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The aim of the study was to evaluate the relation between tricuspid regurgitation (TR) severity and liver stiffness (LS) in patients with TR. A total of 131 patients with various degrees of TR secondary to left-sided heart valve disease were enrolled. Severity of TR was quantitatively assessed by proximal isovelocity surface area-derived effective regurgitant orifice (ERO). Patients were divided into 2 groups: 48 with mild-moderate TR (ERO <0.4 cm(2)) and 83 with severe TR (ERO ≥0.4 cm(2)). Transient elastography was used to measure the level of LS, an established marker of liver fibrosis, with the threshold of significant LS set at ≥12.5 kPa. Patients with severe TR had a higher LS and prevalence of significant LS than those with mild-moderate TR. Furthermore, LS and significant LS independently correlated with TR-ERO, right atrial pressure and inferior vena cava (IVC) diameter. The presence of a large TR-ERO (≥0.4 cm(2)) and IVC diameter (>2.15 cm(2)) provided a high specificity of 78% for significant LS. In conclusion, the present study demonstrates that TR-ERO, right atrial pressure, and IVC diameter are important parameters associated with LS in patients with TR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The burden of atrial fibrillation (AF) and the lack of data on AF and its management in the Asia Pacific highlight the need for a comprehensive prospective study of AF management in this region. To address this need, the REgistry on Cardiac rhythm disORDers (RecordAF-Asia Pacific [AP]) has been initiated to assess the management of AF in 8 countries across the Asia Pacific. RecordAF-AP is a prospective, observational survey of the management of recently diagnosed AF with 1 year of follow-up. Eligible patients with AF, treated or not, were included in the registry; with data recorded prospectively during the follow-up visits at 6 and 12 months. A total of 2,721 patients with AF were recruited, of whom 2,629 were eligible for evaluation (intent-to-treat population). At study inclusion, rhythm- and rate-control strategies were applied to 37% (n = 959) and 62% (n = 1,610) of the patients, respectively. At baseline, the rhythm-control patients were mainly prescribed class III agents (49%), class Ic agents (39%), or β blockers (except for sotalol; 35%). The rate-control patients were mainly prescribed β blockers (except for sotalol; 57%) or cardiac glycosides (32%). Patients receiving rate-control strategies were more likely to have a history of heart failure or valvular heart disease and persistent AF. In contrast, those receiving rhythm-control strategies were more likely to have recently diagnosed or paroxysmal AF. In conclusion, RecordAF-AP will provide much needed insight into the real-life management of patients with AF in the Asia Pacific region., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Smoking is associated with depletion of endothelial progenitor cells (EPCs) and may subsequently contribute to the development of vascular dysfunction. The aim of this study was to investigate the relation between circulating EPCs and pulmonary artery systolic pressure (PASP) as determined by flow cytometry and echocardiography in 174 patients (mean age 69 ± 9 years, 95 smokers) with established coronary artery disease. Smokers had significantly lower circulating log CD34/KDR(+) (0.86 ± 0.03 vs 0.96 ± 0.03 × 10⁻³/ml, p = 0.032) and log CD133/KDR(+) (0.68 ± 0.03 vs 0.82 ± 0.03 × 10⁻³/ml, p = 0.002) EPCs and a higher prevalence of elevated PASP >30 mm Hg (52% vs 30%, p = 0.001) than nonsmokers. Smokers with elevated PASP also had significantly lower circulating log CD34/KDR(+) (0.74 ± 0.04 vs 0.88 ± 0.06 × 10⁻³/ml, p <0.001) and log CD133/KDR(+) (0.61 ± 0.04 vs 0.78 ± 0.05 × 10⁻³/ml, p <0.001) EPCs, higher pulmonary vascular resistance, and larger right ventricular dimensions with impaired function (all p values <0.05). Log CD34/KDR(+) and log CD133/KDR(+) EPC counts were significantly and negatively correlated with PASP (r = -0.30, p <0.001, and r = -0.34, p <0.001, respectively) and pulmonary vascular resistance (r = -0.29, p = 0.002, and r = -0.18, p = 0.013, respectively). In conclusion, this study demonstrated that in patients with coronary artery disease, smoking was associated with a reduced number of EPCs and elevated PASP. This suggests that in smokers, depletion of circulating EPCs might be linked to the occurrence of pulmonary vascular dysfunction., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Hyperthyroidism-induced atrial fibrillation (AF) often spontaneously reverts to sinus rhythm after the return of euthyroid state, but a significant number of patients remain in persistent AF, which requires electrical cardioversion. The long-term outcome of hyperthyroidism-induced persistent AF after successful cardioversion remains unclear. The study group consisted of 58 patients with hyperthyroidism-induced persistent AF (mean age 57 +/- 2 years, 72% men) who had undergone successful electrical cardioversion. The AF recurrence rate was prospectively studied and compared with age- and gender-matched controls with persistent AF of nonthyroid origins. After a 24-month follow-up period, 34 patients (59%) had developed AF recurrence, significantly fewer than among controls (83%) (hazard ratio 0.64, 95% confidence interval 0.39 to 0.97, p = 0.04). Cox regression analysis showed that long AF duration was the only predictor of AF recurrence in patients with hyperthyroidism-induced persistent AF. In conclusion, hyperthyroidism-induced persistent AF carries a lower recurrence rate after conversion to sinus rhythm than non-hyperthyroidism-induced persistent AF, and early electrical cardioversion should be considered.

Purpose: We sought to determine the clinical significance of aspirin resistance measured by a point-of-care assay in stable patients with coronary artery disease (CAD)., Methods: We used the VerifyNow Aspirin (Accumetrics Inc, San Diego, Calif) to determine aspirin responsiveness of 468 stable CAD patients on aspirin 80 to 325 mg daily for > or =4 weeks. Aspirin resistance was defined as an Aspirin Reaction Unit > or =550. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), unstable angina requiring hospitalization, stroke, and transient ischemic attack., Results: Aspirin resistance was noted in 128 (27.4%) patients. After a mean follow-up of 379+/-200 days, patients with aspirin resistance were at increased risk of the composite outcome compared to patients who were aspirin-sensitive (15.6% vs 5.3%, hazard ratio [HR] 3.12, 95% confidence intervals [CI], 1.65-5.91, P < .001). Cox proportional hazard regression modeling identified aspirin resistance, diabetes, prior MI, and a low hemoglobin to be independently associated with major adverse long-term outcomes (HR for aspirin resistance 2.46, 95% CI, 1.27-4.76, P = .007)., Conclusions: Aspirin resistance, defined by an aggregation-based rapid platelet function assay, is associated with an increased risk of adverse clinical outcomes in stable patients with CAD.

The long-term safety and efficacy of autologous bone marrow cell implantation into the myocardium remains undefined. We studied the long-term clinical outcome of 12 patients with severe coronary artery disease who underwent electromechanical mapping-guided catheter-based autologous bone marrow cell implantation. Magnetic resonance imaging at 3 and 6 months showed no evidence of intramyocardial tumor formation, myocardial damage, or worsening of left ventricular ejection fraction. No sustained arrhythmia was detected on 24-hour Holter monitoring. After 44 +/- 10 months of follow-up, 1 patient had died of stroke at 8 months and another patient had died of myocardial infarction at 20 months. Computed tomography at 36 months or postmortem examination showed no tumor formation or intramyocardial calcification at the treated sites, and no sustained ventricular arrhythmia or sudden death was observed. Autologous bone marrow cell implantation into the ischemic human myocardium was not associated with long-term major adverse events regarding tumor, scar, or calcification formation, and the arrhythmogenic risk was low.

Patients on warfarin for mechanical heart valves are at increased risk for thromboembolic events and intracranial hemmorhage. In current guidelines, a low dose of vitamin K is the recommended treatment for moderate over-anticoagulation based on studies in which only minority patients participating had mechanical heart valves. We performed a randomized controlled trial to compare the efficacy and safety profile of low-dose intravenous vitamin K and fresh frozen plasma (FFP) for patients with mechanical heart valves and mild to moderate over-anticoagulation (international normalized ratio [INR] 4 to 7). In a 24-month period, we randomized 102 patients to (1) vitamin K or (2) FFP. The baseline INR at presentation between the vitamin K group and the FFP group was 4.61 +/- 0.007 vs 4.78 +/- 0.07 (p = 0.11). Six hours after treatment, patients in the FFP group had a significantly lower mean INR compared with the vitamin K group (2.75 +/- 0.06 vs 3.44 +/- 0.10, p = 0.01). No patient in both groups had over-correction (INR < 2). One week later, there was no significant difference in mean INR between both groups (2.7 +/- 0.11 vs 2.56 +/- 0.12, p = 0.41). Fifty-eight percent of patients in the FFP group and 51% in the vitamin K group had an INR within the target range. There were no adverse reactions or outcomes in both groups. In conclusion, intravenous low-dose vitamin K is a safe alternative to FFP infusion for warfarin overdose in patients with mechanical heart valves.

Previous studies have shown that more complete platelet inhibition improves the coronary flow reserve (CFR), a measure of microvascular integrity, in patients undergoing percutaneous coronary intervention (PCI). We hypothesized that patients with aspirin resistance would have impaired CFR after elective PCI. We used VerifyNow Aspirin to determine the response to aspirin in 117 consecutive patients who underwent elective single-lesion PCI. The assay results are expressed quantitatively in Aspirin Reaction Units based on the degree of platelet aggregation. All patients received a 300-mg loading dose of clopidogrel >12 hours before and a 75-mg maintenance dose the morning of PCI. CFR was estimated using the Thrombolysis In Myocardial Infarction frame count method. Of the 117 patients, 22 (18.8%) were aspirin resistant. The clinical, angiographic, and procedural characteristics of the aspirin-sensitive and -resistant patients were balanced. All patients underwent successful PCI with <50% residual diameter stenosis and Thrombolysis In Myocardial Infarction grade 3 flow after PCI. Aspirin-resistant patients had a lower CFR than the aspirin-sensitive patients (1.42 +/- 0.35 vs 1.80 +/- 0.64, p = 0.018). Univariate correlates of CFR included the Aspirin Reaction Unit (r = -0.227, p = 0.014) and post-PCI creatine kinase-MB elevation (p = 0.048). Multivariate linear regression analysis revealed the Aspirin Reaction Unit to be the only independent determinant of CFR after PCI (r2 = 0.051, p = 0.014). Thus, aspirin resistance was associated with impaired CFR in patients who underwent elective PCI, implicating insufficient aspirin-induced platelet inhibition as a cause of microvascular dysfunction by distal atherothrombotic embolization and/or spasm.

Purpose: We sought to investigate the association of aspirin dose and aspirin resistance in stable coronary artery disease patients measured by a point-of-care assay., Methods: We studied 468 consecutive stable coronary artery disease patients in a referral cardiac center who were taking aspirin 80 to 325 mg daily for > or =4 weeks. The VerifyNow Aspirin (Ultegra RPFA-ASA, Accumetrics Inc, San Diego, Calif) was used to determine aspirin responsiveness. An aspirin reaction unit (ARU) > or =550 indicates the absence of aspirin-induced platelet dysfunction, based on correlation with epinephrine-induced light transmission aggregometry. Demographic and clinical data were collected to analyze the predictors of aspirin resistance., Results: Aspirin resistance was noted in 128 (27.4%) patients. Univariate predictors of aspirin resistance include elderly (P = 0.002), women (P <0.001), anemia (P <0.001), renal insufficiency (P = 0.009) and aspirin dose < or =100 mg (P = 0.004). Multivariate analysis revealed hemoglobin (odds ratio [OR] 0.6; 95% confidence interval [CI] 0.51 to 0.69; P <0.001) and aspirin dose < or =100 mg (OR 2.23; 95% CI 1.12 to 4.44; P = 0.022) to be independent predictors of aspirin resistance. Daily aspirin dose < or = 100 mg was associated with increased prevalence of aspirin resistance compared with 150 mg and 300 mg daily (30.2% vs 16.7% vs 0%, P = 0.0062)., Conclusion: A 100 mg or less daily dose of aspirin, which may have lower side effects, is associated with a higher incidence of aspirin resistance in patients with coronary artery disease. Prospective randomized studies are warranted to elucidate the optimal aspirin dosage for preventing ischemic complications of atherothrombotic disease.

The aim of this study was to investigate the effect of the Ventricular Response Pacing (VRP) algorithm, which regularizes ventricular rate during atrial fibrillation (AF), on symptoms, quality of life, and functional capacity. VRP regularizes the ventricular rate during AF without increasing the mean ventricular rate, thereby reducing the severity of AF-related symptoms in patients with persistent AF. However, VRP did not improve general quality of life (Medical Outcomes Study 36-item Short-Form General Health Survey), the performance of routine activities (Duke Activity Status Index), or functional capacity (hall walk) in patients with AF.

Background: Data on the phenotypical pattern and natural history of hypertrophic cardiomyopathy in Chinese patients are very limited. The purpose of this study was to describe the clinical characteristics of and long-term outcome in Chinese patients with hypertrophic cardiomyopathy., Methods: We evaluated 118 Chinese patients (62 male) who were diagnosed with hypertrophic cardiomyopathy at Queen Mary Hospital from 1973 to 2002. Diagnosis was based on the demonstration of left ventricular hypertrophy (wall thickness > or =15 mm during diastole), either in a specific region or with diffuse distribution, using echocardiography or magnetic resonance imaging. Clinical predictors of major cardiovascular events related to hypertrophic cardiomyopathy (cardiovascular death, potentially fatal cardiac arrhythmia, and refractory heart failure requiring cardiac transplantation or percutaneous alcohol septal ablation) were evaluated with univariate and multivariate Cox proportional hazards regression models., Results: The mean (+/- SD) age at presentation was 54 +/- 18 years. During a mean follow-up of 5.8 +/- 4.3 years (range, 1 to 29 years) from presentation, major cardiovascular events related to hypertrophic cardiomyopathy occurred in 19 patients (16%), including 9 deaths. Annual cardiovascular mortality was 1.6%. Fifty-five patients (47%) had one or more cardiovascular complications related to hypertrophic cardiomyopathy, of which atrial fibrillation was the most common (35%, n = 41). The most common type of hypertrophic cardiomyopathy was the apical variant (41%, n = 49). In multivariate analysis, female sex was the only independent predictor of major cardiovascular events related to hypertrophic cardiomyopathy (hazard ratio = 5.86; 95% confidence interval: 1.77 to 7.21; P = 0.007)., Conclusion: Hypertrophic cardiomyopathy in Chinese patients is characterized by late onset of presentation, a high incidence of the apical form of the condition, and adverse clinical outcome in female patients, which suggest a different phenotypical pattern than in white patients.

The aim of this study was to investigate the effect of statin therapy on arrhythmia recurrence in patients with lone atrial fibrillation (AF). From July 1998 to December 1999, 62 patients with lone persistent AF lasting >/=3 months underwent successful external cardioversion. After a mean follow-up of 44 months, 85% had recurrence of AF. The use of statins was associated with a significant decrease in the risk of arrhythmia recurrence after successful cardioversion of AF. The result of this retrospective study demonstrates that the use of statins in patients with lone AF was associated with a significant decrease in the risk of arrhythmia recurrence after successful cardioversion.

Angiotensin-converting enzyme (ACE) inhibitors reduce mortality in patients with acute myocardial infarction (AMI), but these benefits might be limited by acute hemodynamic changes and difficulties in titrating to recommended doses. The objective of this study was to compare the hemodynamic changes and tolerability of perindopril with captopril after AMI. We randomized 212 patients to receive either captopril (n = 102) or perindopril (n = 110) within 72 hours of AMI. Captopril was given as an initial dose of 6.25 mg, and then 50 mg/day on day 1 and 100 mg/day thereafter. The corresponding doses of perindopril were 2, 4, and 8 mg/day. Acute hemodynamic changes, the percentage of patients who reached target doses, and in-hospital and 6-month cardiovascular events were monitored. Baseline clinical characteristics of the 2 groups were identical, but patients randomized to perindopril were in a higher Killip class (1.4 +/- 0.6 vs 1.2 +/- 0.5, p = 0.05). During the first 6 hours, treatment with perindopril resulted in higher minimal systolic (97 +/- 15 vs 91 +/- 14 mm Hg, p <0.01) and diastolic blood pressure (BP) (57 +/- 11 vs 54 +/- 10 mm Hg, p <0.02), later occurrence of minimal BP (3.6 +/- 0.2 vs 2.7 +/- 0.1 hour, p <0.001), and a lower incidence of persistent hypotension with systolic BP < 90 mm Hg for > or =1 hour (5% vs 16%; p < 0.01) compared with captopril. At initial administration, target doses of perindopril and captopril were attained in 97% and 82% of the patients, respectively (p < 0.01). After 6 months, there were no differences between patients treated with perindopril and captopril in mortality rates (6% vs 13%, p = 0.16) and need for revascularization (20% vs 21%, p = 0.9). Thus, in patients during AMI, perindopril treatment showed better short-term tolerance than treatment with captopril, with significantly less acute hemodynamic changes and fewer withdrawals.

Atrial pacing has been shown to delay the onset of atrial fibrillation (AF) when compared with ventricular pacing in patients with sick sinus syndrome. The role for pacing in the control of AF in patients without bradycardia is uncertain. We performed a randomized, crossover, single-blinded study in 22 patients (14 women, aged 63 +/- 10 years) with paroxysmal AF refractory to treatment with oral sotalol (202 +/- 68 mg/day) and no bradycardic indication for pacing. All patients received a dual-chamber pacemaker with 2 atrial pacing leads positioned at the high right atrium and coronary sinus ostium, respectively. Patients were randomized in a crossover fashion to be paced for 12 weeks, either with high right atrial (RA) pacing at 30 beats/min ("Off") or dual-site RA pacing with an overdrive algorithm that maintained atrial pacing at a rate slightly above the sinus rate ("On"). Treatment on resulted in a significantly higher percentage of atrial pacing and a reduction in atrial ectopic frequency than the treatment off period. The time to the first clinical AF recurrence was prolonged (15 +/- 17 to 50 +/- 35 days, p = 0.006), and total AF burden was reduced (45 +/- 34% vs 22 +/- 29%, p = 0.04) in the on-treatment phase. However, there was no difference in AF checklist symptom scores or overall quality-of-life measures. Dual-site RA pacing with continued sinus overdrive prolonged the time to AF recurrence and decreased AF burden in patients with paroxysmal AF. The absence of a major impact on symptom control suggests that pacing should be used as an adjunctive therapy with other treatment modalities for AF.

The frequent recurrence of paroxysmal atrial fibrillation (PAF) despite the use of standard antiarrhythmic agents prompted the use of new therapeutic approaches. There are few data on systematic assessment of PAF control with stepwise dose escalation and the use of a drug combination. Low-dose quinidine may promote the efficacy of propafenone by inhibiting its degradation through the cytochrome P450 pathway (CYP2D6). We prescribed propafenone 300 to 450 mg/day to 60 patients with PAF for 8 weeks, and 62% were symptomatically controlled. The 19 refractory patients were randomized in a double-blinded fashion to receive either a higher dose of propafenone (450 to 675 mg/day) or the standard dose of propafenone with low-dose quinidine 150 mg/day, each for an 8-week study period, and subsequently crossed over to the alternative treatment. The resulting serum propafenone concentrations were 259 +/- 208 and 336 +/- 237 mg/day (p >0.5), respectively. Both treatment arms prolonged the time to the first symptomatic atrial fibrillation (AF) recurrence and the interval between attacks, and AF was controlled in 37% of patients. However, the higher dose of propafenone was associated with gastrointestinal side effects not present with the low-dose quinidine combination. Of the 10 refractory patients, 7 were further controlled with a standard dose of propafenone plus quinidine (600 mg/day). Overall, control of PAF was achieved in 85% of patients at the end of 8 months; adverse effects necessitating withdrawal were observed in 6%, and uncontrolled AF in 5% of patients. There was no difference in the mean AF rate during recurrences in all phases, and ventricular proarrhythmia was not seen. This study documents the role of stepwise antiarrhythmic treatment of PAF. The use of a standard dose of propafenone, followed by low-dose quinidine combination to reduce propafenone degradation, and the combined standard dose of propafenone and quinidine may be used to maximize efficacy and tolerability.

The effect of the timing of cardioversion of atrial fibrillation on left atrial mechanical function was studied in 11 patients treated with the implantable atrial defibrillator. Results of this study suggested that prompt cardioversion of spontaneous episodes of atrial fibrillation within 48 hours after onset was associated with early resolution of left atrial mechanical dysfunction seen after cardioversion.

Among various electrocardiographic variables, the QRS duration in V2 was found to be the best discriminator of outcome in patients undergoing radiofrequency catheter ablation of the right ventricular outflow tract tachycardia and/or bigeminy. If the QRS duration is <160 ms in lead V2, the probability of successful ablation is lower than if the QRS duration is longer.

In patients with structural heart disease and left ventricular ejection fraction <40%, internal cardioversion is a safe and effective method for converting persistent atrial fibrillation. The acute success rate and atrial defibrillation requirement for cardioversion in these patients is comparable to patients with lone atrial fibrillation and structurally normal hearts.

The implantable atrial defibrillator is a new potential nonpharmacologic treatment for recurrent atrial fibrillation. The results of this study suggest that a simplified lead configuration, with a single-pass, dual-electrode atrial defibrillation lead can be used for both atrial fibrillation detection and defibrillation with an implantable atrial defibrillator.

Two hundred patients with atrial fibrillation underwent transthoracic cardioversion using adhesive electrodes positioned at the apex and right infraclavicular area, and the apex electrode was randomly selected to serve as the cathode or anode. The mean defibrillation energy requirement with the cathodal configuration was significantly lower than with the anodal configuration.

Internal cardioversion is safe and effective in restoring sinus rhythm, even in patients with persistent AF of prolonged duration. Up to 40% to 50% of patients with AF lasting >1 year but <3 years could be maintained in sinus rhythm using a class III antiarrhythmic drug after successful internal cardioversion, and amiodarone appears to be more effective than sotalol in this patient population.

Long-term atrial pacing with overlapping biphasic impulse stimulation using floating atrial electrodes is limited in its use by the high rate of intermittent failure to capture the atrium and by the occurrence of diaphragmatic stimulation in ambulatory patients.