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Heart failure is a growing epidemic, especially in Taiwan because of the aging population. The 2016 Taiwan Society of Cardiology – Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry showed that the guideline-recommended therapies were prescribed suboptimally both at the time of hospital discharge and during follow-up. We, therefore, conducted this 2019 focused update of the guidelines of the Taiwan Society of Cardiology for the diagnosis and treatment of heart failure to reinforce the importance of new diagnostic and therapeutic modalities of heart failure. The 2019 focused update discusses new diagnostic criteria, pharmacotherapy, non-pharmacological management, and certain co-morbidities of heart failure. Angiotensin receptor neprilysin inhibitor and If channel inhibitor is introduced as new and recommended medical therapies. Latest criteria of cardiac resynchronization therapy, implantable cardioverter-defibrillator, heart transplantation, and ventricular assist device therapy are reviewed in the non-pharmacological management chapter. Co-morbidities in heart failure are discussed including chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and sleep-disordered breathing. We also explain the adequate use of oxygen therapy and non-invasive ventilation in heart failure management. A particular chapter for chemotherapy-induced cardiac toxicity is incorporated in the focused update to emphasize the importance of its recognition and management. Lastly, implications from the TSOC-HFrEF registry and post-acute care of heart failure are discussed to highlight the importance of guideline-directed medical therapy and the benefits of multidisciplinary disease management programs. With guideline recommendations, we hope that the management of heart failure can be improved in our society.

Drug-eluting stents are widely used in coronary artery intervention. However, vessel caging and very late thrombotic events are of persistent and substantial concern. Bioresorbable vascular scaffolds (BVS) were developed to deliver vascular reparative therapy, by eliminating permanent mechanical restraint. However, data regarding its clinical performance is lacking.After the BVS implantation procedure received national approval in May 2014, patients receiving BVS implantation until November 2014 in National Taiwan University Hospital (NTUH) were enrolled. Clinical variables, angiographic data, procedural details, and follow-up information were collected and compared with those receiving BVS at NTUH as part of the global ABSORB EXTEND trial.A total of 35 patients (38 target vessels) with 48 BVS implanted after approval were enrolled, as the "real-world practice" group. Data of the 34 patients (34 target vessels) with 37 BVS implanted in the ABSORB EXTEND trial were also obtained. Differences in lesion complexity (0% type B2/C lesion in ABSORB EXTEND, versus 23.7% in real-world, p = 0.007) and lesion length (20.9 ± 6.1 mm in ABSORB EXTEND, versus 29.5 ± 15.9 mm in real-world, p = 0.008) were noted. The ischemia-driven target vessel revascularization after an average of 732 days follow-up was 11.8% in the ABSORB EXTEND trial. However, there was no ischemia-driven target lesion revascularization (TLR), no scaffold thrombosis, no myocardial infarction (MI), and no patients passed during the follow-up period. In real-world patients, there is 5.3% of MI, 2.6% ischemia-driven TLR, and 2.6% of non-fatal probable scaffold thrombosis.The use of BVS in real-world practice is feasible, with clinical outcomes comparable to those in the ABSORB EXTEND trial.

Atrial fibrillation (AF) is the most common sustained and most important arrhythmia in clinical practice. The mechanisms underlying AF initiation and maintenance are known to be complex and heterogeneous. The general understanding of the detailed molecular basis of AF is still incomplete. Recently, these is increasing evidence that small conductance calcium-activated potassium (SK) channels are associated with atrial action potential repolarization and the pathogenesis of AF. Although the functional role of SK channels in the genesis of AF is not entirely clear, new insights into the basic pathophysiological mechanism of AF have been provided. Besides, genome-wide association studies also implicate that genes coding for SK channels are related to the risk of developing AF. This article reviews recent work on the association of SK channels and AF, genetic studies of SK channels, and discuss future investigation and developments regarding this field.Atrial fibrillation; Genetics; Small conductance calcium-activated potassium channels.

Atrial fibrillation (AF) is associated with increased risk of thromboembolism, and is also a predisposing factor to dementia. Our investigation was a retrospective observational study to evaluate whether the usage of angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) could reduce the incidence of dementia in patients with AF.A total of 5221 patients over 20 years of age who had a history of AF as noted in ambulatory and inpatient claims data were enrolled from the National Health Insurance Research Database of Taiwan in 1997 and 1998. Patients with ACEI or ARB were designated as group 1 (4343 patients), and patients without ACEI or ARB were designated as group 2 (878 patients).During a follow-up of 5.90 ± 3.39 years, 135 patients of group 1 (3.1%) and 25 of group 2 (2.8%) developed new-onset dementia. Group 1 and group 2 had similar proportions of new-onset dementia (p = 0.75). The Kaplan-Meier curve demonstrated that patients with ACEI or ARB were not associated with a lower incidence of dementia during the follow-up period (log rank p = 0.91). Cox-regression analysis also showed that usage of ACEI or ARB was not associated with a lower risk of new-onset dementia after adjustment for gender and comorbidities. (Hazard ratio = 0.942, 95% confidence interval 0.589~1.506, and p = 0.80).ACEI or ARB may be ineffective in reducing the incidence of dementia in patients with AF.Angiotensin-converting-enzyme inhibitor; Angiotensin II receptor blocker; Atrial fibrillation; Dementia.

The phenomenon of CYP2C19 polymorphism affects the metabolism of both clopidogrel and proton-pump inhibitors (PPI). However, concomitant use of both drugs may reduce the desired therapeutic effects. In this study, we evaluated whether individuals with different numbers of reduced-function CYP2C19 alleles were equally affected and whether PPIs with different dependencies on CYP2C19 metabolism were equally involved.Thirty healthy volunteers were recruited to a six-week regimen of clopidogrel. Three PPIs with different metabolic dependencies on CYP2C19 were included and separately administered in this order. Each PPI was given for a week, followed by a one-week washout period before the intervention of the next PPI. The anti-platelet effect was examined by Thromboelastography Platelet Mapping(TM) (TEG®) and vasodilator-stimulated phosphoprotein (VASP) assays.Both TEG® and VASP tests showed the same general qualitative trend, but TEG® detected a statistically significant fluctuation of platelet aggregation in response to different drug interventions. The TEG® results also demonstrated that non-carriers experienced the most significant impairment of anti-platelet effect of clopidogrel after concomitant use of PPIs. This impairment was closely related to the metabolic dependence on CYP2C19 of PPI.Our study indicated that non-carriers of reduced-function CYP2C19 alleles are most susceptible to impairment of the anti-platelet effect of clopidogrel after concomitant PPI use. Individual subjects are not equally affected, and PPIs are not equally involved. However, large-scale randomized clinical trials are needed to evaluate the clinical outcome.Clopidogrel • CYP2C19 polymorphism • Platelet aggregation • Proton pump inhibitors • TEG • VASP.

The aim of this study was to evaluate the independent roles of proteinuria and reduced estimated glomerular filtration rate (GFR) in the development of acute myocardial infarction in a northern Taiwanese population.We conducted a community-based prospective cohort study in Keelung, the northernmost county of Taiwan. A total of 63,129 subjects (63% women) ≥ 20 years of age who had no history of coronary heart disease were recruited and followed-up. Univariate and multivariate proportional hazards regression analysis was performed to assess the association between proteinuria and estimated GFR and the risk of acute myocardial infarction.There were 305 new cases of acute myocardial infarction (114 women and 191 men) documented during a four-year follow-up period. After adjustment of potential confounding covariates, heavier proteinuria (dipstick urinalysis reading 3+) and estimated GFR of less than 60 ml/min/1.73 m(2) independently predicted increased risk of developing acute myocardial infarction. The adjusted hazard ratio (aHR) of heavier proteinuria for occurrence of acute myocardial infarction was 1.85 [95% confidence intervals (CI), 1.17-2.91, p0.01] (vs. the reference group: negative dipstick proteinuria). The aHR of estimated GFR of 30-59 ml/min/1.73 m(2) for occurrence of acute myocardial infarction was 2.4 (95% CI, 1.31-4.38, p0.01) (vs. the reference group: estimated GFR ≥ 90 ml/ min/1.73 m(2)), and that of estimated GFR of 15-29 ml/min/1.73 m(2) was 5.26 (95% CI, 2.26-12.26, p0.01).We demonstrated that both heavier proteinuria and lower estimated GFR are significant independent predictors of developing future acute myocardial infarction in a northern Taiwanese population.Acute myocardial infarction; Estimated glomerular filtration rate; Proteinuria.

The International Human Genome Sequencing Consortium published the first draft of the human genome in the journal Nature in February 2001, providing the sequence of the entire genome's three billion base pairs. The Human Genome Project involves a concerted effort to better understand the human DNA sequence through identification of all the genes. The knowledge that can be derived from the genome could result in the development of novel diagnostic assays, targeted therapies and the improved ability to predict the onset, severity and progression of diseases. This has been made possible by many parallelized, high-throughput technologies such as next-generation sequencing. In this review, we discuss the possible application of next-generation sequencing in finding the susceptibility gene(s) or disease mechanism of an important human arrhythmia called atrial fibrillation.Arrhythmia; Atrial fibrillation; Genetics, Next-generation sequencing.

Radiofrequency catheter ablation (RFCA) for atrial tachyarrhythmias in postoperative congenital heart disease (CHD) patients has a low success rate and a high recurrence rate. This study explores the reasons for these constraints.A total of 49 consecutive postoperative CHD patients who received RFCA for atrial tachyarrhythmias between 1993 and 2010 were enrolled.Overall, there were 86 RFCA procedures performed, 32 with the conventional method and 54 using CARTO-guided mapping. The interval between the operation and the first ablation was 13 years. Isthmus-dependent atrial flutter (AFL) was the most common type of tachycardia (37, 76%), followed by intra-atrial re-entry tachycardia (IART; 37%), and ectopic atrial tachycardia (EAT; 31%). By applying CARTO-guided mapping, the success rate was elevated compared to that of conventional ablation (84% vs. 56%, p = 0.006), but there was no improvement in the recurrence rate (22% vs. 28%, p = 0.75). Multiple atrial tachyarrhythmias occurred in 26 (53%) patients, and 17 presented during the initial electrophysiological study. The presence of multiple arrhythmias during the initial study predicted ablation failure or multiple ablations (11/17 vs. 3/32, p0.001). Among the 15 patients with new tachyarrhythmias, EAT and IART predominated. However, applying antiarrhythmia agents immediately following ablation may decrease arrhythmia recurrence (1/10 vs. 14/25, p = 0.02).Although electroanatomical mapping improves the results of RFCA in atrial tachyarrhythmias, the recurrence rate remains high because of multiple and new atrial tachyarrhythmias. Therefore, short-term pharmacological treatment following RFCA for positive remodeling should be considered.Ablation; Antiarrhythmia agents; Atrial tachyarrhythmia; Congenital heart disease; Multiple arrhythmias.