Obstructive sleep apnea and its malajemente in patients with atrial fibrillation: An International Collaboration of Sleep Apnea Cardiovascular Trialists (INCOSACT) global survey of practicing cardiologists

Background: Among international cardiologists it is unclear whether equipoise exists regarding the benefit of diagnosing and managing obstructive sleep apnea (OSA) to improve atrial fibrillation (AF) outcomes and whether clinical practice and equipoise are linked. Methods: Between January 2019 and June 2020 we distributed a web-based 12-question survey regarding OSA and AF management to practicing cardiologists in 16 countries. Results: The United States, Japan, Sweden, and Turkey accounted for two-thirds of responses. 863 cardiologists responded; half were general cardiologists, a quarter electrophysiologists. Responses regarding treating OSA with CPAP to improve AF endpoints were mixed. 33% of respondents referred AF patients for OSA screening. OSA was diagnosed in 48% of referred patients and continuous positive airway pressure (CPAP) was prescribed for 59% of them. Nearly 70% of respondents believed randomized controlled trials (RCTs) of OSA treatment in AF patients were necessary and indicated willingness to contribute to such trials. Conclusions: There was no clinical equipoise among surveyed cardiologists; a majority expressed certainty that combined OSA and AF treatment is superior to AF treatment alone for improving AF outcomes. However, a minority of surveyed cardiologists referred AF patients for OSA testing, and while half of screened AF patients had OSA, CPAP was prescribed in little more than half of them, reflecting the view that better clinical trial evidence is needed to support this practice. Our results underscore the need for larger, multi-national prospective studies of OSA treatment and AF outcomes to inform more uniform society guideline recommendations

Impact of Ancestral Differences and Reassessment of the Classification of Previously Reported Pathogenic Variants in Patients With Brugada Syndrome in the Genomic Era: A SADS-TW BrS Registry

Brugada syndrome (BrS) is a heritable disease that results in sudden cardiac death. In the exome/genomic era, certain reported pathogenic variants in some genetic diseases have been reclassified as benign owing to their high frequency in some ancestries. In the present study, we comprehensively reassessed all previously reported pathogenic variants of BrS. We collected all pathogenic variants of BrS reported in the Human Gene Mutation Database and ClinVar throughout April 2017. We compared the minor allele frequency (MAF) of each variant among different ancestries by searching public whole-genome and exome databases. After considering the maximum credible allele frequency, variants with a MAF ≥ 0.001 were considered to be of questionable pathogenicity. We also investigated the percentage of SCN5A variants with a MAF ≥ 0.001 in 124 BrS patients from the Han Chinese population. We collected a total of 440 BrS variants, of which 18 had a MAF ≥ 0.001. There was a greater percentage of non-SCN5A variants with a MAF ≥ 0.001 than of SCN5A variants (21.8 versus 1.6%, p < 0.0001). There were fewer frameshift and nonsense mutations than missense mutations (0.9 versus 5.6%, p = 0.032). Of the 18 variants, 14 (77.8%) were present only in the reference Asian population. In our cohort, we identified two SCN5A variants (p.A226V and p.V1340I) with MAFs ≥ 0.001 (0.45%). In conclusion, ancestral differences are important when considering the pathogenicity of BrS variants, especially in the case of missense variants and non-SCN5A variants, which may be pathogenic in some ancestries but only disease-predisposing in others

經 食道超音波心圖應用時代的感染性心內膜炎診療

During a 45-month period, 50 consecutive patients with infective endocarditis were evaluated at the National Taiwan University Hospital with emphasis on the role of transesophageal echocardiography (TEE) in the management of these patients. Among them, rheumatic heart disease was still the most common underlying cardiac disorder (10/50, 20 %), while mitral valve prolapse (8/50, 16%) and congenital heart disease (8/50, 16%) were also frequently encountered. More than one third (19/50, 38%) had no underlying heart disease. Four intravenous drug abusers, quite rare previously in Taiwan, were found during the study period. Native valves involved were mostly mitral valve (n = 18), aortic valve (n = 15), and both mitral and aortic valves (n= 3). Tricuspid valve and pulmonic valve were involved in 3 and 2 patients, respectively. Streptococcus viridans was the leading microorganism isolated (21/50, 42%). Staphylococci and enterococci were found in 9 (18%) and 5 (10%) patients, respectively. Twelve patients (24%) were culture-negative in this series. Embolic complications occurred in 13 patients( 26%), with a total of 17 episodes. No significant correlation was found between the occurrence of embolization and the vegetation size or the location of the vegetation, if patients with right-sided valvular vegetation and no identifiable vegetation were excluded. Surgery was needed by 25 patients (50%), and mortality occurred in 6 (12%). TEE was superior to transthoracic echocardiography in the detection of vegetations at the mitral or prosthetic valves. Concerning the associated complications with infective endocarditis, TEE was also superior in estimating the severity of mitral regurgitation, recognizing ruptured chordae tendineae and detecting subaortic complications such as valve ring abscess and mitral valve perforation.( ABSTRACT TRUNCATED AT 250 WORDS)#A149313

Association of Circulating Matrix Metalloproteinase-1, but Not Adiponectin, with Advanced Coronary Artery Disease

Objective: Recent evidence Suggests that high tissue matrix metalloproteinase-1 (MMP-1) and low adiponectin may serve as biomarkers of atherosclerosis. Results on the associations of circulating MMP-1 and adiponectin concentrations are scarce. We hypothesized that patients with multivessel coronary artery disease (CAD) have elevated high-sensitivity C -reactive protein (hs-CRP), MMP-1 but low adiponectin levels, and concomitant measurements of these biomarkers Could improve predictive strength for advanced CAD. Research design and methods: We analyzed concentrations of MMP-1, hs -CRP and adiponectin in 217 subjects with angiographically documented multivessel CAD (two-, or three-vessel disease by luminal stenosis >= 50%) and 81 controls. MMP-1 and hs-CRP were notably higher in patients with CAD: while adiponectin was not significantly different between two groups. Levels of hs-CRP positively correlated with body mass index and left ventricular dysfunction (R-2 = 0. 16, P<0.0001): while adiponectin was significantly associated with age, gender,and levels of cholesterol and triglyceride (R-2 = 0.09, P < 0. 0001 ). On the contrary, MMP-1 was not associated with any clinical cardiovascular risk factors, and still an independent predictor(OR=1.49, P <0.0001) of multivessel CAD after the adjustment of clinical risk factors and hs-CRP. Conclusion: Elevated MMP-1 and hs-CRP, but not low adiponectin concentrations, could predict the presence of advanced coronary atherosclerosis. In addition, MMP-1 may serve as a more specific market for significant CAD independent of hs-CRP

Increased Matrix Metalloproteinase-1 Concentrations Are Associated with Advanced Coronary Artery Disease

Recent evidence Suggests that high tissue matrix metalloproteinase-1 (MMP -1) and low adiponectin may serve as biomarkers of atherosclerosis. Results on the associations of circulating MMP-1 and adiponectin concentrations are scarce. We hypothesized that patients with multivessel coronary artery disease (CAD) have elevated high-sensitivity C-reactive protein (hs-CRP), MMP-1 but low adiponectin levels, and concomitant measurements of these biomarkers Could improve predictive strength for advanced CAD. Research design and methods: We analyzed concentrations of MMP-1, hs -CRP and adiponectin in 217 subjects with angiographically documented multivessel CAD (two-, or three-vessel disease by luminal stenosis >= 50%) and 81 controls. MMP-1 and hs-CRP were notably higher in patients with CAD: while adiponectin was not significantly different between two groups. Levels of hs-CRP positively correlated with body mass index and left ventricular dysfunction (R-2 = 0.16, P<0.0001): while adiponectin was significantly associated with age,gender,and levels of cholesterol and triglyceride (R-2 = 0.09, P < 0. 0001). On the contrary, MMP-1 was not associated with any clinical cardiovascular risk factors, and still an independent predictor(OR=1.49, P<0.0001) of multivessel CAD after the adjustment of clinical risk factors and hs-CRP. Conclusion: Elevated MMP-1 and hs-CRP, but not low adiponectin concentrations, could predict the presence of advanced coronary atherosclerosis. In addition, MMP-1 may serve as a more specific market for significant CAD independent of hs-CRP

Correlation of the Flow Patterns among the Four Pulmonary Veins as Assessed by Transesophageal Echocardiography: Influence of Significant Mitral Regurgitation

Aims: To evaluate the correlation of the flow patterns of the four pulmonary veins as assessed by transesophageal echocardiography and the influence of significant mitral regurgitation on this correlation. Methods and Results: Eighty-eight patients with normal sinus rhythm and variable underlying cardiovascular diseases underwent transthoracic and transesophageal echocardiographic studies, Doppler flow of the four pulmonary veins could not be adequately interpreted in 19 patients (22%). The left atrial dimension of these patients was significantly larger than that of the patients with complete study of the flow in the four pulmonary veins (49 +/- 6 vs. 43 +/- 7 mm; p < 0.05). Of the 69 patients with complete evaluation of the four pulmonary veins, 48 patients without significant mitral regurgitation were analyzed as group A, and the remaining 21 patients as group B. The peak systolic and diastolic forward flow velocities of the four pulmonary veins were measured and the ratio of peak systolic (S) to diastolic (D) flow velocity was calculated. Group A had a significantly larger S/D ratio in all four pulmonary veins than group B (p < 0.05 in each pulmonary vein measurement). There was good correlation of the flow pattern represented as S/D ratio between left upper and lower pulmonary veins (r = 0.90) and between right upper and lower pulmonary veins (r = 0.89) in group A. The correlation of the flow pattern among the four pulmonary veins deteriorated in group B. Conclusion : Pulmonary veins on the same side share rather similar flow patterns in comparison with pulmonary veins on the opposite sides, The correlation of flow patterns among the four pulmonary veins is good in subjects without significant mitral regurgitation , but it worsens in patients with significant mitral regurgitation. Therefore, cautious interpretation of flow patterns of the four pulmonary veins in patients with significant regurgitation is indicated for grading the severity of mitral regurgitation

台灣之風濕性心臟病

風濕熱(rheumatic fever)是上呼吸道被A群B族溶血性鏈球菌感染後所引起的一種遲 發性及非化膿性的病變,包括心臟、關節、皮下組織及其它臟器,如腦、肺的發炎性疾 病[1-4]。臨床上主要有心臟炎(carditis)、多發性關炎(polyarthritis)、皮下小結 節( subcutaneous nodules)、輪廓狀紅斑(erythema marginatum)及小舞蹈病( chorea minor) 等表徵的各種組合,而且患者有近前時段A群b族溶血性鏈球菌感染的 證據[5-8]。此病的病理機轉至今仍不很清楚。風濕熱的典型急性病理學變化為心臟 、關節、皮膚結締組織的滲出性炎症變化,有基底物質的水腫及淋巴球和漿細胞的侵 潤等。心肌細胞及瓣膜組織的損傷在所難免,發生瓣膜閉鎖不全,臨床上出現心雜音, 關節紅腫熱痛,部分病患有心臟衰竭、心包膜積水、肺炎等現象。兩三週後,在心肌及 心內膜血管週圍即發生大且多核性細胞的增生、呈現風濕熱特殊病徵的Aschoff體。 這些病變多是自限性的,般多於三個月至六個月內消退;偶而也移型為所謂的慢性風濕 熱,纖維化及瘢痕等肉芽腫性病變繼之,導致瓣膜變形。若有風濕熱再發(recurrence) 心肌及心臟瓣膜的變化勢必再發,引起瓣膜再纖化、結疤、腱索縮短及黏合,甚至鈣化 ,因而造成瓣膜以及瓣膜下組織的功能不全,導玫閉鎖不全惡化或合併狹窄,甚至於產 生瓣膜狹窄,統稱為慢性風濕性心臟病(chronic rhcumatic heart disease)。最常侵 犯的瓣膜是僧帽瓣,其次為主動脈瓣,再其次為三尖瓣,而肺動脈瓣的侵犯甚為罕見;因 侵犯甚為罕見;因侵犯瓣膜的位置及嚴重程度的差異,會有不同的臨床表現。一部份病 人因急性期瓣膜侵犯嚴重,或因風濕熱復發,心臟逐漸肥大,加之心房纖維顫動(atrial fibrillation)出現,導致心臟衰竭,而在青年期(adoescent)前亡[9-13]。其餘病人( 約80～90%)雖會繼續存活,但有些病人則在慢性過程中出現嚴重血行力學變化( hemodynamic changes)及臨床症狀,需要接受瓣膜氣球擴張術(percutaneous balloon valvotomy)或外科手術。部份風濕性心臟病病人在慢性病程中又會發生全身性動脈 栓塞症(systemic arterial embolization)、感染性心內膜炎(infective endocarditis)或風濕熱及急性心臟炎的復發等。#A149313