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Objective PsA patients who achieved sustained minimal disease activity (sMDA) had less subclinical atherosclerosis progression. The vascular effects of achieving other potential treatment targets, including the PsA Disease Activity Score (PASDAS) and the Disease Activity in PsA (DAPSA) score, remained uncertain. This study aimed to compare the vascular effects of achieving different treatment targets in PsA patients. Method This is a post hoc analysis of a 2 year treat-to-target study aimed at MDA. A total of 101 consecutive PsA patients without overt cardiovascular disease were recruited. High-resolution carotid ultrasound and arterial stiffness markers were assessed annually. Low disease activity (LDA) was defined as MDA, DAPSA ≤14 or PASDAS ≤3.2. Sustained disease control was defined as achieving these targets at each visit from month 12 until month 24. Results Ninety patients [52 male (57.8%), age 50 years (s.d. 11)] who completed 24 months of follow-up were included in this analysis. A total of 44%, 48% and 45% of patients achieved sustained DAPSA LDA (sDAPDA-LDA), sustained PASDAS LDA (sPASDAS-LDA) and sMDA, respectively. Patients who achieved sMDA had significantly less progression of carotid intima-media thickness than those who did not (P = 0.031). Using multivariate analysis, achieving sMDA and sPASDAS-LDA had a protective effect on plaque progression, less increase in total plaque area, reduced mean intima-media thickness and reduced augmentation index after adjusting for covariates. In contrast, no significant differences in the progression of vascular parameters were demonstrated between patients who did or did not achieve sDAPSA-LDA. Conclusion Achieving sMDA/sDASPAS-LDA, but not sDAPSA-LDA, was associated with a protective effect in subclinical atherosclerosis and arterial stiffness progression. A multidimensional domain of disease control might be better in minimizing cardiovascular risk in PsA.

The most commonly used oscillometric upper-arm (UA) blood pressure (BP) monitors are not convenient enough for ambulatory BP monitoring, given the large size of the arm cuff and the compression of UA during the measurement. Finger-worn oscillometric BP devices featuring miniaturized finger cuff have been developed and researched as an alternative solution to the UA-based measurement, yet the reliability of the finger-based measurement is still questioned. To investigate the feasibility of oscillometric BP measurements at the finger position, we performed model-based analysis and experimental validation to explore the underlying issues associated with extending the cuff-based oscillometric approach from UA to other alternative sites. The simulation results revealed that a larger bone-to-tissue volume ratio produced a lower pressure transmission efficiency, which can account for the inter-site measurement discrepancies of mean blood pressure (MBP). We also experimentally compared the oscillometric MBP measurements at UA, middle forearm, wrist, finger proximal phalanx, and finger distal phalanx (FD) of 20 young adults, and each position was matched with a cuff of appropriate size and kept at the same height with the heart. The experimental results demonstrated that FD could be a superior alternative position for oscillometric BP measurement, as it requires the smallest cuff size while providing the most consistent MBP with the UA. Our analysis also suggested that further study is demanded to identify the appropriate oscillometric algorithm for reliable systolic blood pressure and diastolic blood pressure measurements at FD.

Assessment of patients' knowledge on atrial fibrillation (AF) and its management is important for evaluating their learning needs. However, a validated and comprehensive instrument to be used among Chinese patients is yet to be developed.The aim of this study was to develop and validate the Chinese version of the Atrial Fibrillation Knowledge Scale (AFKS-C) in Chinese patients.The 11-item AFKS was translated, and then content and face validations were conducted by an expert panel and patients with AF. A sample of 255 patients with AF was recruited from a university-affiliated hospital to evaluate its psychometric properties. The internal consistency and test-retest reliability were evaluated using the Kuder-Richardson formula 20 and κ statistics. Item analysis determined the item difficulty index and item discrimination coefficients. Factorial and discriminant validity were evaluated using exploratory factor analysis and the known-groups method.The content validity index of the AFKS-C was 0.94, and the Kuder-Richardson formula 20 value was 0.60. The difficulty indices of the items ranged from 0.36 to 0.89, and the point-biserial coefficients of the items ranged from 0.122 to 0.255, indicating sufficient discriminatory ability. The test-retest reliability was acceptable, because the κ values ranged from 0.234 to 0.710. The principal axis factoring analysis indicated a 3-factor structure that explained 50.4% of the total variance. The AFKS-C also demonstrated satisfactory discriminant validity, having yielded significantly different scores between patients with newly diagnosed and established AF.The AFKS-C has acceptable psychometric properties and can be used to measure the knowledge of patients and evaluate the effects of patient education programs.

Introduction: Diabetes is associated with poorer outcomes and increased complication rates in STEMI patients undergoing percutaneous coronary intervention (PCI). Regional variations have been described but data are notably lacking in the Asia-Pacific region. Aims: We report the associations of diabetes with clinical characteristics and outcomes in STEMI patients undergoing PCI across the Asia-Pacific. Methods: The Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) collaboration consists of data from the registries of contributing PCI centres across Australia, Hong Kong, Singapore, Malaysia, Indonesia and Vietnam. Clinical characteristics, lesion characteristics, and outcomes were provided for STEMI patients. Key outcomes included overall mortality at 30 days, and major adverse cardiovascular events (MACE; defined as peri-procedural myocardial infarctions, emergency CABG, stent thrombosis, target vessel revascularisation, cerebrovascular events, or death) at 30 days. Results: A total of 12,144 STEMI patients (mean(SD) age 59.3(12.3)) were included, of which 3912 (32.2%) had diabetes. Patients with diabetes were likely to be older, have a history of cardiovascular disease and previous acute coronary events (all p20mm (all p Conclusions: Diabetes portends poorer clinical outcomes in STEMI patients undergoing PCI in the Asia-Pacific. The development of effective preventative measures and interventional strategies targeted at this high-risk group is crucial.

Introduction: Intravascular ultrasound (IVUS) on long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is not well established. This study aimed to evaluate IVUS-guided compared to angiography-only-guided CTO-PCI on acute angiographic result and 1-year clinical outcomes. Hypothesis: The application of IVUS in CTO-PCI could improve acute angiographic results and 1-year clinical outcomes for all-comers CTO patients. Methods: We analysed 528 consecutive patients undergoing CTO-PCI at a university affiliated hospital in Hong Kong from February 2009 to December 2016. Baseline characteristics, procedural characteristics, and 1-year clinical outcomes including cardiac death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), and composite target lesion failure (TLF) were evaluated. The use of IVUS, and the choice of PCI devices including plain old balloon angioplasty (POBA), bare metal stent (BMS), and drug eluting stent (DES), were at the discretion of the operator. Propensity score matching (PSM) was performed to reduce treatment selection bias and potential confounding factors. Results: 275 patients underwent 288 angiography-only-guided and 253 patients underwent 268 IVUS-guided CTO-PCI. IVUS-guided CTO-PCI was associated with higher procedural success compared to angiography-only-guided CTO-PCI (77.5% vs. 55.3%, p20% residual stenosis (2.2% vs. 10.8%, p Conclusions: The use of IVUS was associated with higher success rates, more aggressive post-dilatation and better 1-year clinical outcomes compared to angiography-only guided CTO-PCI.

Background Heart failure (HF) evolves as a global pandemic and strains the over-stretched hospital service. Ineffective self-care remains the key factor to explain the avoidable hospital admission. Patient empowerment is as a theory-based strategy to optimize the patients' self-care changes for disease management [1]. Its cost-effectiveness to enhance self-care and health service utilization has yet to be determined. Purpose This was a double-blind randomized controlled trial to compare the effects and cost-effectiveness of a 12-week empowerment self-care program with a didactic education program on self-care maintenance and management as well as health service utilization among the community-dwelling HF patients. Methods A total of 236 HF patients were recruited from the specialist clinics of the Department of Cardiology in two regional hospitals. They were randomized to receive either the 12-week empowerment self-care program (Figure 1) or the 12-week didactic education. Outcome evaluation using the Self-care Heart Failure Index (SCHFI) at baseline, post-intervention (T1) and three months thereafter (T2), with record on the number of emergency room (ER) attendance and hospital admission. Cost effectiveness analyses were performed on total cost (medical, intervention and societal costs) incurred in both interventions as well as incremental cost-effectiveness ratios (ICER) expressed as incremental cost per 1) a reflected clinically meaningful improvement in self-care (i.e. a half standard deviation increase in SCHFI), 2) an ER attendance reduced, 3) a day of hospital stay reduced. Results As compared with the education group, the empowerment group reported significantly greater improvement in self-care management at T1 [B=13.77 (95% CI=6.07, 21.46), p Conclusions The empowerment-based self-care program is a cost-saving strategy to produce a clinical significant change in HF-related self-care. Although it is associated with lower risk for hospital service utilization, its effect is not significant enough to be cost-saving. Future care model may explore the need to integrate dyadic science [2] and e-health [3] to strengthen the care continuity and effects of self-care intervention. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health and Medical Research Fund, Food and Health Bureau, Hong Kong Special Administrative Region Figure 1

Background Inherited cardiomyopathies (CM) represent a clinically heterogeneous group of primary cardiac muscle disorders with a strong genetic underpinning. Recent rapid genomic advances have led to the identification of numerous disease-causing genes for both non-syndromic (nsCM) and syndromic (sCM) cardiomyopathies. This has greatly facilitated molecular genetic testing, thus enabling accurate disease diagnosis needed for the practice of precision medicine and the optimization of patient outcome. However, many cardiomyopathies remain unexplained with the known genes and dominant genetic model of disease. Purpose To reassess the genetic features of known CM genes as a strategy to recover novel candidate CM genes. Methods Known hypertrophic CM (HCM), dilated CM (DCM) and pediatric CM genes were curated from the literature and from 23 commercial CM diagnostic panels. They were classified as non-syndromic and syndromic, and further annotated using two constraint metrics, the missense Z score and pLI score obtained from the GnomAD database. Publicly available mouse (n=6) and human (n=3) single-cell RNA (scRNA) datasets were downloaded and cardiomyocyte specific differentially expressed genes (DEGs) (fold change >0.1; adjusted P Results Analyses of 9 scRNA datasets showed the majority of known nsCM genes are cardiomyocyte specific (Fig. 1a-b). nsCM and sCM genes have distinct expression and genetic profile. nsCM genes are associated with higher heart expression and lower loss intolerance (Fig. 1c). In contrast, syndromic CM genes mostly showed lower expression with high loss intolerance, consistent with their higher clinical impact. However, interestingly some of the nsCM genes (MYLK2, TMPO and KLF10) show low or even no detectable expression in mouse and human cardiac cells. Using the scRNA data, we assessed cellular expression of genes in the 23 commercial CM diagnostic panels. This analysis showed some of the CM genes with high cardiomyocytes expression have low coverage on the current commercial CM panels (Fig. 1d). Using human and mouse scRNA data, we recovered 224 mouse and 157 human nsCM candidate genes. MTUS2 (microtubule-associated tumor suppressor candidate 2) was identified as a strong nsCM candidate gene supported by evidence from both mouse and human studies (Fig. 1e-f). Conclusions Our analysis showed many of the nsCM genes have differential cardiomyocyte expression with low loss intolerance, while the reverse was observed for many sCM genes. We propose increasing commercial panel coverage of cardiomyocytes-specific expressed genes may help increase disease diagnostic yield. Additionally, novel candidate genes uncovered trained on cardiomyocyte expression profile may help accelerate elucidation of unsolved cardiomyopathy cases. Funding Acknowledgement Type of funding sources: None.

Purpose Ticagrelor plus aspirin has been shown to reduce the incidence of cardiovascular (CV) events compared to asprin alone in patients with stable coronary artery disease and diabetes in the THEMIS trial. This study aimed to estimate the potential CV benefit of adding ticagrelor to aspirin among a THMEIS-like Chinese population. Methods We retrospectively analyzed 13,322 patients with stable coronary artery disease and diabetes from 16 public hospitals in Hong Kong between August 2015 and July 2020. 5,642 (42.4%) patients who met inclusion and exclusion criteria of the THEMIS trial were included in final analysis. Estimated absolute risk reduction (eARR) in major adverse CV event (MACE, composite of myocardial infarction (MI), ischemic stroke or CV death) and number needed to treat (eNNT) were extrapolated based on results of the THEMIS trial. Results Of 5,642 THEMIS-like patients (62.1% male; mean age 69.6±10.4 years), 26.5% had history of percutaneous coronary intervention (PCI). During a median follow-up of 17.5 (IQR: 9.3–41.3) months, rates of MACE, MI, stroke and CV-death were 10.7% (n=605), 5.3% (n=298), 2.5% (n=139) and 5.5% (n=308), respectively. Kaplan-Meier estimates at 36 months stratified by history of PCI or not were 16.9% vs. 14.0% for MACE and 9.0% vs 6.7% for MI (both Log-rank p Conclusion Approximately one third of Chinese patients with stable coronary artery disease and diabetes met THEMIS trial criteria. Combined therapy of ticagrelor and aspirin might provide similar clinical benefit in our population observed in the THEMIS trial, with low number needed to treat, especially in patients with previous PCI. Funding Acknowledgement Type of funding sources: None.

Background The Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) Collaboration was established to better understand the characteristics of patients undergoing PCI and cardiac interventions across the Asia Pacific region, including STEMI. The aim of this study was to compare STEMI patient characteristics across Asia Pacific (AP) countries in order to understand regional differences. Methods Each site across Australia, Singapore, Malaysia, Vietnam and Hong Kong provided de-identified individual patient data. Comparison of characteristics by sites were performed using one-way ANOVA, Kruskal-Wallis or Chi-squared tests, using Stata 14.2. Results Of the 12,620 cases, there were more males (p Conclusions Patient characteristics varied significantly across AP countries. On-going analyses will focus on the impact of varying patient characteristics on clinical outcomes. Key messages As characteristics varied, prevention and procedural strategies need to be adapted carefully. Additional input from other AP countries will better inform these strategies.

Objective We evaluated stroke risk in patients with single time-point screen-detected atrial fibrillation (AF) and the effect of oral anticoagulants (OACs). Methods Consecutive patients aged ≥65 years attending medical outpatient clinics were prospectively enrolled for AF screening using handheld single-lead electrocardiogram (ECG; AliveCor) from December 2014 to December 2017 (NCT02409654). Repeated screening was performed in patients with >1 visit during this period. Three cohorts were formed: screen-detected AF, clinically diagnosed AF, and no AF. Ischemic stroke risk was estimated using adjusted subdistribution hazard ratios (aSHRs) from multivariate regression and no AF as reference, and stratified according to OAC use. Results Of 11,972 subjects enrolled, 2,238 (18.7%) had clinically diagnosed AF at study enrollment. The yield of screen-detected AF on initial screening was 2.3% (n = 223/9,734). AF was clinically diagnosed during follow-up in 2.3% (n = 216/9,440) and during subsequent screening in 71 initially screen-negative patients. Compared with no AF, patients with screen-detected AF without OAC treatment had the highest stroke risk (aSHR: 2.63; 95% confidence interval: 1.46–4.72), while aSHR for clinically diagnosed AF without OAC use was 2.01 (1.54–2.62). Among screen-detected AF, the risk of stroke was significantly less with OAC (no strokes in 196 person-years) compared with those not given OAC (12 strokes in 429 person-years), p = 0.01. Conclusion The prognosis of single time-point ECG screen-detected AF is not benign. The risk of stroke is high enough to warrant OAC use, and reduced by OAC.

ImportanceDespite decades of educational efforts, patients’ prolonged delays in seeking care for symptoms of acute myocardial infarction (AMI) remain the greatest obstacle to successful management of the condition.ObjectiveTo compare the effects of a narrative-based psychoeducational intervention with a didactic educative approach on AMI survivors’ intention to seek care for AMI symptoms and on AMI knowledge.Design, Setting, and ParticipantsA multisite randomized clinical trial recruited community-dwelling patients aged 18 years or older with a history of AMI from 4 hospitals in Hong Kong from January 1, 2018, to January 22, 2021, and followed up participants for 1 year.InterventionsAn 8-week narrative-based psychoeducational intervention aimed to create a vivid cognitive experience of complex decision-making and modeled desirable behavioral changes through nurse-led, interactive video sessions using model patients. The control group received 4 nurse-led sessions comprising education about AMI and care seeking delivered using a didactic approach.Main Outcomes and MeasuresThe primary outcome was the behavioral intention between the 2 groups, reflected by participants’ attitudes and beliefs about care seeking for AMI measured using the Acute Coronary Syndrome Response Index—Chinese version. The secondary outcome was AMI knowledge.ResultsSix hundred and eight participants (mean [SD] age, 67.2 [8.3] years; 469 [77.1%] male) were randomized to either the narrative-based psychoeducation group (n = 304) or the didactic education group (n = 304). The psychoeducational intervention group reported greater positive changes than the control group in their attitudes (β = −1.053 [95% CI, −1.714 to −0.391]; P P = .04) toward care seeking at the 3-month follow-up, and the difference was sustained at 12 months for both attitudes (β = −0.797 [95% CI, −1.477 to −0.117]; P = .02) and beliefs (β = −0.692 [95% CI, −1.309 to −0.012]; P = .047). There were no significant differences in AMI knowledge between the 2 study groups at the 3-month and 12-month time points.Conclusions and RelevanceThe results of this randomized clinical trial found that a novel approach of narrative-based psychoeducation was effective in improving patients’ behavioral intention to seek care for AMI symptoms. Longer-term follow-up to evaluate actual care-seeking behavior and clinical outcomes in patients with AMI is warranted to determine the sustained effects of this intervention.Trial RegistrationChiCTR Identifier: ChiCTR-IIC-17010576

Introduction This study aimed to provide information about the clinical and physiochemical effects of pill splitting training in elderly cardiac patients in Hong Kong. Methods A parallel study design was adopted. Patients taking lisinopril, amlodipine, simvastatin, metformin, or perindopril who needed to split pills were recruited from the Prince of Wales Hospital. Patients were divided into two groups at their first visit. Patients in group A split drugs using their own technique, whereas patients in group B used pill cutters after relevant training until their next follow-up visit. The primary outcome was the change in drug content between before and after the pill splitting training. Assays were performed to determine the drug content. Secondary outcomes were the changes in clinical outcomes, patients' attitudes and acceptance towards pill splitting, and patients' knowledge about pill splitting. Results A total of 193 patients were recruited, and 101 returned for the follow-up visit. The percentage of split tablets falling within the assay limits increased from 39.13% to 47.82% (P=0.523) in group A and from 48.94% to 51.06% (P=1.000) in group B. The changes did not reach statistical significance. As for clinical outcomes, the mean triglyceride level decreased from 1.62±1.05 to 1.36±0.80 (P=0.049), whereas the mean heart rate increased significantly from 73.97±11.01 to 77.92±12.72 (P=0.026). Changes in other parameters were not significant. Conclusion This study highlights the high variability of drug content after pill splitting. Pills with dosages that do not require splitting would be preferable, considering patients' preference. Patients should be educated to use pill cutters properly if pill splitting is unavoidable.

Postmortem studies reported plaque erosion is frequent in young women. Recent in vivo studies failed to show age and sex differences in the plaque erosion prevalence. The aim of this study was to investigate the prevalence of plaque erosion by age and sex among acute coronary syndromes (ACS) patients. From 1699 ACS patients, 1083 with plaque erosion or rupture were analyzed. Patients were categorized as 5 age groups (≤ 50, 51-60, 61-70, 71-80, ≥ 81 years). Overall prevalence of plaque erosion was similar between males and females (p = 0.831). Males age ≤ 50 had higher (p = 0.018) and age 71-80 had lower (p = 0.006) prevalence of plaque erosion. Females age 61-70 had higher (p = 0.021) and age 71-80 had lower (p = 0.045) prevalence of plaque erosion. In advanced age groups (≥ 71 years), rupture was the dominant etiology in both sexes. In multivariate analysis of males, age ≤ 50 demonstrated a trend to increase (OR 1.418, 95% CI 0.961-2.093, p = 0.078) the erosion risk. Females age ≤ 70 independently increased (OR 2.138, 95% CI 1.249-3.661, p = 0.006) the risk for erosion. The prevalence of plaque erosion was similar between males and females. Plaque erosion risk was increased in the males age ≤ 50 and in the females age ≤ 70 among ACS patients.

Background This study aimed at investigating the CV health and CV disease knowledge in terms of LS7 score among 3 age groups in Hong Kong. Methods A cross-sectional multicenter observational study was conducted to observe the CV health and disease risk knowledge in Hong Kong. Elderly subjects were recruited from 15 elderly centers, whereas young adults and the middle-aged were recruited from 6 on-campus health check sessions. Subjects’ demographics, lifestyle behavior and risk knowledge were obtained through questionnaire while their body mass index, random capillary blood glucose, blood cholesterol and blood pressure were measured. LS7 score and risk knowledge score was calculated. Results The LS7 of younger adult, middle-aged and elderly were 10.6 ± 1.3, 9.3 ± 1.9 and 9.7 ± 1.7 respectively. Only 0.6% participants have attained ideal CV health and 35.9% have 5 to 7 ideal CV health metrics. Elderly performed worst in risk knowledge with a score of 8.1 ± 3.3 while young adult and middle-aged were similar (9.6 ± 1.8 and 9.7 ± 1.5). 71% of the participants correctly identified ≥9 components. Logistic regression revealed that subjects aged ≤65 years (OR 2.341, 95% CI 1.779 to 3.080) and with tertiary education (OR 2.031, 95% CI 1.527 to 2.701) were more likely to obtain optimum LS7. No association was found between having optimum LS7 and full knowledge. Conclusion Only few adults in this study population had ideal CV health as defined by AHA. Knowledge has no association but young age and tertiary education has positive association with CV health. Electronic supplementary material The online version of this article (10.1186/s12872-019-1171-7) contains supplementary material, which is available to authorized users.

The international guideline recommendations for low-density lipoprotein cholesterol (LDL-C) lowering were made based on the results of randomized controlled trials (RCTs), meta-analyses, and observational studies mostly in the White population. It was not clear whether these LDL-C targets could be applicable to other ethnic groups, for example, Asian patients. This review aimed to address major aspects related to the lipid goal and statin therapy in Asia, including the epidemiology of cardiovascular disease, the LDL-C profiles, the lipid goals from localized guidelines, genetics and lifestyles, and the efficacy and safety of statins. Owing to the geographic, ethnic, genetic, and cultural diversity in this region, we observed a geographic pattern of diversity in cardiovascular epidemiology and statin response in Central Asia, East Asia (particularly for Asia-Pacific region), and South Asia. The rapidly growing literature from Asian countries questioning “lower is better” hypothesis was noticed. However, owing to the nature of these dominantly observational data, the conclusion was hardly confirmative. Despite the rapid expansion of the current literature in this region, efforts should be made to ensure an adequate sample size to assess the significance of a given lipid parameter on overall cardiovascular outcomes in this Asian population.

Aims. Previous studies have demonstrated epidemiological evidence for an association between cancer and the development of new-onset atrial fibrillation (AF). However, these results have been conflicting. This systematic review and meta-analysis was conducted to examine the relationship between cancer and the risk of developing atrial fibrillation. Methods. PubMed and Web of Science were searched for publications examining the association between cancer and atrial fibrillation risk published until June 2017. Adjusted odds ratios (ORs) or hazard ratios (HRs) and 95% CI were extracted and pooled. Results. A total of five studies involving 5,889,234 subjects were included in this meta-analysis. Solid cancer patients are at higher risk developing atrial fibrillation compared to noncancer patients (OR 1.47, 95% CI 1.31 to 1.66, p<0.00001; I2 = 67%, p=0.02). The risk of atrial fibrillation was highest within 90 days of cancer diagnosis (OR 7.62, 95% CI 3.08 to 18.88, p<0.00001) and this risk diminished with time. Conclusions. The risk of AF was highest within 90 days of cancer diagnosis. We should take into account the increased risk of atrial fibrillation development and, after this, study the embolic risk and potential indication of oral anticoagulation.

Objective To investigate the effects of achieving minimal disease activity (MDA) on the progression of subclinical atherosclerosis and arterial stiffness in patients with psoriatic arthritis (PsA). Methods A total of 101 consecutive patients with PsA were recruited for this prospective cohort study. All patients received protocolized treatment targeting MDA for a period of 2 years. High-resolution carotid ultrasound and arterial stiffness markers were assessed annually. The primary outcome measure was the effect of achieving MDA at 12 months (MDA group) on the progression of subclinical atherosclerosis over a period of 24 months. Secondary objectives were to compare the changes in arterial stiffness markers over 24 months between the MDA and non-MDA groups, as well as the changes in subclinical atherosclerosis and arterial stiffness markers in patients who achieved MDA at each visit from month 12 through month 24 (sustained MDA [sMDA]). Results Ninety PsA patients (mean ± SD age 50 ± 11 years, 58% male [n = 52]) who completed 24 months of follow-up were included in this analysis. Fifty-seven patients (63%) had achieved MDA at 12 months. Subclinical atherosclerosis and arterial stiffness outcomes were similar between the MDA and non-MDA groups. Forty-one patients (46%) achieved sMDA. As shown by multivariate analysis, achieving sMDA had a protective effect on plaque progression (odds ratio 0.273 [95% confidence interval 0.088-0.846], P = 0.024), and less of an increase in total plaque area, mean intima-media thickness, and augmentation index values after adjustment for covariates. Conclusion Our results support the recommendation that once MDA is achieved, it should ideally be maintained for a prolonged period in order to prevent progression of carotid atherosclerosis and arterial stiffness in patients with PsA.

Objective With the evolution of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) technique and equipment, the success rate of CTO PCI has improved over the years. We examined the failed cases in this expert registry and looked at the mode of failure. Methods In 2016, consecutive CTO PCI performed by eight high volume CTO with an agreed CTO algorithm were examined in a registry. Results There was a total of 485 patients with 497 CTOs were treated with technical and procedural success rates of 93.8% and 89.9%, respectively. The mean J-CTO score was 2.9 ± 1.2. The main mode of failure in cases with only antegrade attempt was inability to wire to true lumen despite advanced antegrade wiring technique for example, parallel wiring or IVUS guided wiring (10 out of 11 cases). The mode of failure in retrograde attempt was: 30% was due to inability to wire the collateral channel; 30% was due to failed reverse controlled antegrade and retrograde subintimal tracking (CART); 30% was due to inability to cross CTO by retrograde microcatheter. Four cases were terminated prematurely due to procedure complications. Conclusion Similar to previous reported studies, primary failure mode of only antegrade attempt was inability to wire to true lumen. However, contrary to other registries where failure to cross the retrograde channel with wire was the predominant failure mode, the retrograde failure mode was equally divided between failure to cross the channel with wire, failure to do reverse CART, and failure to cross the CTO with the microcatheter.

Direct oral anticoagulants (DOACs) have gained momentum in recent years in patients requiring anticoagulation for the prevention and management of venous thromboembolism and thromboembolic events caused by atrial fibrillation. The use of these agents involves potential bleeding complications, particularly during invasive procedures. With increasing use of DOACs, adequate knowledge regarding the perioperative management of patients on DOACs has become indispensable.This review covers the indications, mechanism of action, and pharmacokinetics of DOACs and their management in different perioperative settings based on various current guidelines and practices. The role of bridging therapy with heparin and the recently developed reversal agents are also discussed.The perioperative management of DOACs is influenced by drug pharmacokinetics, potential comorbidities of the patient and perioperative thrombotic and bleeding risk. In low bleeding risk and minor procedures, continuing DOACs seems to be safe. Interrupting DOACs in high-risk procedures might be necessary and should be based on the elimination half-life of the drug and renal function of the patient. Further research is needed to better clarify the role of recently developed reversal agents in the perioperative setting and to identify specific laboratory tests to guide the perioperative management of DOACs.

Aim: The recommended low-density lipoprotein cholesterol (LDL-C) levels of the guideline may be appropriate for Caucasian patients but not for other ethnic groups. Methods: A cohort study was conducted in Hong Kong, and acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) between 2005 and 2015 were enrolled. The primary outcomes of interest were the total cost of care and cardiovascular-related cost during one-year follow-up. The cost difference by lipid goal attainments was analyzed by Poisson regression with multivariate treatment effects. The clinical outcomes achieved by lipid goal attainments in terms of major adverse cardiovascular events were analyzed by multivariate Cox regression. Results: Among the 4638 patients, 79.50%, 48.64%, and 36.14% attained the LDL-C goals of < 2.6, < 2.0, and < 1.8 mmol/L for one year, respectively. Only about 16% patients achieved the ≥ 50% reduction from baseline. None of these lipid goals was associated with a significant reduction in the total cost of care. We only identified the clinical benefits associated with the lipid goal of < 2.6 mmol/L. Other more stringent lipid goals seemed to bring a significant economic burden on cardiovascular-related cost, but their clinical benefits were uncertain. Conclusions: Lowering LDL-C to achieve the guideline-recommended target levels for post-PCI ACS patients may lead to fewer cardiovascular events, but it may not necessarily lead to economic benefits within one year of follow-up.

Because of the rapid and serious nature of acute cardiovascular disease (CVD) especially ST segment elevation myocardial infarction (STEMI), a leading cause of death worldwide, prompt diagnosis and treatment is of crucial importance to reduce both mortality and morbidity. During a pandemic such as coronavirus disease-2019 (COVID-19), it is critical to balance cardiovascular emergencies with infectious risk. In this work, we recommend using wearable device based mobile health (mHealth) as an early screening and real-time monitoring tool to address this balance and facilitate remote monitoring to tackle this unprecedented challenge. This recommendation may help to improve the efficiency and effectiveness of acute CVD patient management while reducing infection risk.

BACKGROUND The COMBO drug eluting stent is a novel device with luminal endothelial progenitor cell capture technology for rapid homogeneous endothelialization. METHODS AND RESULTS We examined for sex differences in 1-year outcomes after COMBO stenting from the COMBO collaboration, a pooled patient-level dataset from the MASCOT and REMEDEE multicenter registries. The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel-myocardial infarction (TV-MI), or clinically driven target lesion revascularization (CD-TLR). Secondary outcomes included stent thrombosis (ST). Adjusted outcomes were assessed using Cox regression methods. The study included 861 (23.8%) women and 2,753 (76.2%) men. Women were older with higher prevalence of several comorbidities including diabetes mellitus. Risk of 1-year TLF was similar in both sexes (3.8% vs. 3.9%, HR 0.92, 95% CI 0.59-1.42, p = .70), without sex differences in the incidence of cardiac death (1.6% vs. 1.5%, p = .78), TV-MI (1.5% vs. 1.1%, p = .32), or CD-TLR (2.0% vs. 2.2%, p = .67). Definite or probable ST occurred in 0.4% women and 1.0% men (HR 0.26, 95% CI 0.06-1.11, p = .069). CONCLUSIONS Despite greater clinical risks at baseline, women treated with COMBO stents had similarly low 1-year TLF and other ischemic outcomes compared to men.

Background The Atrial Fibrillation Effect on Quality-of-Life Questionnaire (AFEQT) is a psychometrically sound instrument for measuring disease-specific health-related quality of life in atrial fibrillation populations. Objective In this study we aimed to validate the Chinese version of AFEQT (AFEQT-C) among Chinese patients with atrial fibrillation. Methods The AFEQT was translated into Chinese according to Brislin's model. The psychometric properties of internal consistency, stability, and concurrent and factorial validity were examined in a convenience sample. Results A total of 200 participants (mean age, 69.8 ± 5.2 years) were recruited. The Cronbach's α of the AFEQT-C was 0.94, and item-to-total correlations ranged from 0.44 to 0.80. The test-retest reliability was supported by good to excellent intraclass correlation coefficients, which ranged from 0.68 to 0.92. The AFEQT-C scores significantly correlated with the EuroQoL 5-Dimensional Questionnaire score to support concurrent validity. Confirmatory factor analysis demonstrated a 3-factor structure and all items loaded strongly onto their respective factors. Conclusions The AFEQT-C is a reliable and valid measure of health-related quality of life in Chinese patients with atrial fibrillation.

Background Because of a nonresponse to aspirin (aspirin resistance), patients with acute coronary syndrome (ACS) are at increased risk of developing recurrent event. The in vitro platelet function tests have potential limitations, making them unsuitable for the detection of aspirin resistance. We investigated whether miR‐19b‐1‐5p could be utilized as a biomarker for aspirin resistance and future major adverse cardio‐cerebrovascular (MACCE) events in patients with ACS. Methods and Results In this cohort study, patients with ACS were enrolled from multiple tertiary hospitals in Christchurch, Hong Kong, Sarawak, and Singapore between 2011 and 2015. MiR‐19b‐1‐5p expression was measured from buffy coat of patients with ACS (n=945) by reverse transcription quantitative polymerase chain reaction. Platelet function was determined by Multiplate aggregometry testing. MACCE was collected over a mean follow‐up time of 1.01±0.43 years. Low miR‐19b‐1‐5p expression was found to be related to aspirin resistance as could be observed from sustained platelet aggregation in the presence of aspirin (‐Log‐miR‐19b‐1‐5p, [unstandardized beta, 44.50; 95% CI, 2.20–86.80; P P P =0.01) on the risk of MACCE. Conclusions Lower miR‐19b‐1‐5p expression was found to be associated with sustained platelet aggregation on aspirin, and a higher risk of MACCE in patients with ACS. Therefore, miR‐19b‐1‐5p could be a suitable marker for aspirin resistance and might predict recurrence of MACCE in patients with ACS.

Secondary prevention therapy reduces death and reinfarction after acute myocardial infarction (AMI), but it is underutilized in clinical practice. Mechanisms for this therapeutic gap are not well established. In this study, we have explored and evaluated the impact of passive continuation compared to active initiation of secondary prevention therapy for AMI during the index hospitalization. For this purpose, we have analyzed 1083 consecutive patients with AMI to a tertiary referral hospital in Hong Kong and assessed discharge prescription rates of secondary prevention therapies (aspirin, beta-blockers, statins, and ACEI/ARBs). Multivariate analysis was used to identify independent predictors of discharge medication, and Kaplan–Meier survival curve was used to evaluate 12-month survival. Overall, prescription rates of aspirin, beta-blocker, statin, and ACEI/ARBs on discharge were 94.8%, 64.5%, 83.5%, and 61.4%, respectively. Multivariate analysis showed that prior use of each therapy was an independent predictor of prescription of the same therapy on discharge: aspirin (odds ratio (OR) = 4.8, 95% CI = 1.9–12.3, P < 0.01 ), beta-blocker (OR = 2.5, 95% CI = 1.8–3.4, P < 0.01 ); statin (OR = 8.3, 95% CI = 0.4–15.7, P < 0.01 ), and ACEI/ARBs (OR = 2.9, 95% CI = 2.0–4.3, P < 0.01 ). Passive continuation of prior medication was associated with higher 1-year mortality rates than active initiation in treatment-naïve patients (aspirin (13.7% vs. 5.7%), beta-blockers (12.9% vs. 5.6%), and statins (11.0% vs. 4.6%); all P < 0.01 ). Overall, the use of secondary prevention medication for AMI was suboptimal. Our findings suggested that the practice of passive continuation of prior medication was prevalent and associated with adverse clinical outcomes compared to active initiation of secondary preventive therapies for acute myocardial infarction during the index hospitalization.

Background A recent study reported that the outcome of patients with plaque erosion treated with stenting is poor when the underlying plaque is lipid rich. However, the detailed phenotype of patients with plaque erosion, particularly as related to different age groups, has not been systematically studied. Methods and Results Patients with acute coronary syndromes caused by plaque erosion were selected from 2 data sets. Demographic, clinical, angiographic, and optical coherence tomography findings of the culprit lesion were compared between 5 age groups. Among 579 erosion patients, male sex and current smoking were less frequent, and hypertension, diabetes, and chronic kidney disease were more frequent in older patients. ST‐segment–elevation myocardial infarction was more frequent in younger patients. Percentage of diameter stenosis on angiogram was greater in older patients. The prevalence of lipid‐rich plaque (27.3% in age P P =0.027), and calcification (5.5% in age P Conclusions The demographic, clinical, angiographic, and plaque phenotypes of patients with plaque erosion distinctly vary depending on age. This may affect the clinical outcome in these patients. Registration URL: https://www.clinicaltrials.gov . Unique identifiers: NCT03479723, NCT02041650.

Aims To determine risk of ischemic stroke in patients with single timepoint screen-detected atrial fibrillation (AF). Methods Cohort of 11,972 consecutive patients aged ≥65 years attending medical outpatient clinics in Hong Kong underwent AF screening using a handheld single-lead ECG (AliveCor) from Dec 2014 to Dec 2017 (NCT02409654). Repeated screening was performed in patients who had >1 clinic visit during the study period. Cohort was divided into 4 exposure groups: (i) new AF detected by initial screening (S1-AF); (ii) new AF detected by subsequent screening or clinically diagnosed during follow up (FU-AF); (iii) known AF and (iv) no initial or subsequent FU-AF (no AF). Exposure in the FU-AF group was handled as a time-dependent variable. All AF exposure groups were further stratified by oral anticoagulant (OAC) use at the end of FU. Cumulative incidence of ischemic stroke was compared between groups during a median FU period of 2.3 (IQR=1.7–3.3) years, using Fine and Gray regression accounting for death as competing risk and using no AF as reference. Results Of 11,972 subjects enrolled, 2,236 (18.7%) had known AF and 9,736 (81.3%) underwent 13,571 screening events during the study period. The yield of newly diagnosed AF on initial screening was 2.3% (n=223/9,736), with 71 new AF detected by subsequent screening. During FU, 2.3% (221/9,442) screen-negative patients were diagnosed with AF clinically. Compared to no AF, S1-AF without OAC had the highest ischemic stroke risk (subdistribution hazard ratio (SHR)=2.79; 1.47–5.27), then FU-AF without OAC (SHR=2.66; 1.21–5.82) and known AF without OAC (SHR=1.97; 1.50–2.57). All AF groups taking OAC had similar risk of ischemic stroke as no AF. Conclusion This is the first study to report the prognosis of AF detected by single timepoint screening. The prognosis is not benign. Both risks of stroke and benefits from anticoagulation therapy were similar between screen-detected and known AF. Funding Acknowledgement Type of funding source: None

Background Previous studies have reported a circadian variation in the onset of ST-segment elevation myocardial infarction (STEMI). However, underlying mechanisms for the circadian variation have not been fully elucidated. Purpose We investigated the relationship between onset of STEMI and the underlying pathology using optical coherence tomography (OCT). Methods Patients presenting with STEMI were selected from an international, multi-center, longitudinal registry study, which included patients who underwent OCT imaging of the culprit lesion at 11 institutions in 6 countries. Onset of MI was estimated using the time of OCT imaging. Patients were divided into 4 groups based on the estimated time of onset (00:00–05:59, 06:00–11:59, 12:00–17:59, or 18:00–23:59). Underlying pathologies of MI (plaque rupture, plaque erosion, and calcified plaque) were compared among the 4 groups. Results Among 648 patients, plaque rupture was diagnosed in 386 patients (59.6%), plaque erosion in 197 patients (30.4%), and calcified plaque in 65 patients (10.0%). A marked circadian variation was detected in the incidence of plaque rupture with a peak at 9:00, whereas it was not evident in plaque erosion or calcified plaque. The probability of plaque rupture increased in the periods of 06:00–11:59 (odds ratio: 2.13, 95% confidence interval: 1.30 to 3.49, p=0.002) and 12:00–17:59 (odds ratio: 2.10, 95% confidence interval: 1.23 to 3.58, p=0.005), compared to the period of 00:00–05:59. This circadian pattern was observed only during weekdays (p=0.013) and it was not evident during the weekend (p=0.742). Conclusions Plaque rupture occurred most frequently in the morning and the circadian variation was evident only during the weekdays. Acute MI caused by plaque rupture may be related to catecholamine surge. Funding Acknowledgement Type of funding source: None

IntroductionCurrent international guidelines recommend non-vitamin K oral anticoagulants (NOACs) for stroke prevention among patients with non-valvular atrial fibrillation (AF) at significant ischaemic stroke risk given the superior safety and comparable efficacy of NOACs over warfarin. Nonetheless, the safety and effectiveness of NOACs have not been evaluated in patients with AF with underlying moderate or severe mitral stenosis (MS), hence the recommended stroke prevention strategy remains warfarin therapy.Method and analysisMS remains disproportionately prevalent in Asian countries compared with the developed countries. This prospective, randomised, open-label trial with blinded endpoint adjudication aims to evaluate the safety and efficacy of dabigatran for stroke prevention in AF patients with moderate or severe MS. Patients with AF aged ≥18 years with moderate or severe MS not planned for valvular intervention in the coming 12 months will be randomised in a 1:1 ratio to receive dabigatran 110 mg or 150 mg two times per day or warfarin with international normalised ratio 2–3 in an open-label design. Patients with estimated creatinine clearance Ethics and disseminationThe study protocol has been approved by the Institutional Review Board of the University of Hong Kong and Hong Kong West Cluster, Hospital Authority, Hong Kong for Fung Yiu King Hospital, Grantham Hospital, Queen Mary Hospital and Tung Wah Hospital in Hong Kong. Results will be published in peer-reviewed journals.Trial registration numberClinicalTrials.gov Registry (NCT04045093); pre-results.

Background: Secondary prevention therapy reduces death and re-infarction after acute myocardial infarction (AMI) but is under-utilized in clinical practice. Mechanisms for this therapeutic gap are not well established. We aimed to evaluate the impact of passive continuation compared to active initiation of secondary prevention therapy for AMI patients during index hospitalization. Methods: We analyzed 1083 consecutive patients with AMI to a tertiary referral hospital in Hong Kong and assessed discharge prescription rates of secondary prevention therapies (aspirin, clopidogrel, beta-blockers, statins, angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (ACEI/ARBs)). Multivariate analysis was used to identify independent predictors of discharge and 6-month medication, Kaplan-Meier survival curve was used to evaluate 12-month survival. Results: Overall prescription rates of aspirin, clopidogrel, beta-blockers, statins, ACEI/ARBs on discharge was 94.8%, 54.2%, 64.5%, 83.5% and 61.4%, respectively. Multivariate analysis showed that prior use of each therapy, except clopidogrel, was an independent predictor of prescription of the same therapy on discharge: aspirin [Odds ratio (OR) =4.8, 95% CI =1.9-12.3, PConclusions: Overall use of secondary prevention medication for AMI was suboptimal compared to guideline recommendations. Our findings suggested the practice of passive continuation of prior medication was prevalent and associated with adverse clinical outcomes compared to those who received secondary preventive medication for the first time during index hospitalization. Failure to start additional medication and possible inadequate dose titration in the passive continuation group may be in part the reason for the poorer clinical outcome in this group.

INTRODUCTION Time in therapeutic range (TTR) assesses the safety and effectiveness of warfarin therapy using the international normalised ratio. This study investigated the TTR in Hong Kong patients using both European and Japanese therapeutic ranges and patients' economic and clinical outcomes. Predictors of poor warfarin control and patient knowledge concerning warfarin therapy were assessed. METHODS A 5-month observational study with retrospective and prospective components was conducted in the Prince of Wales Hospital. The study examined electronic patient records of patients who received warfarin for at least 1 year during the period from January 2010 to August 2015. Patient knowledge was assessed via phone interview using the Oral Anticoagulation Knowledge (OAK) test. RESULTS In total, 259 patients were included; 174 completed the OAK test. The calculated mean TTR was 40.2±17.1% (European therapeutic range), compared with 49.1±16.1% (Japanese therapeutic range) [P

Background Seasonal variations in acute coronary syndromes ( ACS ) have been reported, with incidence and mortality peaking in the winter. However, the underlying pathophysiology for these variations remain speculative. Methods and Results Patients with ACS who underwent optical coherence tomography were recruited from 6 countries. The prevalence of the 3 most common pathologies (plaque rupture, plaque erosion, and calcified plaque) were compared between the 4 seasons. In 1113 patients with ACS (885 male; mean age, 65.8±11.6 years), the rates of plaque rupture, plaque erosion, and calcified plaque were 50%, 39%, and 11% in spring; 44%, 43%, and 13% in summer; 49%, 39%, and 12% in autumn; and 57%, 30%, and 13% in winter ( P =0.039). After adjusting for age, sex, and other coronary risk factors, winter was significantly associated with increased risk of plaque rupture (odds ratio [OR], 1.652; 95% CI, 1.157–2.359; P =0.006) and decreased risk of plaque erosion (OR, 0.623; 95% CI, 0.429–0.905; P =0.013), compared with summer as a reference. Among patients with rupture, the prevalence of hypertension was significantly higher in winter ( P =0.010), whereas no significant difference was observed in the other 2 groups. Conclusions Seasonal variations in the incidence of ACS reflect differences in the underlying pathobiology. The proportion of plaque rupture is highest in winter, whereas that of plaque erosion is highest in summer. A different approach may be needed for the prevention and treatment of ACS depending on the season of its occurrence. Registration URL : https://www.clini​caltr​ials.gov . Unique identifier: NCT 03479723.

Venography alone may underestimate the extent of common iliac vein compression in May-Thurner syndrome. Peripheral intravascular ultrasound is mandatory to better assess common iliac vein compression.

Paget-Schroetter Syndrome is potentially life-threatening. In this case, multidisciplinary imaging with extravascular and intravascular evaluation guided the proper diagnosis and treatment planning.

Background We have previously demonstrated unselected screening for atrial fibrillation (AF) in patients ≥65 years old in an out-patient setting yielded 1-2% new AF each time screen-negative patients underwent repeated screening at 12 to 18 month interval. Selection criteria to identify high-risk patients for repeated AF screening may be more efficient than repeat screening on all patients. Aims This study aimed to validate CHA2DS2VASC score as a predictive model to select target population for repeat AF screening. Methods 17,745 consecutive patients underwent 24,363 index AF screening (26.9% patients underwent repeated screening) using a handheld single-lead ECG (AliveCor) from Dec 2014 to Dec 2017 (NCT02409654). Adverse clinical outcomes to be predicted included (i) new AF detection by repeated screening; (ii) new AF clinically diagnosed during follow-up and (ii) ischemic stroke/transient ischemic attack (TIA) during follow-up. Performance evaluation and validation of CHA2DS2VASC score as a prediction model was based on 15,732 subjects, 35,643 person-years of follow-up and 765 outcomes. Internal validation was conducted by method of k-fold cross-validation (k = n = 15,732, i.e., Leave-One-Out cross-validation). Performance measures included c-index for discriminatory ability and decision curve analysis for clinical utility. Risk groups were defined as ≤1, 2-3, or ≥4 for CHA2DS2VASC scores. Calibration was assessed by comparing proportions of actual observed events. Results CHA2DS2VASC scores achieved acceptable discrimination with c-index of 0.762 (95%CI: 0.746-0.777) for derivation and 0.703 for cross-validation. Decision curve analysis showed the use of CHA2DS2VASC to select patients for rescreening was superior to rescreening all or no patients in terms of net benefit across all reasonable threshold probability (Figure 1, left). Predicted and observed probabilities of adverse clinical outcomes progressively increased with increasing CHA2DS2VASC score (Figure 1, right): 0.7% outcome events in low-risk group (CHA2DS2VASC ≤1, predicted prob. ≤0.86%), 3.5% intermediate-risk group (CHA2DS2VASC 2-3, predicted prob. 2.62%-4.43%) and 11.3% in high-risk group (CHA2DS2VASC ≥4, predicted prob. ≥8.50%). The odds ratio for outcome events were 4.88 (95%CI: 3.43-6.96) for intermediate-versus-low risk group, and 17.37 (95%CI: 12.36-24.42) for high-versus-low risk group. Conclusion Repeat AF screening on high-risk population may be more efficient than rescreening all screen-negative individuals. CHA2DS2VASC scores may be used as a selection tool to identify high-risk patients to undergo repeat AF screening. Abstract P9 Figure 1

Background As mortality due to cardiovascular disease increases throughout the world, accurate data on risk factors such as hyperlipidemia are required. This is lacking in the Asia-Pacific region. Design The observational Dyslipidemia International Study (DYSIS) II was established to quantify the extent of hyperlipidemia in adults with acute and stable coronary heart disease globally. Methods Patients with stable coronary heart disease or hospitalised with an acute coronary syndrome were enrolled across nine Asia-Pacific countries from July 2013 to October 2014. Lipid-lowering therapy and low-density lipoprotein cholesterol target attainment (Results Of the 4592 patients enrolled, 2794 had stable coronary heart disease and 1798 were admitted with an acute coronary syndrome. In the coronary heart disease cohort, the mean low-density lipoprotein cholesterol level was 86.9 mg/dL, with 91.7% using lipid-lowering therapy and 31% achieving low-density lipoprotein cholesterol of less than 70 mg/dL. In the acute coronary syndrome cohort at admission, the corresponding values were 103.2 mg/dL, 63.4% and 23.0%, respectively. Target attainment was significantly higher in lipid-lowering therapy-treated than non-treated patients in each cohort (32.6% vs. 12.9% and 31.1% vs. 9.0%, respectively). Mean atorvastatin-equivalent dosages were low (20 ± 15 and 22 ± 18 mg/day, respectively), with little use of non-statin adjuvants (13.0% and 6.8%, respectively). Low-density lipoprotein cholesterol target attainment had improved by follow-up for the acute coronary syndrome patients, but remained low (41.7%). Conclusions Many patients in Asia at very high risk of recurrent cardiovascular events had a low-density lipoprotein cholesterol level above the recommended target. Although lipid-lowering therapy was common, it was not used to its full potential.

Objectives: This study aimed to examine the relationship between chronic coronary artery total occlusion (CTO) status and the occurrence of ventricular tachycardia (VT)/ventricular fibrilla...

Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with '0', 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000-$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71-91%, '0' indications, 49-67%, 1 indication, 56-82%, 2 indications, 70-90%, and ≥3 indications, 97-99%.Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with '0' indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.

There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice. The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources. Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results. At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966). At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.

Background Focused cardiac ultrasound (FOCUS) examination using a portable device is increasingly used for bedside diagnosis of cardiovascular diseases. This is a 4-week pilot project aiming to teach medical students to perform FOCUS to detect valvular heart lesions. Methods Patients undergoing routine transthoracic echocardiography (TTE) were recruited by third year medical students who performed physical examination (PE) and FOCUS after 6-hour training to detect significant (moderate-to-severe) valvular lesions. Performance of FOCUS and PE was compared to TTE as reference using kappa statistics. Results 10 medical students performed 212 PE and FOCUS on 107 patients with mean age 63.7 ± 14.9 years. TTE detected 126 significant valvular lesions of which FOCUS correctly identified 54 lesions (κ = 0.45) compared to 32 lesions by PE (κ = 0.28, p, Highlights • Teaching junior medical students to perform and interpret limited pocket-sized ultrasound was feasible after brief training. • Accuracy of student performed limited pocket-sized ultrasound was higher than physical examination in detecting significant valvular lesions.

Impact of percutaneous coronary interventions (PCI) on health-related quality of life (HRQOL) is important but under-reported in elderly patients.To evaluate long-term health status in elderly patients who underwent PCI.Consecutive patients who underwent PCI at a university-affiliated hospital from September 2009 to June 2012 were prospectively enrolled with HRQOL assessment at baseline (up to 2 weeks before PCI) and at 6-, 12-, and 36-month follow-up using the EuroQol five-dimensional questionnaire descriptive profile and visual analogue scale (VAS). Minimally important benefit (MIB) in HRQOL was defined as greater than half an SD improvement in the baseline VAS score.Of 1957 patients, 49.9%, 29.1%, and 21.0% were aged younger than 65 years, 65 to 74 years, and 75 years and older, respectively. Mean VAS scores at baseline (50.1 ± 20.5 vs. 51.6 ± 20.5 vs. 52.6 ± 21.8; P = 0.09) and at 36 months (72.9 ± 14.0 vs. 72.8 ± 16.1 vs. 72.0 ± 14.8; P = 0.77) were similar between the three age groups, respectively. MIB at 36 months was observed in 65.7%, 61.9%, and 61.2% of patients in each age group, respectively. Proportion of patients aged 75 years and older reporting problems in pain/discomfort and self-care reduced from 91.2% and 24.8% at baseline to 41.4% and 10.1% at 36 months, respectively (both P0.01). Independent predictors of MIB in HRQOL at 36 months in patients 75 years and older included poor baseline HRQOL, MIB at 6 months, and presentation with myocardial infarction (all P0.01).Elderly patients experienced sustained long-term improvement in quality of life comparable with younger patients after PCI. Our findings suggest that age per se should not deter against revascularization because of sustained benefit in HRQOL.

A 71-year-old man with atrial fibrillation (CHA2DS2-VASc = 5; HAS-BLED = 4) and history of mitral valve ring annuloplasty 10 years ago was referred for percutaneous left atrial appendage occlusion (LAAO) because of recurrent gastrointestinal bleeding on vitamin K antagonist and direct oral