In the last 40 years, pharmacological therapy for chronic heart failure has rapidly expanded beyond diuretics and digoxin. Standard pharmacological therapy includes beta blockers and renin-angiotensin-aldosterone system antagonists. Even with existing contemporary pharmacological therapy, which has substantially improved outcomes, prognosis is fairly poor. The treatment of heart failure continues to evolve with the integration of the results from landmark clinical trials into contemporary therapy. Development of novel therapeutic strategies for the treatment of this disease is crucial. Some of these new approaches will be briefly discussed.

INTRODUCTIONPeripartum cardiomyopathy (PPCM) is a rare but life-threatening condition. We report 11 patients admitted to the National Heart Centre Singapore with a diagnosis of PPCM over a period of 14 months.

METHODSBaseline demographics, pregnancy history, haematology, serum biochemistry and echocardiographic findings of women admitted with a diagnosis of PPCM were analysed.

RESULTSThe incidence of PPCM was 0.89 per 1,000 live births in our cohort. 63.6% of the patients were Malay and 27.3% were Chinese. 45.5% of the patients were smokers and 45.5% had a history of pregnancy-induced hypertension or preeclampsia. There was no maternal mortality. Mean left ventricular ejection fractions at diagnosis and at six months were 26.9% ± 9.1% and 51.9% ± 10.6%, respectively. Mean left ventricular internal diameters in end-diastole at diagnosis and at six months were 5.5 ± 0.5 cm and 5.1 ± 0.6 cm, respectively. All patients were treated successfully for the acute episode and all but one patient had returned to New York Heart Association functional class I status at six months.

CONCLUSIONPPCM remains a rare condition and appears to occur more commonly in Malay patients. Smoking and pregnancy-induced hypertension appear to be significant risk factors. While short-term outcome remains excellent, collaborative studies with other tertiary centres will help enhance our understanding of the long-term management of and clinical outcomes in these patients.

Adult ; Asian Continental Ancestry Group ; Cardiology ; methods ; Cardiomyopathy, Dilated ; complications ; diagnosis ; therapy ; Echocardiography ; methods ; Female ; Humans ; Hypertension ; complications ; diagnosis ; Pre-Eclampsia ; diagnosis ; Pregnancy ; Pregnancy Complications, Cardiovascular ; Puerperal Disorders ; diagnosis ; therapy ; Retrospective Studies ; Risk Factors ; Singapore ; Smoking ; adverse effects ; Tertiary Care Centers

PURPOSE: Smoking has detrimental effects on asthma symptom control and response to treatment and is prevalent among asthma patients in South Korea. The aim of this study is to determine the prevalence of smoking among asthma patients in South Korea and to compare the medication regimens of asthma patients who do and do not smoke. METHODS: A cross-sectional survey was conducted from August 2010 to January 2011. Participating physicians (N=25) recorded demographic and clinical data on all asthma patients presenting during the study period (N=2,032), and then recruited a subset of patients (N=500) for the survey such that half were self-reported current smokers. Recruited patients were between the ages of 18 and 60. RESULTS: Among presenting asthma patients, 17.3% were current smokers, 19.2% were former smokers, and 63.5% had never smoked. Within the analyzable study population (N=471), 212 patients reported smoking currently, 79 smoking formerly, and 180 never smoking. Among current and former smokers, 79.7% and 81.0%, respectively, were men, while women represented 80.5% of patients who had never smoked. Agreement was strong between physician-determined smoking status and patient-reported smoking status (kappa=0.82; P<0.001). However, asthma medication regimens examined according to GINA treatment steps did not differ by smoking status. In addition, mean quality of life scores and level of asthma control did not differ by smoking status. CONCLUSIONS: In South Korea, physicians are well aware of the smoking status of their patients. However, smoking status did not affect the prescribed medication regimens of this population of asthma patients.
Asthma* ; Cross-Sectional Studies ; Female ; Humans ; Korea ; Male ; Prevalence ; Quality of Life ; Seoul ; Smoke* ; Smoking*

Adult ; Cardiac Imaging Techniques ; Cardiomyopathies ; diagnostic imaging ; Clinical Protocols ; Diet, Carbohydrate-Restricted ; Diet, High-Fat ; Female ; Fluorodeoxyglucose F18 ; Humans ; Middle Aged ; Multimodal Imaging ; Positron-Emission Tomography ; Radiopharmaceuticals ; Sarcoidosis ; diagnostic imaging ; Tomography, X-Ray Computed

INTRODUCTIONWe assessed the local prevalence, characteristics and 10-year outcomes in a heart failure (HF) cohort from the emergency room (ER).

MATERIALS AND METHODSPatients presenting with acute dyspnoea to ER were prospectively enrolled from December 2003 to December 2004. HF was diagnosed by physicians' adjudication based on clinical assessment and echocardiogram within 12 hours, blinded to N-terminal-pro brain natriuretic peptide (NT-proBNP) results. They were stratified into heart failure with preserved (HFPEF) and reduced ejection fraction (HFREF) by left ventricular ejection fraction (LVEF).

RESULTSAt different cutoffs of LVEF of ≥50%, ≥45%, ≥40%, and >50% plus excluding LVEF 40% to 50%, HFPEF prevalence ranged from 38% to 51%. Using LVEF ≥50% as the final cutoff point, at baseline, HFPEF (n = 35), compared to HFREF (n = 55), had lower admission NT- proBNP (1502 vs 5953 pg/mL, P <0.001), heart rate (86 ± 22 vs 98 ± 22 bpm, P = 0.014), and diastolic blood pressure (DBP) (75 ± 14 vs 84 ± 20 mmHg, P = 0.024). On echocardiogram, compared to HFREF, HFPEF had more LV concentric remodelling (20% vs 2%, P = 0.003), less eccentric hypertrophy (11% vs 53%, P <0.001) and less mitral regurgitation from functional mitral regurgitation (60% vs 95%, P = 0.027). At 10 years, compared to HFREF, HFPEF had similar primary endpoints of a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and rehospitalisation for congestive heart failure (CHF) (HR 0.886; 95% CI, 0.561 to 1.399; P = 0.605), all-cause mortality (HR 0.663; 95% CI, 0.400 to 1.100; P = 0.112), but lower cardiovascular mortality (HR 0.307; 95% CI, 0.111 to 0.850; P = 0.023).

CONCLUSIONIn the long term, HFPEF had higher non-cardiovascular mortality, but lower cardiovascular mortality compared to HFREF.

Aged ; Aged, 80 and over ; Cardiovascular Diseases ; mortality ; Dyspnea ; diagnosis ; physiopathology ; Echocardiography ; Emergency Service, Hospital ; Female ; Heart Failure ; blood ; diagnostic imaging ; epidemiology ; physiopathology ; Humans ; Hypertrophy, Left Ventricular ; Male ; Middle Aged ; Mitral Valve Insufficiency ; epidemiology ; Myocardial Infarction ; epidemiology ; Natriuretic Peptide, Brain ; blood ; Peptide Fragments ; blood ; Prevalence ; Prospective Studies ; Singapore ; epidemiology ; Stroke ; epidemiology ; Stroke Volume ; Tertiary Care Centers ; Ventricular Remodeling

INTRODUCTION: The impact of sex and diabetes mellitus (DM) on patients with heart failure with mildly reduced ejection fraction (HFmrEF) is not well elucidated. This study aims to evaluate sex differences in the clinical profile and outcomes in Asian HFmrEF patients with and without DM. METHODS: Patients admitted nationally for HFmrEF (ejection fraction 40-49%) between 2008 and 2014 were included and followed up until December 2016. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular (CV) death and/or heart failure (HF) rehospitalisations. RESULTS: A total of 2,272 HFmrEF patients (56% male) were included. More women had DM than men (60% versus 55%, P=0.013). Regardless of DM status, HFmrEF females were older, less likely to smoke, had less coronary artery disease, narrower QRS and lower haemoglobin compared to men. The odds of having DM decreases in smokers who are women as opposed to men (P_interaction =0.017). In multivariate analysis, DM reached statistical analysis for all-cause mortality and combined CV mortality or HF rehospitalisation in both men and women. However, the results suggest that there may be sex differences in terms of outcomes. DM (vs non-DM) was less strongly associated with increased all-cause mortality (adjusted hazards ratio [adj HR] 1.234 vs adj HR 1.290, P_interaction <0.001] but more strongly associated with the combined CV death/HF rehospitalisation (adj HR 1.429 vs adj HR 1.317, P_interaction =0.027) in women (vs men). CONCLUSION Asian women with HFmrEF had a higher prevalence of DM, with differences in clinical characteristics, compared to men. While diabetes conferred poor outcomes regardless of sex, there were distinct sex differences. These highlight the need for sex-specific management strategies.
Diabetes Mellitus/epidemiology* ; Female ; Heart Failure ; Humans ; Male ; Prognosis ; Stroke Volume ; Ventricular Dysfunction, Left/epidemiology* ; Ventricular Function, Left

INTRODUCTION: Numerous heart failure risk scores have been developed but there is none for Asians. We aimed to develop a risk calculator, the Singapore Heart Failure Risk Score, to predict 1- and 2-year survival in Southeast Asian patients hospitalised for heart failure. MATERIALS AND METHODS: Consecutive patients admitted for heart failure were identified from the Singapore Cardiac Databank Heart Failure registry. The follow-up was 2 to 4 years and mortality was obtained from national registries. RESULTS: The derivation (2008-2009) and 2 validation cohorts (2008-2009, 2013) included 1392, 729 and 804 patients, respectively. Ten variables were ultimately included in the risk model: age, prior myocardial infarction, prior stroke, atrial fibrillation, peripheral vascular disease, systolic blood pressure, QRS duration, ejection fraction and creatinine and sodium levels. In the derivation cohort, predicted 1- and 2-year survival was 79.1% and 68.1% compared to actual 1- and 2-year survival of 78.2% and 67.9%. There was good agreement between the predicted and observed mortality rates (Hosmer-Lemeshow statistic = 14.36, = 0.073). C-statistics for 2-year mortality in the derivation and validation cohorts were 0.73 (95% CI, 0.70-0.75) and 0.68 (95% CI, 0.64-0.72), respectively. CONCLUSION We provided a risk score based on readily available clinical characteristics to predict 1- and 2-year survival in Southeast Asian patients hospitalised for heart failure via a simple online risk calculator, the Singapore Heart Failure Risk Score.

Interferon is an important cytokine that plays a critical role in the initial host defense against viral infection. Recombinant human adenoviruses expressing human interferon-alpha (Ad-HIFNalpha) or pig interferon-beta fused with interleukin-18 (Ad-PIFNbeta-IL18) were constructed and used to induce an early protective response against foot and mouth disease (FMD). To analyze the antiviral effect, bovine thyroid and porcine kidney IBRS-2 cells and ICR mice were treated with Ad-HIFNalpha, Ad-PIFNbeta-IL18, and cocktail of Ad-HIFNalpha and Ad-PIFNbeta-IL18. The survival rate of suckling mice was monitored after foot and mouth disease virus (FMDV) challenge following intra-peritoneal (IP) administration of appropriate adenovirus. Indirect antigen ELISA was performed to evaluate inhibition of FMDV replication following challenge with the FMDV O, A, or Asia 1 serotypes in vitro. These recombinant adenoviruses reduced the replication of FMDV in susceptible cells, thereby decreasing the fatality in mice, suggesting that they can be a useful control method for the early protection against FMD infection in livestock after field trial.
Adenoviridae ; Adenoviruses, Human ; Animals ; Asia ; Enzyme-Linked Immunosorbent Assay ; Foot ; Foot-and-Mouth Disease ; Foot-and-Mouth Disease Virus ; Humans ; Interferon-alpha ; Interferon-beta ; Interferons ; Interleukin-18 ; Kidney ; Livestock ; Mice ; Mice, Inbred ICR ; Survival Rate ; Thyroid Gland

INTRODUCTIONDevice therapy is efficacious in preventing sudden cardiac death (SCD) in patients with reduced ejection fraction. However, few who need the device eventually opt to undergo implantation and even fewer reconsider their decisions after deliberation. This is due to many factors, including unresolved patient barriers. This study identified the factors that influenced patients' decision to decline implantable cardioverter defibrillator (ICD) implantation, and those that influenced patients who initially declined an implant to reconsider having one.

METHODSA single-centre survey was conducted among 240 patients who had heart failure with reduced ejection fraction and met the ICD implantation criteria, but had declined ICD implantation.

RESULTSParticipants who refused ICD implantation were mostly male (84%), Chinese (71%), married (72%), currently employed (54%), and had up to primary or secondary education (78%) and monthly income of < SGD 3,000 (51%). Those who were more likely to reconsider their decision were aware that SCD was a consequence of heart failure with reduced ejection fraction, knowledgeable of the preventive role of ICDs, currently employed and aware that their doctor strongly recommended the implant. Based on multivariate analysis, knowledge of the role of ICDs for primary prophylaxis was the most important factor influencing patient decision.

CONCLUSIONThis study identified the demographic and social factors of patients who refused ICD therapy. Knowledge of the role of ICDs in preventing SCD was found to be the strongest marker for reconsidering ICD implantation. Measures to address this information gap may lead to higher rates of ICD implantation.

Cross-Sectional Studies ; Death, Sudden, Cardiac ; prevention & control ; Defibrillators, Implantable ; Female ; Heart Failure ; mortality ; physiopathology ; therapy ; Humans ; Male ; Middle Aged ; Primary Prevention ; methods ; Risk Factors ; Singapore ; epidemiology ; Stroke Volume ; physiology ; Survival Rate ; trends