• 期刊

The Management and Prognostic Factors of Acute Coronary Syndrome: Evidence from the Taiwan Acute Coronary Syndrome Full Spectrum Registry

Cardiovascular disease (CVD) accounts for approximately one-third of all global deaths, and acute coronary syndrome (ACS) is the most severe form of CVD. It is of notable importance to develop ACS strategies for reducing major adverse cardiac events (MACE) and preventing complications. In the Taiwan ACS Full Spectrum Registry, 1-year mortality among patients with ST-segment elevation myocardial infarction, non ST-segment elevation myocardial infarction and unstable angina was 6.1%, 10.1%, and 6.2%, respectively. ACS patientswith diabetes had significantly worse outcomes in terms of all-cause death and MACE compared to those without diabetes. In-hospital bleeding or chronic kidney disease (CKD) was independently associated with MACE, and ACS patients with both bleeding and CKD had the worst outcome. Use of clopidogrel in conjunction with an invasive strategy could decrease mortality and improve outcomes in the CKD population. CHADS_2 and CHA_2DS_2-VASc scores were useful predictors of subsequent MACE, and renal dysfunction could further improve the prognostic impact of the CHA_2DS_2-VASc score. For high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), percutaneous coronary intervention (PCI) within 24-72 hours from symptom onset was demonstrably the optimal time. Suboptimal secondary preventive therapy demonstrated a need for further improvement. The ACS Full Spectrum Registry provided an in-depth analysis of ACS management in Taiwan.

• 期刊

Procedural Characteristics and Outcomes of Transcatheter Aortic Valve Implantation: A Single-Center Experience of the First 100 Inoperable or High Surgical Risk Patients with Severe Aortic Stenosis

Background: This is the first study of a Taiwanese population reporting transcatheter aortic valve implantation (TAVI) outcomes of the first 100 cases from a single center offering two different transcatheter heart valve technologies via six types of approaches. We herein report the 30-day and one-year outcomes in our first 100 TAVI patients at Taipei Veterans General Hospital. Methods: From May 2010 to April 2016, 100 consecutive patients with severe aortic stenosis (AS) who were considered unsuitable or at high risk for surgical aortic valve replacement underwent TAVI. Patient outcomes were classified according to the Valve Academic Research Consortium-2 (VARC-2) definitions. The device performance was assessed using transthoracic echocardiography by independent investigators. Results: The mean patient age was 81.1 years, where 54% were female, and the mean Logistic EuroSCORE was 21.5%. The Medtronic CoreValve was used in 84 patients and the Edwards Sapien or Sapien XT valve (ESV) in 16. The transfemoral approachwas the most frequently used route (83%), followed by transapical (9%) access. Overall, there was no procedural death. The VARC-2 outcomes were as follows: device success, 95%; stroke, 1%; major vascular complication, 3%; a need for pacemaker implantation, 5.1%. At discharge, the incidence of postoperativemild, moderate or severe paravalvular leak was 30%, 3% and 0%, respectively. At one year, the all-cause mortality rate was 14.0%, and no valve-related dysfunction was observed. Through multivariable analysis, non-transfemoral access [hazard ratios (HR) 4.81; 95% confidence interval (CI) 1.66-14.09; p = 0.004] and advanced chronic kidney disease (stages 4-5), (HR 3.13; 95% CI 1.07-9.09; p = 0.036)were independently associated with an increased risk of one-year mortality. Conclusions:We demonstrated that TAVI shows good early and mid-term outcomes in terms of survival, technical success, valve-related adverse events and haemodynamic performance in high-risk patients with severe AS.

• 期刊

Transcatheter Aortic Valve Implantation in Taiwan: Still Evolving!

• 期刊

The Impact of Fractional Flow Reserve-Guided Coronary Revascularization in Patients with Coronary Stenoses of Intermediate Severity

Background: Previous studies have shown that the use of fractional flow reserve (FFR) in addition to angiography significantly reduced the rate of all major adverse cardiovascular events (MACE). However, this practice has not been widely accepted and limited outcome data exist about FFR-guided percutaneous coronary intervention (PCI) in Taiwan. The aim of the present study was to evaluate the possible impact of FFR-guided PCI in coronary stenoses of intermediate severity. Methods: We performed a retrospective case-control study on 443 cases of intermediate coronary stenoses in 206 patients recruited from our computerized database. The study patients were divided into two groups: the FFR group (n = 101) and the angiography group (n = 105), matched with age, gender, clinical and angiographic lesion characteristics. In the angiography group, the indicated lesions had been treated with PCI by angiographic or anatomical assessment, whereas those patients in the FFR group underwent PCI of indicated lesions only if the FFR was ＜ 0.80. The primary end point was the MACE rate regarding death, nonfatal myocardial infarction (MI), and target vessel failure at a mean follow-up of 418 days. Results: The MACE rate was similar in both groups (6% in the angiography group and 3% in the FFR group, p = 0.06). However, FFR-guided PCI strategy prevented unnecessary revascularization in up to 75% of patients, and markedly reduced costs of the index hospitalization. Moreover,multivariate analysis found that the use of drug-eluting stent and statin therapy, and the presence of family history of premature coronary artery disease and periprocedural MI are independent predictors of clinical outcomes. Conclusions: FFR-guided intervention, compared to angiography-guided intervention for Taiwanese patients with coronary stenoses of intermediate severity, achieved similar clinical outcomes and provided cost-savings.

• 期刊

SYNTAX Score of Infarct-Related Artery Other Than the Number of Coronary Balloon Inflations and Deflations as an Independent Predictor of Contrast-Induced Acute Kidney Injury in Patients with ST-Segment Elevation Myocardial Infarction

Background: Although remote ischemic post-conditioning (RIPC) has been shown to prevent contrast-induced acute kidney injury (CIAKI) in patients with acute coronary syndrome, its efficacy in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We examined the relationship among balloon inflations and deflations (BID) times, SYNTAX score of infarction-related artery (SI), periprocedural complications, and CIAKI in STEMI patients undergoing primary percutaneous coronary intervention (pPCI). Methods: Patients with STEMI undergoing pPCI with Mehran risk score (MRS)≥ 5 were enrolled between February 2007 and September 2012. The study end point was the development of CIAKI. Results: Of 206 patients, the median age was 65 years [interquartile range (IQR): 55-77] with 72.8% male and Mehran risk score (MRS) 8 (IQR: 6-12). Receiver operating characteristic curve showed that BID times ＞ 9 times or SI ＞ 10was the best cut-off associated with CIAKI. In univariate analysis, significant associationwith CIAKI existed in BID ＞ 9 times [odds ratio (OR): 3.106, 95% confidence interval (CI): 1.284-7.513, p = 0.012] and SI ＞ 10 (OR: 3.909, 95% CI: 1.570-9.735, p = 0.003). Other variables associated with CIAKI included creatinine, hemoglobin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker use at discharge. In multivariate analysis, SI ＞ 10 remained an independent predictor of CIAKI in different adjustment model, even on top of MRS (adjusted OR: 3.498, 95% CI: 1.086-11.268, p = 0.036). Conclusions: Vascular complexity of infarct-related artery rather than higher BID times (＞ 9) was the major determinant of the development of CIAKI after pPCI in STEMI patients.

• 期刊

Predictors of Mortality in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome-Data from Taiwan Acute Coronary Syndrome Full Spectrum Registry

Background: Some difficulties and variations remain associated with the care of elderly patients with non-ST elevation acute coronary syndrome (NSTE-ACS). Methods:We included 1470 patients froma Taiwan nationwide registry who fulfilled the criteria of NSTE-ACS, and stratified these patients by age and evaluated the treatment, complications and outcomes in different age groups. Furthermore, we analyzed risk factors and standards of care to determine the predictors of mortality. Results: Patients≥ 75 years of age (n = 396) had significantly higher incidences of 90-daymortality [odd ratio (OR) = 4.5 (1.2-16.3), p = 0.023] and 1-year mortality [OR = 4.9 (2.0-12.3), p = 0.001] compared with those patients 45-64 years of age (n = 595). In the patients _ 75 years of age, previous myocardial infarction (MI) [OR = 3.3 (1.1-9.8), p = 0.035], statins [OR = 0.35 (0.1-0.9), p = 0.037], left ventricular ejection fraction (LVEF) ＜ 35% [OR = 3.9 (1.5-10.4), p = 0.006] were associated with 90-day mortality. Furthermore, previous MI [OR = 4.0 (1.3-12.6), p = 0.019] was an independent predictor of 90-daymortality. Age [OR = 1.1 (1.03-1.2), p = 0.002], previous MI [OR = 2.2 (1.1-4.4), p = 0.034], angiotensin-converting enzyme inhibitor or angiotensin receptor blocker [OR = 0.5 (0.3-0.9), p = 0.028], and LVEF ＜ 35% [OR = 4.3 (1.9-9.5), p ＜ 0.001]were associated with 1-year mortality. Furthermore, previous MI [OR = 2.6 (1.1-6.5), p = 0.037], LVEF ＜ 35% [OR = 4.7 (1.5-14.4), p = 0.007] and percutaneous coronary intervention(PCI) or not [OR = 0.3 (0.1-0.9), p = 0.021] were independent predictors of 1-year mortality. Conclusions: Previous MI, LVEF ＜ 35% and PCI or not could predict 1-year mortality in advanced elderly patients with NSTE-ACS. Despite their elevated morbidities and complications, PCI was still beneficial for these patients.

• 期刊

Predictors of Impaired Reperfusion after Percutaneous Coronary Intervention in Patients with In-Hospital Acute Stent Thrombosis: A Retrospective Analyses of 5 Years of Data

Background: Acute stent thrombosis (STh) is a rare complication of percutaneous coronary intervention (PCI) and is associated with a high-risk of reperfusion failure. However, data focusing on risk factors of reperfusion failure in patients undergoing repeat PCI for treatment of STh remains inadequate. Methods: A total of 8815 patients who underwent PCI with stent implantation from January 2009 to December 2013 were retrospectively reviewed. Among those cases, patients that presented with acute STh and underwent a repeat PCI for acute STh were identified. Results: There were 108 patients who underwent repeat PCI for the treatment of in-hospital acute STh that were retrospectively analyzed. Of these study subjects, 21 (25%) had thrombolysis inmyocardial infarction (TIMI) flow ＜ 3 after repeat PCI. The median value of pain-to-balloon time was 40 minutes in the TIMI ＜ 3 group, 35 minutes in the TIMI = 3 group (p ＜ 0.001), and the first PCI-to-stent thrombosis time was also longer in the TIMI ＜ 3 group (10 hours vs. 2.5 hours, p = 0.001). When patients were evaluated according to PCI time, the percentage of patients with TIMI ＜ 3 was significantly higher in the night period compared to the daytime period (46.4% vs. 17.5 %, p = 0.002). In the multivariable logistic regression analysis, stent length [odds ratio (OR) = 1.18, 95% confidence interval (CI) 1.008-1.38] and pain-to- balloon time (OR = 1.28, 95% CI, 1.06-1.54) were the only independent predictors of failed reperfusion. Conclusions: Baseline stent length and pain-to-balloon time were associated with reperfusion failure in PCI for STh. Moreover, TIMI flow grade showed a circadian variation.

• 期刊

Admission Value of Serum Cathepsin D Level Can be Useful for Predicting In-Hospital Mortality in Patients with NSTEMI

Background: We aimed to investigate the association of serum cathepsin D levels with in-hospital mortality and Syntax scores (SXscore) in non-ST elevation myocardial infarction (NSTEMI) patients. Methods: A total of 88 patients were included in the study. The patients were divided into two groups: those with in-hospital mortality (-), and those with in-hospital mortality (+). The receiver operating characteristics curve was used to showthe sensitivity and specificity of serum cathepsin D levels, and the optimal cut-off value for predicting in-hospital mortality and high SXscore. Results: Patients with (+) in-hospital mortality and high SXscore had lower serum cathepsin D levels compared to the patients with (-) in-hospital mortality and low SXscore. Using a cutoff score of ＜ 16 for the cathepsin D level, in-hospital mortality was predicted with a sensitivity and specificity of 73.4% and 77.6%, respectively, and also predicted high SXscore with a sensitivity and specificity of 72.4% and 67.6%, respectively. Conclusions: Serum cathepsin D levels established upon admission were significantly and independently lower in NSTEMI patients with high rate of mortality, high SXscores, and low left ventricular ejection fraction.

• 期刊

Changes of Atrial Natriuretic Peptides after Defibrillation Threshold Testing Predicted Future Ventricular Arrhythmia Event

Background: We investigated the change of natriuretic peptides during defibrillation threshold (DFT) testing and its relationship with future ventricular arrhythmia (VA) events in patients implanted with an implantable cardioverter defibrillator (ICD). Methods: Atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and c-type natriuretic peptide (CNP) were measured in 21 patients (mean age 61 ± 13 years; 67% male) undergoing ICD implantation. Blood samples of the patients were drawn at pre-implantation, 30minutes, 60minutes, and 24 hours after DFT testing. The patients were followed and divided into two groups according to the occurrence of VA in 18 months. The biomarker levels and their changes were compared in patients with and without further VA. Results: The pre-implantation ANP levelswere higher at pre-implantation and increased significantly at 30minutes after DFT testing (Δ30minANP) among patientswith VA events. The BNP and CNP levels did not change significantly after DFT testing in both groups. The area under curve was 0.82 for the change inΔ30minANP determining further ventricular events. The optimal Δ30minANP cutoff value was 0.51 pg/ml, with sensitivity of 0.83 and specificity of 0.68. Multivariable analysis confirmed that patients with Δ30minANP more than 0.51 pg/ml have a higher risk of further ventricular events (hazard ratio 39.8, 95% confidence interval: 2.87-553.01, p = 0.006). The pre-implantation ANP level could not predict future VA events (hazard ratio 1.06, 95% CI: 1.00-1.14, p = 0.06). Conclusions: The increase of ANP concentration after DFT testing predicted future VA events after ICD implantation while the BNP and CNP levels did not predict future VA events.

• 期刊

Heart Rate Recovery as a Novel Test for Predicting Cardiac Involvement in Beta-Thalassemia Major

Background: Abnormal heart rate recovery (HRR) is predictive of cardiac mortality. Autonomic abnormalities in beta-thalassemia major (TM) patients have been reported in previous studies. However, the importance of low HRR in exercise stress test in TM patients has not yet been ascertained. Therefore, this study will be the first of its kind in the literature. Methods: Exercise stress test was performed on 56 TM patients who were being treated at the Thalassemia Center of our hospital, alongwith 46 non-TM iron deficiency anemia (IDA) patients as a control group. Values for HHR were recorded at 1, 2, 3, 4 and 5 min, and HRR was calculated by the difference of heart rate at peak exercise and at a specific time interval following the onset of recovery. Results: All HRR values were found to be lower in TM patients compared to those in the IDA group. Exercise capacity [metabolic equivalents (METs)] was also found to be low in these patients (p ＜ 0.001) as well. Total exercise time was significantly lower in the TM group compared to the IDA group (8.40 ± 1.7 min vs. 11.17 ± 1.51 min, p ＜ 0.001). Exercise capacity (METs) was also lower in the TM group compared to the IDA group. Mean T2* value was 28.3 ± 13.7ms in TM patients on magnetic resonance imaging (MRI). In addition, there are 18 TM patients with T2* value was ＜ 20ms. Conclusions: This study found that TM was independently associated with low HRR. Such a condition is an indicator of autonomic dysfunction in TM patients, since abnormal HRR is related to impaired autonomic response. In addition, impaired HRR may be a marker of early cardiac involvement in patients, whose T2* value is high on MRI. Modifying HRR with a cardiac rehabilitation program in TM patients with impaired HRR is a field open for further investigation.