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Hepatic steatosis is a recognised risk factor for cardiovascular disease (CVD). However, its effect on patient outcomes following acute myocardial infarction (AMI) remains poorly understood. This study examines the prevalence and prognosis of hepatic steatosis and fibrosis in post-AMI patients.Patients presenting with AMI to a tertiary hospital were examined from 2014 to 2021. Hepatic steatosis and advanced hepatic fibrosis were determined using hepatic steatosis index and fibrosis-4 index respectively. The primary outcome was all-cause mortality. Cox regression models identified determinants of mortality after adjustments and Kaplan-Meier curves were constructed for all-cause mortality, stratified by hepatic steatosis and advanced fibrosis.Of 5,765 patients included, 24.8% had hepatic steatosis, of whom 41.7% were diagnosed with advanced fibrosis. The median follow-up duration was 2.7 years. Patients with hepatic steatosis tended to be younger, female, with elevated BMI and increased metabolic burden of diabetes, hypertension and hyperlipidemia. Patients with hepatic steatosis (24.6% vs 20.9% mortality, p0.001) and advanced fibrosis (45.6% vs 32.9% mortality, p0.001) had higher all-cause mortality rates compared to their respective counterparts. Hepatic steatosis (aHR 1.364, 95%CI 1.145-1.625, p=0.001) was associated with all-cause mortality after adjustment for confounders. Survival curves demonstrated excess mortality in patients with hepatic steatosis compared to those without (p=0.002).Hepatic steatosis and advanced fibrosis have a substantial prevalence among patients with AMI. Both are associated with mortality, with incrementally higher risk when advanced fibrosis ensues. Hepatic steatosis and fibrosis could help risk stratification of AMI patients beyond conventional risk factors. This article is protected by copyright. All rights reserved.

The role of Lp(a) in multi-ethnic Asian populations with coronary artery disease (CAD) has not been well established. The aims of this study were (i) to investigate whether Lp(a) is a predictor of CAD, and (ii) amongst patients with CAD, to ascertain whether Lp(a) is a predictor of acute myocardial infarction (AMI) and severity of CAD.We compared three cardiovascular phenotypes from patients recruited at coronary angiography. CAD was defined as ≥50% coronary artery stenosis and subdivided into a group with AMI history (CAD+AMI+) and a group without (CAD+AMI-). Minimal CAD group (CAD-) was defined as normal or30% coronary artery stenosis and no AMI. The severity of CAD was defined using the modified Gensini score.We studied 2025 patients comprising 94.5% men and 61.4% of Chinese ethnicity. The median Lp(a) level was highest in CAD+AMI+, followed by CAD+AMI- and CAD- (26.2, 20.1, and 15.8 nmol/L respectively). Similarly, the frequency of patients with Lp(a) ≥120 nmol/L were in the same order (11.8%, 9.1% and 2.4%). Lp(a) levels were highest among Asian Indians, followed by Malays and Chinese patients (p 0.001). Lp(a) levels and Lp(a) ≥120 nmol/L were significant predictors of CAD (Odds ratio (OR) = 1.12 per 10 nmol/L increment, p 0.001, and OR = 5.41 p = 0.004 respectively). Among patients with CAD, higher Lp(a) levels were associated with increased AMI risk (OR = 1.02 per 10 nmol/L increment, p = 0.024). Lp(a) ≥120 nmol/L was positively associated with CAD severity (p = 0.020).Plasma Lp(a) concentration is a positive predictor of CAD and AMI in a mostly male South East Asian population.

Background Physician visual assessment (PVA) in invasive coronary angiography (ICA) is the current clinical method to determine stenosis severity and guide percutaneous coronary intervention. This study sought to evaluate the effect of sex differences in assessing coronary stenosis severity between PVA and quantitative coronary angiography (QCA). Methods 209 patients with coronary artery disease (288 coronary lesions) underwent ICA and fractional flow reserve (FFR). ICA image processing including PVA and QCA was used to quantify diameter stenosis (DS). The difference of DS (ΔDS) between PVA and QCA was defined as DSPVA-DSQCA. DS ≥50% was considered anatomically obstructive. FFR ≤0.8 was defined as myocardial ischemia. Results Mean ± SD age was 63 ± 9 years. There were no significant differences in DSPVA (61.1 ± 16.3% vs 60.1 ± 18.9%) and DSQCA (53.1 ± 12.1% vs 55.4 ± 14.3%) between females and males. However, ΔDS between PVA and QCA was higher in females (8.0 ± 10.9%) than in males (4.7 ± 10.9%) (P = 0.03). Thirty-four of 72 vessels (47.2%) in female patients and 75 of 216 vessels (34.7%) in male patients were classified differently by at least one grade using PVA compared to QCA assessment. DSPVA and DSQCA were negatively correlated with FFR in females (rPVA = −0.397, rQCA = −0.448) with an even stronger negative correlation in males (rPVA = −0.607, rQCA = −0.607). ROC analysis demonstrated that DSQCA myocardial ischemia (FFR ≤ 0.80) discrimination capability was superior to DSPVA in both sexes (P Conclusions A systematic bias was found in PVA (QCA reference) for overestimating severity of coronary artery disease in females compared to males.

Background The COVID-19 pandemic has affected patients with ST-segment elevation myocardial infarction (STEMI) requiring primary percutaneous coronary intervention (PCI) worldwide. In this review we examine the global effect of the COVID-19 pandemic on incidence of STEMI admissions, and relationship between the pandemic and door to balloon time (D2B), all-cause mortality, and other secondary STEMI outcomes. Methods We performed a systematic review and meta-analysis to primarily compare D2B time and in-hospital mortality of STEMI patients who underwent primary PCI during and before the pandemic. Subgroup analyses were performed to investigate the influence of geographical region and income status of a country on STEMI care. An online database search included studies that compared the aforementioned outcomes of STEMI patients during and before the pandemic. Results In total, 32 articles were analyzed. Overall, 19,140 and 68,662 STEMI patients underwent primary PCI during and before the pandemic, respectively. Significant delay in D2B was observed during the pandemic (weighted mean difference, 8.10 minutes; 95% confidence interval [CI], 3.90-12.30 minutes; P = 0.0002; I2 = 90%). In-hospital mortality was higher during the pandemic (odds ratio [OR], 1.27; 95% CI, 1.09-1.49; P = 0.002; I2 = 36%), however this varied with factors such as geographical location and income status of a country. Subgroup analysis showed that low–middle-income countries observed a higher rate of mortality during the pandemic (OR, 1.52; 95% CI, 1.13-2.05; P = 0.006), with a similar but insignificant trend seen among the high income countries (OR, 1.17; 95% CI, 0.95-1.44; P = 0.13). Conclusions The COVID-19 pandemic is associated with worse STEMI performance metrics and clinical outcome, particularly in the Eastern low–middle-income status countries. Better strategies are needed to address these global trends in STEMI care during the pandemic.

Omeprazole is commonly co-prescribed with clopidogrel. Clopidogrel requires bio-activation by cytochrome P450 CYP2C19. Omeprazole may reduce clopidogrel’s antithrombotic efficacy by inhibiting CYP2C19. Studies in Caucasians receiving omeprazole with clopidogrel showed no significant increase in death and myocardial infarction with this drug–drug interaction. There are limited large-scale studies in Asians, who may have a greater prevalence of CYP2C19 loss-of-function polymorphisms. A single centre retrospective cohort study was undertaken based on a review of medication records and prescription data. Patients prescribed clopidogrel from 2009 to 2012 were followed-up with until December 2012 (median:29 months). The primary outcome was all-cause mortality and secondary outcomes were myocardial infarction (MI), cerebrovascular accidents, and subsequent coronary interventions. Of 12,440 patients prescribed clopidogrel, 62%(n = 7714) were on omeprazole (63.8% Chinese, 13.9% Malay, 12.4% Indian, 10.0% others), and 38%(n = 4726) were not on omeprazole or other proton pump inhibitors (62.6% Chinese, 13.5% Malay, 10.7% Indian, 13.2% others). Mortality after co-prescription occurred in 14.3%(n = 1101) of patients, compared to 6.3%(n = 300) of patients prescribed clopidogrel only. Multivariate analysis using propensity score adjusted analysis showed no significant increase in all-cause mortality with co-prescription (adjusted hazards ratio [AHR] 1.13, [95%CI 0.95–1.35]). Patients on co-prescription had a higher risk of subsequent MI (16% vs 3.8%; AHR 2.03 [95%CI 1.70–2.44]), but not of cerebrovascular accidents (5.0% vs 2.0%; AHR 0.98 [95%CI 0.76–1.27]) or coronary interventions (1.7% vs 0.7%; AHR 1.28 [95%CI 0.83–1.96]). The risk of a subsequent MI was higher in the Malay (AHR 2.43 [95%CI 1.68–3.52]) and Chinese (AHR 2.06 [95%CI 1.63–2.60]) population as compared to the Indian (AHR 1.56 [95%CI 1.06–2.31]) population. In conclusion, the use of clopidogrel with omeprazole is associated with an increased risk of MI, but not mortality or stroke, in this multi-ethnic Asian population. These risks appear to vary among different ethnic groups.

BACKGROUND: Little is known about the effect of the coronavirus disease 2019 (COVID-19) pandemic and the outbreak response measures on door-to-balloon time (D2B). This study examined both D2B and clinical outcomes of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).Methods and Results:This was a retrospective study of 303 STEMI patients who presented directly or were transferred to a tertiary hospital in Singapore for PPCI from October 2019 to March 2020. We compared the clinical outcomes of patients admitted before (BOR) and during (DOR) the COVID-19 outbreak response. The study outcomes were in-hospital death, D2B, cardiogenic shock and 30-day readmission. For direct presentations, fewer patients in the DOR group achieved D2B time

Automatic segmentation of the left ventricle (LV) in late gadolinium enhanced (LGE) cardiac MR (CMR) images is difficult due to the intensity heterogeneity arising from accumulation of contrast agent in infarcted myocardium. In this paper, we present a comprehensive framework for automatic 3D segmentation of the LV in LGE CMR images. Given myocardial contours in cine images as a priori knowledge, the framework initially propagates the a priori segmentation from cine to LGE images via 2D translational registration. Two meshes representing respectively endocardial and epicardial surfaces are then constructed with the propagated contours. After construction, the two meshes are deformed towards the myocardial edge points detected in both short-axis and long-axis LGE images in a unified 3D coordinate system. Taking into account the intensity characteristics of the LV in LGE images, we propose a novel parametric model of the LV for consistent myocardial edge points detection regardless of pathological status of the myocardium (infarcted or healthy) and of the type of the LGE images (short-axis or long-axis). We have evaluated the proposed framework with 21 sets of real patient and 4 sets of simulated phantom data. Both distance- and region-based performance metrics confirm the observation that the framework can generate accurate and reliable results for myocardial segmentation of LGE images. We have also tested the robustness of the framework with respect to varied a priori segmentation in both practical and simulated settings. Experimental results show that the proposed framework can greatly compensate variations in the given a priori knowledge and consistently produce accurate segmentations., Medical Image Analysis, Volume 17, Issue 6, August 2013, Pages 685-697

An anaerobic bacterial strain, named TLL-A4T, was isolated from fecal pellets of conventionally raised C57BL/6J mice. Analysis of the 16S rRNA gene indicated that the strain belongs to the phylum Bacteroidetes and, more specifically, to the recently proposed Muribaculaceae (also known as S24-7 clade or Candidatus Homeothermaceae). Strain TLL-A4T’s 16S rRNA gene shared 92.8 % sequence identity with the type strain of the only published species of the genus Muribaculum , Muribaculum intestinale DSM 28989T. Genome-sequencing of TLL-A4T was performed to compare average amino acid identity (AAI) value and percentage of conserved proteins (POCP) between both strains. The AAI analysis revealed that strain TLL-A4T had high identity (69.8 %) with M. intestinale DSM 28989T, while the POCP was 56 %. These values indicate that strain TLL-A4T could be considered a member of the genus Muribaculum but not belonging to the species M. intestinale . Quinone analysis indicated MK10 (63 %) and MK11 (32 %) as major quinones in the membrane, while MK9 was only present as a minor component (5 %). The main cellular fatty acid was anteiso-C15 : 0 (42.8 %); summed feature 11 (17.5 %), C15 : 0 iso (13.4 %), C18 : 1 ω9c (5.6 %), C16.0 3-OH (4.5 %) and C15 : 0 (4.2 %) were detected in minor amounts. Analysis of enzyme activities using the API 32A and API 20A kits indicated major differences between strain TLL-A4T and Muribaculum intestinale DSM 28989T. Based on genotypic, phylogenetic and phenotypic differences, strain TLL-A4T is considered to represent a novel species of the genus Muribaculum , for which the name Muribaculum gordoncarteri sp. nov. is proposed. The type strain is TLL-A4T (=DSM 108194T=KCTC 15770T).

While brachial mean blood pressure (MBP) and left ventricular mass (LVM) measured from CTCA are the two CFD simulation input parameters, their effects on noninvasive fractional flow reserve (FFRB) have not been systematically investigated. We demonstrate that inaccurate MBP and LVM inputs differing from patient-specific values could result in misclassification of borderline ischemic lesions. This is important in the clinical application of noninvasive FFR in coronary artery disease diagnosis.

Three bacterial strains, C9, H5 and TLL-A3, were isolated from fecal pellets of conventionally raised C57BL/6J mice. Analysis of 16S rRNA genes indicated that the strains belonged to the Muribaculaceae , and shared 91.6–99.9 % sequence identity with the recently described Duncaniella muris DSM 103720T. Genome-sequencing of the isolates was performed to compare average nucleotide identities (ANI) between strains. The ANI analysis revealed that all isolates shared highest ANI with D. muris DSM 103720T, with strain C9 being most similar (ANI: 98.0 %) followed by strains H5 (ANI: 76.4 %) and TLL-A3 (ANI: 74.4 %). Likewise, digital DNA–DNA hybridization (dDDH) indicated high similarity of strain C9 (dDDH: 86.6 %) to D. muris DSM 103720T, but strains H5 and TLL-A3 showed lower similarity (dDDH Muribaculaceae ( Muribaculum intestinale DSM 28989T , Paramuribaculum intestinale DSM 100749T, D. muris DSM 103720T). MK-10 and MK-11 were abundant in all three isolates, but concentrations varied between species. Based on genotypic, phylogenetic and phenotypic differences, the strains TLL-A3 and H5 are considered to represent novel species of the genus Duncaniella , for which the names Duncaniella freteri sp. nov., and Duncaniella dubosii sp. nov., are proposed. The respective type strains are TLL-A3T (=DSM 108168T=KCTC 15769T), and H5T (=DSM 107170T=KCTC 15734T). Strain C9 reveals limited sequence dissimilarity and minor differences in morphological properties with Duncaniella muris DSM 103720T and is therefore proposed to belong to the same species. The respective strain is C9 (=DSM 107165=KCTC 15733).

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

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results. We performed a systematic review up to May 23, 2021, and 1-stage reconstructed individual patient data meta-analysis (IPDMA) to compare outcomes between both groups. The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke, and unplanned revascularization at 5 years. We performed individual patient data meta-analysis using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups. Of 583 articles retrieved, 5 RCTs were included. A total of 4,595 patients from these 5 RCTs were randomly assigned to PCI (n = 2,297) or CABG (n = 2,298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6%, respectively (hazard ratio [HR] 1.093, 95% confidence interval [CI] 0.925 to 1.292; p = 0.296). PCI conferred similar time-to-MI (restricted mean survival time ratio 1.006, 95% CI 0.992 to 1.021, p=0.391) and stroke (restricted mean survival time ratio 1.005, 95% CI 0.998 to 1.013, p = 0.133) at 5 years. Unplanned revascularization was more frequent after PCI than CABG (HR 1.807, 95% CI 1.524 to 2.144, p0.001) at 5 years. This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Background: Infectious control measures during the COVID-19 pandemic have led to the propensity toward telemedicine. This study examined the impact of telemedicine during the pandemic on the long-term outcomes of ST-segment elevation myocardial infarction (STEMI) patients.Methods: This study included 288 patients admitted 1 year before the pandemic (October 2018–December 2018) and during the pandemic (January 2020–March 2020) eras, and survived their index STEMI admission. The follow-up period was 1 year. One-year primary safety endpoint was all-cause mortality. Secondary safety endpoints were cardiac readmissions for unplanned revascularisation, non-fatal myocardial infarction, heart failure, arrythmia, unstable angina. Major adverse cardiovascular events (MACE) was defined as the composite outcome of each individual safety endpoint.Results: Despite unfavorable in-hospital outcomes among patients admitted during the pandemic compared to pre-pandemic era, both groups had similar 1-year all-cause mortality (11.2 vs. 8.5%, respectively, p = 0.454) but higher cardiac-related (14.1 vs. 5.1%, p < 0.001) and heart failure readmissions in the pandemic vs. pre-pandemic groups (7.1 vs. 1.7%, p = 0.037). Follow-up was more frequently conducted via teleconsultations (1.2 vs. 0.2 per patient/year, p = 0.001), with reduction in physical consultations (2.1 vs. 2.6 per patient/year, p = 0.043), during the pandemic vs. pre-pandemic era. Majority achieved guideline-directed medical therapy (GDMT) during pandemic vs. pre-pandemic era (75.9 vs. 61.6%, p = 0.010). Multivariable Cox regression demonstrated achieving medication target doses (HR 0.387, 95% CI 0.164–0.915, p = 0.031) and GDMT (HR 0.271, 95% CI 0.134–0.548, p < 0.001) were independent predictors of lower 1-year MACE after adjustment.Conclusion: The pandemic has led to the wider application of teleconsultation, with increased adherence to GDMT, enhanced medication target dosing. Achieving GDMT was associated with favorable long-term prognosis.

The clinical significance of coronary artery ectasia (CAE) is not yet fully understood. We aimed to examine differences in clinical and procedural characteristics, clinical management, and outcomes in patients with CAE undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI).This was a retrospective analysis of consecutive patients presenting with STEMI with a culprit native coronary artery from July 2015 to June 2019. Patients were divided into CAE and Non-CAE groups as detected on coronary angiography during PPCI. Comparison between groups was made for baseline clinical and procedural characteristics, as well as complications, pharmacological treatment, and follow-up outcomes.36/1780 (2.0%) patients were found to have CAE. Patients with CAE had a median age of 57.1 ± 11.7 years and were more likely to be male 33/36 (91.7%). Diabetes was less commonly seen in the CAE group (11.1% vs 31.4%, p = 0.010), and there were no differences in the proportion of patients with hypertension and hyperlipidemia. Patients with CAE had more involvement of right coronary artery (RCA) culprit vessel (63.9% vs. 38.4%, p = 0.026), less coronary stenting (25.0% vs 87.2%, p 0.001) and post-PPCI TIMI 3 flow (69.4% vs 95.5%, P 0.001), and were more likely to be discharged with oral anticoagulants (36.1% vs 7.6%, p 0.001). At 3-year follow-up, all-cause mortality rates were higher in the non-CAE group (0.0% vs 11.5%, p 0.028), suggesting that CAE was not associated with unfavorable long-term outcome. On multivariate analysis, CAE was not an independent predictor of MACE.Despite lower rates of post-PPCI TIMI 3 flow, CAE was not associated with unfavorable long-term outcome.

IMPORTANCEThere are growing concerns that patients suffering from acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRFs), including hypertension, hypercholesterolemia, diabetes and smoking, have increased mortality.OBJECTIVEThis study examined the outcomes of ACS in patients without SMuRFs (termed SMuRF-less) in a multi-ethnic Asian population which remains unknown.DESIGNThis retrospective study was conducted from 1st January 2011 to 31st March 2021.SETTINGThis study was conducted in a tertiary healthcare institution in Singapore.PARTICIPANTSConsecutive patients presenting with ACS disease were recruited in the study.EXPOSUREThe outcomes of SMuRF-less patients were compared with SMuRF patients.MAIN OUTCOMES AND MEASURESThe primary outcome was cardiovascular mortality. Secondary outcomes were all-cause mortality, readmission, cardiogenic shock, stroke and heart failure. Multivariable regression analysis adjusted for covariates including age, sex, ethnicity, chronic kidney disease, ACS type, cardiac arrest, and left main and/or left anterior descending coronaryRESULTSOf the 8680 patients studied, 8.6% were SMuRF-less patients. SMuRF-less patients were significantly younger and had fewer comorbidities including stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement compared to the SMuRF group. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI 1.09–1.86, p=0.048), cardiogenic shock (RR: 1.31, 95% CI 1.09–1.52, p=0.015) and stroke (RR: 2.51, 95% CI 1.67–3.34, p=0.030) in SMuRF-less patients compared to SMuRF patients. Both groups had similar readmission (RR: 1.10, 95% CI 0.87–1.39, p=0.413) and heart failure (RR: 0.82, 95% CI 0.56–1.21, p=0.326) rates. Kaplan-Meier curve showed higher 30-day cardiovascular mortality in the SMuRF-less group compared to SMuRF group (HR: 1.84, 95% CI 1.45-2.33, pCONCLUSION AND RELEVANCEAlthough the proportion of ACS patients without standard risk factors in our Asian population is lower than those reported in the West, they also have worse short-term mortality compared to those with SMuRF. This calls for a global focus on the management of this unexpectedly high-risk subgroup of patients.

ObjectiveST segment elevation myocardial infarction (STEMI) is associated with significant mortality leading to loss of productive life years, especially in younger patients. This study aims to compare the characteristics and outcomes of young versus older patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) to help focus public health efforts in STEMI prevention.MethodsData from the Coronary Care Unit database of the National University Hospital, Singapore from July 2015 to June 2019 were reviewed. Patients were divided into young (ResultsOf the 1818 consecutive patients with STEMI who underwent PPCI, 465 (25.6%) were ConclusionYoung patients with STEMI are more often smokers, of Indian ethnicity and had family history of IHD, although cardiometabolic risk factors are also prevalent. Mortality is lower, but not negligible, among the young patients with STEMI. Public health efforts are needed to reduce the prevalence of these risk factors among the constitutionally susceptible population.

Dietary changes are known to alter the composition of the gut microbiome. However, it is less understood how repeatable and reversible these changes are and how diet switches affect the microbiota in the various segments of the gastrointestinal tract. Here, a treatment group of conventionally raised laboratory mice is subjected to two periods of western diet (WD) interrupted by a period of standard diet (SD) of the same duration. Beta-diversity analyses show that diet-induced microbiota changes are largely reversible (q = 0.1501; PERMANOVA, weighted-UniFrac comparison of the treatment-SD group to the control-SD group) and repeatable (q = 0.032; PERMANOVA, weighted-UniFrac comparison of both WD treatments). Furthermore, we report that diet switches alter the gut microbiota composition along the length of the intestinal tract in a segment-specific manner, leading to gut segment-specific Firmicutes/Bacteroidota ratios. We identified prevalent and distinct Amplicon Sequencing Variants (ASVs), particularly in genera of the recently described Muribaculaceae, along the gut as well as ASVs that are differentially abundant between segments of treatment and control groups. Overall, this study provides insights into the reversibility of diet-induced microbiota changes and highlights the importance of expanding sampling efforts beyond the collections of fecal samples to characterize diet-dependent and segment-specific microbiome differences.

During my 3 months’ rotation through the coronary care unit (CCU) as a sophomore in cardiology residency, I had to manage a wide variety of patients with different clinical presentations who were also critically ill. These were patients who presented with ST-segment elevation myocardial

It is unclear whether universal access to primary percutaneous coronary intervention (pPCI) may reduce sex differences in 1-year rehospitalization for heart failure (HF) and myocardial infarction (MI) after ST-elevation myocardial infarction (STEMI). We studied 7,597 consecutive STEMI patients (13.8% women, n = 1,045) who underwent pPCI from January 2007 to December 2013. Cox regression models adjusted for competing risk from death were used to assess sex differences in rehospitalization for HF and MI within 1 year from discharge. Compared with men, women were older (median age 67.6 vs 56.0 years, p0.001) with higher prevalence of co-morbidities and multivessel disease. Women had longer median door-to-balloon time (76 vs 66 minutes, p0.001) and were less likely to receive drug-eluting stents (19.5% vs 24.1%, p = 0.001). Of the medications prescribed at discharge, fewer women received aspirin (95.8% vs 97.6%, p = 0.002) and P2Y

Background Clinicians need improved tools to better identify nonacute heart failure with preserved ejection fraction (HFpEF). Objectives The purpose of this study was to derive and validate circulating microRNA signatures for nonacute heart failure (HF). Methods Discovery and validation cohorts (N = 1,710), comprised 903 HF and 807 non-HF patients from Singapore and New Zealand (NZ). MicroRNA biomarker panel discovery in a Singapore cohort (n = 546) was independently validated in a second Singapore cohort (Validation 1; n = 448) and a NZ cohort (Validation 2; n = 716). Results In discovery, an 8-microRNA panel identified HF with an area under the curve (AUC) 0.96, specificity 0.88, and accuracy 0.89. Corresponding metrics were 0.88, 0.66, and 0.77 in Validation 1, and 0.87, 0.58, and 0.74 in Validation 2. Combining microRNA panels with N-terminal pro–B-type natriuretic peptide (NT-proBNP) clearly improved specificity and accuracy from AUC 0.96, specificity 0.91, and accuracy 0.90 for NT-proBNP alone to corresponding metrics of 0.99, 0.99, and 0.93 in the discovery and 0.97, 0.96, and 0.93 in Validation 1. The 8-microRNA discovery panel distinguished HFpEF from HF with reduced ejection fraction with AUC 0.81, specificity 0.66, and accuracy 0.72. Corresponding metrics were 0.65, 0.41, and 0.56 in Validation 1 and 0.65, 0.41, and 0.62 in Validation 2. For phenotype categorization, combined markers achieved AUC 0.87, specificity 0.75, and accuracy 0.77 in the discovery with corresponding metrics of 0.74, 0.59, and 0.67 in Validation 1 and 0.72, 0.52, and 0.68 in Validation 2, as compared with NT-proBNP alone of AUC 0.71, specificity 0.46, and accuracy 0.62 in the discovery; with corresponding metrics of 0.72, 0.44, and 0.57 in Validation 1 and 0.69, 0.48, and 0.66 in Validation 2. Accordingly, false negative (FN) (81% Singapore and all NZ FN cases were HFpEF) as classified by a guideline-endorsed NT-proBNP ruleout threshold, were correctly reclassified by the 8-microRNA panel in the majority (72% and 88% of FN in Singapore and NZ, respectively) of cases. Conclusions Multi-microRNA panels in combination with NT-proBNP are highly discriminatory and improved specificity and accuracy in identifying nonacute HF. These findings suggest potential utility in the identification of nonacute HF, where clinical assessment, imaging, and NT-proBNP may not be definitive, especially in HFpEF.

Dietary changes are known to alter the composition of the gut microbiome. However, it is less understood how repeatable and reversible these changes are and how diet-switches affect the microbiota in the various segments of the gastrointestinal tract. Here, a treatment group of conventionally raised laboratory mice is subjected to two periods of western diet (WD) interrupted by a period of standard diet (SD) of the same duration. Beta-diversity analyses show that diet-induced microbiota changes are largely reversible (q = 0.1501; PERMANOVA, weighted-UniFrac comparison of the treatment-SD group to the control-SD group) and repeatable (q = 0.032; PERMANOVA, weighted-UniFrac comparison of both WD treatments). Furthermore, we report that diet switches alter the gut microbiota composition along the length of the intestinal tract in a segment-specific manner, leading to gut segment-specific Firmicutes/Bacteroidota ratios. We identified prevalent and distinct Amplicon Sequencing Variants (ASVs), particularly in genera of the recently described Muribaculaceae, along the gut as well as ASVs that are differentially abundant between segments of treatment and control groups. Overall, this study provides insights into the reversibility of diet-induced microbiota changes and highlights the importance to expand sampling efforts beyond the collections of fecal samples to characterize diet-dependent and segment-specific microbiome differences.

Omeprazole is commonly co-prescribed with clopidogrel. Clopidogrel requires bio-activation by cytochrome P450 CYP2C19. Omeprazole may reduce clopidogrel's antithrombotic efficacy by inhibiting CYP2C19. Studies in Caucasians receiving omeprazole with clopidogrel showed no significant increase in death and myocardial infarction with this drug-drug interaction. There are limited large-scale studies in Asians, who may have a greater prevalence of CYP2C19 loss-of-function polymorphisms. A single centre retrospective cohort study was undertaken based on a review of medication records and prescription data. Patients prescribed clopidogrel from 2009 to 2012 were followed-up with until December 2012 (median:29 months). The primary outcome was all-cause mortality and secondary outcomes were myocardial infarction (MI), cerebrovascular accidents, and subsequent coronary interventions. Of 12,440 patients prescribed clopidogrel, 62%(n = 7714) were on omeprazole (63.8% Chinese, 13.9% Malay, 12.4% Indian, 10.0% others), and 38%(n = 4726) were not on omeprazole or other proton pump inhibitors (62.6% Chinese, 13.5% Malay, 10.7% Indian, 13.2% others). Mortality after co-prescription occurred in 14.3%(n = 1101) of patients, compared to 6.3%(n = 300) of patients prescribed clopidogrel only. Multivariate analysis using propensity score adjusted analysis showed no significant increase in all-cause mortality with co-prescription (adjusted hazards ratio [AHR] 1.13, [95%CI 0.95-1.35]). Patients on co-prescription had a higher risk of subsequent MI (16% vs 3.8%; AHR 2.03 [95%CI 1.70-2.44]), but not of cerebrovascular accidents (5.0% vs 2.0%; AHR 0.98 [95%CI 0.76-1.27]) or coronary interventions (1.7% vs 0.7%; AHR 1.28 [95%CI 0.83-1.96]). The risk of a subsequent MI was higher in the Malay (AHR 2.43 [95%CI 1.68-3.52]) and Chinese (AHR 2.06 [95%CI 1.63-2.60]) population as compared to the Indian (AHR 1.56 [95%CI 1.06-2.31]) population. In conclusion, the use of clopidogrel with omeprazole is associated with an increased risk of MI, but not mortality or stroke, in this multi-ethnic Asian population. These risks appear to vary among different ethnic groups.

The life-long relationship between microorganisms and hosts has a profound impact on the overall health and physiology of the holobiont. Changes in microbiome composition throughout the lifespan of a host remain, however, largely understudied. In this study, the fecal microbiome of conventionally raised C57BL/6J mice was analyzed throughout almost the entire expected lifespan, from ‘maturing’ (9 weeks) until ‘very old’ age (112 weeks). Analysis of alpha and beta diversity suggests that gradual microbiome changes occur throughout the entire murine life but appear to be more pronounced in ‘maturing’ to ‘middle-aged’ phases. Phylum-level analysis indicates a shift in the Firmicutes/Bacteroidetes ratio in favor of the Firmicutes in the second year of adulthood. Varying successional patterns throughout life were observed for many Firmicutes OTUs, while relative abundances of Bacteroidetes OTUs varied primarily in the early life phases. Microbiome configurations at given time points were used as training sets in a Bayesian model, which in turn effectively enabled the prediction of host age. The fecal microbiome composition may therefore serve as an accurate biomarker for aging. This study further suggests that age-associated compositional differences may have considerable implications for the interpretation and comparability of animal model-based microbiome studies.ImportanceThe life-long relationship between microorganisms and hosts has a profound impact on the overall physiology of the holobiont. Understanding the extent of gut microbiome compositional changes over the expected mouse lifespan may allow to better understand the interplay of microbiome and the host at the different life stages. In this study, we performed a two-year longitudinal study of murine fecal microbiome. Using fine-scale microbiome profiling we were able to predict the host age from the fecal microbiome composition. Moreover, we observed that the rate of compositional change appears to slow with age. The description of the compositional changes in commonly used C57BL/6J mice can be used to optimize selection of age-associated mouse models and highlights the use of microbiome-profiling as biomarker for aging.

Coronary bifurcation intervention is common but complex. Progress in this field has been made in recent years with considerable contribution from the Asia Pacific (APAC) region. However, the standard of practice varies across the APAC region due to differences in culture, socioeconomic state and healthcare set-up. Practice may also differ from the rest of the world. Hence, a panel of experts was invited to discuss topics relevant to bifurcation intervention in order to make a concerted effort to achieve consensus that is applicable within the region and in line with available evidence.

Background Haptoglobin (Hp) is a plasma protein with strong anti‐inflammation and antioxidant activities. Its plasma level is known to be inversely associated with many inflammatory diseases, including cardiovascular diseases. However, the association of HP genetic variants with coronary artery disease (CAD) severity/mortality, and how they interact with common CAD risk factors are largely unknown. Methods We conducted the analysis in a Singaporean Chinese CAD population with Gensini severity scores (N = 582) and subsequently evaluated the significant findings in an independent cohort with cardiovascular mortality (excluding stroke) as outcome (917 cases and 19,093 controls). CAD risk factors were ascertained from questionnaires, and stenosis information from medical records. Mortality was identified through linkage with the nationwide registry of births and deaths in Singapore. Linear regression analysis between HP genetic variant (rs217181) and disease outcome were performed. Interaction analyses were performed by introducing an interaction term in the same regression models. Results Although rs217181 was not significantly associated with CAD severity and cardiovascular mortality (excluding stroke) in all subjects, when stratified by hypertension status, hypertensive individuals with the minor T allele have more severe CAD (β = 0.073, SE = 0.030, p = 0.015) and non‐hypertensive individuals with the T allele have lower risk for mortality (odds ratio = 0.771 (0.607–0.980), p = 0.033). Conclusion HP genetic variant is not associated with CAD severity and mortality in the general population. However, hypertensive individuals with the rs217181 T allele associated with higher Hp levels had more severe CAD while non‐hypertensive individuals with the same allele had lower risk for mortality in the Chinese population., Hp genetic variant is not associated with CAD severity and mortality in the general population. However, hypertensive individuals with the rs217181 T allele which is associated with higher Hp levels had more severe CAD, while non‐hypertensive individuals with the same allele had lower risk for mortality in the Chinese population.

Androgen dependent tissue factor pathway inhibitor regulating protein (ADTRP) is a novel protein associated with coronary artery disease (CAD) susceptibility, and reduced mRNA expression of ADTRP was shown to be associated with increased CAD risk. This study aimed to determine and compare circulating ADTRP levels between CAD patients and controls, and to test the performance of plasma ADTRP as a biomarker for CAD. We measured plasma ADTRP, tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and high sensitivity-C reactive protein (hs-CRP) levels in 362 CAD patients, 150 angiographically negative CAD controls, and 83 healthy adults with no known clinical or medical conditions using commercial ELISA. Statistical analyses were performed using receiver operator characteristic (ROC) curves, quantile regression and logistic regression, with adjustments for age, gender, ethnicity and BMI. CAD patients had significantly lower plasma ADTRP levels 1,545 (1,087-2,408) pg/ml as compared to CAD controls 2,259 (1,533-3,778) pg/ml and healthy adults 3,904 (2,732-5,463) pg/ml. Plasma ADTRP outperformed the other three inflammatory biomarkers (TNF-α, IL-6 and hs-CRP) for CAD (Area under ROC curve: 0.67, Odds ratio (OR): 0.907). Our study has shown for the first time that ADTRP is present in circulation, and that plasma ADTRP may be a novel independent biomarker for CAD.

Introduction This study aimed to investigate the causes, clinical management and outcomes of clinically significant pericardial effusions, and evaluate the practice of pericardiocentesis within an academic medical centre in Singapore, a multiethnic country in Southeast Asia. Methods Consecutive patients undergoing pericardiocentesis at a single Asian academic medical centre were identified. Patient demographics, echocardiographic findings, investigations, pericardiocentesis procedural details and clinical progress were tracked using a comprehensive electronic medical records system. Results Of 149 patients who underwent pericardiocentesis, malignancy (46.3%) was the most common cause of pericardial effusions, followed by iatrogenic postsurgical complications (17.4%). 77.3% of effusions were large and 69.8% demonstrated tamponade physiology. Pericardiocentesis guided by echocardiography and fluoroscopy was successful in 99.3% of patients and had a complication rate of 2.0%. Likelihood of effusion recurrence and survival to discharge was determined by the aetiology of the pericardial effusion. 24.6% of malignant effusions recurred, and the survival rate 12 months after drainage of a malignant pericardial effusion was 45.0%. Short-term mortality was highest among patients presenting with tamponade due to acute aortic syndromes and those with myocardial rupture due to ischaemic heart disease. Conclusion Cancer and iatrogenic complications were the most common causes of pericardial effusion in this large cohort of Singapore patients. Pericardiocentesis has a high success rate and relatively low complication rate. Prognosis and clinical course after pericardiocentesis are determined by the underlying cause of the pericardial effusion.

Background/purpose Percutaneous coronary intervention (PCI) of diffuse coronary artery disease (CAD) is associated with higher adverse clinical events. This study aimed to compare the clinical outcomes of patients treated with single long 48 mm contemporary drug eluting stents (SL-DES) versus two overlapping contemporary drug eluting stents (OL-DES) for very-long CAD. Methods/materials We analyzed the clinical outcome of 117 patients with SL-DES and 101 patients with OL-DES who underwent PCI between 1st July 2013 to 31st December 2016. The primary endpoint was target lesion failure (TLF) at two years, defined as a composite of cardiac mortality, target vessel myocardial infarction and target lesion revascularization. Results Mean age was 60.8 ± 10.5 years for SL-DES group and 60.5 ± 11.9 years in the OL-DES group. SL-DES has longer mean lesion length as compared to OL-DES (43.1 ± 3.7 mm vs. 41.83 ± 2.3 mm p = 0.003). There was no difference in TLF at two years between SL-DES and OL-DES (5.3% vs. 6.4%, adjusted odds ratio 1.43, 95% CI 0.50–4.11). There was one case of probable ST in each group. Contrast volume usage was lower for SL-DES than OL-DES in patients who underwent single vessel PCI. Conclusions Treatment of very-long CAD showed comparable TLF at two years for SL-DES versus OL-DES. Our results suggest that both strategies are reasonable treatment options for patients with diffuse CAD.

Gender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).We analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03-6.03 years).There were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders.Females were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.

Objectives To evaluate the target lesion failure (TLF) rate of the SYNERGY stent in all-comers, multiethnic Asian population. Background Currently, most drug eluting stents deliver anti-proliferative drugs from a durable polymer which is associated with a risk of late stent thrombosis. The novel everolimus-eluting, platinum chromium SYNERGY stent is coated with a bioabsorbable abluminal polymer that resolves within 4 months. Methods This was a prospective, single center registry of consecutive patients treated with the SYNERGY stent between December 2012 and April 2015. The primary outcome was the incidence of TLF, defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization (TLR) at 1 year. Results A total of 807 patients received the SYNERGY stent during the study period. One-year clinical outcome data was available for 765 patients (94.8%) and were considered for statistical analysis. The mean age was 60.7 ± 10.8 years, and 83.4% were males. Patients with acute myocardial infarction consisted of 50.3% (ST-segment elevation myocardial infarction: 23.0%, Non-ST-segment elevation myocardial infarction: 27.3%) of the study population. The treated lesions were complex (ACC/AHA type B2/C: 72.7%). The primary end point of TLF at 1 year was 5.8%. Rates of cardiac mortality, target vessel myocardial infarction, and TLR were 4.2, 1.0, and 1.3%, respectively, at 1 year. Predictors of the incidence and time to early TLF were female gender, Malay ethnicity, diabetes mellitus, acute myocardial infarction at presentation, a prior history of coronary artery bypass surgery and the presence of lesion calcification. The incidence of definite stent thrombosis was 0.4% at 1 year. Conclusions In this registry, the use of the SYNERGY stent was associated with low rates of TLF at 1 year.

The management of in-stent restenosis continues to be a common challenge in modern interventional cardiology. Drug-eluting stents have emerged to be an effective treatment following bare-metal stent in-stent restenosis as compared with drug-coated balloon angioplasty and repeat bare-metal stenting. The addition of another metallic layer is however undesirable and may limit further treatment options. In the last few years, everolimus-eluting bioresorbable vascular scaffolds have become available in treating native coronary artery disease with complete hydrolysis into water and carbon dioxide within 3-5 years. To exploit this property, we successfully used it to manage a case of drug-eluting stent in-stent restenosis from a previously under-expanded stent as demonstrated in this case. Small registry series have also recently been published supporting favorable outcomes with this approach. To the best of our knowledge, this case has the longest optical coherence tomography follow-up beyond 3 years. .

Due to massive production and improper handling, organohalide compounds are widely distributed in subsurface environments, primarily in anoxic groundwater, soil and sediment. Compared to traditional pump-and-treat or dredging-and-disposal treatments, in situ remediation employing abiotic or biotic reductive dehalogenation represents a sustainable and economic solution for the removal of organohalide pollutants. Both nanoscale zero-valent iron (nZVI) and organohalide-respiring bacteria remove halogens through reductive dehalogenation and have been extensively studied and successfully applied for the in situ remediation of chloroethenes and other organohalide pollutants. nZVI and microbial reductive dehalogenation (Bio-RD) complement each other to boost reductive dehalogenation efficiency, suggesting that the integration of nZVI with Bio-RD (Bio-nZVI-RD) may constitute an even more promising strategy for the in situ remediation of organohalide pollutants. In this review, we first provide an overview of the current literature pertaining to nZVI- and organohalide-respiring bacteria-mediated reductive dehalogenation of organohalide pollutants and compare the pros and cons of individual treatment methods. We then highlight recent studies investigating the implementation of Bio-nZVI-RD to achieve rapid and complete dehalogenation and discuss the halogen removal mechanism of Bio-nZVI-RD and its prospects for future remediation applications. In summary, the use of Bio-nZVI-RD facilitates opportunities for the effective in situ remediation of a wide range of organohalide pollutants.

Background Cardiovascular magnetic resonance (CMR) sequences are commonly used to obtain a complete description of the function and structure of the heart, provided that accurate measurements are extracted from images. New methods of extraction of information are being developed, among them, deep neural networks are powerful tools that showed the ability to perform fast and accurate segmentation. Iq1n order to reduce the time spent by reading physicians to process data and minimize intra- and inter-observer variability, we propose a fully automatic multi-scan CMR image analysis pipeline. Methods Sequence specific U-Net 2D models were trained to perform the segmentation of the left ventricle (LV), right ventricle (RV) and aorta in cine short-axis, late gadolinium enhancement (LGE), native T1 map, post-contrast T1, native T2 map and aortic flow sequences depending on the need. The models were trained and tested on a set of data manually segmented by experts using semi-automatic and manual tools. A set of parameters were computed from the resulting segmentations such as the left ventricular and right ventricular ejection fraction (EF), LGE scar percentage, the mean T1, T1 post, T2 values within the myocardium, and aortic flow. The Dice similarity coefficient, Hausdorff distance, mean surface distance, and Pearson correlation coefficient R were used to assess and compare the results of the U-Net based pipeline with intra-observer variability. Additionally, the pipeline was validated on two clinical studies. Results The sequence specific U-Net 2D models trained achieved fast (≤ 0.2 s/image on GPU) and precise segmentation over all the targeted region of interest with high Dice scores (= 0.91 for LV, = 0.92 for RV, = 0.93 for Aorta in average) comparable to intra-observer Dice scores (= 0.86 for LV, = 0.87 for RV, = 0.95 for aorta flow in average). The automatically and manually computed parameters were highly correlated (R = 0.91 in average) showing results superior to the intra-observer variability (R = 0.85 in average) for every sequence presented here. Conclusion The proposed pipeline allows for fast and robust analysis of large CMR studies while guaranteeing reproducibility, hence potentially improving patient’s diagnosis as well as clinical studies outcome.

Background We evaluated the effects of sleep-study guided multidisciplinary therapy (SGMT) of obstructive sleep apnoea (OSA) in patients presenting with acute coronary syndrome. Methods Eligible patients were randomized into (1) SGMT, comprised a sleep study during the index admission and continuous positive airway pressure and behavioral therapy for those with at least mild OSA or (2) standard therapy. The primary end point was the change in the plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) level from baseline to the 7-month follow-up. Results A total of 159 patients completed the trial. Of the 70 patients randomized to SGMT, 21 (30%), 15 (22%) and 27 (39%) were diagnosed with mild, moderate and severe OSA, respectively. Continuous positive airway pressure and a positional pillow were prescribed to 57 (91%) and 6 (9%) patients with OSA. Although plasma NT-proBNP levels were lower after 7 months compared to the baseline, the levels did not differ significantly between the SGMT and standard therapy groups at baseline (579 ± 1117 vs. 611 ± 899 pg/dL, p = .851) or at 7 months (90 ± 167 vs. 93 ± 174 pg/dL, p = .996). The changes in NT-proBNP levels from baseline to 7 months were similar with SGMT and standard therapy (−489 vs. –518 pg/dL, p = .726). Similar findings were observed for the plasma ST2 and hs-CRP levels. Conclusions OSA screening and multifaceted treatment during the sub-acute phase of acute coronary syndrome did not further reduce the levels of cardiovascular biomarkers when compared with standard therapy. Clinical Trial Registration: clinicaltrial.gov NCT02599298

Background: Obstructive sleep apnea (OSA) is an emerging risk marker for acute coronary syndrome (ACS). This randomized trial determined the effects of Sleep Study Guided Multidisciplinary Therapy (SGMT) in patients with ACS. Methods: Among the 193 patients recruited, 96 were randomized to the SGMT and 97 to the Standard Therapy (control) groups. SGMT comprised sleep study during index admission and, for those with at least mild OSA, continuous positive airway pressure (CPAP) and behavioral therapy. Primary end point was change in plasma NT-pro BNP level between baseline and 7 months. Other biomarker endpoints included suppression of tumorigenicity 2 (ST2) and hs-CRP. Results: 159 (82%) patients completed the trial. Among the 70 patients in the SGMT group, mild (apnea-hypopnea index 5-15 per hour), moderate (>15-30) and severe (>30) OSA were diagnosed in 30%, 22% and 39% of the patients. In addition to behavioral therapy. CPAP was prescribed to 90% and positional pillow to 10% of the OSA patients. The overall CPAP adherence was 3.8±2.6 hrs per night. None of the 89 patients in the Standard Therapy (control) group underwent OSA screening or treatment. Cardiovascular medications, body mass index, blood pressure, and lipid profile were similar between the 2 groups during the course of the trial. The results are shown in Figure 1. Conclusion: In patients treated with guideline-mandated therapy for ACS, screening and treatment of OSA did not result in further lowering of cardiovascular risk.

Background & aims Although Absorb Bioresorbable Vascular Scaffolds (A-BVS) are routinely used in the Asia-Pacific, there is little information on patient selection or deployment technique here. This document investigates the experiences of leading interventional cardiologists from the Asia-Pacific region with a focus on patient characteristics, deployment techniques and management. Methods and results A detailed questionnaire was distributed to 28 highly-experienced interventional cardiologists (‘Authors') from 13 Asia-Pacific countries. The results were discussed at a meeting on patient selection, technical consideration, deployment practices and patient management. Potential patient benefits of Absorb compared to metallic DES, the learning curve for patient selection and preparation, device deployment, and subsequent patient management approaches are presented. Conclusions Current practices are derived from guidelines optimized for European patients. Differences in approach exist in the Asia-Pacific context, including limited access to imaging and frequency of occurrence of complex lesions. Nevertheless, the use of the Absorb BVS (‘Absorb') in certain Asia-Pacific countries has flourished and practices here are continuing to mature.

Objective: We compared intracranial collaterals on pretreatment and day 2 brain CT angiograms (CTA) to assess their evolution and relationship with functional outcomes in acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA). Methods: Consecutive AIS patients who underwent pretreatment and day 2 CTA and received IV tPA during 2010–2013 were included. Collaterals were evaluated by 2 independent neuroradiologists using 3 predefined criteria: the Miteff system, the Maas system, and 20-point collateral scale by the Alberta Stroke Program Early CT Score methodology. We stratified our cohort by baseline pre-tPA state of their collaterals and by recanalization status of the primary vessel for analysis. Good outcomes at 3 months were defined by a modified Rankin Scale score of 0–1. Results: This study included 209 patients. Delayed collateral recruitment by any grading system was not associated with good outcomes. All 3 scoring systems showed that collateral recruitment on the follow-up CTA from a baseline poor collateral state was significantly associated with poor outcome and increased bleeding risk. When the primary vessel remained persistently occluded, collateral recruitment was significantly associated with worse outcomes. Interestingly, collateral recruitment was significantly associated with increased mortality in 2 of the 3 grading systems. Conclusions: Not all collateral recruitment is beneficial; delayed collateral recruitment may be different from early recruitment and can result in worse outcomes and higher mortality. Prethrombolysis collateral status and recanalization are determinants of how intracranial collateral evolution affects functional outcomes.

Genomes of two trichloroethene (TCE)-respiring Dehalococcoides (Dhc) mccartyi, strains MB and 11a, were sequenced to identify reductive dehalogenases (RDase) responsible for oraganohalide respiration. Transcription analyses were conducted to verify the roles of RDase subunit A genes (rdhA) in chloroethene respiration. Some interesting features of the strain MB draft genome include a large genome size, two CRISPR-cas type I systems, and 38 rdhA genes. Strain 11a has a stream-lined genome with 11 rdhA genes, of which nine are distinct. Quantitative real-time PCR transcription analysis of RDase gene transcripts showed that a single RDase gene, designated mbrA, was up-regulated upon exposure to TCE and no other RDase genes were considerably expressed in strain MB. A single RDase gene, designated vcrA, was up-regulated upon exposure to TCE and expressed at a steady level until all chloroethenes were completely dechlorinated to ethene at 147 h in strain 11a. Overall, this study reports the genomes of two distinct Dhc strains; both contain numerous uncharacterized RDase genes, but in each strain only one such gene was expressed highly during organohalide respiration.