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Considerations When Managing Heart Failure during the COVID-19 Pandemic-Consensus from the Taiwan Society of Cardiology

Coronavirus disease 2019 (COVID-19) has spread rapidly around the world since December 2019. Acute heart failure has accounted for 23-24% of the initial presentations in patients with COVID-19 infection. Furthermore, COVID-19 might increase metabolic demand and cause acute decompensation of pre-existing stable heart failure. These patients are thus more susceptible to the evolution of more serious clinical symptoms and a higher mortality rate. Given the lack of knowledge about this new disease, this review provides recommendations for the management of heart failure during the COVID-19 pandemic in Taiwan.

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Relationship between Serum Salusin Beta Levels and Coronary Artery Ectasia

Background: Local or diffuse dilatation of the coronary artery is defined as coronary artery ectasia (CAE). Salusin beta plays a role in the proliferation of cardiomyocytes, inhibition of apoptosis, and proliferation of vascular smooth muscle cells and fibroblasts. In this study, we aimed to investigate the relationship between serum salusin beta and CAE. Methods: This study was conducted between July 2019 and December 2019 and included 71 patients with CAE (age 59.3 ± 11 years, 67.7%male) and 72 healthy subjects (age 57.1 ± 10.2 years, 69.4% male) with coronary artery angiography (CAG) findings. Venous blood samples of the participants were collected for serum salusin beta level evaluation. CAG examinations and the diagnosis of CAE were performed by two invasive cardiologists blinded to the clinical conditions of the patients. Results: Mean systolic (SBP) and diastolic arterial blood pressures were significantly higher in the CAE group than in the control group, and the mean left ventricular ejection fraction (LVEF) was significantly lower (all p ＜ 0.05). The median serum salusin beta value was statistically significantly higher in the CAE group compared to the control group [415 (interquartile range (IQR): 51.7) pg/mL vs. 365 (IQR: 55.8) pg/mL; p ＜ 0.001]. In receiver operating characteristic curve analysis, a cut-off value of salusin beta ≥ 393 pg/mL had 78.9% sensitivity and 75.0% specificity for predicting CAE (area under the curve: 0.822; p ＜ 0.001). Multivariate analysis demonstrated that serum salusin beta [odds ratio (OR): 1.011; p = 0.002], LVEF (OR: 0.816; p = 0.001) and SBP (OR: 1.041;p = 0.001) were independent predictors of CAE. Conclusions: This study revealed a significant and independent relationship between serum salusin beta level and the presence of CAE.

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Comparison of Long-Term Safety and Efficacy of Bioresorbable Scaffolds between Patients with and without Diabetes Mellitus

Introduction: Diabetes mellitus (DM) is a major risk of cardiovascular events. Bioresorbable stent frame materials capable of providing mechanical support and drug-delivery functions have been developed in an attempt to improve long-term outcomes. However, publications about the long-term outcomes of bioresorbable scaffolds (BRS) in DM patients are still limited. The aim of this study was to investigate the long-term safety and efficacy of BRS between patients with and without diabetes. Methods: Data regarding BRS placement in consecutive patients receiving percutaneous coronary interventions were collected from the cardiovascular center of a single tertiary medical center from 2014 to 2017. Results: A total of 138 cases were included and followed up for 4 years. The mortality rate was 1.1% in the non-diabetic group and 4.1% in the diabetic group (p = 0.2542). No cardiac mortality was observed. One patient had an acute myocardial infarction (0.7%) in the non-diabetic group. The rate of target lesion revascularization was 3.4% in the non-diabetic group and 4.08% in the diabetic group. The ratio of target vessel revascularization was 6.74% in the non-diabetic group and 4.1% in the diabetic group. Conclusions: This study demonstrated no significant difference in long-term outcomes after BRS implantation between patients with and without diabetes in a single tertiary medical center.

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Percutaneous Left Atrial Appendage Closure Confirmed by Intra-Procedural Transesophageal Echocardiography under Local Anesthesia: Safety and Clinical Efficacy

Background: Percutaneous left atrial appendage closure (LAAC) is usually performed under general anesthesia (GA) guided by transesophageal echocardiography (TEE), or under local anesthesia (LA) guided by intracardiac echocardiography (ICE). GA is known to carry some disadvantages. It is sometimes technically challenging to obtain adequate imaging of the left atrial appendage (LAA) with LAAC guided by ICE. This study aimed to assess the safety and clinical efficacy of LAAC guided by TEE under LA in patients with non-valvular atrial fibrillation (AF). Methods: A total of 159 patients (70.5 ± 8.2 years; 66% male) with AF who had a high risk of stroke and bleeding or who had contraindications for oral anticoagulation underwent LAAC under LA. TEE or computed tomography (CT) follow-up was scheduled approximately 6 weeks after the procedure. Patients were followed to assess ischemic stroke and major bleeding events. Results: The LAA was successfully occluded in 152 patients (95.6%). There were 2 (1.3%) periprocedural major adverse events. A total of 142 patients (93.4%) finished TEE or CT follow-up. Thrombus formation as seen on the device was documented in 2 patients. All of the LAAs were completely sealed with the absence of flow or with minimal flow. The median follow-up period was 522 days, resulting in a total of 216 patient-years. Ischemic stroke occurred in 4 patients. The annual ischemic stroke rate was 1.9/100 person-years. Major bleeding occurred in 2 patients. The annual major bleeding rate was 1.9/100 person-years. Conclusions: In this study, percutaneous LAAC using TEE under LA was safe and showed encouraging results for stroke prevention and major bleeding reduction.

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Prognostic Effect of Restoring Sinus Rhythm in Patients with New-Onset Atrial Fibrillation during Acute Coronary Syndrome

Background: New-onset atrial fibrillation (NOAF) in acute coronary syndrome (ACS) may be associated with a poor prognosis. However, whether restoring sinus rhythm (SR) at discharge in patients with ACS improves outcomes remains unknown. Methods: A total of 552 patients with ACS at an emergency department during 2011-2016 were enrolled. According to documented electrocardiography at admission and medical records, the patients were classified into without atrial fibrillation (WAF), NOAF, and prior atrial fibrillation (PAF) groups. Major adverse events (MAEs) were defined as cardiac death, recurrent myocardial infarction, heart failure requiring hospitalization, target lesion revascularization, and stroke. The mean follow-up period of MAEs was 25 ± 15 months. Results: Compared with the NOAF and PAF groups, the WAF group was younger and had a significantly lower heart rate, prior stroke rate, CHA_2DS_2-VASc score, and lower Global Registry of Acute Coronary Events (GRACE) score in the emergency department (p ＜ 0.001). The patients in the NOAF group had the highest incidence of MAEs (p ＜ 0.001) during follow-up, and those whose SR was restored at discharge had a lower MAE rate than those with AF at discharge (p = 0.001). In multivariable analysis, prior myocardial infarction, GRACE score, use of beta-blockers, and restoring SR at discharge were independent predictors of MAEs in the NOAF group. Conclusions: The patients with ACS who presented with NOAF had worse outcomes than those with PAF or WAF. The patients with NOAF whose rhythm was restored to SR at discharge were associated with better outcomes than those with AF at discharge.

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Does Employing a Flowchart Improve the Diagnostic Performance of Cardiac Magnetic Resonance Imaging in Left Ventricular Noncompaction?

Background: To test the hypothesis that making a diagnosis of left ventricular noncompaction (LVNC) on cardiac magnetic resonance imaging (CMRI) using a noncompacted-to-compacted (NC/C) myocardium ratio ＞ 2.3 would yield significant errors, and also to test a diagnostic flowchart in patients who undergo CMRI and have clinical and echocardiographic findings suggesting LVNC could improve the diagnosis of LVNC. Methods: A total of 84 patients with LVNC and 162 controls consisting of patients with other diseases and healthy participants who had CMRI and echocardiograms were selected. The diagnostic flowchart of the study involved the use of CMRI with all available sequences for patients with a high pre-test probability of LVNC. Two blinded independent cardiologists evaluated echocardiograms, and patients with suggestive echocardiographic and clinical findings for LVNC were enrolled in the high pre-test probability of LVNC group. Two independent blinded radiologists established the diagnosis of LVNC based on NC/C ratio ＞ 2.3 on CMRI, and they were allowed to re-assess the patients following the diagnostic flowchart. Results: An NC/C ratio ＞ 2.3 identified 83 of 84 LVNC patients, yet incorrectly classified 48 of the 162 controls as having LVNC. Radiologists changed their decision in 23 of 48 patients with incorrect diagnoses, resulted in improved specificity (70.4% to 84.6%). The use of the CMRI diagnostic flowchart in the high pre-test probability group yielded a high specificity (97.2%) and accuracy (95.9%). Conclusions: LVNC diagnosed by CMRI based on the NC/C criterion can lead to overdiagnosis, whereas only using CMRI in patients with a high pre-test probability of LVNC with all available sequences may improve the diagnostic performance.

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Pentraxin 3 as a Marker for Cardiovascular Disease Risk in Overweight and Obese Children

Background: Pentraxin 3 is an inflammatory mediator that may be associated with subclinical inflammation in atherosclerosis and cardiovascular diseases. This study investigated the predictive value of pentraxin 3 as an inflammatory biomarker in overweight and obese children. Methods: Participants were categorized into three groups: overweight (n = 35), obese (n = 35), and healthy controls (n = 70). Cardiovascular parameters and pentraxin 3 were measured in all participants. Results: The mean pentraxin 3 level was significantly higher in the overweight (10.23 ± 4.42 ng/ml) and obese (11.20 ± 4.12 ng/ml) groups compared to the control (7.93 ± 4.35 ng/ml) group. Pentraxin 3 was significantly correlated with carotid intima media thickness and epicardial adipose tissue thickness in the overweight group. In the linear regression analysis, body mass index and systolic blood pressure were significantly correlated with pentraxin 3 levels in the overweight group, whereas only heart rate was correlated with pentraxin 3 levels in the obese group. In receiver operating characteristic analysis, the optimal cut-off value for pentraxin 3 in the obese group was 9.321 ng/mL, with sensitivity and specificity of 77.1% and 74.3%, respectively [area under the curve (AUC) = 0.764, p ＜ 0.001]. In the overweight group, the optimal cut-off value of pentraxin 3 was 9.263 ng/mL, with sensitivity and specificity of 62.9% and 72.9%, respectively (AUC = 0.687, p = 0.002). Conclusion: Pentraxin 3 may be an early marker of cardiovascular risk in overweight children. Future longitudinal studies are needed to evaluate the predictive value of pentraxin 3 for cardiovascular disease.

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Pentraxin 3: A Biomarker Link between Inflammation and Cardiovascular Risk among Obese Children

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Extended-Release Carvedilol in the Treatment of Hypertension: A Double-Blind, Randomized, Placebo-Controlled Trial

Background: Immediate-release carvedilol requires twice-daily dosing and may have low treatment compliance. We assessed the efficacy of a new formulation of once-daily extended-release carvedilol (carvedilol ER) on systolic blood pressure (SBP) and diastolic blood pressure (DBP) among patients with hypertension in this double-blind, randomized, placebo-controlled trial. Methods: A total of 134 patients with untreated or uncontrolled hypertension were randomly assigned in a 1:1:1 ratio to receive placebo, low-dose carvedilol ER, or high-dose carvedilol ER for 8 weeks. The primary endpoint was the reduction in office SBP at 8 weeks. Secondary endpoints included the reduction in office DBP and the proportion of patients with blood pressure (BP) ＜ 140/90 mm Hg. Results: In the intention-to-treat population, placebo-adjusted changes in SBP/DBP were -2.9mmHg [95% confidence interval (CI), -9.6 to 3.7]/-1.7mmHg (95% CI, -5.6 to 2.3) and -4.9mmHg (95% CI, -11.5 to 1.7)/-3.4mmHg (95% CI, -7.3 to 0.5) for low-dose carvedilol ER and high-dose carvedilol ER, respectively. In the per-protocol population, high-dose carvedilol ER was associated with a significant DBP reduction [placebo-adjusted difference, -4.7 mm Hg (95% CI, -8.8 to -0.5); adjusted p = 0.026]. There was a gradational improvement in BP control with carvedilol ER (25%, 37%, and 48% for placebo, low-dose carvedilol ER, and high-dose carvedilol ER, respectively; linear-by-linear association p = 0.028). There were no differences in safety among the three groups. Conclusions: Carvedilol ER, though well tolerated, did not result in a greater reduction in either SBP or DBP compared with placebo.

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Long-Term Effect of Device-Guided Slow Breathing on Blood Pressure Regulation and Chronic Inflammation in Patients with Essential Hypertension Using a Wearable ECG Device

Background: Hypertension is related to autonomic nervous system(ANS) dysfunction, atherosclerosis and chronic inflammation. The stimulation of baroreflex regulation by slow-breathing exercise may improve the interplay among these systems. The objective of this study was to investigate the effect of device-guided slow breathing on ANS, cardiovascular system and chronic inflammation in hypertensive patients. Methods: We prospectively collected 36 essential hypertension patients who were requested to practice slow breathing exercise 5 times per day for 3 months. The breathing exercise was guided by a cellphone app with a wearable electrocardiography device and a rhythm of 6 cycles per minute. Cardiovascular indicators including heart rate variability (HRV), blood pressure, pulse wave velocity and baroreflex indexes were sampled 3 times: at the first visit, and 1 month and 3 months after the intervention. The levels of blood inflammatory biomarkers, including tumor necrosis factor-alpha (TNF-α), interleukin-6, interleukin-1 receptor antagonist and C-reactive protein were also collected at all 3 visits. The longitudinal differences in these variables and their correlations were tested. Results: There was a significant decrease in blood pressure after 1 month of exercise. A significantly continuous decrease in TNF-α was also observed. The baroreflex indexes were significantly increased in the acute intervention of slow-breathing but not in the longitudinal effect. The HRV variables did not show differences with time. There were positive correlations between sympathetic index and TNF-α and galectin-3. Conclusions: The effect of slow-breathing exercise on blood pressure and chronic inflammation was significant. HRV indexes may also be used to assess chronic inflammation.