Acta Cardiologica Sinica
中華民國心臟學會,正常發行
選擇卷期
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Single antiplatelet therapy with aspirin or clopidogrel is widely used in the prevention of adverse cardiovascular and limb events in patients with symptomatic peripheral artery disease (PAD). However, the risk of these events remains high, and the most optimal antithrombotic therapy for PAD is still uncertain. We conducted a literature search to identify the major clinical trials on therapeutic approaches in the prevention of adverse events in patients with PAD. This article provides an overview of the clinical trials that have evaluated the efficacy and safety of intensified antithrombotic strategies for PAD. Due to the heterogeneity of patient populations and the variable definitions of clinical outcomes used in different clinical studies, it was difficult to make direct comparisons between the study results. Although a number of choices are now available, the risk-benefit of each antithrombotic regimen for patients with PAD must be carefully considered.
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Background: Platelets with high hemostatic activity play an important role in the pathophysiology of acute coronary syndrome (ACS), and mean platelet volume (MPV) has been proposed to be an indicator of platelet reactivity. We evaluated the predictive value of MPV and the responsive value of MPV with different antiplatelet agents in association with the clinical outcomes of ACS patients. Methods: A total of 1094 patients with ACS and 472 patients without ACS were included. Blood samples were taken at hospital admission, at routine follow-up within one year, and beyond one year. The patients were divided into a ＂high MPV group＂ (＞ 9.0 fl, n = 305), ＂medium MPV group＂ (7.9-9.0 fl, n = 517), and ＂low MPV group＂ (＜ 7.9 fl, n = 272). The average follow-up time was 2.4 years, and the endpoints were major adverse cardiovascular events (MACEs) including all-cause mortality, time to recurrent ACS, target vessel re-intervention and stroke. Results: MPV was significantly higher in the patients with ACS than in those without ACS (8.6 ± 1.1 vs. 8.4 ± 1.0 fl, p = 0.007). MPV decreased in the following year (8.38 ± 1.02 fl, p ＜ 0.001) and also beyond one year (8.38 ± 0.94 fl, p ＜ 0.001) after ACS events. The changes in MPV were not significantly different between the patients receiving either clopidogrel or ticagrelor. The high MPV group had more cardiovascular risk factors and more MACEs than the low MPV group (p = 0.017). Conclusions: A higher MPV in patients with ACS was associated with more cardiovascular risk factors and more cardiovascular events during clinical follow-up.
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Background: Approximately one-third of cases of dilated cardiomyopathy (DCM) are caused by genetic mutations. With new sequencing technologies, numerous variants have been associated with this inherited cardiomyopathy, however the prevalence and genotype-phenotype correlations in different ethnic cohorts remain unclear. This study aimed to investigate the variants in Chinese DCM patients and correlate them with clinical presentations and prognosis. Methods and Results: From September 2013 to December 2016, 70 index patients underwent DNA sequencing for 12 common disease-causing genes with next generation sequencing. Using a bioinformatics filtering process, 12 rare truncating variants (7 nonsense variants, 4 frameshift variants, and 1 splice site variant) and 29 rare missense variants were identified. Of these, 3 patients were double heterozygotes and 10 patients were compound heterozygotes. Overall, 47.1% (33/70) of the index patients had the seputatively pathogenic variants. The majority (33/41, 80.4%) of these variants were located in titin (TTN). More than 80% of the TTN variants (27/33, 81.8%) were distributed in the A band region of the sarcomere. Patients carrying these variants did not have a different phenotype in disease severity, clinical outcome and reversibility of ventricular function compared with non-carriers. Conclusions: Several new rare variants were identified in a Chinese population in this study, indicating that there are ethnic differences in genetic mutations in DCM patients. TTN remains the major disease-causing gene. Our results could be a reference for future genetic tests in Chinese populations. No specific genotype-phenotype correlations were found, however a prospective large cohort study may be needed to confirm our findings.
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Background: To investigate the effects of levosimendan on right ventricular (RV) function in patients with acute decompensated heart failure (ADHF). Methods: Patients with ADHF admitted from January 2017 to October 2017 were enrolled in this study. The patients were randomized to receive 24-h intravenous levosimendan or placebo. Echocardiographic examinations were performed and the parameters were compared. Epidemiological data were recorded and compared before and after treatment. Major adverse cardiac events during hospitalization and during 1-month follow-up were compared. Results: The baseline characteristics were comparable. After 24-h infusion of levosimendan and placebo, the left ventricular ejection fraction and S' were significantly increased in the levosimendan group compared with the control group (both p ＜ 0.05). The E value in the levosimendan group significantly decreased (75.38 ± 8.32 vs. 88.21 ± 10.36, p ＜ 0.0001), and E/e' significantly increased in the control group (19.61 ± 6.52 vs. 27.58 ± 8.22, p ＜ 0.0001). The levels of right ventricular fractional area change (24 ± 3 vs. 20 ± 2, p ＜ 0.0001) and tricuspid annular plane systolic excursion (1.56 ± 0.36 vs. 1.38 ± 0.21, p ＜ 0.0001) were significantly higher in the levosimendan group than in the control group. After treatment, the values of systolic pulmonary artery pressure (SPAP) decreased in both groups (both p ＜ 0.05), and the value of SPAP in the levosimendan group was lower than that in the control group (47.22 ± 5.6 vs. 55.85 ± 7.41, p ＜ 0.0001). After 1-month follow-up, there was no significance in readmissions due to recurrent heart failure. Conclusions: Levosimendan seems to provide more beneficial effects among patients with ADHF to improve RV function, along with a decrease in pulmonary pressure.
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Background: Low atrial voltage is associated with an increased risk of stroke. The relationship between left atrial appendage voltage (LAAV) and ischemic stroke remains unknown. Low LAAV may predict the prevalence of ischemic stroke in patients with atrial fibrillation (AF). Methods: A total of 1108 patients with AF referred for catheter ablation were consecutively included from January 2015 to May 2018. The patients were divided into stroke and control groups based on previous ischemic stroke by neuroimaging criteria. LAAV was measured with a circular mapping catheter in sinus rhythm after ablation. Variables were compared, and logistic regression was performed to assess the relationship between LAAV and stroke. Results: A total of 120 patients (10.8%) had a history of ischemic stroke. The patients in the stroke group were older and had higher percentages of hypertension, diabetes mellitus and coronary/vascular disease. The CHA_2DS_2-VASc score was higher and left atrial diameter was larger in the patients with stroke. More left atrial appendage thrombi and spontaneous echo contrast were detected in the stroke group. LAAV was significantly lower in the stroke group compared with the controls (5.3 ± 1.8 mV vs. 6.5 ± 1.8 mV; p ＜ 0.001). Multivariate logistic regression revealed that a lower LAAV was associated with increased stroke prevalence [odds ratio = 0.75; 95% confidence interval (CI) 0.65-0.87; p ＜ 0.001]. LAAV had a predictive value, with an area under the curve of 0.83 (95% CI 0.79-0.87; p ＜ 0.001). With an optimal cut-off value of 5.2 mV for LAAV, the sensitivity and specificity were 75% and 74%, respectively. Conclusions: Lower LAAV in AF patients was associated with increased ischemic stroke prevalence. Whether LAAV is related to incident stroke requires further studies.
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Background: Persistent left superior vena cava (PLSVC) is a vascular anomaly that is usually asymptomatic and detected incidentally. The incidence of PLSVC has seldom been evaluated in normal populations. In this study, we determined the incidence of PLSVC in a normal neonatal population using transthoracic echocardiography. We also evaluated the associations between PLSVC and asymptomatic congenital heart diseases. Materials and methods: In this retrospective study, we identified healthy neonates based on echocardiography results from 2008 to 2017. Based on the echocardiography findings, we categorized the patients into a PLSVC group and a control group (patients without PLSVC). Chi-square and logistic regression tests were used for data analysis. Results: Of the 19,488 neonates assessed in this study, 56 were found to have PLSVC, and the remaining 19,432 neonates comprised the control group. The incidence of PLSVC was 0.29% in our population. In the PLSVC group, 3.6% of the patients exhibited bicuspid aortic valves, and 10.7% of the patients exhibited secundum-type atrial septal defects. Both the incidence and association of these conditions were higher in the PLSVC group than in the control group. Conclusions: Based on the echocardiography examination results, we discovered that the incidence of PLSVC in Taiwanese neonates was 0.29%. Although the neonates with PLSVC were asymptomatic and exhibited no health concerns, they were associated with higher incidence rates of bicuspid aortic valves and secundum-type atrial defects. Additional follow-up and evaluation regarding these findings may be warranted.
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Background: Body mass index (BMI), waist circumference (WC) and waist-hip ratio (WHR) are all simple anthropometric tools used to categorize obesity status. This study aimed to determine associations between different anthropometric indices and the attainment of therapeutic lipid goals in patients with atherosclerotic cardiovascular disease (CVD) undergoing secondary prevention. Methods: Between 2010 and 2014, this multi-center study enrolled 5718 patients undergoing secondary prevention for CVD. At study enrollment, total cholesterol, high-density lipoprotein protein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG)were recorded. This cross-sectional study analyzed these three anthropometric obesity indices and correlations with achieving therapeutic lipid goals. Results: Among the 5718 patients, multivariate analysis revealed that those with higher BMI or WC tended not to meet their HDL-C and TG therapeutic goals. However, neither BMI nor WC showed a relationship with achieving the LDL-C target. The patients with an elevated WHR (≥ 0.98 for males and ≥ 0.97 for females) were less likely to achieve all three lipid target values, including LDL-C (p = 0.05), HDL-C (p ＜ 0.001) and TG (p ＜ 0.001). Conclusions: Among Taiwanese patients undergoing secondary prevention for CVD, the higher the WHR the lower the likelihood of achieving the lipid therapeutic goals.
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Background: It is unclear whether renal denervation (RDN) can safely result in blood pressure (BP) reductions in Asian hypertensive patients and whether such reductions would be sustainable. The study is to assess the safety and efficacy of RDN achieved by either main renal artery ablation using the Symplicity Flex^(TM) catheter or main plus branch renal artery ablations using the Symplicity Spyral^(TM) catheter in Taiwanese uncontrolled hypertensive patients enrolled in the Global SYMPLICITY Registry (GSR) with 3 years of follow-up. Methods: The GSR is a prospective, open-label, and all-comer registry to evaluate the safety and effectiveness of RDN in patients with uncontrolled hypertension worldwide. Results: Among 26 patients enrolled (mean age, 59.1 ± 13.8 years), 8 were treated with the Symplicity Flex^(TM) catheter, and 18 were treated with the Symplicity Spyral^(TM) catheter. Baseline office systolic BP was 168.2 ± 19.8 mmHg and diastolic BP was 89.0 ± 14.3 mmHg. Office BP reductions following RDN were sustained throughout the follow-up periods of up to 3 years in the Symplicity Flex^(TM) group and 2 years in the Symplicity Spyral^(TM) group. In the Symplicity Flex^(TM) group, the office systolic BP reductions were 14.9 ± 14.7 mmHg and 29.7 ± 25.9 mmHg at 3 months and 3 years, respectively (both p ＜ 0.05 from baseline). In the Symplicity Spyral^(TM) group, the office systolic BP reductions were 21.2 ± 28.7 mmHg and 42.4 ± 10.7 mmHg at 3 months and 2 years, respectively (both p ＜ 0.05 from baseline). There were no significant changes in heart rate or antihypertensive medication classes. Three protocol-defined adverse events occurred in 2 patients, including new-onset end-stage renal disease, stroke, and hospitalization for new-onset heart failure. Conclusions: Given the susceptibility of Asian populations to hypertension, RDN, as a safe antihypertensive procedure with long-lasting BP-lowering effects, could reliably serve as an alternative or complementary BP-lowering strategy for patients with uncontrolled hypertension in Taiwan and other Asian countries.