SAMe-TT2R2 score for prediction of suboptimal time in therapeutic range in a Thai population with atrial fibrillation

INTRODUCTIONInternational normalised ratio (INR) control is an important factor in patients with non-valvular atrial fibrillation (NVAF) being treated with warfarin. INR control was previously reported to be poorer among Asians compared to Westerners. We aimed to validate the SAMe-TT₂R₂ score for prediction of suboptimal INR control (defined as time in therapeutic range [TTR] < 65% in the Thai population) and to investigate TTR among Thai NVAF patients being treated with warfarin.METHODSINR data from patients enrolled in a multicentre NVAF registry was analysed. Clinical and laboratory data was prospectively collected. TTR was calculated using the Rosendaal method. Baseline data was compared between patients with and without suboptimal INR control. Univariate and multivariate analyses were performed to identify variables independently associated with suboptimal INR control.RESULTSA total of 1,669 patients from 22 centres located across Thailand were included. The average age was 69.1 ± 10.7 years, and 921 (55.2%) were male. The mean TTR was 50.5% ± 27.5%; 1,125 (67.4%) had TTR < 65%. Univariate analysis showed hypertension, diabetes mellitus, heart failure, renal disease and SAMe-TT₂R₂ score to be significantly different between patients with and without optimal TTR. The SAMe-TT₂R₂ score was the only factor that remained statistically significant in multivariate analysis. The C-statistic for the SAMe-TT₂R₂ score in the prediction of suboptimal TTR was 0.54.CONCLUSIONSAMe-TT₂R₂ score was the only independent predictor of suboptimal TTR in NVAF patients being treated with warfarin. However, due to the low C-statistic, the score may have limited discriminative power.     

Management and risk factor control of coronary artery disease in elderly versus nonelderly: a multicenter registry

Background Coronary artery disease (CAD) is a leading cause of death in elderly because aging is the important non-modifiable risk factors of atherosclerosis and also a predictor of poor outcomes. Underuse of guideline directed therapy may contribute to suboptimal risk factor control and worse outcomes in the elderly. We aimed to explore the management of CAD, risk factors control as well as goal attainment in elderly compared to nonelderly CAD patients. Methods The CORE-Thailand is an ongoing multicenter, prospective, observational registry of patients with high atherosclerotic risk in Thailand. The data of 4120 CAD patients enrolled in this cohort was analyzed comparing between the elderly (age ≥ 65 years) vs. nonelderly (age < 65 years). Results There were 2172 elderly and 1948 nonelderly patients. The elderly CAD patients had higher prevalence of hypertension, dyslipidemia, atrial fibrillation and chronic kidney disease. The proportion of patients who received coronary revascularization was not different between the elderly and nonelderly CAD patients. Antiplatelets were prescribed less in the elderly while statin was prescribed in the similar proportion. Goal attainments of risk factor control of glycemic control, low density lipoprotein cholesterol, and smoking cessation except the blood pressure goal were higher in the elderly CAD patients. Conclusions The CORE-Thailand registry showed the equity in the treatment of CAD between elderly and non-elderly. Elderly CAD patients had higher rate of goal attainment in risk factor control except blood pressure goal. The effects of goal attainment on cardiovascular outcomes will be demonstrated from ongoing cohort.     

One-year outcome of cardioversion of atrial fibrillation in patients with mitral stenosis after percutaneous balloon mitral valvuloplasty

Our objectives were to study the success rate of electrical cardioversion after percutaneous balloon mitral valvuloplasty (PBMV) in patients with symptomatic moderate-to-severe mitral stenosis and atrial fibrillation (AF) and the maintenance rate of sinus rhythm for < or =1 year. We studied patients with mitral stenosis and AF who were scheduled for PBMV. Electrical cardioversion was performed 1 month after PBMV. Amiodarone 200 mg/day was started the day after PBMV. The primary outcomes studied were the rate of successful cardioversion and the maintenance rate of sinus rhythm at 12 months. Of 272 patients scheduled for PBMV, 70 were enrolled. The average age was 45 +/- 10 years. The average mitral valve area was 0.82 +/- 0.22 cm(2). Cardioversion was successful in 50 patients (71%). Logistic regression analysis revealed that left atrial size and associated aortic valvular disease were predictors of successful cardioversion. Of the 50 patients with successful cardioversion, AF recurred in 24 (48%). An increased left atrial diameter was the only factor associated with AF recurrence at 12 months. In conclusion, good candidates for cardioversion after PBMV were those with a left atrial diameter of <60 mm and no associated aortic valvular disease -- approximately 43% of patients with AF scheduled for PBMV. In this group, about 2/3 were in sinus rhythm at 12 months after cardioversion.     

Myocardial perfusion cardiac magnetic resonance for the diagnosis of coronary artery disease: do we need rest images?

Adenosine stress cardiovascular magnetic resonance (CMR) has been reported to be useful for the diagnosis of coronary artery disease (CAD). Most studies use rest and stress perfusion images. The objectives of this study were to determine (Barkhausen et al. in J Magn Reson Imaging 19(6):750–757, 1) the accuracy of visual assessment and myocardial perfusion reserve index (MPRI) in the diagnosis of CAD and (Rieber et al. in Fur Heart J 27(12):1465–1471, 2) the accuracy of analysis based on rest–stress and stress images. We enrolled patients with suspected CAD and referred them for coronary angiography (CAG). All the patients underwent adenosine stress CMR before CAG. Rest and stress perfusion images were analyzed by calculation of MPRI and visual assessment separately. Visual assessment was performed separately by using rest and stress images and by using only stress images. CAG was considered the gold standard. Sensitivity, specificity, and accuracy of both methods were calculated and compared. A total of 66 patients (mean age, 61.3 ± 11.7 years) were studied. Thirty-eight patients (57.6%) were diagnosed with CAD. The sensitivity and specificity for the diagnosis of CAD (≥50% stenosis) were 89.5 and 78.6% for MPRI, 76.3 and 75% for stress–rest visual method, and 86.8 and 75% for stress visual method, respectively. CMR perfusion had a relatively lower accuracy in patients with left ventricular systolic dysfunction, high left ventricular mass, or presence of late gadolinium enhancement than in patients without those CMR findings. Visual assessment of stress image of CMR perfusion is accurate and comparable to MPRI for the detection of CAD.     

Improvement of quality of life after percutaneous balloon mitral valvulotomy in patients with mitral stenosis: does rhythm matter?

BACKGROUND AND AIM OF THE STUDY: Limited data are available on the effect of percutaneous balloon mitral valvulotomy (PBMV) on quality of life (QoL) in patients with mitral stenosis (MS), and whether the effect is similar between patients in sinus rhythm (SR) and with atrial fibrillation (AF). The study aim was to determine the effect of PBMV on the QoL of such patient groups. METHODS: A total of 130 patients with symptomatic MS and scheduled for PBMV was studied. Patients with AF were predominantly male, and had more severe symptoms, a larger left atrial size and a lower left ventricular ejection fraction (LVEF). Baseline characteristics were collected together with PBMV outcomes. QoL was assessed using the SF-36 questionnaire at baseline, and at one and six months after PBMV. The QoL assessment included eight aspects: physical functioning; role physical; bodily pain; general health; vitality; social functioning; role emotional; and mental health. The raw scale was transformed into a transformed scale from 0 (worst) to 100 (best). Physical and mental subscales were calculated. RESULTS: The cardiac rhythm was AF in 65 patients (50%). QoL on physical and mental scales was significantly improved after PBMV. There was no difference in the effect of PBMV on QoL improvement in patients with AF and SR. QoL improvement was demonstrated in all aspects, except for bodily pain. PBMV also improved NYHA functional class and mitral valve area, but decreased left atrial diameter and right ventricular systolic pressure in both groups. An increase in LVEF was observed in patients with AF CONCLUSION: PBMV was shown to improve QoL in patients with MS, irrespective of their baseline cardiac rhythm.