Ji-Hung Wang

Serum uric acid as an independent predictor of mortality in high-risk patients with obstructive coronary artery disease: A prospective observational cohort study from the ET-CHD registry, 1997–2003

BACKGROUND Serum uric acid (SUA) has been observed to be highly associated with the development of cardiovascular disease for more than 50 years. Several studies have reported elevated SUA as an independent predictor of mortality in patients with coronary artery disease (CAD) after adjustment for classic risk factors but some studies did not find similar results. METHODS Between January 1997 and December 2003, a prospective cohort study was performed in 1054 patients with angiographically defined CAD, and their classic risk factors and SUA levels were determined at enrollment. The study cohort was followed for an average of 3.2 years, with a median of 3.1 years. The main outcome measure was death from cardiac disease and any cause. RESULTS Of all study patients, 789 (74.9%) were men and 265 (25.1%) were women. The mean age of the male and female patients was 64.8 and 66.9 years, respectively. The mean SUA level of all patients was 410.4 μmol/L. There were grading effects of SUA quartiles on cardiac and all-cause mortality in univariate and multivariate Cox regression analyses. After adjustment, the multivariate analyses revealed that patients in the highest SUA quartile (>487 μmol/L) had 2.08 (95% CI=1.19-3.62, p=0.01) fold increased risk of cardiac death, and 1.68 (95% CI=1.10-2.57, p=0.017) fold increase risk of overall mortality compared with the lowest quartile (<315 μmol/L). CONCLUSIONS SUA may be a significant predictor of cardiac and overall mortality, independent of classic risk factors in high-risk patients with obstructive CAD.

TSOC-HFrEF Registry: A Registry of Hospitalized Patients with Decompensated Systolic Heart Failure: Description of Population and Management

INTRODUCTION Heart failure (HF) is a medical condition with a rapidly increasing incidence both in Taiwan and worldwide. The objective of the TSOC-HFrEF registry was to assess epidemiology, etiology, clinical management, and outcomes in a large sample of hospitalized patients presenting with acute decompensated systolic HF. METHODS The TSOC-HFrEF registry was a prospective, multicenter, observational survey of patients presenting to 21 medical centers or teaching hospitals in Taiwan. Hospitalized patients with either acute new-onset HF or acute decompensation of chronic HFrEF were enrolled. Data including demographic characteristics, medical history, primary etiology of HF, precipitating factors for HF hospitalization, presenting symptoms and signs, diagnostic and treatment procedures, in-hospital mortality, length of stay, and discharge medications, were collected and analyzed. RESULTS A total of 1509 patients were enrolled into the registry by the end of October 2014, with a mean age of 64 years (72% were male). Ischemic cardiomyopathy and dilated cardiomyopathy were diagnosed in 44% and 33% of patients, respectively. Coronary artery disease, hypertension, diabetes, and chronic renal insufficiency were the common comorbid conditions. Acute coronary syndrome, non-compliant to treatment, and concurrent infection were the major precipitating factors for acute decompensation. The median length of hospital stay was 8 days, and the in-hospital mortality rate was 2.4%. At discharge, 62% of patients were prescribed either angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers, 60% were prescribed beta-blockers, and 49% were prescribed mineralocorticoid receptor antagonists. CONCLUSIONS The TSOC-HFrEF registry provided important insights into the current clinical characteristics and management of hospitalized decompensated systolic HF patients in Taiwan. One important observation was that adherence to guideline-directed medical therapy was suboptimal.

Association of low serum albumin concentration and adverse cardiovascular events in stable coronary heart disease

OBJECTIVE Coronary heart disease (CHD) is a leading cause of death in developed countries. Exploration of indicators to identify high risk individuals who develop adverse outcomes despite stable baseline condition is important. This study is to evaluate the association between serum albumin concentration and cardiovascular (CV) outcomes in individuals of stable CHD. METHODS Seven-hundred-thirty-four participants from Biosignature study, a nationwide prospective cohort study aimed to identity risk factors among patients with stable CHD, were enrolled for analysis. They were divided into low serum albumin group (baseline albumin concentration <3.5g/dL, n=98) and normal albumin group (baseline albumin concentration ≥3.5g/dL, n=636). The relations between baseline albumin and adverse CV outcomes within 18months of follow-up were analyzed. RESULTS Compared baseline characteristics with normal albumin group, subjects in low albumin group are older, having more diabetic patients, lower hemoglobin level, lower estimated glomerular filtration rate, lower total cholesterol level, lower left ventricular ejection fraction, and higher blood glucose. While there is no significant difference of total CV events between two groups, low serum albumin concentration is associated with an increased risk of all-cause mortality (10.2% vs. 0.5%, p<0.001) and hard CV events (7.1% vs. 1.4%, p<0.001). The association remains significant after adjustments for confounders (all-cause mortality, HR: 6.81, 95% CI: 1.01-45.62; hard CV events, HR: 3.68, 95% CI: 1.03-13.19). CONCLUSIONS Low serum albumin concentration (<3.5g/dL) worsens prognosis of patients with stable CHD.

Relation of body mass index to mortality among patients with percutaneous coronary intervention longer than 5 years follow-up: A meta-analysis

percutaneous coronary intervention longer than 5 years follow-up: A meta-analysis Yi-Hwei Li ⁎, Gen-Min Lin ⁎, Chin-Lon Lin , Ji-Hung Wang , Chih-Lu Han d a Department of Public Health, Tzu-Chi University, Hualien, Taiwan b Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Taiwan c Division of Cardiology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan d Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

Relation of serum uric acid and body mass index to mortality in high-risk patients with established coronary artery disease: a report from the ET-CHD registry, 1997-2006.

BACKGROUND Hyperuricemia is associated with a higher risk of death in patients with coronary artery disease (CAD). In contrast, overweight or obesity was associated with survival benefits in this population. However, the relation of body mass index (BMI) and serum uric acid (SUA) to mortality has not been clarified in this population. METHODS We studied a cohort of 1202 patients with angiographic CAD from the ET-CHD registry during 1997-2003 in Taiwan. To evaluate the relation of BMI and SUA on mortality, the subjects were categorized into 4 groups by BMI >/= 25 kg/m(2) (overweight or obesity) or BMI<25 kg/m(2) (normal- or under-weight), and SUA levels higher or lower than the median of 6.6 mg/dl. At a median follow-up of 5.4 years, cardiac and all-cause deaths were the primary end points. RESULTS Multivariate analyses demonstrated that high SUA group had a significantly higher cardiac mortality [hazard ratio (HR): 1.79, 95% confidence interval (CI): 1.14-2.82, p=0.023] and overall mortality (HR: 1.68, 95% CI: 1.19-2.36, p=0.003) than low SUA group only in overweight or obese patients. Additionally, high BMI was associated with a significantly lower cardiac mortality (HR: 0.58, 95% CI: 0.38-0.99, p=0.023) and overall mortality (HR: 0.62, 95% CI: 0.41-0.82, p=0.003) than low BMI in patients with low SUA levels. Furthermore, normal-low weight and underweight patients (BMI<21 kg/m(2)) were found to have a higher risk of mortality regardless of SUA levels. CONCLUSIONS Among patients with established CAD, SUA may be a potent predictor to mortality in overweight or obese patients. Moreover, the obesity-mortality paradox phenomenon was mainly driven by higher mortality risk in underweight patients and lower mortality risk in overweight and obese patients with low SUA.

The obesity-mortality paradox in elderly patients with angiographic coronary artery disease: a report from the ET-CHD registry.

Background The body mass index (BMI)-mortality paradox has been well known in patients with obstructive coronary artery disease (CAD). However, this phenomenon has rarely been described among elderly patients over a 5-year follow-up. Methods We studied a cohort of 722 elderly patients (age ≥ 65 years) with angiographic CAD from the ET-CHD registry during 1997-2003 in eastern Taiwan. To evaluate the BMI eff ect on mortality, the elderly subjects were categorized into 5 groups by BMI (kg/m2): underweight and normal-low weight (< 21), normal-high weight (21-23.9) overweight (24-26.9), mild obesity (27-29.9) and moderate/severe obesity (≥ 30). At a maximal 10-year follow-up, cardiac and all-cause deaths were the primary end points. Results After multivariate analysis, patients from the category of underweight and normal-low weight in reference to those from the normal-high weight category had a signifi cantly higher risk of cardiac and all-cause mortality (hazard ratio (HR): 1.68 (95% CI: 1.04-2.70) and 2.02 (95% CI: 1.42-2.87), respectively) following a median of 5.4 years. Obese elderly patients tended to have the lowest risk of all-cause death across all the study BMI categories in the early stage. However, after 5 years, mortality increased in the obese patients surviving beyond 5 years, and was higher than that in overweight patients. Conclusions The obesity-mortality paradox was present in elderly patients with angiographic CAD in Taiwan and the risk of death was signifi cantly higher in those with a BMI < 21 kg/m2. However, a J-shaped relationship between mortality and BMI developed after 5 years of follow-up.

High serum resistin levels are associated with peripheral artery disease in the hypertensive patients

BackgroundHypertension is a risk factor for peripheral arterial disease (PAD). Subjects with PAD are at increased risk of future cardiovascular (CV) events. Resistin is involved in the pathological processes of CV diseases. The aim of this study is to investigate whether resistin level is correlated with PAD in hypertensive patients.MethodsOne hundred and twenty-four hypertensive patients were enrolled in this study. Ankle-brachial index (ABI) values were measured using the automated oscillometric method. An ABI value < 0.9 defined the low ABI group. Anthropometric analysis with waist circumference and body mass index, and fasting serum levels of blood urea nitrogen, creatinine, glucose, total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, total calcium, phosphorus, and high-sensitivity C-reactive protein (hs-CRP) were measured using standard enzymatic automated methods. Serum levels of human resistin were determined using a commercially available enzyme immunoassay.ResultsEighteen hypertensive patients (14.5%) were included in the low ABI group. Hypertensive patients in the low ABI group were older (p = 0.043) and had higher serum creatinine (p < 0.001), high-sensitivity C-reactive protein (hs-CRP; p = 0.013), and resistin (p < 0.001) levels but a lower estimated glomerular filtration rate (p = 0.002) than patients in the normal ABI group. After the adjustment for factors that were significantly associated with PAD on multivariate logistic regression analysis, serum resistin (odds ratio [OR], 1.176; 95% confidence interval [CI], 1.028–1.345; p = 0.018) was also an independent predictor of PAD in hypertensive patients.ConclusionsA high serum resistin level is an independent predictor of PAD in hypertensive patients.

Relation of body mass index to mortality among patients with percutaneous coronary intervention in the drug-eluting stent era: A systematic review and meta-analysis

with percutaneous coronary intervention in the drug-eluting stent era: A systematic review and meta-analysis Gen-Min Lin ⁎, Yi-Hwei Li ⁎, Chin-Lon Lin , Ji-Hung Wang , Chih-Lu Han d a Department of Public Health, Tzu-Chi University, Hualien, Taiwan b Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Taiwan c Division of Cardiology, Buddhist Tzu-Chi General Hospital, Hualien, Taiwan d Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

The "smoker's paradox" in Asian versus non-Asian patients with percutaneous coronary intervention longer than 6 months follow-up: a collaborative meta-analysis with the ET-CHD registry.

Cigarettesmokingis recognizedasanimportantriskfactorfor car-diovascular disease for decades [1]. Among patients with acute coro-nary events, current smoker has been observed to be paradoxicallyassociated with a survival benefit. This is called as the “smokers para-dox” [2,3]. On average, symptomatic smokers were found with youngeragesandlowerratesofcomorbiditythannon-smokersatentryinprevi-ous studies [4]. Therefore, thephenomenon may be mostly reasoned bythe discrepancies in baseline characteristics. In addition, some reportsuncovered that the “smokers paradox” was only present in short-termbutitwasalmostabsentwithfollow-uplongerthan6 months[5].Nota-bly, most of these studies were carried out in the fibrinolysis era. Hencetherewerefewerreportswithregardtotheissuespeci ficallyforpatientsundergoing percutaneous coronary intervention (PCI). Furthermore, arecent large-sized report from the combined Korean Acute MyocardialInfarction Registry (KAMIR) and the Korean Myocardial Infarction(KorMI) registry revealed that current smokers were associated with a48% decrease in the risk of total death in reference to non-smokers at1 year after primary PCI for acute MI [6]. This study implied that anethnic differencemightbe presentin the “smokers paradox”.Thereforewe conducted a meta-analysis to compare the impact of smoking statusat baseline on the subsequent coronary events between Asian andnon-Asian patients with PCI and follow-up longer than 6 months.Detailedsearchstrategiesweredesignedtoidentifystudiesevaluatingtheeffectofbaselinesmokingstatusonthemortalityandcardiaceventsfollowing PCI for at least 6 months. One author (Lin GM) pre-screenedthe search results from MEDLINE and Cochrane Central Register ofControlled Trials (CENTRAL) from 1970 to 2013 and removed citationsthat were not relevant. Two reviewers (Lin GM and Li YH) indepen-dently reviewed the remaining citations and performed data extrac-tion. Disagreements were resolved through consensus. Study qualitywas assessed using the New Castle–Ottawa quality scale (NOS) for ob-servational studies [7]. Studies were required to separately report theadjusted risk ratios of total or cardiac deaths/events in patients by thesmokingstatusatentry.Theprimaryoutcomewastotalorcardiacmor-tality and the secondary outcomes were target vessel revascularization(TVR) and recurrent MI. Finally, there were ten articles (four for Asiansand six for non-Asians) extracted to synthesize their results and thestudy characteristics were displayed in Table 1 [6,8–16].Ofnote,thefollow-upperiodsinmostoftheseselectedPCIregistrieswere reported between 6 months and 1 year(three for Asians and fivefor non-Asians) and longer than 3 years (one for Asians and one fornon-Asians). Additionally, we analyzed the adjusted hazard ratios(HRs) of all-cause death at 1 year and 3 years, respectively betweensmokers and non-smokers with PCI in the Eastern Taiwan integratedhealth care delivery system of Coronary Heart Disease (ET-CHD) regis-try in Table 2 [17–19].The baseline profiles of patients undergoing PCI werepresented aspercentages or as mean ± SD. Chi-square tests were used to testbaseline differences across the study groups for categorical variables.Since most continuous variables in this study did not follow a normaldistribution, Wilcoxon rank sum test, a nonparametric method with-out the requirement of normal assumption, was used to determinethe difference between smokers and non-smokers. Cox proportionalhazard regression models were used to determine the adjusted HRsfor total death associated with the baseline smoking status. All con-founders listed in Table 2 were entered into the model except totalcholesterol, triglycerides, and glucose levels which were removedfrom thefinal model due to their high association with the other co-variates. All statistical analyses were performed with SAS version 9.2(SAS Institute, Cary, NC). A P b 0.05 was considered statisticallysignificant.

Serum resistin as an independent marker of aortic stiffness in patients with coronary artery disease

Background Subjects with higher carotid–femoral pulse wave velocity (cfPWV) will be at an increased risk for cardiovascular (CV) events in future. Resistin is an inflammatory mediator and a biomarker of CV diseases. We evaluated the association between serum resistin and aortic stiffness in patients with coronary artery disease (CAD). Methods A total of 104 patients with CAD were enrolled in this study. cfPWV was measured using the SphygmoCor system. Patients with cfPWV >10 m/s were defined as the high aortic stiffness group. Results Thirty-seven patients (35.6%) had high aortic stiffness and higher percentages of diabetes (p = 0.001), were of older age (p = 0.001) and had higher waist circumference (p < 0.001), systolic blood pressure (p = 0.027), pulse pressure (p = 0.013), high-sensitivity C-reactive protein (p < 0.001) and resistin levels (p < 0.001) but lower estimated glomerular filtration rate (p = 0.009) compared to subjects with low aortic stiffness. After adjusting for factors significantly associated with aortic stiffness by multivariate logistic regression analysis, serum resistin (odds ratio = 1.275, 95% confidence interval: 1.065–1.527, p = 0.008) was also found to be an independent predictor of aortic stiffness in patients with CAD. Conclusions Serum resistin level is a biomarker for aortic stiffness in patients with CAD.