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Bhatty A, Wilkinson C, Batra G, Alfredsson J, Erlinge D, Ferreira J, Guðmundsdóttir IJ, Hrafnkelsdóttir ÞJ, Ingimarsdóttir IJ, Irs A, Járai Z, Jánosi A, Popescu BA, Santos M, Vasko P, Vinereanu D, Yap J, Maggioni AP, Wallentin L, Casadei B, Gale CP. Cohort Profile: the European Unified Registries On Heart care Evaluation and Randomised Trials (EuroHeart) - Acute Coronary Syndrome and Percutaneous Coronary Intervention. Eur Heart J Qual Care Clin Outcomes 2024:qcae025. [PMID: 38609345 DOI: 10.1093/ehjqcco/qcae025] [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: 04/14/2024]
Abstract
AIMS The European Unified Registries On Heart care Evaluation And Randomized Trials (EuroHeart) aims to improve the quality of care and clinical outcomes for patients with cardiovascular disease. The collaboration of acute coronary syndrome/percutaneous coronary intervention (ACS/PCI) registries is operational in seven vanguard European Society of Cardiology member countries. METHODS AND RESULTS Adults admitted to hospitals with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are included, and individual patient-level data collected and aligned according to the internationally agreed EuroHeart data standards for ACS/PCI. The registries provide up to 155 variables spanning patient demographics and clinical characteristics, in-hospital care, in-hospital outcomes, and discharge medications. After performing statistical analyses on patient data, participating countries transfer aggregated data to EuroHeart for international reporting.Between 1st January 2022 and 31st December 2022, 40 021 admissions (STEMI 46.7%, NSTEMI 53.3%) were recorded from 192 hospitals in the seven vanguard countries: Estonia, Hungary, Iceland, Portugal, Romania, Singapore, and Sweden. The mean age for the cohort was 67.9 (standard deviation 12.6) years, and it included 12 628 (31.6%) women. CONCLUSION The EuroHeart collaboration of ACS/PCI registries prospectively collects and analyses individual data for ACS and PCI at a national level, after which aggregated results are transferred to the EuroHeart Data Science Centre. The collaboration will expand to other countries and provide continuous insights into the provision of clinical care and outcomes for patients with ACS and undergoing PCI. It will serve as a unique international platform for quality improvement, observational research, and registry-based clinical trials.
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Affiliation(s)
- Asad Bhatty
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Chris Wilkinson
- Hull York Medical School, University of York, York, UK
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | | | | | - Jorge Ferreira
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Portugal
| | | | | | - Inga Jóna Ingimarsdóttir
- Department of Cardiology, Landspitali University Hospital, Reykjavik, Iceland
- Department of Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Alar Irs
- Tartu University Hospital, Estonia
| | - Zoltán Járai
- South Buda Center Hospital, Szent Imre Teaching Hospital, Hungary
| | - András Jánosi
- György Gottsegen National Cardiovascular Institute, Hungary
| | - Bogdan A Popescu
- University of Medicine and Pharmacy Carol Davila, Emergency Institute for Cardiovascular Diseases Prof Dr C C Iliescu, Bucharest, Romania
| | | | - Peter Vasko
- Linköping University Hospital, Linköping, Sweden
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Emergency Institute for Cardiovascular Diseases Prof Dr C C Iliescu, Bucharest, Romania
- University and Emergency Hospital, Bucharest, Romania
| | | | - Aldo P Maggioni
- ANMCO Research Centre, Heart Care Foundation, 50121 Florence, Italy
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Barabara Casadei
- Division of Cardiovascular Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Uy FM, Vaswani A, Tay KH, Lim ST, Yap J. Transcatheter closure of a coronary artery to pulmonary artery fistula with two sequential giant aneurysms. J Invasive Cardiol 2024. [PMID: 38471152 DOI: 10.25270/jic/24.00024] [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] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
A 73-year-old female presented with exertional dyspnea and was found to have a coronary artery to pulmonary artery fistula with 2 sequential giant aneurysms. Her chest radiograph showed a mass above the cardiac silhouette.
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Affiliation(s)
| | | | - Kiang Hiong Tay
- Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Soo Teik Lim
- National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore.
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3
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Wang ZS, Yap J, Koh YLE, Chia SY, Nivedita N, Ang TWA, Goh SCP, Lee CS, Tan LLJ, Ooi CW, Seow M, Yeo KK, Chua SJT, Tan NC. Correction to: Predicting Coronary Artery Disease in Primary Care: Development and Validation of a Diagnostic Risk Score for Major Ethnic Groups in Southeast Asia. J Gen Intern Med 2024:10.1007/s11606-024-08684-z. [PMID: 38383944 DOI: 10.1007/s11606-024-08684-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Zhen Sinead Wang
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore.
- Duke-NUS Medical School, Singapore, Republic of Singapore.
| | - Jonathan Yap
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | | | - Shaw Yang Chia
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | - N Nivedita
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Teck Wee Andrew Ang
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Soo Chye Paul Goh
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Cia Sin Lee
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | | | - Chai Wah Ooi
- National Healthcare Group Polyclinics - Geylang Branch, Singapore, Republic of Singapore
| | - Matthew Seow
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Khung Keong Yeo
- Duke-NUS Medical School, Singapore, Republic of Singapore
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | - Siang Jin Terrance Chua
- Duke-NUS Medical School, Singapore, Republic of Singapore
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
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4
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Tham MY, Chan CL, Toh D, Poh J, Lim A, Soh S, Peck LF, Foo B, Ng A, Ng P, Ang PS, Dorajoo S, Teo D, Lim TW, Lim YT, Choo J, Ding ZP, Yeo KK, Yap J, Tan HX. An updated analysis on myocarditis and pericarditis cases reported following mRNA SARS-CoV-2 vaccination in Singapore. Singapore Med J 2024:00077293-990000000-00090. [PMID: 38363732 DOI: 10.4103/singaporemedj.smj-2023-089] [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: 04/14/2023] [Accepted: 09/19/2023] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Messenger ribonucleic acid (mRNA) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines have been associated with myocarditis/pericarditis, especially in young males. We evaluated the risk of myocarditis/pericarditis following mRNA vaccines by brand, age, sex and dose number in Singapore. METHODS Adverse event reports of myocarditis/pericarditis following mRNA vaccines received by the Health Sciences Authority from 30 December 2020 to 25 July 2022 were included, with a data lock on 30 September 2022. Case adjudication was done by an independent panel of cardiologists using the US Centers for Disease Control and Prevention case definition. Reporting rates were compared with expected rates using historical data from 2018 to 2020. RESULTS Of the 152 adjudicated cases, males comprised 75.0%. The median age was 30 years. Most cases occurred after Dose 2 (49.3%). The median time to onset was 2 days. Reporting rates were highest in males aged 12-17 years for both primary series (11.5 [95% confidence interval [CI] 6.7-18.4] per 100,000 doses, post-Dose 2) and following booster doses (7.1 [95% CI 3.0-13.9] per 100,000 doses). In children aged 5-11 years, myocarditis remained very rare (0.2 per 100,000 doses). The reporting rates for Booster 1 were generally similar or lower than those for Dose 2. CONCLUSIONS The risk of myocarditis/pericarditis with mRNA vaccines was highest in adolescent males following Dose 2, and this was higher than historically observed background rates. Most cases were clinically mild. The risk of myocarditis should be weighed against the benefits of receiving an mRNA vaccine, keeping in mind that SARS-CoV-2 infections carry substantial risks of myocarditis/pericarditis, as well as the evolving landscape of the disease.
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Affiliation(s)
- Mun Yee Tham
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Cheng Leng Chan
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Dorothy Toh
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Jalene Poh
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Adena Lim
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Sally Soh
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Li Fung Peck
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Belinda Foo
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Amelia Ng
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Patricia Ng
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Pei San Ang
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Sreemanee Dorajoo
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Desmond Teo
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, Singapore
| | | | - Jonathan Choo
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Zee Pin Ding
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Hui Xing Tan
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
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Tan N, Fei G, Rizwan Amanullah M, Lim ST, Abdul Aziz Z, Govindasamy S, Chao VTT, Ewe SH, Ho KW, Yap J. Safety and efficacy of cerebral embolic protection in transcatheter aortic valve implantation: an updated meta-analysis. AsiaIntervention 2024; 10:51-59. [PMID: 38425806 PMCID: PMC10900717 DOI: 10.4244/aij-d-23-00022] [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] [Received: 04/13/2023] [Accepted: 08/23/2023] [Indexed: 03/02/2024]
Abstract
Background The use of cerebral embolic protection devices during transcatheter aortic valve implantation (TAVI) reveals conflicting data. Aims This updated meta-analysis aims to evaluate the efficacy and safety of the SENTINEL Cerebral Protection System. Methods A literature search for relevant studies up to September 2022 was performed. Study outcomes were divided based on time period - overall (up to 30 days) and short (≤7 days). The outcomes studied include stroke (disabling, non-disabling), mortality, neuroimaging findings, transient ischaemic attack, acute kidney injury and major vascular and bleeding complications. Results A total of 15 studies involving 294,134 patients were included. Regarding overall outcomes, significant reductions were noted for mortality (odds ratio [OR] 0.60, 95% confidence interval [CI]: 0.41-0.88; p=0.008), all stroke (OR 0.64, 95% CI: 0.46-0.88; p=0.006) and disabling stroke (OR 0.42, 95% CI: 0.23-0.74; p=0.003) using the SENTINEL device. No significant differences were noted for other outcomes. There was significant heterogeneity across the studies for mortality (p=0.013) and all stroke (p=0.003). Including only randomised data (n=4), there was only significant reduction in the incidence of disabling stroke (OR 0.39, 95% CI: 0.17-0.89; p=0.026) in the SENTINEL group. In studies reporting ≤7-day outcomes (n=8), use of the SENTINEL device demonstrated significantly lower rates of all stroke (p<0.001), disabling stroke (p<0.001) and major bleeding complications (p=0.02). No differences in neuroimaging outcomes were noted. Conclusions In this updated meta-analysis, use of the SENTINEL Cerebral Protection System was associated with lower rates of mortality, all stroke and disabling stroke, although significant heterogeneity was noted for mortality and all stroke. Including exclusively randomised data, there was only significant reduction in the incidence of disabling stroke. No significant adverse outcomes with device use were noted.
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Affiliation(s)
- Nicholas Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Gao Fei
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Soo Teik Lim
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Zameer Abdul Aziz
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Sivaraj Govindasamy
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | | | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
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6
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Fong KY, Low CHX, Chan YH, Ho KW, Keh YS, Chin CT, Chin CY, Fam JM, Wong N, Idu M, Wong ASL, Lim ST, Koh TH, Tan JWC, Yeo KK, Yap J. Role of Invasive Strategy for Non-ST-Elevation Myocardial Infarction in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:369-378. [PMID: 37639763 DOI: 10.1016/j.amjcard.2023.07.178] [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: 07/03/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Patients with chronic kidney disease (CKD) have traditionally been excluded from randomized trials. We aimed to compare percutaneous coronary intervention versus conservative management, and early intervention (EI; within 24 hours of admission) versus delayed intervention (DI; after 24 to 72 hours of admission) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and concomitant CKD. An electronic literature search was performed to search for studies comparing invasive management to conservative management or EI versus DI in patients with NSTEMI with CKD. The primary outcome was all-cause mortality; secondary outcomes were acute kidney injury (AKI) or dialysis, major bleeding, and recurrent MI. Hazard ratios (HRs) for the primary outcome and odds ratios for secondary outcomes were pooled in random-effects meta-analyses. Eleven studies (140,544 patients) were analyzed. Invasive management was associated with lower mortality than conservative management (HR 0.62, 95% confidence interval 0.57 to 0.67, p <0.001, I2 = 47%), with consistent benefit across all CKD stages, except CKD 5. There was no significant mortality difference between EI and DI, but subgroup analyses showed significant benefit for EI in stage 1 to 2 CKD (HR 0.75, 95% confidence interval 0.58 to 0.97, p = 0.03, I2 = 0%), with no significant difference in stage 3 and 4 to 5 CKD. Invasive strategy was associated with higher odds of AKI or dialysis and major bleeding, but lower odds of recurrent MI compared with conservative management. In conclusion, in patients with NSTEMI and CKD, an invasive strategy is associated with significant mortality benefit over conservative management in most patients with CKD, but at the expense of higher risk of AKI and bleeding. EI appears to benefit those with early stages of CKD. Trial Registration: PROSPERO CRD42023405491.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chloe Hui Xuan Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Yann Shan Keh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Chee Yang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jiang Ming Fam
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Ningyan Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Muhammad Idu
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Aaron Sung Lung Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Soo Teik Lim
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Tian Hai Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jack Wei Chieh Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore.
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Sahlén AO, Jiang H, Lau YH, Cuenza L, Cader FA, Al-Omary M, Surunchupakorn P, Ho KH, Sung J, Lee D, Honda S, Tan Wei Chieh J, Yap J. Direct Oral Anticoagulation Versus Warfarin in Left Ventricular Thrombus: Pooled Analysis of Randomized Controlled Trials. J Clin Pharmacol 2023; 63:1101-1107. [PMID: 37139934 DOI: 10.1002/jcph.2267] [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: 03/19/2023] [Accepted: 05/02/2023] [Indexed: 05/05/2023]
Abstract
Patients with impaired left ventricular (LV) function can develop LV thrombus, a potentially life-threatening condition due to risk of stroke and embolization. Conventional treatment with vitamin K antagonists (VKAs; e.g., warfarin) puts patients at risk of bleeding, and the use of direct oral anticoagulants (DOACs) appears promising, although data are scant. We searched the published English language literature for randomized controlled trials (RCTs) comparing DOACs with VKAs in LV thrombus. End points were failure to resolve, thromboembolic events (stroke, embolism), bleeding, or any adverse event (composite of thromboembolism or bleeding), or all-cause death. Data were pooled and analyzed in hierarchical Bayesian models. In three eligible RCTs, 141 patients were studied during an average of 4.6 months (53.8 patient-years; n = 71 assigned to DOAC, n = 70 assigned to VKA). A similar number of patients in each treatment arm demonstrated failure to resolve (DOAC: 14/71 vs. VKA: 15/70) and death events (3/71 vs. 4/70). However, patients on DOACs suffered fewer strokes/thromboembolic events (1/71 vs. 7/70; log odds ratio [OR], -2.02 [95% credible interval (CI95 ), -4.53 to -0.31]) and fewer bleeding events (2/71 vs. 9/70; log OR, -1.62 [CI95 , -3.43 to -0.26]), leading to fewer patients on DOACs with any adverse event versus VKAs (3/71 vs. 16/70; log OR, -1.93 [CI95 , -3.33 to -0.75]). In conclusion, pooled analysis of RCT data favors DOACs over VKAs in patients with LV thrombus in terms of both efficacy and safety.
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Affiliation(s)
- Anders Olof Sahlén
- National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Karolinska Institutet, Huddinge, Sweden
| | - Haowen Jiang
- Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Yee How Lau
- National Heart Centre Singapore, Singapore, Singapore
| | - Lucky Cuenza
- Philippines Heart Center, Quezon City, Philippines
| | - F Aaysha Cader
- Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh
| | | | | | - Ka Hei Ho
- Tuen Mun Hospital, Hong Kong, Hong Kong
| | | | - Derek Lee
- Queen Elizabeth Hospital, Hong Kong, Hong Kong
| | - Satoshi Honda
- National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Jack Tan Wei Chieh
- National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jonathan Yap
- National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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8
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Fong KY, Ong JHW, Chan YH, Yap J, Ho KW, Aslim EJ, Ng LG, Gan VHL, Lim EJ. A Systematic Review and Meta-Analysis of Transcatheter Versus Surgical Aortic Valve Replacement in Kidney Transplant Patients. Am J Cardiol 2023; 204:22-25. [PMID: 37536199 DOI: 10.1016/j.amjcard.2023.07.033] [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: 06/23/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Lay Guat Ng
- Department of Urology, Singapore General Hospital, Singapore
| | - Valerie Huei Li Gan
- Department of Urology, Singapore General Hospital, Singapore; SingHealth Duke-NUS Transplant Centre, Singapore
| | - Ee Jean Lim
- Department of Urology, Singapore General Hospital, Singapore.
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9
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Jiang H, Koh TH, Vengkat V, Fei G, Ding ZP, Ewe SH, Jappar I, Lim ST, Yap J. An Updated Meta-Analysis on the Clinical Outcomes of Percutaneous Left Atrial Appendage Closure Versus Direct Oral Anticoagulation in Patients With Atrial Fibrillation. Am J Cardiol 2023; 200:135-143. [PMID: 37321026 DOI: 10.1016/j.amjcard.2023.05.044] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/09/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023]
Abstract
The availability of direct oral anticoagulants (DOACs) with known lower bleeding risk compared with warfarin have raised questions about the role of left atrial appendage closure (LAAC). We aimed to perform a meta-analysis to compare the clinical outcomes for LAAC versus DOACs. All studies directly comparing LAAC with DOACs up to January 2023 were included. The outcomes studied included the combined major adverse cardiovascular (CV) events outcomes, ischemic stroke and thromboembolic events, major bleeding, CV mortality, and all-cause mortality. Hazard ratios (HRs) and their 95% confidence interval were extracted or estimated from the data and pooled together with a random-effects model. A total of 7 studies (1 randomized controlled trial, 6 propensity-matched observational studies) were finally included, with a pooled population of 4,383 patients who underwent LAAC and 4,554 patients on DOACs. There were no significant differences between patients who underwent LAAC and patients on DOACs in terms of baseline age (75.0 vs 74.7, p = 0.27), CHA2DS2-VASc score (5.1 vs 5.1, p = 0.33), or HAS-BLED score (3.3 vs 3.3, p = 0.36). After a mean weighted follow-up of 22.0 months, LAAC was associated with significantly lower rates of combined major adverse CV event outcomes (HR 0.73 [0.56 to 0.95], p = 0.02), all-cause mortality (HR 0.68 [0.54 to 0.86], p = 0.02), and CV mortality (HR 0.55 [0.41 to 0.72], p<0.01). There were no significant differences in the rates of ischemic stroke or systemic embolism (HR 1.12 [0.92 to 1.35], p = 0.25), major bleeding (HR 0.94 [0.67 to 1.32], p = 0.71), or hemorrhagic stroke (HR 1.07 [0.74 to 1.54], p = 0.74) between LAAC and DOAC. In conclusion, percutaneous LAAC was found to be as efficacious as DOACs for stroke prevention, with lower all-cause and CV mortality. The rates of major bleeding and hemorrhagic stroke were similar. LAAC has a potential role to play in stroke prevention in patients with atrial fibrillation in the era of DOACs, but further randomized data are needed.
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Affiliation(s)
- Haowen Jiang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Cardiology, National Heart Center Singapore, Singapore
| | - Tian Hai Koh
- Department of Cardiology, National Heart Center Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Vijay Vengkat
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gao Fei
- Department of Cardiology, National Heart Center Singapore, Singapore
| | - Zee Pin Ding
- Department of Cardiology, National Heart Center Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - See Hooi Ewe
- Department of Cardiology, National Heart Center Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Ignasius Jappar
- Department of Cardiology, National Heart Center Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Soo Teik Lim
- Department of Cardiology, National Heart Center Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Center Singapore, Singapore; Duke-NUS Medical School, Singapore.
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10
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Tay JCK, Chia SY, Koh SHM, Sim DKL, Chai P, Loh SY, Jaufeerally FR, Guang Lee SS, Yun Lim PZ, Yap J. Clinical characteristics and outcomes in Asian patients with heart failure with mildly reduced ejection fraction. Singapore Med J 2023; 0:377785. [PMID: 37338492 DOI: 10.4103/singaporemedj.smj-2021-096] [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: 06/21/2023]
Abstract
Introduction Data on heart failure (HF) with mildly reduced ejection fraction (HFmrEF) is still emerging, especially in Asian populations. This study aims to compare the clinical characteristics and outcomes of Asian HFmrEF patients with those of HF patients with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Methods Patients admitted nationally for HF between 2008 and 2014 were included in the study. They were categorised according to ejection fraction (EF). Patients with EF <40%, EF 40%-49% and EF ≥50% were categorised into the following groups: HFrEF, HFmrEF and HFpEF, respectively. All patients were followed up till December 2016. Primary outcome was all-cause mortality. Secondary outcomes included cardiovascular death and/or HF rehospitalisations. Results A total of 16,493 patients were included in the study - HFrEF, n = 7,341 (44.5%); HFmrEF, n = 2,272 (13.8%); and HFpEF n = 6,880 (41.7%). HFmrEF patients were more likely to be gender neutral, of mid-range age and have concomitant diabetes mellitus, hyperlipidaemia, peripheral vascular disease and coronary artery disease (P < 0.001). The two-year overall mortality rates for HFrEF, HFmrEF and HFpEF were 32.9%, 31.8% and 29.1%, respectively. HFmrEF patients had a significantly lower overall mortality rate compared to HFrEF patients (adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.83-0.95; P < 0.001) and a significantly higher overall mortality rate (adjusted HR 1.25, 95% CI 1.17-1.33; P < 0.001) compared to HFpEF patients. This was similarly seen with cardiovascular mortality and HF hospitalisations, with the exception of similar HF hospitalisations between HFmrEF and HFpEF patients. Conclusion HFmrEF patients account for a significant burden of patients with HF. HFmrEF represents a distinct HF phenotype with high atherosclerotic burden and clinical outcomes saddled in between those of HFrEF and HFpEF. Further therapeutic studies to guide management of this challenging group of patients are warranted.
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Affiliation(s)
| | - Shaw Yang Chia
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | | | - Ping Chai
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Seet Yoong Loh
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | | | | | | | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
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11
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Giannakopoulos S, Strange DP, Jiyarom B, Abdelaal O, Bradshaw AW, Nerurkar VR, Ward MA, Bakse J, Yap J, Vanapruks S, Boisvert WA, Tallquist MD, Shikuma C, Sadri-Ardekani H, Clapp P, Murphy SV, Verma S. In vitro evidence against productive SARS-CoV-2 infection of human testicular cells: Bystander effects of infection mediate testicular injury. PLoS Pathog 2023; 19:e1011409. [PMID: 37200377 PMCID: PMC10231791 DOI: 10.1371/journal.ppat.1011409] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/31/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023] Open
Abstract
The hallmark of severe COVID-19 involves systemic cytokine storm and multi-organ injury including testicular inflammation, reduced testosterone, and germ cell depletion. The ACE2 receptor is also expressed in the resident testicular cells, however, SARS-CoV-2 infection and mechanisms of testicular injury are not fully understood. The testicular injury could be initiated by direct virus infection or exposure to systemic inflammatory mediators or viral antigens. We characterized SARS-CoV-2 infection in different human testicular 2D and 3D culture systems including primary Sertoli cells, Leydig cells, mixed seminiferous tubule cells (STC), and 3D human testicular organoids (HTO). Data shows that SARS-CoV-2 does not productively infect any testicular cell type. However, exposure of STC and HTO to inflammatory supernatant from infected airway epithelial cells and COVID-19 plasma decreased cell viability and resulted in the death of undifferentiated spermatogonia. Further, exposure to only SARS-CoV-2 Envelope protein caused inflammatory response and cytopathic effects dependent on TLR2, while Spike 1 or Nucleocapsid proteins did not. A similar trend was observed in the K18-hACE2 transgenic mice which demonstrated a disrupted tissue architecture with no evidence of virus replication in the testis that correlated with peak lung inflammation. Virus antigens including Spike 1 and Envelope proteins were also detected in the serum during the acute stage of the disease. Collectively, these data strongly suggest that testicular injury associated with SARS-CoV-2 infection is likely an indirect effect of exposure to systemic inflammation and/or SARS-CoV-2 antigens. Data also provide novel insights into the mechanism of testicular injury and could explain the clinical manifestation of testicular symptoms associated with severe COVID-19.
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Affiliation(s)
- Stefanos Giannakopoulos
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Daniel P. Strange
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Boonyanudh Jiyarom
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Omar Abdelaal
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
- Department of Urology, Faculty of Medicine, Zagazig University, Egypt
| | - Aaron W. Bradshaw
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Vivek R. Nerurkar
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Monika A. Ward
- Institute for Biogenesis Research, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Jackson Bakse
- Institute for Biogenesis Research, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Jonathan Yap
- Center for Cardiovascular Research, Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Selena Vanapruks
- Center for Cardiovascular Research, Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - William A. Boisvert
- Center for Cardiovascular Research, Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Michelle D. Tallquist
- Center for Cardiovascular Research, Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Cecilia Shikuma
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
| | - Hooman Sadri-Ardekani
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Philip Clapp
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Sean V. Murphy
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Saguna Verma
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, United States of America
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12
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Koh SJQ, Yap J, Jiang Y, Sng GGR, Low YH, Lau YH, Sin YKK, Yeo KK. Clinical outcomes in end stage renal disease on dialysis and severe coronary artery disease: A real-world study. Int J Cardiol 2023; 378:105-110. [PMID: 36796490 DOI: 10.1016/j.ijcard.2023.02.029] [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: 06/04/2022] [Revised: 10/23/2022] [Accepted: 02/12/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND The optimal management of patients with end-stage renal disease (ESRD) on dialysis with severe coronary artery disease (CAD) has not been determined. METHODS Between 2013 and 2017, all patients with ESRD on dialysis who had left main (LM) disease, triple vessel disease (TVD) and/or severe CAD for consideration of coronary artery bypass graft (CABG) were included. Patients were divided into 3 groups based on final treatment modality: CABG, percutaneous coronary intervention (PCI), optimal medical therapy (OMT). Outcome measures include in-hospital, 180-day, 1-year and overall mortality and major adverse cardiac events (MACE). RESULTS In total, 418 patients were included (CABG 11.0%, PCI 65.6%, OMT 23.4%). Overall, 1-year mortality and MACE rates were 27.5% and 55.0% respectively. Patients who underwent CABG were significantly younger, more likely to have LM disease and have no prior heart failure. In this non-randomized setting, treatment modality did not impact on 1-year mortality, although the CABG group had significantly lower 1-year MACE rates (CABG 32.6%, PCI 57.3%, OMT 59.2%; CABG vs. OMT p < 0.01, CABG vs. PCI p < 0.001). Independent predictors of overall mortality include STEMI presentation (HR 2.31, 95% CI 1.38-3.86), prior heart failure (HR 1.84, 95% CI 1.22-2.75), LM disease (HR 1.71, 95% CI 1.26-2.31), NSTE-ACS presentation (HR 1.40, 95% CI 1.03-1.91) and increased age (HR 1.02, 95% CI 1.01-1.04). CONCLUSION Treatment decisions for patients with severe CAD with ESRD on dialysis are complex. Understanding independent predictors of mortality and MACE in specific treatment subgroups may provide valuable insights into the selection of optimal treatment options.
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Affiliation(s)
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Yilin Jiang
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Yi Hua Low
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Yee How Lau
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Yoong Kong Kenny Sin
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore.
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13
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Fong KY, Yap J, Ewe SH, Chao V, Amanullah M, Sivaraj G, Aziz ZA, Tan VHH, Ho KW. COMPARISON OF TRANSCATHETER, MINIMALLY INVASIVE AND CONVENTIONAL SURGICAL AORTIC VALVE REPLACEMENT: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01323-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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14
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Wong JJ, Annie L, Jiang Y, Yeo KK, Yap J. UNDERSTANDING PATTERNS, PREDICTORS AND LONG-TERM OUTCOMES OF PATIENTS WITH RECURRENT MYOCARDIAL INFARCTION HOSPITALIZATIONS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01686-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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15
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Jiang H, Koh TH, Vengkat V, Ding ZP, Ewe SH, Jappar IA, Lim ST, Yap J. CLINICAL OUTCOMES OF PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION VS DIRECT ORAL ANTICOAGULATION IN PATIENTS WITH ATRIAL FIBRILLATION: AN UPDATED META-ANALYSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01334-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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16
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Tan N, Gao F, Mohammed RA, Lim ST, Abdul Aziz Z, Govindasamy S, Chao VTT, Ewe SH, Ho KW, Yap J. Safety and efficacy of cerebral embolic protection devices in transcatheter aortic valve implantation: a meta-analysis. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.097] [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
Stroke during Transcatheter Aortic Valve implantation (TAVI) is not an uncommon complication with potential devastating consequences. With the extension of TAVI to the low-risk patient, stroke prevention takes on increasing importance. The use of cerebral embolic protection device (EPD) reveals conflicting data. This meta-analysis aims to evaluate the clinical efficacy and safety of EPDs.
Methods
A comprehensive literature search for all studies till May 2022 reporting clinical safety and efficacy outcomes of the only EPD approved for use by the Food and Drug Administration (FDA) was performed. Study outcomes were divided based on time period - overall (up to 30 days and in-hospital) and short (≤7 days). Primary outcome was stroke - major and minor. Secondary outcomes included transient ischaemic attack (TIA), mortality, acute kidney injury (AKI), major vascular and bleeding complications.
Results
A total of 12 studies involving 288531 patients were analysed, which included 3 randomised controlled trials (RCTs), 7 propensity-matched and 2 cohort studies. Regarding overall outcomes, significant differences were noted for mortality (OR 0.59 [0.42-0.84], p=0.0036) and major stroke (OR 0.40 [0.18-0.91], p=0.028) (Fig 1). No significant differences were noted for all stroke (p=0.058), minor stroke (p=0.32), TIA (p=0.49), AKI (p=0.17), major vascular complications (p=0.40) and major bleeding complications (p=0.11). There was significant heterogeneity across the studies for mortality (p=0.032) and all stroke (p=0.009). In the subgroup analysis of studies reporting ≤7 days outcomes (n=5), EPDs showed significantly lower rates of all stroke (0.33 [95% CI 0.19-0.56], p=<0.0001), major stroke (0.19 [0.08-0.48], p=0.0004) and major bleeding complications (OR 0.29 [0.10-0.79], p=0.016), but no significant differences for mortality (p=0.67) and minor stroke (p=0.070). There was no significant heterogeneity across the studies (all p>0.05)
Conclusions
In this meta-analysis including non-randomised studies, the use of EPDs was associated with lower mortality and major stroke rates, although significant heterogeneity was noted for the studies reporting mortality. Further ongoing larger scale RCTs will further clarify these results.
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Affiliation(s)
- N Tan
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - F Gao
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - R A Mohammed
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - S T Lim
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - Z Abdul Aziz
- National Heart Centre Singapore, Department of Cardiothoracic Surgery , Singapore , Singapore
| | - S Govindasamy
- National Heart Centre Singapore, Department of Cardiothoracic Surgery , Singapore , Singapore
| | - V T T Chao
- National Heart Centre Singapore, Department of Cardiothoracic Surgery , Singapore , Singapore
| | - S H Ewe
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - K W Ho
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - J Yap
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
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17
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Loo G, Yap J, Hon JS, Ismail A, Lim CL, Sumanthy P, Ruan W, Sewa DW, Phua GC, Ng SA, Hong C, Low A, Lim ST, Tan JL. Real-world outcomes of Selexipag for treatment of pulmonary hypertension in an Asian population. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.081] [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
Selexipag is an oral selective prostacyclin IP receptor agonist indicated for treatment of pulmonary arterial hypertension (PAH). Data on its real-world safety and efficacy in Asians is lacking.
Purpose
We sought to evaluate the clinical characteristics, treatment regimens and outcomes of patients initiated on selexipag in a tertiary cardiac centre in Asia.
Methods
This was a retrospective study on all patients initiated on selexipag from January 2017 to December 2020. Baseline and follow up characteristics including demographics, functional status and clinical data were collected. Clinical outcomes evaluated included hospitalisation for PH related complications and all-cause mortality. Patients were risk stratified using the COMPERA 2.0 risk scores.
Results
A total of 36 PAH patients were treated with selexipag. At baseline, most patients were WHO functional class II or III (36.4% and 51.5% respectively), with a NT-proBNP of 1335 pg/ml (557 – 2918) and 6 minute walk test (6MWT) duration of 327.5 ±126.4 meters. Selexipag was initiated at 200mcg twice daily dosage for all except one patient (started at 200mcg once daily) and the maximum tolerated dose ranged from 200mcg twice daily to 1400mcg twice daily, with majority tolerating up to a dose of 600mcg twice daily (58.3%). Side effects were reported in 23 patients (63.9%), of which headache (27.8%), diarrhea (30.6%) or musculoskeletal symptoms (27.8%) were predominant. After a median follow up duration of 25.9 ± 23.1 months, selexipag was stopped in 20 patients (55.6%), of which eight patients were due to PAH progression requiring alternative therapy, and 12 patients due to side effects from selexipag. At baseline, patients were classified into low (8.3%), intermediate-low (30.6%), intermediate-high (33.3%) and high risk (27.8%) respectively. Patients who continued on selexipag at follow up showed no change (46.2%), improvement (15.4%) and deterioration (38.5%) in risk score. In the overall cohort of 36 patients, majority (75%) had at least one hospitalisation for PAH related complications and 15 patients (41.7%) demised.
Conclusion
In this real-world study, while selexipag was associated with a stable or improved PAH risk scores in majority of patients, there was a subset of patients with disease progression or intolerance to the medication. Further studies are warranted to identify patients who will benefit most from this therapy.
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Affiliation(s)
- G Loo
- National Heart Centre Singapore , Singapore , Singapore
| | - J Yap
- National Heart Centre Singapore , Singapore , Singapore
| | - J S Hon
- National Heart Centre Singapore , Singapore , Singapore
| | - A Ismail
- National Heart Centre Singapore , Singapore , Singapore
| | - C L Lim
- National Heart Centre Singapore , Singapore , Singapore
| | - P Sumanthy
- National Heart Centre Singapore , Singapore , Singapore
| | - W Ruan
- National Heart Centre Singapore , Singapore , Singapore
| | - D W Sewa
- Singapore General Hospital , Singapore , Singapore
| | - G C Phua
- Singapore General Hospital , Singapore , Singapore
| | - S A Ng
- Singapore General Hospital , Singapore , Singapore
| | - C Hong
- Singapore General Hospital , Singapore , Singapore
| | - A Low
- Singapore General Hospital , Singapore , Singapore
| | - S T Lim
- National Heart Centre Singapore , Singapore , Singapore
| | - J L Tan
- National Heart Centre Singapore , Singapore , Singapore
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18
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Jiang H, Cuenza LR, Cader A, Al-Omary MS, Ho KH, Sung JG, Tan J, Yap J. Contemporary review of the management of left ventricular thrombus. Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.061] [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
Left ventricular thrombus (LVT) is a known complication of acute myocardial infarction (AMI) and other cardiomyopathies. LVT increases the risk of stroke and systemic embolism, hence treatment with oral anticoagulation is indicated. While the initial treatment options for LVT is clear, the management of patients after the initial duration of anticoagulation is more complex and varied.
Purpose
We aimed to undertake a comprehensive literature review to study the currently available evidence regarding not only the initial type and duration of anticoagulation for LVT, but also potential treatment options after the initial period of anticoagulation in the setting of both LVT persistence and resolution.
Methods
MEDLINE, EMBASE, Scopus, and Google Scholar were searched from inception to August 2022. Data from randomized controlled trials (RCTs), observational studies and case series discussing management of LVT were included in this summarized synthesis.
Results
Of 2050 studies screened, 30 studies (24 observational studies, 3 case series, 2 RCTs, 1 non-randomized, open-label trial) were included. A total of 17 studies compared warfarin with direct oral anticoagulants (DOACs) for the initial anticoagulation strategy, with the vast majority showing similar outcomes (Table 1). Half (n = 9/18) of the studies repeated imaging between 3-6 months. All studies (n=30) used transthoracic echo with or without contrast as the imaging modality of choice, with selected patients undergoing computed tomography (CT) or cardiac magnetic resonance (CMR). If the LVT persisted, most studies recommended continuing anticoagulation (n = 11/16, 69%) or switching to a different class of anticoagulants (n = 6/16, 38%). In the event of LVT non-resolution, high-risk features of embolization (protruding, mobile vs layered clot) may aid in the discussion of risk and benefit of long-term anticoagulation. Even upon resolution of the LVT, some studies (n=5) recommend continuing anticoagulation in the presence of high-risk features of recurrence (eg. persistently depressed left ventricle ejection fraction (LVEF) and/or apical wall dyskinesis). Regardless, medical management should be optimized together with the appropriate revascularization strategy as clinically indicated.
Conclusions
Current evidence on the management of LVT is limited. This updated review summarizes the available evidence for the management for LVT. Evidence-based recommendations on the management of these patients is warranted to appropriately guide clinicians.
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Affiliation(s)
- H Jiang
- Lee Kong Chian School of Medicine , Singapore , Singapore
| | - L R Cuenza
- Phillipine Heart Center, Cardiology , Quezon City , Philippines
| | - A Cader
- Ibrahim Cardiac Hospital and Research Institute, Cardiology , Dhakan , Bangladesh
| | - M S Al-Omary
- John Hunter Hospital, Cardiology , Newcastle , Australia
| | - K H Ho
- Tuen Mun Hospital, Cardiology , Hong Kong , Hong Kong
| | - J G Sung
- Tuen Mun Hospital, Cardiology , Hong Kong , Hong Kong
| | - J Tan
- National Heart Centre Singapore, Cardiology , Singapore , Singapore
| | - J Yap
- National Heart Centre Singapore, Cardiology , Singapore , Singapore
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Tan JY, Chia YW, Chan M, Lim SL, Chin C, Yap J, Richards AM, Teo ZW, Amanullah MR, Peck KH, Choo TLJ, Sim HW, Young BE, Macary P, Yeo KK. Pathophysiologic mechanism for MYOcarditis in COVID-19 VAccinations ("MYOVAx" Study). Eur Heart J 2023. [DOI: 10.1093/eurheartj/ehac779.075] [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 grant(s) – National budget only. Main funding source(s): NMRC COVID-19 Research Fund
Objective
This is the first prospective cohort study in Singapore to investigate the COVID-19 vaccine-associated myocarditis to understand its pathophysiology.
Introduction
Acute myocarditis and other cardiovascular symptoms have been observed to be associated with the two mRNA-based coronavirus disease 2019 (COVID-19) vaccines—namely Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273)—currently in-use in Singapore. The mechanisms through which myocarditis occurs are unknown, hence our study aims to understand the pathophysiology of myocarditis associated with COVID-19 vaccines.
Methods
Patients with onset of cardiac manifestations were recruited from multiple hospital outpatient clinics between November 2021 and September 2022. Clinical history and physical examination data was collected with blood sample collection, echocardiography, 12-lead electrocardiogram (ECG), coronary angiography and magnetic resonance imaging (MRI) at recruitment and 6-month follow-up. Analysis of biomarkers, genetic, serological and MRI data was conducted.
Results
As of 6 September 2022, a total of 5 patients have been enrolled (4 males, 1 female). The most commonly reported symptoms across all patients were chest pain/discomfort (80%), followed by palpitations (40%). MRI evidence of myocarditis has been detected in 2 (50%) of the male patients, of which both reported two or more symptoms occurring 1-2 days post-vaccination. Both patients have each received at least two doses of either the Pfizer-BioNTech BNT162b2 vaccine or Moderna mRNA-1273 vaccine. Their MRI findings were consistent with myocarditis. On late gadolinium enhancement (LGE) imaging, epicardial enhancement at the basal inferolateral segment and mid-wall enhancement at the apical anterior, lateral and inferior walls were observed in one patient. Patchy, mid-wall LGE in the basal inferior/inferolateral wall was observed in the other patient. No MRI evidence of myocarditis was available for the sole female patient.
Conclusion
While more data is needed to definitively prove the association of the two mRNA-based Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273 COVID-19 vaccines with post-vaccination myocarditis, we believe our findings may support further investigations to enable risk stratification for vaccine-associated myocarditis and identify potential preventative strategies accordingly.
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Affiliation(s)
- J Y Tan
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - Y W Chia
- Tan Tock Seng Hospital, Department of Cardiology , Singapore , Singapore
| | - M Chan
- National University Heart Centre, Department of Cardiology , Singapore , Singapore
| | - S L Lim
- National University Hospital, Department of Cardiology , Singapore , Singapore
| | - C Chin
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - J Yap
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
| | - A M Richards
- National University Hospital, Cardiovascular Research Institute , Singapore , Singapore
| | - Z W Teo
- Changi General Hospital, Department of Cardiology , Singapore , Singapore
| | - M R Amanullah
- Sengkang General Hospital, NHCS Cardiology @ SKH , Singapore , Singapore
| | - K H Peck
- Khoo Teck Puat Hospital, Department of Cardiology , Singapore , Singapore
| | - T L J Choo
- KK Women's and Children's Hospital, Cardiology Service , Singapore , Singapore
| | - H W Sim
- Ng Teng Fong General Hospital, Department of Medicine , Singapore , Singapore
| | - B E Young
- National Centre for Infectious Diseases , Singapore , Singapore
| | - P Macary
- National University of Singapore, Department of Microbiology and Immunology , Singapore , Singapore
| | - K K Yeo
- National Heart Centre Singapore, Department of Cardiology , Singapore , Singapore
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Yap J, Irei J, Lozano-Gerona J, Vanapruks S, Bishop T, Boisvert WA. Macrophages in cardiac remodelling after myocardial infarction. Nat Rev Cardiol 2023; 20:373-385. [PMID: 36627513 DOI: 10.1038/s41569-022-00823-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [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: 11/25/2022] [Indexed: 01/12/2023]
Abstract
Myocardial infarction (MI), as a result of thrombosis or vascular occlusion, is the most prevalent cause of morbidity and mortality among all cardiovascular diseases. The devastating consequences of MI are compounded by the complexities of cellular functions involved in the initiation and resolution of early-onset inflammation and the longer-term effects related to scar formation. The resultant tissue damage can occur as early as 1 h after MI and activates inflammatory signalling pathways to elicit an immune response. Macrophages are one of the most active cell types during all stages after MI, including the cardioprotective, inflammatory and tissue repair phases. In this Review, we describe the phenotypes of cardiac macrophage involved in MI and their cardioprotective functions. A specific subset of macrophages called resident cardiac macrophages (RCMs) are derived from yolk sac progenitor cells and are maintained as a self-renewing population, although their numbers decrease with age. We explore sophisticated sequencing techniques that demonstrate the cardioprotective properties of this cardiac macrophage phenotype. Furthermore, we discuss the interactions between cardiac macrophages and other important cell types involved in the pathology and resolution of inflammation after MI. We summarize new and promising therapeutic approaches that target macrophage-mediated inflammation and the cardioprotective properties of RCMs after MI. Finally, we discuss future directions for the study of RCMs in MI and cardiovascular health in general.
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Affiliation(s)
- Jonathan Yap
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Jason Irei
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Javier Lozano-Gerona
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Selena Vanapruks
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Tianmai Bishop
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - William A Boisvert
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA.
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21
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Gorny AW, Yap J, Neo JW, Chow WE, Yeo KK, Tan CS, Müller-Riemenschneider F. Cardiorespiratory fitness, body mass index, cardiovascular disease, and mortality in young men: A cohort study. Front Public Health 2023; 11:1076065. [PMID: 36875358 PMCID: PMC9975166 DOI: 10.3389/fpubh.2023.1076065] [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: 10/21/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023] Open
Abstract
Objective We examined the association between cardiorespiratory fitness (CRF), body mass index (BMI), incidence of major acute cardiovascular events (MACE), and all-cause mortality (ACM). Methods We conducted a retrospective cohort study involving 212,631 healthy young men aged 16 to 25 years who had undergone medical examination and fitness testing (2.4 km run) from 1995 to 2015. Information on the outcomes of major acute cardiovascular events (MACE) and all-cause mortality (ACM) were obtained from the national registry data. Results During 2,043,278 person-years of follow-up, 371 first MACE and 243 ACM events were recorded. Compared against the first run-time quintile, adjusted hazard ratios (HR) for MACE in the second to fifth quintiles were 1.26 (95% CI 0.84-1.91), 1.60 (95% CI 1.09-2.35), 1.60 (95% CI 1.10-2.33), and 1.58 (95% CI 1.09-2.30). Compared against the "acceptable risk" BMI category, the adjusted HRs for MACE in the "underweight," "increased risk," and "high-risk" categories were 0.97 (95% CI 0.69-1.37), 1.71 (95% CI 1.33-2.21), and 3.51 (95% CI 2.61-4.72), respectively. The adjusted HRs for ACM were increased in participants from the fifth run-time quintile in the "underweight" and "high-risk" BMI categories. The combined associations of CRF and BMI with MACE showed elevated hazard in the "BMI≥23-fit" category, which was more pronounced in the "BMI≥23-unfit" category. The hazards for ACM were elevated across the "BMI<23-unfit," "BMI≥23-fit," and "BMI≥23-unfit" categories. Conclusion Lower CRF and elevated BMI were associated with increased hazards of MACE and ACM. A higher CRF did not fully compensate for elevated BMI in the combined models. CRF and BMI remain important targets for public health intervention in young men.
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Affiliation(s)
- Alexander Wilhelm Gorny
- Centre of Excellence for Soldier Performance, Singapore Armed Forces, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Jonathan Yap
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Jia Wei Neo
- Centre of Excellence for Soldier Performance, Singapore Armed Forces, Singapore, Singapore
| | - Wei En Chow
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.,Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Khung Keong Yeo
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Digital Health Center, Berlin Institute of Health, Berlin, Germany
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22
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McCurdy S, Yap J, Irei J, Lozano J, Boisvert WA. IL-37-a putative therapeutic agent in cardiovascular diseases. QJM 2022; 115:719-725. [PMID: 33486516 DOI: 10.1093/qjmed/hcab011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 11/13/2022] Open
Abstract
Although it is a member of the Interleukin (IL)-1 family, IL-37 is unique in that it has wide-ranging anti-inflammatory characteristics. It was originally thought to prevent IL-18-mediated inflammation by binding to the IL-18-binding protein. However, upon discovery that it binds to the orphan receptor, IL-1R8, further studies have revealed an expanded role of IL-37 to include several intracellular and extracellular pathways that affect various aspects of inflammation. Its potential role specifically in cardiovascular diseases (CVD) stemmed initially from the discovery of elevated plasma IL-37 levels in human patients with acute coronary syndrome and atrial fibrillation. Other studies using mouse models of ischemia/reperfusion injury, vascular calcification and myocardial infarction have revealed that IL-37 can have a beneficial role in these conditions. This review will explore recent research on the effects of IL-37 on the pathogenesis of CVD.
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Affiliation(s)
- S McCurdy
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - J Yap
- Department of Medicine, Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - J Irei
- Department of Medicine, Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - J Lozano
- Department of Medicine, Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - W A Boisvert
- Department of Medicine, Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlevskaya Str., Kazan, 420008, Russia
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23
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Koh SJQ, Yap J, Jiang Y, Tay JCK, Quah KKH, Thiagarajan N, Tan SY, Amanullah MR, Lim ST, Aziz ZA, Govindasamy S, Chao VTT, Ewe SH, Ho KW. Impact of aortic annular size and valve type on haemodynamics and clinical outcomes after transcatheter aortic valve implantation. Ann Acad Med Singap 2022. [DOI: 10.47102/annals-acadmedsg.2022167] [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: 11/06/2022]
Abstract
Introduction: Data on patients with small aortic annuli (SAA) undergoing transcatheter aortic valve implantation (TAVI) are limited. We aim to describe the impact of aortic annular size, particularly SAA and TAVI valve type on valve haemodynamics, durability and clinical outcomes.
Method: All patients in National Heart Centre Singapore who underwent transfemoral TAVI for severe symptomatic native aortic stenosis from July 2012 to December 2019 were included. Outcome measures include valve haemodynamics, prosthesis-patient mismatch (PPM), structural valve degeneration (SVD) and mortality.
Results: A total of 244 patients were included. The mean Society of Thoracic Surgeons score was 6.22±6.08, with 52.5% patients with small aortic annulus (<23mm), 33.2% patients with medium aortic annulus (23–26mm) and 14.3% patients with large aortic annulus (>26mm). There were more patients with self-expanding valve (SEV) (65.2%) versus balloon-expandable valve (BEV) (34.8%). There were no significant differences in indexed aortic valve area (iAVA), mean pressure gradient (MPG), PPM, SVD or mortality across all aortic annular sizes. However, specific to the SAA group, patients with SEV had larger iAVA (SEV 1.19±0.35cm2/m2 vs BEV 0.88±0.15cm2/m2, P<0.01) and lower MPG (SEV 9.25±4.88 mmHg vs BEV 14.17±4.75 mmHg, P<0.01) at 1 year, without differences in PPM or mortality. Aortic annular size, TAVI valve type and PPM did not predict overall mortality up to 7 years. There was no significant difference in SVD between aortic annular sizes up to 5 years.
Conclusion: Valve haemodynamics and durability were similar across the different aortic annular sizes. In the SAA group, SEV had better haemodynamics than BEV at 1 year, but no differences in PPM or mortality. There were no significant differences in mortality between aortic annular sizes, TAVI valve types or PPM.
Keywords: Aortic stenosis, small aortic annulus, transcatheter aortic valve implantation
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24
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Giannakopoulos S, Strange DP, Jiyarom B, Abdelaal O, Bradshaw AW, Nerurkar VR, Ward MA, Bakse J, Yap J, Vanapruks S, Boisvert W, Tallquist MD, Shikuma C, Sadri-Ardekani H, Clapp P, Murphy S, Verma S. In vitro evidence against productive SARS-CoV-2 infection of human testicular cells: Bystander effects of infection mediate testicular injury. bioRxiv 2022:2022.09.21.508904. [PMID: 36172118 PMCID: PMC9516847 DOI: 10.1101/2022.09.21.508904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The hallmark of severe COVID-19 involves systemic cytokine storm and multi-organ failure including testicular injury and germ cell depletion. The ACE2 receptor is also expressed in the resident testicular cells however, SARS-CoV-2 infection and mechanisms of testicular injury are not fully understood. The testicular injury can likely result either from direct virus infection of resident cells or by exposure to systemic inflammatory mediators or virus antigens. We here characterized SARS-CoV-2 infection in different human testicular 2D and 3D models including primary Sertoli cells, Leydig cells, mixed seminiferous tubule cells (STC), and 3D human testicular organoids (HTO). Data shows that SARS-CoV-2 does not establish a productive infection in any testicular cell types. However, exposure of STC and HTO to inflammatory supernatant from infected airway epithelial cells and COVID-19 plasma depicted a significant decrease in cell viability and death of undifferentiated spermatogonia. Further, exposure to only SARS-CoV-2 envelope protein, but not Spike or nucleocapsid proteins led to cytopathic effects on testicular cells that was dependent on the TLR2 receptor. A similar trend was observed in the K18h-ACE2 mouse model which revealed gross pathology in the absence of virus replication in the testis. Collectively, data strongly indicates that the testicular injury is not due to direct infection of SARS-CoV-2 but more likely an indirect effect of exposure to systemic inflammation or SARS-CoV-2 antigens. Data also provide novel insights into the mechanism of testicular injury and could explain the clinical manifestation of testicular symptoms associated with severe COVID-19.
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Affiliation(s)
- Stefanos Giannakopoulos
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Daniel P Strange
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Boonyanudh Jiyarom
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Omar Abdelaal
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Aaron W Bradshaw
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Vivek R Nerurkar
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Monika A Ward
- Institute for Biogenesis Research, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Jackson Bakse
- Institute for Biogenesis Research, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Jonathan Yap
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Selena Vanapruks
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - William Boisvert
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Michelle D Tallquist
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Cecilia Shikuma
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Hooman Sadri-Ardekani
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Philip Clapp
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Sean Murphy
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Saguna Verma
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
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25
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Tay JCK, Chia SY, Sim DKL, Chai P, Loh SY, Shum AKL, Lee SSG, Lim PZY, Yap J. Interaction of sex and diabetes in Asian patients with heart failure with mildly reduced left ventricular ejection fraction. Ann Acad Med Singap 2022; 51:473-482. [PMID: 36047522 DOI: 10.47102/annals-acadmedsg.2022113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The impact of sex and diabetes mellitus (DM) on patients with heart failure with mildly reduced ejection fraction (HFmrEF) is not well elucidated. This study aims to evaluate sex differences in the clinical profile and outcomes in Asian HFmrEF patients with and without DM. METHODS Patients admitted nationally for HFmrEF (ejection fraction 40-49%) between 2008 and 2014 were included and followed up until December 2016. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular (CV) death and/or heart failure (HF) rehospitalisations. RESULTS A total of 2,272 HFmrEF patients (56% male) were included. More women had DM than men (60% versus 55%, P=0.013). Regardless of DM status, HFmrEF females were older, less likely to smoke, had less coronary artery disease, narrower QRS and lower haemoglobin compared to men. The odds of having DM decreases in smokers who are women as opposed to men (Pinteraction =0.017). In multivariate analysis, DM reached statistical analysis for all-cause mortality and combined CV mortality or HF rehospitalisation in both men and women. However, the results suggest that there may be sex differences in terms of outcomes. DM (vs non-DM) was less strongly associated with increased all-cause mortality (adjusted hazards ratio [adj HR] 1.234 vs adj HR 1.290, Pinteraction <0.001] but more strongly associated with the combined CV death/HF rehospitalisation (adj HR 1.429 vs adj HR 1.317, Pinteraction =0.027) in women (vs men). CONCLUSION Asian women with HFmrEF had a higher prevalence of DM, with differences in clinical characteristics, compared to men. While diabetes conferred poor outcomes regardless of sex, there were distinct sex differences. These highlight the need for sex-specific management strategies.
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Affiliation(s)
- Julian C K Tay
- Department of Cardiology, National Heart Centre Singapore, Singapore
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26
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Zhou W, Chan YE, Foo CS, Zhang J, Teo JX, Davila S, Huang W, Yap J, Cook S, Tan P, Chin CWL, Yeo KK, Lim WK, Krishnaswamy P. High-Resolution Digital Phenotypes From Consumer Wearables and Their Applications in Machine Learning of Cardiometabolic Risk Markers: Cohort Study. J Med Internet Res 2022; 24:e34669. [PMID: 35904853 PMCID: PMC9377462 DOI: 10.2196/34669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/09/2021] [Revised: 04/12/2022] [Accepted: 05/29/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Consumer-grade wearable devices enable detailed recordings of heart rate and step counts in free-living conditions. Recent studies have shown that summary statistics from these wearable recordings have potential uses for longitudinal monitoring of health and disease states. However, the relationship between higher resolution physiological dynamics from wearables and known markers of health and disease remains largely uncharacterized. OBJECTIVE We aimed to derive high-resolution digital phenotypes from observational wearable recordings and to examine their associations with modifiable and inherent markers of cardiometabolic disease risk. METHODS We introduced a principled framework to extract interpretable high-resolution phenotypes from wearable data recorded in free-living conditions. The proposed framework standardizes the handling of data irregularities; encodes contextual information regarding the underlying physiological state at any given time; and generates a set of 66 minimally redundant features across active, sedentary, and sleep states. We applied our approach to a multimodal data set, from the SingHEART study (NCT02791152), which comprises heart rate and step count time series from wearables, clinical screening profiles, and whole genome sequences from 692 healthy volunteers. We used machine learning to model nonlinear relationships between the high-resolution phenotypes on the one hand and clinical or genomic risk markers for blood pressure, lipid, weight and sugar abnormalities on the other. For each risk type, we performed model comparisons based on Brier scores to assess the predictive value of high-resolution features over and beyond typical baselines. We also qualitatively characterized the wearable phenotypes for participants who had actualized clinical events. RESULTS We found that the high-resolution features have higher predictive value than typical baselines for clinical markers of cardiometabolic disease risk: the best models based on high-resolution features had 17.9% and 7.36% improvement in Brier score over baselines based on age and gender and resting heart rate, respectively (P<.001 in each case). Furthermore, heart rate dynamics from different activity states contain distinct information (maximum absolute correlation coefficient of 0.15). Heart rate dynamics in sedentary states are most predictive of lipid abnormalities and obesity, whereas patterns in active states are most predictive of blood pressure abnormalities (P<.001). Moreover, in comparison with standard measures, higher resolution patterns in wearable heart rate recordings are better able to represent subtle physiological dynamics related to genomic risk for cardiometabolic disease (improvement of 11.9%-22.0% in Brier scores; P<.001). Finally, illustrative case studies reveal connections between these high-resolution phenotypes and actualized clinical events, even for borderline profiles lacking apparent cardiometabolic risk markers. CONCLUSIONS High-resolution digital phenotypes recorded by consumer wearables in free-living states have the potential to enhance the prediction of cardiometabolic disease risk and could enable more proactive and personalized health management.
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Affiliation(s)
- Weizhuang Zhou
- Institute for Infocomm Research, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
| | - Yu En Chan
- Institute for Infocomm Research, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
| | - Chuan Sheng Foo
- Institute for Infocomm Research, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
| | - Jingxian Zhang
- Institute for Infocomm Research, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
| | - Jing Xian Teo
- SingHealth Duke-NUS Institute of Precision Medicine, Singapore, Singapore
| | - Sonia Davila
- SingHealth Duke-NUS Institute of Precision Medicine, Singapore, Singapore.,SingHealth Duke-NUS Genomic Medicine Centre, Singapore, Singapore.,Cardiovascular and Metabolic Disorders Program, Duke-NUS Medical School, Singapore, Singapore
| | - Weiting Huang
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Stuart Cook
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Medical School, Singapore, Singapore
| | - Patrick Tan
- SingHealth Duke-NUS Institute of Precision Medicine, Singapore, Singapore.,Cancer and Stem Biology Program, Duke-NUS Medical School, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Genome Institute of Singapore, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
| | - Calvin Woon-Loong Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Khung Keong Yeo
- SingHealth Duke-NUS Institute of Precision Medicine, Singapore, Singapore.,Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Weng Khong Lim
- SingHealth Duke-NUS Institute of Precision Medicine, Singapore, Singapore.,SingHealth Duke-NUS Genomic Medicine Centre, Singapore, Singapore.,Cancer and Stem Biology Program, Duke-NUS Medical School, Singapore, Singapore
| | - Pavitra Krishnaswamy
- Institute for Infocomm Research, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
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Lee ZC, Noviani M, Yap J, Chin CWL, Ng SA, Low AHL. Tocilizumab for systemic sclerosis with cardiac involvement: a case report. Clin Exp Rheumatol 2022; 40:2006-2007. [DOI: 10.55563/clinexprheumatol/cibdmf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/04/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Zheng Cong Lee
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Maria Noviani
- Department of Rheumatology and Immunology, Singapore General Hospital, and Duke-NUS Medical School Singapore, Singapore
| | - Jonathan Yap
- National Heart Centre, Singapore, and Duke-NUS Medical School Singapore
| | | | - Sue-Ann Ng
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, and Duke-NUS Medical School Singapore
| | - Andrea Hsiu Ling Low
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, and Duke-NUS Medical School Singapore.
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28
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Tay JCK, Yap J. Epicardial adipose tissue: More than meets the eye. Int J Cardiol 2022; 362:174-175. [DOI: 10.1016/j.ijcard.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 11/05/2022]
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29
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Li T, Yap J, Chng WQ, Tay JCK, Shahidah N, Yeo C, Gan HN, Tong KL, Ng YY, Wu JH, Wang M, Ong MEH, Ching CK. Clinicopathological correlates of out‐of‐hospital cardiac arrests. J Arrhythm 2022; 38:416-424. [PMID: 35785374 PMCID: PMC9237307 DOI: 10.1002/joa3.12705] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/13/2022] [Accepted: 03/16/2022] [Indexed: 11/06/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Tony Li
- Department of Cardiology National University Heart Center, Singapore Singapore Singapore
| | - Jonathan Yap
- Department of Cardiology National Heart Center Singapore Singapore Singapore
- Duke‐NUS Graduate Medical School Singapore Singapore
| | - Wei Qiang Chng
- Department of Cardiology National University Heart Center, Singapore Singapore Singapore
| | | | - Nur Shahidah
- Department of Emergency Medicine Singapore General Hospital Singapore Singapore
| | - Colin Yeo
- Department of Cardiology Changi General Hospital Singapore Singapore
| | - Han Nee Gan
- Department of Emergency Medicine Changi General Hospital Singapore Singapore
| | - Khim Leng Tong
- Department of Cardiology Changi General Hospital Singapore Singapore
| | - Yih Yng Ng
- Medical Department Singapore Civil Defence Force, Singapore Singapore Singapore
| | - Jia Hao Wu
- Forensic Medicine Division Health Sciences Authority Singapore Singapore
| | - Marian Wang
- Forensic Medicine Division Health Sciences Authority Singapore Singapore
| | - Marcus Eng Hock Ong
- Duke‐NUS Graduate Medical School Singapore Singapore
- Department of Emergency Medicine Singapore General Hospital Singapore Singapore
| | - Chi Keong Ching
- Department of Cardiology National Heart Center Singapore Singapore Singapore
- Duke‐NUS Graduate Medical School Singapore Singapore
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30
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Gan E, Keh YS, Fei G, Ewe SH, Amanullah MR, Chao V, Lim ST, Ho KW, Yap J. CLINICAL OUTCOMES OF THE BALLOON-EXPANDABLE VS SELF-EXPANDABLE VALVES IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT - A META-ANALYSIS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01676-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Choo J, Yap J, Ismail AIDILA, Lim CL, Sumathy P, Ruan W, Sewa DW, Phua GC, Hong C, Low AHL, Lim ST, Tan JL. Intravenous epoprostenol therapy in the treatment of pulmonary arterial hypertension: the Singapore experience. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.116] [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: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Pulmonary arterial hypertension (PAH) is a progressive disease with significant morbidity and mortality. While intravenous (IV) Epoprostenol, a prostacyclin analogue, has been shown to improve exercise tolerance, symptoms, hemodynamics and survival, there are challenges with initiation and maintenance of this IV therapy.
Purpose
We aim to describe our local experience of the use of IV Epoprostenol in the treatment of PAH patients in Singapore, highlighting various issues and challenges.
Methods
From 2016, patients at a tertiary cardiac institution diagnosed with Group 1 PAH and remaining in intermediate to high risk class with progressive symptoms (despite being on maximum tolerable doses of PhosphoDiEsterase-5 inhibitors and Endothelin-1 receptor antagonists) were assessed and counselled for initiation of Epoprostenol therapy. With a fixed set of local protocols, comprehensive assessment and support of a multi-disciplinary team including physicians, specialist nurses and pharmacists, suitable patients were started on this treatment.
Results
A total of 12 patients (11 female, mean age 42.8 +/- 11.0 years) were included. The average New York Heart Association class of the patients initiated on Epoprostenol was II-III. The pulmonary artery pressures and pulmonary vascular resistance on right heart catheterization prior to initiation was 52.5 (IQR 47.0-54.0) mmHg and 12.6 (IQR 10.0-14.2) Woods respectively. The duration from diagnosis to time of initiating Epoprostenol was 89 (IQR 62-140) months. Epoprostenol was generally well tolerated. The most common side effect experienced was diarrhea (5/12 patients) followed by headache and musculoskeletal complains (3/12 patients each). Of the 12 patients, 6 passed away after 12 (IQR 10-16) months of Epoprostenol therapy. Of the remaining 6, PAH was diagnosed 110 (IQR 104-136) months ago and Epoprostenol therapy has been continued for 17 (IQR 14-27) months. Of those who survived, right ventricle size and PA pressures on echocardiography remained relatively stable as compared to those who passed on. 2 patients had line related infections requiring a line change 1 and 2 times respectively.
Conclusion
While not without its challenges, the establishment of concrete protocols with the support of a multidisciplinary team allows for the introduction of IV Epoprostenol as an additional potential line of effective therapy for PAH patients in Singapore.
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Affiliation(s)
- J Choo
- National Heart Centre Singapore, Singapore, Singapore
| | - J Yap
- National Heart Centre Singapore, Singapore, Singapore
| | - AIDILA Ismail
- National Heart Centre Singapore, Singapore, Singapore
| | - C L Lim
- National Heart Centre Singapore, Singapore, Singapore
| | - P Sumathy
- National Heart Centre Singapore, Singapore, Singapore
| | - W Ruan
- National Heart Centre Singapore, Singapore, Singapore
| | - D W Sewa
- Singapore General Hospital, Singapore, Singapore
| | - G C Phua
- Singapore General Hospital, Singapore, Singapore
| | - C Hong
- Singapore General Hospital, Singapore, Singapore
| | - A H L Low
- Singapore General Hospital, Singapore, Singapore
| | - S T Lim
- National Heart Centre Singapore, Singapore, Singapore
| | - J L Tan
- National Heart Centre Singapore, Singapore, Singapore
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Yap J, Tham MY, Poh J, Toh D, Chan CL, Lim TW, Lim SL, Chia YW, Lim YT, Choo J, Ding ZP, Foo LL, Kuo S, Lau YH, Lee A, Yeo KK. Pericarditis and myocarditis after COVID-19 mRNA vaccination in a nationwide setting. Ann Acad Med Singap 2022; 51:96-100. [PMID: 35224605] [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] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Despite reports suggesting an association between COVID-19 mRNA vaccination and pericarditis and myocarditis, detailed nationwide population-based data are sparsely available. We describe the incidence of pericarditis and myocarditis by age categories and sex after COVID-19 mRNA vaccination from a nationwide mass vaccination programme in Singapore. METHODS The incidence of adjudicated cases of pericarditis and myocarditis following COVID-19 mRNA vaccination that were reported to the vaccine safety committee between January to July 2021 was compared with the background incidence of myocarditis in Singapore. RESULTS As of end July 2021, a total of 34 cases were reported (9 pericarditis only, 14 myocarditis only, and 11 concomitant pericarditis and myocarditis) with 7,183,889 doses of COVID-19 mRNA vaccine administered. Of the 9 cases of pericarditis only, all were male except one. The highest incidence of pericarditis was in males aged 12-19 years with an incidence of 1.11 cases per 100,000 doses. Of the 25 cases of myocarditis, 80% (20 cases) were male and the median age was 23 years (range 12-55 years) with 16 cases after the second dose. A higher-than-expected number of cases were seen in males aged 12-19 and 20-29 years, with incidence rates of 3.72 and 0.98 case per 100,000 doses, respectively. CONCLUSION Data from the national registry in Singapore indicate an increased incidence of pericarditis and myocarditis in younger men after COVID-19 mRNA vaccination.
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Affiliation(s)
- Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
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Chiou A, Yap J, Russo S, Stripe BR, Wong GB, Southard JA. Understanding repeat hospitalizations in intermediate-to-high risk aortic stenosis patients following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2022; 99:1188-1196. [PMID: 35019207 DOI: 10.1002/ccd.30066] [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: 09/07/2021] [Revised: 12/04/2021] [Accepted: 12/25/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We describe the causes, timing and predictors of readmissions and analyze its impact on clinical outcomes in intermediate-to-high-risk patients with severe symptomatic aortic stenosis (AS) who underwent transcatheter aortic valve replacement (TAVR). BACKGROUND Intermediate-high risk TAVR patients with severe AS have an increased risk for hospital readmissions due to the high burden of comorbidities. METHODS Patients who underwent TAVR from 2012 to 2018 at a single tertiary cardiac center were included and followed for 1 year. Readmissions were categorized as noncardiovascular (non-CV) and CV. RESULTS A total of 611 patients (410 with no readmissions, 201 with ≥1 readmissions) were included. There was a total of 317 readmissions (mean: 1.58 ± 1.09 per readmitted patient) with 65 patients having ≥2 readmissions. 64.0% were non-CV and 36.0% were CV. The top three CV causes were pacemaker/implantable cardioverter-defibrillator placement, bleeding, and stroke. About 23% occurred at 1 m, the majority were CV; 45% occurred between 7 and 12 m, the majority were non-CV. Those with ≥1 readmissions had a higher burden of comorbidities including peripheral arterial disease, diabetes, immunosuppression, prior percutaneous coronary interventions, and dialysis. Readmissions were associated with higher 1-year mortality (adjusted hazard ratio: 2.53, 95% confidence interval: 1.40-4.59; p = 0.002). High-risk patients had higher non-CV readmissions (0.37 ± 0.79 vs. 0.25 ± 0.62; p = 0.044) compared to intermediate-risk patients but similar CV readmissions (p = 0.645). CONCLUSIONS Understanding readmissions post-TAVR will promote the early identification of at-risk groups and the implementation of preventative measures to improve outcomes and reduce the burden and costs of readmissions.
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Affiliation(s)
- Andrew Chiou
- Department of Internal Medicine, University of California Davis, Davis, California, USA
| | - Jonathan Yap
- Division of Cardiovascular Medicine, University of California Davis, California, Davis, USA.,Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.,Department of Cardiology, Duke-NUS Medical School, Singapore, Singapore
| | - Steven Russo
- Department of Internal Medicine, University of California Davis, Davis, California, USA
| | - Benjamin R Stripe
- Division of Cardiovascular Medicine, University of California Davis, California, Davis, USA
| | - Garrett B Wong
- Division of Cardiovascular Medicine, University of California Davis, California, Davis, USA
| | - Jeffrey A Southard
- Division of Cardiovascular Medicine, University of California Davis, California, Davis, USA
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Wong JJ, Umapathy S, Keh YS, Lau YH, Yap J, Idu M, Chin CY, Fam JM, Liew BW, Chin CT, Wong PEH, Koh TH, Yeo KK. Coronary Intravascular Lithotripsy Versus Rotational Atherectomy in an Asian Population: Clinical Outcomes in Real-World Patients. Korean Circ J 2021; 52:288-300. [PMID: 35043608 PMCID: PMC8989791 DOI: 10.4070/kcj.2021.0155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 10/10/2021] [Accepted: 11/03/2021] [Indexed: 11/11/2022] Open
Abstract
Intravascular lithotripsy (IVL) is a newer calcium modification therapy with limited clinical experience compared to other established techniques. Single-armed studies have shown IVL is safe and effective for heavily calcified coronary lesions. This study compares our initial IVL experience with rotational atherectomy in real-world high-risk patients. We found that in-hospital adverse outcomes were not statistically significant, although 30-day major adverse cardiovascular events was higher with IVL. Differences in baseline characteristics and the small cohort numbers preclude definitive conclusions. With better experience and case selection, these outcomes are likely to improve, allowing IVL to effectively treat complex calcified coronary lesions. Background and Objectives We compared real-world clinical outcomes of patients receiving intravascular lithotripsy (IVL) versus rotational atherectomy (RA) for heavily calcified coronary lesions. Methods Fifty-three patients who received IVL from January 2017 to July 2020 were retrospectively compared to 271 patients who received RA from January 2017 to December 2018. Primary endpoints were in-hospital and 30-day major adverse cardiovascular events (MACE). Results IVL patients had a higher prevalence of acute coronary syndrome (56.6% vs 24.4, p<0.001), multivessel disease (96.2% vs 73.3%, p<0.001) and emergency procedures (17.0% vs 2.2%, p<0.001) compared to RA. In-hospital MACE (11.3% vs 5.9%, p=0.152), MI (7.5% vs 3.3%, p=0.152), and mortality (5.7% vs 3.0%, p=0.319) were not statistically significant. 30-day MACE was higher in the IVL cohort vs RA (17.0% vs 7.4%, p=0.035). Propensity score adjusted regression using IVL was also performed on in-hospital MACE (odds ratio [OR], 1.677; 95% confidence interval [CI], 0.588–4.779) and 30-day MACE (OR, 1.910; 95% CI, 0.774–4.718). Conclusions These findings represent our initial IVL experience in a high-risk, real-world cohort. Although the event rate in the IVL arm was numerically higher compared to RA, the small numbers and retrospective nature of this study preclude definitive conclusions. These clinical outcomes are likely to improve with greater experience and better case selection, allowing IVL to effectively treat complex calcified coronary lesions.
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Affiliation(s)
- Jie Jun Wong
- Department of Cardiology, National Heart Centre, Singapore
| | | | - Yann Shan Keh
- Department of Cardiology, National Heart Centre, Singapore
| | - Yee How Lau
- Department of Cardiology, National Heart Centre, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre, Singapore
| | - Muhammad Idu
- Department of Cardiology, National Heart Centre, Singapore
| | - Chee Yang Chin
- Department of Cardiology, National Heart Centre, Singapore
| | - Jiang Ming Fam
- Department of Cardiology, National Heart Centre, Singapore
| | - Boon Wah Liew
- Department of Cardiology, Changi General Hospital, Singapore
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre, Singapore
| | | | - Tian Hai Koh
- Department of Cardiology, National Heart Centre, Singapore
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Jiang J, Eichler J, Bodner W, Fox J, Garg M, Kabarriti R, Kalnicki S, Mehta K, Rivera A, Tang J, Yap J, Ohri N, Klein J. Predictors of Financial Toxicity in Patients Receiving Concurrent Radiation and Chemotherapy. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Makhija J, Samantha S, Forseen C, Taskar V, Yap J. 338: A serendipitous role of telehealth in postpandemic CF care. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01762-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wong CJ, Yap J, Gao F, Lau YH, Huang W, Yeo KK. Clinical characteristics and outcomes of myocardial infarction with nonobstructive coronary arteries. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1492] [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: 11/12/2022] Open
Abstract
Abstract
Background
Myocardial infarction with nonobstructive coronary arteries (MINOCA) is caused by a heterogenous group of conditions with clinically significant sequelae.
Purpose
This study aims to compare the clinical characteristics and prognosis of MINOCA with myocardial infarction with obstructive coronary artery disease (MICAD).
Methods
Data was obtained from the Singapore Cardiac Longitudinal Outcomes Database (SingCLOUD), a national multicenter registry of patients with cardiovascular disease. Patients with a first presentation of acute myocardial infarction who underwent coronary angiography between 1 January 2011 and 31 December 2014 were extracted from the database. Follow up was conducted until 31 December 2017. Subjects were classified as having either MICAD or MINOCA based on angiographic findings. The primary outcomes were all-cause mortality and major adverse cardiac events (MACE) defined as a composite of all-cause mortality, recurrent myocardial infarction, hospitalization for heart failure and ischemic stroke.
Results
All 4124 patients who met the inclusion criteria were included in this study, of which 159 (3.9%) were diagnosed with MINOCA. Patients with MINOCA were more likely to be female, present with a non-ST elevation myocardial infarction (NSTEMI), have a higher left ventricular ejection fraction and less likely to have diabetes mellitus, previous ischemic stroke or smoking history. Over a mean follow-up duration of 4.5 years, MINOCA patients had a lower incidence of all-cause mortality (10.1% vs. 16.5%, p=0.030) and MACE (20.8% vs. 35.5%, p<0.0001) compared to patients with MICAD. On multivariable analysis, patients with MINOCA had a significantly lower risk of all-cause mortality (HR 0.42; 95% CI 0.21–0.82; p=0.011), MACE (HR 0.42; 95% CI 0.26–0.69; p=0.001) and recurrent myocardial infarction (HR 0.35; 95% CI 0.15–0.85; p=0.021). Within the MINOCA group, older age, higher creatinine, a STEMI presentation and the absence of antiplatelet use predicted all-cause mortality and MACE.
Conclusions
While patients with MINOCA had better clinical outcomes compared to MICAD patients, MINOCA is not a benign entity with about one in five patients experiencing a major adverse cardiovascular event in the mid-term.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Project Grant
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Affiliation(s)
- C J Wong
- National Heart Centre Singapore, Singapore, Singapore
| | - J Yap
- National Heart Centre Singapore, Singapore, Singapore
| | - F Gao
- National Heart Centre Singapore, Singapore, Singapore
| | - Y H Lau
- National Heart Centre Singapore, Singapore, Singapore
| | - W Huang
- National Heart Centre Singapore, Singapore, Singapore
| | - K K Yeo
- National Heart Centre Singapore, Singapore, Singapore
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Tan ESJ, Chan SP, Liew OW, Chong JPC, Leong GKT, Yeo DPS, Ong HY, Jaufeerally F, Yap J, Sim D, Ng TP, Ling LH, Lam CSP, Richards AM. Atrial Fibrillation and the Prognostic Performance of Biomarkers in Heart Failure. Clin Chem 2021; 67:216-226. [PMID: 33279970 DOI: 10.1093/clinchem/hvaa287] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/28/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Consideration of circulating biomarkers for risk stratification in heart failure (HF) is recommended, but the influence of atrial fibrillation (AF) on prognostic performance of many markers is unclear. We investigated the influence of AF on the prognostic performance of circulating biomarkers in HF. METHODS N-terminal pro-B-type natriuretic peptide (NT-proBNP), mid-regional-pro-atrial natriuretic peptide, C-type natriuretic peptide (CNP), NT-proCNP, high-sensitivity troponin-T, high-sensitivity troponin-I, mid-regional-propeptide adrenomedullin, co-peptin, growth differentiation factor-15, soluble Suppressor of Tumorigenicitiy (sST2), galectin-3, and procalcitonin plasma concentrations were measured in a prospective, multicenter study of adults with HF. AF was defined as a previous history of AF, and/or presence of AF/flutter on baseline 12-lead electrocardiogram. The primary outcome was the composite of HF-hospitalization or all-cause mortality at 2 years. RESULTS Among 1099 patients (age 62 ± 12years, 28% female), 261(24%) patients had AF. Above-median concentrations of all biomarkers were independently associated with increased risk of the primary outcome. Significant interactions with AF were detected for galectin-3 and sST2. In considering NT-proBNP for additive risk stratification, sST2 (adjusted hazard ratio [AHR]1.85, 95%confidence interval [C.I.] 1.17-2.91) and galectin-3 (AHR1.85, 95%C.I. 1.09-2.45) were independently associated with increased primary outcome only in the presence of AF. The prognostic performance of sST2 was also stronger in AF for all-cause mortality (AF: AHR2.82, 95%C.I. 1.26-6.21; non-AF: AHR1.78, 95% C.I. 1.14-2.76 without AF), while galectin-3 predicted HF-hospitalization only in AF (AHR1.64, 95%C.I. 1.03-2.62). CONCLUSIONS AF modified the prognostic utility of selected guideline-endorsed HF-biomarkers. Application of markers for prognostic purposes in HF requires consideration of the presence or absence of AF. CLINICAL TRIAL REGISTRATION ACTRN12610000374066.
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Affiliation(s)
- Eugene S J Tan
- National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University, Singapore
| | - Siew-Pang Chan
- National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University, Singapore
| | - Oi-Wah Liew
- Yong Loo Lin School of Medicine, National University, Singapore
| | - Jenny P C Chong
- Yong Loo Lin School of Medicine, National University, Singapore
| | | | - Daniel P S Yeo
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Hean-Yee Ong
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore
| | - Fazlur Jaufeerally
- Department of Internal Medicine, Singapore General Hospital.,Duke-NUS Graduate Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre, Singapore
| | - David Sim
- Duke-NUS Graduate Medical School, Singapore.,Department of Cardiology, National Heart Centre, Singapore
| | - Tze-Pin Ng
- Yong Loo Lin School of Medicine, National University, Singapore
| | - Lieng-Hsi Ling
- National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University, Singapore
| | - Carolyn S P Lam
- Duke-NUS Graduate Medical School, Singapore.,Department of Cardiology, National Heart Centre, Singapore.,University Medical Centre Groningen, Netherlands
| | - Arthur M Richards
- National University Heart Centre, Singapore.,Christchurch Heart Institute, University of Otago, New Zealand.,Cardiovascular Research Institute, National University Health System, Singapore
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Yap J, Anbalakan K, Tay WT, Ting D, Cheung CY, Sabanayagam C, Cheng CY, Wong TY, Yeo KK. Impact of type 2 diabetes and microvascular complications on mortality and cardiovascular outcomes in a multiethnic Asian population. BMJ Open Diabetes Res Care 2021; 9:9/1/e001413. [PMID: 34244217 PMCID: PMC8268896 DOI: 10.1136/bmjdrc-2020-001413] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/17/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Diabetes mellitus is a growing public health epidemic in Asia. We examined the impact of type 2 diabetes, glycemic control and microvascular complications on mortality and cardiovascular outcomes in a multiethnic population-based cohort of Asians without prior cardiovascular disease. RESEARCH DESIGN AND METHODS This was a prospective population-based cohort study in Singapore comprising participants from the three major Asian ethnic groups: Chinese, Malays and Indians, with baseline examination in 2004-2011. Participants with type 1 diabetes and those with cardiovascular disease at baseline were excluded. Type 2 diabetes, Hemoglobin A1c (HbA1c) levels and presence of microvascular complications (diabetic retinopathy and nephropathy) were defined at baseline. The primary outcome was all-cause mortality and major adverse cardiovascular events (MACEs), defined as a composite of cardiovascular mortality, myocardial infarction, stroke and revascularization, collected using a national registry. RESULTS A total of 8541 subjects were included, of which 1890 had type 2 diabetes at baseline. Subjects were followed for a median of 6.4 (IQR 4.8-8.8) years. Diabetes was a significant predictor of mortality (adjusted HR 1.74, 95% CI 1.45 to 2.08, p<0.001) and MACE (adjusted HR 1.64, 95% CI 1.39 to 1.93, p<0.001). In those with diabetes, higher HbA1c levels were associated with increased MACE rates (adjusted HR (per 1% increase) 1.18, 95% CI 1.11 to 1.26, p<0.001) but not mortality (p=0.115). Subjects with two microvascular complications had significantly higher mortality and MACE compared with those with only either microvascular complication (adjusted p<0.05) and no microvascular complication (adjusted p<0.05). CONCLUSION Diabetes is a significant predictor of mortality and cardiovascular morbidity in Asian patients without prior cardiovascular disease. Among patients with type 2 diabetes, poorer glycemic control was associated with increased MACE but not mortality rates. Greater burden of microvascular complications identified a subset of patients with poorer outcomes.
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Affiliation(s)
- Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Wan Ting Tay
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Daniel Ting
- Department of Ophthalmology, Singapore Eye Research Institute, Singapore
- Duke-NUS Medical School, Singapore
| | - Carol Yim Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Ching-Yu Cheng
- Department of Ophthalmology, Singapore Eye Research Institute, Singapore
- Duke-NUS Medical School, Singapore
| | - Tien-Yin Wong
- Department of Ophthalmology, Singapore Eye Research Institute, Singapore
- Duke-NUS Medical School, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
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Tay E, Khaing T, Yin WH, Posas EF, Kao PHL, Buddhari W, Hayashida K, Ho KW, Lin MS, Yap J, Zhang JJ, Chiam PTL, Rosli MA, Park SJ, Udayacherm W, Yanagisawa R, Tan HC, Lee MK. Asia Pacific TAVI registry (an APSIC initiative): initial report of early outcomes: Asia Pacific TAVI registry. AsiaIntervention 2021; 7:54-59. [PMID: 34913003 PMCID: PMC8657041 DOI: 10.4244/aij-d-18-00053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 05/18/2021] [Indexed: 06/14/2023]
Abstract
AIMS The aim of the study was to report the clinical experience, 30-day mortality and acute outcomes of patients undergoing transcatheter aortic valve implantation (TAVI) in the Asia Pacific region. METHODS AND RESULTS The Asia Pacific TAVI registry is an international, multicentre, prospective, observational registry managed under the auspices of the Asian Pacific Society of Interventional Cardiology (APSIC). Patients undergoing TAVI in seven centres from Hong Kong, Japan, Philippines, Singapore and Taiwan, treated with TAVI devices for severe symptomatic aortic stenosis, were assessed. This first review presents the acute results and 30-day mortality. A multivariable analysis was also performed to identify independent predictors of early all-cause mortality. The enrolment was from 2009 to 2017 and a total of 1,125 patients were recruited. The 30-day mortality rate was 2.5%. Baseline logistic EuroSCORE more than 16 was independently associated with a 2.8-times increased risk of 30-day all-cause mortality (p=0.016). Post-procedural stroke (HR 4.9, p=0.008) was also associated with increased mortality. CONCLUSIONS This initial report of the Asia Pacific TAVI registry demonstrated good acute success and low 30-day mortality. The preprocedural logistic EuroSCORE and post-procedural stroke incidence were strongly associated with acute mortality. Further attempts to reduce post-procedural stroke should be explored.
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Affiliation(s)
- Edgar Tay
- Cardiology Department, National University Heart Centre, Singapore, Singapore
- National University Singapore, Singapore
| | - Thet Khaing
- National University Heart Centre, 5 Lower Kent Ridge Rd, Singapore 119074. E-mail:
| | - Wei Hsian Yin
- Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Paul Hsien-Li Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wacin Buddhari
- Division of Cardiovascular Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kentaro Hayashida
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Kay Woon Ho
- Duke-NUS Medical School, Singapore
- National Heart Centre Singapore, Singapore
| | - Mao Shin Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | - Ryo Yanagisawa
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Huay Cheem Tan
- Cardiology Department, National University Heart Centre, Singapore, Singapore
- National University Singapore, Singapore
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Sheriff I, Lima A, Tseng O, Aviña A, Dawes M, Barber CEH, Esdaile J, Shojania K, Koehn CL, Hoens A, Mcquitty S, Singh S, Yap J, Page D, Kur J, Hobson B, Price M, Lacaille D. POS0303 PREVENTION OF CHRONIC DISEASES DUE TO INFLAMMATION IN INFLAMMATORY ARTHRITIS: RESULTS OF A DELPHI PROCESS TO SELECT CARE RECOMMENDATIONS FOR AN ELECTRONIC MEDICAL RECORD (EMR) INTERVENTION. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Inflammatory arthritis (IA) predisposes patients to several chronic conditions including cardiovascular diseases (CVD), diabetes (DM), osteoporosis (OP) and infections, likely due to systemic effects of inflammation. Studies have found that patients with IA often receive suboptimal care for screening and managing these conditions.Objectives:This is the first phase of a study which will develop and pilot test automated EMR reminders for family physicians. The reminders will prompt family physicians to screen for and address risk factors for these conditions. We conducted a Delphi process to select care recommendations to be addressed by the EMR reminders.Methods:We conducted a review of current BC, Canadian and international guidelines for screening and addressing risk factors for CVD, DM, OP and infection. A list of 22 care recommendations, including their level of evidence and risks/benefits of implementation, was reviewed by a panel of six family physicians, three rheumatologists and three IA patients, in a three-round online modified Delphi process. Panelists rated each care recommendation, using 9-point scales, on 1) their clinical importance, 2) their likelihood of improving outcomes, and 3) implementation feasibility. Results were discussed in an online forum. Panelists then rated slightly revised care recommendations, modified based on feedback from the discussion. Care recommendations were retained if the median rating was ≥7 with no disagreement as defined by the RAND/UCLA Method handbook.Results:A list of 15 care recommendations was selected by the Delphi process for EMR integration, including recommendations that address CVD risk assessment (1), hypertension screening (1), DM screening (2), fracture risk assessment (1), BMD testing (1), osteoporosis prevention (1) and treatment (1) with bisphosphonates, preventing infections through immunization (2), minimizing steroids (1) and hepatitis screening (1), screening for hydroxychloroquine retinal toxicity (1), and counselling for lifestyle modifications (2). We excluded 7 recommendations which addressed lipid testing (1), BMD testing in steroid users (1), immunizations (2), weight management (1), and DMARD laboratory test monitoring (2). Recommendations were excluded on the basis of importance (1) or feasibility (6).Conclusion:The results of the Delphi process will inform the development of reminders, integrated in EMRs, that will support family physicians in their efforts to engage IA patients in addressing risk factors for chronic diseases related to inflammation. We hope to improve the prevention of these diseases, which represent an important cause of morbidity and mortality for people with inflammatory arthritis.Acknowledgements:Iman Sheriff’s work on this project was funded by the CRA summer studentship programme. Dr. Lacaille is supported by the Mary Pack Chair in Arthritis Research from UBC and The Arthritis Society of Canada. Thank you to all who participated in the Delphi survey.Disclosure of Interests:None declared
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Wang ZS, Yap J, Koh YLE, Chia SY, Nivedita N, Ang TWA, Goh SCP, Lee CS, Tan LLJ, Ooi CW, Seow M, Yeo KK, Chua SJT, Tan NC. Predicting Coronary Artery Disease in Primary Care: Development and Validation of a Diagnostic Risk Score for Major Ethnic Groups in Southeast Asia. J Gen Intern Med 2021; 36:1514-1524. [PMID: 33772443 PMCID: PMC8175488 DOI: 10.1007/s11606-021-06701-z] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) risk prediction tools are useful decision supports. Their clinical impact has not been evaluated amongst Asians in primary care. OBJECTIVE We aimed to develop and validate a diagnostic prediction model for CAD in Southeast Asians by comparing it against three existing tools. DESIGN We prospectively recruited patients presenting to primary care for chest pain between July 2013 and December 2016. CAD was diagnosed at tertiary institution and adjudicated. A logistic regression model was built, with validation by resampling. We validated the Duke Clinical Score (DCS), CAD Consortium Score (CCS), and Marburg Heart Score (MHS). MAIN MEASURES Discrimination and calibration quantify model performance, while net reclassification improvement and net benefit provide clinical insights. KEY RESULTS CAD prevalence was 9.5% (158 of 1658 patients). Our model included age, gender, type 2 diabetes mellitus, hypertension, smoking, chest pain type, neck radiation, Q waves, and ST-T changes. The C-statistic was 0.808 (95% CI 0.776-0.840) and 0.815 (95% CI 0.782-0.847), for model without and with ECG respectively. C-statistics for DCS, CCS-basic, CCS-clinical, and MHS were 0.795 (95% CI 0.759-0.831), 0.756 (95% CI 0.717-0.794), 0.787 (95% CI 0.752-0.823), and 0.661 (95% CI 0.621-0.701). Our model (with ECG) correctly reclassified 100% of patients when compared with DCS and CCS-clinical respectively. At 5% threshold probability, the net benefit for our model (with ECG) was 0.063. The net benefit for DCS, CCS-basic, and CCS-clinical was 0.056, 0.060, and 0.065. CONCLUSIONS PRECISE (Predictive Risk scorE for CAD In Southeast Asians with chEst pain) performs well and demonstrates utility as a clinical decision support for diagnosing CAD among Southeast Asians.
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Affiliation(s)
- Zhen Sinead Wang
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore.
- Duke-NUS Medical School, Singapore, Republic of Singapore.
| | - Jonathan Yap
- National Heart Centre Singapore, Singapore, Republic of Singapore.
| | | | - Shaw Yang Chia
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | - N Nivedita
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Teck Wee Andrew Ang
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Soo Chye Paul Goh
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Cia Sin Lee
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | | | - Chai Wah Ooi
- National Healthcare Group Polyclinics - Geylang Branch, Singapore, Republic of Singapore
| | - Matthew Seow
- Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Khung Keong Yeo
- Duke-NUS Medical School, Singapore, Republic of Singapore
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | - Siang Jin Terrance Chua
- Duke-NUS Medical School, Singapore, Republic of Singapore
- National Heart Centre Singapore, Singapore, Republic of Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore, Singapore, Republic of Singapore
- Duke-NUS Medical School, Singapore, Republic of Singapore
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Wong MYZ, Yap J, Huang W, Tan SY, Yeo KK. Impact of Age and Sex on Subclinical Coronary Atherosclerosis in a Healthy Asian Population. JACC: Asia 2021; 1:93-102. [PMID: 36338370 PMCID: PMC9627875 DOI: 10.1016/j.jacasi.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022]
Abstract
Background The influence of age and sex on clinical atherosclerotic cardiovascular disease is well reported, but literature remains sparse on whether these extend to the disease in its preclinical stage. Objectives The purpose of this study was to report the prevalence, risk factors, and impact of age and sex on the burden of subclinical coronary atherosclerosis in a healthy Asian population. Methods Healthy subjects age 30 to 69 years, with no history of cardiovascular disease or diabetes were recruited from the general population. Subclinical coronary atherosclerosis was quantified via the coronary artery calcium score (CAC) with CAC of 0 indicating absence of calcified plaque, 1 to 10 minimal plaque, 11 to 100 mild plaque, and >100 moderate to severe plaque. Results A total of 663 individuals (mean age 49.4 ± 9.2 years; 44.8% men) were included. The prevalence of any CAC was 29.3%, with 9% having CAC >100. The prevalence was significantly higher in men than women (43.1% vs 18.0%; P < 0.001). Multivariable analysis revealed significant associations of increasing age, male sex, higher blood pressure, increased glucose levels, and higher low-density lipoprotein cholesterol levels with the presence of any CAC. Low-density lipoprotein cholesterol was more significantly associated with CAC in women compared with men (Pinteraction = 0.022). Conclusions The prevalence of preclinical atherosclerosis increased with age, and was higher in men, with sex-specific differences in associated risk factors. These results will better inform individualized future risk management strategies to prevent the development and progression of coronary artery disease within healthy individuals.
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Wong M, Yap J, Yeo KK. Impact of age and sex on subclinical coronary atherosclerosis in a healthy asian population. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.052] [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: 11/14/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background and Aims
The influence of age and gender on clinical atherosclerotic cardiovascular disease is well reported, but literature remains sparse on whether these extend to the disease in its preclinical stage. We aim to report the prevalence, risk-factors and impact of age and gender on the burden of subclinical coronary atherosclerosis in a healthy Asian population.
Methods
Healthy subjects aged 30-69 years old, with no history of cardiovascular disease or diabetes were recruited from the general population. Subclinical coronary atherosclerosis was quantified via the Coronary Artery Calcium Score (CACS) with CACS of 0 indicating the absence of calcified plaque, 1 to 10 minimal plaque, 11 to 100 mild plaque, and >100 moderate to severe plaque.
Results
A total of 663 individuals (mean age 49.4 ± 9.2 years, 44.8% male) were included. The prevalence of any CAC was 29.3% with 9% having CAC > 100. The prevalence was significantly higher in males than females (43.1 vs 18.0%, p < 0.001). These gender differences became increasingly pronounced with increasing age, especially in those with moderate-severe CAC. Multivariable analysis revealed significant associations between increasing age, male, higher blood pressure, increased glucose levels and higher LDL cholesterol levels with the presence of any CAC. LDL cholesterol was more significantly associated with CAC in females compared to males (Pinteraction = 0.022).
Conclusions
The prevalence of preclinical atherosclerosis increased with age, and was higher in males than females, with gender-specific differences in associated risk factors. These results will better inform individualised future risk management strategies to prevent the development and progression of coronary artery disease within healthy individuals.
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Affiliation(s)
- M Wong
- National Heart Centre Singapore, Singapore, Singapore
| | - J Yap
- National Heart Centre Singapore, Singapore, Singapore
| | - KK Yeo
- National Heart Centre Singapore, Singapore, Singapore
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Kiat JTC, Chia SY, Koh SHM, Sim D, Chai P, Loh SY, Jaufeerally FR, Guang SLS, Lim ZYP, Yap J. CLINICAL CHARACTERISTICS AND OUTCOMES IN ASIAN PATIENTS WITH HEART FAILURE AND MID-RANGE EJECTION FRACTION. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01983-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yap J, Slade D, Goddard H, Dawson C, Ganesan R, Velangi S, Sahu B, Kaur B, Hughes A, Luesley D. Sinecatechins ointment as a potential novel treatment for usual type vulval intraepithelial neoplasia: a single-centre double-blind randomised control study. BJOG 2021; 128:1047-1055. [PMID: 33075197 DOI: 10.1111/1471-0528.16574] [Citation(s) in RCA: 3] [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] [Accepted: 10/08/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare the safety and efficacy of 10% sinecatechins (Veregen® ) ointment against placebo in the treatment of usual type vulvar intraepithelial neoplasia (uVIN). DESIGN A Phase II double-blind randomised control trial. SETTING A tertiary gynaecological oncology referral centre. POPULATION All women diagnosed with primary and recurrent uVIN. METHODS Eligible patients were randomised 1:1 to receive either sinecatechins or placebo ointment (applied three times daily for 16 weeks) and were followed up at 2, 4, 8, 16, 32 and 52 weeks. MAIN OUTCOME MEASURES The primary outcome measure, recorded at 16 and 32 weeks, was histological response (HR). Secondary outcome measures included clinical (CR) response, toxicity, quality of life and pain scores. RESULTS There was no observed difference in HR between the two arms. However, of the 26 patients who were randomised, all 13 patients who received sinecatechins showed either complete (n = 5) or partial (n = 8) CR, when best CR was evaluated. In placebo group, three patients had complete CR, two had partial CR, six had stable disease and two were lost to follow up. Patients in the sinecatechins group showed a statistically significant improvement in best observed CR as compared with the placebo group (P = 0.002). There was no difference in toxicity reported in either group. CONCLUSION Although we did not observe a difference in HR between the two treatment arms, we found that 10% sinecatechins application is safe and shows promise in inducing clinical resolution of uVIN lesions and symptom improvement, thus warranting further investigation in a larger multicentre study. TWEETABLE ABSTRACT A randomised control study indicating that sinecatechins ointment may be a novel treatment for uVIN.
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Affiliation(s)
- J Yap
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
| | - D Slade
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - H Goddard
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
| | - C Dawson
- Department of Microbiology & Infection, Warwick Medical School, University of Warwick, Coventry, UK
| | - R Ganesan
- Department of Histopathology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - S Velangi
- Department of Dermatology, Queen Elizabeth Hospital, Birmingham, UK
| | - B Sahu
- Department of Obstetrics and Gynaecology, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - B Kaur
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A Hughes
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - D Luesley
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
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Wong M, Yap J, Sultana R, Yeo KK. ASSOCIATIONS BETWEEN NONALCOHOLIC FATTY LIVER DISEASE AND SUBCLINICAL ATHEROSCLEROSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01439-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Malhotra P, Yap J, Aman E, Rogers JH. The Yin-Yang Sign of Severe Mitral Regurgitation. J Invasive Cardiol 2021; 33:E314. [PMID: 33794480] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In select patients with severe, eccentric mitral regurgitation, we have observed that the regurgitant jet may entrain blood along the left atrial wall to produce a Chinese yin-yang symbol on color Doppler. This clinical imaging series demonstrates this unique phenomenon in an 81-year-old woman with symptomatic, severe, functional mitral regurgitation secondary to non-ischemic cardiomyopathy who was referred for transcatheter mitral valve repair. The yin-yang symbol resolved on transthoracic echocardiography after placement of 2 MitraClip NTR devices.
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Affiliation(s)
| | | | | | - Jason H Rogers
- Division of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA 95817 USA.
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Ruan W, Yap J, Quah K, Cheah FK, Phua GC, Sewa DW, Ismail AB, Chia A, Jenkins D, Tan JL, Chao V, Lim ST. Pulmonary endarterectomy and balloon pulmonary angioplasty in chronic
thromboembolic pulmonary hypertension: The Singapore experience. Ann Acad Med Singap 2021. [DOI: 10.47102/annals-acadmedsg.2020126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Wen Ruan
- National Heart Centre, Singapore
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Lim Y, Gochuico CFS, D'Ascenzo F, Ho KW, Lin MS, Gil IJN, Ielasi A, Tespili M, Mejía AC, DePaoli A, Yap J, Kao HL, Lee MKY, Tay E. Assessing the Impact of Transcatheter Aortic Valve Implantation on Cardiac Catheterisation: A Multicentric Study. Heart Lung Circ 2021; 30:1397-1405. [PMID: 33812787 DOI: 10.1016/j.hlc.2021.02.014] [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: 09/03/2020] [Revised: 12/07/2020] [Accepted: 02/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The success rate of coronary angiography (CA) after transcatheter aortic valve implantation (TAVI) is variable. Our aim was to investigate CA difficulty, outcomes, and predictors of difficult CA after TAVI. METHOD This was an international multicentric retrospective cohort study that included patients with TAVI and subsequent CA between January 2010 and December 2019. Difficulty with CA was graded as 1 (normal), 2 (partial engagement, complete vessel opacification), 3 (partial engagement, incomplete vessel opacification), and 4 (unsuccessful angiography). Patients were grouped as (a) "easy" (grade 1 for left and right) or (b) "difficult" (grade >1 for either). We compared baseline characteristics and outcomes, and performed multivariate logistic regression for predictors of difficult CA. RESULTS Of 96 patients included (mean age 77.4±8.7 years, 48 [50%] male), 88 (92%) had successful CA. Right CA was successful in 80 (83%) patients and left CA in 91 (95%) (p<0.0001). The "difficult" group (n=41 [43%]) had higher Society of Thoracic Surgery (STS) scores (7.6±4.9 vs 5.4±4.0; p=0.022), smaller annulus perimeters (72.4±5.4 mm vs 76.2±9.4 mm; p=0.049), greater use of self-expanding valves (83% vs 18%; p<0.0001), increased valve size (26.8±2.1 mm vs 25.6±3.0 mm; p=0.032), and increased oversizing for area (44.3%±17.4% vs 23.6%±22.0%; p=0.0002) and perimeter (17.5%±8.2% vs 7.1%±10.8%; p<0.0001). There was no difference in outcomes except for increased major bleeding (7.3% vs 0.0%; p=0.042). The strongest predictor for "difficult" CA was self-expanding valves when compared to balloon-expandable valves (adjusted odds ratio [aOR], 15.23; 95% confidence interval [CI], 2.27-102.40). Society of Thoracic Surgery score was borderline predictive (aOR, 1.26; 95% CI, 1.04-1.52). CONCLUSIONS Our results show that after TAVI, CA success rate is high, right CA is more difficult than left, self-expanding valves predispose to difficult CA, and STS score weakly predicts difficult CA. This study is hypothesis-generating and more research is required to confirm these findings.
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Affiliation(s)
- Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore.
| | | | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Science, University of Turin, Città della Salute e Della Scienza, Turin, Italy
| | | | - Mao-Shin Lin
- Cardiovascular Centre, National Taiwan University Hospital Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital Medical School, National Taiwan University, Taipei City, Taiwan
| | - Iván J Núñez Gil
- Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Maurizio Tespili
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Alex Castro Mejía
- Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Alessandro DePaoli
- Division of Cardiology, Department of Medical Science, University of Turin, Città della Salute e Della Scienza, Turin, Italy
| | | | - Hsien-Li Kao
- Cardiovascular Centre, National Taiwan University Hospital Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital Medical School, National Taiwan University, Taipei City, Taiwan
| | | | - Edgar Tay
- Department of Cardiology, National University Heart Centre, Singapore
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