Shao-Sung Huang

Efficacy and Safety of Rosuvastatin in Taiwanese Patients

Background: Statins are effective in decreasing low‐density lipoprotein cholesterol (LDL‐C). The efficacy and safety of rosuvastatin, a newly launched statin, have not been determined in Taiwanese patients. Methods: Patients with hypercholesterolemia receiving rosuvastatin 10 mg/d in this hospital were prospectively followed and retrospectively analyzed. Men and women with primary hypercholesterolemia were eligible for inclusion in the study if they were either lipid‐lowering therapy (LTT)‐naïve or had been receiving starting doses of other LLT that had proved ineffective in reaching goals. The primary measurement was the percentage of change in LDL‐C from baseline at 12 weeks. Other measurements included: percentages of change from baseline in total cholesterol (TC), high‐density lipoprotein cholesterol (HDL‐C), triglyceride (TG), TC/HDL ratio, percentage of patients reaching therapeutic goals, and any adverse effects at 12 weeks. Both intention‐to‐treat analysis and on‐treatment analysis were used. Results: A total of 447 patients, including 375 LTT‐naïve and 72 switched patients were enrolled. In LLT‐naïve patients, rosuvastatin 10 mg/d reduced LDL‐C by a mean of 48.9% from baseline (p < 0.0001) by the on‐treatment analysis and by a mean of 44.2% from baseline (p < 0.0001) by the intention‐to‐treat analysis. In switched patients, LDL‐C was reduced by a mean of 26.2% from baseline (p < 0.0001) by both analyses. TC, TG, and TC/HDL ratio, but not HDL‐C, were also significantly reduced. Overall, more than 75% patients reached their therapeutic goals. The safety profiles were excellent. Only 2.2% of patients complained of myalgia, 0.2% had elevation of creatine kinase > 3 ×upper limit of normal (ULN), and 0.6% had an elevation of ALT > 3 ×ULN. All the abnormal laboratory tests returned to pretreatment values after drug discontinuation. Only 2.7% of patients discontinued medication due to adverse effects. Conclusion: Rosuvastatin 10 mg/d is safe and effective in Taiwanese patients.

Chitosan Potentiation of Warfarin Effect

Objective: To report a case in which the anticoagulation effect of warfarin appeared to have been potentiated by chitosan, probably due to interference with the absorption of vitamin K. Case Summary: An 83-year-old male with hypertensive cardiovascular disease, type 2 diabetes mellitus, and chronic atrial fibrillation complicated by loft atrial thrombus formation was maintained on warfarin 2.5 mg/day. Marked elevation of the international normalized ratio (INR) was noticed after self-medication with chitosan 1200 mg twice daily. He denied taking any other drugs, natural substances, herbal medicines, and nutritional supplements, and stated that he had not changed his dietary habits. After parenteral administration of vitamin K and discontinuation of chitosan, the INR returned to within the target range. However, the patient took chitosan again, and the INR increased to well above the target range. Following strong medical advice, the patient stopped taking chitosan, and the INR remained stable thereafter. Discussion: Chitosan is a positively charged polymer that binds to the negatively charged lipids and bile acids in the gastrointestinal tract. It can affect the absorption of vitamins A, D, E, and K. Therefore, the anticoagulation effect of warfarin may bo potentiated by chitosan through this mechanism. Use of the Naranjo probability scale revealed that the adverse effect was probably due to chitosan. Conclusions: The interaction between warfarin and chitosan has not previously been reported. Healthcare professionals should be aware of this potential interaction

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.

Clinical outcomes of percutaneous coronary intervention with rotablation in patients with acute or recent myocardial infarction

Background Although rotational atherectomy (RA) has been an accepted and widely used medical procedure for more than 15 years, the clinical outcomes of RA in high‐risk populations remain elusive. Therefore, the purpose of this study was to investigate the safety and efficacy of RA for patients with acute or recent myocardial infarction (MI), and report the short‐ and long‐term clinical outcomes in this population. Methods We enrolled patients undergoing percutaneous coronary intervention (PCI) and RA at two medical centers in Taiwan between January 2004 and December 2013. Individuals who suffered an acute MI within 30 days before RA were assigned to the MI group; the remaining subjects were assigned to the non‐MI group. Results A total of 154 subjects were enrolled in our study, among them: 47 (30.5%) had an acute MI within 30 days of RA (MI group), and the remaining 107 (69.5%) patients without MI comprised the non‐MI group. PCI and RA procedures were performed successfully in 150 patients. The 30‐day and 1‐year total death, MI, and major adverse cardiac event (MACE included all‐cause death, MI, and clinical‐driven target lesion revascularization) rates were 6.5%, 12.3%, and 15.6%, and 9.7%, 15.2%, and 30.5%, at the 30‐day and 1‐year follow‐ups, respectively. MI was identified as an independent predictor for both 30‐day MACE and total death (MACE, OR: 3.95, P = 0.006; total death, OR: 4.67, P = 0.043), and remained an independent predictor for 1‐year total death and MI (total death, HR: 4.47, P = 0.007; MI, HR: 2.62, P = 0.016). Conclusion Our study demonstrated the safety and efficacy of RA in patients with acute or recent MI, and identified MI as an independent predictor of both short‐ and long‐term outcomes.

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.

Long-term outcome of patients with very small coronary artery disease: A comparison of drug-eluting and bare metal stents.

Background Among patients with very small vessel disease and chronic kidney disease (CKD), the comparative efficacy of bare metal stents (BMSs) versus drug‐eluting stents (DESs) is not frequently addressed. This study aimed to evaluate the long‐term outcomes of patients with very small vessel disease managed with percutaneous coronary intervention. Methods Our study included 158 consecutive patients undergoing percutaneous coronary intervention from January 2003 to December 2013. The primary end points were cardiovascular death and target vessel failure, which consisted of cardiovascular death, target vessel‐related myocardial infarction, and ischemia‐driven target vessel revascularization. Results BMSs were used in 37 patients, while DESs were utilized in 121 patients. During the mean follow‐up period of 2.7 ± 2.2 years (median 2.1 years; interquartile range, 1.3−4.2 years), the target vessel failure rate was 48.6% versus 28.1% (BMS vs. DES, p = 0.020) and the cardiovascular death rate was 27% versus 18.2% (BMS vs. DES, p = 0.241). The use of a DES (hazard ratio: 0.44, 95% confidence interval: 0.24–0.79, p = 0.006) remained the most significant predictor of target vessel failure after multivariate analysis. In CKD subgroup analysis, the benefit of a 2.25 mm DES was evident only in the subgroup with CKD, but such a benefit disappeared in those without CKD. Conclusion Compared with BMSs, implantation of DESs in a patient population with very small vessel disease effectively reduced target vessel failure. However, the beneficial effects of DESs appeared to be evident only in the subgroup with CKD.

Association of Serum Bilirubin with SYNTAX Score and Future Cardiovascular Events in Patients Undergoing Coronary Intervention

BACKGROUND Bilirubin has emerged as an important endogenous antioxidant molecule, and increasing evidence shows that bilirubin may protect against atherosclerosis. The SYNTAX score has been developed to assess the severity and complexity of coronary artery disease. The aim of this study was to evaluate whether serum bilirubin levels are associated with SYNTAX scores and whether they could be used to predict future cardiovascular events in patients undergoing coronary intervention. METHODS Serum bilirubin levels and other blood parameters in patients with at least 12-h fasting states were determined. The primary endpoint was any composite cardiovascular event within 1 year, including death, nonfatal myocardial infarction, and target-vessel revascularization. RESULTS In total, 250 consecutive patients with stable coronary artery disease (mean age 70 ± 13) who had received coronary intervention were enrolled. All study subjects were divided into two groups: group 1 was defined as high SYNTAX score (> 22), and group 2 was defined as low SYNTAX score (≤ 22). Total bilirubin levels were significantly lower in the high SYNTAX score group than in the low SYNTAX score group (0.51 ± 0.22 vs. 0.72 ± 0.29 mg/dl, p < 0.001). By multivariate analysis, serum total bilirubin levels were identified as an independent predictor for high SYNTAX score (adjusted odds ratio: 0.28, 95% confidence interval 0.04-0.42; p = 0.004). Use of the Kaplan-Meier analysis demonstrated a significant difference in 1-year cardiovascular events between high (> 0.8 mg/dl), medium (> 0.5, ≤ 0.8 mg/dl), and low (≤ 0.5 mg/dl) bilirubin levels (log-rank test p = 0.011). CONCLUSIONS Serum bilirubin level is associated with SYNTAX score and predicts future cardiovascular events in patients undergoing coronary intervention.

The impact of successful revascularization of coronary chronic total occlusions on long-term clinical outcomes in patients with non-ST-segment elevation myocardial infarction

OBJECTIVES The purpose of this study was to assess the long-term clinical impact of revascularization of coronary concomitant coronary chronic total occlusion (CTO) in patients with Non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND CTO is associated with poorer prognosis in patients with NSTEMI. The evidence of revascularization of CTO in patients with NSTEMI is still conflicting. METHODS Consecutive patients with NSTEMI and CTO who underwent percutaneous coronary intervention (PCI) within 72 h of admission from 2006 to 2015 were retrospectively recruited and analyzed. A total of 967 patients underwent PCI for NSTEMI. Among them, 106 (11%) patients had concomitant CTO and were recruited for analysis. CTO lesions were revascularized successfully in 67 (63.2%) patients (successful CTO PCI group), while the CTO in the remaining 39 patients were either not attempted or failed (No/failed CTO PCI group). RESULTS The 30-day cardiac death and major adverse cardiac events (MACE) were significantly lower in the successful CTO PCI group (both cardiac death and MACE were 3% vs 30%, P < 0.001, respectively). A landmark analysis set at 30th day for 30-day survivals was performed. After a mean of 2.5-year follow-up, the long-term cardiac death was still significantly lower (16.9% vs 42.3%, P < 0.001), whereas the MACE showed a trend toward lower incidence (26.2% vs 40.7%, P = 0.051) in the successful CTO PCI group. In multivariate Cox regression analysis, successful revascularization of CTO is an independent protective predictor for long-term cardiac death (HR 0.310, 95% CI, 0.109-0.881, P = 0.028) in all population and in propensity-score matched cohort (P = 0.007). CONCLUSIONS Successful revascularization of CTO was associated with reduced risk of long-term cardiac death in patients with NSTEMI and concomitant CTO.