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Objective: Metabolic dysfunction‐associated steatotic liver disease (MASLD) and obesity increases risk of cardiovascular disease. This cohort study examines the prognostic value of MASLD, across body weight categories, in a secondary preventative acute myocardial infarction (AMI) cohort. Methods: Patients with AMI were stratified into four phenotypes—obesity MASLD, non‐obesity MASLD, obesity non‐MASLD, non‐obesity non‐MASLD. The primary outcome was all‐cause mortality. Cox regression analysis was performed to investigate determinants of long‐term all‐cause mortality. Results: Of 5702 patients, majority were in the non‐obesity non‐MASLD group (66.7%), followed by obesity MASLD (16.1%), non‐obesity MASLD (11.2%) and non‐obesity MASLD (6.0%). Across the four phenotypes, obesity MASLD had the highest cardiometabolic burden, followed by non‐obesity MASLD. Non‐obesity MASLD had the highest risk of heart failure (p = 0.034), cardiogenic shock (p < 0.001), and all‐cause long‐term mortality (p = 0.019). The non‐obesity MASLD (HR 1.400, 95%CI 1.077–1.820, p = 0.012) and obesity MASLD phenotypes (HR 1.222, 95%CI 1.005–1.485, p = 0.044) were independently associated with long‐term all‐cause mortality. Conclusions: Obesity and non‐obesity MASLD phenotypes were predictors of all‐cause mortality following AMI, with an even larger magnitude of mortality risk in the non‐obesity MASLD group. The recognition of MASLD and its body weight phenotypes will be beneficial in the prognostication following AMI. [ABSTRACT FROM AUTHOR]

Yeo's index, the product of the mitral leaflet separation index and dimensionless index of mitral valve (MV), was recently described to accurately identify severe rheumatic mitral stenosis (MS). We assess the association between Yeo's index and clinical outcomes in patients with rheumatic MS. We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo's index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, MV intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. The median follow up was 6.3 years; 145 patients (48.8%) developed the composite outcome. Yeo's index (p < 0.001), mitral valve area (MVA) by pressure half-time (PHT) (p = 0.028) and planimetry (p < 0.001), age (p = 0.016), history of diabetes mellitus (p = 0.029), previous HF (p = 0.021), left ventricular ejection fraction (p = 0.022), and pulmonary artery systolic pressure (p = 0.007) were univariately associated with the composite outcome. Yeo's index remained independently associated with the composite outcome in multivariate analysis (p < 0.001, HR 0.094, 95% CI 0.260–0.340). This was primarily driven by MV intervention. In a subgroup analysis of patients without pre-existing AF, Yeo's index was independently associated with new onset AF (p = 0.024, HR 0.354, 95% CI 0.143–0.874). This demonstrated that Yeo's index was independently associated with clinical outcomes in patients with rheumatic MS which was mainly driven by MV intervention. [ABSTRACT FROM AUTHOR]

Surgical weight loss (SWL) improves myocardial mechanics as measured by speckle-tracking imaging. However non-surgical versus SWL and the subsequent impact on myocardial function in overweight Asian subjects has not been evaluated. 66 patients underwent a 16-week lifestyle intervention (LSI) programme consisting of dietary interventions and exercise prescription. Echocardiography with speckle tracking was performed at baseline and post-intervention. This group was compared against a group of 12 subjects who had undergone bariatric surgery and a control group of 10 lean Asian subjects. A generalised structural equation model (gSEM) was constructed to ascertain the effect of modality of weight loss on strain parameters, adjusting for BMI. Participants attained significant weight loss after LSI (28.2 ± 2.66 kg/m2 vs. 25.8 ± 2.84 kg/m2, p = 0.001). This was associated with a non-significant trend towards improvement in strain parameters. SWL participants had significant improvement in the left ventricular global longitudinal strain (− 20.52 ± 3.34 vs. − 16.68 ± 4.15, p < 0.01) and left atrium reservoir strain (44.32 ± 14.23 vs. 34.3 ± 19.31, p = 0.02). Lean subjects had significantly higher strain parameters than overweight subjects. The gSEM model demonstrated surgical modality of weight loss as an independent predictor of improvement in strain parameters. Significant improvement in echocardiographic parameters were documented in patients who underwent bariatric surgery. [ABSTRACT FROM AUTHOR]

The impact of age (≥ 85 vs < 85 years) on clinical outcomes and pacemaker performance of conduction system pacing (CSP) compared to right ventricular pacing (RVP) were examined. Consecutive patients from a prospective, observational, multicenter study with pacemakers implanted for bradycardia were studied. The primary endpoint was a composite of heart failure (HF)-hospitalizations, pacing-induced cardiomyopathy requiring cardiac resynchronization therapy or all-cause mortality. Secondary endpoints were acutely successful CSP, absence of pacing-complications, optimal pacemaker performance defined as pacing thresholds < 2.5 V, R-wave amplitude ≥ 5 V and absence of complications, threshold stability (no increases of > 1 V) and persistence of His-Purkinje capture on follow-up. Among 984 patients (age 74.1 ± 11.2 years, 41% CSP, 16% ≥ 85 years), CSP was independently associated with reduced hazard of the primary endpoint compared to RVP, regardless of age-group (< 85 years: adjusted hazard ratio [AHR] 0.63, 95% confidence interval [CI] 0.40–0.98; ≥ 85 years: AHR 0.40, 95% CI 0.17–0.94). Among patients with CSP, age did not significantly impact the secondary endpoints of acute CSP success (86% vs 88%), pacing complications (19% vs 11%), optimal pacemaker performance (64% vs 69%), threshold stability (96% vs 96%) and persistent His-Purkinje capture (86% vs 91%) on follow-up (all p > 0.05). CSP improves clinical outcomes in all age-groups, without compromising procedural safety or pacemaker performance in the very elderly. [ABSTRACT FROM AUTHOR]

Aim: Patients with metabolic dysfunction‐associated steatotic liver disease (MASLD) are at increased risk of incident cardiovascular disease. However, the clinical characteristics and prognostic importance of MASLD in patients presenting with acute myocardial infarction (AMI) have yet to be examined. Methods: This study compared the characteristics and outcomes of patients with and without MASLD presenting with AMI at a tertiary centre in Singapore. MASLD was defined as hepatic steatosis, with at least one of five metabolic criteria. Hepatic steatosis was determined using the Hepatic Steatosis Index. Propensity score matching was performed to adjust for age and sex. The Kaplan‐Meier curve was constructed for long‐term all‐cause mortality. Cox regression analysis was used to investigate independent predictors of long‐term all‐cause mortality. Results: In this study of 4446 patients with AMI, 2223 patients with MASLD were matched with patients without MASLD using propensity scores. The mean follow‐up duration was 3.4 ± 2.4 years. The MASLD group had higher rates of obesity, diabetes and chronic kidney disease than their counterparts. Patients with MASLD had early excess all‐cause mortality (6.8% vs. 3.6%, p <.001) at 30 days, with unfavourable mortality rates sustained in the long‐term (18.3% vs. 14.5%, p =.001) compared with those without MASLD. After adjustment, MASLD remained independently associated with higher long‐term all‐cause mortality (hazard ratio 1.330, 95% confidence interval 1.106‐1.598, p =.002). Conclusion: MASLD embodies a higher burden of metabolic dysfunction and is an independent predictor of long‐term mortality in the AMI population. Its early identification may be beneficial for risk stratification and provide therapeutic targets for secondary preventive strategies in AMI. [ABSTRACT FROM AUTHOR]

Screening for autism in childhood has been advocated as a part of standard care. Challenges exist with screening implementation and performance of screening tools in clinical practice. This study aimed to examine the validity and feasibility of using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) for screening of autism in Singapore. Caregivers completed the M-CHAT-R/F as a part of the routine 18-month well-child visit in seven primary care clinics. Screening and follow-up interviews were administered by trained nursing staff. Children screened positive and a subset of those screened negative underwent diagnostic assessments for autism, which included an Autism Diagnostic Observation Schedule, Second Edition. Participants were 5336 multiethnic children (mean age 18.6 ± 0.9 months, 51.3% male gender). In total, 113 (2.1%) were screened positive, of which 54 (1.0%) were classified to have autism after their diagnostic assessment. Sensitivity of the M-CHAT-R/F was 88.6%, specificity 71.4%, and positive predictive value 90.7% for an autism diagnosis. The majority of respondents rated the screening process as feasible within the clinic setting. The M-CHAT-R/F had acceptable psychometric properties and high feasibility when used in primary care settings in Singapore. Recommendations for implementation of systematic screening and future research are presented. Systematic screening for autism in early childhood has been suggested to improve eventual outcomes by facilitating earlier diagnosis and access to intervention. However, clinical implementation of screening has to take into account effectiveness and feasibility of use within a healthcare setting for accurate diagnosis of autism. In Singapore, autism screening using a structured screening tool is not currently employed as a part of routine well-child visits for children in primary care clinics. In this study, 5336 children (aged 17–20 months) were screened for autism using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) during their 18-month well-child visit in seven primary care clinics. Screening and follow-up interviews were administered by nursing staff at each clinic. Children screened positive and a portion of those screened negative then underwent diagnostic assessments to determine whether they met the diagnostic criteria for autism. In total, 113 (2.1%) were screened positive, of which 54 (1.0%) met the criteria for autism. Children who screened positive and received a diagnosis accessed autism-specific intervention at an average age of 22 months. Nurses and physicians rated the acceptability and practicality of the M-CHAT-R/F highly. Therefore, the M-CHAT-R/F questionnaire was an effective and feasible tool for autism screening among 18-month-old children in this study. Future studies will be designed to determine the optimal age of screening and role of repeated screening in Singapore, as well as to better understand any potential improved outcomes nationwide compared with pre-implementation of autism screening. [ABSTRACT FROM AUTHOR]

Introduction: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) mortality remains high despite revascularization and the use of the intra-aortic balloon pump (IABP). Advanced mechanical circulatory support (MCS) devices, such as catheter-based ventricular assist devices (cVAD), may impact mortality. We aim to identify predictors of mortality in AMI-CS implanted with IABP and the proportion eligible for advanced MCS in an Asian population. Methods: We retrospectively analyzed a cohort of Society for Cardiovascular Angiography and Intervention (SCAI) stage C and above AMI-CS patients with IABP implanted from 2017–2019. We excluded patients who had IABP implanted for indications other than AMI-CS. Primary outcome was 30-day mortality. Binary logistic regression was used to calculate adjusted odds ratios (aOR) for patient characteristics. Results: Over the 3-year period, 242 patients (mean age 64.1 ± 12.4 years, 88% males) with AMI-CS had IABP implanted. 30-day mortality was 55%. On univariate analysis, cardiac arrest (p < 0.001), inotrope/vasopressor use prior to IABP (p = 0.004) was more common in non-survivors. Non-survivors were less likely to be smokers (p = 0.001), had lower ejection fraction, higher creatinine/ lactate and lower pH (all p < 0.001). On multi-variate analysis, predictors of mortality were cardiac arrest prior to IABP (aOR 4.00, CI 2.28–7.03), inotrope/vasopressor prior to IABP (aOR 2.41, CI 1.18–4.96), lower arterial pH (aOR 0.02, CI 0.00–0.31), higher lactate (aOR 2.42, CI 1.00–1.19), and lower hemoglobin (aOR 0.83, CI 0.71–0.98). Using institutional MCS criteria, 106 patients (44%) would have qualified for advanced MCS. Conclusions: Early mortality in AMI-CS remains high despite IABP. Many patients would have qualified for higher degrees of MCS. [ABSTRACT FROM AUTHOR]

Introduction: Clinical outcomes of long‐term ventricular septal pacing (VSP) without His‐Purkinje capture remain unknown. This study evaluated the differences in clinical outcomes between conduction system pacing (CSP), VSP, and right ventricular pacing (RVP). Methods: Consecutive patients with bradycardia indicated for pacing from 2016 to 2022 were prospectively followed for the clinical endpoints of heart failure (HF)‐hospitalizations and all‐cause mortality at 2 years. VSP was defined as septal pacing due to unsuccessful CSP implant or successful CSP followed by loss of His‐Purkinje capture within 90 days. Results: Among 1016 patients (age 73.9 ± 11.2 years, 47% female, 48% atrioventricular block), 612 received RVP, 335 received CSP and 69 received VSP. Paced QRS duration was similar between VSP and RVP, but both significantly longer than CSP (p <.05). HF‐hospitalizations occurred in 130 (13%) patients (CSP 7% vs. RVP 16% vs. VSP 13%, p =.001), and all‐cause mortality in 143 (14%) patients (CSP 7% vs. RVP 19% vs. VSP 9%, p <.001). The association of pacing modality with clinical events was limited to those with ventricular pacing (Vp) > 20% (pinteraction <.05). Adjusting for clinical risk factors among patients with Vp > 20%, VSP (adjusted hazard ratio [AHR]: 4.74, 95% confidence interval [CI]: 1.57–14.36) and RVP (AHR: 3.08, 95% CI: 1.44‐6.60) were associated with increased hazard of HF‐hospitalizations, and RVP (2.52, 95% CI: 1.19–5.35) with increased mortality, compared to CSP. Clinical endpoints did not differ between VSP and RVP with Vp > 20%, or amongst groups with Vp < 20%. Conclusion: Conduction system capture is associated with improved clinical outcomes. CSP should be preferred over VSP or RVP during pacing for bradycardia. [ABSTRACT FROM AUTHOR]

Background: Heart failure (HF) and diabetes are associated with increased incidence and worse prognosis of each other. The prognostic value of global longitudinal strain (GLS) measured by cardiovascular magnetic resonance (CMR) has not been established in HF patients with diabetes. Methods: In this prospective, observational study, consecutive patients (n = 315) with HF underwent CMR at 3T, including GLS, late gadolinium enhancement (LGE), native T1, and extracellular volume fraction (ECV) mapping. Plasma biomarker concentrations were measured including: N-terminal pro B-type natriuretic peptide(NT-proBNP), high-sensitivity troponin T(hs-TnT), growth differentiation factor 15(GDF-15), soluble ST2(sST2), and galectin 3(Gal-3). The primary outcome was a composite of all-cause mortality or HF hospitalisation. Results: Compared to those without diabetes (n = 156), the diabetes group (n = 159) had a higher LGE prevalence (76 vs. 60%, p < 0.05), higher T1 (1285±42 vs. 1269±42ms, p < 0.001), and higher ECV (30.5±3.5 vs. 28.8±4.1%, p < 0.001). The diabetes group had higher NT-pro-BNP, hs-TnT, GDF-15, sST2, and Gal-3. Diabetes conferred worse prognosis (hazard ratio (HR) 2.33 [95% confidence interval (CI) 1.43–3.79], p < 0.001). In multivariable Cox regression analysis including clinical markers and plasma biomarkers, sST2 alone remained independently associated with the primary outcome (HR per 1 ng/mL 1.04 [95% CI 1.02–1.07], p = 0.001). In multivariable Cox regression models in the diabetes group, both GLS and sST2 remained prognostic (GLS: HR 1.12 [95% CI 1.03–1.21], p = 0.01; sST2: HR per 1 ng/mL 1.03 [95% CI 1.00-1.06], p = 0.02). Conclusions: Compared to HF patients without diabetes, those with diabetes have worse plasma and CMR markers of fibrosis and a more adverse prognosis. GLS by CMR is a powerful and independent prognostic marker in HF patients with diabetes. [ABSTRACT FROM AUTHOR]

This study aim to investigate if remote intensive coaching for the first 6 months post-AMI will improve adherence to the twice-a-day antiplatelet medication, ticagrelor. Between July 8, 2015, to March 29, 2019, AMI patients were randomly assigned to remote intensive management (RIM) or standard care (SC). RIM participants underwent 6 months of weekly then two-weekly consultations to review medication side effects and medication adherence coaching by a centralized nurse practitioner team, whereas SC participants received usual cardiologist face-to-face consultations. Adherence to ticagrelor were determined using pill counting and serial platelet reactivity measurements for 12 months. A total of 149 (49.5%) of participants were randomized to RIM and 152 (50.5%) to SC. Adherence to ticagrelor was similar between RIM and SC group at 1 month (94.4 ± 0.7% vs. 93.6±14.7%, p = 0.537), 6 months (91.0±14.6% vs. 90.6±14.8%, p = 0.832) and 12 months (87.4±17.0% vs. 89.8±12.5%, p = 0.688). There was also no significant difference in platelet reactivity between the RIM and SC groups at 1 month (251AU*min [212–328] vs. 267AU*min [208–351], p = 0.399), 6 months (239AU*min [165–308] vs. 235AU*min [171–346], p = 0.610) and 12 months (249AU*min [177–432] vs. 259AU*min [182–360], p = 0.678). Sensitivity analysis did not demonstrate any association of ticagrelor adherence with bleeding events and major adverse cardiovascular events. RIM, comprising 6 months of intensive coaching by nurse practitioners, did not improve adherence to the twice-a-day medication ticagrelor compared with SC among patients with AMI. A gradual decline in ticagrelor adherence over 12 months was observed despite 6 months of intensive coaching. [ABSTRACT FROM AUTHOR]

Patients undergoing transcatheter aortic valve implantation (TAVI) commonly have co-morbidities requiring anticoagulation. However, the optimal post-procedural anticoagulation regimen is not well-established. This meta-analysis investigates safety and efficacy outcomes of direct oral anticoagulants (DOACs) and Vitamin K Antagonist (VKA), with or without concomitant antiplatelet therapy. We searched EMBASE and MEDLINE for appropriate studies. Subgroup analyses were performed for anticoagulant monotherapy and combined therapy with antiplatelet agents. Eleven studies (6359 patients) were included. Overall, there were no differences between DOACs and VKA for all-cause mortality (Odds Ratio [OR]:.69; Credible Interval [CrI]:.40–1.06), cardiovascular-related mortality (OR:.76; Crl:.13–3.47), bleeding (OR:.95; CrI:.75–1.17), stroke (OR: 1.04; CrI:.65–1.63), myocardial infarction (OR: 1.51; CrI:.55–3.84), and valve thrombosis (OR:.29; CrI:.01–3.54). For DOACs vs VKA monotherapy subgroup, there were no differences in outcomes. For the combined therapy subgroup, there was decreased odds of all-cause mortality in the DOACs group compared with the VKA group (OR:.13; CrI:.02–.65), but no differences for bleeding and stroke. DOACs and VKA have similar safety and efficacy profiles for post-TAVI patients with anticoagulation indication. However, if concomitant antiplatelet therapy is required, DOACs were more favorable than VKA for all-cause mortality. [ABSTRACT FROM AUTHOR]

Introduction: The benefits of cardiac resynchronization therapy (CRT) with biventricular pacing (BiV) is significantly lower when applied to heart failure (HF) patients with non‐left bundle branch block (LBBB) conduction delay. We investigated clinical outcomes of conduction system pacing (CSP) for CRT in non‐LBBB HF. Methods: Consecutive HF patients with non‐LBBB conduction delay undergoing CSP were propensity matched for age, sex, HF‐etiology, and atrial fibrillation (AF) in a 1:1 ratio to BiV from a prospective registry of CRT recipients. Echocardiographic response was defined as an increase in left ventricular ejection fraction (LVEF) by ≥10%. The primary outcome was the composite of HF‐hospitalizations or all‐cause mortality. Results: A total of 96 patients were recruited (mean age 70 ± 11years, 22% female, 68% ischemic HF and 49% AF). Significant reductions in QRS duration and LV dimensions were seen only after CSP, while LVEF improved significantly in both groups (p < 0.05). Echocardiographic response occurred more frequently in CSP than BiV (51% vs. 21%, p < 0.01), with CSP independently associated with four‐fold increased odds (adjusted odds ratio 4.08, 95% confidence interval [CI] 1.34–12.41). The primary outcome occurred more frequently in BiV than CSP (69% vs. 27%, p < 0.001), with CSP independently associated with 58% risk reduction (adjusted hazard ratio [AHR] 0.42, 95% CI 0.21–0.84, p = 0.01), driven by reduced all‐cause mortality (AHR 0.22, 95% CI 0.07–0.68, p < 0.01), and a trend toward reduced HF‐hospitalization (AHR 0.51, 95% CI 0.21–1.21, p = 0.12). Conclusions: CSP provided greater electrical synchrony, reverse remodeling, improved cardiac function and survival compared to BiV in non‐LBBB, and may be the preferred CRT strategy for non‐LBBB HF. [ABSTRACT FROM AUTHOR]

The subset of plasma extracellular vesicles (EVs) that coprecipitate with low-density lipoprotein (LDL-EVs) carry coagulation and fibrinolysis pathway proteins as cargo. We investigated the association between LDL-EV hemostatic/fibrinolysis protein ratios and post-acute myocardial infarction (post-AMI) left ventricular (LV) remodeling which precedes heart failure. Protein concentrations of von Willebrand factor (VWF), SerpinC1 and plasminogen were determined in LDL-EVs extracted from plasma samples obtained at baseline (within 72 h post-AMI), 1 month and 6 months post-AMI from 198 patients. Patients were categorized as exhibiting adverse (n = 98) or reverse (n = 100) LV remodeling based on changes in LV end-systolic volume (increased or decreased ≥15) over a 6-month period. Multiple level longitudinal data analysis with structural equation (ML-SEM) model was used to assess predictive value for LV remodeling independent of baseline differences. At baseline, protein levels of VWF, SerpinC1 and plasminogen in LDL-EVs did not differ between patients with adverse versus reverse LV remodeling. At 1 month post-AMI, protein levels of VWF and SerpinC1 decreased whilst plasminogen increased in patients with adverse LV remodeling. In contrast, VWF and plasminogen decreased whilst SerpinC1 remained unchanged in patients with reverse LV remodeling. Overall, compared with patients with adverse LV remodeling, higher levels of SerpinC1 and VWF but lower levels of plasminogen resulted in higher ratios of VWF:Plasminogen and SerpinC1:Plasminogen at both 1 month and 6 months post-AMI in patients with reverse LV remodeling. More importantly, ratios VWF:Plasminogen (AUC = 0.674) and SerpinC1:Plasminogen (AUC = 0.712) displayed markedly better prognostic power than NT-proBNP (AUC = 0.384), troponin-I (AUC = 0.467) or troponin-T (AUC = 0.389) (p < 0.001) to predict reverse LV remodeling post-AMI. Temporal changes in the ratios of coagulation to fibrinolysis pathway proteins in LDL-EVs outperform current standard plasma biomarkers in predicting post-AMI reverse LV remodeling. Our findings may provide clinical cues to uncover the cellular mechanisms underpinning post-AMI reverse LV remodeling. [ABSTRACT FROM AUTHOR]

Background: Infections following cardiac implantable electronic device (CIED) implantation can require surgical device removal and often results in significant cost, morbidity, and potentially mortality. We aimed to systemically review the literature and identify risk factors associated with mortality following CIED infection. Methods: Electronic searches (up to June 2021) were performed on PubMed and Scopus. Twelve studies (10 retrospective, 2 prospective cohort studies) were included for analysis. Meta-analysis was conducted with the restricted maximum likelihood method, with mortality as the outcome. The overall mortality was 13.7% (438/1398) following CIED infection. Results: On meta-analysis, the male sex (OR 0.77, 95%CI 0.57–1.01, I2 = 2.2%) appeared to have lower odds for mortality, while diabetes mellitus appeared to be associated with higher mortality (OR 1.47, 95%CI 0.67–3.26, I2 = 81.4%), although these trends did not reach statistical significance. Staphylococcus aureus as the causative organism (OR 2.71, 95%CI 1.76–4.19, I2 = 0.0%), presence of heart failure (OR 1.92, 95%CI 1.42–4.19, I2 = 0.0%) and embolic phenomena (OR 4.00, 95%CI 1.67–9.56, I2 = 69.8%) were associated with higher mortality. Surgical removal of CIED was associated with lower mortality compared with conservative management with antibiotics alone (OR 0.22, 95%CI 0.09–0.50, I2 = 62.8%). Conclusion: We identified important risk factors associated with mortality in CIED infections, including Staphyloccocus aureus as the causative organism, and the presence of complications, such as heart failure and embolic phenomena. Surgery, where possible, was associated with better outcomes. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction (AMI) is associated with heightened thrombin generation. There are limited data relating to thrombin generation and left ventricular (LV) scarring and LV dilatation in post-MI LV remodeling. We studied 113 patients with ST-segment elevation myocardial infarction (STEMI) who had undergone primary percutaneous coronary intervention (PPCI) (n = 76) or pharmaco-invasive management (thrombolysis followed by early PCI, n = 37). Endogenous thrombin potential (ETP) was measured at baseline, 1 month and 6 months. Cardiovascular magnetic resonance imaging was performed at baseline and 6 months post-MI. Outcomes studied were an increase in scar change, which was defined as an increase in left ventricular infarct size of any magnitude detected by late gadolinium enhancement, adverse LV remodeling, defined as dilatation (increase) of left ventricular end-diastolic volume (LVEDV) by more than 20% and an increase in left ventricular ejection fraction (LVEF). The mean age was 55.19 ± 8.25 years and 91.2% were men. The baseline ETP was similar in the PPCI and pharmaco-invasive groups (1400.3 nM.min vs. 1334.1 nM.min, p = 0.473). Each 10-unit increase in baseline ETP was associated with a larger scar size (adjusted OR 1.020, 95% CI 1.002–1.037, p = 0.027). Baseline ETP was not associated with adverse LV remodeling or an increase in LVEF. There was no difference in scar size or adverse LV remodeling among patients undergoing PPCI vs. pharmaco-invasive management or patients receiving ticagrelor vs. clopidogrel. Enhanced thrombin generation after STEMI is associated with a subsequent increase in myocardial scarring but not LV dilatation or an increase in LVEF at 6 months post-MI. [ABSTRACT FROM AUTHOR]

Background: Mask wearing is an essential strategy to combat the spread of SARS-CoV-2. Some individuals may wear masks during physical activity to reduce disease transmission. This study aimed to investigate the real-world effect of wearing a surgical face mask on physiological parameters at peak exercise in healthy individuals. Methods: In this crossover design study, participants underwent maximal treadmill electrocardiogram exercise tests using the Bruce protocol on two separate occasions, once with a standard 3-ply surgical face mask and once without. Heart rate, oxygen saturation, blood pressure, rate pressure product, metabolic equivalents (METS) and total exercise time were measured. Subjective rate of perceived exertion was also assessed using the modified Borg Scale. Results: 50 adults (mean age = 31.7 ± 6.5 years; 27 males) completed both treadmill tests. Mask wearing resulted in a significant reduction in peak METS by 1.5 units, maximum speed by 0.5 km/h, exercise time by 68.4 s with a significantly lower peak heart rate by 4.4 bpm, and lower percentage of age-predicted maximum heart rate by 2.5% (p < 0.001 for all parameters). During each corresponding stage of the Bruce protocol, the average modified Borg score was found to be significantly higher in subjects exercising with mask after adjusting for age, gender and body mass index (p < 0.03). Conclusion: In a cohort of healthy individuals, wearing of a surgical face mask during maximal treadmill exercise lead to reduced physical performance and increased rate of perceived exertion. Individuals exercising with surgical masks need to be mindful of these limitations while undergoing physical training in order to differentiate these physiological responses from symptoms of early respiratory illness. [ABSTRACT FROM AUTHOR]

Newer generation durable polymer drug-eluting stents (DP-DES) and biodegradable polymer DES (BP-DES) have similar efficacy with dual-antiplatelet therapy (DAPT) duration of > 6 months. However, this difference in outcomes have not been well studied in shorter DAPT regime. This study compares the safety and efficacy profiles of DP-DES and BP-DES based on short-term (1–3 months), intermediate-term (4–6 months) and standard DAPT (6–12 months) durations. A search was conducted on Embase and Medline for Randomized Controlled Trials (RCTs) comparing stent types, and DAPT durations. Primary endpoints include cardiac death, myocardial infarction (MI), definite stent thrombosis, stroke, target vessel revascularization (TVR) and major bleeding. Network analysis was conducted to summarize the evidence. A total of 15 RCTs involving 43,875 patients were included. DP-DES was associated with significantly lower major bleeding rates compared to BP-DES (RR 0.44, Crl 0.22–0.83) in short-term DAPT. Among DP-DES patients, short-term DAPT was associated with lower major bleeding risk compared to standard DAPT (RR 0.47, CrI 0.32–0.69). This favorable bleeding profile with short DAPT was not found in BP-DES patients. Cardiac death, MI, definite stent thrombosis, stroke and TVR rates were similar across the various DAPT durations and stent types. Our preliminary findings demonstrated comparable efficacy and safety outcomes between BP-DES and newer generation BP-DES across various DAPT durations. In patients requiring short DAPT, DP-DES had more favourable major bleeding profile compared to BP-DES, without compromising anti-thrombotic efficacy. [ABSTRACT FROM AUTHOR]

Background: The Singapore Cardiac Databank was designed to monitor the performance and outcomes of catheter ablation. We investigated the outcomes of paroxysmal supraventricular tachycardia (PSVT)‐ablation in a prospective, nationwide, cohort study. Methods: Atrioventricular nodal re‐entrant tachycardia (AVNRT), atrioventricular re‐entry tachycardia (AVRT), or atrial tachycardia (AT)‐ablations in Singapore from 2010 to 2018 were studied. Outcomes include acute success, periprocedural‐complications, postoperative pacing requirement, arrhythmic recurrence and 1‐year all‐cause mortality. Results: Among 2260 patients (mean age 45 ± 18 years, 50% female, 57% AVNRT, 37% AVRT, 6% AT), overall acute success rates of PSVT‐ablation was 98.4% and increased in order of AT, AVRT, and AVNRT (p <.001). Periprocedural cardiac tamponade occurred in two AVRT patients. A total of 15 pacemakers (6 within first 30‐days, 9 after 30‐days) were implanted (seven AV block, eight sinus node dysfunction [SND]), with the highest incidence of pacemaker implantation after AT‐ablation (5% vs. 0.6% AVNRT vs. 0.1% AVRT, p <.001). Repeat ablations (0.9% AVNRT, 7% AVRT, 4% AT, p <.001) were performed in 78 (3.5%) patients and 13 (0.6%) patients died within a year of ablation. Among outcomes considered adjusting for age, sex, PSVT‐type and procedure‐time, AT was independently associated with 6‐fold increased odds of total (adjusted odds ratio [AOR] 6.32, 95% confidence interval [CI] 1.95–20.53) and late (AOR 6.38, 95% CI 1.39–29.29) pacemaker implantation, while AVRT was associated with higher arrhythmic recurrence with repeat ablations (AOR 4.72, 95% CI 2.36–9.44) compared to AVNRT. Conclusions: Contemporary PSVT ablation is safe with high acute success rates. Long‐term outcomes differed by nature of the PSVT. [ABSTRACT FROM AUTHOR]

Purpose: Obstructive sleep apnea (OSA) during the rapid eye movement (REM) stage of the sleep cycle is associated with intense hypoxemia and cardiovascular instability. We characterized OSA during REM sleep in patients after percutaneous coronary intervention. Methods: In this multicenter study, 204 patients who had undergone percutaneous coronary intervention in the prior 6 to 36 months were recruited for in-laboratory polysomnography. The primary measure was respiratory events during REM sleep. The patients were divided into 2 groups: (1) OSA during REM sleep (≥ 15 events/h) and (2) absence of OSA during REM sleep (< 15 events/h). Results: Based on the overall apnea-hypopnea index ≥ 15, 148 patients (74.0%) had OSA. After excluding patients with failed polysomnography or REM sleep < 30 min, 163 patients formed the cohort for this analysis. OSA during REM sleep was diagnosed in 132 patients (81%). Compared with the patients without OSA during REM sleep, those with OSA during REM sleep had a higher body mass index (p = 0.003) and systolic blood pressure (p = 0.041), and a higher prevalence of diabetes mellitus (p = 0.029). Logistic regression analysis, including age, sex, diabetes mellitus, indication for percutaneous coronary intervention, and indication for multi-vessel percutaneous coronary intervention, showed that diabetes mellitus was the only independent predictor of OSA during REM sleep (odds ratio 2.83; 95% CI, 1.17 to 6.83; p = 0.021). Conclusion: In patients treated with percutaneous coronary intervention, there was a high prevalence of OSA during REM sleep. Diabetes mellitus was an independent predictor of OSA during REM sleep. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury is common in the surgical intensive care unit (ICU). It is associated with poor patient outcomes and high healthcare resource usage. This study's primary objective is to help identify which ICU patients are at high risk for acute kidney injury. Its secondary objective is to examine the effect of acute kidney injury on a patient's prognosis during and after the ICU admission.Methods: A retrospective cohort of patients admitted to a Singaporean surgical ICU between 2015 to 2017 was collated. Patients undergoing chronic dialysis were excluded. The outcomes were occurrence of ICU acute kidney injury, hospital mortality and one-year mortality. Predictors were identified using decision tree algorithms. Confirmatory analysis was performed using a generalized structural equation model.Results: A total of 201/940 (21.4%) patients suffered acute kidney injury in the ICU. Low ICU haemoglobin levels, low ICU bicarbonate levels, ICU sepsis, low pre-ICU estimated glomerular filtration rate (eGFR) and congestive heart failure was associated with the occurrence of ICU acute kidney injury. Acute kidney injury, together with old age (> 70 years), and low pre-ICU eGFR, was associated with hospital mortality, and one-year mortality. ICU haemoglobin level was discretized into 3 risk categories for acute kidney injury: high risk (haemoglobin ≤9.7 g/dL), moderate risk (haemoglobin between 9.8-12 g/dL), and low risk (haemoglobin > 12 g/dL).Conclusion: The occurrence of acute kidney injury is common in the surgical ICU. It is associated with a higher risk for hospital and one-year mortality. These results, in particular the identified haemoglobin thresholds, are relevant for stratifying a patient's acute kidney injury risk. [ABSTRACT FROM AUTHOR]

Aims: Extracellular vesicles (EVs) are small double‐membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients. Methods and results: Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2. The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub‐fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co‐morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub‐fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub‐fractions, and with presence of heart failure in the high density lipoprotein sub‐fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub‐fractions and in plasma, but not with renal dysfunction. Conclusions: We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment. [ABSTRACT FROM AUTHOR]

Coronary artery disease is a leading cause of morbidity and mortality worldwide. Despite significant advances in revascularization strategies and antiplatelet therapy with aspirin and/or P2Y12 receptor antagonist, patients with acute coronary syndrome (ACS) continue to be at long-term risk of further cardiovascular events. Besides platelet activation, the role of thrombin generation (TG) in atherothrombotic complications is widely recognized. In this study, we hypothesized that there is an elevation of coagulation activation persists beyond 12 months in patients with ACS and chronic coronary syndrome (CCS) when compared with healthy controls. We measured TG profiles of patients within 72 h after percutaneous coronary intervention, at 6-month, 12-month and 24-month. Our results demonstrated that TG of patients with ACS (n = 114) and CCS (n = 40) were persistently elevated when compared to healthy individuals (n = 50) in peak thrombin (ACS 273.1 nM vs CCS 287.3 nM vs healthy 234.3 nM) and velocity index (ACS 110.2 nM/min vs CCS 111.0 nM/min vs healthy 72.9 nM/min) at 24-month of follow-up. Our results suggest a rationale for addition of anticoagulation to antiplatelet therapy in preventing long-term ischemic events after ACS. Further research could clarify whether the use of TG parameters to enable risk stratification of patients at heightened long-term procoagulant risk who may benefit most from dual pathway inhibition. [ABSTRACT FROM AUTHOR]

Introduction: Compared to clinic blood pressure (BP), sleep-time BP and non-dipping BP pattern are better predictors of target organ damage and cardiovascular sequalae.Aim: In a retrospective study, we determined whether diabetes mellitus (DM) status is associated with high sleep-time BP and non-dipping pattern.Methods: We analyzed 1092 patients who underwent ambulatory BP monitoring between 2015 and 2017 in a tertiary cardiology institution. During a 24-hour period, BP was automatically measured every 15 minutes between 7:00 AM and 11:59 PM and every 30 minutes thereafter.Results: Compared with the non-DM group (n = 910), the DM group (n = 182) had a higher 24-hour systolic BP (137 ± 17 vs. non-DM, 132 ± 14 mmHg, p < 0.001) and sleep-time systolic BP (132 ± 20 vs. 123 ± 16 mmHg, p < 0.001), and was more likely to exhibit non-dipping (63% vs 42%, p˂0.001). The DM group was also less likely to meet the guideline-recommended target of 120/70 mmHg for the sleep-time BP measured via ambulatory monitoring (22% vs. 34%, p = 0.002). After adjusting for the effects of age, sex, body mass index, smoking, urea, eGFR, previous myocardial infarction, previous percutaneous coronary intervention, previous coronary artery bypass surgery, and previous stroke, DM remained a significant independent predictor of a higher 24-hour systolic BP (coefficient: 2.8, 95% confidence interval: 0.1-5.5, p = 0.042) and higher sleep-time systolic BP (coefficient: 4.2, 95% confidence interval: 1.1-7.3, p = 0.008). There was a trend toward more sleep-time non-dipping BP pattern (odds ratio: 1.4, 95% confidence interval: 1.0-2.0, p = 0.087) in the DM group.Conclusion: DM is independently associated with suboptimal 24-hour BP control. This association is mainly attributed to a high sleep-time systolic BP. [ABSTRACT FROM AUTHOR]

Aims: The performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in diagnosing acute decompensated heart failure (ADHF) among patients presenting with breathlessness is markedly impaired in the presence of atrial fibrillation (AF). We evaluated the diagnostic performance of mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin T as possible alternative markers for discrimination of ADHF in this setting.Methods and Results: Breathless patients (n = 1107) were prospectively and contemporaneously recruited in emergency departments in Singapore and New Zealand. The diagnoses of ADHF and presence of AF were adjudicated by two clinician specialists, blinded to MR-proADM, NT-proBNP and high-sensitivity cardiac troponin T (hs-cTnT) results. MR-proADM exhibited strong discrimination of ADHF with little change in performance irrespective of the presence of AF (area under the curve 0.83 in non-AF vs. 0.76 in AF) compared to NT-proBNP (0.91 vs. 0.71) and hs-cTnT (0.83 vs. 0.62), respectively. The accuracy of MR-proADM (73.3%) for diagnosing ADHF among patients with AF was superior to both NT-proBNP (61.6%) and hs-cTnT (64.6%). The superior performance of MR-proADM remained apparent when data from Singapore and New Zealand were analysed separately.Conclusion: In the presence of AF, MR-proADM showed greater discrimination and accuracy, and less impairment in performance compared to that in non-AF cases, for the diagnosis of ADHF, compared to the guideline-endorsed NT-proBNP. [ABSTRACT FROM AUTHOR]

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Objective: This study aimed to compare the associations of positron emission tomography (PET), magnetic resonance (MR), and infrared thermography (IRT) imaging modalities with energy expenditure (EE) after brown adipose tissue (BAT) activation using capsinoid ingestion and cold exposure.Methods: Twenty participants underwent PET-MR, IRT imaging, and whole-body calorimetry after capsinoid ingestion and cold exposure. Standardized uptake values (SUV) and the fat fraction (FF) of the supraclavicular brown adipose tissue regions were estimated. The anterior supraclavicular temperature (Tscv) from IRT at baseline and postintervention was measured. Two-hour post-capsinoid ingestion EE and post-cold exposure EE served as a reference to correlate fluorodeoxyglucose uptake, FF, and Tscv for BAT assessment. IRT images were geometrically transformed to overlay on PET-MR for visualization of the hottest regions.Results: The supraclavicular hot spot identified on IRT closely corresponded to the area of maximal fluorodeoxyglucose uptake on PET images. Controlling for body weight, post-cold exposure Tscv was a significant variable associated with EE (P = 0.025). The SUV was significantly inversely correlated with FF (P = 0.012) and significantly correlated with peak of Tscv during cold exposure in BAT-positive participants (P = 0.022).Conclusions: Tscv correlated positively with EE and was also significantly correlated with SUV after cold exposure. Both IRT and MR FF are promising methods to study BAT activity noninvasively. [ABSTRACT FROM AUTHOR]

Introduction: Genetic polymorphisms are important in explaining the wide interpatient variability that exists in the development of acute kidney injury (AKI) post cardiac surgery. We hypothesised that polymorphisms in 4 candidate genes, namely angiotensin-converting enzyme (ACE), apolipoprotein-E (ApoE), interleukin-6 (IL-6), and tumour necrosis factor-alpha (TNF-α) are associated with AKI. Methods: 870 patients who underwent cardiac surgery in Singapore were analysed. All patients who fulfilled stage 1 KDIGO criteria and above were considered to have AKI. This was investigated against various demographic, clinical and genetic factors. Results: Increased age, history of hypertension, anaemia and renal impairment remained important preoperative risk factors for AKI. Intraoperatively, longer cardiopulmonary bypass (CPB) time and the use of intra-aortic balloon pump (IABP) were shown to be associated with AKI. Among the genetic factors, ACE-D allele was associated with an increased risk of AKI while IL6-572C allele was associated with a decreased risk of AKI. Conclusion: ACE-D allele was associated with the development of AKI similar to other studies. On the other hand, IL6-572C was shown to have a protective role against the development of AKI, contradictory to studies done in the Caucasian population. This contradictory effect of IL6-572C is a result of a complex interplay between the gene and population specific modulating factors. Our findings further underscored the necessity of taking into account population specific differences when developing prediction models for AKI. [ABSTRACT FROM AUTHOR]

Background and objective: Pulmonary arterial hypertension (PAH) is a rare and fatal disease. Data from Asia are lacking compared with the West. We aim to describe disease characteristics in an ethnically diverse South‐East Asian population and assess predictors for survival. Methods: We consecutively enrolled patients with PAH referred to our pulmonary hypertension specialty centre from January 2003 to December 2016. Baseline characteristics and survival were analysed. Based on a forward predictor selection procedure, a multi‐level structural equation model was applied to identify predictors associated with mortality. Results: Out of 148 patients enrolled, 77% were females and mean age was 50.8 ± 15.9 years. Racial distribution was consistent with our population census. The most common aetiologies were congenital heart disease‐associated PAH (35.8%), idiopathic PAH (29.7%) and then connective tissue disease‐associated PAH (24.3%). Most patients presented in World Health Organization (WHO) Functional Class (FC) II (48.6%), followed by FC III (28.8%). Majority of patients (54.1%) were on phosphodiesterase type 5 (PDE5) inhibitor monotherapy. Survival rates were 85.8% at the end of the first year, 70.9% at 3 years, 66.9% at 5 years, 61.5% at 7 years and 55.4% at 10 years. The Registry to Evaluate Early And Long‐term PAH Disease Management (REVEAL) score (RS) was found to be the best predictor of mortality. A score > 6 was identified as a cut‐off. Other predictors include mean right atrial pressure, heart rate, aetiology, age and N‐terminal pro‐brain natriuretic peptide. Conclusion: In this first registry study from a South‐East Asian population, our survival rates are comparable with other national registries. The RS is validated in our population to be a good predictor of mortality. This is the first detailed pulmonary arterial hypertension (PAH) registry study from a multi‐ethic Asian cohort with a long 14‐year follow‐up. Data are sorely lacking in the East compared with the West. We were able to apply and validate risk predictors including the REVEAL (Registry to Evaluate Early And Long‐term PAH Disease Management) score. See relatedEditorial [ABSTRACT FROM AUTHOR]

Abstract: Background: Watch‐PAT 200, a novel portable sleep device worn on the wrist, has been validated against polysomnography. Although sleep disordered breathing (SDB) screening is recommended in patients with cardiovascular disease, no study has reported a comparison of results from Watch‐PAT 200 and level III portable devices. Methods: Patients (n = 140) admitted with a first ST‐segment elevation myocardial infarction (STEMI) participated in a hospital‐based sleep study using the Watch‐PAT 200 and a level III portable device (Embletta Gold) simultaneously within five days of admission. SDB was defined as an apnea‐hypopnea index (AHI) of >15 events/h. Results: The left ventricular ejection fraction was normal (≥50%), impaired (30%‐49%) and poor (<30%) in 66 (47.1%), 71 (50.7%), and three (2.2%) patients, respectively. Among 116 patients with a successful paired sleep study, the prevalence of SDB was 53.5% (Watch‐PAT 200) and 51.7% (Embletta Gold). The agreement of AHI measured by the two devices was moderately good, with an intra‐class correlation value of 0.72 (95% confidence interval, 0.62‐0.80; P < .01). Agreement between the two devices in diagnosing at least mild (AHI ≥5), moderate‐to‐severe (AHI ≥15) and severe (AHI ≥30) SDB was 78% (kappa 0.47; P < .01), 77% (kappa 0.55; P < .01) and 80% (kappa 0.49; P < .01), respectively. At a 15‐month follow‐up, SDB status based on the two devices was associated with the occurrence of adverse cardiovascular events in 48.3% and 44.8%, respectively (P = .56). Conclusion: We found a high prevalence of SDB in patients presenting with a first STEMI. Agreement between two portable sleep devices was moderately good. [ABSTRACT FROM AUTHOR]

Background: We investigated the association of subjective (perceived) and objective (geographical information system [GIS]-based) measures of the neighborhood built environment (BE) attributes with cognitive function among older persons, and the mediating effect of transportation physical activity (TPA) and leisure time (physical, social and productive) activities (LTA).Method: A cross-sectional study of 402 residents aged 55 years and above in the Singapore Longitudinal Ageing Study. Perceived neighborhood BE attributes (residential density, street connectivity, land use mix - diversity, land use mix - access, infrastructure for walking or cycling, aesthetics, traffic safety, and crime safety) and objective GIS measures of walkability and accessibility were related to participants' cognitive global and domain-specific performance measured by Repeatable Battery for the Assessment of Neurocognitive Status (RBANS).Results: Controlling for age, sex, education, race, chronic medical illnesses, self-rated health, Geriatric Depression Scale depression score, POMA measures of balance and gait, and other BE attributes, the subjective measure of land use mix-diversity (standardized coefficient β = 0.161, p = 0.008) and GIS measure of walkability (β = 0.163, p = 0.002) were positively and significantly associated with RBANS global z-score, and immediate and delayed memory recall, visuospatial/ constructional ability and language, except attention. In hierarchical modeling, TPA and LTA attenuated the effect estimates, but the associations remained significant.Conclusion: BE features which increase opportunities and easy access to a diversity of destinations for services and facilities that promote physical, social and cognitively stimulating activities is associated with better cognitive functioning in older people. [ABSTRACT FROM AUTHOR]

Background: Right ventricular (RV) dysfunction is recognized as a major prognostic factor in left-sided heart failure (HF). However, the relative contribution of RV dysfunction in HF with preserved (HFpEF) vs. reduced ejection fraction (HFrEF) is unclear. Methodsand results: Right ventricular longitudinal strain (RVLS), tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were determined by echocardiography in 657 age- and gender-matched groups of patients with HFpEF [left ventricular ejection fraction (LVEF) =50%; n=219] and HFrEF (LVEF <50%; n=219) and in controls without HF (n=219) from an Asian population-based cohort study. Across control to HFpEF and HFrEF groups, RV function deteriorated as measured by RVLS (-26.7±5%, -22.7±6.6% and -18.2±6.7%, respectively) and TAPSE (21.0±3.9, 17.5±5.1 and 14.7±4.7 mm, respectively), whereas PASP increased (26.8±7.1, 34.5±11.9 and 39.3±16.2 mmHg, respectively) (all P<0.001). Controlling for PASP in control, HFpEF and HFrEF subjects, the magnitude of RVLS/PASP (-1.06±0.32, -0.75±0.32 and -0.56±0.36, respectively) and TAPSE/PASP ratios (0.83±0.23, 0.54±0.24 and 0.55±0.29, respectively) similarly decreased across groups. Right ventricular dysfunction (by both TAPSE and RVLS) was independently associated with left ventricular systolic dysfunction and atrial fibrillation, but not with PASP. Among patients with HF, both TAPSE/PASP and RVLS/PASP ratios were related to the composite endpoint of all-cause death and HF hospitalization, even after multivariable adjustment [hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.14-0.74 and HR 3.09; 95% CI 1.52-6.26, respectively], with no difference between HFrEF and HFpEF. Conclusions: Right ventricular dysfunction is present in HFpEF and is even more pronounced in HFrEF for any given degree of pulmonary hypertension. It is independently predicted by left ventricular dysfunction but not by PASP. Right ventricular-arterial coupling is prognostically important in HF regardless of LVEF. [ABSTRACT FROM AUTHOR]

Background: Right ventricular (RV) dysfunction is recognized as a major prognostic factor in left-sided heart failure (HF). However, the relative contribution of RV dysfunction in HF with preserved (HFpEF) vs. reduced ejection fraction (HFrEF) is unclear.Methods and Results: Right ventricular longitudinal strain (RVLS), tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) were determined by echocardiography in 657 age- and gender-matched groups of patients with HFpEF [left ventricular ejection fraction (LVEF) ≥50%; n=219] and HFrEF (LVEF <50%; n=219) and in controls without HF (n=219) from an Asian population-based cohort study. Across control to HFpEF and HFrEF groups, RV function deteriorated as measured by RVLS (-26.7 ± 5%, -22.7±6.6% and -18.2 ± 6.7%, respectively) and TAPSE (21.0 ± 3.9, 17.5 ± 5.1 and 14.7 ± 4.7 mm, respectively), whereas PASP increased (26.8 ± 7.1, 34.5 ± 11.9 and 39.3 ± 16.2 mmHg, respectively) (all P<0.001). Controlling for PASP in control, HFpEF and HFrEF subjects, the magnitude of RVLS/PASP (-1.06 ± 0.32, -0.75 ± 0.32 and -0.56 ± 0.36, respectively) and TAPSE/PASP ratios (0.83 ± 0.23, 0.54 ± 0.24 and 0.55 ± 0.29, respectively) similarly decreased across groups. Right ventricular dysfunction (by both TAPSE and RVLS) was independently associated with left ventricular systolic dysfunction and atrial fibrillation, but not with PASP. Among patients with HF, both TAPSE/PASP and RVLS/PASP ratios were related to the composite endpoint of all-cause death and HF hospitalization, even after multivariable adjustment [hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.14-0.74 and HR 3.09; 95% CI 1.52-6.26, respectively], with no difference between HFrEF and HFpEF.Conclusions: Right ventricular dysfunction is present in HFpEF and is even more pronounced in HFrEF for any given degree of pulmonary hypertension. It is independently predicted by left ventricular dysfunction but not by PASP. Right ventricular-arterial coupling is prognostically important in HF regardless of LVEF. [ABSTRACT FROM AUTHOR]

Introduction: Transcatheter aortic valve implantation (TAVI) is an effective treatment for high-risk or inoperative patients with severe aortic stenosis. Given the unique characteristics of Asian populations, questions regarding mid-term outcomes in Asians undergoing TAVI have yet to be addressed. We evaluated the two-year clinical outcomes of TAVI in an Asian population using Valve Academic Research Consortium-2 definitions.Methods: This prospective study recruited 59 patients from a major academic medical centre in Singapore. The main outcomes were two-year survival rates, peri-procedural complications, symptom improvement, valvular function and assessment of learning curve.Results: Mean age was 76.8 years (61.0% male), mean body surface area 1.6 m2 and mean logistic EuroSCORE 18.7%. Survival was 93.2%, 86.0% and 79.1% at 30 days, one year and two years, respectively. At 30 days post TAVI, the rate of stroke was 1.7%, life-threatening bleeding 5.1%, acute kidney injury 25.0%, major vascular complication 5.1%, and new permanent pacemaker implantation 6.8%. 29.3% of TAVI patients were rehospitalised (47.1% cardiovascular-related) within one year. These composite outcomes were measured: device success (93.2%); early safety (79.7%); clinical efficacy (66.1%); and time-related valve safety (84.7%). Univariate analysis found these predictors of two-year all-cause mortality: logistic EuroSCORE (hazard ratio [HR] 1.07; p < 0.001); baseline estimated glomerular filtration rate (HR 0.97; p = 0.048); and acute kidney injury (HR 5.33; p = 0.022). Multivariate analysis identified non-transfemoral TAVI as a predictor of cardiovascular-related two-year mortality (HR 14.64; p = 0.008).Conclusion: Despite the unique clinical differences in Asian populations, this registry demonstrated favourable mid-term clinical and safety outcomes in Asians undergoing TAVI. [ABSTRACT FROM AUTHOR]

The ability to alter the amount and activity of brown adipose tissue (BAT) in human adults is a potential strategy to manage obesity and related metabolic disorders associated with food, drug, and environmental stimuli with BAT activating/recruiting capacity. Infrared thermography (IRT) provides a non-invasive and inexpensive alternative to the current methods (e.g. F-FDG PET) used to assess BAT. We have quantified BAT activation in the cervical-supraclavicular (C-SCV) region using IRT video imaging and a novel image computational algorithm by studying C-SCV heat production in healthy young men after cold stimulation and the ingestion of capsinoids in a prospective double-blind placebo-controlled randomized trial. Subjects were divided into low-BAT and high-BAT groups based on changes in IR emissions in the C-SCV region induced by cold. The high-BAT group showed significant increases in energy expenditure, fat oxidation, and heat output in the C-SCV region post-capsinoid ingestion compared to post-placebo ingestion, but the low-BAT group did not. Based on these results, we conclude that IRT is a promising tool for quantifying BAT activity. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to compare the clinical outcomes of elderly hip fracture patients who received surgical treatment with those who received non-surgical treatment.Methods: This retrospective study involved 2,756 elderly patients with hip fractures who were admitted over a six-year period. The patients' biodata, complications, ambulatory status at discharge and length of hospital stay were obtained from the institution's hip fracture registry.Results: Among the 2,756 hip fracture patients, 2,029 (73.6%) underwent surgical intervention, while 727 (26.4%) opted for non-surgical intervention. The complication rate among the patients who underwent surgical intervention was 6.6%, while that among the patients who underwent non-surgical intervention was 12.5% (p < 0.01). The mean length of hospital stay for the surgical and non-surgical hip fracture patients was 15.7 days and 22.4 days, respectively (p < 0.01).Conclusion: Surgical management of hip fractures among the elderly is associated with a lower complication rate, as well as a reduced length of hospital stay. [ABSTRACT FROM AUTHOR]

To investigate the relationship between plasma soluble semaphorin4D (sSema4D) and obstructive sleep apnea-hypopnea syndrome (OSAHS), and to ascertain the effect of sSema4D on cognitive dysfunction in patients with OSAHS. We prospectively recruited 30 men with moderate-severe OSAHS diagnosed by polysomnography, and 30 healthy controls with matched gender, age and education level. Montreal Cognitive Assessment (MoCA) was administered to determine cognitive impairment. Plasma sSema4D levels were measured. Among the total of 60 study patients, the overall plasma sSema4D level was 7.81 ± 1.91 ng/ml. Plasma sSema4D level in OSAHS group was significantly higher than that in controls (8.92 ± 1.79 vs 6.70 ± 1.28 ng/ml, p < 0.001). In OSAHS subgroup, patients with cognition impairment (CI) had higher plasma sSema4D level (10.50 ± 1.16 vs 8.00 ± 1.41 ng/ml, p < 0.001) and apnea-hypopnea index (AHI) (48.1 ± 14.0 vs 30.3 ± 9.2, p < 0.001) than those in non-CI group. Multiple logistic regression revealed that plasma sSema4D level (AOR 2.824, 95 % CI 1.562-5.103; p = 0.001) and BMI (AOR 2.237, 95 % CI 1.345-3.722; p = 0.002) were significantly associated with OSAHS, and plasma sSema4D was a significant predictor of CI after adjustment for other confounders (AOR 4.956, 95 % CI 1.581-15.538; p = 0.006). OSAHS patients, especially those with cognition impairment, are featured by elevated plasma sSema4D level, and sSema4D is significantly associated with cognition impairment induced by OSAHS. [ABSTRACT FROM AUTHOR]

Aims: This study was conducted to test the diagnostic performance of NT-proBNP for discrimination of acute decompensated heart failure (ADHF) among breathless patients presenting in an Asian compared with a Western centre.Methods and Results: Patients with breathlessness were prospectively and contemporaneously recruited in Emergency Departments in Singapore and New Zealand (NZ). The diagnosis of ADHF was adjudicated by two clinician specialists. A total of 606 patients were recruited in Singapore and 500 in NZ. The discriminative power of NT-proBNP for ADHF was superior in Singapore compared with NZ [area under the curve (AUC) 0.926 vs. 0.866; P = 0.012] both overall and among selected subgroups stratified according to age, renal function, body mass index, and presence or absence of AF or diabetes. Previously established cut-off point values of plasma NT-proBNP yielded comparable sensitivity and negative predictive values, but superior specificity and accuracy in Singapore compared with NZ. The difference in test performance was driven by the younger age (median age 56 years vs. 73 years; P < 0.001), associated with better renal function (estimated glomerular filtration rate 89 vs. 62 mL/min/1.73 m2 ; P < 0.001), and lower prevalence of AF (9.7% vs. 25.7%; P < 0.001) in acutely breathless patients in Singapore.Conclusion: Considering emerging evidence of a lower average age of presentation with ADHF over most of Asia compared with Western countries, NT-proBNP is likely to be more accurate when applied in Asian centres than in the West. [ABSTRACT FROM AUTHOR]

Background: Understanding changes in the ecology and epidemiology of dengue is important to ensure resource intensive control programmes are targeted effectively as well as to inform future dengue vaccination strategies.Methods: We analyzed data from a multicentre longitudinal prospective study of fever in adults using a nested test negative case control approach to identify epidemiological risk factors for dengue disease in Singapore. From April 2005 to February 2013, adult patients presenting with fever within 72 h at selected public primary healthcare clinics and a tertiary hospital in Singapore were recruited. Acute and convalescent blood samples were collected and used to diagnose dengue using both PCR and serology methods. A dengue case was defined as having a positive RT-PCR result for DENV OR evidence of serological conversion between acute and convalescent blood samples. Similarly, controls were chosen from patients in the cohort who tested negative for dengue using the same laboratory methods.Results: The host epidemiological factors which increased the likelihood of dengue disease amongst adults in Singapore were those aged between 21 and 40 years old (2 fold increase) while in contrast, Malay ethnicity was protective (OR 0.57, 95%CI 0.35 to 0.91) against dengue disease. Spatial factors which increased the odds of acquiring dengue was residing at a foreign workers dormitory or hostel (OR 3.25, 95 % CI 1.84 to 5.73) while individuals living in the North-West region of the country were less likely to get dengue (OR 0.50, 95%CI 0.29 to 0.86). Other factors such as gender, whether one primarily works indoors or outdoors, general dwelling type or floor, the type of transportation one uses to work, travel history, as well as self-reported history of mosquito bite or household dengue/fever were not useful in helping to inform a diagnosis of dengue.Conclusions: We have demonstrated a test negative study design to better understand the epidemiological risk factors of adult dengue over multiple seasons. We were able to discount other previously speculated factors such as gender, whether one primarily works indoors or outdoors, dwelling floor in a building and the use of public transportation as having no effect on one's risk of getting dengue. [ABSTRACT FROM AUTHOR]

Assessment weighting within a given module can be a motivating factor for students when deciding on their commitment level and time given to study a specific topic. In this study, an analysis of assessment performances of second year anatomy students was performed over four years to determine if (1) students performed better when a higher weighting was given to a set of practical session assessments and (2) whether an improved performance in the practical session assessments had a carry-over effect on other assessment tasks within that anatomy module and/or other anatomy modules that follow. Results showed that increasing the weighting of practical session assessments improved the average mark in that assessment and also improved the percentage of students passing that assessment. Further, it significantly improved performance in the written end-semester examination within the same module and had a carry-over effect on the anatomy module taught in the next teaching period, as students performed better in subsequent practical session assessments as well as subsequent end-semester examinations. It was concluded that the weighting of assessments had significant influences on a student's performance in that, and subsequent, assessments. It is postulated that practical session assessments, designed to develop deep learning skills in anatomy, improved efficacy in student performance in assessments undertaken in that and subsequent anatomy modules when the weighting of these assessments was greater. These deep learning skills were also transferable to other methods of assessing anatomy. Anat Sci Educ 9: 330-336. © 2015 American Association of Anatomists. [ABSTRACT FROM AUTHOR]

Introduction Fitness to drive skills progressively deteriorate following a diagnosis of Alzheimer’s disease/cognitive decline. Occupational therapists require standardised assessments to help them make recommendations to clients and licensing authorities regarding client fitness to drive. This research aimed to determine whether drivers in the early stages of Alzheimer’s disease/cognitive decline can drive safely, and if this could be predicted using the occupational therapy – driver off-road assessment battery (OT-DORA Battery). Method Drivers with Alzheimer’s disease/cognitive decline were assessed by one of nine driver assessors over 18 months. Client data were collected on the OT-DORA Battery and following on-road assessment; the outcome was recorded as pass, pass with conditions, or fail. Results A total of 63 clients were assessed, and n  =  40 (63.5%) were passed as fit to drive, of whom 33(83%) had at least one condition placed on their licence. Client age and scores on four subtests of the OT-DORA Battery were predictive of outcome. Conclusion A diagnosis of Alzheimer’s disease/cognitive decline should not automatically preclude driving. Scores on four of the subtests from the OT-DORA Battery may be used to help determine whether a client is fit to drive or not fit to drive, or whether a client should be referred for specialist occupational therapy driver assessment. [ABSTRACT FROM AUTHOR]

Relationship education and couple counseling services have been targeted to groups differing in severity of marital problems. However, there is evidence that couples seeking these services may be more similar than previously thought. We examined profiles of couples attending both services across eight community relationship service agencies in Australia; 460 participants (230 couples) completed a preservice survey. Multivariate analysis found that those seeking couple counseling had more children, more serious relationship issues, higher depression and aggression, lower education, and more financial difficulty. Modeling was also undertaken by gender. Differentiated profiles of couples seeking different relationship services are useful to inform service delivery and professional training. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the benefit of a Saturday rehabilitation service in improving employees' return to work outcomes at 12 months. The study involved a randomized controlled trial in a general inpatient rehabilitation service. Results show that the service has demonstrated no improvement in work outcomes.

Background: Pain is a prominent feature of acute dengue as well as a clinical criterion in World Health Organization guidelines in diagnosing dengue. We conducted a prospective cohort study to compare levels of pain during acute dengue between different ethnicities and dengue severity. Methods: Demographic, clinical and laboratory data were collected. Data on self-reported pain was collected using the 11-point Numerical Rating Scale. Generalized structural equation models were built to predict progression to severe disease. Results: A total of 499 laboratory confirmed dengue patients were recruited in the Prospective Adult Dengue Study at Tan Tock Seng Hospital, Singapore. We found no statistically significant differences between pain score with age, gender, ethnicity or the presence of co-morbidity. Pain score was not predictive of dengue severity but highly correlated to patients’ day of illness. Prevalence of abdominal pain in our cohort was 19%. There was no difference in abdominal pain score between grades of dengue severity. Conclusion: Dengue is a painful disease. Patients suffer more pain at the earlier phase of illness. However, pain score cannot be used to predict a patient’s progression to severe disease. [ABSTRACT FROM AUTHOR]

Most Australian public health-care services have established a range of initiatives designed to help 'protect' nurses and midwives from patient and visitor assault (PVA); however, few studies have specifically examined their effectiveness. The present study is part of a larger survey that explored nurses' and midwives' experiences of PVA using the Department of Human Services, Victoria (2007) definition of occupational violence and bullying. Participants were asked about the presence of 'protective' factors in their workplace and the importance of having these factors to prevent and manage workplace aggression. Binary logistic regression was applied to ascertain the association between 'protective' factors and the occurrence of PVA, with adjusted odds ratios and their reported 95% confidence intervals for ascertaining the significance of the associations. The study found more 'protection' from assault when there was a high standard of patient facilities, sufficient staffing, effective enforcement of policies, and when staff were provided with personal protective equipment. Working in private health care, and being a registered nurse, also conferred 'protection'. A higher occurrence of staff assault was associated with specific clinical settings, and being on rotation and on night duty. Findings point to important insights into factors associated with 'protection' for PVA. [ABSTRACT FROM AUTHOR]