Publications by authors named "Jinghao Nicholas Ngiam"

37 Publications

Haematological profile of COVID-19 patients from a centre in Singapore.

Hematology 2021 Dec;26(1):1007-1012

Department of Cardiology, National University Heart Centre Singapore, Singapore.

Background: Haematological markers such as absolute lymphopenia have been associated with severe COVID-19 infection. However, in the literature to date, the cohorts described have typically included patients who were moderate to severely unwell with pneumonia and who required intensive care stay. It is uncertain if these markers apply to a population with less severe illness. We sought to describe the haematological profile of patients with mild disease with COVID-19 admitted to a single centre in Singapore.

Methods: We examined 554 consecutive PCR positive SARS-COV-2 patients admitted to a single tertiary healthcare institution from Feb 2020 to April 2020. In all patients a full blood count was obtained within 24 h of presentation.

Results: Patients with pneumonia had higher neutrophil percentages (66.5 ± 11.6 vs 55.2 ± 12.6%, < 0.001), lower absolute lymphocyte count (1.5 ± 1.1 vs 1.9 ± 2.1 x109/L, < 0.011) and absolute eosinophil count (0.2 ± 0.9 vs 0.7 ± 1.8 × 109/L, = 0.002). Platelet counts (210 ± 56 vs 230 ± 61, = 0.020) were slightly lower in the group with pneumonia. We did not demonstrate significant differences in the neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio and platelet-lymphocyte ratio in patients with or without pneumonia. Sixty-eight patients (12.3%) had peripheral eosinophilia. This was more common in migrant workers living in dormitories.

Conclusion: Neutrophilia and lymphopenia were found to be markers associated with severe COVID-19 illness. We did not find that combined haematological parameters: neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio and platelet-lymphocyte ratio, had any association with disease severity in our cohort of patients with mild-moderate disease. Migrant workers living in dormitories had eosinophilia which may reflect concurrent chronic parasitic infection.
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http://dx.doi.org/10.1080/16078454.2021.2005311DOI Listing
December 2021

Prevalence and outcomes of concomitant cardiac amyloidosis and aortic stenosis: A systematic review and meta-analysis.

Hellenic J Cardiol 2021 Nov 29. Epub 2021 Nov 29.

Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore. Electronic address:

Background: Cardiac amyloidosis (CA) is an increasingly recognised condition in patients with aortic stenosis (AS). However, there is large variation in the reported prevalence figures, due to differences in populations and diagnostic methods. We aimed to investigate the prevalence, risk factors and outcomes of concomitant CA and AS.

Methods: We performed a systematic review and meta-analysis of the literature searched on Medline, EMBASE, Scopus and CENTRAL. We analysed the prevalence of CA in AS grouped according to diagnostic techniques, and the risk factors and outcomes of concomitant CA and AS was analysed in AS patients referred for surgical or transcatheter aortic valve replacement (AVR).

Results: A total of 21 studies were included, involving 4,243 patients. The pooled prevalence of CA in patients with AS was 14.4%, with substantial heterogeneity. The pooled prevalence of AS in CA was 8.7%, with substantial heterogeneity. Patients with both AS and CA had higher all-cause mortality than those with AS or CA alone. In AS patients requiring AVR, CA was associated with increasing age, male sex, higher NT-proBNP levels, increased interventricular septal end diastole thickness and lower left ventricular ejection fraction. Concomitant AS and CA was associated with increased all-cause mortality and pacemaker implantation post-procedure. Study limitations included the heterogeneity of results and the fair to good quality of studies published.

Conclusion: Overall, a substantial proportion of patients with AS may have CA, and they have poorer prognosis. A high degree of clinical suspicion is needed to identify "red flags" and perform appropriate diagnostic imaging.
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http://dx.doi.org/10.1016/j.hjc.2021.11.001DOI Listing
November 2021

Inter-Ethnic Differences in Valvular Dysfunction, Aortopathy, and Progression of Disease of an Asian Bicuspid Aortic Valve Population.

Heart Lung Circ 2021 Nov 26. Epub 2021 Nov 26.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Electronic address:

Background: There are differences in bicuspid aortic valve (BAV) characteristics between Asian and European populations, but little is known about the inter-ethnic differences in bicuspid valve function and aortic root dimensions within the diverse Asian population.

Methods: From 1992-2017, 562 patients with index echocardiographic diagnosis of BAV in a tertiary health care institution in Singapore were analysed according to their ethnic groups: Chinese, Malay, Indian, and Eurasian. Study outcomes included BAV complications (infective endocarditis, aortic dissection) and clinical outcomes (aortic valve surgery, aortic root surgery, all-cause mortality). Total events were defined as composite outcome of all BAV complications and outcomes. Aortic dimensions and aortic dilatation rates were also studied.

Results: There were 379 (67.5%) Chinese, 79 (14.0%) Malay, 73 (13.0%) Indian, and 31 (5.5%) Eurasian patients. Type 1 BAV (58.5%) was the most prevalent BAV morphology, with moderate-to-severe aortic stenosis (AS) (36.8%) being the most common complication in the overall population. There was a higher prevalence of type 0 BAV in Chinese and Indian groups, and type 1 BAV with fusion of left-right coronary cusp in Eurasian and Malay groups (p=0.082). There was no difference in significant AS among groups. The highest prevalence of moderate-to-severe aortic regurgitation was observed amongst the Eurasian group, followed by Chinese, Indian, and Malay groups (p=0.033). The Chinese group had the largest mean indexed diameters of the aortic root. Multivariable linear regression demonstrated that only the Chinese had significantly larger indexed diameters in the aortic annulus, sinotubular junction (STJ), and ascending aorta (AA), relative to the Eurasian group, after adjusting for age, sex, smoking, hypertension, hyperlipidaemia, diabetes, and aortic regurgitation. On follow-up echocardiography, there was a trend towards the highest dilatation rates of sinus of Valsalva and STJ amongst Indian, and AA amongst Malay groups. Kaplan-Meier curves showed the highest incidence of total events amongst Chinese, followed by Malay, Indian and Eurasian (log-rank=9.691; p=0.021) patients.

Conclusion: There were differences in BAV morphology, valve dysfunction, aortopathy, and prognosis within the Asian population. Chinese patients had one of the highest prevalence of significant aortic regurgitation, with the largest aortic dimensions and worst outcomes compared with other Asian ethnicities. Closer surveillance is warranted in BAV patients within the Asian population.
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http://dx.doi.org/10.1016/j.hlc.2021.10.023DOI Listing
November 2021

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

J Stroke Cerebrovasc Dis 2021 Nov 20;31(1):106215. Epub 2021 Nov 20.

Department of Cardiology, National University Heart Centre, National University Health System, Singapore.

Objectives: 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).

Materials And Methods: 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).

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106215DOI Listing
November 2021

A review of COVID-19 vaccination and the reported cardiac manifestations.

Singapore Med J 2021 Nov 19. Epub 2021 Nov 19.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

In Singapore, 9.03 million doses of the mRNA COVID-19 vaccines by Pfizer-BioNTech and Moderna have been administered, and 4.46 million people are fully vaccinated. An additional 87,000 people have been vaccinated with vaccines in World Health Organization's Emergency Use Listing. The aim of this review is to explore the reported cardiac adverse events associated with different types of COVID-19 vaccines. 42 studies that reported cardiac side effects after COVID-19 vaccination were included in this study. Reported COVID-19 vaccine-associated cardiac adverse events were mainly myocarditis and pericarditis, most commonly seen in adolescent and young adult male individuals after mRNA vaccination. Reports of other events such as acute myocardial infarction, arrhythmia and stress cardiomyopathy were rare. Outcomes of post-vaccine myocarditis and pericarditis were good. Given the good vaccine efficacy and the high number of cases of infection, hospitalisation and death that could potentially be prevented, COVID-19 vaccine remains of overall benefit, based on the current available data.
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http://dx.doi.org/10.11622/smedj.2021210DOI Listing
November 2021

Utility of conventional clinical risk scores in a low-risk COVID-19 cohort.

BMC Infect Dis 2021 Oct 24;21(1):1094. Epub 2021 Oct 24.

Department of Infectious Diseases, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 10, Singapore, 119228, Singapore.

Background: Several specific risk scores for Coronavirus disease 2019 (COVID-19) involving clinical and biochemical parameters have been developed from higher-risk patients, in addition to validating well-established pneumonia risk scores. We compared multiple risk scores in predicting more severe disease in a cohort of young patients with few comorbid illnesses. Accurately predicting the progression of COVID-19 may guide triage and therapy.

Methods: We retrospectively examined 554 hospitalised COVID-19 patients in Singapore. The CURB-65 score, Pneumonia Severity Index (PSI), ISARIC 4C prognostic score (4C), CHADS-VASc score, COVID-GRAM Critical Illness risk score (COVID-GRAM), Veterans Health Administration COVID-19 index for COVID-19 Mortality (VACO), and the "rule-of-6" score were compared for three performance characteristics: the need for supplemental oxygen, intensive care admission and mechanical ventilation.

Results: A majority of patients were young (≤ 40 years, n = 372, 67.1%). 57 (10.3%) developed pneumonia, with 16 (2.9% of study population) requiring supplemental oxygen. 19 patients (3.4%) required intensive care and 2 patients (0.5%) died. The clinical risk scores predicted patients who required supplemental oxygenation and intensive care well. Adding the presence of fever to the CHADS-VASc score and 4C score improved the ability to predict patients who required supplemental oxygen (c-statistic 0.81, 95% CI 0.68-0.94; and 0.84, 95% CI 0.75-0.94 respectively).

Conclusion: Simple scores including well established pneumonia risk scores can help predict progression of COVID-19. Adding the presence of fever as a parameter to the CHADS-VASc or the 4C score improved the performance of these scores in a young population with few comorbidities.
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http://dx.doi.org/10.1186/s12879-021-06768-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8542362PMC
October 2021

Prognostic Implications of Bicuspid and Tricuspid Aortic Valve Phenotype on Progression of Moderate Aortic Stenosis and Ascending Aorta Dilatation.

Am J Cardiol 2021 12 6;161:76-83. Epub 2021 Oct 6.

Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. Electronic address:

Studies on the impact of aortic valve anatomy (bicuspid aortic valve [BAV] or tricuspid aortic valve [TAV]) on the progression of moderate aortic stenosis (AS) and ascending aorta (AA) dilatation and its prognostic implications are limited. From 1991 to 2016, 288 asymptomatic patients with moderate AS detected during index echocardiography with at least 1 year of echocardiographic follow-up were retrospectively studied. Baseline clinical and echocardiographic characteristics were compared between patients with BAV (n = 80) and patients with TAV (n = 208). Co-primary outcomes were 1-year hemodynamic and anatomic progression of AS and AA dilatation. Secondary end points were the incidence of AA rapid progressors, all-cause mortality, aortic valve replacement, and congestive heart failure. Determinants of AS progression, AA diameters, AA dilatation, and prognostic outcomes were evaluated. Similar 1-year progression of the aortic valve peak velocity, V (9 ± 18 vs 9 ± 23 cm/s), mean gradient (1.5 ± 2.3 vs 1.3 ± 3.2 mm Hg), and aortic valve area (AVA) (-0.04 ± 0.09 vs -0.05 ± 0.10 cm) were noted for BAV and TAV groups, respectively. One-year progressions of AA were similar at Valsalva (0.11 ± 0.88 vs 0.14 ± 1.10 mm) and tubular levels (0.12 ± 0.68 vs 0.30 ± 1.51 mm) in BAV and TAV groups, respectively. A trend toward increased rapid AA progression in patients with BAV (31.3%) was observed compared with patients with TAV (14.8%, p = 0.099). BAV was associated with progression of V (β = 0.17, p = 0.036), the dimensionless index (β = -0.17, p = 0.008), and AVA (β = -0.14, p = 0.048), but not mean gradient after adjusting for age, baseline severity indexes, gender, hypertension, diabetes, and body surface area. Although BAV was a determinant of larger baseline AA diameter, there was no significant association between BAV and AA rapid progressors. Adjusted Kaplan-Meier curves demonstrated no differences in congestive heart failure, aortic valve replacement, or mortality between valve morphology. In conclusion, there was a similar 1-year disease progression in terms of AVA, V, mean gradient, and AA diameters between patients with BAV and patients with TAV. BAV was associated with a significant increase in V, dimensionless index, and AVA after adjusting for important confounders. Close and prolonged follow-up is warranted in both groups of patients.
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http://dx.doi.org/10.1016/j.amjcard.2021.08.050DOI Listing
December 2021

The association of face mask use with self-reported cardiovascular symptoms during the COVID-19 pandemic.

Singapore Med J 2021 Oct 3. Epub 2021 Oct 3.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

Introduction: Countries are mandating the use of face masks to stem the spread of COVID-19. Face mask use has been associated with discomfort due to its effects on thermoregulation, breathing and oxygenation. We evaluated the prevalence and severity of self-reported cardiovascular symptoms before and during face mask use.

Methods: This was a cross-sectional study of 1001 participants residing in Singapore, who participated in a self-administered questionnaire between 25th April 2020 to 4th May 2020. Symptom severity before and during mask use and health-seeking behaviour information were collected. The study outcome was the self-reported worsening of cardiovascular symptoms, and its association with the type of mask worn, duration of mask worn per day, and intensity of physical activities during mask use.

Results: The commonest symptom reported during mask use was dyspnoea. Independent predictors for self-reported cardiovascular symptoms during mask use were moderate-high physical activity during mask use (OR 1.634, 95% CI 1.176-2.270, p=0.003), duration of mask use ≥3 hours (OR 1.672, 95% CI 1.189-2.352, p=0.003) and the type of mask used, after adjusting for age, sex, healthcare-based worker status and presence of comorbidities. N95 mask was associated with worse symptoms when compared to surgical mask. Participants with ≥3 worsening symptoms, or worsening dyspnoea, palpitations, fatigue and dizziness were more likely to seek medical help.

Conclusion: Face mask use is proven to be an effective way in curbing COVID-19 transmission. However, participants in this study had concerns regarding its use and these concerns should be urgently addressed to enable mask-use policies to be enacted.
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http://dx.doi.org/10.11622/smedj.2021140DOI Listing
October 2021

Silent hypoxia: pulse oximetry and its relation to COVID-19 in Singapore.

Singapore Med J 2021 Sep 28. Epub 2021 Sep 28.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

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http://dx.doi.org/10.11622/smedj.2021134DOI Listing
September 2021

Elevated liver enzymes in hospitalized patients with COVID-19 in Singapore.

Medicine (Baltimore) 2021 Jul;100(30):e26719

Division of Infectious Diseases, National University Health System, Singapore.

Abstract: Liver dysfunction in patients with COVID-19 (coronavirus disease 2019) has been described. However, it is not clear if the presence of abnormal liver function tests at presentation was related to underlying undiagnosed liver disease, or a result of the viral infection.We retrospectively examined the first 554 consecutive polymerase chain reaction positive SARS-CoV-2 patients admitted from February 2020 to April 2020 to our academic medical centre. We reviewed their clinical data, chest radiography and laboratory studies obtained within 24 hour of admission.Despite similar hemodynamic parameters, we found significant aspartate transaminase elevation (64 ± 141 vs 35 ± 23 U/L, P < .001) in those with pneumonia compared to those without. Elevated liver enzymes were seen in 102 patients (18.4%). They presented with higher temperatures (38.5 ± 0.9 vs 37.5 ± 0.8 degC, P = .011), higher total white cell counts (6.95 ± 2.29 vs 6.39 ± 2.19 x109/L, P = .021), serum ferritin (240 ± 274 vs 165 ± 198 ng/ml, P = .002) and lactate dehydrogenase (632 ± 912 vs 389 ± 107 U/L, P < .001). These patients were more likely to require intensive care (6.9% vs 2.7% P = .036) and mechanical ventilation (5.9% vs 2.2%, P = .046). Migrant workers from dormitories had a higher rate of baseline liver function test abnormalities (88/425 vs 14/129, P = .01), which were more likely to persist at the time of discharge.Despite relatively mild COVID-19 disease, there was a significant prevalence of liver dysfunction, particularly amongst migrant workers. Elevated liver enzymes were associated with more severe disease, despite similar haemodynamic characteristics. Future studies should explore whether pre-existing liver disease may predispose to more severe COVID-19 disease.
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http://dx.doi.org/10.1097/MD.0000000000026719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322538PMC
July 2021

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus <70 Years.

Am J Cardiol 2021 10 7;157:93-100. Epub 2021 Aug 7.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Electronic address:

Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.
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http://dx.doi.org/10.1016/j.amjcard.2021.07.015DOI Listing
October 2021

Deranged Coagulation Profile Secondary to Cefazolin Use: Case Report.

Infect Dis Rep 2021 Mar 1;13(1):187-190. Epub 2021 Mar 1.

Division of Infectious Diseases, Department of Medicine, National University Health System, Singapore 119228, Singapore.

Cefazolin is a widely used first-generation cephalosporin. While generally well tolerated, several case reports have described severe coagulopathy induced by intravenous (IV) cefazolin. This was seen particularly in patients with impaired renal function, where antibiotic choice is limited and may require specific dose adjustments. Altered renal handling of antibiotics and their metabolites may potentiate toxicity and side effects. We report a case of a 72-year-old Chinese man who had been treated for methicillin-sensitive staphylococcus aureus (MSSA, coagulase-positive) infective endocarditis with cefazolin and, consequently, developed significantly elevated international normalised ratio (INR) while on therapy. This resolved within 48 h after cessation of cefazolin and administration of oral vitamin K. Malnourished patients with pre-existing or acute kidney injury may be at an increased risk of cefazolin-related coagulopathy.
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http://dx.doi.org/10.3390/idr13010021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931061PMC
March 2021

Plasma Clearance of B-Type Natriuretic Peptide (BNP) before and after Bariatric Surgery for Morbid Obesity.

Clin Chem 2021 03;67(4):662-671

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore.

Background: Obese patients have lower plasma concentrations of the cardiac natriuretic peptides (NPs) than their age- and sex-matched counterparts. This may reflect lower production and/or increased peptide clearance. It is unclear whether NP bioactivity is affected by obesity.

Methods: We studied the effects of obesity on B-type natriuretic peptide (BNP) clearance and bioactivity by comparing results from standardized intravenous infusions of BNP administered 2 weeks before and 6 months after bariatric surgery in 12 consecutive patients with morbid obesity (body mass index, BMI > 35 kg/m2). Anthropometric, clinical, neurohormonal, renal, and echocardiographic variables were obtained pre- and postsurgery. Pre- vs postsurgery calculated intrainfusion peptide clearances were compared.

Results: BMI (44.3 ± 5.0 vs 33.9 ± 5.2 kg/m2, P < 0.001) and waist circumference (130.3 ± 11.9 vs 107.5 ± 14.7 cm, P < 0.001) decreased substantially after bariatric surgery. Calculated plasma clearance of BNP was reduced (approximately 30%) after surgery. Though not controlled for, sodium intake was presumably lower after bariatric surgery. Despite this, preinfusion endogenous plasma NP concentrations did not significantly differ between pre- and postsurgery studies. The ratio of plasma N-terminal (NT)-proBNP to 24 h urine sodium excretion was higher postsurgery (P = 0.046; with similar nonsignificant findings for BNP, atrial NP (ANP) and NT-proANP), indicating increased circulating NPs for a given sodium status. Mean plasma NP concentrations for given calculated end-systolic wall stress and cardiac filling pressures (as assessed by echocardiographic E/e') rose slightly, but not significantly postsurgery. Second messenger, hemodynamic, renal, and neurohormonal responses to BNP were not altered between studies.

Conclusion: Obesity is associated with increased clearance, but preserved bioactivity, of BNP.
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http://dx.doi.org/10.1093/clinchem/hvaa308DOI Listing
March 2021

An Asia-Pacific study on healthcare workers' perceptions of, and willingness to receive, the COVID-19 vaccination.

Int J Infect Dis 2021 May 26;106:52-60. Epub 2021 Mar 26.

Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore.

Objective: In the fight against COVID-19, vaccination is vital in achieving herd immunity. Many Asian countries are starting to vaccinate frontline workers; however, expedited vaccine development has led to hesitancy among the general population. We evaluated the willingness of healthcare workers to receive the COVID-19 vaccine.

Methods: From 12 to 21 December 2020, we recruited 1720 healthcare workers from 6 countries: China, India, Indonesia, Singapore, Vietnam and Bhutan. The self-administrated survey collected information on willingness to vaccinate, perception of COVID-19, vaccine concerns, COVID-19 risk profile, stigma, pro-socialness scale, and trust in health authorities.

Results: More than 95% of the healthcare workers surveyed were willing to vaccinate. These respondents were more likely to perceive the pandemic as severe, consider the vaccine safe, have less financial concerns, less stigmatization regarding the vaccine, higher pro-socialness mindset and trust in health authorities. A high perceived pandemic risk index, low vaccine harm index and high pro-socialness index were independent predictors in multivariable analysis.

Conclusions: The majority of healthcare workers in Asia are willing to receive COVID-19 vaccination. Perceived COVID-19 susceptibility, low potential risk of vaccine harm and pro-socialness are the main drivers. These findings may help formulate vaccination strategies in other countries.
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http://dx.doi.org/10.1016/j.ijid.2021.03.069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997703PMC
May 2021

Fever as a predictor of adverse outcomes in COVID-19.

QJM 2021 Feb 3. Epub 2021 Feb 3.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

Introduction: There are little data on outcomes of COVID-19 patients with the presence of fever compared to the presence of symptoms. We examined the associations between symptomology, presence of fever, and outcomes of a COVID-19 cohort.

Methods: Between 23rd January to 30th April 2020, 554 COVID-19 patients were admitted to a tertiary hospital in Singapore. They were allocated into 4 groups based on symptomology and fever - Group 1: asymptomatic and afebrile, Group 2: symptomatic but afebrile, Group 3: febrile but asymptomatic, Group 4: symptomatic and febrile. The primary outcomes were intensive care unit (ICU) admissions and mortality. The composite end-point included ICU admissions, mortality or any COVID-19 related end-organ involvement.

Results: There were differences in ferritin (p = 0.003), C-reactive protein (CRP) levels (p < 0.001) and lymphopenia (p = 0.033) across all groups, with the most favourable biochemical profile in Group 1, and the least in Group 4. Symptomatic groups (Groups 2 and 4) had higher ICU admissions (1.9% and 6.0%, respectively, p = 0.003) than asymptomatic groups (Groups 1 and 3). Composite end-point was highest in Group 4 (24.0%), followed by Group 3 (8.6%), Group 2 (4.8%) and Group 1 (2.4%) (p < 0.001). The presence of fever (OR 4.096, 95% CI 1.737-9.656, p = 0.001) was associated with the composite end-point after adjusting for age, pulse rate, comorbidities, lymphocyte, ferritin, CRP. Presence of symptoms was not associated with the composite end-point.

Conclusion: In this COVID-19 cohort, presence of fever was a predictor of adverse outcomes. This has implications on the management of febrile but asymptomatic COVID-19 patients.
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http://dx.doi.org/10.1093/qjmed/hcab023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928573PMC
February 2021

Inadequately low left ventricular mass in patients with significant aortic stenosis predicts favourable prognostic outcomes.

Int J Cardiovasc Imaging 2021 May 16;37(5):1611-1619. Epub 2021 Jan 16.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore.

In patients with significant aortic stenosis (AS), the prognostic effect of the increase in left ventricular mass (LVM) in relation to one's hemodynamic load has been described. Inappropriately high LVM has been shown to predict adverse cardiovascular events. However, little is known about the prognostic impact of inadequately low LVM (i-lowLVM) in patients with significant AS. I-lowLVM was defined as the measured LVM < 73% of the predicted LVM based on sex, stroke work and height from the reference adult population, used in previous established studies. For outcome analysis, the end-point was defined as all-cause mortality, aortic valve replacement and/or admission for congestive heart failure. Kaplan-Meier curves and multivariable Cox regression models were constructed to compare outcomes on follow-up. During the follow-up (4.5 ± 4.1 years), 132 patients (11.1%) had i-lowLVM, 868 (73.1%) had adequate-LVM, 188 (15.8%) had inappropriately high LVM. Outcome analysis only included patients with i-lowLVM and adequate-LVM (N = 1000). An adverse composite event occurred in 41.7% of the i-lowLVM group and 52.4% of the adequate-LVM group (p = 0.021). Event-free survival in patients with i-lowLVM and appropriate-LVM was 76% versus 68% at 2-year, 55% versus 46% at 4-year, 33% versus 27% at 6-year, 20% versus 17% at 8-year, and 17% versus 11% at 10-year follow-up, respectively (p < 0.001). Cox analysis revealed that i-lowLVM was independently associated with lower composite adverse outcome (HR 0.624, 95% CI 0.460-0.846, p = 0.002) after adjusting for sex, age, ejection fraction, ischemic heart disease, diabetes and transaortic valve mean gradient. In the separate Cox subanalyses, the presence of i-lowLVM remained a predictor of lower composite adverse outcome in the severe AS subgroup (HR 0.587, 95% CI 0.396-0.870, p = 0.008), and the LVH subgroup (HR 0.574, 95% CI 0.401-0.824, p = 0.003) after adjusting for confounders. I-lowLVM despite significant AS may represent a distinct group that is associated with improved survival outcomes independent of other prognostic covariates.
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http://dx.doi.org/10.1007/s10554-020-02146-3DOI Listing
May 2021

Optimal vortex formation time index in mitral valve stenosis.

Int J Cardiovasc Imaging 2021 May 12;37(5):1595-1600. Epub 2021 Jan 12.

Department of Cardiology, National University Heart Centre, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore.

Left ventricular vortex formation time (VFT) is a novel dimensionless index of flow propagation during left ventricular diastole, which has been demonstrated to be useful in heart failure and cardiomyopathy. In mitral stenosis (MS), flow propagation in the LV may be suboptimal. We studied VFT in varying degrees of MS. Echocardiography was performed on 20 healthy controls and 50 cases of rheumatic MS. Patients with atrial fibrillation, LV ejection fraction < 50% and other valvular heart diseases were excluded. VFT was obtained using the length-to-diameter ratio (L/D), where L is the continuous-wave Doppler velocity time integral stroke distance, divided by D, the mitral leaflet separation index. This was correlated against varying degrees of MS severity, left atrial (LA) volume and function. In controls, VFT was 3.92 ± 2.00 (optimal range) and was higher (suboptimal) with increasing severity of mitral stenosis (4.98 ± 2.43 in mild MS; 7.22 ± 2.98 in moderate MS; 11.55 ± 2.67 in severe MS, p < 0.001). VFT negatively correlated with mitral valve area (R = 0.463, p < 0.001) and total LA emptying fraction (R = 0.348, p < 0.001), and positively correlated with LA volume index (R = 0.440, p < 0.001) and mean transmitral pressure gradient (R = 0.336, p < 0.001). More severe MS correlated with suboptimal (higher) VFT. The restricted mitral valve opening may disrupt vortex formation and optimal fluid propagation in the LV. Despite the compensatory increase in LA size with increasingly severe MS, reduced LA function also contributed to the suboptimal LV vortex formation.
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http://dx.doi.org/10.1007/s10554-020-02140-9DOI Listing
May 2021

The Utility of CHA(2)DS(2)-VASc Scores as a Risk Assessment Tool in Low-Risk In-Hospital Patients With Coronavirus Disease 2019 Infection.

Am J Cardiol 2021 02 4;141:160-162. Epub 2020 Dec 4.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716726PMC
February 2021

The obesity paradox: association of obesity with improved survival in medically managed severe aortic stenosis.

Singapore Med J 2020 12 2. Epub 2020 Dec 2.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore.

Introduction: The obesity paradox, where obesity is associated with improved survival, has been described in patients undergoing haemodialysis and in heart failure. It was also demonstrated in patients undergoing valve replacement for aortic stenosis (AS). We explored this phenomenon in medically managed severe AS.

Methods: 154 patients with medically managed severe AS (aortic valve area index [AVAi] < 0.6 cm2/m2; mean pressure gradient > 40 mmHg and peak velocity > 400 cm/s) and preserved left ventricular ejection fraction (> 50%) were categorised into the obese (body mass index [BMI] Asian cut-off ≥ 27.5 kg/m2) and non-obese groups. Their clinical and echocardiographic profiles were compared.

Results: 24 (15.6%) patients were obese. Obese patients were similar to non-obese patients in age (68.5 ± 11.6 vs. 68.9 ± 13.1 years) but had higher prevalence of cardiovascular risk factors. Left atrial diameter (43.7 ± 6.7 vs. 38.5 ± 10.2 mm) was larger in obese patients, while left ventricular outflow tract diameter (19.5 ± 1.7 vs. 20.4 ± 2.1 mm) was smaller. Despite lower AVAi in obese patients (0.36 ± 0.10 vs. 0.43 ± 0.11 cm2/m2), there was lower mortality (37.5% vs. 41.0%, log-rank 4.06, p = 0.045) on follow-up (8.0 ± 5.7 years). After adjusting for age and AVA, higher BMI ≥ 27.5 kg/m2 remained protective for mortality (hazard ratio 0.38, 95% confidence interval 0.15 to 0.98, p = 0.046).

Conclusion: We demonstrated that obesity was associated with improved survival in severe AS despite lower AVAi and increased prevalence of cardiovascular risk factors.
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http://dx.doi.org/10.11622/smedj.2020169DOI Listing
December 2020

Demographic shift in COVID-19 patients in Singapore from an aged, at-risk population to young migrant workers with reduced risk of severe disease.

Int J Infect Dis 2021 Feb 19;103:329-335. Epub 2020 Nov 19.

Division of Infectious Diseases, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Electronic address:

Objectives: The vast majority of COVID-19 cases in Singapore have occurred amongst migrant workers. This paper examined trends in the hospitalised cases and tested the assumption that the low severity of disease was related to the relatively young affected population.

Methods: All patients with PCR-positive SARS-CoV-2 admitted from February to April 2020 were divided into: (i) imported cases, (ii) locally-transmitted cases outside migrant worker dormitories and (iii) migrant worker dormitory cases. They were examined for underlying comorbidities, clinical progress and outcomes.

Results: Imported cases (n = 29) peaked in mid-March 2020, followed by local cases (n = 100) in mid-April 2020; migrant worker cases (n = 425) continued to increase in late April 2020. Migrant worker cases were younger, had few medical comorbidities and less severe disease. As the migrant worker cases increased, the proportion of patients with pneumonia decreased, whilst patients presenting earlier in their illness and asymptomatic disease became more common.

Conclusion: Singapore experienced a substantial shift in the population at risk of severe COVID-19. Successful control in the community protected an aging population. Large migrant worker dormitory outbreaks occurred, but the disease incurred was less severe, resulting in Singapore having one of the lowest case fatality rates in the world.
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http://dx.doi.org/10.1016/j.ijid.2020.11.157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674985PMC
February 2021

Asian-Pacific perspective on the psychological well-being of healthcare workers during the evolution of the COVID-19 pandemic.

BJPsych Open 2020 Oct 8;6(6):e116. Epub 2020 Oct 8.

Division of Neurology, Department of Medicine, National University Health System, Singapore; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to significant strain on front-line healthcare workers.

Aims: In this multicentre study, we compared the psychological outcomes during the COVID-19 pandemic in various countries in the Asia-Pacific region and identified factors associated with adverse psychological outcomes.

Method: From 29 April to 4 June 2020, the study recruited healthcare workers from major healthcare institutions in five countries in the Asia-Pacific region. A self-administrated survey that collected information on prior medical conditions, presence of symptoms, and scores on the Depression Anxiety Stress Scales and the Impact of Events Scale-Revised were used. The prevalence of depression, anxiety, stress and post-traumatic stress disorder (PTSD) relating to COVID-19 was compared, and multivariable logistic regression identified independent factors associated with adverse psychological outcomes within each country.

Results: A total of 1146 participants from India, Indonesia, Singapore, Malaysia and Vietnam were studied. Despite having the lowest volume of cases, Vietnam displayed the highest prevalence of PTSD. In contrast, Singapore reported the highest case volume, but had a lower prevalence of depression and anxiety. In the multivariable analysis, we found that non-medically trained personnel, the presence of physical symptoms and presence of prior medical conditions were independent predictors across the participating countries.

Conclusions: This study highlights that the varied prevalence of psychological adversity among healthcare workers is independent of the burden of COVID-19 cases within each country. Early psychological interventions may be beneficial for the vulnerable groups of healthcare workers with presence of physical symptoms, prior medical conditions and those who are not medically trained.
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http://dx.doi.org/10.1192/bjo.2020.98DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542327PMC
October 2020

Stress Hyperglycaemia is Associated with Poor Functional Outcomes in Patients with Acute Ischaemic Stroke after Intravenous Thrombolysis.

QJM 2020 Aug 18. Epub 2020 Aug 18.

Division of Neurology, Department of Medicine, National University Health System, Singapore.

Background: Transient hyperglycaemia in the context of illness with or without known diabetes has been termed as 'stress hyperglycaemia'. Stress hyperglycaemia can result in poor functional outcomes in patients with acute ischaemic stroke who underwent mechanical thrombectomy. We investigated the association between stress hyperglycaemia and clinical outcomes in acute ischaemic stroke patients undergoing intravenous thrombolysis (IVT).

Methods: We examined 666 consecutive patients with acute ischaemic stroke who underwent IVT from 2006-2018. All patients had a glycated haemoglobin level (HbA1c) and fasting venous blood glucose measured within 24 hours of admission. Stress hyperglycaemia ratio (SHR) was defined as the ratio of the fasting glucose to the HbA1c. Univariate and multivariate analyses were employed to identify predictors of poor functional outcomes (modified Rankin Scale 3-6 at 3 months) after IVT.

Results: Three-hundred and sixty-one patients (54.2%) had good functional outcomes. These patients tended to be younger (60.7±12.7 vs 70 ±14.4 years, p < 0.001), male (70.7% vs 51.5%, p < 0.001), had lower prevalence of atrial fibrillation (13.0% vs 20.7%, p = 0.008) and lower SHR (0.88±0.20 vs 0.99±26, p < 0.001). Patients with high SHR (≥0.97) were slightly older than those with low SHR (<0.97), and were more likely to have diabetes mellitus. On multivariate analysis, higher SHR was independently associated with poor functional outcomes (adjusted odds ratio 3.85, 95% CI 1.59 - 9.09, p = 0.003).

Conclusions: SHR appears to be an important predictor of functional outcomes in patients with AIS undergoing IVT. This may have important implications on the role of glycaemic control in the acute management of ischaemic stroke.
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http://dx.doi.org/10.1093/qjmed/hcaa253DOI Listing
August 2020

COVID-19: local lessons from a global pandemic.

Singapore Med J 2020 07 26;61(7):341-342. Epub 2020 Jun 26.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

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http://dx.doi.org/10.11622/smedj.2020097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926598PMC
July 2020

Novel Echocardiography-Derived Left Ventricular Stiffness Index in Low-Flow Versus Normal-Flow Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction.

Sci Rep 2020 06 3;10(1):9086. Epub 2020 Jun 3.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore, Singapore.

Background Paradoxical low-flow (LF) severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) may have poorer prognosis than normal-flow (NF) AS, though its pathophysiology remained unclear. In particular, LV stiffness has not been compared between LF vs NF. We used a novel echocardiography-derived index of LV stiffness to compare between these groups. Consecutive patients with medically-managed isolated severe AS (aortic valve area < 1 cm) and preserved LVEF (>50%) were studied. Echocardiographic LV stiffness index was measured by a method previously validated against cardiac catheterization. We compared LF (stroke volume index, SVI < 35 ml/m) and NF severe AS. Of the 352 patients, 121 (34%) were LF. Both LF and NF groups had similar demographics, valve areas and indices. Compared to NF, LF severe AS had higher LV stiffness indices (>0.11 ml OR 3.067, 95% CI 1.825-5.128, p < 0.001). Increased LV stiffness was associated with concentric remodelling and more severe diastolic dysfunction, especially in LF AS. An LV stiffness index of > 0.11 ml was independently associated with increased mortality, after adjusting for age, clinical and echocardiographic parameters (HR 2.283 95% CI 1.318-3.968, p = 0.003). Non-invasive echocardiographic-derived index of LV stiffness may be important in LF AS. Increased LV stiffness was related to LV concentric remodelling and diastolic dysfunction, and associated with poorer clinical outcomes in medically-managed AS.
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http://dx.doi.org/10.1038/s41598-020-65758-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270100PMC
June 2020

Differences in Clinical and Echocardiographic Profiles and Outcomes of Patients With Atrial Fibrillation Versus Sinus Rhythm in Medically Managed Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction.

Heart Lung Circ 2020 Dec 14;29(12):1773-1781. Epub 2020 Apr 14.

Department of Cardiology, National University Heart Centre, Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Electronic address:

Background: Atrial fibrillation (AF) results in the loss of atrial booster pump function and portends poorer outcome in aortic valve stenosis (AS). However, its characteristics and impact on medically managed AS remained under-recognised. We compared these patients with AF to sinus rhythm (SR).

Method: In total, 347 consecutive patients with medically managed severe AS (aortic valve area <1 cm) and preserved left ventricular ejection fraction (>50%) were studied, in terms of echocardiographic characteristics and clinical outcomes. Appropriate univariate and multivariate models were used, while Kaplan-Meier curves and Cox regression models were constructed to compare clinical outcomes (mortality, admissions for congestive cardiac failure, and stroke).

Results: Ninety (90) (25.9%) patients had AF. Patients with AF had lower body mass index (BMI 18.5±10.4 vs 23.8±6.2 g/m; p<0.001), larger left ventricular mass index (LVMI 127.9±39.0 vs 116.7±36.5; p=0.017), and left atrial volume index (53.2±20.0 vs 31.0±9.2 mL/m; p=0.004). Atrial fibrillation was associated with higher mortality (52.2% vs 37.4%; Kaplan-Meier log-rank 7.18; p=0.007), admissions for congestive cardiac failure (log-rank 6.42; p=0.011), and poorer composite outcomes (log-rank 6.29; p=0.012). The incidence of stroke in both groups were similar on follow-up (log-rank 0.08; p=0.776). After adjusting for age, BMI, LVMI, and left atrial volume index on Cox regression, AF remained independently associated with poorer composite clinical outcomes (hazard ratio, 1.66; 95% confidence interval 1.07-2.58).

Conclusions: Atrial fibrillation remained an important comorbidity affecting a quarter of patients with medically managed severe AS. It was independently associated with poorer clinical outcomes and may thus aid in prognostication and management.
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http://dx.doi.org/10.1016/j.hlc.2020.02.018DOI Listing
December 2020

Controversies and discrepancies in the effect of dietary fat and cholesterol on cardiovascular risk.

Singapore Med J 2021 Feb 21;62(2):56-62. Epub 2020 Apr 21.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

Cardiovascular disease (CVD) is the leading cause of death worldwide. The top ten causes of death in Singapore include many cardiovascular-related diseases such as ischaemic heart disease. The increasing prevalence of CVD poses a burden to both the economy and healthcare system of a country. Dietary habits, in particular dietary fats and cholesterol intake, have been shown to greatly influence CVD risks. Therefore, reference and adherence to relevant dietary guidelines could be crucial in CVD prevention. Recent research findings have provided novel insights into the relationship between certain dietary fats or cholesterol intake and CVD risks, challenging or reinforcing previous guidelines. These findings may, however, be conflicting, and there are still controversies over the effects of dietary fats and cholesterol as well as their association with cardiovascular risk. This review paper aims to evaluate common controversies, identify gaps in relevant research areas and summarise evidence-based dietary recommendations.
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http://dx.doi.org/10.11622/smedj.2020065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027141PMC
February 2021

Echocardiographic discrepancies in severity grading of aortic valve stenosis with left ventricular outflow tract (LVOT) cut-off values in an Asian population.

Int J Cardiovasc Imaging 2020 Apr 2;36(4):615-621. Epub 2020 Jan 2.

Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore, Singapore.

Inconsistencies in grading of aortic stenosis (AS) severity have been reported. However, it remains to be studied in an Asian population. We investigated consistency of grading AS severity at various left ventricular outflow tract diameter (LVOTd) categories, and postulated alternative cut-offs for more consistent grading of AS severity. Consecutive Asian patients (n = 350) with index echocardiographic diagnosis of severe AS were divided them into three groups based on LVOTd: 'small' (< 20 mm), 'average' (20-22 mm) and 'large' (> 22 mm). In each group, the consistency of flow-dependent (transaortic mean pressure gradient (MG)) and flow-independent parameters (AVA) were used for classification of AS severity. Of 350 patients, 51.7% had small LVOTd, while 30.8% and 17.5% had average and large LVOTd respectively. Consistent grading by LVOTd based on AVA and MG, was seen in 33.7% of patients with small, 47.6% with average, 57.7% with large LVOTd. When an AVA cut-off of 0.9 cm was used, consistent grading improved to 38.0% in small, 56.5% in average and 70.0% in large LVOTd. At an AVA cut-off of 0.8 cm, there was further incremental improvement in the small LVOTd group to 54.1% (p < 0.05). In conclusion, current severe AS guidelines are most inconsistent with those in the small LVOTd group. With majority of the study's Asian population having small LVOTd, this raises concerns that current AS guidelines may overestimate the severity of AS in the Asian cohort. Improved consistency in echocardiographic grading may be attained with a lower AVA cut-off in this Asian cohort.
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http://dx.doi.org/10.1007/s10554-019-01755-xDOI Listing
April 2020

Clinical and echocardiographic features of paradoxical low-flow and normal-flow severe aortic stenosis patients with concomitant mitral regurgitation.

Int J Cardiovasc Imaging 2020 Mar 27;36(3):441-446. Epub 2019 Nov 27.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

Mitral regurgitation (MR) coexists in a significant proportion of patients with severe aortic stenosis (AS), and portends inferior therapeutic outcomes. In severe AS, MR is thought to contribute to a low-flow state by decreasing forward stroke volume. We investigated concomitant MR on the clinical and echocardiographic features of patients with "paradoxical" low-flow (PLF) and normal-flow (NF) severe AS. Clinical and echocardiographic profiles of 886 consecutive patients with index echocardiographic diagnosis of severe AS (AVA < 1.0 cm) were analysed retrospectively. All patients had preserved ejection fraction (LVEF  ≥ 50%, n = 645), and were divided into PLF (stroke volume index, SVI < 35 mL/m) and NF AS. They were then further subdivided based on the presence or absence of moderate-or-severe MR (msMR). A higher prevalence of concomitant msMR was observed in patients with PLF AS (14.9%; n = 33/221) compared to those with NF AS (8.0%; n = 34/424). Concomitant msMR was associated with echocardiographic features of increased diastolic dysfunction in both PLF AS and NF AS patients, as evidenced by increased LA diameter (PLF AS 52.9 ± 12.5 to 43.9 ± 8.9 mm; NF AS 29.6 ± 10.8 to 42.4 ± 8.8 mm; p < 0.001) and increased transmitral E/A ratio (PLF AS 1.26 ± 0.56 to 0.92 ± 0.43; NF AS 1.19 ± 0.63 to 0.94 ± 0.45; p = 0.004). Amongst patients with NF AS, msMR was additionally associated with increased E:e' ratio (25.5 ± 15.1 vs 19.3 ± 10.8; p = 0.025). Concomitant MR was more common in PLF AS compared to NF. Although possibly related to the MR, patients severe AS and MR appeared to have more severe diastolic dysfunction. Further studies are warranted to evaluate prognosis and guide management.
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http://dx.doi.org/10.1007/s10554-019-01735-1DOI Listing
March 2020
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