Min-Tsun Liao

Primary prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with end-stage renal disease undergoing dialysis

Current evidence suggests that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reduce the incidence of new atrial fibrillation (AF) in a variety of clinical conditions, including the treatment of left ventricular dysfunction or hypertension. Here we assessed whether ACEIs and ARBs could decrease incidence of new-onset AF in patients with end-stage renal disease (ESRD). We identified patients from the Registry for Catastrophic Illness, a nation-wide database encompassing almost all of the patients receiving dialysis therapy in Taiwan from 1995 to 2008. Propensity score matching and Cox proportional hazards regression models were used to estimate hazard ratios for new-onset AF. Among 113,186 patients, 13% received ACEIs, 14% received ARBs therapy, and 9% received ACEIs or ARBs alternatively. After a median follow-up of 1524 days, the incidence of new-onset AF significantly decreased in patients treated with ACEIs (hazard ratio 0.587, 95% confidence interval 0.519-0.663), ARBs (0.542, 0.461-0.637), or ACEIs/ARBs (0.793, 0.657-0.958). The prevention of new-onset AF was significantly better in patients taking longer duration of ACEI or ARB therapy. The effect remained robust in subgroup analyses. Thus both ACEIs and ARBs appear to be effective in the primary prevention of AF in patients with ESRD. Hence, renin-angiotensin system inhibition may be an emerging treatment target for the primary prevention of AF.

Comparative Effectiveness and Safety of Dabigatran and Rivaroxaban in Atrial Fibrillation Patients.

Background We aimed to examine the comparative effectiveness and safety between dabigatran and rivaroxaban in atrial fibrillation patients. Methods and Results We conducted a population‐based, retrospective, new‐user cohort study based on the National Health Insurance claims database in Taiwan. Adult atrial fibrillation patients who initiated dabigatran (N=10 625) or rivaroxaban (N=4609) between June 1, 2012 and May 31, 2014 were identified as the overall population. A propensity score was derived using logistic regression to model the probability of receipt of rivaroxaban as a function of potential confounders. Altogether, 4600 dabigatran users were matched with 4600 rivaroxaban users to create a propensity score–matched population. The marginal proportional hazards model was applied among the propensity score–matched population as the primary analysis, and the proportional hazards model with adjustment of the quintiles of the propensity score among the overall population was used as the secondary analysis. Rivaroxaban users had a higher risk of all‐cause death than dabigatran users (hazard ratio 1.44, 95%CI 1.17‐1.78 in the primary analysis and hazard ratio 1.47, 95%CI 1.23‐1.75 in the secondary analysis). Rivaroxaban users also possessed a higher risk of gastrointestinal hemorrhage needing transfusion than dabigatran users in the primary analysis (hazard ratio 1.41, 95%CI 1.02‐1.95), but the difference diminished in the secondary analysis (hazard ratio 1.20, 95%CI 0.92‐1.56). The risks of ischemic stroke, acute myocardial infarction, arterial embolism/thrombosis, and intracranial hemorrhage were similar between the 2 groups. Conclusions Rivaroxaban therapy was associated with a statistically significant increase in all‐cause death compared with dabigatran therapy in atrial fibrillation patients.

Association between urine aldosterone and diastolic function in patients with primary aldosteronism and essential hypertension

OBJECTIVE To investigate the association between aldosterone and cardiac diastolic dysfunction. DESIGN AND METHODS We prospectively enrolled 20 patients with primary aldosteronism (PA) and 22 patients with essential hypertension (EH). Plasma aldosterone concentration, plasma renin activity, and 24-h urine aldosterone level were measured. Echocardiography, including tissue Doppler image recordings, was performed. RESULTS PA patients had a significantly higher left ventricular (LV) mass index and worse LV diastolic function than those in EH patients. Among various measures of aldosterone, log-transformed 24-h urine aldosterone level had the most consistent correlation with diastolic function. CONCLUSIONS Aldosterone is strongly associated with LV diastolic dysfunction. Twenty-four hour urine aldosterone is a good indicator to evaluate the impact of aldosterone on LV diastolic function.

Aortocoronary dissection with extension to the suprarenal abdominal aorta: a rare complication after percutaneous coronary intervention.

A 53-year-old man presented with chest tightness and a positive treadmill test. A percutaneous coronary intervention (PCI) was performed on the distal total occlusion of the right coronary artery (RCA) with a 6-F Amplatz Left 1 guiding catheter and a Runthrough floppy wire (Terumo, Leuven, Belgium

Primary prevention of atrial fibrillation with beta-blockers in patients with end-stage renal disease undergoing dialysis

Current evidence suggests that beta-blocker lower the risk of development of atrial fibrillation (AF) and in-hospital stroke after cardiac surgery. This study was to assess whether beta-blockers could decrease incidence of new-onset AF in patients with end stage renal disease (ESRD). We identified patients from a nation-wide database called Registry for Catastrophic Illness, which encompassed almost 100% of the patients receiving dialysis therapy in Taiwan from 1995 to 2008. Propensity score matching and Cox’s proportional hazards regression model were used to estimate hazard ratios (HRs) for new-onset AF. Among 100066 patients, 41.7% received beta-blockers. After a median follow-up of 1500 days, the incidence of new-onset AF significantly decreased in patients treated with beta-blockers (HR = 0.483, 95% confidence interval = 0.437-0.534). The prevention of new-onset AF was significantly better in patients taking longer duration of beta-blockers therapy (P for time trend <0.001). The AF prevention effect remains robust in subgroup analyses. In conclusion, beta-blockers seem effective in the primary prevention of AF in ESRD patients. Hence, beta-blockers may be the target about upstream treatment of AF.

Amiodarone-induced hepatic and pulmonary toxicity

An 88-year-old woman presented with a 5-day history of nausea, vomiting and abdominal pain at the emergency department. Her medical history included sick sinus syndrome and atrial flutter, for which she underwent permanent pacemaker implantation and radiofrequency catheter ablation 4 and 6 months earlier, respectively. She had been prescribed amiodarone for 5 months (600 mg/day for 2 months, then 400 mg/day for 3 months) due to relapsing atrial flutter after ablation. The level of alanine aminotransferase was 45 U/L (reference range, 0–41), total bilirubin was 0.66 mg/dL (reference range, 0.3–1.0) and direct …

Dabigatran, Rivaroxaban, and Warfarin in the Oldest Adults with Atrial Fibrillation in Taiwan: Dabigatran, Rivaroxaban, and Warfarin

To compare the effectiveness and safety of reduced‐dose dabigatran, reduced‐dose rivaroxaban, and warfarin in individuals aged 85 and older with atrial fibrillation (AF).

Primary prevention of myocardial infarction with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in hypertensive patients with rheumatoid arthritis—A nationwide cohort study

Background Rheumatoid arthritis (RA) is regarded as a high risk factor for myocardial infarction. Hypertension is a major modifiable risk factor contributing to increased risk of myocardial infarction (MI). Dual blood pressure (BP)-lowering and anti-inflammatory effect of renin-angiotensin-system (RAS) inhibitors may possess protective effect from MI in RA population. However, treatment of hypertension with RAS inhibitors and MI in RA population remains unclear. Methods We investigated whether RAS blockade could decrease risk of incident MI in hypertensive patients with RA. We identified patients with RA and hypertension from the Registry for Catastrophic Illness, a nation-wide database encompassing almost all of the RA patients in Taiwan from 1995 to 2008. The primary endpoint was MI and the median duration of follow up was 2,986 days. Propensity score weighting and Cox proportional hazards regression models were used to estimate hazard ratios for MI. Results Among 27,335 subjects, 9.9% received angiotensin-converting enzyme inhibitors (ACEIs), 25.9% received angiotensin II receptor blockers (ARBs) and 20.0% received ACEIs or ARBs alternatively. The incidence of MI significantly decreased in patients treated with ACEIs (hazard ratio 0.707; 95% confidence interval 0.595–0.840), ARBs (0.641; 0.550–0.747) and ACEIs/ARBs (0.631; 0.539–0.739). The protective effect of ACEI or ARB therapy was significantly better in patients taking longer duration. The effect remained robust in subgroup analyses. Conclusions Therapy of ACEIs or ARBs is associated with a lower risk of MI among patients with RA. Hence, hypertension in patients with RA could comprise a compelling indication for RAS inhibitors.

Reversal of Arterial Stiffness in Patients with Primary Aldosteronism after Treatment

Background: Primary aldosteronism (PA) is one the most common cause of secondary hypertension. Exposure to excessive aldosterone leads to various complications on cardiovascular system, and some are reversible after treatment, such as hypertension, left ventricular hypertrophy and even arterial stiffness. However, the time course of arterial stiffness reversal and the predicting factors on PA patients are still unclear. Method: We prospectively collect aldosterone producing adenoma (APA) patients from March 2006 to January 2012. We measured the right brachial-ankle pulse wave velocity (PWV) to represent arterial stiffness. All patients were followed 6 months and 12 months after operation. Results: Total 108 patients were included in this study with 62 female and 46 male. The pre-treatment PWV averaged as 1642.44 ± 317.892 cm/s. After correlation and multi-variable linear regression analysis, age, duration from diagnosis of hypertension to enrollment, and baseline systolic blood pressure are the determinant factors to baseline PWV. After treatment, the patients’ PWV decreased significantly during the first 6-month (1543.08 ± 288.799 at 6-month, p < 0.001)but not significant during the latter 6 month (1578.83 ± 337.745 at 12-month, p = 0.155). After correlation study and multi-variable regression analysis, the decrement of diastolic pressure (&Dgr;DBP) and the baseline PWV correlated most significantly with PWV decrement (&Dgr;PWV). Conclusion: The arterial stiffness of APA patients could be reversed after treatment. The determinant factors of baseline PWV included age, duration of hypertension and baseline systolic pressure. The determinant factors of &Dgr;PWV are baseline PWV and &Dgr;DBP.

Feasibility and Safety of Coronary Procedures via an Arteriovenous Graft Approach in Patients on Maintenance Hemodialysis.

BACKGROUND Traditionally, a radial or brachial arterial approach is unadvisable in hemodialysis patients. Consequently, coronary angiography or angioplasty is usually performed via a femoral artery approach in these patients, who carry a higher risk of vascular access complications. In hemodialysis patients, arteriovenous grafts (AVG) are created for repeated punctures; however, the feasibility and safety of a trans-AVG approach for coronary angiography or angioplasty remains unclear. METHODS In our institution, cardiac catheterizations were attempted via AV grafts in hemodialysis patients with a U-shaped forearm AVG. We retrospectively identified coronary angiography or angioplasty procedures in hemodialysis patients from a computer-based database in our hospital. The procedure details and outcomes were obtained from review of the clinical, angiographic and hemodialysis records. RESULTS From 2008 to 2013, 167 procedures in hemodialysis patients were identified from 2866 diagnostic or interventional coronary procedures in our institution. Out of these, 24 procedures in 17 patients were performed via a trans-AVG approach. In all AVG procedures, a 6F 16-cm or 7F 10-cm sheath was placed from the AVG into the brachial artery. All diagnostic procedures were successfully performed. In 14 procedures, the patients also underwent angioplasty and all of the angioplasty procedures were successful. There was no arterial spasm, arterial dissection, puncture site hematoma, or acute thrombosis of the AVG during or after the procedures. CONCLUSIONS A trans-AVG approach appears to be a feasible and safe route for coronary angiography or angioplasty in hemodialysis patients with a U-shaped forearm AVG. However, further studies with a larger patient number are necessary. KEY WORDS Arteriovenous graft; Hemodialysis; Percutaneous coronary intervention.