Geographic differences in outcomes in outpatients with established atherothrombotic disease: results from the REACH Registry.

AIMS: There are major differences in the prevalence and management of patients with atherothrombotic disease including coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral artery disease (PAD) across different geographical regions. There is, however, little data allowing comparisons of management and outcomes across broad geographic regions. We aimed to describe geographical differences in baseline characteristics, management and outcomes in stable outpatients with established atherothrombotic disease. METHODS AND RESULTS: From the REACH Registry of atherothrombosis, patients with documented CAD, PAD or CVD and with 4-year follow-up were included. Baseline characteristics, treatments and 4-year outcomes were recorded. Event rates were compared between geographical regions and were adjusted for risk scores predicting ischemic and bleeding events. The analyses of baseline characteristics and medications according to geographical region showed marked differences. For the composite primary outcome (cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal stroke), rates ranged from 12.1% in Japan to 18.2% in Eastern Europe. After adjustment, substantial variations remained: taking North America as a reference, patients from Western Europe and Japan had a lower risk of primary outcome event (hazard ratio (HR) 0.93; p = 0.045, and HR = 0.67; p < 0.001 respectively) whereas patients from Eastern Europe had a higher risk (HR = 1.24; p < 0.001). There were no obvious differences between patients from North America and those from Latin America, the Middle East and Asia. CONCLUSION: There are important variations in the outcomes of patients with atherothrombotic across geographic regions. These observations have important implications for public health and clinical research.

Risk-factor profile, drug usage and cardiovascular events within a year in patients with and at high risk of atherothrombosis recruited from Asia as compared with those recruited from non-Asian regions: a substudy of the REduction of Atherothrombosis for Continued Health (REACH) registry.

OBJECTIVE: To clarify the differences in the baseline characteristics, prevalence and incidence of atherothrombosis in patients recruited from Asia versus non-Asian regions. DESIGN: International Prospective Cohort Study. SETTING: Region focused substudy. PATIENTS: The Reduction of Atherothrombosis for Continued Health (REACH) Registry recruited 68 236 stable outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors from 44 countries. INTERVENTIONS: No intervention. MAIN OUTCOME MEASURES: Risk factors, use of medications, vascular disease bed location, and 1-year cardiovascular (CV) outcomes (CV death, myocardial infarction, stroke). RESULTS: The percentages of patients recruited with CVD (Cerebrovascular Disease) were higher in Asia (41.0%) than in non-Asian regions (25.1%) (p<0.0001). The prevalence of diabetes mellitus was higher in Asia (46.6%) than in non-Asian regions (43.3%) (p<0.0001) despite the former having a lower body mass index (BMI) (24.4±3.9 vs 28.8±5.6) (p<0.0001). The combined endpoint of CV death/myocardial infarction/stroke of patients recruited from non-Asian regions of 4.38% (95% CI 4.20 to 4.56) is equivalent to those from the Asian region excluding Japan of 4.65% (95% CI 4.04 to 5.25), but that is significantly lower in patients recruited from Japan of 3.40% (95% CI 2.76 to 4.04, p<0.05). CONCLUSIONS: There is a higher prevalence of CVD and higher prevalence of diabetus mellitus with lower body mass index in patients recruited from the Asian region as compared those recruited from non-Asian regions. The CV event rate in patients recruited from non-Asian regions is equivalent to that of patients recruited from the Asian region excluding Japan, but significantly lower in patients recruited from Japan.

Expert recommendations on the challenges of hypertension in Asia.

A consensus meeting of leading Asian hypertension experts was held in January 2007 in Seoul, Korea, to discuss how to address the growing challenge of hypertension management in the region. This report summarises key recommendations from the group, including: raising public awareness about the impact of hypertension; improving physician education and training; increasing early detection, for example through routine blood pressure measurement; and development and adoption of pan-Asian treatment guidelines, which would greatly facilitate research into hypertension and its management. The group conclude that these challenges can only be met through a collaborative effort of government, healthcare professionals, food and healthcare industries, and patients and the public. Food and healthcare industries need to develop healthy foods and support healthy living programmes, while increasing research into antihypertensive medications in Asia. Government officials and policy makers need to be made aware of the value of investing in hypertension awareness, prevention and management programmes.

Xanthelasma is not associated with increased risk of carotid atherosclerosis in normolipidaemia.

OBJECTIVES: Extracranial carotid artery (ECCA) atherosclerosis is well known to be associated with cardiovascular diseases. This study aims to investigate the difference of ECCA atherosclerosis between patients with xanthelasma and control subjects in normolipidaemia. METHODS: Carotid atherosclerosis (CA) of 41 (8 males and 33 females) patients with xanthelasma and normolipidaemia, defined as levels of cholesterol below 6.21 mmol/l and triglyceride below 2.26 mmol/l, recruited from Department of Dermatology was compared with that of 85 age- and gender-matched control subjects. The extent and severity of CA were measured by high-resolution B-mode ultrasound and expressed as the mean intima-media thickness (IMT) of the common carotid artery (CCA) and ECCA plaque score. Mixed-effects model and multivariate logistic regression analyses were used to estimate the association between xanthelasma and CA. RESULTS: Patients with xanthelasma showed significantly higher levels of low-density lipoprotein cholesterol (LDL-C) levels and higher body mass index (BMI) compared with the control group. Mixed models identified age, male gender, smoking and subjects of hypertension with medication, but not the presence of xanthelasma, were associated with an increase of CCA IMT. Multivariate logistic regression analysis revealed subjects of male gender, and hypertension with medication, but not the presence of xanthelasma, associated with thicker IMT, defined as IMT >or= 75th percentile, or ECCA plaque score >or= 3. CONCLUSIONS: Normolipidaemia with xanthelasma is not significantly associated with CA, but did relate with adverse cardiovascular profiles, such as higher BMI, waist circumference and LDL-C levels.

Postchallenge hyperglycaemic spike associate with arterial stiffness.

Several large-scale epidemiological and intervention studies strongly indicate that postchallenge hyperglycaemia is the main factor associated with increasing the risk of morbidity and mortality in type 2 diabetes. However, the mechanisms that increase the risk of cardiovascular disease remain unclear. We aimed to study the relationship between postchallenge hyperglycaemia and arterial stiffness. We recruited 40 healthy subjects from a physical examination in 2005. Cardio-ankle vascular index (CAVI) was automatically calculated by VaSera VS-1000. For the reliability study, we performed the baseline study in the first 20 subjects who were returned to receive repeated measurements of CAVI 2 weeks later. The determinants of mean CAVI at different timings of oral glucose tolerance test (OGTT) study were analysed by constructing multivariate linear regression models. In reliability test, the inter-observer correlation coefficient was 0.82 for right CAVI, 0.87 for left CAVI and 0.85 for mean CAVI. Age, systolic blood pressure (SBP), diastolic blood pressure (DBP), glucose levels at 60 min (Glu60) and glucose area under the curve of OGTT (GluAUC) are found to be significantly and positively correlated to right CAVI, left CAVI and mean CAVI (p < 0.05). After adjustment for age, gender and SBP, Glu60 and GluAUC are still independent determinants of CAVI. In subjects without clinical diagnosis of type 2 diabetes, postchallenge hyperglycaemic spike is highly associated with CAVI, a good parameter of aortic stiffness, independent of age, gender and blood pressure.

Clinical features and predictors for mortality in patients with infective endocarditis at a university hospital in Taiwan from 1995 to 2003.

The clinical features and microbiological characteristics of 315 patients with definite or possible infective endocarditis (IE) from January 1995 to December 2003 were evaluated. There were 187 males and 128 females with a mean age of 51 years (range, 1 month to 92 years). Ninety-three patients (30%) had a diagnosis of valvular heart disease and 24 (8%) had received prosthetic valve replacement. Blood culture was negative in 62 patients (20%). Staphylococci (91 patients, 32%), including methicillin-susceptible Staphylococcus aureus (15%), methicillin-resistant S. aureus (11%), and coagulase-negative staphylococci (6%), were the most commonly encountered pathogens followed by viridans group streptococci (77 patients, 24%). Eight patients (25%) had various neurological, renal, embolic, and cardiac complications. Patients with neurological complications [odds ratio (OR) 8.175, P<0.001], nosocomial IE (OR 6.661, P<0.001), underlying malignancy (OR 4.993, P<0.001), elevated serum creatinine level (OR 3.132, P=0.001), or elevated WBC count (>15000/mm3) (OR 2.537, P=0.007) were at significantly increased risk of mortality. This study found mortality from IE was associated with several factors, among which neurological complications were the most hazardous. Patients with more than one risk factor had poorer prognosis. These results suggest the need for more aggressive management in patients with IE when multiple risk factors for mortality are identified.

Heart transplantation using donors positive for hepatitis.

From May 1994 to September 2003, 177 hearts were procured for heart transplantation (HTx) from donors ranging in age from 1 year 2 months to 66 years 5 months (mean = 30 years). All donors and recipients received serologic tests for hepatitis B surface antigen (HBsAg) and antibody (anti-HBs), and hepatitis C virus antibody (anti-HCV). Thirty-two donors were HBsAg-positive and another four were anti-HCV-positive. Two HBsAg-positive donors were transplanted to patients with no previous evidence of hepatitis. After HTx, one received hepatitis B immunoglobulin prophylaxis and no hepatitis was noted during a 5 years follow-up. The other seroconverted at 4 months after HTx, requiring lamivudine treatment. Another four HBsAg-positive donors were transplanted to HBsAg-positive recipients. All four recipients had hepatitis flare-ups requiring lamivudine treatment. The other 26 HBsAg-positive donors were transplanted to anti-HBs-positive recipients. None suffered from hepatitis. Among the four patients receiving anti-HCV-positive hearts, seroconversion was noted in one recipient at 26 months. This patient never had clinical hepatitis before he died of allograft rejection at 3 years after HTx. The other three recipients remain anti-HCV negative during follow-up of 80, 50, and 46 months. It was concluded the hepatitis B- or C-positive donors could be used as heart donors for status 1 patients. Donors with positive HBsAg may be transplanted to anti-HBs-positive recipients with no HBV infection.

Heart transplantation in the patient under ventricular assist complicated with device-related infection.

Ventricular assist devices (VAD) have benefited patients with end-stage heart failure as a bridge to heart transplantation (HTx). We present our experience of HTx in the presence of device-related infection (DRI) including driveline exit site with pocket infections. From May 1996 to April 2003, mechanical circulatory support with the HeartMate VAD was performed in eight patients, and with the Thoratec VAD in seven patients. Although 151 patients underwent HTx during that period, only 8 of the 15 patients had suitable donors and underwent orthotopic HTx. Six of the eight patients developed DRI. Their ages ranged from 18 to 59 years (mean = 36 +/- 14 years). The duration of VAD support ranged from 8 to 287 days (mean = 125 +/- 117 days). The general condition and cardiac function improved gradually under VAD support. At the time of HTx, all six male patients were suffering from DRI. The causative microorganisms were Acinetobacter baumannii (n = 3) methicillin-resistant Staphylococcus aureus (n = 2), and Enterococcus faecium (n = 1). All patients underwent successful HTx, and were discharged in good condition. It is concluded that under the coverage of appropriate antibiotics, HTx can be successfully performed for the patients for VAD support with DRI. It is important to prevent the spread of infection during HTx. Adequate debridement and drainage of the infected materials prevents postoperative wound infections.

Efficacy and safety of barnidipine compared with felodipine in the treatment of hypertension in Chinese patients.

The efficacy and safety profiles of barnidipine in the treatment of hypertension were evaluated in an open parallel-group study. Fifty-nine Chinese patients with mild-to-moderate essential hypertension were randomized to receive either barnidipine or felodipine (5 mg once daily, titrated to 10 mg or 15 mg once daily, as indicated) for 12 weeks. Both drugs reduced blood pressures significantly with > or = 68% of cases obtaining marked or moderate blood pressure reduction. Mean reductions in systolic and diastolic blood pressure for barnidipine treatment were 23.7 +/- 13.5 mmHg and 12.7 +/- 7.9 mmHg, and for felodipine, 24.3 +/- 18.4 mmHg and 14.5 +/- 10.0 mmHg, respectively. There was no significant difference between these two drugs in anti-hypertensive effect, heart rate, laboratory measurements or incidence of adverse events. The only difference was that more patients taking felodipine experienced palpitations. We conclude that barnidipine has similar efficacy and a similar safety profile to felodipine in the treatment of mild-to-moderate essential hypertension in Chinese patients.

Relation of Chlamydia pneumoniae infection in Taiwan to angiographically demonstrated coronary artery disease and to the presence of acute myocardial infarction or unstable angina pectoris.

Reports of the association of Chlamydia pneumoniae (C. pneumoniae) infection with coronary artery disease (CAD) are scarce in the Oriental population. We therefore conducted a case-control study to explore this issue in Taiwan. There were 242 consecutive subjects (166 men and 76 women) who underwent cardiac catheterization at the National Taiwan University Hospital Cardiac Catheterization Laboratory. Patients with CAD (n = 156) had > or = 1 coronary artery lesion of > 50% diameter stenosis on angiography. Controls (n = 86) had no demonstrable CAD angiographically. Antibodies to C. pneumoniae were tested by using an enzyme-linked immunosorbent assay. The prevalence of antibodies to C. pneumoniae was as follows: immunoglobulin-G (IgG), 50% (122 of 242 patients); immunoglobulin-A (IgA), 72% (176 of 242 patients); and either IgG or IgA, 79% (192 of 242 patients ). The odds ratio (OR) for CAD with either IgG or IgA was 1.4 (95% confidence interval [CI] 0.7 to 2.7, p = 0.31). After adjusting for the known CAD risk factors, the OR decreased to 0.8 (95% CI 0.3 to 2.1, p = 0.60). The OR for unstable angina or acute myocardial infarction with the presence of either IgG or IgA was 0.5 (95% CI 0.2 to 1.1, p = 0.08) and 0.4 ( 95% CI 0.1 to 1.0, p = 0.049) after adjusting for other risk factors. These results suggest a high prevalence of C. pneumoniae infection in Taiwan. However, C. pneumoniae infection is not associated with angiographically documented CAD, and, in contrast, is a negative predictor for the development of acute coronary syndromes.

Efficacy of cholesterol levels and ratios in predicting future coronary heart disease in a Chinese population.

In this study, we assessed the efficacy of various lipid and lipoprotein measurements at baseline for predicting the risk for coronary heart disease (CHD) and determined the associated risk of CHD in subgroups stratified by different lipid and lipoprotein screening strategies to evaluate the adequacy of current total and low-density lipoprotein (LDL) cholesterol-based approaches in lipid management. We analyzed data from the Chin-Shan Community Cardiovascular Cohort study, a Chinese population-based prospective cohort study that began in 1990. During an 8-year follow-up period, 213 of 3,159 participants (6.7%) without CHD (aged > or =35 years) developed CHD. The total cholesterol/high-density lipoprotein (HDL) cholesterol ratio was the most powerful lipoprotein predictor of future CHD (hazard ratio 1.21 for a 1.0 increment in ratio; p <0.001). Subjects with "high-risk" LDL cholesterol levels (>160 mg/dl) and low total cholesterol/HDL cholesterol ratios (< or =5) had an incidence of CHD similar to those with low levels of both LDL cholesterol (< or =130 mg/dl) and total cholesterol/HDL cholesterol ratios (4.9% vs 4.6%). In contrast, subjects with "low-risk" LDL cholesterol levels (< or =130 mg/dl) and high total cholesterol/HDL cholesterol ratios (>5) had a 2.5-fold higher incidence of CHD than those with similar LDL cholesterol levels but low total cholesterol/HDL cholesterol ratios (p <0.001). Compared with using an LDL cholesterol level of 130 mg/dl as the cut-off point, using a total cholesterol/HDL cholesterol ratio of 5 was associated with superior specificity (73% vs 59%, p <0.001) and accuracy (72% vs 58%, p <0.001), and similar sensitivity (50% vs 53%). Our data indicate that current guidelines for lipid management may misclassify subjects with high levels of HDL and LDL cholesterol as well as those with low levels of HDL and LDL cholesterol. Using the ratio of total to HDL cholesterol as the initial screening tool can obviate this discrepancy.

Increased levels of tissue plasminogen activator antigen and factor VIII activity in nonvalvular atrial fibrillation: relation to predictors of thromboembolism.

INTRODUCTION: Given that nonvalvular atrial fibrillation (AF)-associated stroke can be either cardioembolic or atherothrombotic, we investigated the relationships between nonvalvular AF and hemostatic factors reflecting intrinsic thrombogenic and atherogenic potentials (tissue plasminogen activator [t-PA] antigen, plasminogen activator inhibitor-1, and factor VIII activity). We also evaluated the clinical applicability of these hemostatic factors by examining whether AF subjects with established clinical or echocardiographic predictors of thromboembolism had higher levels of these factors. METHODS AND RESULTS: Of the 3,212 participants of a Chinese population-based study, 53 subjects (1.7%) with AF were identified. Among the hemostatic factors measured, t-PA antigen (median 12.8 vs 8.1 ng/mL; P < 0.01) and factor VIII activity (median 155% vs 133%; P < 0.05) were significantly higher in AF subjects after adjustment for age and sex. In multivariate analysis, features independently associated with t-PA antigen levels were AF, sex, body mass index, systolic blood pressure, total cholesterol, triglycerides, and left ventricular systolic dysfunction. Features independently associated with factor VIII activity levels included AF, age, and total cholesterol. Levels of both t-PA antigen and factor VIII activity were primarily elevated in AF subjects with predictors of thromboembolism (age > 75 years, hypertension, diabetes, and left ventricular systolic dysfunction), whereas in AF subjects with no thromboembolic predictors, plasma levels of hemostatic factors examined were similar to those without AF. CONCLUSION: We demonstrated that nonvalvular AF was independently associated with increased peripheral levels of t-PA antigen and factor VIII activity. Levels of both hemostatic factors were primarily elevated in AF subjects with predictors of thromboembolism. Whether these hemostatic factors are independently predictive of future thromboembolic events in AF patients requires further investigation.

Aortic stenting on a type B aortic dissection with visceral and limb ischemia.

Aortic dissection complicated with limb and visceral ischemia is a clinical dilemma since surgical intervention carries high risk of morbidity and mortality. The management is further complicated when renal perfusion is impaired and thus associated with severe renovascular hypertension. As catheterization techniques advanced over the past decade, percutaneous endovascular intervention provides a less invasive alternative for management of such cases. We report a case of chronic Stanford type B aortic dissection complicated with visceral and limb ischemia presenting with marked renovascular hypertension, which was successfully treated with percutaneous endovascular aortic stenting.

Derangement of heart rate variability during a catastrophic earthquake: a possible mechanism for increased heart attacks.

At 1:47 AM on September 21, 1999, the middle part of Taiwan was struck by a major earthquake measuring 7.3 on the Richter scale. It has been shown that the mental stress caused by an earthquake could lead to a short- or long-term increase in frequency of cardiac death probably through activation of the sympathetic nervous system. The aim of this study was to investigate the effects of emotional stress on the autonomic system during an actual earthquake. Fifteen patients receiving a 24-hour Holter ECG study starting from 10+/-4 hours before the onset of the earthquake were included for the analysis of time- and frequency-domains of heart rate variability (HRV) at several time periods. A 24-hour Holter study recorded 2-6 months before the earthquake in 30 age- and sex-matched subjects served as the control group. Heart rate and the low frequency (LF) to high frequency (HF) ratio increased significantly after the earthquake and were attributed mainly to the withdrawal of the high frequency component (parasympathetic activity) of HRV. Sympathetic activation was blunted in elderly subjects > 60 years old. The concomitant ST-T depression observed in the Holter study correlated with a higher increment of LF as compared to HF components. The changes observed in HRV recovered completely 40 minutes following the earthquake. The derangement of HRV results from the withdrawal of the parasympathetic component and the arousal of sympathetic activity by the stressful earthquake. However, this autonomic derangement returned towards normal 40 minutes following the earthquake.

Gender differences in the patterns of coronary angiography and PTCA use in a university hospital in Taiwan.

BACKGROUND AND PURPOSE: Coronary artery angiography (CAG) and percutaneous transluminal coronary angioplasty (PTCA) are important procedures for the diagnosis and treatment of patients with coronary artery disease. However, long-term trends in the frequency of CAG and PTCA use and their relation to gender have not been clearly determined in the Asian population. The purpose of this study was to investigate gender differences in the patterns of CAG and PTCA use in a university hospital in Taiwan during the period of 1983 through 1996. METHODS: We studied the monthly data of all patients who underwent CAG or PTCA in a university hospital in Taipei from 1983 through 1996. A time series analysis was used to estimate gender differences in the patterns of CAG and PTCA use. RESULTS: The frequency of CAG and PTCA increased significantly during this period. Before 1990, only a small number of patients underwent PTCA. However, this number increased steadily after 1990. Men were more likely to undergo CAG and PTCA than women. A time series analysis with fitted models was used to create an integrated moving average model. For CAG, the value of the estimated intercept for men was 2.5 times greater than that for women. In the PTCA series, the value of the intercept in men was 4.4 times greater than that in women. The patterns of trend change showed greater increases in men than in women, and a greater increase in the PTCA than in the CAG series. By transfer function modeling and intervention analysis, we found that the effect of CAG on the frequency of PTCA in men was 1.8 times greater than its effect in women. The estimated influence of the use of a new catheterization room (added in 1993) was 2.8 times greater in men than in women. The fitted model correlated well with the observed values in the next 12 months for both genders. CONCLUSIONS: We concluded that women had fewer CAG and PTCA procedures than men, and the influence of CAG on the PTCA series was significantly higher in men than in women.

Comparison of simultaneous dobutamine echocardiography and thallium-201 stress-reinjection single-photon emission computed tomography in predicting improvement of chronic myocardial dysfunction after revascularization.

Previous studies have shown that ultrasonic integrated backscatter is valuable in characterizing stunned myocardium. Recent investigations have demonstrated that resting cardiac cycle-dependent variation of integrated backscatter closely paralleled the contractile reserve in patients with chronic left ventricular ischemic dysfunction. The purpose of this study was to validate whether ultrasonic tissue characterization (UTC) compared with dobutamine stress echocardiography (DSE) and thallium-201 stress-reinjection single-photon emission computed tomography (Tl-SPECT) could predict reversible myocardial dyssynergy in patients with chronic coronary artery disease. Forty-eight patients with stable coronary artery disease underwent UTC, DSE, and Tl-SPECT simultaneously before successful coronary revascularization and were followed up with echocardiograms at rest >3 months later. Among the 58 investigated segments, the weighted amplitude, a composite parameter derived from the integrated backscatter power curve, was larger for those groups with greater functional recovery (p <0.001). For the persistent akinetic segments, the weighted amplitudes were small with large deviations of the nadir ratios that represented the asynchrony between the intramural contractile events and the global systole. Using the cut-off value 2.0 of the weighted amplitude, the sensitivity and specificity for predicting functional improvement after revascularization were both 82.8% (kappa = 0.66) and comparable to the sensitivity and specificity of DSE and Tl-SPECT. UTC, delineating the myocardial physical state and intramural contraction, can be a novel approach in predicting functional improvement of chronic dyssynergy after revascularization.

Amyotrophic lateral sclerosis with a 'pseudo-infarction' pattern on the electrocardiograph. A case report.

Amyotrophic lateral sclerosis (ALS) is a motor neuron disease involving both the upper and lower motor neurons in the brain stem and spinal cord. Although it is well known that various central nervous system disorders can produce a 'pseudo-infarction' pattern on the electrocardiogram, there have been no reports of this particular pattern in ALS patients. This report concerns an ALS patient who presented with an ECG pattern of S-T elevation followed by biphasic T and inverted T without any detectable myocardial abnormality. Data from the present case suggest that this pattern may be an inherent characteristic of ALS.