Publications by authors named "Rungroj Krittayaphong"

139 Publications

Average Systolic Blood Pressure and Clinical Outcomes in Patients with Atrial Fibrillation: Prospective Data from COOL-AF Registry.

Clin Interv Aging 2021 12;16:1835-1846. Epub 2021 Oct 12.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

Purpose: Hypertension is associated with incident atrial fibrillation (AF) and AF-related complications. We investigated the associations between average systolic blood pressure (SBP) and outcomes in a nationwide cohort of Asian patients with non-valvular atrial fibrillation (NVAF).

Patients And Methods: A multicenter nationwide registry of patients with NVAF in Thailand was conducted during 2014-2017. Clinical data, including blood pressure, were recorded at baseline and then every 6 months. Average SBP was calculated from the average of SBP from every visit. Cox regression models were used to calculate the rate of clinical outcomes of interest, ie ischemic stroke or transient ischemic attack (TIA), intracerebral hemorrhage (ICH), and all-cause death. Average SBP was categorized into three groups: <120, 120-140, and ≥140 mmHg.

Results: A total of 3402 patients were included, and the mean age was 67.4±11.3 years. The mean (±SD) baseline and average SBPs were 128.5±18.5 and 128.0±13.4 mmHg, respectively. The mean follow-up duration was 25.7±10.6 months. The median rate of ischemic stroke/TIA, ICH, and all-cause death was 1.43 (1.17-1.74), 0.70 (0.52-0.92), and 3.77 (3.33-4.24) per 100 person-years, respectively. The rate of ischemic stroke/TIA and ICH was lowest in patients with average SBP <120 mmHg, and highest among those with average SBP ≥140 mmHg. The death rates were consistent with a J-curve effect, being lowest in patients with an average SBP 120-140 mmHg. Sustained SBP control is more important than the SBP from a single visit.

Conclusion: Sustained control of SBP was significantly associated with a reduction in adverse clinical outcomes in patients with NVAF.
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http://dx.doi.org/10.2147/CIA.S335321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8520416PMC
October 2021

Cardio-ankle vascular index with renal progression and mortality in high atherosclerosis risk: a prospective cohort study in CORE-Thailand.

Clin Exp Nephrol 2021 Oct 13. Epub 2021 Oct 13.

Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.

Background: Increased arterial stiffness is linked to markers of endothelial dysfunction and vasculopathy such as albuminuria, vascular calcification, left ventricular hypertrophy and cardiovascular (CV) diseases. Studies of arterial stiffness on renal progression are limited.

Objective: The study aimed to evaluate the association between high cardio-ankle vascular index (CAVI) and renal endpoint and all-cause mortality in a Thai population with high atherosclerosis risk.

Methods: A multicenter prospective cohort study was conducted among subjects with high CV risk or established CV diseases in Thailand. Subjects were divided into 3 groups with mean CAVI < 8, 8-8.9, and ≥ 9, respectively. Primary composite outcome consisted of estimated glomerular filtration rate (eGFR) decline over 40%, eGFR less than 15 mL/min/1.73 m, doubling of serum creatinine, initiation of dialysis and death related to renal causes. The secondary outcomes were all-cause mortality, CV mortality and eGFR decline.

Results: A total of 4898 subjects (2743 men and 2155 women) were enrolled. Cox proportional hazards model showed a significant relationship of high CAVI (CAVI ≥ 9) and primary composite outcome. Subjects with high CAVI at baseline had a 1.45-fold (95% CI 1.13-1.84) significant risk for the primary composite outcome and 1.72-fold (95% CI 1.12-2.63) risk for all-cause mortality, compared with normal CAVI (CAVI < 8). After stepwise multivariate analysis, the high CAVI group was only positively associated with primary composite outcome. Kaplan-Meier curve of the primary composite outcome and all-cause mortality demonstrated the worst survival in the high CAVI group (log-rank test with P < 0.05).

Conclusion: In a Thai cohort with high atherosclerosis risk, increased arterial stiffness was a risk factor for worsening renal function, including end-stage renal disease and initiation of dialysis.
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http://dx.doi.org/10.1007/s10157-021-02149-xDOI Listing
October 2021

Prospective randomised trial examining the impact of an educational intervention versus usual care on anticoagulation therapy control based on an SAMe-TTR score-guided strategy in anticoagulant-naïve Thai patients with atrial fibrillation (TREATS-AF): a study protocol.

BMJ Open 2021 Oct 11;11(10):e051987. Epub 2021 Oct 11.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK

Introduction: The burden of atrial fibrillation (AF) in Thailand is high and associated with increased morbidity, mortality and healthcare costs. Vitamin K antagonists (eg, warfarin), commonly used for stroke prevention in patients with AF in Thailand, are effective but are often suboptimally controlled. We aim to evaluate the impact of an SAMe-TTR score-guided strategy and educational intervention compared to usual care on anticoagulation control expressed by the time in therapeutic range (TTR) at 12 months, in anticoagulant-naïve Thai patients with AF.

Methods And Analysis: Multicentre, open-label, parallel-group, randomised controlled trial conducted in Thailand among adult patients (age: 18 years) with AF who are anticoagulant naïve. Patients will be randomised to one of two groups; an SAMe-TTR score-guided strategy with educational intervention and usual care versus usual care alone. The planned follow-up period is 12 months. The primary outcome is TTR at 12 months. Secondary outcomes include: (1) TTR at 6 months; (2) thromboembolic and bleeding events at 12 months; (3) composite major adverse cardiovascular events at 12 months; (4) change in patients' knowledge of AF between baseline and 6 months and 12 months; (5) cost effectiveness; (6) quality of life at baseline, 6 months and 12 months using EQ-5D-5L (Thai version) and (7) patient satisfaction/perceptions of the TREAT intervention. An embedded qualitative study will assess patient perceptions of the TREAT intervention.

Ethics And Dissemination: The study has been approved by the Ethical Review Committee, Ministry of Public Health of Thailand, and registered in the Thai Clinical Trials Registry. The results of this trial will be submitted for publication in a peer-reviewed journal. Participants will be informed via a link to a preview of the publication. A lay summary will also be provided to all participants prior to publication.

Trial Registration Number: TCTR20180711003.
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http://dx.doi.org/10.1136/bmjopen-2021-051987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8506852PMC
October 2021

Biomarkers for atrial fibrillation and chronic kidney disease: what are the evidences?

Kardiol Pol 2021 Oct 6. Epub 2021 Oct 6.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

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http://dx.doi.org/10.33963/KP.a2021.0124DOI Listing
October 2021

An automated liver segmentation in liver iron concentration map using fuzzy c-means clustering combined with anatomical landmark data.

BMC Med Imaging 2021 09 28;21(1):138. Epub 2021 Sep 28.

Haematology/Oncology Division, Department of Pediatrics and Thalassemia Center, Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: To estimate median liver iron concentration (LIC) calculated from magnetic resonance imaging, excluded vessels of the liver parenchyma region were defined manually. Previous works proposed the automated method for excluding vessels from the liver region. However, only user-defined liver region remained a manual process. Therefore, this work aimed to develop an automated liver region segmentation technique to automate the whole process of median LIC calculation.

Methods: 553 MR examinations from 471 thalassemia major patients were used in this study. LIC maps (in mg/g dry weight) were calculated and used as the input of segmentation procedures. Anatomical landmark data were detected and used to restrict ROI. After that, the liver region was segmented using fuzzy c-means clustering and reduced segmentation errors by morphological processes. According to the clinical application, erosion with a suitable size of the structuring element was applied to reduce the segmented liver region to avoid uncertainty around the edge of the liver. The segmentation results were evaluated by comparing with manual segmentation performed by a board-certified radiologist.

Results: The proposed method was able to produce a good grade output in approximately 81% of all data. Approximately 11% of all data required an easy modification step. The rest of the output, approximately 8%, was an unsuccessful grade and required manual intervention by a user. For the evaluation matrices, percent dice similarity coefficient (%DSC) was in the range 86-92, percent Jaccard index (%JC) was 78-86, and Hausdorff distance (H) was 14-28 mm, respectively. In this study, percent false positive (%FP) and percent false negative (%FN) were applied to evaluate under- and over-segmentation that other evaluation matrices could not handle. The average of operation times could be reduced from 10 s per case using traditional method, to 1.5 s per case using our proposed method.

Conclusion: The experimental results showed that the proposed method provided an effective automated liver segmentation technique, which can be applied clinically for automated median LIC calculation in thalassemia major patients.
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http://dx.doi.org/10.1186/s12880-021-00669-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477544PMC
September 2021

Cost-Utility Analysis of Sacubitril-Valsartan Compared with Enalapril Treatment in Patients with Acute Decompensated Heart Failure in Thailand.

Clin Drug Investig 2021 Oct 17;41(10):907-915. Epub 2021 Sep 17.

Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, 239 Huaykaew Road, Suthep, Chiang Mai, 50200, Thailand.

Background: Sacubitril-valsartan is effective in reducing the N-terminal pro-B-type natriuretic peptide level of hospitalized patients with acute decompensated heart failure, with a high acquisition cost compared with enalapril treatment.

Objective: This study aimed to determine the cost utility of sacubitril-valsartan compared with enalapril for acute decompensated heart failure treatment.

Methods: A Markov model was constructed to project the total costs, life-years, quality-adjusted life-years (QALYs) of early initiation, and a 2-month delay of sacubitril-valsartan treatment and enalapril treatment in hospitalized patients with acute decompensated heart failure over a lifetime horizon from a Thai healthcare system perspective. Clinical inputs were mainly derived from the PIONEER-HF and PARADIGM-HF trials, together with Thai epidemiological data. Cost data were based on the Thai population. All costs and outcomes were discounted at 3% annually. A series of sensitivity analyses were performed.

Results: Compared with enalapril, sacubitril-valsartan incurred a higher total cost per year (THB 42,994 [US$1367.48] vs THB 19,787 [US$629.37]), and it gained more QALYs (4.969 vs 4.755). The incremental cost-effectiveness ratio was THB 108,508/QALY (US$3451.26/QALY). Early initiation of sacubitril-valsartan treatment was more cost effective than delayed treatment. Sensitivity analyses revealed that at a level of willingness to pay of THB 160,000/QALY (US$5089/QALY), sacubitril-valsartan was a cost-effective strategy of about 60%.

Conclusions: Sacubitril-valsartan is cost effective in patients with acute decompensated heart failure. However, the results are highly dependent on the long-term cardiovascular mortality, and they are applicable only to Thailand or countries with a similarly structured healthcare system. Long-term registries should be pursued to decrease the uncertainty around long-term mortality.
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http://dx.doi.org/10.1007/s40261-021-01079-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446182PMC
October 2021

Association of body mass index with kidney function and mortality in high cardiovascular risk population: A nationwide prospective cohort study.

Nephrology (Carlton) 2021 Aug 31. Epub 2021 Aug 31.

Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.

Background: There is increasing awareness of the impact of obesity and underweight on cardiovascular (CV) disease, chronic kidney disease (CKD) and mortality. Abnormal body mass index (BMI) might be associated with worse clinical outcomes, including CKD progression, but limited evidence exists among Asian patients with high CV risk.

Objective: To investigate the association of BMI with progressive loss of kidney function and all-cause mortality in Thai patients with high CV risk.

Methods: In a national cohort of 5887 high CV risk subjects, we assessed the association of high BMI with the composite renal outcome (estimated glomerular filtration rate [eGFR] decline over 40%, eGFR less than 15 mL/min/1.73 m , doubling of serum creatinine, initiation of dialysis and death related to renal causes) and with all-cause mortality in Cox proportional hazards models.

Results: A total of 5887 participants (3217 male and 2670 female) with high CV risk were enrolled. Participants were classified into five groups by their baseline BMI; <20 kg/m (n = 482), 20-24.9 kg/m (n = 2437), 25-29.9 kg/m (n = 2140), 30-34.9 kg/m (n = 665) and 35 kg/m (n = 163), respectively. On multivariate analysis of Cox proportional hazards models, adjusted for other covariates, baseline BMI ≥35 kg/m was an independent predictor of loss of kidney function (HR 1.60, 95% CI 1.04-2.40) and all-cause mortality (HR 2.68, 95% CI 1.50-4.80). Baseline BMI <20 kg/m was an independent predictor of all-cause mortality as well (adjusted HR 2.26, 95% CI 1.50-3.42).

Conclusion: In the high CV risk Thai population, a BMI of 35 kg/m or more is associated with loss of kidney function and mortality. On the other hand, a BMI less than 20 kg/m is also associated with all-cause mortality.
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http://dx.doi.org/10.1111/nep.13970DOI Listing
August 2021

Tackling cardiometabolic risk in the Asia Pacific region.

Am J Prev Cardiol 2020 Dec 8;4:100096. Epub 2020 Nov 8.

Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Australia.

With the global spread of abdominal obesity, cardiovascular disease continues to spread to all countries of the world. Given the large population, the challenges presented by cardiometabolic risk in the Asia Pacific region are considerable. In addition to the clinical consequences of cardiovascular disease, in terms of its morbidity and mortality, the diversity of the Asia Pacific region brings heterogeneity in approaches to prevention, diagnosis and treatment of cardiometabolic risk. In this manuscript, we will review the current state of knowledge of cardiometabolic risk in Asia Pacific and highlight the needs moving forward to tackle this public health challenge.
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http://dx.doi.org/10.1016/j.ajpc.2020.100096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315619PMC
December 2020

Outcomes of patients with atrial fibrillation with and without diabetes: A propensity score matching of the COOL-AF registry.

Int J Clin Pract 2021 Nov 4;75(11):e14671. Epub 2021 Aug 4.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: To investigate the clinical outcomes of patients with non-valvular atrial fibrillation (NVAF) compared between those with and without diabetes mellitus (DM).

Methods: We conducted a prospective multicenter nationwide registry for patients with NVAF from 27 hospitals in Thailand. Patients were followed-up every 6 months until 3 years. The outcome measurements were ischemic stroke (IS) or transient ischemic attack (TIA), major bleeding, and heart failure (HF). All reported events were confirmed by the adjudication committee. DM was diagnosed by history or laboratory data.

Results: We studied 3402 patients. DM was diagnosed in 923 patients (27.1%). The average follow-up duration was 25.74 ± 10.57 months (7912 persons-year). The rate of IS/TIA, major bleeding, and HF was 1.42, 2.11, and 3.03 per 100 person-years. Patients with DM had a significantly increased risk of IS/TIA, major bleeding, and HF. After adjusting for age, gender, comorbid conditions, and the use of oral anticoagulant (OAC) using propensity score matching, DM remained a significant predictor of ischemic stroke/TIA, major bleeding and HF with Hazard ratio and 95% confidence interval of 1.67 (1.02, 2.73), 1.65 (1.13, 2.40), and 1.87 (1.34, 2.59), respectively. The net clinical benefit of OAC was more pronounced in DM patients (0.88 events per 100 person-years) than in those without DM (-0.73 events per 100 person-years).

Conclusions: DM increases the risk of adverse clinical outcomes in NVAF patients. The benefit of OAC outweighs the risk in DM patients.
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http://dx.doi.org/10.1111/ijcp.14671DOI Listing
November 2021

Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: Consensus Recommendations by the Asian Pacific Society of Cardiology on Strategies for Thrombotic and Bleeding Risk Management.

Eur Cardiol 2021 Feb 28;16:e23. Epub 2021 May 28.

National Heart Centre Singapore.

The disease burden of AF is greater in Asia-Pacific than other areas of the world. Direct oral anticoagulants (DOACs) have emerged as effective alternatives to vitamin K antagonists (VKA) for preventing thromboembolic events in patients with AF. The Asian Pacific Society of Cardiology developed this consensus statement to guide physicians in the management of AF in Asian populations. Statements were developed by an expert consensus panel who reviewed the available data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting 17 statements provide guidance on the assessment of stroke risk of AF patients in the region, the appropriate use of DOACs in these patients, as well as the concomitant use of DOACs and antiplatelets, and the transition to DOACs from VKAs and vice versa. The periprocedural management of patients on DOAC therapy and the management of patients with bleeding while on DOACs are also discussed.
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http://dx.doi.org/10.15420/ecr.2020.43DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8201470PMC
February 2021

Native T1 mapping and extracellular volume fraction for differentiation of myocardial diseases from normal CMR controls in routine clinical practice.

BMC Cardiovasc Disord 2021 06 3;21(1):270. Epub 2021 Jun 3.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

Background: This study aimed to determine native T1 and extracellular volume fraction (ECV) in distinct types of myocardial disease, including amyloidosis, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), myocarditis and coronary artery disease (CAD), compared to controls.

Methods: We retrospectively enrolled patients with distinct types of myocardial disease, CAD patients, and control group (no known heart disease and negative CMR study) who underwent 3.0 Tesla CMR with routine T1 mapping. The region of interest (ROI) was drawn in the myocardium of the mid left ventricular (LV) short axis slice and at the interventricular septum of mid LV slice. ECV was calculated by actual hematocrit (Hct) and synthetic Hct. T1 mapping and ECV was compared between myocardial disease and controls, and between CAD and controls. Diagnostic yield and cut-off values were assessed.

Results: A total of 1188 patients were enrolled. The average T1 values in the control group were 1304 ± 42 ms at septum, and 1294 ± 37 ms at mid LV slice. The average T1 values in patients with myocardial disease and CAD were significantly higher than in controls (1441 ± 72, 1349 ± 59, 1345 ± 59, 1355 ± 56, and 1328 ± 54 ms for septum of amyloidosis, DCM, HCM, myocarditis, and CAD). Native T1 of the mid LV level and ECV at septum and mid LV with actual and synthetic Hct of patients with myocardial disease or CAD were significantly higher than in controls.

Conclusions: Although native T1 and ECV of patients with cardiomyopathy and CAD were significantly higher than controls, the values overlapped. The greatest clinical utilization was found for the amyloidosis group.
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http://dx.doi.org/10.1186/s12872-021-02086-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173747PMC
June 2021

The Clinical Outcomes of Different eGFR Strata and Time in Therapeutic Range in Atrial Fibrillation Patients with Chronic Kidney Disease: A Nationwide Cohort Study.

Curr Probl Cardiol 2021 Sep 19;46(9):100838. Epub 2021 Mar 19.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Electronic address:

Chronic kidney disease (CKD) is associated with increased risk of stroke, major bleeding, morbidity and overall mortality in atrial fibrillation patients. The aim of this study is to demonstrate the effect of different eGFR strata and the TTR on clinical outcomes in AF patients with CKD.NVAF patients were consecutively enrolled from hospitals across Thailand. eGFR were categorized into three different eGFR categories; eGFR >60, 30-59 and <30 mL/min/1.73 m. TTR values were also categorized into TTR >75%, TTR 60-75 and TTR <60%. We identified 1,739 patients who received warfarin. Among patients who acquired TTR<60, those with eGFR <30 ml/min/1.73 m demonstrated the highest stroke/SSE rate of 8.5% (P<0.001). Patients with eGFR <30 ml/min/1.73 m, in addition to the presence of TTR<60, were at the highest risk to developing major bleeding with the rate of 17.9% (p <0.001). However, intracranial hemorrhage (ICH) appeared towards increasing rate with the combination of eGFR at even <60 ml/min/1.73 m and TTR <60. Death was also considerably high with the rate of 17.9% in patients with the combination of TTR <60 and eGFR <30 ml/min/1.73 m. Severe CKD resulted in higher risks of stroke/SSE, major bleeding and death in patients with low TTR. Patients with TTR >60, especially TTR >75%, is associated with reduced risk of stroke/SSE, major bleeding and death irrespective of eGFR level. The combination of low TTR <60 and eGFR level less than 60 ml/min/1.73 m substantially increased risks of all cardiovascular outcomes.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100838DOI Listing
September 2021

Consensus Recommendations by the Asian Pacific Society of Cardiology: Optimising Cardiovascular Outcomes in Patients with Type 2 Diabetes.

Eur Cardiol 2021 Feb 19;16:e14. Epub 2021 Apr 19.

Singapore General Hospital Singapore.

The Asian Pacific Society of Cardiology convened a consensus statement panel for optimising cardiovascular (CV) outcomes in type 2 diabetes, and reviewed the current literature. Relevant articles were appraised using the Grading of Recommendations, Assessment, Development and Evaluation system, and consensus statements were developed in two meetings and were confirmed through online voting. The consensus statements indicated that lifestyle interventions must be emphasised for patients with prediabetes, and optimal glucose control should be encouraged when possible. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are recommended for patients with chronic kidney disease with adequate renal function, and for patients with heart failure with reduced ejection fraction. In addition to SGLT2i, glucagon-like peptide-1 receptor agonists are recommended for patients at high risk of CV events. A blood pressure target below 140/90 mmHg is generally recommended for patients with type 2 diabetes. Antiplatelet therapy is recommended for secondary prevention in patients with atherosclerotic CV disease.
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http://dx.doi.org/10.15420/ecr.2020.52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086420PMC
February 2021

Influence of gender on the clinical outcomes of Asian non-valvular atrial fibrillation patients: insights from the prospective multicentre COOL-AF registry.

BMJ Open 2021 05 6;11(5):e043862. Epub 2021 May 6.

Division of Cardiology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

Objective: To determine the effect of gender on clinical outcomes of Asian non-valvular atrial fibrillation patients.

Design: This is a cohort study.

Setting: 27 university and regional hospitals in Thailand.

Participants: Patients with non-valvular atrial fibrillation.

Primary And Secondary Outcomes Measures: The clinical outcomes were ischaemic stroke/transient ischaemic attack (TIA), major bleeding, intracerebral haemorrhage (ICH), heart failure and death. Follow-up data were recorded every 6 months until 3 years. Differences in clinical outcomes between males and females were determined. Multivariate analysis was performed to assess the effect of gender on clinical outcomes. Survival analysis and log-rank test were performed to determine the time-dependent effect of clinical outcomes, and the difference between males and females. Effect of oral anticoagulant (OAC) on outcomes and net clinical benefit of OAC was assessed. The analysis was performed both for the whole dataset and propensity score matching with multiple imputation.

Results: A total of 3402 patients (mean age: 67.4±11.3 years; 58.2% male) were included. Average follow-up duration 25.7±10.6 months (7192.6 persons-year). Rate of ischaemic stroke/TIA, major bleeding, ICH, heart failure and death were 1.43 (1.17-1.74), 2.11 (1.79-2.48), 0.70 (0.52-0.92), 3.03 (2.64-3.46) and 3.77 (3.33-4.25) per 100 person-years. Females had increased risk for ischaemic stroke/TIA and heart failure and males had increased risk for major bleeding and ICH. Ischaemic stroke/TIA risk in females and major bleeding and ICH risk in males remained even after correction for age, comorbid conditions and anticoagulation treatment. OAC reduced the risk of ischaemic stroke/TIA in males and females, and markedly increased the risk of major bleeding and ICH in males.

Conclusions: Females had a higher risk of ischaemic stroke/TIA and heart failure, and a lower risk of major bleeding and ICH compared with males. OAC reduced risk of ischaemic stroke/TIA in females, and markedly increased risk of major bleeding and ICH in males.
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http://dx.doi.org/10.1136/bmjopen-2020-043862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103947PMC
May 2021

Age-Related Clinical Outcomes of Patients with Non-Valvular Atrial Fibrillation: Insights from the COOL-AF Registry.

Clin Interv Aging 2021 28;16:707-719. Epub 2021 Apr 28.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Purpose: We aimed to compare the rate of clinical outcomes among three age groups (<65, 65-74, and ≥75 years) of adult patients with non-valvular atrial fibrillation (NVAF).

Patients And Methods: We prospectively enrolled NVAF patients from 27 Thailand medical centers. The following were collected at baseline: demographic data, risk factors, comorbid conditions, laboratory data, and medications. The clinical outcomes were ischemic stroke (IS) or transient ischemic attack (TIA), major bleeding (MB), intracerebral hemorrhage (ICH), heart failure (HF), and death. All events were adjudicated. Patients were categorized according to age group into three groups; age <65, 65-74, and ≥75 years.

Results: Among the 3402 patients that were enrolled during 2014-2017, the mean age was 67.4±11.3 years, and 2073 (60.9%) were older. The average follow-up was 25.7±10.6 months. Oral anticoagulants were given in 75.4% of patients (91.1% of OAC was warfarin). The incidence rate of IS/TIA, MB, ICH, HF, and death was 1.43 (1.17-1.74), 2.11 (1.79-2.48), 0.70 (0.52-0.92), 3.03 (2.64-3.46), and 3.77 (3.33-4.24) per 100 person-years, respectively. The risk of IS/TIA, MB, ICH, HF, and death increased with age both before and after adjustment for potential confounders. Even though OAC reduced the risk of IS/TIA, it increased the risk of MB. Net clinical benefit (NCB) analysis favored oral anticoagulant (OAC) in the high-risk subset of older adults.

Conclusion: Older adult NVAF patients had a significantly increased risk of IS/TIA, MB, ICH, HF, and death compared to younger NVAF before and after adjustment for potential confounders. Strategies to reduce overall risk, including OAC use and choice and integrated care, should be implemented.
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http://dx.doi.org/10.2147/CIA.S302389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089026PMC
June 2021

Characteristics and antithrombotic treatment patterns of patients with concomitant coronary artery disease and atrial fibrillation from Thailand's COOL-AF registry.

BMC Cardiovasc Disord 2021 03 2;21(1):117. Epub 2021 Mar 2.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

Background: Concomitant coronary artery disease (CAD) and atrial fibrillation (AF) are common in clinical practice. The aim of this study was to investigate the characteristics and antithrombotic treatment patterns of patients with concomitant CAD and AF from the COhort of antithrombotic use and Optimal INR Level in patients with non-valvular atrial fibrillation in Thailand (COOL-AF Thailand) registry.

Methods: Registry enrollment criteria included patients aged ≥ 18 years who were diagnosed with AF for any duration at any of 27 public hospitals located across Thailand during 2014-2017. The That Clinical Trials Registry study registration number is TCTR20160113002. Statistical comparisons of characteristics and treatment strategies were performed between patients with and without CAD.

Results: Of a total of 3461 AF patients, 557 had concomitant CAD (16.1%). Patients with concomitant CAD and AF were significantly older, more likely to be male, had more comorbidities, and had more cardiovascular implantable electronic devices. History of stroke/transient ischemic attack and prior bleeding was not significantly different between groups. CHADS-VASc score and HAS-BLED score were both higher in patients with CAD than in patients without CAD (4.17 vs. 2.78, p < 0.001, and 2.01 vs. 1.45, p < 0.001, respectively). Utilization of oral anticoagulant was less in patients with CAD (76.0% vs. 84.3%, p < 0.001). Concomitant use of antiplatelet was found to be a major cause of oral anticoagulant (OAC) underutilization. Specifically, the rate of OAC prescription was 95.9% in patients without antiplatelet, and 43.7% in patients with antiplatelet. Among patients with CAD who were on OAC, the rate of concomitant antiplatelet prescription was still high. In this group, 63% of patients were on triple therapy when percutaneous coronary intervention (PCI) with drug eluting stent was performed within 1 year, and 32.2% of patients without prior PCI or acute coronary syndrome were taking at least one antiplatelet with OAC.

Conclusion: Among patients with concomitant CAD and AF, physicians were reluctant to discontinue antiplatelet. The use of antiplatelet discourages physicians from prescribing OAC. Underutilization of OAC may increase the risk of ischemic stroke, and an inappropriate combination of OAC and antiplatelet may increase the risk of bleeding. Trial registration The trial has been registered with the Thai Clinical Trials Registry (TCTR) which complied with WHO International Clinical Trials Registry Platform dataset. The Registration Number is TCTR20160113002 (05/01/2016).
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http://dx.doi.org/10.1186/s12872-021-01928-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927385PMC
March 2021

Impact of anemia on clinical outcomes of patients with atrial fibrillation: The COOL-AF registry.

Clin Cardiol 2021 Mar 4;44(3):415-423. Epub 2021 Feb 4.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: To determine whether anemia is an independent risk factor for ischemic stroke and major bleeding in patients with non-valvular atrial fibrillation (NVAF).

Hypothesis: Anemia in patients with NVAF increase risk of clinical complications related to atrial fibrillation.

Methods: We conducted a prospective multicenter registry of patients with NVAF in Thailand. Demographic data, medical history, comorbid conditions, laboratory data, and medications were collected and recorded, and patients were followed-up every 6 months. The outcome measurements were ischemic stroke or transient ischemic attack (TIA), major bleeding, heart failure (HF), and death. All events were adjudicated by the study team. We analyzed whether anemia is a risk factor for clinical outcomes with and without adjusting for confounders.

Results: There were a total of 1562 patients. The average age of subjects was 68.3 ± 11.5 years, and 57.7% were male. The mean hemoglobin level was 13.2 ± 1.8 g/dL. Anemia was demonstrated in 518 (33.16%) patients. The average follow-up duration was 25.8 ± 10.5 months. The rate of ischemic stroke/TIA, major bleeding, HF, and death was 2.9%, 4.9%, 1.8%, 8.6%, and 9.2%, respectively. Anemia significantly increased the risk of these outcomes with a hazard ratio of 2.2, 3.2, 2.9, 1.9, and 2.8, respectively. Oral anticoagulants (OAC) was prescribed in 74.8%; warfarin accounts for 89.9% of OAC. After adjusting for potential confounders, anemia remained a significant predictor of major bleeding, heart failure, and death, but not for ischemic stroke/TIA.

Conclusion: Anemia was found to be an independent risk factor for major bleeding, heart failure, and death in patients with NVAF.
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http://dx.doi.org/10.1002/clc.23559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7943899PMC
March 2021

Optimal INR level in elderly and non-elderly patients with atrial fibrillation receiving warfarin: a report from the COOL-AF nationwide registry in Thailand.

J Geriatr Cardiol 2020 Oct;17(10):612-620

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: Asian population are at increased risk of bleeding during the warfarin treatment, so the recommended optimal international normalized ratio (INR) level may be lower in Asians than in Westerners. The aim of this prospective multicenter study was to determine the optimal INR level in Thai patients with non-valvular atrial fibrillation (NVAF).

Methods: Patients with NVAF who were on warfarin for stroke prevention were recruited from 27 hospitals in the nationwide COOL-AF registry in Thailand. We collected demographic data, medical history, risk factors for stroke and bleeding, concomitant disease, electrocardiogram and laboratory data including INR and antithrombotic medications. Outcome measurements included ischemic stroke/transient ischemic attack (TIA) and major bleeding. Optimal INR level was assessed by the calculation of incidence density for six INR ranges (< 1.5, 1.5-1.99, 2-2.49, 2.5-2.99, 3-3.49, and ≥ 3.5).

Results: A total of 2, 232 patients were included. The mean age of patients was 68.5 ± 10.6 years. The mean follow-up duration was 25.7 ± 10.6 months. There were 63 ischemic stroke/TIA and 112 major bleeding events. The lowest prevalence of ischemic stroke/TIA and major bleeding events occurred within the INR range of 2.0-2.99 for patients < 70 years and 1.5-2.99 for patients ≥ 70 years.

Conclusions: The INR range associated with the lowest risk of ischemic stroke/TIA and bleeding in the Thai population was 2.0-2.99 for patients < 70 years and 1.5-2.99 for patients ≥ 70 years. The rates of major bleeding and ischemic stroke/TIA were both higher than the rates reported in Western population.
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http://dx.doi.org/10.11909/j.issn.1671-5411.2020.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657951PMC
October 2020

Clinical assessment of adenosine stress and rest cardiac magnetic resonance T1 mapping for detecting ischemic and infarcted myocardium.

Sci Rep 2020 09 7;10(1):14727. Epub 2020 Sep 7.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.

Cardiac magnetic resonance (CMR) spin-lattice relaxation time (T1) may be influenced by pathologic conditions due to changes in myocardial water content. We aimed to validate the principle and investigate T1 mapping at rest and adenosine stress to differentiate ischemic and infarcted myocardium from controls. Patients with suspected coronary artery disease who underwent CMR were prospectively recruited. Native rest and adenosine stress T1 maps were obtained using standard modified Look-Locker Inversion-Recovery technique. Among 181 patients included, T1 values were measured from three groups. In the control group, 72 patients showed myocardium with a T1 profile of 1,039 ± 75 ms at rest and a significant increase during stress (4.79 ± 3.14%, p < 0.001). While the ischemic (51 patients) and infarcted (58 patients) groups showed elevated resting T1 compared to controls (1,040 ± 90 ms for ischemic; 1,239 ± 121 ms for infarcted, p < 0.001), neither of which presented significant T1 reactivity (1.38 ± 3.02% for ischemic; 1.55 ± 5.25% for infarcted). We concluded that adenosine stress and rest T1 mapping may be useful to differentiate normal, ischemic and infarcted myocardium.
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http://dx.doi.org/10.1038/s41598-020-71722-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477195PMC
September 2020

Low Body Weight Increases the Risk of Ischemic Stroke and Major Bleeding in Atrial Fibrillation: The COOL-AF Registry.

J Clin Med 2020 Aug 22;9(9). Epub 2020 Aug 22.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK.

We aimed to determine if low body weight (LBW) status (<50 kg) is independently associated with increased risk of ischemic stroke and bleeding in Thai patients with non-valvular atrial fibrillation (NVAF). (1) Background: It has been unclear whether LBW influence clinical outcome of patients with NVAF. (2) Methods: This prospective multicenter cohort study included patients enrolled in the COOL-AF Registry. The following data were collected: demographic data, medical history, risk factors and comorbid conditions, laboratory and investigation data, and medications. Follow-up data were collected every 6 months. Clinical events during follow-up were confirmed by the adjudication committee. (3) Results: A total of 3367 patients were enrolled. The mean age was 67.2 ± 11.2 years. LBW was present in 338 patients (11.3%). Anticoagulant and antiplatelet was prescribed in 75.3% and 26.2% of patients, respectively. Ischemic stroke, major bleeding, intracerebral hemorrhage (ICH), and death occurred during follow-up in 2.9%, 4.4%, 1.4%, and 7.7% of patients, respectively, during 25.7 months follow-up. LBW was an independent predictor of ischemic stroke, major bleeding, ICH, and death, with a hazard ratio of 2.40, 1.79, 2.37, and 2.65, respectively. (4) Conclusions: LBW was independently associated with increased risk of adverse outcomes in Thai patients with NVAF. This should be carefully considered when balancing the risks and benefits of stroke prevention among patients with different body weights.
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http://dx.doi.org/10.3390/jcm9092713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565915PMC
August 2020

Oral anticoagulation and cardiovascular outcomes in patients with atrial fibrillation and chronic kidney disease in Asian Population, Data from the COOL-AF Thailand registry.

Int J Cardiol 2021 01 21;323:90-99. Epub 2020 Aug 21.

Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Electronic address:

Background And Objectives: Patients with AF and chronic kidney disease(CKD) encountered increased risks of stroke, bleeding, morbidity, and overall mortality. Oral anticoagulation in these populations definitely enhances major bleeding but the benefit of stroke reduction remained inconclusive.The aim of this study is to evaluate the effect of oral anticoagulation (OAC) on the 2-year cardiovascular outcomes in patients with AF and CKD.

Method: NVAF patients were consecutively enrolled from 27 hospitals located all across Thailand.Baseline demographic and clinical data were collected within 6 months from enrollment.GFR was calculated using CKD-EPI formula. CKD patients were defined as GFR less than 60 mL/min/1.73 m according to KDOQI of the National Kidney Foundation. Clinical outcomes included ischemic stroke or transient ischemic attack (TIA) and major bleeding.

Results: At 25.7 ± 10.6 months of follow up, we identified 2538 patients with complete renal follow-up data. Among these were 1594 patients with CKD (stage 3-5) and 944 patients without CKD. The rate of ischemic stroke in patients with and without CKD were 3.7% and 1.7% respectively (p = 0.004),the rate of major bleeding was 5.6 and 3.5% accordingly (p = 0.015) and, likewise, the death rate was substantially high in patients with CKD (10.0% and 6.5%, p = 0.02). The rate of ischemic stroke/TIA in patients with CKD who were and were not on OAC did not differ significantly, 3.6% and 4.2% respectively (p = 0.602). NOAC and warfarin did not differ significantly in the propensity score-matched rate of both ischemic stroke/TIA (0 and 1.2%, p = 0.554) and major bleeding (3.3% and 7.4%, p = 0.122).The net clinical benefit of NOAC over warfarin was 2.153 per 100-patient years.

Conclusions: COOL AF registry demonstrated that AF patients with CKD had increased risks of ischemic stroke/TIA, major bleeding and death. The benefit of stroke/TIA reduction was not significantly evident for either warfarin or NOAC. However, NOAC was associated with the positive net clinical benefit over no OAC.
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http://dx.doi.org/10.1016/j.ijcard.2020.08.068DOI Listing
January 2021

Cost-utility analysis of add-on dapagliflozin treatment in heart failure with reduced ejection fraction.

Int J Cardiol 2021 01 13;322:183-190. Epub 2020 Aug 13.

Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand. Electronic address:

Background: Dapagliflozin is an antidiabetic medication that has been shown to reduce the risk of heart failure hospitalization and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF). This study aimed to determine the cost-utility of add-on dapagliflozin treatment for HFrEF.

Methods: An analytical decision model was constructed to assess lifetime costs and outcomes from a healthcare system perspective. The cohort comprised HFrEF patients with left ventricular ejection fraction (LVEF) ≤40%, and New York Heart Association (NYHA) class II-IV with an average age of 65 years. Clinical inputs were derived from the results of the Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure (DAPA-HF) trial. Risk of non-cardiovascular death data, readmission rate data, and treatment-related cost data were based on Thai population. The outcomes and costs were discounted at 3% annually. A series of sensitivity analyses were also conducted.

Results: The increased cost of dapagliflozin add-on treatment from 17,442 THB (559 USD) to 54,405 THB (1745 USD) was associated with a QALY gain from 6.33 to 6.92 compared to standard therapy, yielding an ICER of 62,090 THB/QALY (1991 USD/QALY). Sensitivity analyses revealed that the addition of dapagliflozin to the standard treatment demonstrated an 87% cost-effectiveness strategy at a level of willingness to pay (WTP) of 160,000 THB/QALY (5131 USD/QALY). ICER was higher in non-diabetes compared to diabetes (68,304 vs 47,613 THB/QALY or 2191 vs 1527 USD/QALY).

Conclusions: Dapagliflozin is a cost-effective add-on therapy for patients with HFrEF at a WTP of 160,000 THB/QALY (5131 USD/QALY).
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http://dx.doi.org/10.1016/j.ijcard.2020.08.017DOI Listing
January 2021

Statin intolerance: an updated, narrative review mainly focusing on muscle adverse effects.

Expert Opin Drug Metab Toxicol 2020 Sep 11;16(9):837-851. Epub 2020 Aug 11.

Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University , Melbourne, Australia.

Introduction: Statins have been established as the standard of care for dyslipidemia and preventing cardiovascular diseases while posing few safety concerns. However, misconceptions about statin intolerance lead to their underuse, indicating a need to improve the understanding of the safety of this treatment.

Areas Covered: We searched PubMed and reviewed literatures related to statin intolerance published between February 2015 and February 2020. Important large-scale or landmark studies published before 2015 were also cited as key evidence.

Expert Opinion: Optimal lowering of low-density lipoprotein cholesterol with statins substantially reduces the risk of cardiovascular events. Muscle adverse events (AEs) were the most frequently reported AEs by statin users in clinical practice, but they usually occurred at a similar rate with statins and placebo in randomized controlled trials and had a spurious causal relationship with statin treatment. We proposed a rigorous definition for identifying true statin intolerance and present the criteria for defining different forms of muscle AEs and an algorithm for their management. True statin intolerance is uncommon, and every effort should be made to exclude false statin intolerance and ensure optimal use of statins. For the management of statin intolerance, statin-based approaches should be prioritized over non-statin approaches.
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http://dx.doi.org/10.1080/17425255.2020.1802426DOI Listing
September 2020

Common and rare susceptibility genetic variants predisposing to Brugada syndrome in Thailand.

Heart Rhythm 2020 12 30;17(12):2145-2153. Epub 2020 Jun 30.

Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Pacific Rim Electrophysiology Research Institute, Bumrungrad Hospital, Bangkok, Thailand.

Background: Mutations in SCN5A are rarely found in Thai patients with Brugada syndrome (BrS). Recent evidence suggested that common genetic variations may underlie BrS in a complex inheritance model.

Objective: The purpose of this study was to find common and rare/low-frequency genetic variants predisposing to BrS in persons in Thailand.

Methods: We conducted a genome-wide association study (GWAS) to explore the association of common variants in 154 Thai BrS cases and 432 controls. We sequenced SCN5A in 131 cases and 205 controls. Variants were classified according to current guidelines, and case-control association testing was performed for rare and low-frequency variants.

Results: Two loci were significantly associated with BrS. The first was near SCN5A/SCN10A (lead marker rs10428132; odds ratio [OR] 2.4; P = 3 × 10). Conditional analysis identified a novel independent signal in the same locus (rs6767797; OR 2.3; P = 2.7 × 10). The second locus was near HEY2 (lead marker rs3734634; OR 2.5; P = 7 × 10). Rare (minor allele frequency [MAF] <0.0001) coding variants in SCN5A were found in 8 of the 131 cases (6.1% in cases vs 2.0% in controls; P = .046; OR 3.3; 95% confident interval [CI] 1.0-11.1), but an enrichment of low-frequency (MAF<0.001 and >0.0001) variants also was observed in cases, with 1 variant (SCN5A: p.Arg965Cys) detected in 4.6% of Thai BrS patients vs 0.5% in controls (P = 0.015; OR 9.8; 95% CI 1.2-82.3).

Conclusion: The genetic basis of BrS in Thailand includes a wide spectrum of variant frequencies and effect sizes. As previously shown in European and Japanese populations, common variants near SCN5A and HEY2 are associated with BrS in the Thai population, confirming the transethnic transferability of these 2 major BrS loci.
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http://dx.doi.org/10.1016/j.hrthm.2020.06.027DOI Listing
December 2020

Long-term antithrombotic management patterns in Asian patients with acute coronary syndrome: 2-year observations from the EPICOR Asia study.

Clin Cardiol 2020 Sep 2;43(9):999-1008. Epub 2020 Jul 2.

Department of Cardiology, Sarawak General Hospital, Kuching, Malaysia.

Background: Despite guideline recommendations, dual antiplatelet therapy (DAPT) is frequently used for longer than 1 year after an acute coronary syndrome (ACS) event. In Asia, information on antithrombotic management patterns (AMPs), including DAPT post discharge, is sparse. This analysis evaluated real-world AMPs up to 2 years post discharge for ACS.

Hypothesis: There is wide variability in AMP use for ACS management in Asia.

Methods: EPICOR Asia (NCT01361386) is a prospective observational study of patients discharged after hospitalization for an ACS in eight countries/regions in Asia, followed up for 2 years. Here, we describe AMPs used and present an exploratory analysis of characteristics and outcomes in patients who received DAPT for ≤12 months post discharge compared with >12 months.

Results: Data were available for 12 922 patients; of 11 639 patients discharged on DAPT, 2364 (20.3%) received DAPT for ≤12 months and 9275 (79.7%) for >12 months, with approximately 60% still on DAPT at 2 years. Patients who received DAPT for >12 months were more likely to be younger, obese, lower Killip class, resident in India (vs China), and to have received invasive reperfusion. Clinical event rates during year 2 of follow-up were lower in patients with DAPT >12 vs ≤12 months, but no causal association can be implied in this non-randomized study.

Conclusions: Most ACS patients remained on DAPT up to 1 year, in accordance with current guidelines, and over half remained on DAPT at 2 years post discharge. Patients not on DAPT at 12 months are a higher risk group requiring careful monitoring.
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http://dx.doi.org/10.1002/clc.23400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462192PMC
September 2020

Poor Time in Therapeutic Range Control is Associated with Adverse Clinical Outcomes in Patients with Non-Valvular Atrial Fibrillation: A Report from the Nationwide COOL-AF Registry.

J Clin Med 2020 Jun 2;9(6). Epub 2020 Jun 2.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK.

Background: Warfarin remains the most commonly used oral anticoagulant (OAC) in Thailand for stroke prevention among patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to investigate the relationship between time in therapeutic range (TTR) after warfarin initiation and clinical outcomes of NVAF.

Methods: TTR was calculated by the Rosendaal method from international normalized ratio (INR) data acquired from a nationwide NVAF registry in Thailand. Patients were followed-up every six months. The association between TTR and clinical outcomes was analyzed.

Results: There was a total of 2233 patients from 27 hospitals. The average age was 68.4 ± 10.6 years. The average TTR was 53.56 ± 26.37%. Rates of ischemic stroke/TIA, major bleeding, ICH, and death were 1.33, 2.48, 0.76, and 3.3 per 100 person-years, respectively. When patients with a TTR < 65% were compared with those with TTR ≥ 65%, the adjusted hazard ratios (aHR) for the increased risks of ischemic stroke/TIA, major bleeding, ICH, and death were 3.07, 1.90, 2.34, and 2.11, respectively.

Conclusion: Poor TTR control is associated with adverse clinical outcomes in patients with NVAF who were on warfarin. Efforts to ensure good TTR (≥65%) after initiation of warfarin are mandatory to minimize the risk of adverse clinical outcomes.
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http://dx.doi.org/10.3390/jcm9061698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355466PMC
June 2020

Adherence to Anticoagulant Guideline for Atrial Fibrillation Improves Outcomes in Asian Population: The COOL-AF Registry.

Stroke 2020 06 11;51(6):1772-1780. Epub 2020 May 11.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.).

Background and Purpose- Guideline adherent oral anticoagulant (OAC) management of patients with nonvalvular atrial fibrillation has been associated with improved outcomes, but limited data are available from Asia. We aimed to investigate outcomes in patients who received guideline compliant management compared with those who were OAC undertreated or overtreated, in a large nationwide multicenter cohort of patients with nonvalvular atrial fibrillation in Thailand. Methods- Patients with nonvalvular atrial fibrillation were prospectively enrolled from 27 hospitals-all of which are data contributors to the COOL-AF Registry (Cohort of Antithrombotic Use and Optimal INR Level in Patients With Non-Valvular Atrial Fibrillation in Thailand). Patients were categorized as follows: (1) guideline adherence group when OAC was given in high-risk or intermediate-risk, but not in low-risk patients; (2) undertreatment group when OAC was not given in the high-risk or intermediate-risk groups; and (3) overtreatment group when OAC was given in the low-risk group or when OAC was given in combination with antiplatelets without indication. Results- A total of 3327 patients who had follow-up clinical outcome data were included. The mean age of patients was 67.4 years and 58.1% were male. The numbers of patients in the guideline adherence group, undertreatment group, and overtreatment group were 2267 (68.1%), 624 (18.8%), and 436 (13.1%) patients, respectively. The overall rate of ischemic stroke, major bleeding, all bleeding, and death was 3.0%, 4.4%, 15.1%, and 7.8%, respectively. Undertreated patients had a higher risk of ischemic stroke and death compared with guideline adherent patients, and overtreated patients had a higher risk of bleeding and death compared with OAC guideline-managed patients. Conclusions- Adherence to OAC management guidelines is associated with improved clinical outcomes in Asian nonvalvular atrial fibrillation patients. Undertreatment or overtreatment was found to be associated with increased risk of adverse outcomes compared with guideline-adherent management.
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http://dx.doi.org/10.1161/STROKEAHA.120.029295DOI Listing
June 2020

Two-year outcomes post-discharge in Asian patients with acute coronary syndrome: Findings from the EPICOR Asia study.

Int J Cardiol 2020 09 7;315:1-8. Epub 2020 May 7.

Sarawak General Hospital, Kuching, Malaysia.

Aims: Approximately half of cases of cardiovascular disease (CVD) worldwide occur in Asia, with acute coronary syndrome (ACS) a leading cause of mortality. Long-term ACS-related outcomes data in Asia are limited. This analysis examined 2-year ACS-related outcomes in patients enrolled in the EPICOR Asia study, and the association between patient characteristics and management on outcomes.

Methods: EPICOR Asia is a multinational, prospective, primary data collection study of real-world management of Asian patients with ACS. Overall, 12,922 eligible adults (hospitalized for ACS within 48 h of symptom onset and who survived to discharge) were enrolled from 219 centers in eight Asian countries. Patients were followed up post-discharge for 2 years and clinical outcomes recorded.

Results: Patients were of mean age 60 years and 76% were male. Diagnoses were STEMI (51.2%), NSTEMI (19.9%), and UA (28.9%). During follow-up, 5.2% of patients died; NSTEMI patients had the highest risk profile. Mortality rate (adjusted HR [95% CI]) was similar in NSTEMI (0.97 [0.81-1.17]) and lower in UA (0.52 [0.33-0.82]) vs STEMI. Similar trends (adjusted) were seen for the composite endpoint of death, myocardial infarction, or ischemic stroke, and bleeding rates did not differ significantly. For all three diagnoses, patients who were medically managed had a markedly elevated risk of both death and the composite endpoint.

Conclusions: During 2-year follow-up, adjusted risks of mortality, the composite endpoint, and bleeding rates were similar in NSTEMI and STEMI patients. Outcomes risk was better for invasive management. Long-term management strategies in Asia need to be optimized.
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http://dx.doi.org/10.1016/j.ijcard.2020.05.022DOI Listing
September 2020

History of major bleeding predicts risk of clinical outcome of patients with atrial fibrillation: results from the COOL-AF registry.

J Geriatr Cardiol 2020 Apr;17(4):184-192

Her Majesty Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Objective: To compare clinical outcomes between patients with and without history of major bleeding according to types of antithrombotic medications in patients with non-valvular atrial fibrillation (NVAF).

Methods: We conducted a multicenter registry of patients with NVAF during 2014 to 2017 in Thailand. The following data were collected: demographic data, type of NVAF, medical illness, components of CHADS-VASc and HAS-BLED scores, history of bleeding and severity, investigations, and antithrombotic medications. Clinical outcomes were death, bleeding, and ischemic stroke/transient ischemic attack (TIA).

Results: There were a total of 3218 patients. The average age was 67.3 ± 11.3 years, and 58.3% were men. Sixty-nine patients (2.14%) had a history of major bleeding. Antithrombotic use was, as follows: 2126 patients (75.3%) received oral anticoagulant (OAC) alone, 555 (17.2%) received antiplatelet alone, 298 (9.3%) received both, and 239 (7.4%) received neither. During follow-up, 9.9% had major adverse outcomes, including death (5.9%), ischemic stroke/TIA (2.5%), and major bleeding (4.0%). There were no significant differences in the types of antithrombotic medications between patients with and without history of major bleeding. Multivariate analysis revealed old age, low body mass index, hypertension, diabetes, heart failure, and history of major bleeding to be independently associated with major adverse outcome. Adverse events significantly increased in patients with OAC plus antiplatelet.

Conclusions: History of major bleeding was identified as a factor that significantly affects clinical outcome. Inappropriate use of OAC plus antiplatelet should be avoided. Special caution should be made in this high-risk patients.
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http://dx.doi.org/10.11909/j.issn.1671-5411.2020.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189265PMC
April 2020
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