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Three-Dimensional Echocardiography: Current Status and Real-Life Applications

The use of cardiac ultrasound is fundamental to the understanding of normal heart function and crucial to pathophysiological diagnosis. The growing availability of 3D echocardiography (3DE) over the last decade has allowed its applications to expand from establishing reference values for chamber size and elucidating ventricular mechanics, to assessing valvular disease severity and playing pivotal roles in interventional procedures. Several important advantages of 3DE include eliminating geometric assumptions, quantifying complex geometric shape volumes, viewing structures from any perspective, assessing lesion in simultaneous multiplanes or multislice mode, all of which are not possible with traditional 2D echocardiography (2DE). Real-time 3DE has been shown to be simple, accurate, reproducible, and versatile, and generally has superior outcome prognosis compared to the 2DE.

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Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in Patients with Diabetic Nephropathy and Left Main Coronary Artery Disease

Background: Patients with diabetic nephropathy and unprotected left main (LM) coronary artery disease suffer from high cardiovascular morbidity and mortality. Although surgical revascularization is currently recommended in this special patient population, the optimal revascularization method for this distinct patient group has remained unclear. Methods:We collected 99 consecutive patients with unprotected LMdisease and diabetic nephropathy, including 46 patients who had undergone percutaneous coronary intervention (PCI), and 53 who had coronary artery bypass grafting (CABG), with a mean age of 72 ± 10; with 80.8% male. Diabetic nephropathy was defined as overt proteinuria (proteinuria ＞ 500 mg/day) and estimated glomerular filtration rate (eGFR) by the modified Modification of Diet in Renal Disease (MDRD) equation of less than 60 mL/min/1.73m^2. The baseline characteristics, angiographic results and long-term clinical outcomes were retrospectively analyzed. Results: The baseline characteristic of all patients were similar except for smokers, low density lipoprotein (LDL) level and extension of coronary artery disease involvement. The median follow-up period was 3.8 years. There were 73 patients (74%) considered as high risk with additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥ 6. During follow-up period, the long term rate of all-cause death (PCI vs. CABG: 45.7% vs. 58.5%, p = 0.20) and all-cause death/myocardial infarction (MI)/stroke (PCI vs. CABG: 52.2% vs. 60.4%, p = 0.41) were comparable between the PCI and CABG group, whereas the repeat revascularization rate was significantly higher in the PCI group (PCI vs. CABG: 32.6% vs. 9.4%, p ＜ 0.01). eGFR remained an independent predictor for all-cause death [hazard ratio: 0.97, 95% confidence interval: 0.96 to 0.99; p = 0.002] in multivariate logistic regression. Conclusions: In the real-world practice of high-risk patients with unprotected LM disease and diabetic nephropathy, we found that PCI was a comparable alternative to CABG in terms of long-term risks of all-cause death/MI/stroke, with significantly higher repeat revascularization rate. Given the small patient number and retrospective nature, our findings should be validated by larger-scale randomized studies.

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One-Year Outcomes of Acute Decompensated Systolic Heart Failure in Taiwan: Lessons from TSOC-HFrEF Registry

Background: Heart failure (HF) is a global health problem. The Taiwan Society of Cardiology-Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry was a multicenter, observational survey of patients admitted with HFrEF in Taiwan. The aim of this study was to report the one-year outcome in this large-cohort of hospitalized patients presenting with acute decompensated HFrEF. Methods: Patients hospitalized for acute HFrEF were recruited in 21 hospitals in Taiwan. A total of 1509 patients were enrolled into the registry by the end of October 2014. Clinical status, readmission rates and dispensed medications were collected and analyzed 1 year after patient index hospitalization. Results: Our study indicated that re-hospitalization rates after HFrEF were 31.9% and 38.5% at 6 and 12 months after index hospitalization, respectively. Of these patients, 9.7% of themwere readmittedmore than once. At 6 and 12 months after hospital discharge, all-cause mortality rates were 9.5% and 15.9%, respectively, and cardiovascular mortality rateswere 6.8% and 10.5%, respectively. Twenty-three patients (1.5%) underwent heart transplantation. During a follow-up period of 1 year, 46.4% of patients were free from mortality, HF re-hospitalization, left ventricular assist device use and heart transplantation. At the conclusion of follow-up, 57.5% of patients were prescribed either with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; also, 66.3% were prescribed with beta-blockers and 40.8% were prescribed with mineralocorticoid receptor antagonists. Conclusions: The TSOC-HFrEF registry showed evidence of suboptimal practice of guideline-directed medical therapy and high HF re-hospitalization rate in Taiwan. The one-year mortality rate of the TSOC-HFrEF registry remained high. Ultimately, our data indicated a need for further improvement in HF care.

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Circulating Adiponectin Levels Following Treatment Can Predict Late Clinical Outcomes in Chronic Heart Failure

Background: Circulating adiponectin concentration increases in patients with chronic heart failure (HF).We sought to explore the prognostic value of temporal changes in adiponectin concentration following treatment for chronic HF. Methods: Serum adiponectin levels were measured at baseline and after a 3-month anti-failure treatment in 124 patients with symptomatic chronic systolic HF. Major adverse cardiac events (MACE) including death, heart transplantation, or hospitalization with worsening HF during a median follow-up period of 752 days were determined. Results: Univariate and multivariate analysis showed that high levels of adiponectin after a 3-month treatment were associated with a 3.8-fold increased risk of MACE (p = 0.03), independent of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Moreover, the combining of circulating levels of adiponectin with NTproBNP provided independent and additional prognostic value in identifying high risk patients with MACE during follow-up. Conclusions: Changes in adiponectin and NT-proBNP over time provide prognostic information.When adiponectin is used in conjunction with NT-proBNP in chronic HF, the prognostic value may be better than if each biomarker is used separately.

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Hyperbaric Oxygen Preconditioning Provides Preliminary Protection Against Doxorubicin Cardiotoxicity

Background: Doxorubicin (DOX) is generally recognized to have important cardiotoxic side effects. Studies are contradictory about the interaction between hyperbaric oxygen (HBO_2) therapy and doxorubicin-induced cardiomyotoxicity. Recent data suggests that HBO_2 therapy can lead to preconditioning of myocardium while generating oxidative stress. Herein we have investigated the effect of HBO_2 therapy in a DOX-induced cardiomyocyte injury animal model. Methods: Twenty-one rats were divided into three equal groups as follows: 1) Group 1 is a control group (without any intervention), used for evaluating the basal cardiac structures and determining the normal value of cardiacs and serum oxidative markers; 2) Group 2 is the doxorubicin group (single dose i.p. 20 mg/kg doxorubicin) for detecting the cardiotoxic and systemic effects of doxorubicin; 3) Group 3 is the doxorubicin and HBO_2 group (100% oxygen at 2.5 atmospheric for 90 minutes, daily), for evaluating the effect of HBO_2 in doxorubicin induced cardiotoxicity. At the end of the protocols, the hearts were harvested and blood samples (2 ml) were obtained. Results: The doxorubicin treated animals (Group 2) had increased oxidative stress markers (both cardiac and serum) and severe cardiac injury as compared to the basal findings in the control group. Nevertheless, the highest cardiac oxidative stress index was detected in Group 3 (control vs. Group 3, p = 0.01). However, histological examination revealed that cardiac structures were well preserved in Group 3 when compared with Group 2. Conclusions: Our results suggest that HBO_2 preconditioning appears to be protective in the doxorubicin-induced cardiotoxicity model. Future studies are required to better elucidate the basis of this preconditioning effect of HBO_2.

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Determinants of Treatment Modification in Hypercholesterolemic Patients

Background: There is a lack of knowledge of those contemporary factors associated with modifying subtherapeutic treatments in hypercholesterolemic patients. The aim of this study was to assess determinants of treatment modification in patients not attaining their low-density lipoprotein cholesterol goals. Methods: The CEntralized Pan-Asian survey on tHE Under-treatment of hypercholeSterolemia enrolled patients taking stable lipid-lowering medications. The study physicians then determined existing patient treatments, which were to be continued or modified when treatments failed. The patient questionnaire surveying patient attitudes and perceptions toward their hypercholesterolemia management was prospectively collected. The odds ratios (ORs) (95% confidence intervals) were calculated. Results: Among the 420 patients included for analysis, 35.7%were designated for planned treatment modification. Those patients assigned to treatment modification were more likely to have a family history of premature coronary heart disease (40% vs. 19%), an indication for secondary prevention (76% vs. 61%), elevated triglyceride (60% vs. 48%) and fasting sugar (84% vs. 67%), and were less adherent to their medications (29% vs. 12%) than patients assigned to treatment continuation. Patient recognition of treatment failure [OR, 1.82 (1.13-2.94)], the lower frequency of cholesterol checkup [OR, 2.40 (1.41-4.08)], patient satisfaction with provided cholesterol information [OR, 2.30 (1.21-4.39)], and their feelings toward cholesterol management [OR, 0.25 (0.10-0.62) and 3.80 (2.28- 6.32)] for confusion and no strong feeling, respectively were determinants of the treatment modification assignment. Conclusions: There was a large gap between evidence-based goals and modification of subtherapeutic treatments, particularly among patients with lower treatment satisfaction and better compliance. Our findings have emphasized the need to further reduce inertia in implementing hypercholesterolemia management.

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Insomnia and the Risk of Atrial Fibrillation: A Population-Based Cohort Study

Background: Although advancements in the treatment of atrial fibrillation have improved patient prognosis for this persistent condition, interest in atrial fibrillation development is growing. Of note is the fact that additional attention is being focused on the accompanying effect of insomnia. The aim of the study was to investigate the effects of insomnia on the risk of atrial fibrillation development. Methods: This was a nationwide population-based retrospective cohort study using data from the Taiwan National health Insurance Research Database. We analyzed 64,421 insomnia cases and 128,842 matched controls without insomnia from January 1, 2000, to December 31, 2010. A Cox regression model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for atrial fibrillation development. Results: During the follow-up period, the incidence of atrial fibrillation development was significantly higher in the insomnia cases than in the comparison cohort (2.6% vs. 2.3%, p ＜ 0.001). Insomnia was associated with an increased risk of atrial fibrillation (HR = 1.08, 95% CI: 1.01-1.14). Males, those ＞ 65 years of age, and patients with peripheral artery disease who have insomnia had a higher rate of atrial fibrillation development. Conclusions: The findings of this nationwide analysis support the hypothesis that insomnia is associated with a significant risk of atrial fibrillation development.

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Impact of Physician-Coordinated Intensive Follow-Up on Long-Term Medical Costs in Patients with Unstable Angina Undergoing Percutaneous Coronary Intervention

Background: To investigate the impact of professional physician-coordinated intensive follow-up on long-term expenditures after percutaneous coronary intervention (PCI) in unstable angina (UA) patients. Methods: In this study, therewere 669 UA patients who underwent successful PCI and followed up for 3 years, then divided into the intensive follow-up group (N = 337), and the usual follow-up group (N = 332). Patients were provided with detailed discharge information and individualized follow-up schedules. The intensive group received the extra follow-up times and medical consultations, and all patients were followed up for approximately 3 years. Results: At the 3-year mark after PCI, the cumulative major adverse cardiac events (MACE), recurrence ofmyocardial ischemia, cardiac death, all-cause death and revascularization in the intensive group were lower than in the usual group. Additionally, the proportion of good medication adherence was significantly higher than in the usual group (56.4% vs. 46.1%, p ＜ 0.001). The hospitalization daytime, total hospitalization cost and total medical cost in the intensive group were lower. Multiple linear regression showed that diabetes, hypertension, intensive follow-up and good medication adherence were associated with emergency and regular clinical cost (p ＜ 0.05), the re-hospitalization cost (p ＜ 0.05) and the total medical cost (p ＜ 0.05) of patient care. Intensive follow-up and good adherence were negatively correlated with the cost of re-hospitalization (standardized coefficients = -0.132, -0.128, p ＜ 0.05) and total medical costs (standardized coefficients = -0.072, -0.086, p ＜ 0.05). Conclusions: Intensive follow-up can reduce MACE, improve medication adherence and save long-term total medical costs, just by increasing the emergency and regular clinical visits cost in UA patients after PCI.

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Impaired Left Ventricular Diastolic Functions and Thickened Epicardial Adipose Tissue in Rheumatoid Arthritis Patients is Correlated with DAS-28 Score

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease that is known to be associated with high cardiovascular (CV) morbidity and mortality. In this study, we aimed to demonstrate whether RA disease activity reflected with disease activity score-28 (DAS-28) had an impact on left ventricular diastolic functions and epicardial adipose tissue (EAT) thickness in RA patients with no traditional CV risk factors. Methods: In this retrospective study, 41 patients newly diagnosed with RA were included. In addition to medical history, detailed physical examination findings and laboratory tests, left ventricular systolic and diastolic functions, chamber dimensions, and EAT thickness were evaluated with transthoracic echocardiography in the study population. Results: This study included 41 subjects with a median age of 45 years (38.00-55.50), of which 29.27% were male. In the binomial logistic regression analysis, DAS-28 score was found to be an independent associate of diastolic dysfunction, Additionally, DAS-28 was found to be independently associated with EAT thickness. Conclusions: Patients with high DAS-28 score should be evaluated thoroughly for CV disease, and patients should undergo advanced diagnostic studies as required and receive appropriate treatment.

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Anti-Platelet Factor 4/Heparin Antibody Plays a Significant Role in Progression of Arterial Stiffness among Hemodialysis Patients

Background: Arterial stiffness is a determinant of cardiovascular disease in end stage renal disease. Hemodialysis patients may develop anti-platelet factor 4/heparin antibody (PF4-H Ab) because of heparin treatment in dialysis. We tested whether PF4-H Ab was associated with progression of arterial stiffness in a 3-year follow-up. Methods: We enrolled 74 hemodialysis patients and studied their clinical, biochemical and arterial stiffness measurement with brachial-ankle pulse wave velocity (baPWV) over 3 years. Baseline and changes in baPWV after 3 years (ΔbaPWV) were collected and compared with related clinical and biochemical parameters. PF4-H Ab was evaluated by the enzyme-linked immunosorbent assay and titer ≥ 0.4 was defined to have PF4-H Ab. Results:We found a positive PF4-H Ab status in 25 of 74 patients.Mean baPWVwas 16.1 ± 3.8 (m/s) at baseline and 17.6 ± 4.0 (m/s) after 3 years. Mean ΔbaPWV was 3.4 ± 2.2 (m/s) in the PF4-H Ab positive group, and 0.6 ± 1.2 (m/s) in the PF4-H Ab negative group. Baseline baPWV was only significantly associated with age (β = 0.49, p ＜ 0.01). ΔbaPWV was significantly different between the PF4-H Ab positive and negative groups (p ＜ 0.01). In multivariate regression analysis, only PF4-H Ab was positively associated with ΔbaPWV (β= 0.71, p ＜ 0.01). Conclusions: Our study concluded that PF4-H Abwas associated with progression of arterial stiffness in hemodialysis patients.