I-Chang Hsieh

Background: Angina, the primary symptom reported by patients with coronary artery disease (CAD), is an essential consideration in CAD treatment strategies and evaluations of treatment efficacy. However, research exploring the relationship between angina symptom characteristics (severity, type, and frequency) and obstructive CAD is scarce. Purpose: This study was designed to investigate the association between obstructive CAD and angina symptom severity, type, and frequency. Methods: A cross-sectional approach was used to analyze baseline data from two studies conducted from March 2018 to September 2021 at a medical center in northern Taiwan. The sample comprised 723 patients undergoing invasive coronary angiography for suspected or known CAD. The participants were categorized into obstructive (≥50% stenosis in at least one epicardial artery) and control groups. Angina symptom severity, type, and frequency were assessed using the Angina Evaluation Form. Results: The average age of the participants was 60.1 years, and most (83.7%) were male. Nearly three-quarters (73.1%) had Class 1 or 2 angina, 60.3% reported experiencing typical angina, and 46% had angina episodes at least once per week. The results of multiple logistic regression analysis found older age, male sex, history of diabetes, currently smoking, higher low-density lipoprotein levels, lower estimated glomerular filtration rate, and typical angina to be associated with a higher risk of obstructive CAD. Risk of obstructive CAD was twice as high in participants experiencing typical angina symptoms than those experiencing atypical angina symptoms (OR=1.97, 95% CI=[1.09, 3.54], p=.025). Subgroup analysis findings identified associations to be higher in younger (OR=2.22, 95% CI=[1.23, 3.99], p=.008) and male (OR=1.83, 95% CI=[1.08, 3.09], p=.024) participants. Also, the risk of obstructive CAD was higher for those experiencing angina episodes less than twice per week, only in the subgroup of older individuals. No significant relationship between angina symptom severity and risk of obstructive CAD was found. Conclusions/Implications for Practice: Angina type, rather than severity or frequency, is significantly associated with obstructive CAD. The findings of this study emphasize the importance of conducting comprehensive angina symptom evaluation in risk assessments on patients with suspected or known CAD. Furthermore, large-scale prospective studies should be conducted in different population groups and settings to validate angina symptoms as a predictor of obstructive CAD.

Background: Invasive coronary angiography is the gold standard for assessing in-stent restenosis (ISR) in patients with coronary artery disease. However, the predictive value of non-invasive Tissue Doppler Imaging (TDI) to evaluate patients with ISR has not been studied extensively. Methods: A total of 41 patients (19 with acute myocardial infarction and 22 with stable angina pectoris) who received percutaneous coronary intervention (PCI) were enrolled in the study. Time-to-peak velocities (TpV) of 12 non-apical segments of the left ventricle, by pulse wave TDI echocardiography, were obtained within two days prior to the PCI and six months later. Results: A 12-segmental mean TpV ≥ 279.6 ms at six months after PCI was able to detect ISR (odds ratio: 2.09, 95% CI 1.004–4.352, p = 0.049). Moreover, a significant decrease in the standard deviation of TpV was demonstrated in patients without ISR (85.8 ± 44.8 vs. 60.3 ± 31.7 ms, p = 0.001), but not in patients with ISR (97.7 ± 53.3 vs. 91.2 ± 52.6 ms, p = 0.57). Conclusions: Pulse-wave TDI echocardiography is a promising tool in the detection of ISR six months after PCI in patients with coronary artery disease.

Beta-blockers are widely used, but the benefit is now challenged in patients at risk of atherosclerotic cardiovascular disease (ASCVD) in the present coronary reperfusion era. We aimed to identify the risk factors of a major adverse cardiac event (MACE) and the long-term effect of beta-blockers in two large cohorts in Taiwan. Two prospective observational cohorts, including patients with known atherosclerosis cardiovascular disease (T-SPARCLE) and patients with at least one risk factor of ASCVD but without clinically evident ASCVD (T-PPARCLE), were conducted in Taiwan. The primary endpoint is the time of first occurrence of a MACE (cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, and cardiac arrest with resuscitation). Between December 2009 and November 2014, with a median 2.4 years follow-up, 11,747 eligible patients (6921 and 4826 in T-SPARCLE and T-PPARCLE, respectively) were enrolled. Among them, 273 patients (2.3%) met the primary endpoint. With multivariate Cox PH model analysis, usage of beta-blocker was lower in patients with MACE (42.9% vs. 52.4%, p < 0.01). In patients with ASCVD, beta-blocker usage was associated with lower MACEs (hazard ratio 0.72; p < 0.001), but not in patients without ASCVD. The event-free survival of beta-blocker users remained higher during the follow-up period (p < 0.005) of ASCVD patients. In conclusion, in ASCVD patients, reduced MACE was associated with beta-blocker usage, and the effect was maintained during a six-year follow-up. Prescribing beta-blockers as secondary prevention is reasonable in the Taiwanese population.

In critically ill patients, risk scores are used; however, they do not provide information for nutritional intervention. This study combined the levels of phenylalanine and leucine amino acids (PLA) to improve 30-day mortality prediction in intensive care unit (ICU) patients and to see whether PLA could help interpret the nutritional phases of critical illness. We recruited 676 patients with APACHE II scores ≥ 15 or intubated due to respiratory failure in ICUs, including 537 and 139 patients in the initiation and validation (multicenter) cohorts, respectively. In the initiation cohort, phenylalanine ≥ 88.5 μM (indicating metabolic disturbance) and leucine < 68.9 μM (indicating malnutrition) were associated with higher mortality rate. Based on different levels of phenylalanine and leucine, we developed PLA scores. In different models of multivariable analyses, PLA scores predicted 30-day mortality independent of traditional risk scores (p < 0.001). PLA scores were then classified into low, intermediate, high, and very-high risk categories with observed mortality rates of 9.0%, 23.8%, 45.6%, and 81.8%, respectively. These findings were validated in the multicenter cohort. PLA scores predicted 30-day mortality better than APACHE II and NUTRIC scores and provide a basis for future studies to determine whether PLA-guided nutritional intervention improves the outcomes of patients in ICUs.

Acute myocardial infarction (AMI) complicated by cardiogenic shock has high mortality and remains challenging even in the revascularization era. We conducted this study to understand patients’ outcomes. We retrospectively analyzed electronic medical records data from 1175 patients with AMI complicated by cardiogenic shock that developed within 3 days of admission to a multicenter medical care system between January 1, 2000, and July 31, 2018. Patients with AMI were classified into the ST-segment elevation MI (STEMI) group or the non-ST-segment elevation MI (NSTEMI) group. The short-term and 1-year mortality and adverse events after index admission were analyzed via logistic regression and a Cox proportional hazards model. When compared with NSTEMI, patients with STEMI tended to be younger (65.68 ± 14.05 years vs 70.70 ± 12.99 years, P < .001), men (73.29% vs 60.87%, P < .001), and have fewer underlying chronic diseases. Short-term mortality at index hospitalization was 14.83% in the STEMI group and 21.30% in the NSTEMI group; long-term mortality was 17.06% for the STEMI group and 24.13% for the NSTEMI group. No difference was observed between the 2 groups for patients who developed a cerebral vascular accident during the admission period. However, the major and gastrointestinal bleeding rates were higher in the STEMI group (2.66% vs 0.22%, P = .014; 3.36% vs 0.22%, P = .007, respectively). Age and respiratory failure were the most significant risk factors for short-term mortality. Revascularization may be beneficial for the short-term outcome but did not reach significance in multivariable analysis. In patients with AMI with cardiogenic shock, NSTEMI was associated with a significantly higher mortality rate in short-term results.

Background: Coronary perfusion pressure (CPP) and coronary artery stenosis are responsible for myocardial perfusion. However, how CPP-related survival outcome affects revascularization is unclear.Objective: The aim of this study is to investigate the prognostic role of CPP in patients with left ventricular systolic dysfunction (LVSD) undergoing percutaneous coronary intervention (PCI) with complete revascularization (CR) or reasonable incomplete revascularization (RIR).Methods: We retrospectively screened 6,076 consecutive patients in a registry. The residual synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) score (rSS) was used to define CR (rSS = 0) and RIR (0 42 mmHg. Moreover, 101 pairs of RIR and CR were present in patients with CPP ≤ 42 mmHg. In patients with CPP > 42 mmHg, RIR was not significantly different from CR in long-term mortality [hazard ratio (HR) 1.20; 95% confidence interval (CI):0.70–2.07; p = 0.513]; However, in patients with CPP≤42 mmHg, RIR had a significantly higher mortality risk than CR (HR 2.39; 95% CI: 1.27–4.50; p = 0.007).Conclusions: The CPP had a risk stratification role in selecting different revascularization strategies in patients with LVSD. When patients with LVSD had CPP > 42 mmHg, RIR was equivalent to CR in survival. However, when patients with LVSD had CPP ≤ 42 mmHg, RIR had a significantly higher mortality risk than CR.

Coronary computed tomography angiography (CCTA) is a widely used imaging modality for diagnosing coronary artery disease (CAD) but is limited by a high false positive rate when evaluating coronary arteries with stents and heavy calcifications. Virtual intravascular endoscopy (VIE) images generated from CCTA can be used to qualitatively assess the vascular lumen and might be helpful for overcoming this challenge. In this study, one hundred subjects with coronary stents underwent both CCTA and invasive coronary angiography (ICA). A total of 902 vessel segments were analyzed using CCTA and VIE. The vessel segments were first analyzed on CCTA alone. Then, using VIE, the segments were classified qualitatively as either negative or positive for in-stent restenosis (ISR) or CAD. These results were compared, using ICA as the reference, to determine the added diagnostic value of VIE. Of the 902 analyzed vessel segments, CCTA/VIE had sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (shown in %) of 93.9/90.2, 96.2/98.2, 96.0/97.7, 70.0/83.1, and 99.4/99.0, respectively, in diagnosing ISR or CAD, with significantly improved specificity (p = 0.025), accuracy (p = 0.046), and positive predictive value (p = 0.047). VIE can be a helpful addition to CCTA when evaluating coronary arteries.

Coronary artery disease (CAD) is one of the leading causes of death in Taiwan. Despite the use of current guideline-recommended therapies for secondary prevention, the residual risk of recurrent cardiovascular events remains high in CAD, warranting the need for new treatment options. Antithrombotic drugs are one of the most important medical therapies for CAD. In this article, we review the unmet needs of the current antithrombotic agents and summarize the results of clinical trials with dual antiplatelet therapy in stable CAD. We also review data from a recent study demonstrating the benefits of a dual pathway inhibition strategy with antiplatelet and anticoagulant therapy, a new option for CAD treatment. Finally, we propose a treatment algorithm for choosing different antithrombotic regimens for CAD based on current scientific evidence and expert opinions.