Sarawut Siwamogsatham

Purpose: Hemodialysis (HD) patients have increased cardiovascular risk. Coronary artery disease (CAD) may not typically manifest in these patients, and the investigational results can be confounded by the fluctuation of body fluid and electrolytes. This study explored the accuracy of these findings in identifying CAD in HD patients. Methods: Medical record data of all HD patients undergoing coronary angiography (CAG) at a tertiary hospital between January 2017 and March 2021 were retrospectively reviewed as a discovery cohort to identify factors discriminating patients with and without significant CAG‐established CAD. HD patients receiving CAG between April 2021 and March 2023 were assigned as a validation cohort. Results: The discovery and validation cohorts included 108 and 41 patients, respectively. Chest pain out of the dialysis session, but not pulmonary congestion/edema nor other intradialytic events, was associated with significant CAD (odds ratio 3.281, 95% CI 1.313–8.200). The presence of regional wall motion abnormality (RWMA) from echocardiogram, but not other echocardiographic and electrocardiographic findings, significantly predicted significant CAD (odds ratio 2.579, 95% CI 1.052–6.324). Initial high‐sensitivity troponin T > 111 ng/L and percent of troponin change > 22% had area under the ROC curve of 0.71 (95% CI 0.52–0.89) and 0.67 (95% CI 0.50–0.85), respectively, for predicting CAD. Applying a combination of these predictors resulted in a specificity of 100%, but low sensitivity for CAD in the validation cohort. Conclusion: Most intradialytic symptoms possibly result from noncardiac etiologies, while chest pain out of the HD session should alarm the physicians for further management. Applying the suggested cardiac enzyme cut points or the presence of RWMA could prioritize at‐risk patients for timed cardiologist referral.

Objectives: To assess the association of the Cardio‐Ankle Vascular Index (CAVI) and ankle‐brachial index (ABI) with all‐cause mortality and major adverse cardiovascular events (MACE) in older people with HIV receiving long‐term antiretroviral therapy (ART) in Thailand. Methods: We conducted a prospective cohort study of 307 virologically suppressed participants aged ≥50 years who underwent baseline CAVI and ABI measurements. ABI was analysed both as a continuous variable and as a categorical variable using a cut‐off p = 0.004) but did not reach statistical significance for the composite outcome (aHR 1.64, 95% CI: 0.89–3.01, p = 0.112). However, when modelled as a continuous variable, each unit increase in CAVI was associated with an increased risk of composite outcome (aHR 1.29, 95% CI: 1.08–1.54, p = 0.004). Ever smoking, hypertension and elevated IL‐6 were significantly associated with increased risk of mortality and MACE. ABI < 0.9 was strongly associated with mortality (aHR 4.20, 95% CI: 1.43–12.27). Conclusions: In older people with HIV on long‐term ART, traditional cardiovascular risk, systemic inflammation (IL‐6) and low ABI (<0.9) were stronger predictors of mortality and MACE. CAVI demonstrated prognostic value for mortality and the composite outcome, suggesting a potential complementary role in cardiovascular risk assessment. Clinical trial registration: HIVNAT 006 (NCT00411983).

Background: There are limited data on the performance of bleeding risk scores in predicting postoperative bleeding in anticoagulated patients undergoing elective non-cardiac surgery. Objectives: To evaluate the predictive accuracy of the HAS-BLED and BleedMAP scores for postoperative bleeding risk in this population. Methods: This retrospective study enrolled anticoagulated patients undergoing elective surgery referred to the Preoperative Medical Consultation clinic. The C-statistic was used to evaluate the discriminatory performance of the HAS-BLED and BleedMAP scores in predicting overall bleeding following non-cardiac surgery. The predictive performance of the two scores was compared using DeLong's method. Results: Among 591 patients who had previously received anticoagulation therapy, 84.9% received warfarin, 9.5% enoxaparin, and 5.6% direct oral anticoagulants. Indications included atrial fibrillation (67.9%), venous thromboembolism (18.1%), and mechanical valve replacement (13.5%). Procedures were classified as minor (16.6%), low to moderate risk (46.4%), or high bleeding risk (37.1%). The mean HAS-BLED and BleedMAP scores were 2.35 ± 1.36 and 0.94 ± 0.81, respectively. At 1-month postoperative follow-up, the overall bleeding rate was 40.4%, with 2.5% classified as major bleeding events. The HAS-BLED score had a C-statistic of 0.512 (95% confidence intervals (CI): 0.434–0.591) for predicting overall bleeding, while the BleedMAP score showed moderate predictive ability (C-statistic: 0.581; 95% CI: 0.531-0.631). The two scores had no statistically significant difference ( P = .13). Conclusions: The HAS-BLED score showed limited discriminatory ability for postoperative bleeding in anticoagulated patients, though its negative predictive value was high. No significant difference in predictive performance was observed between the HAS-BLED and BleedMAP scores.

Intrinsic factors such as age and ethnicity influence statin pharmacokinetics (PK) and may increase the risk of muscle‐related adverse events. This study investigated the effect of age on the PK of simvastatin (SV) and its active metabolite, simvastatin acid (SVA), in healthy Thai subjects using an LC–MS/MS assay while accounting for key SLCO1B1 variants known to affect statin exposure. We further compared our results with published data across multiple ethnic populations via meta‐analysis and conducted an exploratory pharmacogenetic analysis of SVA disposition‐related genes to identify potential candidate variants contributing to PK differences observed between Thai and Caucasian populations. The pharmacokinetic results showed that aging significantly increased SV C _max but did not alter SVA exposure, while SLCO1B1 decreased and poor functions were associated with higher SVA exposure. The meta‐analysis revealed that Thai subjects showed significantly higher SVA levels than Caucasians, Chinese, and Japanese. The pharmacogenetic analysis identified functional or promoter variants in SLCO1B1 and PON genes with allele frequency differences directionally consistent with the observed PK differences between Thais and Caucasians. Our results may partly explain the higher incidence of SV‐associated rhabdomyolysis previously reported in Thais compared with Caucasians and highlight the relevance of these intrinsic factors in SV and SVA PK, with implications for dosing considerations in Thai patients. Additional studies are warranted to further support the involvement of these polymorphic variants in the observed interethnic differences in SVA PK and adverse outcomes.

BACKGROUND: There has been incongruent evidence on the outcomes relating to whether continuing or withholding renin-angiotensin-aldosterone system inhibitors (RAASi) preoperatively. This study aimed to systematically analyze the effect of preoperative RAASi on perioperative and postoperative outcomes in patients undergoing noncardiac surgeries. METHODS: PubMed, Scopus, ScienceDirect, and Cochrane databases were used with no limitation of the starting date, till 30th September 2024. The revised Cochrane risk-of-bias tool (RoB-2) and the Newcastle-Ottawa Scale were used for quality assessment. The primary study outcomes were hemodynamic outcomes while the secondary outcomes included postoperative 30-day mortality, myocardial infarction (MI), stroke and postoperative atrial fibrillation (POAF). RESULTS: Among 1897 articles, 6 eligible randomized control trials and 6 observational studies were enrolled. The patients preoperatively continuing RAASi had a higher risk of intraoperative hypotension [OR (odds ratio) = 1.54; 95% CI (confidence interval) = 1.31, 1.82], along with lower systolic and diastolic blood pressures compared to those withholding RAASi. Postoperative complications including 30-day mortality, MI, stroke, atrial fibrillation, acute kidney injury, septicemia, myocardial injury, postoperative hypertension and unplanned ICU admission, showed no significant differences. However, there was a marginal significance in lower POAF in the RAASi-continuing group (OR = 0.73, 95% CI = 0.52, 1.02). CONCLUSIONS: Withholding RAASi prior to noncardiac operation significantly reduced the risk of intraoperative hypotension but may increase the chance to develop POAF without significant impact on 30-day mortality and other postoperative complications. Discontinuation of RAASi before noncardiac surgery is recommended unless obligate indication.

Since 1987, King Chulalongkorn Memorial Hospital (KCMH) has performed a substantial number of heart transplants as a specific therapy for advanced‐stage heart failure. This descriptive study aimed to analyze post‐transplant survival in the recent era compared to earlier periods and examine the pharmacogenetics of related immunosuppressants. Data from all recipients who underwent heart transplants from 1987 to 2021 were retrospectively retrieved from the electronic medical record. The genotypes of relevant pharmacogenes were analyzed in recipients who were alive during the enrollment period. Kaplan–Meier analysis revealed improved overall survival rates in the recent era compared to the past. Dilated cardiomyopathy was identified as the most common pretransplant diagnosis, while infection remained the leading cause of mortality. In conclusion, the findings demonstrate significant advancements in the quality of heart transplantation in Thailand. Future studies are warranted to explore the correlation between pharmacogenetic variations identified in this study and subsequent clinical outcomes, with a focus on genetic‐guided treatment to optimize patient care.

Background: Evidence of decline in native renal function after heart transplantation (HTx) in the Asian population is limited. This study determined the incidence and risk factors associated with declining kidney function after HTx and its impact on survival.Methods: A retrospective study of consecutive adult heart transplant patients was conducted in a single center between 2010 and 2020. The decline in kidney function was defined as the presence of one of the following criteria, including a ≥ 40% decline in eGFR, absolute value 2 (calculated by the CKD‐EPI method), doubling of serum creatinine, or dialysis.Results: A total of 79 patients (77% male, mean age 44.5 ± 11.53 years, with a mean eGFR at discharge from the heart transplant admission of 87.9 ± 25.48 mL/min/1.73 m²) were included. During the median follow‐up of 42 months, the rate of decline in eGFR was 3.9 mL/min/1.73 m² per year, with a cumulative probability of decline in kidney function of 22% at 1 year and 43% at 5 years. The need for dialysis was 2.5% at 1 year and 5% at 5 years. The decline in kidney function within 1 year after discharge (hazard ratio (HR), 22.24; p = .007) and pre‐HTx diabetes mellitus (DM) (HR, 8.99; p = .034) were independently associated with the need for dialysis. Post‐HTx dialysis predicted all‐cause mortality (HR, 4.47; p = .017).Conclusions: Approximately 20% of HTx patients developed a decline in kidney function within 1 year after discharge. These individuals and pre‐HTx DM patients needed preventive measures to prevent progression to chronic dialysis, which impacted survival. (thaiclinicaltrials.org number, TCTR20230620004).

Objectives Curcumin has been claimed to have gastrointestinal benefits, including dyspepsia, a common disorder that could be managed in a primary care setting with behavioral and dietary modifications as well as over-the-counter medications. This study aimed to compare the efficacy of curcumin versus omeprazole in improving patient-reported outcomes. Design Patients with functional dyspepsia were randomized to curcumin alone (C), omeprazole alone (O), or curcumin plus omeprazole (C+O). Patients in the combination group received 2 capsules of 250 mg curcumin 4 times daily and 1 capsule of 20 mg omeprazole once daily for 28 days. The primary outcomes were functional dyspepsia symptoms on days 28 and 56 assessed using the Severity of Dyspepsia Assessment (SODA) scores. Secondary outcomes were the occurrence of adverse events (AEs) and serious adverse events (SAEs). Results A total of 206 enrolled patients were randomly assigned to the three groups, of which 151 completed the study. Demographic data (age 49.7±11.9 years; female 73.4%), clinical characteristics, and baseline dyspepsia scores were comparable between the three groups. SODA scores in each group showed significant improvement on day 28 and day 56 in the pain, non-pain, and satisfaction categories. No significant differences were observed among the three groups and no serious adverse events occurred. Conclusion Curcumin and omeprazole have comparable efficacy for functional dyspepsia with no obvious synergistic effect. What is already known Dyspepsia is one of the most common disorders in which patients usually try behavioral and diet modifications, and over-the-counter drugs before seeing a physician. Proton pump inhibitors have been established as an effective treatment for functional dyspepsia. Curcumin, an active ingredient in turmeric, is currently used for the treatment of dyspepsia in countries in Southeast Asia. However, there is no clinical trial evidence to support the use of curcumin as a first-line treatment. What this study adds Based on this double-blind, placebo-controlled clinical trial, oral curcumin is safe and well tolerated. Patients with functional dyspepsia were treated with curcumin, curcumin plus omeprazole, and omeprazole, which showed a similar significant symptomatic improvement. There was no synergistic effect detected between omeprazole and curcumin. How this study might affect research, practice, or policy This study provides a possible additional drug option for patients with functional dyspepsia. More clinical trials are required to assess long-term outcomes and adverse events.

Background Effective COVID-19 mRNA vaccines are mainly available in high-income countries. ChulaCov19, a prefusion non-stabilized Spike protein-encoding, nucleoside-modified mRNA, lipid nanoparticle encapsulated vaccine development, aims to enhance accessibility of mRNA vaccine and future pandemic preparedness for low- to middle-income countries. Methods Seventy-two eligible volunteers, 36 aged 18-55 (adults) followed by 36 aged 56-75 (elderly) enrolled in a dose escalation study of ChulaCov19 mRNA vaccine. Two doses of vaccine were given 21 days apart at 10, 25, or 50 µg/dose (12/group). Safety was the primary and immunogenicity the secondary outcome. Human convalescents’ (HCS) and Pfizer/BioNTech vaccinees’ sera provided comparison panels. Results All three doses of ChulaCov19 were well tolerated and elicited robust dose-dependent and age- dependent B- and T-cell responses. Transient mild/moderate injection site pain, fever, chills, fatigue, and headache were more common after the second dose. Four weeks after the second ChulaCov19: dose at 10, 25, and 50 µg dose, MicroVNT-50 Geometric mean titer (GMT) against wild-type was 848, 736 and 1,140 IU/mL, respectively, versus 267 IU/mL for HCS. All dose levels elicited 100% seroconversion, with GMT ratio 4-8-fold higher than for HCS (pConclusions ChulaCov19 at 50 µg/dose is well tolerated and elicited higher neutralizing antibodies than HCS with strong T-cell responses. These antibodies cross neutralized four variants of concern and ChulaCov19 has therefore proceeded to phase 2 and 3 clinical trials. Trial registration number ClinicalTrials.gov Identifier NCT04566276