mild renal dysfunction (estimated glomerular filtration rate [eGFR] > 60 ml/minute/1.73 m 2 , n = 809 [44.5%]), moderate renal dysfunction (eGFR 30-60 ml/minute/1.73 m 2 , n = 706 [38.9%]), and severe renal dysfunction (eGFR < 30 ml/minute/1.73 m 2 , n = 301 [16.6%]). Results: Of the 1,816 patients with mean follow-up 10.8 months, the mean age was 65 years, and 59.2 percent of the groups were male. Patients with severe renal dysfunction were significantly older, less likely to be male (45.2%, p < 0.001) and had a greater prevalence of diabetes (63.1%, p < 0.001) and hypertension (85.4%, p < 0.001). In-hospital and 1-year mortality were 13.5% and 22.5% respectively. According to discharge diagnosis, unadjusted hazard ratios for overall in-hospital mortality was statistically significant only in ST elevation MI subgroup, hazard ratio was 2.73 (95% CI, 1.72 to 4.34) and 6.27 (95% CI, 3.78 to 10.4) for moderate and severe renal dysfunction group, respectively. The risk of death for all types of ACS at 1-year follow up increased when eGFR decreased below 60 ml/minute/1.73 m 2 , the adjusted hazard ratio was 1.66 (95% CI,1.22 to 2.23) and 1.91 (95% CI,1.34 to 2.72) for moderate and severe renal dysfunction group, respectively. Conclusion: From Thai ACS registry, renal dysfunction at presentation is an independent predictor for the overall 1- year mortality and appeared to associate with an increase in hospital mortality in the subsets with STEMI.
Background Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions. Methods and Results In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS 2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms ( P =0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P <0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P <0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677). Conclusions In a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival. Clinical Trial Registration URL : https://www.clinicaltrials.gov/ . Unique identifier: NCT 00403767.
High levels of low density lipoprotein (LDL) cholesterol is a known major factor in atherosclerosis. In addition to LDL-cholesterol, an increase in the triglycerides-rich lipoprotein and a decrease in HDL-cholesterol increase the risk of coronary artery disease. Fenofibrate, a fibric acid derivative, is highly effective in reducing serum triglycerides and LDL-cholesterol and produces a modest increase in HDL-cholesterol. The present study was done to evaluate the efficacy of fenofibrate at 300 mg daily on serum lipid profiles and to study the drug safety and tolerability of fenofibrate in Thai patients.Forty patients with elevated serum total cholesterol, LDL cholesterol were recruited for 12 weeks of 300 mg per day of fenofibrate therapy. Blood analysis for lipid profiles, liver function test, creatinine and muscle enzyme were done at the begining and end of the study.The mean baseline total cholesterol, LDL-cholesterol, triglycerides and HDL-cholesterol were 249 mg/dl, 160 mg/dl, 325 mg/dl and 43 mg/dl respectively. Significant changes of all lipid parameters from baseline were observed after 12 weeks of treatment. Reduction of serum total cholesterol, LDL-cholesterol and triglycerides were 16, 23, and 41 percent respectively. Increased serum HDL-cholesterol of 14 percent was also observed. One patient withdrew from the trial due to chest pain. Two asymptomatic elevated transaminase were detected during the study.Fenofibrate at 300 mg per day is effective and safe in treating Thai patients with dyslipidemia.
OBJECTIVE To assess the efficacy and safety of transradial approach compared with transfemoral approach for coronary angiography and ad hoc angioplasty in Phramongkutklao hospital at the time of initiation of transradial program. MATERIAL AND METHOD Prospective data collection of consecutive patients who underwent coronary angiography with ad hoc angioplasty during October 2004 to January 2005 was conducted. Baseline demographic data and the details of the procedure were recorded. The complications were assessed by a single doctor using standard protocol. RESULTS There were 75 included in our study. Transradial approach and transfemoral approach was performed in 23 cases (30.7%) and 52 cases (69.3%), respectively. The baseline characteristics, procedure results were similar except the there was higher prevalence of NST-ACS symptoms (92.31% vs. 65.22%, p = 0.004) and access site complications in transfemoral group (23.08% vs. 4.35%, p = 0.035). The success rate was very high (> 90%) and not significantly different in both groups. However the transradial group was associated with lower assess site complications earlier ambulation and better patient's satisfaction. CONCLUSION Even at the time of initiation of transradial program, transradial approach for coronary angiography and ad hoc angioplasty can be performed with similar efficacy, less local complication, earlier ambulation and better patient's satisfaction compared to the standard transfemoral approach.
To evaluate the efficacy and safety of atorvastatin at the starting doses of 10, 20, 40 mg and evaluate the effectiveness of 1 step titrate up regimen.Two hundred and forty two subjects with dyslipidemia were enrolled and assigned the appropriate dose in relation to their individual cardiovascular risk status and baseline LDL-C levels. If the NCEP targets were not achieved, the doses were titrated up at week 4 and the primary efficacy was evaluated at week 8.A majority of subjects (88.8%) achieved their LDL-C goals at week 8. Almost all of the subject's LDL-C levels reached their goals by week 2 and 4 (81.6% and 87.1%, respectively). Only 10.7% (n = 25) required the sole titration. Each dose provided significant decreases in LDL-C (average -46.4%). Only 36 subjects experienced treatment related adverse events, the majority of these were in the high-risk group (n = 22) with only one subject registering a serious adverse event.Atorvastatin is effective and safe for Thai patients with dyslipidemia. The appropriate starting dose has contributed in the achievement of cholesterol reduction.
Objective: To compare the outcome after immediate thrombolytic therapy in the emergency department versus primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) in Phramongkutklao Hospital. Methods: We prospectively enrolled 24 hemodynamically stable acute STEMI patients presenting within 12 hours of the clinical onset. All of them were treated with standard medical regimen, and then randomly assigned to undergo primary PCI or to receive intravenous thrombolytic therapy with tenecteplase tissue type plasminogen activator (TNK-tPA) in the emergency department followed by standard care. Coronary angiography was performed within 1 week after thrombolysis in all patients. The primary endpoint was a composite of outcomes of death, recurrent myocardial infarction (MI) and stroke at 30 days. The secondary endpoints were recurrent ischemia, heart failure, cardiogenic shock, arrhythmia, repeat revascularization (rescue PCI, further PCI), coronary artery bypass graft (CABG), usage of intra-aortic balloon pump (IABP), mechanical ventilator support, major bleeding, cost and length of stay at 30 days. Results: Twenty-four patients with acute STEMI were enrolled. The median time interval from symptom onset to random assignment was 2.1 hours in the TNK-tPA group and 2.5 hours in the PCI group. The median time to needle and time to balloon inflation were 116 minutes and 122 minutes respectively, (p = 0.90). The primary end-point was only one patient in the PCI group had re-infarction and hemorrhagic stroke. However, half of the patients in the thrombolytic group still required further PCI. The cost was 248,714 ± 266,854 baht in the PCI group and 191,960 ± 110,029 baht in theTNKtPA group (p = 0.95). The duration of hospital stay was 10.6 ± 14 days in the PCI group and 6 ± 3 days in theTNK-tPA group (p = 0.88). Conclusion: This pilot study shows that the immediate TNK-tPA intravenous therapy in the emergency department for treating patients with acute uncomplicated STEMI appears to be safe and may be a worthy alternative treatment in selected patients. Thai Heart J 2009; 22 : 69-78 E-Journal : http://www.thaiheartjournal.org Introduction Acute ST-segment elevation myocardial infarction (STEMI) is a serious medical condition, affecting people Corresponding author: Nakorn Sithinamsuwan, MD Division of Cardiology, Department of Medicine, Phramongkutklao Hospital. 315 Rajvithi road, Phrayathai district, Rachatavee, Bangkok, Thailand 10400. E mail address: Nink_MD@hotmail.com worldwide (1). It has been recognized that there are approximately 500,000 patients suffering annually in the United States from this condition (1). In Thailand, around 1,000 patients per year were diagnosed with STEMI (2). Additionally, our medical institute has had about 50 newly diagnosed STEMI patients per annum. It is widely accepted that STEMI is not only a common medical problem, but also a fatal condition. It occurs because of a clot-occluded coronary artery through multiple pathogeneses. Hence, cardiac muscle ischemia and then THAI HEART JOURNAL Vol. 22 No.3 July 2009 THAI HEART JOURNAL Vol. 22 No.3 July 2009 Nakorn Sithinamsuwan, MD infarction occur. The STEMI mortality in the GRACE registry and Thailand were 7% and 17% respectively (2). Prompt and complete restoration of coronary flow is the principal mechanism that improves survival and other clinical outcomes in patients with acute STEMI (1). Nevertheless, reperfusion therapy for STEMI is different among hospitals. At selected centers, coronary angioplasty, especially primary percutaneous coronary intervention (PCI), can be performed expeditiously in such patients, resulting in better coronary blood flow and 30-day survival rates than patients who received intravenous thrombolytic therapy (3-14). In general, the problem is that a PCI facility is available in only certain medical centers, so that physicians need to choose other available treatments. Another standard strategy to combat acute STEMI is intravenous thrombolytic therapy. It has many favorable properties such as high efficacy, widespread availability and reduces mortality in some reports (16). Therefore, this strategy has been used in more than a million patients over the past decade (1). Tenecteplase tissue type plasminogen activator (TNK-tPA) is a thrombolytic agent, which has been recently used. It is a variant of the native tissue type plasminogen activator (tPA) molecule that has a 16-fold greater fibrin specificity than alteplase, a longer half-life, slower plasma clearance, and 80-fold greater resistance to inhibition by plasminogen activator inhibitor type 1 (15-18). Its half-life of 18 minutes allows a singlebolus administration. Moreover, in comparative clinical trials, tenecteplase was found to have equivalent efficacy to recombinant tPA (alteplase) (17-18). The rate of intracranial hemorrhage with tenecteplase was similar to that with alteplase, and tenecteplase was associated with fewer non-cerebral complications and less need for blood transfusions (17). Furthermore in the Thai Acute Coronary Syndrome (ACS) Registry (2), the average door-to-balloon time in the Primary PCI group were more than 120 minutes, so thrombolytic therapy may have a role in treating the STEMI patients. The use of TNK-tPA in the Emergency Department may further reduce the differences in outcome between thrombolysis and coronary intervention. Therefore, the aim of this study was to compare the outcome after immediate thrombolytic therapy in the emergency department versus primary PCI in patients with acute STEMI in Phramongkutklao Hospital. Methods Study design This study was a prospective randomized trial, performed at Phramongkutklao Hospital from June 1st to December 31st, 2007. Eligible patients Patients presenting within 12 hours after the onset of acute myocardial infarction, who had chest pain lasting at least 20 minutes, accompanied by electrocardiographic (ECG) with ST-segment elevation of at least 0.1 mV in two or more contiguous leads or new left bundle branch block or posterior wall myocardial infarction (MI) (STsegment depression at least 0.1 mV with tall R wave in lead V1-2), were eligible for enrollment. The exclusion criteria Figure 1. Stratified randomization flow chart
Rilmenidine is an antihypertensive agent that selectively binds to imidazoline I1 receptor located in the brainstem and kidney. It acts both centrally by reducing sympathetic overactivity and in the kidney by decreasing water and sodium overload. This dual action leads to the immediate and delayed control of blood pressure caused by this drug.The aim of this study was to assess the efficacy and safety of rilmenidine as monotherapy in mild-to-moderate essential hypertensive patients.An 8-week, open-labeled, multicenter study was conducted in Thai patients with mild-to-moderate essential hypertension. Rilmenidine 1 mg/day was given for 8 weeks. The dose could be titrated up to 2 mg/day according to the patient's blood pressure response at week 4. The primary efficacy parameters were the mean reductions in systolic and diastolic blood pressure. The proportions of patients whose blood pressure normalized or responded were evaluated as secondary efficacy parameters. Safety parameters were assessed by the changes in heart rate and reported side effects during the treatment period.103 subjects (44.7% men) with a mean age of 53 +/- 9.7 years completed the 8-week follow-up. At baseline, 46.6 per cent and 53.4 per cent of the patients were classified with mild and moderate hypertension, respectively. The mean blood pressure was 154/93 mmHg. After the 8-week treatment, there was a significant decrease in blood pressure to 140/86 mmHg (p < 0.001), with mean pressure reduction of 14/7.5 mmHg. The normalization rate was 44 per cent and the response rate was 68 per cent. No significant changes were found for mean heart rate and any laboratory parameters tested. Only 17 patients reported mild and transient side effects such as drowsiness and dryness of the mouth and throat, which required no treatment.This study has shown that rilmenidine is an effective and well tolerated monotherapy in Thai patients with mild-to-moderate essential hypertension.
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