A comparative study of portable monitors (CoaguCheck XS) for international normalized ratio (INR) determination with a laboratory-based system for control of oral anticoagulant treatment.

long-term warfarin therapy. Methods: 39 patients receiving long-term warfarin were eligible in this study. Parallel INR measurements were performed. Capillary INR (INR_C) measurements were determined with CoaguCheckÒ XS and venous INR (INR_V) were determined with standard laboratory methods. Results: We found an excellent correlation coefficient (r2 = 0.968, 95%CI = 0.82 – 0.99) between INR_V and INR_C among 39 patients receiving long-term warfarin. The mean difference between the two methods was 0.16 (p<0.0001). Although these differences were statistically significant, they were not clinically significant. In 97.4% of the INR parallel measurements the differences between the two methods were within 0.5 INR units. The Bland-Altman difference plot showed greater variation with increasing mean INR values. The coefficient of variation of CoaguCheckÒ XS was 1.07%. Conclusion: The CoaguCheckÒ XS was comparable in accuracy to a standard laboratory method. Its precision was good. It might be a suitable alternative to monitor INR values among patients receiving oral anticoagulants by increasing patient compliance with INR monitoring, and facilitating more frequent INR monitoring especially in highly educated patients.

Acute coronary syndrome in 1366 patients at Siriraj Hospital: clinical characteristics, management and in-hospital outcomes.

OBJECTIVE: To characterize the baseline characteristics, management and in-hospital outcomes of all patients admitted with acute coronary syndrome (ACS). MATERIAL AND METHOD: The present study is a prospective, observational study of all consecutive patients admitted with ACS. From August 1, 2002 through October 31, 2005, data from 1366 ACS patients were collected. RESULTS: The patients were classified according to the final discharge diagnosis as ST-segment elevation myocardial infarction (STEMI, 33.5%), non-ST-segment elevation myocardial infarction (NSTEMI, 47%) and unstable angina (UA, 19.5%). Approximately half of the patients were older than 65 years old. The STEMI patients were significantly younger and had a higher percentage of men than the NSTE-ACS patients. There was a very high prevalence of diabetes, hypertension and dyslipidemia in the patients. Only 60% of the STEMI patients received reperfusion therapy. Of these, primary percutaneous coronary intervention (PCI) was performed more frequently (35%) than thrombolytic therapy (24%). There were substantial delays in time to treatment. Median door to needle and door to balloon time were 135 and 130 minutes respectively. Half of the NSTEMI and UA patients underwent coronary angiography and about one-third had PCI or coronary artery bypass grafting in the same hospital admission. In-hospital mortality rate was high: STEMI 19%, NSTEMI 16% and UA 4%. CONCLUSION: The present study provides invaluable information regarding the spectrum of ACS in our country. Overall in-hospital mortality was higher than that reported from international registries. The present findings represent a significant opportunity for quality improvement in the care of patients with ACS and the implementation of preventive strategies for patients with and at risk for coronary artery disease.

Primary percutaneous transluminal coronary intervention compared with intravenous thrombolysis in patients with ST segment elevation myocardial infarction.

BACKGROUND: Primary percutaneous transluminal coronary intervention (PCI) and thrombolytic therapy (TT) are alternative means of achieving reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). OBJECTIVE: To compare the outcomes between both reperfusion strategies. The authors sought to compare in-hospital outcomes after PCI or TT for patients with acute STEMI. MATERIAL AND METHOD: From August 2002 through June 2004, data from all patients who received reperfusion therapy for acute STEMI were collected prospectively. The decision regarding type of reperfusion strategy was at the attending cardiologist's discretion. The patient's data on demographics, procedures, medications, and in-hospital outcomes were analyzed. RESULTS: From August 2002 through June 2004, 234 patients were admitted to the authors' institute with the diagnosis of acute STEMI. Of the 146 patients who received reperfusion therapy, 91 were treated with primary PCI and 55 received intravenous TT as the reperfusion modality. In the TT group, 51 (93%) patients received streptokinase and 11 (21.6%) underwent rescue angioplasty. The two groups had similar baseline characteristics. Both patient groups had frequent presence of diabetes (PCI 44.2% vs. TT 39.6%, p = 0. 6). Cardiogenic shock on admission was present in 11% of the PCI patients and 7.3% of the TT patients (p = ns). In-hospital mortality was not significantly different in the two groups (PCI 14.3% vs. TT 10. 9%, p = 0.56). In the TT group, there was a trend toward a higher rate of major bleeding (PCI 6.6% vs. TT 16.4%, p = 0.06) and stroke (PCI 2.2% vs. TT 7.3%, p = 0.13) complications without statistical significance. CONCLUSION: The present findings suggest that both PCI and TT are comparable alternative methods of reperfusion among STEMI patients in terms of in-hospital mortality. In certain subgroups that are at increased risk of bleeding or stroke, primary PCI may be the preferred treatment strategy.

Nadroparin and percutaneous transluminal coronary angioplasty in elderly Thais with unstable angina.

Objective: Unstable angina (UA) is one of the leading problems in healthcare management in developing countries where facilities of catheterization laboratory are scarce and well-trained operators who are able to manage acute coronary syndrome often unavailable. In this scenario, strategy to arrive at optimal management to stabilize the condition medically is always a controversy. There is still controversy concerning the optimal management strategy during medical stabilization at places with inadequate catheterization laboratory facilities and a lack of well-trained operators who are able to manage acute coronary syndrome. Furthermore, the choices of medical and invasive management, including the use of percutaneous transluminal coronary angioplasty (PTCA) are still debatable. Curious by the challenge, we launch this prospective randomized controlled study to compare the efficacy of nadroparin with percutaneous transluminal coronary angioplasty (PTCA) in elderly patients with UA or non ST-elevation myocardial infarction (NSTEMI). Methods: Ninety-three elderly patients with UA, whose clinical manifestations were classified according to Braunwald’s classification, were recruited. All patients underwent coronary angiography within 96 hours after hospitalization; those who had angiographic coronary arterial stenosis that was feasible for PTCA were randomized to receive either nadroparin 7,500 IU subcutaneously twice daily for 5 days or PTCA. All clinical events in hospital and post-discharge up to 12 months, including death, composite end point [myocardial infarction (MI), recurrent angina/or ischemia], re-intervention (either PTCA or coronary artery bypass surgery) and rehospitalization, were recorded. Results: Only Forty-six patients were randomized equally into NAD group (n =23) and PTCA group (n =23). There were no statistically significant differences between NAD vs. PTCA regarding their baseline clinical characteristics, ECG, number of diseased vessels involved and outcomes (death and MI). The composite end point occurred more frequently in the NAD group [(34.5% vs. 4.3%); p = 0.01]. After a 12-month follow-up there was no difference in death rate or MI between the two groups but there was a clinically significant difference with regard to post-discharge outcomes in the NAD group, i.e, higher recurrent angina in NAD vs. PTCA (43.5% vs. 23.7%; p = 0.012), requiring additional PTCA (39.1% vs. 21.7%; p = 0.012), rehospitalization (47.8% vs. 30.4%; p = 0.015) and composite endpoint (47.8% vs. 30.4%; p = 0.015). Conclusions: PTCA achieve less composite endpoint than conservative management while nadroparin was easy to administer, but one-third of the patients still experienced recurrent angina or ischemia. PTCA is another option and could be performed safely, resulting in a less recurrent angina and shorter hospital stay. It is suggested that in the elderly with UA, nadroparin may be considered is the initial optimal management where PTCA facility is not available; those with recurrent angina symptoms should be referred afterwards for PTCA.

Balloon expandable stents for coarctation of the aorta: current status and technical considerations: case report.

BACKGROUND: Balloon expandable stents have been used to manage coarctation of the aorta (Co) in selected patients with very encouraging results. MATERIAL AND METHOD: The authors report here the first group of patients with Co who underwent a successful implantation of the new Palmaz Genesis stent with intermediate term follow up. RESULTS: There were 5 patients with an age range from 14 to 23 years old. All of them had significant Co and were receiving multiple anti-hypertensive medications. Primary stenting was performed in all patients. All of them had an immediate relief of the gradient. All antihypertensive medications were discontinued immediately in 4 patients. All patients had one year follow up which revealed a minimum gradient. One patient continues to receive oral antihypertensive medication. CONCLUSION: In patients with coarctation of the aorta (native or recoarctation of aorta), stent implantation may be a feasible and improved option to relieve the stenosis. Short and mid term followup of these patients have shown encouraging results.

Stent placement compared with balloon angioplasty for obstructed coronary artery disease in Thai elderly patients: initial result and 6 months follow-up.

Percutaneous Old Balloon Angioplasty (POBA) is accepted worldwide for the treatment of obstructive coronary artery disease because this technique is safe, and quick and the patient may return to work earlier than with bypass surgery (particularly elderly patients). But the major problem with POBA is restenosis which occurs between 20-40 per cent. Stent placement has been reported to reduce the restenosis rate to 10-20 per cent. OBJECTIVE: The purpose of this study was to compare the effects of stent placement with those of balloon angioplasty on clinical and angiographic outcomes in elderly Thai patients with obstructive coronary artery disease. METHOD: The study was a randomized controlled trial. The sample size was 45 lesions in 42 patients who were assigned into 2 groups; 23 in the balloon angioplasty group and 22 in the stent placement group (Crown Stent). Clinical information and coronary angiography were recorded and performed at the time of the index procedure and six months later. RESULTS: There was 100 per cent procedural success in 22 lesions treated in the stent group and 82.6 per cent in the 23 lesions treated in the balloon angioplasty group. Patients in the stent group had a lesser degree of stenosis immediately after the procedure (8.78 +/- 8.63 vs 30.92 +/- 9.01%, p < 0.001) and a greater minimal luminal diameter (MLD) (3.04 +/- 0.44 vs 2.15 +/- 0.33 mm, p < 0.001). There were no major complications in either group during the procedure or during their hospital stay. These were not maintained at the six months follow-up. (26.88 +/- 16.23 vs 33.82 +/- 14.63 mm, p = 0.19, 2.28 +/- 0.67 vs 2.01 +/- 0.51 mm, p = 0.17) for the degree of stenosis and the MLD respectively. The restenosis rate, which was the primary endpoint of the study, was 4.5 per cent in the stent group and 21 per cent in the balloon angioplasty group (p = 0.10). CONCLUSIONS: Stenting in Thai elderly ischemic patients has a higher procedural success rate when compared with balloon angioplasty. The restenosis rate of stenting is also lower than that of balloon angioplasty but did not reach statistical significance. However, both techniques had no major complications either during the procedure or in-hospital.

An abnormal systemic and regional hypercoagulable state in patients with mitral stenosis.

Mitral stenosis still remains a major problem in Southeast Asia including Thailand. It contributes to the morbidity and mortality related to thromboembolism which was associated with the left atrial thrombus. However, the pathogenesis of left atrial thrombus in these patients is not completely understood. Therefore, the objective of this study was to investigate the coagulation and platelet activity including the function of the endocardium in the left atrium and peripheral circulation in patients with mitral stenosis who were free of left atrial thrombus and to compare those hematologic markers activity in the peripheral venous blood between the patients with mitral stenosis and the control. Thirty-six patients with moderate to severe mitral stenosis were included in the study. Most of the patients were in functional class II and 50 per cent had atrial fibrillation. Blood was obtained from the femoral vein, femoral artery, pulmonary artery and left atrium of these patients before heparin was administered to determine the value of various hematologic markers. In the control group, blood for determining the hematologic markers was collected only from the antecubital vein. The results of this study demonstrated that the levels of prothrombin activation fragment 1+2 (F1+2), thrombin-antithrombin III complex (TAT) and Beta-thromboglobulin (beta-TG) in the left atrium of the patients with mitral stenosis were significantly higher than those in the femoral vein and femoral artery, whereas the level of thrombomodulin was significantly lower in the left atrium compared with the femoral artery and vein. When comparing with the control group, the levels of TAT, plasminogen activator inhibitors-1 (PAI-1) from the peripheral vein were significantly higher and the level of thrombomodulin was also significantly lower in the patients with mitral stenosis. In conclusion, the present study demonstrated an abnormal hypercoagulable state of the left atrium and systemic circulation related to the abnormalities of coagulation, platelets and the endocardium which may cause the formation of left atrial thrombus in patients with mitral stenosis.

Early postoperative coronary angiography result in Off-pump Coronary Artery Bypass (OPCAB) patients.

Objective : The purpose of this study was to evaluate the early results of coronary artery bypass without cardiopulmonary bypass (off-pump coronary artery bypass - OPCAB) at Siriraj Hospital. Patients and methods : From September, 2001 to April 2002, eight selected coronary artery disease patients were operated on using the off-pump coronary artery bypass technique. Operative data were collected and postoperative coronary angiography was studied in all patients before discharge. Results : There were no death and no need to resort to the conventional procedure. Postoperative coronary angiography revealed good patency of all 17 grafts. Postoperative cardiac enzymes were elevated in one patient. Conclusion : The early of OPCAB in this study showed good outcomes. Early postoperative angiography demonstrated excellent anastormoses. This procedure needed fewer blood transfusions than the conventional technique. However, long-term follow up of these procedures should be evaluated.

An electrocardiographic survey of elderly Thai people in the rural community.

Electrocardiographic findings in the elderly reflect both common cardiac diseases and physiologic ageing change. This cross-sectional population-based study explored the prevalence of various abnormalities in the electrocardiograms of active older people and those who are free from any cardiac pathology and determined their relationship to age and gender in a rural area of Thailand. Nine hundred and sixty three people aged 60 years or more were recruited. The electrocardiographic prevalence of ischemic heart disease, atrial fibrillation, left axis deviation and conduction defect were 5.5 per cent, 2.2 per cent, 2.5 per cent and 3.1 per cent respectively. After excluding diseases potentially affecting the heart, the prevalence of atrial fibrillation, left axis deviation and conduction defect decreased to 1.3 per cent, 2.0 per cent and 2.2 per cent. The prevalence of atrial fibrillation and ischemic heart disease were significantly less (p = 0.015 and 0.003) in the 80+ year old group. Regarding gender difference, only left axis deviation was found significantly more frequently in older men with an odds ratio of 5.23 (95% confidence interval, 1.28-30.29) in those who were free from diseases potentially affecting the heart. IN CONCLUSION: Atrial fibrillation should not be regarded as degenerative change, but the result of cardiac pathology instead. The most common electrocardiographic abnormality in normal older men was left axis deviation and was found consistently more often than in older women. Therefore, it is appropriate to investigate for any reversible causes of atrial fibrillation while it is not so for left axis deviation in older men.

Efficacy and safety of percutaneous metallic mitral valvuloplasty in rheumatic mitral stenosis at Siriraj Hospital.

Mitral stenosis is an important problem that leads to heart failure and stroke in Thailand. The options of treatment at present are either surgical or balloon mitral commissurotomy. However, the cost of balloon is very expensive. To reduce the expense of the procedure, the authors prospectively did a study using a new device called the metallic valvulotome in symptomatic severe mitral stenosis to assess the safety, feasibility and immediate outcomes. Fifty-seven patients were included in the study. The successful outcome achieved by the metallic valvulotome was 96.2 per cent in patients in whom the procedure was actually performed. The mean transmitral gradient, left atrial pressure and pulmonary artery pressure were significantly decreased and the mitral valve area was also significantly increased. Three cases failed the procedure due to inappropriate position of the septal puncture. No death occurred in the study and complications of the procedure included only two cases of hemopericardium. In the future, it is believed that this new innovative device will provide improvement and reduce the cost of the procedure in patients with severe mitral stenosis.

Thallium scan in patients with coronary artery disease: A preliminary report.

Exercise thallium studies of forty-eight patients performed to evaluate coronary artery disease were reviewed. The results of the exercise thallium studies were compared to those of exercise ECG tests done simultaneously, and coronary arteriography performed 2 weeks to more than one year after. The sensitivity and specificity of exercise thallium study were 81.8 and 100 percent whereas those of exercise ECG test were 81.8 and 50 percent, respectively. Sites of abnormalities detected by coronary arteriography correlated with 77.8 percent of thallium studies, but 44.4 percent of exercise ECG tests. The results of exercise thallium studies and exercise ECG tests agreed in 81.3 percent of patients. Exercise thallium study is sensitive and specific and has good correlation with coronary arteriography. It is useful in detection of coronary artery disease, evaluation of extent of the diseased myocardium as well as potency of coronary artery bypass graft.