Non-vitamin K oral anticoagulants versus warfarin for the treatment of left ventricular thrombus.

INTRODUCTION: Left ventricular thrombus (LVT) is associated with significant morbidity and mortality. Conventional treatment comprises warfarin-mediated anticoagulation; it is unclear whether non-vitamin K oral anticoagulants (NOACs) exhibit comparable efficacy and safety. Limited data are available for Asian patients. This study compared NOACs with warfarin in terms of clinical efficacy and safety for managing LVT. METHODS: Clinical and echocardiographic records were retrieved for all adult patients with echocardiography-confirmed LVT at a major regional centre in Hong Kong from January 2011 to January 2020. Discontinuation of anticoagulation by 1 year was recorded. Outcomes were compared between patients receiving NOACs and those receiving warfarin. Primary outcomes were cumulative mortality and net adverse clinical events (NACEs). Secondary outcomes were complete LVT resolution and percentage reduction in LVT size at 3 months. RESULTS: Forty-three patients were included; 28 received warfarin and 15 received NOACs, with follow-up periods (mean ± standard deviation) of 20 ± 12 months and 22 ± 9 months, respectively (P=0.522). Use of NOACs was associated with significantly lower NACE risk (hazard ratio [HR]=0.111, 95% confidence interval [CI]=0.012-0.994; P=0.049) and a tendency towards lower cumulative mortality (HR=0.184, 95% CI=0.032-1.059; P=0.058). There were no significant differences in secondary outcomes. Considering LVT resolution, discontinuation of anticoagulation by 1 year was not significantly associated with different outcomes. CONCLUSION: Non-vitamin K oral anticoagulants may be an efficacious and safe alternative to warfarin for LVT management. Future studies should explore the safety and efficacy of anticoagulation discontinuation by 1 year as an overall strategy.

Renal outcomes in Asian patients receiving oral anticoagulants for non-valvular atrial fibrillation.

INTRODUCTION: Patients with non-valvular atrial fibrillation (NVAF) may be prescribed warfarin or a non-vitamin K oral anticoagulant (NOAC). There is increasing evidence that NOACs are superior to warfarin in terms of renal function preservation. This study aimed to compare renal outcomes in Chinese patients with NVAF between patients receiving NOACs and patients receiving warfarin. METHODS: In total, 600 Chinese patients with NVAF receiving oral anticoagulant therapy were retrospectively identified from an administrative database. The renal outcomes (≥30% decline in estimated glomerular filtration rate [eGFR], doubling of serum creatinine, and kidney failure) were compared among four propensity-weighted treatment cohorts (warfarin, n=200; rivaroxaban, n=200; dabigatran, n=100; and apixaban, n=100). RESULTS: The mean follow-up period across all groups was 1000 ± 436 days. Compared with warfarin, the three NOACs (pooled for consideration as a single unit) had significantly lower risks of ≥30% decline in eGFR (hazard ratio [HR]=0.339; 95% confidence interval [CI]=0.276-0.417) and doubling of serum creatinine (HR=0.550; 95% CI=0.387-0.782). Dabigatran and rivaroxaban users both had lower risks of ≥30% decline in eGFR (both P<0.001) and doubling of serum creatinine (both P<0.05). Apixaban was only significantly associated with a lower risk of ≥30% decline in eGFR (P<0.001). CONCLUSIONS: Compared with warfarin, NOACs may be associated with a significantly lower risk of decline in renal function among Chinese patients with NVAF.

Vitamins B-12 and C Supplementation Improves Arterial Reactivity and Structure in Passive Smokers: Implication in Prevention of Smoking-Related Atherosclerosis.

BACKGROUND: Atherosclerosis is an important medical problem of modern society. High environmental tobacco smoke in casino is associated with an accelerated atherogenic process. We have previously shown vitamin B12 and C supplementation improves vascular reactivity and may be beneficial in vascular protection. OBJECTIVE: To evaluate the impact of vitamin supplementation on atherosclerosis (brachial artery reactivity FMD and carotid intima-media thickness IMT) in subjects exposed to high environmental tobacco smoke. DESIGN: Double-blind 2x2 factorial design fashion. SETTING: Computer randomization in 4 treatment groups: placebo (n=24), vitamin B12 (n=21), vitamin C (n=23) and vitamin B12+C (n=23) groups. PARTICIPANTS: 91 passive-smoking casino employees (19.2% male, mean age 45.0±8.2 years). INTERVENTION: Subjects were randomized to receive vitamin B12 (500µg daily), vitamin C (200mg daily), vitamin B12+C or image-matched placebo capsules for 1 year. MEASUREMENT: Brachial FMD and carotid IMT (surrogate atherosclerotic markers) were measured by ultrasound at baseline and on completion at 12 months. METHODS: 91 passive smoking casino employees (19.2% male, mean age 45.0±8.2 years) were randomized to receive vitamin B12 (500µg daily), vitamin C (200mg daily), vitamin B12+C or image-matched placebo capsules in double-blind 2 x 2 factorial design fashion for 1 year. Brachial FMD and carotid IMT (surrogate atherosclerotic markers) were measured by ultrasound at baseline and 12 months. RESULTS: Of the 78 (85.7%) passive-smoking employees completed the study, 11.5% had hypertension, 5.1% diabetes mellitus and 15.4% hypercholesterolemia. There were no significant changes in their blood pressures, lipid profiles, glucose and body mass index after supplementation for 1 year, but mild decrease in DBP (p<0.001) and blood creatinine (p<0.01) after combined vitamin B12 and C, and significant increase in blood B12 after vitamin B12 (p<0.01) and vitamin B12+C supplementations (p<0.001). Brachial FMD and cartotid IMT improved after the 3 vitamin supplementations (p<0.001), but not after placebo, being more significant after combined vitamin supplementations (p<0.0001). No adverse effects were reported. CONCLUSION: Vitamin B12 or C supplementation in passive smokers improved vascular reactivity and structures at 1 year, with implication in long term atherosclerosis prevention.

Cardiac Manifestations of Sarcopenia.

OBJECTIVES: Screening questions for sarcopenia used in the community (SARC-F) may be regarded as indicators of exercise tolerance. DESIGN: Observational study. SETTING: We tested the hypothesis that community-living older people who are screened positive for sarcopenia using the SARC-F tool but without a history of heart failure (HF) have a higher prevalence of cardiac abnormalities compared with those who are SARC-F negative. PARTICIPANTS: Participants were recruited from a territory-wide primary care needs assessment for older people based in community centres, and from non-acute hospitals in the same region as the study centre. MEASUREMENTS: Participants with a total score of >=4 and who did not have any history of HF were invited to attend for further cardiac assessment. Grip strength, walking speed, and the 6-minute walk test and echocardiography were carried out. Patients with frailty and at least Grade II diastolic dysfunction were considered to have heart failure with preserved ejection fraction (HFpEF) if they also had concomitant elevated N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) of at least 300 pg/ml. RESULTS: Diastolic dysfunction (DD) was significantly associated with SARC-F score >=4 and higher circulating NT-proBNP levels. ROC curves evaluating the predictive values of SARC-F, HGS and gait speed for DD showed that a combination of SARC-F and HGS or gait speed provided significant incremental value in predicting DD. CONCLUSIONS: Community living older people with sarcopenia detected using a simple questionnaire have a higher prevalence of DD accompanied by elevated NT proBNP. Addition of hand grip strength or walking speed improve the magnitude of the association. SARC-F may be used as a tool to detect early cardiac dysfunction in the community.

Echocardiography update for primary care physicians: a review.

Echocardiography is a key evaluation tool for the diagnosis, prognosis, and guidance of interventional management of numerous cardiovascular conditions, including ischaemia, heart failure, and structural heart diseases. Recent technological advancements have also seen the exploration of artificial intelligence, intracardiac vortex imaging, and three-dimensional printing in echocardiography. With cardiovascular diseases increasing in prevalence worldwide, it is important for clinicians including general practitioners to have updated knowledge of appropriate use of echocardiography. As such, this article reviews the current literature and summarises the latest developments and the general clinical usage of echocardiography.

Utility of the FRAIL Questionnaire in Detecting Heart Failure with Preserved Ejection Fraction.

OBJECTIVE: To test the utility of the FRAIL questionnaire as a screening tool for heart failure. DESIGN: Cross sectional study. SETTING: Chinese older people in Hong Kong. PARTICIPANTS: Participants aged 60 years and over were recruited from a territory-wide primary care needs assessment for older people based in community centers as well as two nonacute hospitals. MEASUREMENTS: Questionnaire administered included the five-item FRAIL scale, and information regarding sociodemographic data, smoking and alcohol use, history of cardiovascular disease and diabetes, and heart failure symptoms. Handgrip strength, walking speed and 6 minute walk distance were recorded. Cardiac assessment included electrocardiogram, echocardiography, and blood assay for N-terminal prohormone of B-type natriuretic peptide (NT-proBNP). RESULTS: The prevalence of diastolic dysfunction was high, being 52% in the robust group, increasing to 65% in the pre-frail and 85% in the frail group. This finding is accompanied by a corresponding increase in NT-proBNP from 64.18 pg/ml in the robust group, to 118.57 pg/ml in the pre-frail and 167.98 pg/ml in the frail group. Three of the five components of the FRAIL scale, fatigue, resistance and ambulation, were associated with increased odds ratios of diastolic dysfunction among those aged 75 years and older, while resistance alone was associated with increased odds ratio among those less than 75 years old. CONCLUSION: Frailty is associated with heart failure with preserved ejection fraction (HFpEF), and frailty screening may be used to detect undiagnosed HFpEF. The findings support the proposal that HFpEF be considered a geriatric syndrome.

Improvement of left ventricular myocardial short-axis, but not long-axis function or torsion after cardiac resynchronisation therapy: an assessment by two-dimensional speckle tracking.

AIMS: To evaluate whether short-axis function plays a part in determining left ventricular (LV) geometric and functional improvement after cardiac resynchronisation therapy (CRT). METHODS AND RESULTS: 39 patients who received CRT were enrolled. 2D speckle tracking echocardiography was performed at baseline and three months after CRT to assess mean systolic circumferential (epsilon-circum), radial (epsilon-radial) and longitudinal (epsilon-long) strain and torsion. Responders of reverse remodelling (n = 21) had higher baseline mean epsilon-circum than non-responders (p<0.05), who also had improvement in mean epsilon-circum and mean epsilon-radial (both p<0.05) after CRT. Also, the increase in mean epsilon-circum correlated with increase in ejection fraction (r = 0.57, p<0.001) and decrease in mid-cavity width (r = -0.52, p = 0.001). A baseline mean epsilon-circum of >or=6.5% predicted a gain in ejection fraction >or=5%, with a sensitivity of 73% and a specificity of 71%. The baseline epsilon-long was not different between the two groups, and remained unchanged after CRT. The torsion did not improve in responders, but was worsened in non-responders (p<0.05). CONCLUSIONS: The improvement of LV short-axis function but not long-axis function or torsion contributes to the improvement in LV global function and geometry at three-month follow up. A relatively preserved mean epsilon-circum of >or=6.5% might be useful to predict favourable responses after CRT.