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Type 2 diabetes is a major threat to human health in the 21st century. More than half a billion people may suffer from this pandemic disease in 2030, leading to a huge burden of cardiovascular complications. Recently, 2 novel antidiabetic agents, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, reduced cardiovascular complications in a number of randomized control trials. To integrate new information and to achieve a streamlined process for better patient care, a working group was appointed by the Taiwan Society of Cardiology to formulate a stepwise consensus pathway for these therapies to reduce cardiovascular events in patients with type 2 diabetes. This consensus pathway is complementary to clinical guidelines, acting as a reference to improve patient care.

Background/Purpose: Currently, data on the real-world use of dronedarone, an antiarrhythmic drug for atrial fibrillation (AF), are contradictory and often based on patient populations comprised of Caucasians. We prospectively investigated the efficacy and safety of dronedarone and risk factors related to treatment outcomes in a real-world use setting. Methods: The prospective, observational, single-arm, multi-center study included a total of 824 Taiwanese patients with a diagnosis of paroxysmal or persistent AF and receiving dronedarone treatment. Risk factors analysis, efficacy, and safety of dronedarone were assessed with a follow-up of six months. Results: Of the 824 patients enrolled (mean age, 75.3 ± 7.2 years), 95.2% had at least one cardiovascular risk factor. An increase in the proportion of patients with sinus rhythm following treatment was seen (52.1% at baseline vs. 67.4% at 6 months). A decrease in the mean duration of AF episodes (388.4 min vs. 62.3 min) and an increase in total AFEQT (65.4 ± 16.2 vs. 74.0 ± 11.8) were also observed after 6 months of treatment. Females, those under the age of 75, and those with symptomatic AF had higher odds of treatment success. At 6 months, 10.5% of patients reported treatment-related AEs. However, only 0.2% of the AEs were both severe in nature and causally related to dronedarone. Conclusion: This six-month study showed dronedarone to be relatively safe and efficacious and to improve quality-of-life in Taiwanese patients with atrial fibrillation. Odds of treatment success were related to the patient's gender, age, and AF type. Keywords: Atrial fibrillation, Dronedarone, Observational, Safety, Quality of life

Young-onset hypertensives (YOHs) with resistant hypertension (RH) have a greater long-term cardiovascular risk. The present study examined whether a functional adiponectin T94G polymorphism (rs2241766) is associated with RH in YOHs. We analyzed data from the Academia Sinica Collaborative Study on Hypertension Genetics in Taiwanese subjects to compare rs2241766 between YOHs with and without RH (≤50 years of age). RH was defined as the need for at least 3 drugs, including a diuretic to control blood pressure. Genotyping of rs2241766 was performed using TaqMan allelic discrimination. A total of 861 YOHs were enrolled and 54 had RH in enrolled population. For the rs2241766 in the allelic model, the odds ratio (OR) of RH allele frequency was 2.45 (p = 0.008), and there was a linear relationship between allele numbers and the presence of RH (p = 0.005). In multivariate analysis, the rs2241766 (OR = 2.766, p = 0.002), age (OR = 1.103, p = 0.001), uric acid (OR = 1.322, p = 0.001), high-sensitivity C-reactive protein (OR = 2.769, p = 0.001) and aldosterone (OR = 1.004, p = 0.001) were independently associated with the presence of RH. In the Taiwanese population, the adiponectin T94G polymorphism (rs2241766) is associated with RH in YOHs.

Patient Initials or Identifier Number 26459085 ### Relevant Clinical History and Physical Exam A 78-year-old male patient presented with chest tightness at CV OPD. Other symptoms included cold sweating (+), dyspnea (+), Nausea/vomiting (-) Past History: Hypertension, DM, CKD (eGFR = 30), 2-D

ObjectivesBoth atrial fibrillation (AF) and vascular disease share several risk factors and the two diseases often coexist. The patients with AF were reported to have a decreased ankle-brachial index (ABI). However, ABI was also reported to have an inverse relationship with heart rate (HR). Because AF patients often have a transiently or persistently rapid HR, this study aimed to assess whether AF was significantly associated with decreased ABI and whether HR could significantly influence the relationship between AF and ABI.MethodsWe included 166 AF and 1336 non-AF patients from subjects undergoing echocardiographic examinations. ABI was measured using an ABI-form device.ResultsCompared to non-AF patients, AF patients had a decreased ABI (p

PurposeThe pre-ejection period-derived myocardial performance index measured from tissue Doppler echocardiography (PEPa-derived MPI) was reported to be associated with left ventricular systolic and diastolic function in atrial fibrillation (AF). However, its relationship with cardiovascular outcomes in AF has never been evaluated. This study sought to examine the ability of PEPa-derived MPI in predicting adverse cardiovascular events in AF patients.MethodsIn 196 persistent AF patients, we performed comprehensive echocardiography with measurement of PEPa-derived MPI using index beat method. The index beat was defined as the beat following the nearly equal preceding (RR1) and pre-preceding (RR2) intervals. The cycle length of index beat and RR1 and RR2 must be >500ms and the difference between RR1 and RR2 must be

Background p-Cresylsulfate (PCS), a protein-bound uraemic retention solute, is known to cause endothelial dysfunction and possibly plays a role in coronary atherosclerosis. Furthermore, the association among serum total PCS, major adverse cardiovascular events, and all-cause mortality were also found in previous studies. However, little is known about the relationship between total PCS level and prolonged QT interval. We assessed whether serum total PCS level is related with prolonged QT interval by measuring 12-lead electrocardiogram (ECG) recording in stable angina patients with early stage of renal failure. Methods Serum total PCS concentrations were measured by using the Ultra Performance LC System in 154 consecutive stable angina patients. A 12-lead ECG recording was obtained from each subject. Results Patients with abnormal corrected QT (QTc) interval have higher median serum total PCS levels than patients with normal QTc interval. Statistically significant associations were observed between the serum total PCS levels and the QTc interval (r = 0.217, P = 0.007). Using multivariate and trend analyses, serum total PCS level was independently associated with QTc prolongation. Conclusions This study indicates that serum total PCS levels are significantly higher in the presence of abnormal QTc interval and are associated with the QTc prolongation. Whether total PCS plays a role in the pathogenesis of QTc prolongation requires future investigation.

Previous studies demonstrated CHADS2 score and impaired renal function were both associated with ankle-brachial index (ABI) 0.9 in patients without atrial fibrillation (AF). Hence, we hypothesized the R2CHADS2 score had a significant correlation with ABI 0.9 and the aim of this study was to validate this association in non-AF patients.A total of 1482 patients without AF were included. ABI was measured using an ABI-form device. Peripheral arterial occlusive disease (PAOD) was defined as ABI 0.9 in either leg.Of the 1482 subjects, the prevalence of ABI 0.9 was 5.6%. Multivariate analysis showed that increased age (odds ratio [OR], 1.049; P 0.001), decreased estimated glomerular filtration rate (OR, 0.978; P = 0.006), and increased R2CHADS2 score (OR, 1.738; P 0.001) were associated with ABI 0.9. In addition, in patients with CHADS2 score ≧ 2, the presence of chronic kidney disease (CKD) was significantly associated with ABI 0.9 (P ≦ 0.006), but in patients with CHADS2 score 2, there was no such association (P = 0.357).Our study demonstrated R2CHADS2 score was positively correlated with ABI 0.9. In addition, the presence of CKD was a risk factor of ABI 0.9 in patients with CHADS2 score ≧ 2. Hence, increased R2CHADS2 score in non-AF patients and the presence of CKD in non-AF patients with CHADS2 score ≧ 2 were useful parameters in identifying the high risk group of PAOD.

Background Arterial stiffness, peripheral artery disease and left ventricular systolic dysfunction contributed to left ventricular hypertrophy (LVH). Using an ABI-form device, we can obtain brachial-ankle pulse wave velocity (baPWV), ankle-brachial index (ABI) and the ratio of brachial pre-ejection period to ejection time (bPEP/bET), which are markers for arterial stiffness, peripheral artery disease and left ventricular systolic function, respectively. The aim of this study was to assess whether “BAP score” calculated from the 3 measures of baPWV, ABI and bPEP/bET is associated with LVH. Methods A total of 1,146 patients were included in the study. BAP score was calculated based on a point system in which 1 point was assigned for baPWV above the median value of 1670 cm/s, ABI 0.38. Results There was a significant trend for a stepwise increase in the left atrial diameter, left ventricular mass index (LVMI) and the prevalence of LVH and a stepwise decrease in the left ventricular ejection fraction corresponding to advancement in BAP score from 0 to 3. In addition, increased BAP score is significantly associated with increased LVMI and LVH. Conclusions our results demonstrated increased BAP score was related to increased LVMI and LVH independent of traditional risk factors such as old age, diabetes, hypertension, obesity, anemia, hyperlipidemia and chronic kidney disease. Therefore, the BAP score obtained from the same examination might be useful and convenient in identifying patients with increased LVMI and LVH.

Patient Initials or Identifier Number Mr. S. ### Relevant Clinical History and Physical Exam This 74 year old male was a case of Tongue cancer(cT2N0M0,stage II) -s/p wide excision of oral cancer with modified radical next dissection + tracheostomy + ALT free flap on 2016/09/08 under R/T.

Patient Initials or Identifier Number HN ### Relevant Clinical History and Physical Exam A 52 year-old male patient presented to our hospital for progressive angina and shortness of breath for three days. His coronary risk factors were heavy smoker and hyperlipidemia. Physical examination was

Patient Initials or Identifier Number Lee ### Relevant Clinical History and Physical Exam A 46-year-old male with a history of diabetes mellitus and hyperlipidemia was admitted to our cardiac centre due to intermittent chest discomfort in the recent months. His physical exam was unremarkable

Coronary collateral circulation plays an important role in protecting myocardium from ischemia and reducing cardiovascular events. Advanced age might be associated with poor coronary collateral development and cardiovascular outcome. However, limited studies investigate the predictors for collateral development in the elderly population.The authors evaluated 950 consecutive patients undergoing coronary angiography and finally analyzed 207 patients of 65 years or more. The collateral scoring system developed by Rentrop was used to classify patients into those with poor or good collateral formation.The patients with poor collateral were older age, had lower incidence of smoking, more male sex, had fewer diseased vessels and had a trend to be diabetic. Multivariate analysis showed age (odds ratio (OR) = 1.068; P = 0.019), diabetes (OR = 2.681; P = 0.003) and diseased vessels numbers (OR = 0.337; P0.001) were significant predictors of poor collaterals development. Furthermore, age and diabetes have a synergistic effect on poor collateral development (P = 0.041 for interaction).Even in the elderly population, age and diabetes might negatively influence the coronary collaterals development.

Background The 12-lead electrocardiogram (ECG) is a commonly used tool to access left atrial enlargement, which is a marker of left ventricular diastolic dysfunction (LVDD). The aim of this study was to evaluate any association of the P-wave measurements in ECG with left atrial volume (LAV) index and LVDD. Methods This study enrolled 270 patients. In this study, 4 ECG P-wave parameters corrected by heart rate, that is, corrected P-wave maximum duration (PWdur-MaxC), corrected P-wave dispersion (PWdisperC), corrected P-wave area (PWareaC) and corrected mean P-wave duration (meanPWdurC), were measured. LAV and left ventricular diastolic parameters were measured from echocardiography. LVDD was defined as a pseudonormal or restrictive mitral inflow pattern. Results The 4 P-wave parameters were significantly correlated with the LAV index after adjusting for age, sex, diabetes, hypertension, coronary artery disease, body mass index and diastolic blood pressure in multivariate analysis. The standardized β coefficients of PWdurMaxC, PWdisperC, meanPWdurC and PWareaC were 0.338, 0.298, 0.215 and 0.296, respectively. The 4 P-wave parameters were also significantly correlated with LVDD after multivariate logistic regression analysis. The odds ratios (95% confidence intervals) of PWdurMaxC, PWdisperC, meanPWdurC and PWareaC were 1.03 (1.01–1.04), 1.02 (1.04–1.04), 1.04 (1.02–1.07) and 1.01 (1.00–1.02), respectively. Conclusions This study demonstrated that PWdurMaxC, PWdisperC, meanPWdurC and PWareaC were important determinants of the LAV index and LVDD. Therefore, screening patients by means of the 12-lead ECG may be helpful in identifying a high-risk group of increased LAV index and LVDD.

Pulmonary vein isolation and atrial substrate modification using catheter ablation have been developed as a standard treatment for atrial fibrillation (AF). However, the standard end-point for these procedures is still not well established. This study aimed to investigate the characteristics among positive and negative AF vulnerability patients with normal structural heart, in order to define the endpoint of the atrial substrate modification. Fifty supraventricular tachycardia patients with normal heart structure referred for electrophysiological study and catheter ablation were enrolled. After eliminating the underling arrhythmias, the basic cycle length, effective refractory period of the right atrium, and the P wave indices in 12-lead electrocardiograms were measured. The AF vulnerability test was performed by atrial burst decremental pacing with a pacing cycle length decreasing from 290 ms to 200 ms. The AF vulnerability test was considered as positive when the duration of the induced AF or atrial tachyarrhythmias (ATs) was longer than 10 seconds. The parameters of atrial substrates were compared between patients with positive and negative values of the AF vulnerability test. ATs or AF were induced in 24 (48%) patients. Among these patients, 12 (24%) induced ATs or AF were found to be sustained (duration more than 10 seconds). However, only two of these patients could reproduce the positive result after 10 minutes of the first induced protocol. Comparing the patient baseline characteristics, P wave characteristics and cardiac echo parameters, there were no significant differences between the positive and negative AF vulnerability groups. In conclusion, AF and ATs could be induced in patients with a structurally normal heart. The traditional clinical indices of atrial substrates were not significantly different between the positive and negative AF vulnerability patients. Protocols other than atrial burst decremental pacing should be investigated to evaluate the endpoint of the atrial substrate modification.

Background: The prevalence ofatrial fibrillation (AF) increased in patients with the metabolic syndrome (MetS) compared with the general population. MetS is often accompanied with very-low-density lipoprotein (VLDL) elevation, we examined whether VLDL, isolated from MetS patients, may adversely affect the physiology of gap junction as an underlying mechanism of AF.Methods and Results: Pooled plasma VLDL was isolated from normal and MetS individuals. Wild type C57BL/6 male mice were divided into 3 groups to receive tail-vein injections of saline (Control), normal-VLDL (N-VLDL, 15 µg/g) or MetS-VLDL (MetS-VLDL, 15 µg/g) three times/week for 6 consecutive weeks. After eletrocardiography recordings, hearts were harvested for RNA using quantitative RT-PCR and tissue histology. Compared with Control, MetS-VLDL significantly retarded atrial conduction (widening P wave of electrocardiography 30.2±4.3 ms vs 38.8±5.8 ms, P=0.0187, and PR prolongation 49.4±10.9 ms vs 72.2±17.3 ms, P=0.0224; n=5), but N-VLDL did not. MetS-VLDL also significantly reduced gap junction GJA5 mRNA from the Control value of 1.00±0.68 (folds to control in AU) to 0.53±0.14 (P=0.01; n=6); the changes induced by N-VLDL (1.64±0.68) were not significant. Immunohistologic analysis confirmed reduction of the GJA5 protein connexin 40 (Cx40) in atrial tissues. Immunoprecipitation showed O-GlcNAc-Cx40 in MetS-VLDL-treated atrial myocytes. Conclusions: The VLDL-induced morphological (gap junction) and electrophysiological (atrial conduction) disturbances may explain the increased prevalence of AF in MetS. This study strongly suggests VLDL as a treatment target in MetS.

Patient initials or identifier number Mrs Chen ### Relevant clinical history and physical exam A 60 year-old female patient, presented with chest tightness after working in the morning on June 8, 2015. Then she was sent to our ER Other symptom : Cold sweating (+), Palpitation (+), Nausea/

Patient initials or identifier number 29761759 ### Relevant clinical history and physical exam A 60 year-old man with past medical history: Hypertension, type 2 diabetes Mellitus (complicated with right DM foot), Hyperlipidemia, old cerebral vessel disease, bilateral low extremities

Background/Purpose Despite availability of effective antihypertensives, blood pressure (BP) control is usually inadequate. The Reasons for not Intensifying Antihypertensive Treatment (RIAT) registry evaluated the reasons behind not modifying treatment in an international, cross-sectional study in 16 countries. Methods and results The Taiwanese cohort of RIAT consisted of 8922 patients with untreated/uncontrolled essential hypertension recruited from 22 centers in the country. At the first visit, physicians selected target BP and antihypertensive treatment, and at the next three visits they measured BP and modified treatment/provided justification for not modifying treatment. Mean target BP selected by physicians was 134.6/84.6 ± 5.1/5.0 mmHg, respectively. Patients’ individual risk stratification determined the BP goals. More patients achieved targets according to the physicians’ opinion than based on actual BP measurements: visit 2–50.6% vs. 48.6%; visit 3–58.4% vs. 55.2%; and visit 4–61.2% vs. 57.0%. At each visit, treatment remained unchanged for >60% patients not reaching target; the most common reason for this at visit 2 was the assumption that the time was too short to assess new drug therapy and at visits 3 and 4 was the assumption that target was reached/had almost been reached. Conclusion About 40% Taiwanese hypertensive patients in RIAT did not reach BP targets after an average of 4 months’ follow-up. The most common reason for not modifying treatment was the assumption that the target had been reached or had almost been reached.

Mitral regurgitation (MR) can affect left ventricular diastolic parameters because of interference with regurgitation flow. This study compared left ventricular diastolic parameters between patients with and without significant MR. The MR group included 57 consecutive patients with significant MR. Fifty-seven age-, sex- and Tei index-matched patients without significant MR were selected as the reference group. Baseline characteristics and Tei index and its components were comparable between the MR and reference groups. The MR group had higher left atrial volume index, transmitral E wave velocity (E), ratio of E to transmitral A wave velocity, early diastolic mitral annular velocity (Ea), E/Ea, and ratio of E to isovolumic relaxation flow propagation velocity (IRFPV) (p ≤ 0.025), and lower E-wave deceleration time (p = 0.019) and late diastolic mitral annular velocity (p < 0.001). However, the two groups had similar IRFPV (p = 0.844). In conclusion, MR apparently affects E and Ea, but not IRFPV. IRFPV could potentially be a reliable relaxation parameter in patients with significant MR, but further confirmation by invasive studies is needed.

Acute carbon monoxide (CO) poisoning with cardiac complications is well documented in the literature. However, ST segment elevation is a rare presentation, and most of these cases with ST elevation have revealed non-occlusive or normal coronary arteries. We report a case of CO poisoning complicated with ST elevation myocardial infarction. Emergency coronary angiography revealed total occlusion of the left anterior descending artery and primary percutaneous coronary intervention was performed. This report of a rare case should remind physicians that cardiovascular investigations, including electrocardiography, must be performed in cases with CO poisoning because mortality might increase if reperfusion therapy or appropriate medical treatments are not performed in patients with acute coronary artery occlusion.

Acute pancreatitis complicated with acute myocardial infarction has rarely been reported and the precise mechanisms of myocardial injury remain unclear. We report a 49-year-old man presenting with epigastralgia who had been hospitalized for acute necrotizing pancreatitis, and who subsequently developed ST elevation myocardial infarction. The patient eventually died because of severe heart failure and complications of progressive necrotizing pancreatitis. Although a standard management protocol for these patients has not yet been developed, administration of thrombolytic agents may cause severe complications based on the limited case reports already published. We suggest that coronary angiography and further interventions such as angioplasty and possibly stenting should be performed in these cases.

Accurate diagnosis of wide QRS complex tachycardia is difficult in emergent situations. According to the Advanced Cardiac Life Support (ACLS) tachycardia algorithm of the American Heart Association, immediate synchronized cardioversion should be applied to patients with wide QRS tachycardia with any evidence of hemodynamic instability. However, this may not be appropriate in all patients, especially those with idiopathic left ventricular tachycardia. In our patient, repetitively synchronized cardioversion failed to convert the arrhythmia. It is important for emergency physicians to recognize the electrocardiographic features of idiopathic left ventricular tachycardia and to manage these patients appropriately.

Inducible atrioventricular nodal reentrant tachycardia was demonstrated by electrophysiological studies in a 55-year-old female who suffered from intermittent palpitation, in which paroxysmal atrial fibrillation (AF) was consistently documented by electrocardiogram recordings. After ablation of the slow pathway, the atrioventricular nodal reentrant tachycardia and AF were not inducible. During 2 years of follow-up, there were no recurrences of AF in terms of symptoms or findings from Holter electrocardiograms. We suggest that the AF was triggered by the atrioventricular nodal reentrant tachycardia and the successful ablation of atrioventricular nodal reentrant tachycardia was associated with freedom arising from ablation of AF.

Various patterns of mid-diastolic mitral annular motion may imply different left ventricular (LV) diastolic function and filling pressure. To be a reliable marker in the evaluation of LV diastolic function and filling pressure, these findings must be validated by invasive method. Hence, this study was designed to compare the LV diastolic properties among different patterns of mid-diastolic mitral annular motion by invasive method. Fifty-five patients undergoing elective cardiac catheterization were included. Study subjects were classified into three groups according to mid-diastolic mitral annular motion patterns. Upward and downward La waves were respectively defined as a clear apically- and atrially-directed mid-diastolic annular motion on at least three consecutive beats with the average peak velocityor=2 cm/s. Subjects with upward La wave, with downward but without upward La wave, and without La wave were categorized as groups 1, 2 and 3, respectively. The time constant of isovolumic LV pressure decline (tau) and LV end-diastolic pressure (LVEDP) were obtained from a micromanometer-tipped catheter. The tau was shorter and LVEDP was lower in group 1 than in groups 2 and 3 (p0.047) but these parameters were comparable between groups 2 and 3. In conclusion, patients with upward La wave had better LV relaxation function and lower LVEDP than patients without it. However, these diastolic properties were comparable between patients with only downward La wave and those without La wave. Therefore, mid-diastolic mitral annular motion is a useful and promising marker in the evaluation of LV relaxation and LVEDP.

Mid-diastolic mitral annular motion may be driven by strain energy, an energy for myocardial recoil, stored during the previous systole. Hence, various patterns of mid-diastolic mitral annular motion may imply different left ventricular (LV) diastolic function. The purpose of this study is to compare LV diastolic properties among different types of mid-diastolic mitral annular motion. Two-hundred and three consecutive subjects underwent an echocardiographic examination at our outpatient clinic. Study subjects were classified into three groups according to mid-diastolic mitral annular motion patterns. Upward and downward La waves were defined, respectively, as a clear apically and atrially directed mid-diastolic annular motion on at least three consecutive beats with the average peak velocityor =2 cm/s. Subjects with upward La wave, with downward but without upward La wave and without La wave were categorized as groups 1, 2 and 3, respectively. Early diastolic mitral annular velocity (Ea) was higher and the ratio of transmitral E wave velocity to Ea was lower in group 1 than in groups 2 and 3 (all p0.001). The diagnostic accuracy of upward La wave in prediction of normal diastolic function fell between 75% and 88%. In conclusion, patients with upward La wave had better LV diastolic function and lower LV filling pressure than patients without it. Upward La wave is useful in prediction of normal diastolic function. Therefore, analysis of mid-diastolic mitral annular motion may be complementary to other measures of LV diastolic function. (

Ventricular repolarization abnormality plays a crucial role in cardiac arrhythmia. Polymorphisms in renin—angiotensin system genes are associated with occurrence of ventricular arrhythmia. We previously demonstrated that subjects carrying the angiotensin converting enzyme (ACE) D-allele but not the angiotensinogen (AGT) M235T polymorphism had a higher magnitude of QT dispersion (QTd) prolongation. The aim of this study was to test whether the AGT [−6G > A] and angiotensin II type 1 receptor (AT1R) [1166A > C] polymorphisms influence repolarization parameters, including QTd and the peak and end of the T wave interval (Tpe). Of 1,500 people screened, 106 normotensive, non-diabetic participants aged ≥60 were recruited. ECGs were recorded at baseline and in the second and fourth years. QTd and Tpe were manually calculated. Gene polymorphisms were analyzed by polymerase chain reaction. Mean age was 72.7 ± 4.1 years (range, 62.81 years). QTd and Tpe were significantly prolonged in the second and fourth years (all p < 0.001). Neither gene polymorphism was associated with the magnitudes of QTd and Tpe prolongations. This longitudinal study shows that the AT1R [1166A > C] and AGT [−6G > A] polymorphisms do not influence repolarization parameters in this Chinese population in Taiwan, and so are not suitable markers to identify individuals susceptible to changes in these parameters.

Anemia and decreased kidney function are recognized as risk factors for morbidity and mortality in the elderly. The role of hemoglobin in renal function changes among elderly patients is not fully understood.Of 1,500 people screened, 121 normotensive non-diabetic elderly patients were recruited, and underwent biochemistry examinations at the baseline, second and fourth years of a 4-year longitudinal study. Serum creatinine and calculated renal parameters, including the Cockroft-Gault (CG) formula, Modification of Diet in Renal Disease (MDRD) Study and abbreviated MDRD (abMDRD) equations were used to evaluate renal function and progression of kidney disease. Chronic kidney disease (CKD) was defined as a glomerular filtration rate (GFR) of60 ml/min/1.73 m(2). Multivariate regression analyses were used to explore predictors for decline in renal parameters.Ages ranged from 60 to 81 year (mean: 71.8+/-3.8). Baseline hemoglobin concentrations ranged from 11.9 to 17.3 g/dl (mean: 14.1+/-1.1). Serum creatinine increased and CG creatinine clearance (CrCl), MDRD and abMDRD GFR decreased during follow-up (all por =0.001). The prevalence of CKD significantly increased only in those with baseline hemoglobin concentrations of14 g/dl (por =0.03, based on findings of both MDRD and abMDRD GFR). Baseline hemoglobin correlates with 4-year changes of MDRD and abMDRD GFR in univariate (both p0.001) and multivariate regression analyses (both p0.05).This longitudinal study revealed that the aging process was associated with decline of renal function in the elderly. Because hemoglobin concentrations are an independent predictor for subsequent decline in kidney function, it should be considered in the assessment of renal disease and GFR in the elderly.

Objective In reperfusion strategy for ST-elevation myocardial infarction (STEMI), emergency surgical bypass grafting might be considered for patients with significant multivessel coronary diseases complicated by cardiogenic shock. The culprit lesions in STEMI can be predicted from electrocardiographic (ECG) findings. However, whether the complexity of coronary artery lesions in STEMI can be predicted from characteristic ECG findings remained unclear. Materials and Methods The initial 12-lead ECG parameters in each lead recording from patients with STEMI receiving primary percutaneous coronary intervention within 12 hours were retrospectively analyzed. A sequential ECG algorithm was developed to predict the complexity of coronary artery lesions. Results In patients with inferior wall STEMI, the presence of the following 2-step criteria indicated 3-vessel disease (3VD), with a sensitivity of 92.1% and a specificity of 81.8%: (1) ST depression or flat T wave in leads V5 or V6; and (2) ST elevation of more than 2 mm in at least 1 of II, III, aVF, or Q (loss of septal r) without ST elevation in aVR. In patients with anterior wall STEMI, the following criteria indicated 3VD: (1) ST elevation of more than 4 mm in at least 1 of the precordial leads and combined with QRS interval of more than 120 ms; then (2) a flat T wave over aVR, or aVL combined with flat T wave ST depression over lead I or Q wave over all leads II, III, and aVF. This algorithm detects patients with 3VD with a sensitivity of 76.5% and a specificity of 100%. However, when the whole algorithm is completed, the sensitivity can reach up to 88.4% and the specificity can still be 100%. Conclusion By using this ECG algorithm, 3VD might be distinguished early from single-vessel disease in patients with STEMI for appropriate reperfusion strategy.

Matrix metalloproteinases (MMP) and tissue inhibitor of metalloproteinases (TIMP) trigger the signal cascade instigating cardiac remodeling and fibrosis, which lead to changes of repolarization variables. We investigate the influence of MMP9-1562 C/T and TIMP2-418 G/C gene polymorphisms on repolarization parameters including QT dispersion (QTd) and the peak and the end of the T wave interval (Tpe) in a prospective cohort.Of 1500 people screened, 106 elderly Chinese without organic heart disease were recruited and received electrocardiography at the baseline, second and 4th year follow-ups. The QTc (corrected QT), QTd, QTc dispersion (QTcd) and Tpe were manually calculated.Age was 72.7+/-4.1 y (range 62-81 y). QTd, QTcd and Tpe were significantly prolonged (all p0.001 at the 2nd and 4th year). At the 4th year the magnitude of QTd prolongation but not Tpe was significantly higher in subjects carrying the TIMP2 C-allele than non C-allele carriers (p=0.033) as well as QTcd (p=0.010). This association was still significant in multivariate analyses (p=0.012 and p=0.003 for QTd and QTcd, respectively) but not in MMP9 genotype.The elderly Chinese with TIMP2 C-allele have higher magnitude of QTd and QTcd prolongation.

The aim of this study was to identify which phase of wall shear stress (SS) augmentation during reactive hyperemia (RH) is the crucial determinant of endothelial reactivity. Fifty-three patients with untreated essential hypertension were enrolled. A 7.5-MHz linear array transducer was used to record the 2D images and Doppler flow signals of brachial artery at baseline and during RH. Wall SS and flow-mediated vasodilation were calculated sequentially. The result of this study demonstrated that augmentation of wall SS at end-diastolic phase during peak RH is the main rheologic determinant of endothelial function in patients with untreated essential hypertension.

Background Although the superior vena cava (SVC) may be involved in the triggering or maintenance of atrial fibrillation (AF), the electrophysiological properties of SVC in human are ill-defined. Methods The baseline effective refractory periods (ERPs) of high right atrium (HRA), SVC and the conduction time (CT) between HRA and SVC were measured at pacing cycle lengths (PCL) of 600 and 400 ms respectively in 20 patients (12 females, age 46±13 years) with paroxysmal supraventricular tachycardia. Immediately after acute electrical remodeling (ER) induced by constant HRA or SVC pacing at PCL of 400 ms for 5 min, ERPs of HRA, SVC and the CT between HRA and SVC were determined. After verapamil was administered, the same protocols for determining ERPs of HRA, SVC and the CT between HRA and SVC were repeated. Results The baseline ERP of SVC was significantly longer than that of HRA. The CT from SVC to HRA was significantly longer than that from HRA to SVC. After acute ER, both the ERPs of HRA and SVC were significantly shortened. However, no significant changes of the CT between HRA and SVC could be demonstrated. After verapamil infusion, significant shortening of the ERP of HRA and SVC still occurred following acute ER and the ERP of SVC was still longer than that of HRA. Conclusions In human, ER can occur both in HRA and SVC after a short and moderately rapid heart rate pacing either from HRA or SVC. Verapamil cannot prevent such ER from occurring.

To test the applicability of isovolumic relaxation flow propagation velocity (IRFPV) as an indicator of relaxation, 38 patients undergoing cardiac catheterization for chest pain were included. The time constant of isovolumic left ventricular (LV) pressure decline (tau) had a significant correlation with the LV end-diastolic pressure, the peak negative dp/dt, the LV end-diastolic dimension, the fractional shortening, the late diastolic transmitral flow velocity, the early and late diastolic mitral annular velocities, the rapid filling flow propagation velocity, and the natural logarithms of heart rate, ejection fraction, LV end-systolic dimension and IRFPV (r = -0.773, p0.001). IRFPV was selected as the major independent determinant of tau, explaining 46% of its variance. In prediction of tauor =42 ms, the sensitivity and specificity were 100% and 83% for IRFPVor =104 cm/s, 77% and 67% for the rapid filling flow propagation velocityor =50 cm/s, and 58% and 67% for the early diastolic mitral annular velocityor =8 cm/s, respectively. In conclusion, our data suggest that IRFPV could be a better marker of LV relaxation than other parameters, as the rapid filling flow propagation velocity or the early diastolic mitral annular velocity.

Successful catheter ablation of idiopathic left ventricular tachycardia (ILVT) can be performed at the site of the earliest Purkinje potential or at the site with recording of diastolic and presystolic Purkinje potentials simultaneously during ventricular tachycardia (VT). However, these critical potentials might be difficult to be recorded and mapped in some patients during VT. It is rare to report the ablation of ILVT during sinus rhythm. We present a case with ILVT who received successful catheter ablation during sinus rhythm.

Patients with infective endocarditis usually developed persistent fever and heart failure, especially when the valve structures are invaded and destroyed. Persistent bacteremia often leads to severe sepsis or overwhelming septic shock. Septic emboli from the vegetation will possibly result in systemic thromboembolism with multiple organ infarction. Patients with infective endocarditis have been reported to present with either ruptured sinus of Valsalva or complete atrioventricular block. However, both of these serious complications occurring in a single patient is rare. In this case report, we present a 54-year-old man with a previous history of alcoholic cirrhosis and chronic renal failure who suffered from a fulminant course of infective endocarditis. Simultaneously, ruptured sinus of Valsalva and complete atrioventricular block further complicated the preexisting septic shock and multiple organ failure.

Acromegaly is a disorder caused by the excess production of pituitary growth hormone and is characterized by the enlargement of the hands, feet and head. Increased morbidity and mortality with acromegaly is associated with cardiovascular complications, hypertension, glucose intolerance, cardiomyopathy and coronary artery disease. We report a case of acromegaly, which presented with ST-segment elevation acute myocardial infarction. The patient received successful primary transluminal coronary angioplasty with stent implantation. Acromegaly was suspected from typical appearance, and confirmed with hormonal examination and imaging of the pituitary mass. We discuss this case in comparison with previous literature.

To predict pulmonary capillary wedge pressure (PCWP) noninvasively, several Doppler combination indices have been developed. Recently, a fair correlation has been found between the time constant of isovolumic left ventricular (LV) relaxation (tau) and pulsed wave Doppler LV inflow propagation velocity (LVIPVpw) derived through the application of range ambiguity phenomenon. In the measurement of LVIPVpw, we can simultaneously measure the peak phantom E-wave velocity (Ep) from the same heartbeat. Hence, it is hypothesized that Ep/LVIPVpw is a useful index in predicting PCWP. In all, 29 patients who underwent elective cardiac catheterization for suggested coronary artery disease were included. Mean PCWP (mPCWP) obtained from right heart catheterization was compared with echocardiographic data before and 5 minutes after sublingual application of nitroglycerin (0.6 mg). Nitroglycerin caused a significant decrease in Ep and mPCWP, but not in LVIPVpw (P.001, P.001, and P = .687, respectively). By stepwise multiple linear regression analysis, only the Ep/LVIPVpw (beta = 0.832, P.001) was the independent predictor of mPCWP. After nitroglycerin intake, the change in mPCWP was significantly correlated with the change in Ep/LVIPVpw (r = 0.455, P = .015). The sensitivity and specificity of Ep/LVIPVpw0.74 in predicting mPCWP15 mm Hg were 78% and 90%, respectively (area under curve 0.86). In conclusion, Ep/LVIPVpw derived from the same heartbeat provides a good estimate of mPCWP and can be used to rapidly track the change in mPCWP.

To test whether left ventricular inflow propagation velocity at the pulsed wave Doppler analysis (IPVpw) is a useful noninvasive index of relaxation, 21 patients under coronary angiography for chest pain were included for simultaneous catheter-based and Doppler studies. IPVpw was derived through the application of range ambiguity, and the time constant of isovolumic left ventricular pressure decline (tau) was acquired by a previously described method. At baseline status, IPVpw correlated significantly with the peak negative dP/dt and tau ( r = -0.609, P = .003), but not with the peak velocity of transmitral early flow (E) wave. Sublingual application of nitroglycerin increased heart rate, decreased the transmitral E velocity and transmitral E-to-A velocity ratio, and prolonged the deceleration time of the transmitral E wave. However, there was no significant impact on IPVpw, peak negative dP/dt, or tau. IPVpw correlated with tau ( r = -0.533, P.001) at the combined analysis of the data before and after nitroglycerin application. In conclusion, IPVpw is a preload-independent, noninvasive index of left ventricular relaxation.

In addition to lowering lipid profile, statins have pleiotropic effects on improving vascular function. Changes of these pleiotropic effects and their relationship to lipid profile after withdrawal of statin treatment remained unclear.We investigated the changes of lipid profile and plasma concentrations of human soluble vascular cell adhesion molecule-1 (sVCAM-1) and human tissue type plasminogen activator (tPA) after withdrawal of statin treatment. Twenty-two patients (14 F, 8 M, aged 63+/-13 years) with hypercholesterolemia were treated with atorvastatin (ATOR; 10 mg/day) for 12 weeks. Blood samplings for serum lipid and markers were collected before, after and withdrawal of statin treatment.The total cholesterol, LDL-cholesterol and sVCAM-1 (from 394.4+/-251.7 to 321.0+/-198.9 ng/ml, p0.05) all decreased significantly and the tPA (from 9.47+/-3.57 to 11.62+/-3.99 ng/ml, p0.05) increased significantly after atorvastatin treatment. During the following 3 days after withdrawal of atorvastatin, the total cholesterol and LDL-cholesterol did not show any significant change. However, the plasma sVCAM-1 significantly elevated on day 2 (from 321.0+/-198.9 to 371.2+/-220.4 ng/ml, p0.05) and the plasma tPA significantly decreased on day 1 (from 11.62+/-3.99 to 10.52+/-3.55 ng/ml, p0.05) and day 3 (from 11.62+/-3.99 to 10.27+/-3.69 ng/ml, p0.05). Both the significant elevation of sVCAM-1 and decrease of tPA after withdrawal of atorvastatin treatment occurred within 3 days, while the serum cholesterol and LDL-chol levels did not have any significant change and were still within the therapeutic range.After 12 weeks of atorvastatin treatment, the beneficial pleiotropic effects can be demonstrated simultaneously with lowering the lipid profile. However, after withdrawal of atorvastatin, the beneficial pleiotropic effects are abrogated rapidly within days and are independent on elevation of serum cholesterol.

Acute respiratory distress syndrome (ARDS) is characterized by acute-onset dyspnea, diffuse bilateral pulmonary infiltration, low pulmonary capillary wedge pressure (PCWP), and an arterial oxygen tension/inspired oxygen fraction (PaO2/FiO2) ratio of less than 200 mmHg. Acute myocardial infarction (AMI), whether complicated by circulatory arrest, cardiogenic shock, and hypotension or not, was reported as an etiologic factor in the development of ARDS in the prethrombolytic era. In the thrombolytic era, two cases of AMI complicated with ARDS have been reported. ARDS in these two patients resulted from anaphylactic reaction to the thrombolytic agent and not from the hemodynamic consequences of AMI. Development of ARDS during the AMI period has not been reported after early successful primary percutaneous coronary intervention (PCI). Herein, we report a 61-year-old male patient with persistent chest pain who was diagnosed with Killip II anterior ST-segment elevation AMI. He was treated successfully with primary PCI 2.5 hours after the onset of chest pain. Unfortunately, on the third hospital day, acute-onset dyspnea (respiratory rate, 33 beats/min), fever (38.5 degrees C), leukocytosis (white blood cell count, 18,360/microL), and diffuse bilateral pulmonary infiltration were noted. ARDS was diagnosed from the low PCWP (8 mmHg) and a PaO2/FiO2 of less than 200 mmHg (160 mmHg). No usual causes of ARDS such as infection, aspiration, trauma, shock, or drug reactions were noted. We assumed that, in this particular patient, the systemic inflammatory response syndrome frequently induced by AMI might have caused this episode of ARDS. This may imply that AMI itself is a possible etiology of ARDS.

Electrocardiographic changes in neurovascular disease are not rare. Patients with subarachnoid hemorrhage have electrocardiographic (ECG) abnormalities that may mimic ischemic heart disease and acute myocardial infarction. Outflow of catecholamines in the early stage of subarachnoid hemorrhage contributes to elevated blood pressure in most patients. Hypotension is a rare presentation in subarachnoid hemorrhage. We report a case of subarachnoid hemorrhage with transient ST elevation and intractable shock simulating acute myocardial infarction, and review the mechanism of ECG changes in subarachnoid hemorrhage.

To evaluate if pericardium is a suitable calibration reference in the integrated backscatter (IBS) analysis, the grossly normal pericardial specimens from 23 patients without a history of pericarditis were mounted on a steel platform and immersed in a 0.9% saline bath. The 2-D IBS images acquired at the uniform time gain compensation settings of 50 and 70 dB were analyzed. For the pericardial IBS, the limits of agreement for intraobserver and interobserver measurements were −1.2 to 1.4 dB and −1.6 to 2.2 dB, respectively. However, the calibrated IBS intensity of the pericardium presented a rather wide range of variation and was −13 ± 5 (−5 to −29) and −10 ± 4 (−4 to −22) dB at the overall gain settings of 50 and 70 dB, respectively. Conclusively, pericardium may not be an ideal IBS calibration reference in a population study of cardiac tissue characterization. (E-mail: wcvoon@giga.net.tw )

The transit time of mitral late flow (A wave) to the outflow tract (A-Ar interval) has been demonstrated to be shorter in the presence of increased ventricular stiffness. However, the A-Ar interval is just a measure of time duration and the data of intraventricular A-wave propagation velocity are still unavailable. In this study we presented the aging trend in various intracardiac Doppler signals, including the mitral A-wave propagation velocity toward the apex (APV apex ). It was measured as the slope of the first aliasing velocity line segment of the mitral A wavefront at color M-mode Doppler analysis. Age correlated significantly with peak velocity of mitral early flow (E wave), peak A velocity, velocity ratio of E to A wave, deceleration time of E wave, and mitral E-wave propagation velocity toward the apex, but not with the A-Ar interval ( r = −0.262, P = .066) or the APV apex ( r = −0.047, P = .748). Neither the A-Ar interval nor the APV apex was different between the young and the elderly groups. Furthermore, there was no significant correlation between the APV apex and the A-Ar interval ( r = −0.135, P = .348). In conclusion, aging has a major adverse impact on myocardial relaxation associated with a minor one on the noninvasive indices of ventricular compliance. The APV apex is age-independent and, moreover, there is no significant correlation between the APV apex and the A-Ar interval.

Heart rate turbulence (HRT) has been described as a predictor of high-risk patients with cardiac diseases. The purpose of this study is to determine how the degree of prematurity of a ventricular premature beat (VPB%) and retrograde ventriculoatrial (VA) conduction of VPBs affect HRT. We studied 30 patients without organic heart disease. We calculated turbulent slope (TS) and turbulent onset (TO) from VPBs induced by programmed stimulation from the right ventricular apex. TS was inversely and TO was positively correlated to VPB%. Without retrograde VA conduction of VPBs, TS was inversely and TO was positively correlated to VPB%. In VPBs with retrograde VA conduction, there were no significant correlations between TO and TS with VPB%. In conclusion, TS and TO calculated from VPBs with different degrees of prematurity varied widely. Both VPB% and characteristics of retrograde VA conduction may affect HRT.

KMCP-98 is a newly synthesized adenosine receptor agonist by alkylation at the 7-position of the xanthines nucleus. We first investigated the pharmacological activities of KMCP-98 under in vivo and in vitro conditions. Acute intravenous injection of KMCP-98 (1.0, 2.0 and 3.0 mg/kg) produced a temporary fall in blood pressure and heart rate, followed by a sustained fall in heart rate in pentobarbital-anesthetized Wistar rats. The hypotensive and bradycardiac responses were inhibited by pretreatment with an A(1) adenosine receptor antagonist 8-phenyltheophylline (8-PT, 0.5 mg/kg). Both KMCP-98 and adenosine (0.3-100 microM) produced negative inotropic activity in isolated guinea pig left atria. The negative inotropic activity of KMCP-98 was significantly blocked by pretreatment with A(1) receptor antagonists 8-PT (10 microM) and xanthine amine congener (XAC, 10 microM), a nonselective adenosine antagonist theophylline (10 microM), a K(+) channel blocker tetraethylammonium (TEA, 10 mM) and a K(ATP) channel blocker glibenclamide (1 microM). KMCP-98 (0.03-30 microM) produced concentration-dependent relaxations in carbachol (1 microM) precontracted guinea pig tracheal smooth muscle. The trachea relaxant response of KMCP-98 was markedly inhibited by A(2), A(2a) and A(2b) adenosine receptor antagonists 3,7-dimethyl-1-propargylxanthine (DMPX, 10 microM), 8-(3-chlorostyryl)caffeine (CSC, 10 microM) and alloxazine (10 microM), respectively, the nitric oxide synthase (NOS) inhibitor L-NAME (100 microM) and also by TEA and glibenclamide. In addition, KMCP-98 (0.03-30 microM) elicited relaxant response in norepinephrine (3 microM) precontracted rat thoracic aorta in a concentration-dependent manner. The thoracic aorta relaxant response of KMCP-98 was also significantly inhibited by DMPX, CSC, alloxazine, L-NAME, TEA and glibenclamide. Furthermore, the binding characteristics of KMCP-98, adenosine and 5'-N-ethylcarboxaminoadenosine (NECA) were evaluated in [(3)H]DPCPX and [(3)H]CGS 21680 binding to rat cortex and striatum, respectively. The K(i) values of KMCP-98 for predominate A(1) and A(2) adenosine receptor sites were 3908+/-952 and 158+/-10 nM, respectively. In conclusion, KMCP-98 was found to be a xanthine-based adenosine receptor agonist associated cardiac depression, tracheal and aortic smooth muscle relaxations.

Mitochondrial diseases such as mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS), myoclonus epilepsy with ragged-red fibers (MERRF), and Kearns–Sayre syndrome are manifested due to reduced production of Adenosine triphosphate (ATP) in mitochondria. The disorders in mitochondria comprise a heterogeneous group of diseases with multi-system involvement. Although mitochondrial cardiomyopathy is a common manifestation of mitochondrial respiratory chain disorders, cardiac involvement rarely causes the initial symptoms or the major clinical manifestation in previous literature reports, especially less mentioned in adult cases. Here we reported a 36-year-old male of hypertrophic cardiomyopathy which was diagnosed in his thirties, and he was treated as having heart failure for about years. He presented with progressive symptoms and signs of heart failure and bilateral lower leg weakness for weeks before admission, and later complicated with respiratory failure during hospitalization. The final diagnosis was mitochondrial disease with A-to-G 3243 tRNA Leu(UUR) point mutation by gene analysis and ragged-red fibers in muscle biopsy.

Transient and massive glomerular proteinuria, previously reported as one of the nephrotoxic reactions after ionic radiocontrast medium (RCM) exposure, is rarely observed in patients since the introduction of non-ionic RCM. However, whether the very low-range microalbuminuria might be encountered after non-ionic RCM exposure remains unknown. In this study we sought to investigate the effects of non-ionic RCM (Ultravist 370) exposure on the presence of microalbuminuria, defined as urine albumin-to-creatinine ratio (UACR) >30 mg/g, by a turbidmetric method in total of 64 patients (17 female, mean age 58+/-12 years) undergoing coronary angiography. The results showed that after non-ionic RCM (mean volume 103+/-57 ml) exposure, no significant differences were found in urinary albumin concentration or UACR; however, urinary creatinine was significantly reduced from 116+/-62 to 69+/-43 mg/dl (p