Background Data comparing outcomes in heart failure ( HF ) across Asia are limited. We examined regional variation in mortality among patients with HF enrolled in the ASIAN ‐HF (Asian Sudden Cardiac Death in Heart Failure) registry with separate analyses for those with reduced ejection fraction ( EF ; <40%) versus preserved EF (≥50%). Methods and Results The ASIAN ‐ HF registry is a prospective longitudinal study. Participants with symptomatic HF were recruited from 46 secondary care centers in 3 Asian regions: South Asia (India), Southeast Asia (Thailand, Malaysia, Philippines, Indonesia, Singapore), and Northeast Asia (South Korea, Japan, Taiwan, Hong Kong, China). Overall, 6480 patients aged >18 years with symptomatic HF were recruited (mean age: 61.6±13.3 years; 27% women; 81% with HF and reduced r EF ). The primary outcome was 1‐year all‐cause mortality. Striking regional variations in baseline characteristics and outcomes were observed. Regardless of HF type, Southeast Asians had the highest burden of comorbidities, particularly diabetes mellitus and chronic kidney disease, despite being younger than Northeast Asian participants. One‐year, crude, all‐cause mortality for the whole population was 9.6%, higher in patients with HF and reduced EF (10.6%) than in those with HF and preserved EF (5.4%). One‐year, all‐cause mortality was significantly higher in Southeast Asian patients (13.0%), compared with South Asian (7.5%) and Northeast Asian patients (7.4%; P <0.001). Well‐known predictors of death accounted for only 44.2% of the variation in risk of mortality. Conclusions This first multinational prospective study shows that the outcomes in Asian patients with both HF and reduced or preserved EF are poor overall and worst in Southeast Asian patients. Region‐specific risk factors and gaps in guideline‐directed therapy should be addressed to potentially improve outcomes. Clinical Trial Registration URL : https://www.clinicaltrials.gov/ . Unique identifier: NCT 01633398.
Background Although de Winter T-wave electrocardiography pattern is rare, it signifies proximal left anterior descending artery occlusion and is often unrecognized by physicians. The aim of this case report was to highlight the dilemma in the management of a patient with de Winter T-wave pattern in the hospital without interventional cardiology facility. Case Presentation A 65-year-old male presented with typical chest pain since 2 hours before admission, and ECG showed sinus rhythm of 57 bpm and >1 mm upsloping ST depression with symmetric tall T in lead V2-3 characteristic of de Winter T-wave ECG pattern. He was given dual antiplatelet therapy, nitrate, statin, and anticoagulant. He refused referral to interventional cardiology available hospital. 3 hours after admission, the electrocardiography transformed into Q-waves consistent with final stages of acute STEMI and ST-segment elevation that barely meets the threshold in the guideline, and thrombolytic was administered and successful. There is a suggestion that de Winter T-wave electrocardiography should be treated as ST-segment myocardial infarction equivalent and should undergo coronary angiography; however, not every hospital has the luxury of interventional cardiology facility. The other modality for reperfusion is thrombolysis; however, without a clear guideline and scarcity of study, we prefer to resort to conservative treatment. “Fortunately,” transformation into ST-segment elevation helps us to determine the course of action which is reperfusion using thrombolytic. Conclusions de Winter T-wave ECG pattern is not mentioned in any guidelines regarding acute coronary syndromes, and there are no clear recommendations. Physicians in rural area without interventional cardiology facility face a dilemma with the lack of evidence-based guideline. Fibrinolytic may be appropriate in those without contraindications with strong chest pain consistent with acute coronary occlusion, less than 3 hours of symptoms, and convincing de Winter T-wave ECG pattern for a rural non-PCI hospital far away from PCI capable hospital.
Background Coronary artery ectasia is characterized by an abnormal dilatation of the coronary arteries. Coronary artery ectasia is observed in 3–8% of patients undergoing coronary angiography and sometimes leads to acute coronary syndrome regardless of the presence or absence of coronary stenosis or atrial fibrillation. Case presentation A 61-year-old Indonesian man presented with typical angina that began 1 week before admission and had worsened 3 hours prior to admission. Accompanying symptoms included dyspnea, nausea, and sweating. He was hemodynamically stable and had a history of tobacco smoking and dyslipidemia. An electrocardiogram showed ST-segment depression and T inversion. Laboratory results showed an international normalized ratio of 1.28. Dual antiplatelet therapy was administered along with fondaparinux, and symptoms were alleviated. Coronary angiography showed an ectatic and turbulent mid-distal right coronary artery and slow flow at the first presentation. There was a patent stent in the proximal-mid left anterior descending coronary artery. This patient had previously presented with recurrent acute coronary syndrome and received two coronary stents for the stenotic vessels. Discussion He had right coronary artery ectasia and experienced recurrent acute coronary syndrome. He received dual antiplatelet therapy along with warfarin after stenting of his left anterior descending coronary artery. However, he presented with unstable angina pectoris 7 months before the latest admission and at the latest admission despite a patent stent and no other significant obstructive lesion. The unstable angina pectoris might have been caused by slow flow, microvascular angina caused by small thrombi and/or vasospasm, or epicardial thrombosis at the ectatic coronary artery that dissolved after anticoagulation therapy prior to coronary angiography. Anticoagulant therapy may have a greater benefit than antiplatelet therapy in this patient due to the turbulence and stasis of blood in the ectatic vessel, although coexisting coronary conditions mandated antiplatelet therapy. His international normalized ratio was suboptimal and needed to be improved. Conclusion Coronary ectasia may play a role in recurrent acute coronary syndrome, and administration of an anticoagulant to prevent acute coronary syndrome in this patient was in accordance with the varying hemodynamic property of coronary artery ectasia.
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