Effect of Beta-Blocker on Long-Term Major Cardiovascular Events in High Atherosclerotic Risk Population.

PURPOSE: Beta-blocker is a frequently used medication in cardiovascular diseases. However, long-term benefit of beta-blocker in patients with preserved left ventricular ejection function (LVEF) on major adverse cardiovascular events (MACEs) is uncertain. METHODS: The Cohort Of patients with high Risk for cardiovascular Events (CORE-Thailand) was a prospective study that enrolled Thai patients with high atherosclerotic risk including multiple atherosclerotic risk factors and established atherosclerotic cardiovascular diseases. Baseline demographic data, co-morbidities and medication were recorded. Patients were followed for 5 years. Patients with LVEF<50% were excluded. Primary outcome was the effect of beta-blocker on the occurrence of MACEs including all-cause death, non-fatal myocardial infarction and non-fatal stroke (3P-MACEs). Propensity score matching was used to control confounding factors. RESULTS: There was a total of 8513 patients in the pre-matched cohort, 4418 were taking beta-blocker and 4095 were not. After adjustment of confounders, beta-blocker was an independent predictor of 3P-MACEs (adjusted HR 1.29;95% CI 1.12-1.49;p<0.001). After propensity score matching, 4686 patients remained in the post-matched cohort. Propensity score analysis showed consistent results in which patient taking beta-blocker had higher risk of 3P-MACEs (adjusted HR 1.29;95% CI 1.10-1.53;p=0.002). Subgroup analysis in patients with coronary artery disease (CAD) indicated that taking beta-blocker did not increase the incidence of 3P-MACEs (adjusted HR 0.99;95% CI 0.76-1.29) while those without CAD did (adjusted HR 1.51; 95% CI, 1.22-1.86;p-interaction=0.015). CONCLUSION: In patients with high atherosclerotic cardiovascular risk, taking beta-blockers had a higher risk of 3P-MACEs. Care should be taken when prescribing beta-blockers to patients without a clear indication. TRIAL REGISTRATION: TCTR20130520001 registered in Thai Clinical Trials Registry (TCTR) https://www.thaiclinicaltrials.org/ , date of registration 20 May 2013.

Increased small extracellular vesicle levels and decreased miR-126 levels associated with atrial fibrillation and coexisting diabetes mellitus.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Diabetes mellitus (DM) is one of the risk factors for the development of stroke and thromboembolism in patients with AF. Early identification may reduce the incidence of complications and mortality in AF patients. HYPOTHESIS: AF patients with DM have different pattern of small extracellular vesicle (sEV) levels and sEV-derived microRNA (miRNA) expression compared with those without DM. METHODS: We compared sEV levels and sEV-miRNA expression in plasma from AF patients with and without DM using nanoparticle tracking analysis and droplet digital polymerase chain reaction, respectively. RESULTS: We observed a significant increase in total sEV levels (p = .004) and a significant decrease in sEV-miR-126 level (p = .004) in AF patients with DM. Multivariate logistic regression analysis revealed a positive association between total sEV levels and AF with DM (p = .019), and a negative association between sEV-miR-126 level and AF with DM (p = .031). The combination of clinical data, total sEVs, and sEV-miR-126 level had an area under the curve of 0.968 (p < .0001) for discriminating AF with DM, which was shown to be significantly better than clinical data analysis alone (p = .0368). CONCLUSIONS: These results suggest that an increased level of total sEV and a decreased sEV-miR-126 level may play a potential role in the pathophysiology and complications of AF with DM, especially endothelial dysfunction, and can be considered as an applied biomarker for distinguishing between AF with and without DM.

Increased expression of six-large extracellular vesicle-derived miRNAs signature for nonvalvular atrial fibrillation.

BACKGROUNDS: Non-valvular atrial fibrillation (AF) is the most common type of cardiac arrhythmia. AF is caused by electrophysiological abnormalities and alteration of atrial tissues, which leads to the generation of abnormal electrical impulses. Extracellular vesicles (EVs) are membrane-bound vesicles released by all cell types. Large EVs (lEVs) are secreted by the outward budding of the plasma membrane during cell activation or cell stress. lEVs are thought to act as vehicles for miRNAs to modulate cardiovascular function, and to be involved in the pathophysiology of cardiovascular diseases (CVDs), including AF. This study identified lEV-miRNAs that were differentially expressed between AF patients and non-AF controls. METHODS: lEVs were isolated by differential centrifugation and characterized by Nanoparticle Tracking Analysis (NTA), Transmission Electron Microscopy (TEM), flow cytometry and Western blot analysis. For the discovery phase, 12 AF patients and 12 non-AF controls were enrolled to determine lEV-miRNA profile using quantitative reverse transcription polymerase chain reaction array. The candidate miRNAs were confirmed their expression in a validation cohort using droplet digital PCR (30 AF, 30 controls). Bioinformatics analysis was used to predict their target genes and functional pathways. RESULTS: TEM, NTA and flow cytometry demonstrated that lEVs presented as cup shape vesicles with a size ranging from 100 to 1000 nm. AF patients had significantly higher levels of lEVs at the size of 101-200 nm than non-AF controls. Western blot analysis was used to confirm EV markers and showed the high level of cardiomyocyte expression (Caveolin-3) in lEVs from AF patients. Nineteen miRNAs were significantly higher (> twofold, p < 0.05) in AF patients compared to non-AF controls. Six highly expressed miRNAs (miR-106b-3p, miR-590-5p, miR-339-3p, miR-378-3p, miR-328-3p, and miR-532-3p) were selected to confirm their expression. Logistic regression analysis showed that increases in the levels of these 6 highly expressed miRNAs associated with AF. The possible functional roles of these lEV-miRNAs may involve in arrhythmogenesis, cell apoptosis, cell proliferation, oxygen hemostasis, and structural remodeling in AF. CONCLUSION: Increased expression of six lEV-miRNAs reflects the pathophysiology of AF that may provide fundamental knowledge to develop the novel biomarkers for diagnosis or monitoring the patients with the high risk of AF.

Neck circumference as a predictor of metabolic syndrome: A cross-sectional study.

BACKGROUND: Data relating to the association between neck circumference (NC) and metabolic syndrome (MetS) in Southeast Asian population are scarce. AIMS: We aimed to investigate association between NC and MetS in Thai adults, and to determine gender-specific NC cutoff values for predicting MetS. METHODS: This cross-sectional study enrolled patients aged ≥18years that attended the health examination center at Siriraj Hospital (Bangkok, Thailand) during February 2016 to January 2017. Demographic, clinical, anthropometric data, and biochemical investigations for diagnosing MetS were collected. RESULTS: 390 patients (age 35.5±9.7years with range 20-73years; 81.3% women) were included. Mean NC was significantly higher in MetS than in non-MetS (p<0.001). Receiver operating characteristic curve analysis revealed NC ≥38cm and ≥33cm to be the optimal cutoff points for MetS in men and women, respectively. Body mass index and anthropometric indices were positively correlated with NC in both men and women. Among women, all components of MetS were significantly associated with NC. CONCLUSIONS: Using the identified gender-specific cutoff values, NC is a useful tool for predicting MetS in Thais. NC was found to be well-correlated with almost all of the metabolic risk factors, anthropometric indices, and MetS components evaluated in this study.

Effect of Breast Sling Use on Transthoracic Echocardiographic Examination Time and Image Quality in Women with Large Breasts.

BACKGROUND: Transthoracic echocardiographic examinations in women with large breasts are technically demanding and can lead to suboptimal image quality, excessive scan time, and cause pain and discomfort to patients. OBJECTIVE: Evaluate the effects of self-made breast sling used during transthoracic echocardiographic examination on scanning time, image quality, pain, and satisfaction in women with large breasts. MATERIAL AND METHOD: A self-made breast sling was developed by the study team and tested in 26 women with bra cup size of C or larger, who were scheduled for transthoracic echocardiography. Each patient underwent transthoracic echocardiographic examination twice, with and without breast sling use. The sequence of the examinations was determined at random. The primary outcome was scan time in apical views. Secondary outcomes included total scan time, image quality in apical views (qualitative scores), patients' and sonographers' pain (qualitative scores), and patients' satisfaction (qualitative scores). Outcomes were compared within individual subjects. RESULTS: The use of self-made breast sling did not reduce scan time in apical views (mean difference 2.8 minutes, p = 0.053), but it reduced total scan time (mean difference 5.9 minutes, p = 0.04). Breast sling use was not associated with improvement in image quality scores (p = 0.59), patients' pain (p = 0.21), and sonographers' shoulder-back-neck pain (p = 0.052). It improved patients' satisfaction (p = 0.01) and sonographers' wrist pain (p = 0.035). CONCLUSION: In women with large breasts who required transthoracic echocardiographic examination, the use of self-made breast sling did not improve scan time and image quality in apical views. It may improve total scan time, patients' satisfaction, and sonographers' wrist pain.

Certain hormonal markers in urban Thai adults with metabolic syndrome.

BACKGROUND: The prevalence of metabolic syndrome (MS) accompanied with cardiometabolic complications has progressively increased in Thailand. The roles of insulin resistance, leptin, adiponectin, and free testosterone as prognostic indicators of MS among Thai population were evaluated MATERIAL AND METHOD: Men and women aged 34 to 89 years (n = 308) having 0-5 criteria of MS according to NCEP III with Asian-specific cut-points for waist circumference were enrolled in this cross-sectional study. Blood glucose, lipids, insulin, leptin, adiponectin, and free testosterone were measured RESULTS: Each component of MS, especially the enlarged waist, adversely affected insulin sensitivity. MS subjects were at higher risk for developing insulin resistance, decreasing of plasma adiponectin, and increasing of leptin and the leptin/ adiponectin ratio in comparison to non-MS individuals. The hormonal changes that have been shown to be associated with increased cardiometabolic risk were amplifiedas more MS criteria have been met. Odds ratios of increased leptin/adiponectin ratio among MS group were highest in comparison to others. Free testosterone levels declined with age and did not discriminate men with MS. CONCLUSION: The results indicate the benefit of hormonal assessment, particularly the leptin/adiponectin ratio in identifying MS individuals with high cardiometabolic disease risk.

Abnormal liver enzymes in Thai patients with metabolic syndromes.

OBJECTIVE: Elevated transaminases have been found to be associated with metabolic syndrome (MS) in many populations but little is known in Asians. The present study aimed to investigate the association between elevated hepatic enzymes in Thai patients diagnosed with MS. MATERIAL AND METHOD: A cross-sectional study on 2,585 Thais was conducted. Blood pressure, waist circumference, fasting plasma glucose, triglyceride, HDL-cholesterol, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were measured. MS was diagnosed using NCEP/ATP III criteria with modified waist circumference for Asian. The association between MS with elevated liver enzymes was performed using logistic regression. RESULTS: Twenty-seven percent of the subjects were found to have MS. The MS group had significantly higher mean AST, ALT, and ALP levels than the non-MS group (mean (SD) for AST 29.86 (18.97), 24.08 (12.71); ALT 38.39 (29.14), 24.38 (18.57); and ALP 73.45 (27.09), 65.72 (21.27) for MS and non-MS, respectively, p < 0.05). MS was significantly associated with elevated liver enzymes. The adjusted odds ratios (OR) were 2.2 (95% confidence interval (CI): 1.6-2.9), 2.3 (95% CI: 1.8-3.0), and 2.2 (95% CI: 1.1-4.2) for elevated AST, ALT, and ALP, respectively. ALT/AST ratio of > or = 1 was significantly associated with MS in both genders (adjusted ORs: 1.72 (95% CI: 1.28-2.32) for men and 2.30 (95% CI: 1.68-3.16) for women). CONCLUSION: There is a strong association between metabolic syndrome and elevated liver enzymes. Further study is needed to investigate the long-term sequelae of liver abnormalities in those with metabolic syndrome in Thai population.

Dobutamine stress echocardiography for the evaluation of coronary artery disease in Thai population: Siriraj experience.

OBJECTIVE: No previous report of dobutamine stress echocardiography in the Thai population has been available. The present study seeks to document the protocol, indications, results and safety of dobutamine stress echocardiography performed at Siriraj Hospital. MATERIAL AND METHOD: The authors studied 421 [mean age 67.7 +/- 11.0 years, 179 (43%) men] consecutive Thai patients undergoing dobutamine stress echocardiography at Siriraj Hospital. The protocol, indications and echocardiographic analysis were described. Clinical characteristics, hemodymanics, results and adverse effects were recorded at the time of dobutamine stress echocardiography. RESULTS: Dobutamine stress echocardiography was performed for preoperative assessment before non-cardiac surgery in 212 patients (50%), for the diagnosis of suspected Coronary Artery Disease (CAD) in 179 patients (43%), for risk stratification of CAD in 24 patients (6%), and for other reasons in six patients (1%). The results were normal and positive for inducible ischemia in 276 (66%) and 80 (19%) patients, respectively. Limiting side effects were observed in 3%. No death, myocardial infarction or life-threatening arrhythmias occurred. Transient stress-associated tachyarrhythmias, such as atrialfibrillation, nonsustained ventricular tachycardia or supraventricular tachycardia, occurred in 3.5% of patients. CONCLUSION: Dobutamine stress echocardiography was considered a safe and tolerable technique for the evaluation of CAD in Thai population.

Effectiveness of amiodarone for conversion of atrial fibrillation to sinus rhythm: a meta-analysis.

BACKGROUND: Although clinicians sometimes choose amiodarone to convert atrial fibrillation (AF) to sinus rhythm, no current and comprehensive systematic review has summarized its effectiveness. OBJECTIVE: To review the effectiveness of amiodarone in converting AF to sinus rhythm over a 4-week period. METHODS: Two reviewers conducted a systematic search for randomized trials in databases, complemented by hand searches and contact with experts. Selected trials compared amiodarone with placebo, digoxin, or calcium channel blockers for conversion of AF to sinus rhythm. Reviewers evaluated the methodology and extracted data from each primary study. RESULTS: Twenty-one studies met eligibility criteria. Duration of AF proved to be a source of heterogeneity, leading to 2 analyses. The relative risk (RR) for achieving sinus rhythm was 4.33 (95% confidence interval [CI], 2.76-6.77) for trials with mean AF duration of greater than 48 hours and 1.40 (95% CI, 1.25-1.57) for those with AF of 48 hours or less. The risk differences for these 2 groups were 27% and 26%, respectively, yielding a number needed to treat of 4 for both groups. The low control event rate among trials with long duration of AF, compared with that of trials with a duration of 48 hours or less, explained the difference in the RR for conversion. We found that the size of the left atrium, presence of cardiovascular disease, and protocols of amiodarone administration did not influence the magnitude of effect. Serious adverse events were infrequent. CONCLUSIONS: Amiodarone is effective for converting AF to sinus rhythm in a wide range of patients. Although use of amiodarone is apparently safe, safety data are too scarce for definitive conclusions.