Atrial fibrillation (AF) is the most common sustained arrhythmia. Both the incidence and prevalence of AF are increasing, and the burden of AF is becoming huge. Many innovative advances have emerged ...in the past decade for the diagnosis and management of AF, including a new scoring system for the prediction of stroke and bleeding events, the introduction of non-vitamin K antagonist oral anticoagulants and their special benefits in Asians, new rhythm- and rate-control concepts, optimal endpoints of rate control, upstream therapy, life-style modification to prevent AF recurrence, and new ablation techniques. The Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology aimed to update the information and have appointed a jointed writing committee for new AF guidelines. The writing committee members comprehensively reviewed and summarized the literature, and completed the 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the Management of Atrial Fibrillation. This guideline presents the details of the updated recommendations, along with their background and rationale, focusing on data unique for Asians. The guidelines are not mandatory, and members of the writing committee fully realize that treatment of AF should be individualized. The physician's decision remains most important in AF management.
Perfluorinated chemicals (PFCs) have been largely used for years in a variety of products worldwide. However, the toxic effect of PFCs on exposure to the liver in the general population has not yet ...been determined.
In this study, 2,216 adults (18 years of age or older) were recruited in a National Health and Nutrition Examination Survey (NHANES) in 1999-2000 and 2003-2004 to determine the relationship between serum level of PFCs and the levels of liver enzymes. The data were adjusted for all other confounding variants.
After performing mathematical analysis, we determined when serum log-perfluorooctanoic acid (PFOA) increases in one unit, the serum alanine aminotransferase (ALT) concentration (U/l) increases by 1.86 units (95% confidence interval (CI), 1.24-2.48; P=0.005), and the serum log-gamma-glutamyltransferase (GGT) concentration (U/l) is 0.08 unit higher (95% CI, 0.05-0.11; P=0.019). The association between PFOA and liver enzymes was more evident in obese subjects, as well as subjects with insulin resistance and/or metabolic syndromes. When dividing the serum PFOA into quartiles in the fully adjusted models in subjects with a body mass index>or=30 kg/m2, the ALT level trend across the serum PFOA quartiles was significant (P=0.003).
On the basis of these data, we conclude that a higher serum concentration of PFOA may cause liver enzymes to increase abnormally in the general population, particularly in obese individuals. Further studies are warranted to clarify the casual relationship between PFCs and these liver enzymes.
Background Myocardial steatosis and fibrosis may play a role in the pathophysiology of heart failure with preserved ejection fraction. We therefore investigated the prognostic significance of ...epicardial fat (epicardial adipose tissue EAT) and myocardial diffuse fibrosis. Methods and Results Myocardial fibrosis, estimated as extracellular volume (ECV), and EAT were measured using cardiac magnetic resonance imaging in 163 subjects with heart failure with preserved ejection fraction. We also evaluated cardiac structure and diastolic and systolic function by echocardiography and cardiac magnetic resonance imaging. After 24 months' follow‐up, 39 (24%) subjects had experienced cardiovascular events, including hospitalization for heart failure, acute coronary syndrome, and cardiovascular death. Median EAT and mean ECV were significantly higher in subjects with cardiovascular events than survivors (EAT, 35 25–45 versus 31 21–38, P =0.006 and ECV, 28.9±3.16% versus 27.2±3.56%, P =0.04). Subjects with high EAT (≥42 g) had increased risk of cardiovascular events (hazard ratio HR, 2.528 95% CI, 1.704–4.981; P =0.032). High ECV (>29%) was also significantly associated with poorer outcomes (HR, 1.647 95% CI, 1.263–2.548; P =0.013). With respect to secondary end points, high EAT and high ECV were associated with increased risk of the incident acute coronary syndrome (HR, 1.982 95% CI, 1.008–4.123; P =0.049) and hospitalization for heart failure (HR, 1.789 95% CI, 1.102–6.987; P =0.033), respectively. Conclusions Our study suggested that increased epicardial fat and ECV detected by cardiac magnetic resonance imaging have an impact on cardiovascular prognosis, in particular acute coronary syndrome and hospitalization for heart failure, respectively.
Objectives
To assess treatment patterns of statin and/or ezetimibe and possible statin intolerance among patients initiating statin or statin plus ezetimibe and with clinical atherosclerotic ...cardiovascular disease (ASCVD) or diabetes mellitus (DM) in Taiwan.
Methods
A retrospective cohort study using Taiwan's 2005 to 2013 National Health Insurance Research Database (NHIRD) was conducted. Patients with history of clinical ASCVD or DM (without previous clinical ASCVD) and initiating statin or statin plus ezetimibe therapy during 2006 to 2012 were identified. The treatment initiation date was defined as index date. Treatment patterns (including discontinuation, reinitiation, subtraction, switching, and augmentation), adherence (medication possession ratio MPR), persistence (gap no greater than 60 d) of statin and/or ezetimibe, and possible statin intolerance during 12‐month follow‐up from the index date were examined.
Results
Among patients initiating statin or statin plus ezetimibe, 11 092 patients with history of clinical ASCVD and 31 100 patients with DM but without clinical ASCVD were analysed. The discontinuation, reinitiation, and switching rates among patients with clinical ASCVD were 54.0%, 11.3%, and 25.7% during 12‐month follow‐up period, respectively. Among patients with DM, the rates were 57.5%, 14.2%, and 28.5%. The MPRs of statin among clinical ASCVD and DM cohorts were 0.62 and 0.60, respectively. As for ezetimibe, the MPRs were 0.56 and 0.59. Persistence to statin treatment was 46.1% among ASCVD patients and 42.6% among DM patients. Among the ASCVD and DM cohorts, possible statin intolerance was observed among 19.9% and 21.4% of patients, respectively.
Conclusions
Large number of patients with either ASCVD or DM discontinued lipid‐lowering therapies with suboptimal adherence and persistence among Taiwanese population. There is a large unmet medical need to provide safe and more effective therapies, which can be used in combination with statins or alone, to reduce the risk of CV events and improve outcomes in high‐risk patients.
Many patients with coronary artery heart disease are unable to access traditional psychosocial rehabilitation conducted face to face due to excessive travel distance. Therefore, this study developed ...and assessed the feasibility and acceptability of an 8-week Internet-based cognitive-behavior group therapy program, described the patterns of use and measured change in risk factors.
This study adopted an online video conference system, JointNet, to maintain group interaction functions similar to face to face groups online, and also built an self-learning platform to deliver psychoeducation content and cognitive-behavior therapy related materials and homework. Forty-three out-patients were recruited in the pilot study, who then chose to participate in either the Internet-based cognitive-behavior group therapy or face to face group based on their preference. Fourteen patients were assigned to the waiting-list control.
Seventeen participants (17/43 = 39.5%) chose the Internet-based cognitive-behavior group therapy program. Among them, thirteen participants (13/17 = 76.5%) finished the program and were more male (92.3% vs. 50%), employed (53.8% vs. 35.3%), and had longer education duration (13.9 vs. 12.5 years) than the counterparts of the face to face group. Furthermore, they were highly motivated with average number of log-ins (66.5 time), website surfing time (950.94 min), reading frequency (78.15 time) and reading time (355.90 min) for the self-learning platform during eight weeks; and also highly satisfied (97%) with visiting the self-learning platform and video conferences. The treatment effectiveness of Internet-based cognitive-behavior group therapy was comparable with face to face one in reducing anxiety, hostility, respiration rate, and in improving vasodilation but not depression compared with the waiting-list control.
These results indicated that the Internet-based group therapy program using video conference is feasible and acceptable for the psychosocial rehabilitation of patients with coronary artery heart disease, and provides an alternative for patients who are unable to obtain conventional psychosocial rehabilitation conducted face to face.
It is still unknown whether long-term inhalation of indoor air pollutants from ambient essential oil is associated with increased cardiopulmonary events. We recruited 200 healthy homemakers to ...conduct a prospective observation study in Northern Taiwan. We measured heart rate (HR), systolic blood pressure (SBP), diastolic BP (DBP), peak expiratory flow rate (PEFR), and indoor air pollutants four times per year for each participant between 2008 and 2018. Moreover, a questionnaire related to essential oil usage, home characteristics, and health status was filled out with each participant. The association between essential oil usage and cardiopulmonary health was determined using mixed-effects models. The mixed-effects models showed a significant association between essential oil usage and adverse cardiopulmonary effects including increased HR and BP and decreased % predicted PEFR among participants with heavy use of essential oils. No significant association between essential oils usage and adverse cardiopulmonary effects was observed among participants without essential oils usage or participants with mild use of essential oils (less than one hour per day). We concluded that exposure to indoor air pollution related to essential oils was associated with adverse cardiopulmonary effects among participants with essential oil usage more than one hour per day.
Sport-specific adaptations of athlete's hearts are still under investigation. This study sought to 1) identify athlete groups with similar characteristics by clustering echocardiographic data; 2) ...externally validate the data-driven clusters with sport classifications of various dynamic or static loads to support the conventional hypothesis-driven approach in delineating the athlete's heart.
Anthropometric, echocardiographic and electrocardiographic assessments were collected during the 2017 Summer Universiade in Taiwan. Besides standard echocardiography and strain measurements, ventricular-arterial coupling (VAC) was assessed by the ratio of effective arterial elastance (Ea) to left ventricular end-systolic elastance (Ees) as calculated by a modified single-beat algorithm.
We grouped 598 elite athletes (348 male, age 23 ± 2.5 years, across 24 disciplines) using Mitchell's classification. The hypothesis-driven analysis showed dynamic training-related adaptations in heart rate and morphology, including ventricular size, mass, and stroke volume. In comparison, the unsupervised approach found two clusters for each sex. Male athletes participating in high dynamic-load exercises had larger chambers, supranormal diastolic functions, depressed Ees, lower Ea and preserved optimal VAC implicating the resting status of a reservoir-rich pump, which affirmed sport-specific adaptation. The female athletes could be clustered with more noticeable functional alterations, such as depressed biventricular strain. However, the imbalanced number between clusters impeded the validation of load-related remodeling.
Hierarchical clustering could analyze complicated multiparametric interactions among numerous echocardiography-derived phenotypes to discern the adaptive propensity of the athlete's heart. The endorsement or generation of hypotheses by a data-driven approach can be applied to various domains.
Diabetes and chronic kidney disease (CKD) are a high-stakes combination for cardiovascular disease. Patients with decreased kidney function and end-stage renal disease (ESRD) have increased risk of ...hypoglycemia when attaining better glycemic control, leading to higher risk of myocardial infarction (MI). For these patients, which kinds of anti-hyperglycemic agents would be associated with higher risk of MI is not clear.
We identified patients from a nation-wide database called Registry for Catastrophic Illness, which encompassed almost 100% of the patients receiving dialysis therapy in Taiwan from 1995 to 2008. Patients with diabetes and ESRD were selected as the study cohort. Propensity score adjustment and Cox's proportional hazards regression model were used to estimate the hazard ratios (HRs) for new-onset MI.
Among 15,161 patients, 39% received insulin, 40% received sulfonylureas, 18% received meglitinides and 3% received thiazolidinedione (TZD). After a median follow-up of 1,357 days, the incidence of MI was significant increase in patients taking sulfonylureas (HR = 1.523, 95% confidence interval CI = 1.331-1.744), meglitinides (HR = 1.251, 95% CI = 1.048-1.494) and TZD (HR = 1.515, 95% CI = 1.071-2.145) by using patients receiving insulin therapy as the reference group. The risk of MI remains higher in other three groups in subgroup analyses.
In conclusion, among diabetic patients with ESRD undergoing dialysis, the use of sulfonylureas, meglitinides and TZD are associated with higher risk of new-onset MI as compared with insulin.
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