The Modification Effect of Influenza Vaccine on Prognostic Indicators for Cardiovascular Events after Acute Coronary Syndrome: Observations from an Influenza Vaccination Trial

Introduction. The prognosis of acute coronary syndrome (ACS) patients has been improved with several treatments such as antithrombotics, beta-blockers, and angiotensin-converting enzyme inhibitors (ACEI) as well as coronary revascularization. Influenza vaccination has been shown to reduce adverse outcomes in ACS, but no information exists regarding the interaction of other treatments. Methods. This study included 439 ACS patients from Phrommintikul et al. A single dose of inactivated influenza vaccine was given by intramuscular injection in the vaccination group. The cardiovascular outcomes were described as major cardiovascular events (MACEs) which included mortality, hospitalization due to ACS, and hospitalization due to heart failure (HF). The stratified and multivariable Cox’s regression analysis was performed. Results. The stratified Cox’s analysis by influenza vaccination for each cardiovascular outcome and discrimination of hazard ratios showed that beta-blockers had an interaction with influenza vaccination. Moreover, the multivariable hazard ratios disclosed that influenza vaccine is associated with a significant reduction of hospitalization due to HF in patients who received beta-blockers (HR = 0.05, 95% CI = 0.004–0.71, P=0.027), after being adjusted for prognostic indicators (sex, dyslipidemia, serum creatinine, and left ventricular ejection fraction). Conclusions. The influenza vaccine was shown to significantly modify the effect of beta-blockers in ACS patients and to reduce the hospitalization due to HF. However, further study of a larger population and benefits to HF patients should be investigated

The Role of Mean Platelet Volume as a Predictor of Mortality in Critically Ill Patients: A Systematic Review and Meta-Analysis

Background. An increase in the mean platelet volume (MPV) has been proposed as a novel prognostic indicator in critically ill patients. Objective. We conducted a systematic review and meta-analysis to determine whether there is an association between MPV and mortality in critically ill patients. Methods. We did electronic search in Medline, Scopus, and Embase up to November 2015. Results. Eleven observational studies, involving 3724 patients, were included. The values of initial MPV in nonsurvivors and survivors were not different, with the mean difference with 95% confident interval (95% CI) being 0.17 (95% CI: −0.04, 0.38; p=0.112). However, after small sample studies were excluded in sensitivity analysis, the pooling mean difference of MPV was 0.32 (95% CI: 0.04, 0.60; p=0.03). In addition, the MPV was observed to be significantly higher in nonsurvivor groups after the third day of admission. On the subgroup analysis, although patient types (sepsis or mixed ICU) and study type (prospective or retrospective study) did not show any significant difference between groups, the difference of MPV was significantly difference on the unit which had mortality up to 30%. Conclusions. Initial values of MPV might not be used as a prognostic marker of mortality in critically ill patients. Subsequent values of MPV after the 3rd day and the lower mortality rate unit might be useful. However, the heterogeneity between studies is high

Breaches in Infection Prevention and Controls Discovered During an Outbreak Investigation of Two Unlinked Cases of Pseudomonas aeruginosa Bloodstream Infections in a Cardiovascular Thoracic Surgery Unit

Two patients with Pseudomonas aeruginosa bloodstream infections were diagnosed a week apart in a cardiovascular thoracic (CVT) surgery unit where there had been no cases of P. aeruginosa infections in the preceding 6 months. An outbreak investigation was conducted. Medical records were reviewed to identify potential common exposure in both patients. Outbreak investigation procedures included cultures of intravenous infusions and various solutions in the operating theatre and the general CVT surgery unit, the intensive care unit and the intermediate care unit, and monitoring compliance with the central line associated bloodstream infection prevention bundle. Both the blood cultures of the two patients as well as the liquid soap used for hand washing in the unit grew P. aeruginosa. However, there were three clonalities of isolates, the first from patient A, the second from patient B, and the third from the liquid soap. Other intravenous infusions and various solutions, i.e., normal saline solution, lactate ringer solutions, solutions for cardiopulmonary bypass circuits, and skin antisepsis, did not grow potential pathogens. In conclusion, although these were unlinked cases, investigation of the cases uncovered breaches in infection control practices and provided an opportunity to improve the infection control strategies in our institution.. KEYWORDS P. aeruginosa, bloodstream infection, outbreak, outbreak investigation, infection contro

Statin therapy in patients with acute coronary syndrome: low-density lipoprotein cholesterol goal attainment and effect of statin potency

Background: Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of coronary artery disease. Current guidelines recommend an LDL-C target of <70 mg/dL (< 1.8 mmol/L) for acute coronary syndrome (ACS) patients, and the first-line treatment to lower lipids is statin therapy. Despite current guidelines and the efficacious lipid-lowering agents available, about half of patients at very high risk, including ACS patients, fail to achieve their LDL-C goal. This study assessed LDL-C goal attainment according to use of high and low potency statins in routine practice in Thailand. Methods: A retrospective cohort study was performed by retrieving data from medical records and the electronic hospital database for a tertiary care hospital in Thailand between 2009 and 2011. Included were ACS patients treated with statins at baseline and with follow-up of LDL-C levels. Patients were divided into high or low potency statin users, and the proportion reaching the LDL-C goal of <70 mg/dL was determined. A Cox proportional hazard model was applied to determine the relationship between statin potency and LDL-C goal attainment. Propensity score adjustment was used to control for confounding by indication. Results: Of 396 ACS patients (60% males, mean age 64.3+11.6 years), 229 (58%) were treated with high potency statins and 167 (42%) with low potency statins. A quarter reached their target LDL-C goal (25% for patients on high potency statins and 23% on low potency statins). High potency statins were not associated with increased LDL-C goal attainment (adjusted hazards ratio 1.22, 95% confidence interval 0.79-1.88; P=0.363). Conclusion: There was no significant effect of high potency statins on LDL-C goal attainment. Moreover, this study showed low LDL-C goal attainment for patients on either low or high potency statins. The reasons for the low LDL-C goal attainment rate warrants further investigation

Increased sympathovagal imbalance evaluated by heart rate variability is associated with decreased T2* MRI and left ventricular function in transfusion-dependent thalassemia patients

Early detection of iron overload cardiomyopathy is an important strategy for decreasing the mortality rate of patients with transfusion-dependent thalassemia (TDT). Although cardiac magnetic resonance (CMR) T2* is effective in detecting cardiac iron deposition, it is costly and not generally available. We investigated whether heart rate variability (HRV) can be used as a screening method of iron overload cardiomyopathy in TDT patients. HRV, evaluated by 24-h Holter monitoring, non-transferrin bound iron (NTBI), serum ferritin, left ventricular (LV) ejection fraction (LVEF), and CMR-T2* were determined. Patients with a cardiac iron overload condition had a significantly higher low frequency/high frequency (LF/HF) ratio than patients without a cardiac iron overload condition. Log-serum ferritin (r = −0.41, P=0.008), serum NTBI (r = −0.313, P=0.029), and LF/HF ratio (r = −0.286, P=0.043) showed a significant correlation with CMR-T2*, however only the LF/HF ratio was significantly correlated with LVEF (r = −0.264, P=0.043). These significant correlations between HRV and CMR-T2* and LVEF in TDT confirmed the beneficial role of HRV as a potential early screening tool of cardiac iron overload in thalassemia patients, especially in a medical center in which CMR T2* is not available. A larger number of TDT patients with cardiac iron overload are needed to confirm this finding

The COOL-AF Phase 2 Registry: COhort of Antithrombotic Use and Clinical Outcomes in Atrial Fibrillation Patients

Background: Atrial fibrillation (AF) is a common condition leading to an increased risk of death and complications such as stroke. Even though direct oral anticoagulants (DOACs) can reduce the risk of ICH, the rate of DOAC use remains low in many Asian countries because of cost concerns. Objectives: The purpose of this protocol paper of the COOL-AF (COhort of antithrOmbotic use and cLinical outcomes in patients with Atrial Fibrillation) Phase 2 registry is to determine the rate of clinical outcome, changes in antithrombotic patterns, and their impact on clinical outcomes, and to develop a prediction model for clinical outcomes. Methods: The COOL-AF Phase 2 study is a prospective observational multicenter study of patients with known or newly diagnosed nonvalvular AF in Thailand. The aim is to achieve a sample size of 3,667 patients from 33 centers. Patients will be followed up every 6 months for up to 3 years. Data collection on and doses of oral anticoagulants (warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban) and antiplatelets are collected. The study outcomes include death, ischemic stroke/systemic embolism, major bleeding, myocardial infarction, heart failure, and quality of life. All events will be adjudicated. Results: Enrollment started in June 2024. The results of the COOL-AF phase 2 registry will be reported when enrollment is complete and one year of follow-up data is available. Conclusions: The COOL-AF Phase 2 trial will provide valuable information about the real-world practice of AF management and outcomes in Asia, which should be able to improve AF outcomes in the future.</p

Impact of Educational Intervention on Anticoagulation Control Using SAMe-TT₂2R₂ Score-Guided Strategy in Atrial Fibrillation

Background: An educational-behavioral intervention has been shown to improve anticoagulation control with warfarin in atrial fibrillation (AF) patients, but widespread application may not be practical. The SAMe-TT2R2 score was formulated to identify the likelihood of achieving optimal time in therapeutic range (TTR). Objectives: The authors conducted a randomized controlled trial to evaluate the impact of a SAMe-TT2R2 score-guided strategy for an educational-behavioral intervention, compared with usual care on patient’s anticoagulation control. Methods: Anticoagulant-naive adult AF patients were randomized to a SAMe-TT2R2 score-guided strategy or usual care. In the SAMe-TT2R2 score-guided strategy group, scores 0 to 2 received usual care, &gt;2 received educational-behavioral intervention plus usual care. All received warfarin targeting international normalized ratio 2.0 to 3.0. Primary outcome was TTR at 12 months. Secondary outcomes included TTR at 6 months, thromboembolic and bleeding events, major adverse cardiovascular events at 12 months, and change in AF knowledge at 6 and 12 months. Results: A total of 320 patients (mean age 69.5 years; 48.8% female) were randomized to a SAMe-TT2R2 score-guided strategy plus usual care (n = 156) or usual care alone (n = 164). Mean CHA2DS2-VASc score and SAMe-TT2R2 score were 3.1 ± 1.4 and 3.3 ± 0.9, respectively. At 12 months, mean TTR was not significantly different between groups (41.0 [95% CI: 36.7-45.2] in the SAMe-TT2R2 score-guided strategy vs 40.2 [95% CI: 35.9-44.4] with usual care, and the difference between the 2 groups was 0.7 [95% CI: −5.2 to 6.6]). There were no significant differences in secondary outcomes. Conclusions: SAMe-TT2R2 score-guided strategy for an educational-behavioral intervention, compared with usual care did not significantly improve outcomes over 12 months. (Thai Clinical Trials Registry identification number TCTR20180711003

Prospective randomised trial examining the impact of an educational intervention versus usual care on anticoagulation therapy control based on an SAMe-TT2R2 score-guided strategy in anticoagulant-naive Thai patients with atrial fibrillation (TREATS-AF): a study protocol

INTRODUCTION: The burden of atrial fibrillation (AF) in Thailand is high and associated with increased morbidity, mortality and healthcare costs. Vitamin K antagonists (eg, warfarin), commonly used for stroke prevention in patients with AF in Thailand, are effective but are often suboptimally controlled. We aim to evaluate the impact of an SAMe-TT2R2 score-guided strategy and educational intervention compared to usual care on anticoagulation control expressed by the time in therapeutic range (TTR) at 12 months, in anticoagulant-naïve Thai patients with AF.METHODS AND ANALYSIS: Multicentre, open-label, parallel-group, randomised controlled trial conducted in Thailand among adult patients (age: 18 years) with AF who are anticoagulant naïve. Patients will be randomised to one of two groups; an SAMe-TT2R2 score-guided strategy with educational intervention and usual care versus usual care alone. The planned follow-up period is 12 months. The primary outcome is TTR at 12 months. Secondary outcomes include: (1) TTR at 6 months; (2) thromboembolic and bleeding events at 12 months; (3) composite major adverse cardiovascular events at 12 months; (4) change in patients' knowledge of AF between baseline and 6 months and 12 months; (5) cost effectiveness; (6) quality of life at baseline, 6 months and 12 months using EQ-5D-5L (Thai version) and (7) patient satisfaction/perceptions of the TREAT intervention. An embedded qualitative study will assess patient perceptions of the TREAT intervention.ETHICS AND DISSEMINATION: The study has been approved by the Ethical Review Committee, Ministry of Public Health of Thailand, and registered in the Thai Clinical Trials Registry. The results of this trial will be submitted for publication in a peer-reviewed journal. Participants will be informed via a link to a preview of the publication. A lay summary will also be provided to all participants prior to publication.TRIAL REGISTRATION NUMBER: TCTR20180711003.</p