Publications by authors named "Koo Hui Chan"

25 Publications

  • Page 1 of 1

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

Post-ST-Segment Elevation Myocardial Infarction Follow-Up Care During the COVID-19 Pandemic and the Possible Benefit of Telemedicine: An Observational Study.

Front Cardiovasc Med 2021 22;8:755822. Epub 2021 Oct 22.

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

Infectious control measures during the COVID-19 pandemic have led to the propensity toward telemedicine. This study examined the impact of telemedicine during the pandemic on the long-term outcomes of ST-segment elevation myocardial infarction (STEMI) patients. This study included 288 patients admitted 1 year before the pandemic (October 2018-December 2018) and during the pandemic (January 2020-March 2020) eras, and survived their index STEMI admission. The follow-up period was 1 year. One-year primary safety endpoint was all-cause mortality. Secondary safety endpoints were cardiac readmissions for unplanned revascularisation, non-fatal myocardial infarction, heart failure, arrythmia, unstable angina. Major adverse cardiovascular events (MACE) was defined as the composite outcome of each individual safety endpoint. Despite unfavorable in-hospital outcomes among patients admitted during the pandemic compared to pre-pandemic era, both groups had similar 1-year all-cause mortality (11.2 vs. 8.5%, respectively, = 0.454) but higher cardiac-related (14.1 vs. 5.1%, < 0.001) and heart failure readmissions in the pandemic vs. pre-pandemic groups (7.1 vs. 1.7%, = 0.037). Follow-up was more frequently conducted via teleconsultations (1.2 vs. 0.2 per patient/year, = 0.001), with reduction in physical consultations (2.1 vs. 2.6 per patient/year, = 0.043), during the pandemic vs. pre-pandemic era. Majority achieved guideline-directed medical therapy (GDMT) during pandemic vs. pre-pandemic era (75.9 vs. 61.6%, = 0.010). Multivariable Cox regression demonstrated achieving medication target doses (HR 0.387, 95% CI 0.164-0.915, = 0.031) and GDMT (HR 0.271, 95% CI 0.134-0.548, < 0.001) were independent predictors of lower 1-year MACE after adjustment. The pandemic has led to the wider application of teleconsultation, with increased adherence to GDMT, enhanced medication target dosing. Achieving GDMT was associated with favorable long-term prognosis.
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http://dx.doi.org/10.3389/fcvm.2021.755822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8569238PMC
October 2021

Diagnostic Performance of Fractional Flow Reserve From CT Coronary Angiography With Analytical Method.

Front Cardiovasc Med 2021 20;8:739633. Epub 2021 Oct 20.

National Heart Centre Singapore, Singapore, Singapore.

The aim of this study was to evaluate a new analytical method for calculating non-invasive fractional flow reserve (FFR) to diagnose ischemic coronary lesions. Patients with suspected or known coronary artery disease (CAD) who underwent computed tomography coronary angiography (CTCA) and invasive coronary angiography (ICA) with FFR measurements from two sites were prospectively recruited. Obstructive CAD was defined as diameter stenosis (DS) ≥50% on CTCA or ICA. FFR was derived from CTCA images and anatomical features using analytical method and was compared with computational fluid dynamics (CFD)-based FFR (FFR) and invasive ICA-based FFR. FFR, FFR, and invasive FFR ≤ 0.80 defined ischemia. A total of 108 participants (mean age 60, range: 30-83 years, 75% men) with 169 stenosed coronary arteries were analyzed. The per-vessel accuracy, sensitivity, specificity, and positive predictive and negative predictive values were, respectively, 81, 75, 86, 81, and 82% for FFR and 87, 88, 86, 83, and 90% for FFR. The area under the receiver operating characteristics curve for FFR (0.89 and 0.87) and FFR (0.90 and 0.86) were higher than both CTCA- and ICA-derived DS (all < 0.0001) on per-vessel and per-patient bases for discriminating ischemic lesions. The computational time for FFR was much shorter than FFR (2.2 ± 0.9 min . 48 ± 36 min, excluding image acquisition and segmentation). FFR calculated from a novel and expeditious non-CFD approach possesses a comparable diagnostic performance to CFD-derived FFR, with a significantly shorter computational time.
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http://dx.doi.org/10.3389/fcvm.2021.739633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8564016PMC
October 2021

One-year outcomes of patients with ST-segment elevation myocardial infarction during the COVID-19 pandemic.

J Thromb Thrombolysis 2021 Aug 26. Epub 2021 Aug 26.

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

The pandemic has led to adverse short-term outcomes for patients with ST-segment elevation myocardial infarction (STEMI). It is unknown if this translates to poorer long-term outcomes. In Singapore, the escalation of the outbreak response on February 7, 2020 demanded adaptation of STEMI care to stringent infection control measures. A total of 321 patients presenting with STEMI and undergoing primary percutaneous coronary intervention at a tertiary hospital were enrolled and followed up over 1-year. They were allocated into three groups based on admission date-(1) Before outbreak response (BOR): December 1, 2019-February 6, 2020, (2) During outbreak response (DOR): February 7-March 31, 2020, and (3) control group: November 1-December 31, 2018. The incidence of cardiac-related mortality, cardiac-related readmissions, and recurrent coronary events were examined. Although in-hospital outcomes were worse in BOR and DOR groups compared to the control group, there were no differences in the 1-year cardiac-related mortality (BOR 8.7%, DOR 7.1%, control 4.8%, p = 0.563), cardiac-related readmissions (BOR 15.1%, DOR 11.6%, control 12.0%, p = 0.693), and recurrent coronary events (BOR 3.2%, DOR 1.8%, control 1.2%, p = 0.596). There were higher rates of additional PCI during the index admission in DOR, compared to BOR and control groups (p = 0.027). While patients admitted for STEMI during the pandemic may have poorer in-hospital outcomes, their long-term outcomes remain comparable to the pre-pandemic era.
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http://dx.doi.org/10.1007/s11239-021-02557-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8390088PMC
August 2021

Recurrent Stent Thrombosis Secondary to Immunoglobulin G4-Related Disease.

Can J Cardiol 2021 Oct 6;37(10):1659-1660. Epub 2021 Jun 6.

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

Immunoglobulin G4-related disease (IgG4-RD) is an insidiously progressive multiorgan disease. However, lack of familiarity with IgG4-RD results in patients often being undiagnosed and undertreated. IgG4-RD can affect any organ, and manifests as aortitis within the cardiovascular system. Cardiac involvement is less common, and myocardial infarction is rarely reported. We report the first case of a patient with multiple myocardial infarctions caused by recurrent stent thrombosis associated with IgG4-RD, which resolved upon treatment of IgG4-RD. This case highlights the importance for cardiologists to consider IgG4-RD as a rare but possible association with stent thrombosis.
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http://dx.doi.org/10.1016/j.cjca.2021.05.016DOI Listing
October 2021

Long-term clinical outcomes of biodegradable polymer drug eluting stents versus second-generation durable polymer drug eluting stents for ST-segment elevation myocardial infarction.

Cardiovasc Revasc Med 2021 Apr 16. Epub 2021 Apr 16.

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

Background: Biodegradable polymer drug eluting stents (BP-DES) may offer the advantage of vascular healing in ST-segment elevation myocardial infarction (STEMI). Long-term outcome data comparing BP-DES and second-generation durable polymer drug eluting stents (DP-DES) in STEMI is lacking. This study aims to compare the long-term clinical outcomes of BP-DES versus second-generation DP-DES in STEMI.

Methods: This is an observational study of consecutive patients with STEMI who received either BP-DES (n = 854) or DP-DES (n = 708) during primary percutaneous coronary intervention (PCI) from 1st February 2007 to 31st December 2016. The primary outcome was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (MI), and target lesion revascularization with follow up till 30th November 2019.

Results: The baseline demographics, lesion and procedural characteristic were similar between the two groups except for more prior MI and chronic obstructive pulmonary disease in the BP-DES group. At a median follow up of 4.2 years (interquartile range: 2.6-6.2 years), the incidence of TLF was similar between BP-DES and DP-DES (adjusted hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.70-1.26). Likewise, incidence of major adverse cardiovascular events (MACE: all-cause death, any MI or target vessel revascularization) and definite stent thrombosis were similar in both groups (MACE: adjusted HR 1.04, 95% CI 0.82-1.32; definite stent thrombosis: adjusted HR 1.06, 95% CI 0.31-3.64).

Conclusion: Among patients with STEMI who underwent primary PCI, BP-DES and DP-DES implantation was associated with similar long-term clinical outcomes.
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http://dx.doi.org/10.1016/j.carrev.2021.04.014DOI Listing
April 2021

Characteristics and outcomes of young patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: retrospective analysis in a multiethnic Asian population.

Open Heart 2021 01;8(1)

Cardiology, National University Heart Centre, Singapore.

Objective: ST segment elevation myocardial infarction (STEMI) is associated with significant mortality leading to loss of productive life years, especially in younger patients. This study aims to compare the characteristics and outcomes of young versus older patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) to help focus public health efforts in STEMI prevention.

Methods: Data from the Coronary Care Unit database of the National University Hospital, Singapore from July 2015 to June 2019 were reviewed. Patients were divided into young (<50 years old) or older (≥50 years old) groups.

Results: Of the 1818 consecutive patients with STEMI who underwent PPCI, 465 (25.6%) were <50 years old. Young compared with older patients were more likely to be male, current smokers, of Indian ethnicity, have family history of ischaemic heart disease (IHD) and had lower 1 year mortality (3.4% vs 10.4%, p<0.0001). Although diabetes, hypertension or dyslipidaemia was less common among young patients, the prevalence of having any one of these risk factors was high in the range of 28% to 38%. Age was an independent predictor of mortality in the older but not younger patients with STEMI, and diabetes showed a trend towards mortality in both groups.

Conclusion: Young patients with STEMI are more often smokers, of Indian ethnicity and had family history of IHD, although cardiometabolic risk factors are also prevalent. Mortality is lower, but not negligible, among the young patients with STEMI. Public health efforts are needed to reduce the prevalence of these risk factors among the constitutionally susceptible population.
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http://dx.doi.org/10.1136/openhrt-2020-001437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812097PMC
January 2021

Three coronary arteries arising from one coronary cusp.

Cardiol J 2020 ;27(5):644-645

National University Heart Centre, 1E Kent Ridge Road, 119228 Singapore, Singapore.

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http://dx.doi.org/10.5603/CJ.2020.0156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078969PMC
August 2021

Impact of the COVID-19 Pandemic on Door-to-Balloon Time for Primary Percutaneous Coronary Intervention - Results From the Singapore Western STEMI Network.

Circ J 2021 01 7;85(2):139-149. Epub 2020 Nov 7.

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

Background: Little is known about the effect of the coronavirus disease 2019 (COVID-19) pandemic and the outbreak response measures on door-to-balloon time (D2B). This study examined both D2B and clinical outcomes of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).Methods and Results:This was a retrospective study of 303 STEMI patients who presented directly or were transferred to a tertiary hospital in Singapore for PPCI from October 2019 to March 2020. We compared the clinical outcomes of patients admitted before (BOR) and during (DOR) the COVID-19 outbreak response. The study outcomes were in-hospital death, D2B, cardiogenic shock and 30-day readmission. For direct presentations, fewer patients in the DOR group achieved D2B time <90 min compared with the BOR group (71.4% vs. 80.9%, P=0.042). This was more apparent after exclusion of non-system delay cases (DOR 81.6% vs. BOR 95.9%, P=0.006). Prevalence of both out-of-hospital cardiac arrest (9.5% vs. 1.9%, P=0.003) and acute mitral regurgitation (31.6% vs. 17.5%, P=0.006) was higher in the DOR group. Mortality was similar between groups. Multivariable regression showed that longer D2B time was an independent predictor of death (odds ratio 1.005, 95% confidence interval 1.000-1.011, P=0.029).

Conclusions: The COVID-19 pandemic and the outbreak response have had an adverse effect on PPCI service efficiency. The study reinforces the need to focus efforts on shortening D2B time, while maintaining infection control measures.
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http://dx.doi.org/10.1253/circj.CJ-20-0800DOI Listing
January 2021

Intravascular lithotripsy for the treatment of severe calcific neointimal hyperplasia in a bare metal stent 17 years after implantation.

Coron Artery Dis 2021 Mar;32(2):172-174

Department of Cardiology, National University Heart Centre, Singapore.

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http://dx.doi.org/10.1097/MCA.0000000000000905DOI Listing
March 2021

Treating Very Long Coronary Artery Lesions in the Contemporary Drug-Eluting-Stent Era: Single Long 48 mm Stent Versus Two Overlapping Stents Showed Comparable Clinical Outcomes.

Cardiovasc Revasc Med 2020 09 13;21(9):1115-1118. Epub 2020 Feb 13.

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

Background/purpose: Percutaneous coronary intervention (PCI) of diffuse coronary artery disease (CAD) is associated with higher adverse clinical events. This study aimed to compare the clinical outcomes of patients treated with single long 48 mm contemporary drug eluting stents (SL-DES) versus two overlapping contemporary drug eluting stents (OL-DES) for very-long CAD.

Methods/materials: We analyzed the clinical outcome of 117 patients with SL-DES and 101 patients with OL-DES who underwent PCI between 1st July 2013 to 31st December 2016. The primary endpoint was target lesion failure (TLF) at two years, defined as a composite of cardiac mortality, target vessel myocardial infarction and target lesion revascularization.

Results: Mean age was 60.8 ± 10.5 years for SL-DES group and 60.5 ± 11.9 years in the OL-DES group. SL-DES has longer mean lesion length as compared to OL-DES (43.1 ± 3.7 mm vs. 41.83 ± 2.3 mm p = 0.003). There was no difference in TLF at two years between SL-DES and OL-DES (5.3% vs. 6.4%, adjusted odds ratio 1.43, 95% CI 0.50-4.11). There was one case of probable ST in each group. Contrast volume usage was lower for SL-DES than OL-DES in patients who underwent single vessel PCI.

Conclusions: Treatment of very-long CAD showed comparable TLF at two years for SL-DES versus OL-DES. Our results suggest that both strategies are reasonable treatment options for patients with diffuse CAD.
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http://dx.doi.org/10.1016/j.carrev.2020.02.005DOI Listing
September 2020

Clinical Outcomes One Year and Beyond After Combination Sirolimus-Eluting Endothelial Progenitor Cell Capture Stenting During Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction.

Cardiovasc Revasc Med 2019 09 7;20(9):739-743. Epub 2018 Nov 7.

Department of Cardiology, National University Heart Center, Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, 119228, Singapore. Electronic address:

Background/purpose: Primary percutaneous coronary intervention (PCI) during acute ST-segment elevation myocardial infarction (STEMI) represents a thrombotic milieu and is associated with delayed healing after stenting. The pro-healing combination sirolimus eluting endothelial progenitor cell (EPC) capture stents encourage early endothelialization after stenting and may be beneficial in the STEMI population. We aim to evaluate the clinical outcomes one year and beyond for patients with STEMI who received the combination sirolimus eluting EPC capture stents during primary PCI.

Methods/material: All STEMI patients implanted with combination sirolimus eluting EPC capture stents during primary PCI from November 2013 to December 2016 were enrolled. The primary outcome was target lesion failure (TLF) at in-hospital, one-month, one-year and beyond one year.

Results: A total of 260 consecutive STEMI patients (283 lesions) were implanted with 313 combination sirolimus eluting EPC capture stents during primary PCI. Mean age was 56.1 ± 11.2 years and 88.8% were male. One in ten patients (10.9%) had cardiogenic shock on presentation, 7.3% needed mechanical ventilation and 7.7% had intra-aortic balloon pump inserted. A total of 97.9% of lesions achieve final TIMI 3 flow. Device success was seen in all patients. At extended follow up period (median 23.4 months), the clinical outcomes were TLF 8.8%, major adverse cardiovascular events 10.8%, cardiac mortality 4.2%, target vessel myocardial infarction 3.4%, target lesion revascularization 3.8%, and definite stent thrombosis 1.9%.

Conclusions: This study demonstrated acceptable clinical outcomes for an all-comers STEMI patients undergoing primary PCI with the use of combination sirolimus eluting EPC cell capture stents.
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http://dx.doi.org/10.1016/j.carrev.2018.11.004DOI Listing
September 2019

Treatment of Very Small De Novo Coronary Artery Disease With 2.0 mm Drug-Coated Balloons Showed 1-Year Clinical Outcome Comparable With 2.0 mm Drug-Eluting Stents.

J Invasive Cardiol 2018 07 15;30(7):256-261. Epub 2018 Apr 15.

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

Objective: To evaluate the 1-year clinical outcomes of patients treated with 2.0 mm drug-coated balloon (DCB) vs 2.0 mm drug-eluting stent (DES) implantation in small-caliber vessel de novo coronary artery disease (CAD).

Methods: All patients treated with 2.0 mm DCB or 2.0 mm DES for very small vessel de novo CAD from July 2014 to June 2016 were included in this study. The primary endpoint was the occurrence of target-lesion failure (TLF) and time to TLF, defined as a combination of cardiac mortality, target-vessel myocardial infarction, and target-lesion revascularization (TLR).

Results: A total of 87 patients (96 lesions) were implanted with 2.0 mm DCBs and 200 patients (223 lesions) were implanted with 2.0 mm DESs during the study period. Mean reference vessel diameter was similar between the DCB and DES groups (1.88 ± 0.38 mm vs 1.95 ± 0.21 mm, respectively; P=.11). The 1-year TLF rates were 7.0% in the DCB group and 8.2% in the DES group (P=.73). TLF was driven by TLR in both groups. Bailout stenting was performed in 7 patients (8 lesions) who received a DCB. Stent thrombosis was seen in 4 patients (2.0%) who underwent DES implantation. There was no vessel thrombosis noted in the DCB group. Cardiogenic shock was identified as a direct and significant predictor for both the occurrence of TLF and time to TLF.

Conclusions: In this first report, treatment of very small vessel CAD with 2.0 mm DCB vs 2.0 mm DES was associated with similar 1-year TLF rates.
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July 2018

Incidence and predictors of target lesion failure in a multiethnic Asian population receiving the SYNERGY coronary stent: A prospective all-comers registry.

Catheter Cardiovasc Interv 2018 11 7;92(6):1097-1103. Epub 2018 Mar 7.

Department of Cardiology, National University Heart Centre, Singapore.

Objectives: To evaluate the target lesion failure (TLF) rate of the SYNERGY stent in all-comers, multiethnic Asian population.

Background: Currently, most drug eluting stents deliver anti-proliferative drugs from a durable polymer which is associated with a risk of late stent thrombosis. The novel everolimus-eluting, platinum chromium SYNERGY stent is coated with a bioabsorbable abluminal polymer that resolves within 4 months.

Methods: This was a prospective, single center registry of consecutive patients treated with the SYNERGY stent between December 2012 and April 2015. The primary outcome was the incidence of TLF, defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization (TLR) at 1 year.

Results: A total of 807 patients received the SYNERGY stent during the study period. One-year clinical outcome data was available for 765 patients (94.8%) and were considered for statistical analysis. The mean age was 60.7 ± 10.8 years, and 83.4% were males. Patients with acute myocardial infarction consisted of 50.3% (ST-segment elevation myocardial infarction: 23.0%, Non-ST-segment elevation myocardial infarction: 27.3%) of the study population. The treated lesions were complex (ACC/AHA type B2/C: 72.7%). The primary end point of TLF at 1 year was 5.8%. Rates of cardiac mortality, target vessel myocardial infarction, and TLR were 4.2, 1.0, and 1.3%, respectively, at 1 year. Predictors of the incidence and time to early TLF were female gender, Malay ethnicity, diabetes mellitus, acute myocardial infarction at presentation, a prior history of coronary artery bypass surgery and the presence of lesion calcification. The incidence of definite stent thrombosis was 0.4% at 1 year.

Conclusions: In this registry, the use of the SYNERGY stent was associated with low rates of TLF at 1 year.
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http://dx.doi.org/10.1002/ccd.27577DOI Listing
November 2018

Very late bioresorbable vascular scaffold thrombosis at 25 months post implantation.

Singapore Med J 2017 09;58(9):571-572

Cardiac Department, National University Heart Centre, Singapore.

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http://dx.doi.org/10.11622/smedj.2017089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605831PMC
September 2017

Spontaneous Coronary Dissection Masquerading as Benign Fascicular Ventricular Tachycardia.

Heart Lung Circ 2016 Jan 25;25(1):e9-11. Epub 2015 Sep 25.

Cardiac Department, National University Heart Centre Singapore, National University Health System, Singapore.

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome. Diagnosis of coronary artery dissection is made on coronary angiogram and prompt revascularisation is the key in management. We present a case of coronary artery dissection with an atypical presentation of cardiac arrhythmia mimicking benign fascicular ventricular tachycardia. A high index of suspicion and early coronary angiogram allowed us to diagnose and treat this potentially life-threatening disease.
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http://dx.doi.org/10.1016/j.hlc.2015.08.013DOI Listing
January 2016

Long-term Outcomes of Medical Therapy Versus Coronary Revascularisation in Patients with Intermediate Stenoses Guided by Pressure Wire.

Ann Acad Med Singap 2015 May;44(5):157-63

Department of Cardiology, Shanghai Chest Hospital, People's Republic of China.

Introduction: This study aimed to examine the long-term clinical outcomes of coronary fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in a real-world population in an Asian tertiary centre.

Materials And Methods: All patients who underwent FFR measurement for intermediate coronary lesions in our centre from June 2002 to December 2009 were enrolled. A threshold of FFR ≤0.75 was used for revascularisation. All the patients were prospectively followed-up for major adverse cardiac events (MACE) of death, myocardial infarction (MI), target vessel revascularisation (TVR) and stent thrombosis.

Results: Based on FFR measurement, 368 (57%) patients were treated medically while 278 (43%) underwent revascularisation. At a mean follow-up duration of 29.7 ± 16 months, 53 (14.4%) patients in the medical therapy group and 32 (11.5%) patients in the revascularised group experienced MACE (P = 0.282). There were no statistical differences in all the clinical endpoints between the 2 groups.

Conclusion: Medical therapy based on FFR measurement is associated with low incidences of MACE at long-term follow-up.
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May 2015

Safety of combination therapy with milrinone and esmolol for heart protection during percutaneous coronary intervention in acute myocardial infarction.

Eur J Clin Pharmacol 2014 May 25;70(5):527-30. Epub 2014 Jan 25.

Cardiac Department, National University Heart Center, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 19228, Singapore,

Purpose: Ischemia/reperfusion injury remains an untreated clinical problem in patients with acute myocardial infarction (AMI) despite significant advances in emergent revascularization through percutaneous coronary intervention (PCI). Pharmacological intervention for infarct size reduction is unavailable. We have identified that the medications milrinone and esmolol, when administered together at the beginning of the reperfusion, significantly decrease infarct size via reducing reperfusion injury in an experimental model. The present study tested the safety of combination therapy of milrinone and esmolol (M + E) in patients with AMI.

Methods: Sixteen subjects with AMI requiring PCI were consecutively recruited. M + E was intravenously infused simultaneously for 10 min started at 5 min before anticipated angioplasty balloon inflation. Another 16 consecutively recruited AMI patients requiring PCI served as a placebo arm treated per routine clinical protocol. Blood pressure (BP) and heart rate (HR) were monitored continuously during PCI.

Results: M + E combination therapy resulted in a trend of non-significant reduction in BP compared with a control group. There was a modest but significant increase in HR at the later phase of M + E infusion compared with a control group. No significant cardiac arrhythmia was induced during M + E infusion.

Conclusions: The combination therapy with M + E produces a minimal change in hemodynamics and appears safe as an adjunctive therapy to PCI in AMI patients. Further studies are warranted.
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http://dx.doi.org/10.1007/s00228-014-1650-9DOI Listing
May 2014

Everolimus-eluting bioresorbable vascular scaffold (BVS) implantation in patients with ST-segment elevation myocardial infarction (STEMI).

EuroIntervention 2013 Aug;9(4):501-4

Cardiac Department, National University Heart Centre Singapore, Singapore.

Aims: Recent studies have demonstrated favourable clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease. There are currently no data on its use in patients with ST-segment elevation myocardial infarction (STEMI). We assessed the safety and impact of BVS in the setting of primary percutaneous coronary intervention (PCI) in patients presenting with STEMI to our institution.

Methods And Results: A total of 11 patients who underwent primary PCI with intent for BVS implantation between October 2012 and April 2013 at our institution were included. Median follow-up period was 53.0 ± 45.9 days. One patient presented to the hospital with cardiogenic shock and subsequently died. The other 10 patients did not have any major adverse cardiac events (MACE). There were no acute or subacute stent thromboses at short-term follow-up.

Conclusions: These are the first real-world data using BVS in patients with STEMI. The ABSORB™ BVS may be safely used in patients with STEMI undergoing primary PCI with favourable short-term outcome.
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http://dx.doi.org/10.4244/EIJV9I4A80DOI Listing
August 2013

A single-center experience of transitioning from a routine transfemoral to a transradial intervention approach in ST-elevation myocardial infarction: Impact on door-to-balloon time and clinical outcomes.

J Cardiol 2013 Jul 22;62(1):12-7. Epub 2013 Apr 22.

Cardiac Department, National University Heart Centre Singapore, Singapore.

Background: In the emergent setting of ST-elevation myocardial infarction (STEMI), transradial intervention (TRI) is less frequently employed than transfemoral intervention (TFI). Because of the greater technical complexity of TRI, a potential compromise in door-to-balloon (DTB) time remains a major concern of centers adopting TRI for STEMI.

Methods: We performed a propensity-matched analysis, with 1:1 matching of TRI and TFI patients comparing DTB time, 30-day major adverse cardiac event (MACE), and bleeding outcomes of 1052 consecutive STEMI patients managed at our center during a 2-year transition program from routine TFI to TRI access for STEMI.

Results: From January 2008 to April 2010, 359 (34.1%) STEMI patients underwent TRI and the remaining 693 (65.9%) STEMI patients underwent TFI. In 283 propensity score matched pairs of TRI and TFI patients, TRI was associated with shorter DTB time (63.6min vs 69.4min, p=0.027) and more patients having DTB time<90min (88.3% vs 82.3%, p=0.043). Thirty-day MACE occurred in 1.0% in the TRI group and 3.0% in the TFI group (p=0.129). There was no significant difference in major (p=0.313) or minor bleeding (p=0.714) between the TRI and TFI groups. There was a twofold greater use of glycoprotein (GP) IIb/IIIa inhibitor in the TRI group (68.5%) compared with the TFI group (36.4%) (p<0.001).

Conclusion: Compared with TFI, TRI was not associated with longer DTB time during our center's transition from routine TFI to TRI in STEMI. Our experience suggests that the transition to TRI in STEMI can be safely achieved with DTB times that are comparable and possibly better than propensity-matched TFI cases.
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http://dx.doi.org/10.1016/j.jjcc.2013.02.008DOI Listing
July 2013

Initial experience in the clinical use of everolimus-eluting bioresorbable vascular scaffold (BVS) in a single institution.

Int J Cardiol 2013 Sep 3;168(2):1536-7. Epub 2013 Jan 3.

National University Heart Centre, Singapore, Singapore; National University Health System, Singapore.

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http://dx.doi.org/10.1016/j.ijcard.2012.12.037DOI Listing
September 2013

Angiographic and platelet reactivity outcomes with prasugrel 60 mg pretreatment and clopidogrel 600 mg pretreatment in primary percutaneous coronary intervention.

J Thromb Thrombolysis 2012 Nov;34(4):499-505

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

Pretreatment with 60 mg of prasugrel is more effective than 300 mg of clopidogrel in reducing thrombotic complications with primary percutaneous coronary intervention (PCI). We compared angiographic outcomes and platelet reactivity between treatment with 60 mg of prasugrel and 600 mg of clopidogrel administered before primary PCI. In this single centre non-randomized study, 65 consecutive Asian patients with ST-elevation myocardial infarction (STEMI) received 60 mg of prasugrel before primary PCI. The pre- and post-PCI corrected thrombolysis in myocardial infarction frame count (CTFC) and the 8-h post-treatment platelet vasodilator-stimulated phosphoprotein (VASP) index was compared with a matched historical Asian STEMI cohort (n = 65) receiving 600 mg of clopidogrel pretreatment. Comparing the prasugrel and clopidogrel groups, the mean age was 54.1 ± 10.2 versus 55.5 ± 11.8 years, P = 0.238, and the mean body mass index was 24.6 ± 2.0 versus 24.7 ± 2.8 kg m(-2), P = 0.393. The mean pre-PCI CTFC was 82.1 ± 30.2 versus 86.1 ± 27.6, P = 0.045, and the mean post-PCI CTFC was 21.1 ± 13.9 versus 20.1 ± 9.2, P = 0.309. Pre-PCI coronary thrombi were visualised in 6.3 versus 18.1 %, P = 0.038. The median VASP index was 22.2 ± 24.5 versus 70.5 ± 17.5 %, P < 0.001, and high on-treatment platelet reactivity (VASP index > 50 %) was observed in 13.8 versus 84.3 %, P = 0.001. Rescue intracoronary glycoprotein inhibitors were administered to 29.7 versus 51.0 %, P = 0.018, respectively. Treatment with 60 mg of prasugrel before primary PCI was associated with lower platelet reactivity, a modest trend towards better pre-PCI angiographic outcomes, less pre-PCI coronary thrombi and less rescue glycoprotein inhibitor use compared with 600 mg of clopidogrel. The very high frequency of high on-clopidogrel platelet reactivity with 600 mg of clopidogrel in this Asian STEMI cohort deserves further study.
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http://dx.doi.org/10.1007/s11239-012-0782-yDOI Listing
November 2012

Bare metal stent restenosis is not a benign clinical entity.

Am Heart J 2006 Nov;152(5):e51; author reply e53

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http://dx.doi.org/10.1016/j.ahj.2006.08.015DOI Listing
November 2006
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