Pai-Feng Hsu

Systolic time intervals revisited: correlations with N-terminal pro-brain natriuretic peptide in a community population

The usefulness of automated measurements of the systolic time intervals in community screening deserves investigation. The systolic time intervals, including pre-ejection period (PEP), the left ventricular ejection time (LVET), and PEP/LVET were automatically and rapidly determined from signals of electrocardiography, phonocardiography, and pulse volume recording in 1087 residents aged ≥40 years in a community of homogeneous Chinese. Receiver operating characteristics analysis was performed to determine the cutoff values for PEP, ET, and PEP/LVET in predicting high N-terminal pro-brain natriuretic peptide (NT-proBNP). The prevalence of high NT-proBNP was 12.3% in men and 8.3% in women. NT-proBNP was linearly related to both PEP and PEP/LVET, while there was a U-shaped relationship between NT-proBNP and LVET. In men, the sensitivity and specificity in predicting high NT-proBNP levels were 60% and 60%, respectively, for PEP ≥ 89 ms; 60% and 62% for PEP/LVET ≥ 0.31; and 63% and 60% for LVET < 272 ms or LVET ≥ 310 ms. Various combinations of the criteria further improved either sensitivity or specificity. Women had slightly different cutoff values and performance for the various criteria of abnormal systolic time intervals and their combinations. Automated systolic time intervals appear to be useful in the screening of subjects with high NT-proBNP in a community.

Determinants and Prognostic Impact of Hyperuricemia in Hospitalization for Acute Heart Failure

BACKGROUND Hyperuricemia is a prognostic factor in patients with chronic heart failure, but whether uric acid level can predict clinical outcome of acute heart failure (AHF) remains to be elucidated. We therefore investigated the association of uric acid with mortality in patients hospitalized for AHF. METHODSANDRESULTS Data for patients hospitalized for AHF were drawn from an intramural registry. Biochemistry data, echocardiographic characteristics, and uric acid level were collected. National Death Registry was linked for the identification of mortality data. Among a total of 1,835 participants (age, 75 ± 13 years, 68% men), 794 patients died during follow-up. Patients who died were older, had lower hemoglobin and estimated glomerular filtration rate, and higher pulmonary artery systolic pressure, NT-proBNP, and uric acid. Uric acid was a significant predictor of mortality on univariate analysis (HR per 1 SD, 1.18; 95% CI: 1.11-1.26) and in multivariate Cox models (HR, 1.15; 95% CI: 1.02-1.29). Survival analysis showed an increasing risk of death along the quartile distribution of uric acid level. Given renal function, cardiac performance, and kidney perfusion as major determinants of hyperuricemia, the prognostic impact of uric acid level was diminished as renal function deteriorated. CONCLUSIONS Uric acid level was an independent predictor of mortality in patients hospitalized for AHF, but the prognostic impact of hyperuricemia was attenuated by worsening renal function.

Hyponatremia and Worsening Sodium Levels Are Associated With Long‐Term Outcome in Patients Hospitalized for Acute Heart Failure

Background Hyponatremia predicts poor prognosis in patients with acute heart failure (AHF). However, the association of the severity of hyponatremia and changes of serum sodium levels with long‐term outcome has not been delineated. Methods and Results The study population was drawn from the HARVEST registry (Heart Failure Registry of Taipei Veterans General Hospital), so that patients hospitalized for acute heart failure (AHF) composed this study. The National Death Registry was linked to identify the clinical outcomes of all‐cause mortality and cardiovascular death, with a follow‐up duration of up to 4 years. Among a total of 2556 patients (76.4 years of age, 67% men), 360 had on‐admission hyponatremia, defined as a serum sodium level of <135 mEq/L on the first day of hospitalization. On‐admission hyponatremia was a predictor for all‐cause mortality (hazard ratio and 95% CI: 1.43, 1.11–1.83) and cardiovascular mortality (1.50, 1.04–2.17), independent of age, sex, hematocrit, estimated glomerular filtration rate, left ventricular ejection fraction, and prescribed medications. Subjects with severe hyponatremia (<125 mEq/L) would even have worse clinical outcomes. During hospitalization, a drop of sodium levels of >3 mEq/L was associated with a marked increase of mortality than those with minimal or no drop of sodium levels. In addition, subjects with on‐admission hyponatremia and drops of serum sodium levels during hospitalization had an incremental risk of death (2.26, 1.36–3.74), relative to those with normonatremia at admission and no treatment‐related drop of serum sodium level in the fully adjusted model. Conclusions On‐admission hyponatremia is an independent predictor for long‐term outcomes in patients hospitalized for AHF. Combined the on‐admission hyponatremia with drops of serum sodium levels during hospitalization may make a better risk assessment in AHF patients.

Prognostic Nutritional Index and the Risk of Mortality in Patients With Acute Heart Failure

Background Nutritional status has been related to clinical outcomes in patients with heart failure. We assessed the association between nutritional status, indexed by prognostic nutritional index (PNI), and survival in patients hospitalized for acute heart failure. Methods and Results A total of 1673 patients (age 76±13 years, 68% men) hospitalized for acute heart failure in a tertiary medical center were analyzed. PNI was calculated as 10×serum albumin (g/dL)+0.005×total lymphocyte count (per mm3). National Death Registry was linked to identify the clinical outcomes of all‐cause and cardiovascular death. With increasing tertiles of PNI, age and N‐terminal probrain natriuretic peptide decreased, and body mass index, estimated glomerular filtration rate, and hemoglobin increased. During a mean follow‐up duration of 31.5 months, a higher PNI tertile was related to better survival free from all‐cause and cardiovascular mortality in the total study population and in participants with either reduced or preserved left ventricular ejection fraction. After accounting for age, sex, estimated glomerular filtration rate, left ventricular ejection fraction, serum sodium level, and on‐admission systolic blood pressure, PNI was independently associated with cardiovascular death and total mortality (hazard ratio per 1 SD of the natural logarithm of the PNI: 0.76 [95% CI, 0.66–0.87] and 0.79 [95% CI, 0.73–0.87], respectively). In subgroup analyses stratified by age, sex, left ventricular ejection fraction, body mass index, or estimated glomerular filtration rate, PNI was consistently related to mortality. Conclusions PNI is independently associated with long‐term survival in patients hospitalized for acute heart failure with either reduced or preserved left ventricular ejection fraction.

Diabetes and 15-year cardiovascular mortality in a Chinese population: Differential impact of hypertension and metabolic syndrome.

Background: It remains unclear if the risk for cardiovascular (CV) mortality in patients with diabetes mellitus (DM) is equivalent to that in patients with a history of cardiac disease in Asian populations. The aims of the present study were to investigate whether or not non‐heart disease (HD) DM subjects have a similar risk of CV mortality as HD patients without DM (non‐DM HD), and whether or not hypertension (HT) or metabolic syndrome (MS) is a CV mortality marker for diabetic subjects identified from a community‐based population. Methods: We followed 11,058 Chinese people aged ≥ 30 years on Kinmen island for a median of 15.0 years. Results: The age‐, sex‐ and smoking‐adjusted hazard ratios for CV mortality were 3.56 [95% confidence interval (CI): 1.99–6.36] for DM subjects with HD, 1.64 (95% CI: 1.25–2.16) for DM without HD (non‐HD DM) subjects, and 1.63 (95% CI: 1.09–2.44) for non‐DM HD patients, when compared with subjects without DM and HD. Among the 827 non‐HD DM subjects identified at the baseline survey, the age‐, sex‐ and smoking‐adjusted hazard ratios for CV mortality were 2.36 (95% CI: 1.30–4.28) for the presence versus absence of HT, and 1.23 (95% CI: 0.65–2.34) for the presence versus absence of MS. Conclusion: Non‐HD DM subjects had a similar risk of CV mortality to non‐DM HD subjects in this Chinese population. The presence of HT but not MS substantially increased CV mortality risk in the DM subjects.

Double-barrel coronary artery dissection.

Coronary artery dissection is a common occurrence after percutaneous transluminal coronary angioplasty (PTCA). However, we report herein a rare case of double-barrel coronary artery dissection occurring 1 year after PTCA for stenosis in the left circumflex coronary artery. The case history and angiographic findings are reported, and relevant literature is reviewed.

High health literacy is associated with less obesity and lower Framingham risk score: Sub-study of the VGH-HEALTHCARE trial

Backgrounds Lower health literacy (HL) is associated with several cardiovascular disease (CVD) risk factors such as diabetes, hypertension, and metabolic syndrome (MS). The aim of our study was to investigate the association between HL and the Framingham 10-year risk score of CVD. Methods From 2015–2016, 1010 subjects aged 23 to 88 years receiving health check-up in Taipei Veterans General Hospital had complete clinical evaluations and laboratory examinations. Fatty liver was diagnosed by ultrasonography. The short form questionnaire adapted from the Mandarin Health Literacy Scale was used to assess HL. The Framingham risk score was calculated by patient characteristics. Results Subjects with higher BMIs were associated with lower HL scores. The proportion of subjects with MS was higher in the lower health literacy score group (≤ 9) at 28.8%; further analysis found that lower HL was significantly associated with MS in women but not in men. The Spearman’s rho demonstrated that the HL score was significantly associated with the BMI-based (rho = -0.11; P < 0.001) or lipid-based (rho = -0.09; P < 0.004) Framingham risk score. Conclusions Higher HL scores were associated with less CVD risk such as lower BMIs, less MS in women, and less fatty liver disease. Furthermore, HL had an inverse association with the Framingham risk score as expected. Therefore, HL in patients with CVD risk should be improved and considered as an important issue in terms of CVD reduction.

Hemographic indices are associated with mortality in acute heart failure

Hemographic indices have been associated with clinical outcomes in patients with chronic heart failure. We therefore investigated the prognostic values of hemographic indices in patients hospitalized for acute heart failure (AHF). Patients hospitalized primarily for AHF were drawn from an intramural registry. Hemographic indices, including white blood cell counts, neutrophil counts, neutrophil-to-lymphocyte ratio, reciprocal of lymphocyte (RL) and platelet-to-lymphocyte ratio were recorded. Among a total of 1923 participants (mean age 76 ± 12 years, 68% men), 875 patients died during a mean follow-up of 28.6 ± 20.7 months. Except for white blood cell counts, all the other hemographic indices were related to mortality, independently. In a forward stepwise Cox regression analysis among hemographic indices, RL was the strongest predictor (HR and 95% CI per-1SD:1.166,1.097–1.240) for mortality, after accounting for confounders. However, conditioned on the survivals, the hemographic indices were independently related to mortality within 3 years of follow-up, rather than beyond. Hemographic indices were independent risk factors of mortality in patients hospitalized for AHF, especially in patients with impaired left ventricular systolic function. As an acute presentation of inflammation, hemographic indices might be useful to identify subjects at risk of mortality soon after the index hospitalization.

Long-term results of stenting versus coronary artery bypass surgery for left main coronary artery disease—A single-center experience

Background Percutaneous coronary intervention (PCI) has emerged as an alternative treatment to coronary artery bypass grafting (CABG) for unprotected left main (LM) coronary artery disease, but the results of both treatments are less clear in real‐world practice. We aimed to assess the long‐term outcomes of unprotected LM disease treated with CABG or PCI with stenting in high‐risk population from a single center. Methods We collected 478 consecutive patients with unprotected LM disease (PCI/CABG: 208/270; mean age: 70 ± 11 years; 85% male), and 252 patients were considered to be at high risk (European System for Cardiac Operative Risk Evaluation ≥6). The median follow‐up was 4.3 years (interquartile range: 2.7–6.5 years). Results All‐cause death (PCI/CABG: 27.4%/31.5%; p = 0.36) and all‐cause death/myocardial infarction (MI)/stroke (PCI/CABG: 30.8%/35.9%; p = 0.49) were comparable between the two groups, whereas the repeat revascularization rate was significantly higher in the PCI group (PCI/CABG: 22.6%/11.0%; p < 0.01). These results remained similar after adjustment with the propensity score. Notably, CABG tended to be associated with higher periprocedural mortality (adjusted p = 0.08) and long‐term stroke (adjusted p = 0.05), while PCI was associated with higher long‐term MI (adjusted p = 0.09). Analyses of the diabetic subgroup (PCI/CABG: 98/124) yielded similar results. Conclusion PCI was a comparable alternative to CABG for high‐risk patients with unprotected LM disease in terms of long‐term risks of all‐cause death/MI/stroke, but with a significantly higher repeat revascularization rate.

Serum bilirubin improves the risk predictions of cardiovascular and total death in diabetic patients

BACKGROUND Bilirubin is a potential endogenous inhibitor of atherosclerosis. We investigated the association of bilirubin and cardiovascular (CV) and all-cause mortality including potential improvements in bilirubin risk reclassification in asymptomatic diabetic patients. METHODS We enrolled 2936 asymptomatic diabetic subjects. The serum bilirubin was measured, and future CV and all-cause death were the primary endpoints. RESULTS The follow-up period was 5.4 ± 3.0 y. There were 218 deaths including 95 cardiovascular deaths. The occurrence of CV death and all-cause death were negatively correlated with increasing serum bilirubin quintiles and actual bilirubin values. Serum bilirubin was negatively associated with incident cardiovascular death (hazard ratio: 0.26, 95% CI, 0.11-0.61, p = .01) and all-cause death (hazard ratio: 0.30, 95% CI, 0.17-0.51, p ≤.001). The addition of bilirubin for cardiovascular death increased the C-statistic from 0.713 (95% CI, 0.664-0.762) to 0.729 (95% CI, 0.681-0.776) (P = .008) and showed an integrated discrimination improvement (IDI) of 0.012 (P < .0171) with 8.57% improvement in net reclassification analysis (P = .0224). These results suggest additional predictive value is possible via total bilirubin levels for future CV deaths in diabetic patients. In terms of all-death, the addition of bilirubin significantly increased the C-statistic (from 0.769 to 0.78, P = .0064)-a 3.52% net reclassification improvement (P = .0307). It did not improve the IDI (p = .1505). CONCLUSIONS Higher serum concentrations of bilirubin are associated with a decreased risk of developing CV and all-cause death in diabetic patients. Bilirubin improved the risk prediction of cardiovascular death but provided only a slightly better prediction of all-cause death than conventional risk factors.