Cardiovascular disease is the leading cause of mortality in patients with chronic kidney disease (CKD) and dyslipidaemia is an important contributor. The use of statins in this subgroup of patients appears to be beneficial in lowering the cardiovascular (CV) risk from the body of evidence available, although there are some important considerations that need to be taken into account. These include the dose and choice of statin, depending on the stage of the CKD and risk profile of the patient. This review looks at some of the important studies that support the clinical use of statins in patients with CKD and summarises some of the key points that the practising clinician should consider.

INTRODUCTIONUnexplained syncope is a common condition with a significant impact both on the patient and on healthcare expenditure. Often, the diagnosis is hampered due to the temporary sporadic nature of the symptoms. Conventional monitoring methods have a low yield for identifying an abnormality during a spontaneous event. The implantable loop recorder (ILR), often underutilised, is an important diagnostic device that may fi ll this void in the early assessment of patients presenting with syncope.

MATERIALS AND METHODSThis article begins with 2 case vignettes which highlight the clinical utility of ILRs in making a definitive diagnosis and guiding subsequent management. This is followed by a review of the existing evidence for ILRs, including the recent international guidelines, underpinning the role of ILRs in the present management algorithm of patients presenting with unexplained syncope. The technical aspects and cost implications will also be reviewed.

RESULTSPresent evidence-based international guidelines have recommended the early use of ILRs in the management of patients with unexplained syncope. Furthermore, there may also be an important role for ILR use in patients with presumed epilepsy refractory to treatment and in the neurally mediated syncope cohort with recurrent symptoms. Cost benefit analysis also demonstrates advantages with early ILR use.

CONCLUSIONThe early use of ILR in selected patients remains an accurate, cost-effective, high yield tool for diagnosis and management of patients with unexplained syncope. However, its use should not detract from the importance of taking a detailed medical history and physical examination in the initial assessment to facilitate identification of the aetiology and risk stratification of patients.

Adult ; Aged ; Algorithms ; Arrhythmias, Cardiac ; complications ; diagnosis ; Cost-Benefit Analysis ; Electrocardiography, Ambulatory ; economics ; instrumentation ; methods ; Female ; Heart Arrest ; complications ; diagnosis ; Heart Diseases ; complications ; diagnosis ; Humans ; Syncope ; diagnosis ; etiology

Many patients who survive an acute myocardial infarction (AMI) remain at risk of recurrent cardiac events and sudden cardiac death after discharge, despite optimal medical treatment. Assessment of the degree of left ventricular dysfunction and residual myocardial ischaemia is useful to identify the patients at greatest risk. In addition, there is increasing evidence that a number of other cardiovascular tests can be used to detect autonomic dysfunction and myocardial substrate abnormalities postAMI that increase the risk of life-threatening ventricular arrhythmias. These investigations include ECG-based tests (signal averaged ECG and T-wave alternans), Holter-based recordings (heart rate variability and heart rate turbulence) and imaging techniques (echocardiography and cardiac magnetic resonance), as well as invasive electrophysiological testing. This article reviews the current evidence for the use of these additional cardiac investigations among survivors of AMI to aid in their risk stratification for malignant ventricular arrhythmias and sudden cardiac death.
Age Factors ; Death, Sudden, Cardiac ; etiology ; Echocardiography ; Electrocardiography ; Electrocardiography, Ambulatory ; Electrophysiologic Techniques, Cardiac ; Female ; Humans ; Magnetic Resonance Imaging ; Male ; Myocardial Infarction ; complications ; Risk Assessment ; Sex Factors ; Tachycardia, Ventricular ; complications ; diagnosis ; Ventricular Dysfunction, Left ; complications ; diagnosis

Primary percutaneous coronary intervention (PPCI) has been shown to be superior to thrombolysis in patients presenting with ST-segment elevation acute myocardial infarction (STEMI) in reducing death, stroke and re-infarction. However, bleeding and thrombotic complications can occur despite successful PPCI and slow fl ow/no-reflow or poor microvascular reperfusion can occur in a significant minority despite a technically successful procedure. Bleeding or need for peri-procedural transfusion has been shown to increase short- and long-term mortality. Newer anticoagulants appear to reduce the bleeding risk and improve overall clinical outcomes. A novel combination of antiplatelet agents also appears to further improve the outcomes after PPCI. Although PPCI can achieve high rates of epicardial artery patency, some patients experience suboptimal microvascular perfusion, which affects long-term prognosis. Several pharmacologic agents have been shown to improve microvascular perfusion and left ventricular function, although none impacts on clinical outcomes. Of the mechanical devices available to reduce distal embolisation, the simple aspiration catheter holds the most promise in reducing clinical adverse events. Additional research and well designed studies are needed to further enhance the outcomes after PPCI.
Angioplasty, Balloon, Coronary ; adverse effects ; instrumentation ; Anticoagulants ; therapeutic use ; Cardiac Catheterization ; instrumentation ; Electrocardiography ; Embolism ; prevention & control ; Humans ; Myocardial Infarction ; drug therapy ; surgery ; Platelet Aggregation Inhibitors ; therapeutic use

Angioplasty, Balloon, Coronary ; Bradycardia ; etiology ; Cardiac Pacing, Artificial ; adverse effects ; Carotid Artery, Common ; abnormalities ; Heart Block ; etiology ; Humans ; Jugular Veins ; abnormalities ; Male ; Middle Aged ; Shock, Cardiogenic ; etiology ; Thromboembolism ; complications ; Torsades de Pointes ; etiology

Patients with long QT syndrome can sometimes present with a ventricular fibrillation (VF) storm. Catheter ablation of culprit premature ventricular complexes responsible for the triggering of the VF episodes may be required in rare cases of electrical storm that do not respond to conventional measures, and this can be life-saving. We describe a case of emergency catheter ablation in a young woman with a normal corrected QT interval, who presented with malignant VF storm for the first time. We also discuss the diagnostic and management challenges involved, as well as the value of genetic testing in refining the diagnosis.
Cardiology ; Catheter Ablation ; methods ; Electrocardiography ; methods ; Female ; Heart Arrest ; genetics ; therapy ; Heterozygote ; Humans ; Long QT Syndrome ; genetics ; Tachycardia, Ventricular ; therapy ; Treatment Outcome ; Ventricular Fibrillation ; therapy ; Ventricular Premature Complexes ; genetics ; therapy ; Young Adult

Atrial Fibrillation/surgery* ; Catheter Ablation/adverse effects* ; Heart Septal Defects, Atrial/surgery* ; Humans ; Iatrogenic Disease ; Treatment Outcome

INTRODUCTIONThis study was carried out to (i) provide the methodology for determining left atrial (LA) volume, emptying fraction and ejection force (LAEF), from real-time 3-dimensional echocardiography (RT3DE), and (ii) evaluate the effects of age and gender on LA volume and LAEF in a wide age range of healthy participants.

MATERIALS AND METHODSRT3DE was performed in 102 healthy participants (age range, 20 to 80 years). From full-volume data sets, LA endocardial borders were automatically traced and LA volumes were determined. LAEF was calculated as 1/3×mitral annular area × (blood density) × (peak velocity of A wave)(2) according to Newton's law of motion and hydrodynamics; wherein the mitral annular area (MVA) is traced using RT3DE and A is the peak Doppler-derived blood velocity at atrial systole with the sample volume placed at the mitral annulus level.

RESULTSANOVA analysis revealed that LA volume indices were significantly correlated with age (r = 0.366, P <0.0001 for maximal volume index and r = 0.288, P <0.005 for minimal volume index). LAEF was also significantly positively correlated with age (r = 0.49, P <0.0001). The LA emptying fraction was maintained across ages. LA volume indices and LAEF did not differ significantly with gender.

CONCLUSIONOur data can be used as normal reference values for LA volumes and LAEF. We have demonstrated that age is positively related to LA volume indices and LAEF, which suggests that age-dependent cut-off values should be considered in those with heart disease.

Adult ; Age Factors ; Aged ; Aged, 80 and over ; Analysis of Variance ; Atrial Function, Left ; physiology ; Echocardiography, Three-Dimensional ; methods ; Female ; Heart Atria ; diagnostic imaging ; Humans ; Male ; Middle Aged ; Mitral Valve ; diagnostic imaging ; Sex Factors ; Stroke Volume ; physiology

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.