functional outcomes, mortality, emboli, complications, or SICH. CONCLUSION There was no significant difference in successful reperfusion and FPE between the combined techniques and the stent retriever and BGC alone groups. Neither was there any difference in functional outcomes, complications, or mortality.
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Affiliation(s)
| | - Ching-Hui Sia
- National University of Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore
| | - Benjamin Y Q Tan
- National University of Singapore, Singapore .,National University Health System, Singapore
| | - Jing Mingxue
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Bernard Chan
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Vijay Kumar Sharma
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Andrew Makmur
- National University of Singapore, Singapore.,Diagnostic Imaging, National University Hospital, Singapore
| | - Anil Gopinathan
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Cunli Yang
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Stanley Loh
- National University of Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore
| | - Sheldon Ng
- National University of Singapore, Singapore.,Diagnostic Imaging, National University Health System, Singapore
| | - Shao Jin Ong
- National University of Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore
| | - Hock-Luen Teoh
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Rahul Rathakrishnan
- National University of Singapore, Singapore.,National University Health System, Singapore
| | - Tommy Andersson
- Departments of Radiology and Neurology, AZ Groeninge, Kortrijk, Belgium.,Department of Neuroradiology and Department of Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | | | | | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital Linkou Branch, Gueishan, Taoyuan, Taiwan
| | - Volker Maus
- Knappschaftskrankenhaus Bochum Langendeer, Bochum, Germany
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | | | - Oliver Spooner
- Department of Interventional Neuroradiology, Royal London Hospital, London, London, UK
| | - Tony Yw Li
- National University of Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore
| | - Rodney Yh Soh
- National University of Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore
| | - Leonard Ll Yeo
- National University of Singapore, Singapore.,National University Health System, Singapore
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45
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Ngiam JN, Chhabra S, Goh W, Sim MY, Chew NWS, Sia CH, Cross GB, Tambyah PA. Continued demographic shifts in hospitalised patients with COVID-19 from migrant workers to a vulnerable and more elderly local population at risk of severe disease. Int J Infect Dis 2023; 127:77-84. [PMID: 36509335 PMCID: PMC9733964 DOI: 10.1016/j.ijid.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES In the early months of the COVID-19 pandemic in Singapore, the vast majority of infected persons were migrant workers living in dormitories who had few medical comorbidities. In 2021, with the Delta and Omicron waves, this shifted to the more vulnerable, elderly population within the local community. We examined evolving trends among the hospitalised cases of COVID-19. METHODS All patients with polymerase chain reaction-positive SARS-CoV-2 admitted from February 2020 to October 2021 were included and subsequently stratified by their year of admission (2020 or 2021). We compared the baseline clinical characteristics, clinical course, and outcomes. RESULTS A majority of cases were seen in 2020 (n = 1359), compared with 2021 (n = 422), due to the large outbreaks in migrant worker dormitories. Nevertheless, the greater proportion of locally transmitted cases outside of dormitories in 2021 (78.7% vs 12.3%) meant a significantly older population with more medical comorbidities had COVID-19. This led to an observably higher proportion of patients with severe disease presenting with raised inflammatory markers, need for therapeutics, supplemental oxygenation, and higher mortality. CONCLUSION Changing demographics and the characteristics of the exposed populations are associated with distinct differences in clinical presentation and outcomes. Older age remained consistently associated with adverse outcomes.
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Affiliation(s)
- Jinghao Nicholas Ngiam
- Department of Infectious Diseases, National University Health System, Singapore,Corresponding author: Fax: (65) 67794112, Tel: (65) 67795555
| | - Srishti Chhabra
- Department of Medicine, National University Health System, Singapore
| | - Wilson Goh
- Department of Medicine, National University Health System, Singapore
| | - Meng Ying Sim
- Department of Medicine, National University Health System, Singapore
| | - Nicholas WS Chew
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gail Brenda Cross
- Department of Infectious Diseases, National University Health System, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul Anantharajah Tambyah
- Department of Cardiology, National University Heart Centre Singapore, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
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Teoh SE, Tan EWX, Teo YN, Basker G, Teo YH, Chai P, Wong RCC, Yip JWL, Kuntjoro I, Lim YH, Poh KK, Yeo TC, Kong WKF, Sia CH. Effects of medical therapy, transcatheter intervention, and surgery on outcomes of patients with functional mitral regurgitation: a systematic review and network meta-analysis. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): Ching-Hui Sia was supported by the National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Fellowship Scheme.
Background
Functional mitral regurgitation (FMR) is the most common valvular heart disease worldwide. Despite recent major trials, the relative efficacy between medical therapy, transcatheter intervention, and surgery for the treatment of FMR remains poorly understood.
Purpose
We performed a systematic review and network meta-analysis of all published randomised controlled trials (RCTs) and observational studies to compare the efficacy between medical therapy, transcatheter intervention, and surgery on the clinical outcomes of patients with FMR.
Methods
Four electronic databases (PubMed, EMBASE, SCOPUS, and the Cochrane Library) were searched from inception to March 13, 2022, for studies reporting clinical outcomes in patients with FMR and comparing the efficacy between either medical therapy, transcatheter intervention, or surgery. Frequentist network meta-analysis models were utilised to summarise the studies. This study was registered in the International Prospective Register of Systematic Reviews.
Results
10 articles were included in the analysis, comprising a combined cohort of 1,981 patients. Network meta-analysis demonstrated that compared to medical therapy, transcatheter intervention achieved a lower relative risk in the composites of all-cause mortality (risk ratio [RR]: 0.43; 95% confidence interval [CI] 0.22-0.82) and mitral regurgitation (MR) severity grade ≥3+ (RR: 0.06; 95% CI 0.01-0.42). Compared to surgery, transcatheter intervention achieved a lower relative risk in the composites of cardiovascular death (RR: 0.36; 95% CI 0.17-0.75) and MR severity grade ≥3+ (RR: 0.25; 95% CI 0.09-0.70) and higher relative risk in the composite of heart failure hospitalisation (RR: 2.94; 95% CI 1.26-6.82). Compared to medical therapy, surgery achieved a higher relative risk in the composite of cardiovascular death (RR: 2.54; 95% CI 1.18-5.47) and lower relative risks in the composites of all-cause mortality (RR: 0.56; 95% CI 0.34-0.91) and heart failure hospitalisation (RR: 0.28; 95% CI 0.13-0.61).
Conclusion
Medical therapy, transcatheter intervention, and surgery in patients with FMR displayed differing effects on the various clinical outcomes. Further head-to-head trials are required to better understand the optimal treatment modality in this population.
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Affiliation(s)
- S E Teoh
- National University of Singapore, Yong Loo Lin School of Medicine , Singapore , Singapore
| | - E W X Tan
- National University of Singapore, Yong Loo Lin School of Medicine , Singapore , Singapore
| | - Y N Teo
- National University of Singapore, Yong Loo Lin School of Medicine , Singapore , Singapore
| | - G Basker
- National University of Singapore, Yong Loo Lin School of Medicine , Singapore , Singapore
| | - Y H Teo
- National University of Singapore, Department of Medicine , Singapore , Singapore
| | - P Chai
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - R C C Wong
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - J W L Yip
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - I Kuntjoro
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - Y H Lim
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - K K Poh
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - T C Yeo
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - W K F Kong
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - C H Sia
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
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47
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Low CHX, Ong JSP, Li TYW, Ho JSY, Sharma VK, Tan BYQ, Seow SC, Yeo LLL, Yeo TC, Chai P, Chan MYY, Sia CH. Sex-based comparisons of clinical characteristics and outcomes of patients with embolic stroke of undetermined source with implantable loop recorders. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Embolic strokes of undetermined source (ESUS) constitute a significant proportion of all ischemic strokes, but sex-based comparisons of clinical characteristics and outcomes of ESUS patients have not been well explored. As such, we aimed to examine how sex influences outcomes of ESUS patients.
Methods
Retrospective cohort study performed on consecutive ESUS patients with an implanted ILR between December 2013 to September 2021. We obtained information on the patients’ characteristics, treatments, and outcomes from the electronic medical records. Cox regression was used to investigate whether sex was independently associated with outcomes.
Results
There were 176 patients included in this study. The mean duration of follow-up was 1254 ± 724 days. Mean age was 60.8 ± 12.0 and 47 (26.7%) of patients were female. On univariable Cox regression analysis for subsequent atrial fibrillation (AF) on implantable loop recorder (ILR), patients with subsequent AF on ILR were more likely to be female (HR 2.19, 95% CI 1.04–4.63, p = 0.040), older (HR 1.07, 95% CI 1.03–1.12, p = 0.001), have a lower glomerular filtration rate (eGFR) (HR 0.98, 95% CI 0.97– 0.99, p = 0.004), and have previous percutaneous coronary intervention (PCI) (HR 2.60, 95% CI 1.05–6.46, p = 0.039). On multivariable Cox regression, after adjustment for age, eGFR and previous PCI status, female sex remained independently associated with the development of subsequent AF on ILR. Female sex was not associated with other outcomes including mortality, subsequent acute myocardial infarction, stroke/transient ischemic attack and heart failure.
Conclusions
In this cohort of ESUS patients with ILR implantation, female sex was independently associated with a higher risk of development of AF on ILR. However, female sex was not a predictor of mortality, subsequent acute myocardial infarction, stroke/transient ischemic attack and heart failure.
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Affiliation(s)
- C H X Low
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - J S P Ong
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - T Y W Li
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - J S Y Ho
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - V K Sharma
- National University Hospital, Division of Neurology, Department of Medicine , Singapore , Singapore
| | - B Y Q Tan
- National University Hospital, Division of Neurology, Department of Medicine , Singapore , Singapore
| | - S C Seow
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - L L L Yeo
- National University Hospital, Division of Neurology, Department of Medicine , Singapore , Singapore
| | - T C Yeo
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - P Chai
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - M Y Y Chan
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - C H Sia
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
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Sari NY, Li TYW, Yeo S, Ngiam NJH, Lee CH, Evangelista LKM, Lee ECY, Yeo TC, Yip JWL, Poh KK, Kong WKF, Lin WQ, Lim YC, Sia CH, Wong RCC. Association of left atrial ejection fraction and cardiovascular outcomes in Asian patients with hypertrophic cardiomyopathy. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Fellowship Scheme
Background
The optimal method of risk stratification of hypertrophic cardiomyopathy (HCM) patients, especially in the Asian population, is unknown. Left atrial ejection fraction (LAEF) is an emerging risk marker for cardiovascular outcomes. This study aimed to investigate whether LAEF was associated with cardiovascular outcomes in Asian patients with HCM.
Methods
This was a retrospective cohort study performed in a tertiary academic centre involving 291 consecutive patients diagnosed with HCM between 2010 and 2017. We collected the relevant clinical characteristics of these patients and retrospectively analysed the index transthoracic echocardiograms for novel left atrial indices including LAEF. We obtained the maximum (LAVmax) and minimum left atrial volumes (LAVmin) using the biplane method of disks in apical 4- and 2-chamber views. LAEF was derived by dividing the difference between LAVmax and LAVmin by LAVmax. We assessed the patients for outcomes of (1) heart failure requiring admission, and (2) a composite of adverse outcomes including all-cause mortality, ventricular tachycardia / ventricular fibrillation (VT/VF) events, appropriate device therapy if an implantable cardioverter defibrillator (ICD) was implanted, stroke and heart failure hospitalization.
Results
The patients had a mean age of 59.0 ± 16.7 years-old at diagnosis and had a male preponderance (71.2%). The most common comorbidities were hypertension, diabetes mellitus and ischemic heart disease. On univariable logistic regression analysis, maximum and minimum left atrial volume index (LAVI) as well as LAEF showed a significant association with heart failure and the predefined composite outcome. On Cox regression analysis adjusting for variables of age, sex, left ventricular ejection fraction (LVEF), left ventricular maximal wall thickness >30mm, significant left ventricular outflow tract (LVOT) gradient of > 30mmHg and more than moderate mitral regurgitation, maximum and minimum LAVI as well as LAEF retained an association with heart failure admission but only minimum LAVI and LAEF were associated with the composite outcome [(OR 0.019, 95% CI 0.02-0.230, p=0.002), (OR 0.226, 95% CI 0.053-0.960, p=0.044), (OR 1.030, 95% CI 1.016-1.045, p<0.001), and (OR 1.016, 95% CI 1.005-1.026, p=0.004) respectively].
Conclusion
LAEF was an independently associated with congestive heart failure as well as a composite of adverse outcomes in Asian patients with HCM.
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Affiliation(s)
- N Y Sari
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - T Y W Li
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - S Yeo
- National University of Singapore, Cardiology , Singapore , Singapore
| | - N J H Ngiam
- National University Health System, Medicine , Singapore , Singapore
| | - C H Lee
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - L K M Evangelista
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - E C Y Lee
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - T C Yeo
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - J W L Yip
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - K K Poh
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - W K F Kong
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - W Q Lin
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - Y C Lim
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - C H Sia
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - R C C Wong
- National University Heart Centre, Cardiology , Singapore , Singapore
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Lim ICZY, Teo YH, Fang JT, Teo YN, Ho JSY, Lee YQ, Chen X, Ong KHX, Leow AST, Ho AFW, Lim Y, Low TT, Kuntjoro I, Yeo LLL, Sia CH, Sharma VK, Tan BYQ. Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management. J Clin Med 2023; 12:jcm12030941. [PMID: 36769589 PMCID: PMC9917737 DOI: 10.3390/jcm12030941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke. METHODS Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF. RESULTS The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043]. CONCLUSIONS In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.
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Affiliation(s)
- Isis Claire Z. Y. Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Jamie S. Y. Ho
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Yong Qin Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Xintong Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Kathleen Hui-Xin Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Aloysius S. T. Leow
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
- Pre-Hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
- Centre for Population Health Research and Implementation, Singhealth Regional Health System, Singapore 168753, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Ting Ting Low
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Leonard L. L. Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Vijay K. Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
- Correspondence: ; Tel.: +65-9138-9555; Fax: +65-6908-2222
| | - Benjamin Y. Q. Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
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Zheng Y, Li TYW, Goh FQ, Ong JSP, Low CHX, Ho JSY, Chan MY, Seow SC, Kong WKF, Poh KK, Wong RCC, Yeo TC, Yeo LLL, Tan BYQ, Sia CH. Abnormal left atrial strain is associated with eventual diagnosis of atrial fibrillation in patients with embolic stroke of undetermined source. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Patients with embolic stroke of undetermined source (ESUS) have no immediate attributable cause despite initial evaluation. Occult paroxysmal atrial fibrillation (pAF) diagnosed on prolonged electrocardiographic monitoring may be subsequently found in 20% of patients initially classified as ESUS [1]. Anatomic and functional alterations of left atrium (LA) are known to predict pAF in the general population [2]. Recent studies have suggested that LA dysfunction is linked to the risk of development of pAF in stroke patients and may precede LA enlargement [1]. LA strain analysis may be helpful to predict the development of pAF as it can detect subclinical functional impairment [2]. The aim of this study was to analyse whether LA strain can be a marker for the development of new-onset AF in patients with ESUS and sinus rhythm.
Methods
Our single-centre observational cohort study examined 157 patients hospitalised for ESUS in our tertiary hospital between October 2014 and October 2017 who underwent AF monitoring with an implantable loop recorder (ILR). These patients were followed up for occurrence of new-onset pAF and recurrence of ischaemic stroke. All patients underwent transthoracic echocardiography (TTE) during index hospitalisation as part of the workup for ESUS. Echocardiographic images were obtained and analysed post-hoc for two-dimensional (2D) speckle tracing deformation parameters. These LA strain parameters were analysed against the primary outcome of AF detection and secondary outcome of recurrent ischaemic stroke.
Results
A total of 157 ESUS patients, with a mean age of 61.0 (±11.6) years, were followed up for a median duration of 3.5 (interquartile range 3.29) years. ILR monitoring detected AF in 27 patients (17.2%). 27 patients developed recurrent ischaemic strokes. Of the 27 patients with newly diagnosed AF on ILR, 24 (88.9%) were commenced on oral anticoagulation; the remaining 3 patients were not on anticoagulation due to high bleeding risk and frailty.
Patients who had newly diagnosed AF had more impaired left atrial reservoir strain (LASr; 23.5% ± 10.3%, P = 0.042) and left atrial conduit strain (LAScd; -10.5% ± 5.3%, P = 0.003) compared with patients who remained in sinus rhythm. Multivariable logistic regression analysis adjusting for age, sex, hypertension, hyperlipidaemia, diabetes mellitus and left ventricular ejection fraction (LVEF) showed that LAScd was associated with occult AF (adjusted odds ratio [aOR] = 1.110, 95% CI, 1.019-1.209, P = 0.017) and the composite outcome of AF and recurrent ischaemic stroke (OR = 1.069, 95% CI, 1.014-1.138, P = 0.038). Abnormal LAScd was significantly associated with occult AF even when stratified by normal LA volume index (LAVI) (OR = 2.672, 95% CI, 1.035-8.548, P = 0.048) and high LAVI (OR = 1.713, 95% CI, 1.023-2.869, P = 0.041).
Conclusion
Impaired left atrial strain was associated with occult AF detection in patients with ESUS undergoing ILR monitoring.
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Affiliation(s)
- Y Zheng
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - T Y W Li
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - F Q Goh
- National University Health System, Medicine , Singapore , Singapore
| | - J S P Ong
- National University of Singapore, Medicine , Singapore , Singapore
| | - C H X Low
- National University of Singapore, Medicine , Singapore , Singapore
| | - J S Y Ho
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - M Y Chan
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - S C Seow
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - W K F Kong
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - K K Poh
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - R C C Wong
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - T C Yeo
- National University Heart Centre, Cardiology , Singapore , Singapore
| | - L L L Yeo
- National University Health System, Medicine , Singapore , Singapore
| | - B Y Q Tan
- National University Health System, Medicine , Singapore , Singapore
| | - C H Sia
- National University Heart Centre, Cardiology , Singapore , Singapore
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