Heart Asia最新文献

Objective: To undertake an ECG in high level athletes to determine the morphology of the ECG and to assess the influences on the ECG of the amount of time in a high-performance programme and the type of sport played.

Design: Cross-sectional cohort study.

Setting: High-performance sports programme.

Interventions: Current symptoms (questionnaire) and length of time in a high-performance sports programme were recorded. Sports were classified as either high maximal oxygen uptake continuous, high maximal oxygen uptake repeated effort or static. An ECG was performed and classified by 2010 European Society of Cardiology guidelines into Groups 0 (normal), Group 1 (common and training-related ECG changes) and Group 2 (uncommon and training unrelated ECG changes).

Results: The following were recorded: length of time in high performance sport programme (mean 2.3 years), type of sport (Continuous 103, Repeated effort 133, Static 37), ECG changes Group 0 (n=83, 31%), Group 1 (n=173, 63%) and Group 2 (n=17, 6.2%). Athletes with an increased length of time in a high performance programme demonstrated a higher likelihood of Group 2 ECG changes when compared with Groups 0 and 1 (p=0.05). The questionnaire did not help detect athletes with Group 2 ECG changes.

Conclusions: This study demonstrates that an increased length of time in a high performance programme was associated with an increased number of detectable Group 2 ECG changes. Overall, the further investigation rate was 6.2%.

Background: Morphine is widely used for pain control in patients with acute coronary syndrome (ACS). Several studies have questioned the safety of morphine in this setting with a concern of interaction with and reduced efficacy of antiplatelet agents.

Objective: This study aims to systematically review the safety of morphine use in ACS.

Methods: MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were queried from inception through April 2018. Studies comparing morphine to nonmorphine use in ACS were included. Study endpoints included: in-hospital myocardial infarction (MI), all-cause mortality, stroke, major bleeding, minor bleeding and dyspnoea.

Results: A total of 64 323 patients with ACS were included from eight studies, seven of which were observational studies and one was a randomised controlled trial. The use of morphine was associated with increased risk of in-hospital recurrent MI (OR 1.30, 95% CI 1.18 to 1.43, p < 0.00001). There was, however, no significant difference in terms of all-cause mortality (OR 0.87, 95% CI 0.62 to 1.22, p = 0.44), stroke (OR 0.81, 95% CI 0.39 to 1.66, p = 0.57), major bleeding (OR 0.49, 95% CI 0.24 to 1.00, p = 0.05), minor bleeding (OR 0.98, 95% CI 0.41 to 2.34, p = 0.97), or dyspnoea (OR 0.55, 95% CI 0.16 to 1.83, p = 0.33).

Conclusion: The use of morphine for pain control in ACS was associated with an increased risk of in-hospital recurrent MI. Randomised clinical trials are needed to further investigate the safety of morphine in ACS.

Background: The SUrvey of Risk Factors (SURF) indicated poor control of risk factors in subjects with established coronary heart disease (CHD). The present study aimed to investigate determinants of risk factor management in patients with CHD.

Methods and results: SURF recruited 9987 consecutive patients with CHD from Europe, Asia and the Middle East between 2012 and 2013. Risk factor management was summarised as a Cardiovascular Health Index Score (CHIS) based on six risk factor targets (non-smoker/ex-smoker, body mass index <30, adequate exercise, controlled blood pressure, controlled low-density lipoprotein and controlled glucose). Logistic regression models assessed the associations between determinants (age, sex, family history, cardiac rehabilitation, previous hospital admission and diabetes) and achievement of moderate CHIS (≥3 risk factors controlled). The results are presented as OR with corresponding 95% CI. A moderate CHIS was less likely to be reached by women (OR 0.90, 95% CI 0.69 to 1.00), those aged <55 years old (OR 0.62, 95% CI 0.53 to 0.76) and those with diabetes (OR 0.41, 95% CI 0.37 to 0.46). Attendance in cardiac rehabilitation was associated with better CHIS achievements (OR 1.62, 95% CI 1.42 to 1.87). Younger Asian and European patients had poorer risk factor management, whereas for patients from the Middle East age was not significantly associated with risk factor management. The availability and applicability of cardiac rehabilitation varied by region.

Conclusions: Overall, risk factor management was poorer in women, those younger than 55 years old, those with diabetes and those who did not participate in a cardiac rehabilitation. Determinants of cardiovascular risk factor management differed by region.

Objective: Data describing outcomes after implantable cardioverter-defibrillator (ICD) unit generator replacement in patients with heart failure (HF) with primary prevention devices are limited.

Method: Data on patients with HF who underwent primary prevention ICD/cardiac resynchronisation therapy-defibrillator (CRT-D) implantation from 2007 until mid-2015 who subsequently received unit generator replacement were analysed. Outcomes assessed were mortality, appropriate ICD therapy and shock, and procedural complications.

Results: 61 of 385 patients with HF with primary prevention ICD/CRT-D undergoing unit generator replacement were identified. Follow-up period was 1.8±1.5 years after replacement. 43 (70.5%) patients had not received prior appropriate ICD therapy prior to unit replacement. The cumulative risks of appropriate ICD therapy at 1, 3 and 5 years after unit replacement in those without prior ICD therapy were 0%, 6.2% and 50% compared with 6.2%, 59.8% and 86.6%, respectively (p=0.005) in those with prior ICD therapies. No predictive factors associated with appropriate ICD therapy after replacement could be identified. 41 (32.8%) patients no longer met guideline indications at the time of unit replacement but risks of subsequent appropriate ICD interventions were not different compared with those who continued to meet primary prevention ICD indications.The 5-year mortality risk after unit replacement was 18.4% and there were high procedural complication rates (9.8%).

Conclusion: No predictive marker successfully stratified patients no longer needing ICD support prospectively. Finding such a marker is important in decision-making about device replacement particularly given the concerns about the complication rates. These factors should be considered at the time of ICD unit replacement.

Clinical introduction: A 25-year-old woman with a diagnosis of hypertrophic cardiomyopathy (HCM) and pre-excitation on ECG presented with unexplained syncope and daily palpitation. Genetic testing was positive for lysosome-associated membrane protein 2 (LAMP2) mutation which confirmed the diagnosis of Danon disease. Her younger sister was diagnosed with a similar condition and received a defibrillator implantation. Her 12-lead ECG (figure 1) and a long strip tracing (figure 2) are shown below.Figure 112-lead ECG.

Question: Where is the location of the accessory pathway and what is the next appropriate management?Anteroseptal pathway and catheter ablationMid-septal pathway and pacemaker/defibrillator implantationRight lateral pathway and catheter ablationFasciculoventricular pathway and electrophysiological studyLeft lateral pathway and electrophysiological study.

Objective: To study knowledge of risk factors and consequences of hypertension in a rural population in South India.

Methods: This is a community-based study conducted among adults of a rural population in the Rishi Valley, India. Residents of randomised rural villages were invited to participate in a study of hypertension. We obtained measures of blood pressure, height, weight, waist and hip circumferences and questionnaire-based information on knowledge about hypertension, sociodemographic characteristics and health behaviours. Multivariable logistic regression analyses were conducted to determine the factors associated with knowledge of risk factors for hypertension (knowledge of ≥2 risk factors).

Results: The study comprised 641 adults; 132 aware and 218 unaware of their hypertension, and 291 with normal blood pressure. Only 31% of participants knew that hypertension adversely affects an individual's health and 7% knew the benefits of treating hypertension. Almost a third (30%) of those aware of their hypertensive status, and 48% overall, did not know any of the risk factors for hypertension. Being aware of one's hypertensive status (OR 2.51, 95% CI 1.44 to 4.39), being treated for hypertension, male sex, younger age, having some schooling, abdominal obesity and physical inactivity were associated with better knowledge of risk factors for hypertension.

Conclusion: Knowledge of risk factors and consequences of hypertension in this disadvantaged population was poor. There was better knowledge of risk factors in some, but not all, people who were aware of having hypertension. Screening and targeted educational programmes are warranted in this population to improve health behaviours and reduce the consequences of hypertension.

A 58-year-old man presented to the chest pain unit with crescendo angina over 24 hours and worsening dyspnoea of 10 hours duration. He was a known diabetic and hypertensive on regular treatment for 10 years and a habitual smoker with over 15 pack-years smoking duration. Examination revealed a profusely diaphoretic and dyspnoeic (respiratory rate of 45/min) individual with a blood pressure of 100/60 mm Hg and heart rate of 124 beats/min. He was hypoxic and his oxygen saturation in the ambient air was 64%. His jugular venous pressure was elevated with a prominent V wave. Cardiovascular examination revealed a harsh grade IV/VI systolic murmur over the lower left parasternal border. There were bilateral extensive crepitations heard over the lung fields. ECG on admission revealed presence of Q wave and ST elevation in leads II and III, aVF with ST depression in I and aVL. X-ray chest showed normal cardiac shadow and features of grade III pulmonary venous hypertension. Transthoracic echocardiography is shown in figure 1.Figure 1Transthoracic echocardiogram short axis view at mid cavity level, 2D (A) and colour Doppler (B) image.

Question: What is the most likely diagnosis?A. Left ventricular (LV) true aneurysmB. LV pseudoaneurysmC. LV pseudo-pseudoaneurysmD. Ventricular septal rupture (VSR)E. LV free wall rupture.

Hypertension is a global public health issue and a major cause of morbidity and mortality. Its prevalence is increasing in many Asian countries, with a number of countries with blood pressure above the global average. Although the average systolic blood pressure is decreasing worldwide since the 1980s at the rate of about 1 mm Hg systolic blood pressure per decade, it is increasing in low-income and middle-income countries, especially in the East and South Asian population. Of note, the much larger base Asian population results in a considerably larger absolute number of individuals affected. When compared with Western countries, hypertension among Asian populations has unique features in terms of its onset, clustering of associated cardiovascular risk factors, complications and outcomes. Moreover, only a minority of hypertensive individuals are receiving treatment and achieving control. Projected number of deaths related to hypertension dramatically increased in the last 25 years in some Asian regions with a disproportionately high mortality and morbidity from stroke compared with Western countries. The relation between blood pressure and the risk of stroke is stronger in Asia than in Western regions. Although new Guidelines for hypertension diagnosis and management have been recently released from Europe and North America, the unique features of Asian hypertensive patients raise concerns on the clinical applicability of Western Guidelines to Asian populations. To this purpose, we critically reviewed key elements from the most updated Guidelines. We also discussed their core concepts to verify the impact on hypertension prevention and management in Asian countries.

Aims: MicroRNAs (miRNAs), small non-coding RNAs, have been implicated as regulators of multiple phases of atherothrombosis, and some reports have suggested altered levels in coronary artery in-stent restenosis (ISR). We recently demonstrated that miR-93-5 p was able to discriminate between patients with stable coronary artery disease (CAD) and those with no CAD, after adjusting for traditional risk factors (RFs). Thus, we wanted to determine if circulating miRNAs could predict coronary ISR.

Objective: To determine if circulating miRNAs have diagnostic capability for determining ISR in a cohort of matched patients with and without ISR.

Approach and results: To determine if miRNA plasma levels are elevated in coronary ISR, we conducted a study comprising 78 patients (39 with no ISR and 39 with ISR) and measured plasma miRNAs in each. We then determined the predictive ability of differential miRNAs, adjusting for Framingham Heart Study (FHS) RFs, and stent length and diameter, to discriminate between ISR and no ISR. After correction for multiple testing, two miRNAs-miR425-5p and miR-93-5 p-were differential between patients with ISR and patients without ISR. Only miR-93-5 p remained a strong independent predictor of ISR after correction for FHS RFs (OR 6.30, p=0.008) and FHS RFs plus stent length and diameter (OR 4.80, p=0.02) and improved discriminatory power for ISR over FHS RFs alone in receiver operator characteristic curve analysis.

Conclusion: This novel finding that miR-93-5 p independently predicts ISR extends our recent observation that miR-93-5 p predicted CAD after adjustment for traditional CAD RFs. These data suggest further potential diagnostic utility.