Abstract Background It is unclear whether the non–vitamin K antagonist oral anticoagulant agents rivaroxaban and dabigatran are superior to warfarin for efficacy and safety outcomes in Asians with ...nonvalvular atrial fibrillation (NVAF). Objectives The aim of this study was to compare the risk for thromboembolic events, bleeding, and mortality associated with rivaroxaban and dabigatran versus warfarin in Asians with NVAF. Methods A nationwide retrospective cohort study was conducted of consecutive patients with NVAF taking rivaroxaban (n = 3,916), dabigatran (n = 5,921), or warfarin (n = 5,251) using data collected from the Taiwan National Health Insurance Research Database between February 1, 2013 and December 31, 2013. The propensity score weighting method was used to balance covariates across study groups. Patients were followed until the first occurrence of any study outcome or the study end date (December 31, 2013). Results A total of 3,425 (87%) and 5,301 (90%) patients were taking low-dose rivaroxaban (10 to 15 mg once daily) and dabigatran (110 mg twice daily), respectively. Compared with warfarin, both rivaroxaban and dabigatran significantly decreased the risk for ischemic stroke or systemic embolism (p = 0.0004 and p = 0.0006, respectively), intracranial hemorrhage (p = 0.0007 and p = 0.0005, respectively), and all-cause mortality (p < 0.0001 and p < 0.0001, respectively) during the short follow-up period. In comparing the 2 non–vitamin K antagonist oral anticoagulant agents with each other, no differences were found regarding risk for ischemic stroke or systemic embolism, intracranial hemorrhage, myocardial infarction, or mortality. Rivaroxaban carried a significantly higher risk for hospitalization for gastrointestinal bleeding than dabigatran (p = 0.0416), but on-treatment analysis showed that the risk for hospitalized gastrointestinal bleeding was similar between the 2 drugs (p = 0.5783). Conclusions In real-world practice among Asians with NVAF, both rivaroxaban and dabigatran were associated with reduced risk for ischemic stroke or systemic embolism, intracranial hemorrhage, and all-cause mortality without significantly increased risk for acute myocardial infarction or hospitalization for gastrointestinal bleeding compared with warfarin.
Abstract Background Whether dabigatran is associated with a lower risk of acute kidney injury (AKI) in patients with nonvalvular atrial fibrillation (NVAF) remains unknown. Objectives The authors ...compared the risk of AKI in Asians with NVAF who were prescribed dabigatran versus warfarin. Methods The authors analyzed patients enrolled in the Taiwan nationwide retrospective cohort study from June 1, 2012, to December 31, 2013. Dabigatran and warfarin were taken by 7,702 and 7,885 NVAF patients without a history of chronic kidney disease (CKD) and 2,256 and 2,089 NVAF patients with a history of CKD, respectively. A propensity-score weighted method was used to balance covariates across study groups. Results A total of 6,762 (88%) and 940 (12%) CKD-free patients and 2,025 (90%) and 231 (10%) CKD patients took dabigatran 110 mg and 150 mg twice daily, respectively. Dabigatran was associated with a lower risk of AKI than warfarin for either the CKD-free (hazard ratio HR: 0.62; 95% confidence interval CI: 0.49 to 0.77; p < 0.001) or CKD (HR: 0.56; 95% CI: 0.46 to 0.69; p < 0.001) cohort. As the increment in CHA2 DS2 -VASc score (a risk score based on congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, aged 65 to 74 years, and female sex) increased from 0/1 to 6+ points, the incidence of AKI for the dabigatran group was relatively stable (1.87% to 2.91% per year for the CKD-free cohort; 7.31% to 13.15% per year for the CKD cohort) but increased obviously for patients taking warfarin for either CKD-free (2.00% to 6.16% per year) or CKD cohorts (6.82 to 26.03% per year). The warfarin group had a significantly higher annual risk of AKI than the dabigatran group for those with a high CHA2 DS2 -VASc score (≥4 for the CKD-free cohort and ≥3 for the CKD cohort). Subgroup analysis revealed that among dabigatran users, those taking either low-dose or standard-dose dabigatran, those with a warfarin-naïve or warfarin-experienced history, those with or without diabetes, and those with CHA2 DS2 -VASc ≥4 or HAS-BLED ≥3 (risk score based on hypertension, abnormal renal and liver function, stroke, prior major bleeding, labile international normalized ratios, age 65 years or older, drugs or alcohol usage history) all had a lower risk of AKI than those taking warfarin. Conclusions Among Asians with NVAF, dabigatran is associated with a lower risk of AKI than warfarin.
Abstract Aims Impaired left ventricular (LV) strain is associated with an increased risk of cardiac events in asymptomatic severe aortic stenosis (AS). We aimed to evaluate the prognostic value of ...global LV strain in conservatively treated patients with symptomatic AS. Methods and results This cohort study retrospectively reviewed symptomatic AS patients who were treated conservatively or surgically between July 2007 and April 2010. We measured their global longitudinal strain (GLS) and global circumferential strain (GCS). Clinical events were defined as readmission for heart failure or all-cause death for 2 years. GLS and GCS could predict a worse outcome in the conservatively treated group at cut-offs of =−16.5% (77% sensitivity and 67% specificity) and =−22.2% (92% sensitivity and 83% specificity), respectively. By univariate Cox regression analysis, age, logistic EuroSCORE, aortic valve area, GLS, and GCS were significant predictors. When adjusted for age, logistic EuroSCORE, and aortic valve area, impaired GLS and GCS were independently associated with a higher risk of clinical events. Conclusion In conservatively treated patients with symptomatic AS, impaired GLS and GCS were associated with an increased risk of cardiac events during a 2-year follow-up. Global LV strain may help to define a higher risk subset; therefore, a larger and prospective observation study would be necessary.
Previous studies have identified four clinical characteristics associated with a favorable response to cardiac resynchronization therapy (CRT): female gender, left bundle branch block (LBBB), QRS ...duration ≥ 150 msec, and nonischemic etiology of heart failure. The aim of this study was to evaluate the incremental value of baseline inefficient deformation and time delay indices over clinical characteristics for predicting CRT response.
Speckle-tracking longitudinal strain was analyzed in 119 CRT candidates. Patients were divided into subgroups according to sex (male vs. female), QRS morphology (LBBB vs. non-LBBB), QRS duration (≥150 vs. <150 msec), and heart failure etiology (ischemic vs nonischemic). Inefficient deformation was indexed by the septal systolic stretching that occurred after prematurely terminated shortening (systolic rebound stretch in the septal wall) and the absolute differences between peak strain and end-systolic strain across 16 segments (strain delay index). Time to peak strain was measured to derive the septal-to-lateral delay and the 12-segment standard deviation of time to peak strain. CRT response was defined as 6-month end-systolic volume reduction ≥ 15%.
Patients with one of the four favorable characteristics were more likely to exhibit other favorable characteristics and had greater amounts of inefficient deformation than those without. In contrast, time delay indices were not significantly different in any pairwise comparison except for that between patients with and those without LBBB. Of the 43 patients for whom 6-month follow-up data were available, CRT response was found in 26 (60%). Systolic rebound stretch in the septal wall and strain delay index rather than time delay indices provided significant incremental value over clinical characteristics when predicting CRT response.
Combined systolic rebound stretch in the septal wall (or strain delay index) and favorable characteristics may help identify CRT responders.
Purpose To compare responsiveness of the Michigan Hand Outcomes Questionnaire (MHQ) with that of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire in patients with hand injuries. ...We postulated that the MHQ may be more sensitive to functional changes in the hands, whereas the DASH questionnaire would have a closer association with days of disability. Methods Patients with hand injuries were consecutively recruited from 2 community hospitals. Each patient was asked to complete out the MHQ, the DASH questionnaire, the satisfaction with their health-related quality of life (Sat-HRQOL) measure, and Chinese Health Questionnaire (CHQ), which is a measure of psychological stressors. Disability days were defined as the duration of restricted activities of daily living during the previous 4 weeks. Patients repeated the same questionnaires between 2 and 9 months after enrollment (average: 4 mo). Results A total of 105 patients with hand injuries were recruited, and 50 of the 105 patients returned for the second evaluation. There were no statistical differences between responders and nonresponders for age, gender, disability days, the MHQ, the DASH questionnaire, the CHQ, or the Sat-HRQOL. Responsiveness was evaluated by effect sizes and standardized response means: Those for the MHQ were 0.84 and 1.05, and those for the DASH were 0.67 and 0.86, respectively. A mixed model analysis for repeated measurements of the 50 participants showed a significant influence of psychological factors (CHQ) for both the Sat-HRQOL and disability days. After adjustment for the effects of age, gender, and the CHQ, there was an increment of one Sat-HRQOL unit for an MHQ score increment of 3.2, whereas the score decrement for the DASH questionnaire was 3.3 units. Conclusions The MHQ might be slightly more sensitive to functional changes, but the DASH questionnaire seemed more correlated with disability days. Psychological factors are the strongest determinants of the HRQOL and disability.
Introduction:
In our study, we aimed to investigate the association between a traumatic brain injury (TBI) and subsequent erectile dysfunction (ED). This is a population-based study using the claims ...dataset from The National Health Insurance Research Database.
Methods:
We included 72,642 patients with TBI aged over 20 years, retrospectively, selected from the longitudinal health insurance database during 2000–2010, according to the ICD-9-CM. The control group consisted of 217,872 patients without TBI that were randomly chosen from the database at a ratio of 1:3, with age- and index year matched. Cox proportional hazards analysis was used to estimate the association between the TBI and subsequent ED.
Results:
After a 10-year follow-up, the incidence rate of ED was higher in the TBI patients when compared with the non-TBI control group (24.66 and 19.07 per 100,000, respectively). Patients with TBI had a higher risk of developing ED than the non-TBI cohort after the adjustment of the confounding factors, such as age, comorbidity, residence of urbanization and locations, seasons, level of care, and insured premiums (adjusted hazard ratio (HR) = 2.569, 95% CI 1.890, 3.492, p < .001).
Conclusion:
This is the first study using a comprehensive nationwide database to analyze the association of ED and TBI in the Asian population. After adjusted the confounding factors, patients with TBI have a significantly higher risk of developing ED, especially organic ED, than the general population. This finding might remind clinicians that it’s crucial in early identification and treatment of ED in post-TBI patients.
Abstract Purposes Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in ...OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC). Methods This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2008. The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pNH3 ), and the results were depicted as a receiver operating characteristics curve with an area under the curve. Results Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pNH3 in the non-ROSC group were significantly higher than those in the ROSC group (167.0 μ mol/L vs 80.0 μ mol/L, P < .05; 2.61 × 10 − 5 vs 1.67 × 10 − 5 mm Hg, P < .05, respectively). The predictive capacity of area under the curve for ammonia and pNH3 for non-ROSC was 0.85 (95% confidence interval, 0.75-0.95) and 0.73 (95% confidence interval, 0.61-0.84), respectively. The multivariate analysis confirmed that ammonia and pNH3 are independent predictors of non-ROSC. The prognostic value of ammonia was better than that of pNH3 . The cutoff level for ammonia of 84 μ mol/L was 94.5% sensitive and 75.0% specific for predicting non-ROSC with a diagnostic accuracy of 89.9%. Conclusions Hyperammonemia on ED arrival is independently predictive of non-ROSC for OHCA patients. The findings may offer useful information for clinical management.
Acute abdominal pain is one of the most common conditions confronted in the emergency department. Clues related to splenic infarction may be obscured, and the diagnosis is quite challenging even for ...experienced physicians or surgeons. For every patient diagnosed with splenic infarction, a scrutiny on the possible source of emboli should be carried out. In addition, splenic abscess must be suspected in patients of splenic infarction, especially if the infectious signs persist despite appropriate treatment. Rapid diagnosis and treatment are essential as its course can prove fatal. Infective endocarditis is the most common condition predisposing a patient to splenic abscess. Indeed, splenic abscess or infarction may be a disease entity at different stages in patients of infective endocarditis due to septic emboli of the spleen. The treatment of choice has been antibiotics, splenectomy, and valve replacement surgery. Herein, we report a case of splenic abscess and infective endocarditis cured by antibiotic treatment without the aid of drainage or surgery.
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