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Aims Atrial fibrillation (AF) is a preventable cause of ischaemic stroke but it is often undiagnosed and undertreated. The utility of smartphone electrocardiogram (ECG) for the detection of AF after ischaemic stroke is unknown. The aim of this study is to determine the diagnostic yield of 30-day smartphone ECG recording compared with 24-h Holter monitoring for detecting AF ≥30 s. Methods and results In this multicentre, open-label study, we randomly assigned 203 participants to undergo one additional 24-h Holter monitoring (control group, n = 98) vs. 30-day smartphone ECG monitoring (intervention group, n = 105) using KardiaMobile (AliveCor®, Mountain View, CA, USA). Major inclusion criteria included age ≥55 years old, without known AF, and ischaemic stroke or transient ischaemic attack (TIA) within the preceding 12 months. Baseline characteristics were similar between the two groups. The index event was ischaemic stroke in 88.5% in the intervention group and 88.8% in the control group (P = 0.852). AF lasting ≥30 s was detected in 10 of 105 patients in the intervention group and 2 of 98 patients in the control group (9.5% vs. 2.0%; absolute difference 7.5%; P = 0.024). The number needed to screen to detect one AF was 13. After the 30-day smartphone monitoring, there was a significantly higher proportion of patients on oral anticoagulation therapy at 3 months compared with baseline in the intervention group (9.5% vs. 0%, P = 0.002). Conclusions Among patients ≥55 years of age with a recent cryptogenic stroke or TIA, 30-day smartphone ECG recording significantly improved the detection of AF when compared with the standard repeat 24-h Holter monitoring.

Background Data on clinical characteristics of acute decompensated heart failure (ADHF) in Malaysia especially in East Malaysia is lacking. Methods This is a prospective observational study in Sarawak General Hospital, Medical Department, from October 2017 to September 2018. Patients with primary admission diagnosis of ADHF were recruited and followed up for 90 days. Data on patient’s characteristics, precipitating factors, medications and short-term clinical outcomes were recorded. Results Majority of the patients were classified in lower socioeconomic group and the mean age was 59 years old. Hypertension, diabetes mellitus and dyslipidaemia were the common underlying comorbidities. Heart failure with ischemic aetiology was the commonest ADHF admission precipitating factor. 48.6% of patients were having preserved ejection fraction HF and the median NT-ProBNP level was 4230 pg/mL. Prescription rate of the evidence-based heart failure medication was low. The in-patient mortality and the average length of hospital stay were 7.5% and 5 days respectively. 43% of patients required either ICU care or advanced cardiopulmonary support. The 30-day, 90-day mortality and readmission rate were 13.1%, 11.2%, 16.8% and 14% respectively. Conclusion Comparing with the HF data from West and Asia Pacific, the short-term mortality and readmission rate were high among the ADHF patients in our study cohort. Maladaptation to evidence-based HF prescription and the higher prevalence of cardiovascular risk factors in younger patients were among the possible issues to be addressed to improve the HF outcome in regions with similar socioeconomic background.

Statins have been established as the standard of care for dyslipidemia and preventing cardiovascular diseases while posing few safety concerns. However, misconceptions about statin intolerance lead to their underuse, indicating a need to improve the understanding of the safety of this treatment.We searched PubMed and reviewed literatures related to statin intolerance published between February 2015 and February 2020. Important large-scale or landmark studies published before 2015 were also cited as key evidence.Optimal lowering of low-density lipoprotein cholesterol with statins substantially reduces the risk of cardiovascular events. Muscle adverse events (AEs) were the most frequently reported AEs by statin users in clinical practice, but they usually occurred at a similar rate with statins and placebo in randomized controlled trials and had a spurious causal relationship with statin treatment. We proposed a rigorous definition for identifying true statin intolerance and present the criteria for defining different forms of muscle AEs and an algorithm for their management. True statin intolerance is uncommon, and every effort should be made to exclude false statin intolerance and ensure optimal use of statins. For the management of statin intolerance, statin-based approaches should be prioritized over non-statin approaches.

The aim of this study is to gain insight into the differences in demographics of ST-elevation myocardial infarction (STEMI) patients in Asia-Pacific, as well as inter-country variation in treatment and mortality outcomes. Systematic review of published studies and reports from known registries in Australia, Japan, Korea, Singapore, and Malaysia that began data collection after the year 2000. Supplementary self-report survey questionnaire on public health data answered by representative cardiologists working in these countries. Twenty studies comprising of 158 420 patients were included in the meta-analysis. The mean age was 61.6 years. Chronic kidney disease prevalence was higher in Japan, while dyslipidaemia was low in Korea. Use of aspirin, P2Y12 inhibitors, and statins were high throughout, but ACEi/ARB and β-blocker prescriptions were lower in Japan and Malaysia. Reperfusion strategies varied greatly, with high rates of primary percutaneous coronary intervention (pPCI) in Korea (91.6%), whilst Malaysia relies far more on fibrinolysis (72.6%) than pPCI (9.6%). Similarly, mortality differed, with 1-year mortality from STEMI was considerably greater in Malaysia (17.9%) and Singapore (11.2%) than in Korea (8.1%), Australia (7.8%), and Japan (6.2%). The countries were broadly similar in development and public health indices. Singapore has the highest gross national income and total healthcare expenditure per capita, whilst Malaysia has the lowest. Primary PCI is available in all countries 24/7/365. Despite broadly comparable public health systems, differences exist in patient profile, in-hospital treatment, and mortality outcomes in these five countries. Our study reveals areas for improvements. The authors advocate further registry-based multi-country comparative studies focused on the Asia-Pacific region.

Background Although the burden of premature myocardial infarction (MI) is high in Malaysia, direct evidence on the determinants of MI in this multi-ethnic population remains sparse. Objective The Malaysian Acute Vascular Events Risk (MAVERIK) study is a retrospective case-control study established to investigate the genomic, lipid-related, and other determinants of acute MI in Malaysia. In this paper, we report the study protocol and early results. Methods By June 2019, we had enrolled approximately 2500 patients with their first MI and 2500 controls without cardiovascular disease, who were frequency-matched by age, sex, and ethnicity, from 17 hospitals in Malaysia. For each participant, serum and whole blood have been collected and stored. Clinical, demographic, and behavioral information has been obtained using a 200-item questionnaire. Results Tobacco consumption, a history of diabetes, hypertension, markers of visceral adiposity, indicators of lower socioeconomic status, and a family history of coronary disease were more prevalent in cases than in controls. Adjusted (age and sex) logistic regression models for traditional risk factors indicated that current smoking (odds ratio [OR] 4.11, 95% CI 3.56-4.75; P30 kg/m2; OR 1.19, 95% CI 1.05-1.34; P=.009) were associated with MI in age- and sex-adjusted models. Conclusions The MAVERIK study can serve as a useful platform to investigate genetic and other risk factors for MI in an understudied Southeast Asian population. It should help to hasten the discovery of disease-causing pathways and inform regionally appropriate strategies that optimize public health action. International Registered Report Identifier (IRRID) RR1-10.2196/31885

Background The common method of assessing left ventricle (LV) volumes and ejection fraction (EF) is hand-tracing Biplane Simpson method. Alternatively, ultrasound vendors offer different semi-automated LV endocardial border detection software with anatomical intelligence to assess LV volumes and EF. By using speckle-tracking technique, this software tracks the LV endocardium throughout the cardiac cycle and computes the LV volumes in every image frame using the disk summation method from which a volume-curve is generated, and the EF is calculated using the maximum and minimum volumes obtained. Data on the performance of this method in comparison with the hand-tracing Biplane Simpson method in daily clinical practice is scarce. Purpose To determine the accuracy of LV volumes and EF using semi-automated LV endocardial detection tracing, and to compare the reproducibility of this method with the hand-tracing Biplane Simpson method, among operators with varying level of experience in echocardiography. Methods This was a single center retrospective observational study, conducted in year 2020. 127 patients, aged >18 years, who underwent clinically indicated transthoracic echocardiography were recruited. The echocardiographic images were analyzed independently in a blinded fashion by 3 operators – a sonographer, a fellow-in-training and a cardiologist specialized in echocardiography. The LV volumes and EF were first measured using hand-tracing Biplane Simpson method, then repeated using semi-automated tracing at a different time and the operator were blinded to the initial hand-tracing measurements. Results The mean age of patients was 50±16 years, 35.4% were male, mean body surface area was 1.62±0.18m2, 92.1% were in sinus rhythm, and 61.4% had good acoustic window. Table 1 shows the LV end-diastolic volume (EDV), end-systolic volume (ESV) and EF, measured using different method, by the 3 operators. There were excellent correlation and agreement between semi-automated tracing measurements and hand-tracing measurements of LV EDV (r=0.985, LOA [mean ± 1.96 SD] 16.9 ml, ICC 0.991), ESV (r=0.990, LOA 12.7 ml, ICC 0.994) and EF (r=0.962, LOA 7.43%, ICC 0.967) by experienced cardiologist. The limit of agreement (LOA) between cardiologist and sonographer for semi-automated tracing measurement of LV EDV, ESV and EF were 29.13 ml, 19.74 ml and 9.25% respectively, which was comparable with that of hand-tracing measurement. The agreement between cardiologist and fellow-in-training for semi-automated tracing measurement of LV volumes and EF was slightly better than hand-tracing method, with a LOA of 25.60 ml, 17.48 ml and 7.08%, for EDV, ESV and EF respectively (Table 2). Conclusion In daily clinical practice, measurement of LV volumes and EF using semi-automated LV endocardial tracing method is accurate and demonstrates comparable reproducibility with hand-tracing Biplane Simpson method among operators with different level of experience in echocardiography. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health Malaysia Background Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes. Substantial number of patients were classified as indeterminate diastolic function based on the current ASE/EACVI guidelines. The implication of current diastolic function classification in predicting MACE among diabetic patients is not well established. Purpose To assess prognostic impact of current guidelines-based diastolic function classification, and determine predictors of 2-year MACE based on individual LVDD parameters. Methods A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients had no prior cardiovascular events, had preserved left ventricular (LV) ejection fraction on echocardiography and sinus rhythm on ECG at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LV diastolic function. The 2016 ASE/EACVI guidelines were applied to classify diastolic function. All patients were followed up until 2 years to assess MACE. Results There were 65 (58.6%) female patients. Mean age was 59.86 ± 7.45 years; mean duration of type 2 diabetes was 10.5 ± 5.41 years. 80 (72.1%) patients were classified as having normal diastolic function (nDF); 24 (21.6%) patients were classified as indeterminate diastolic function (iDF); 7 patients (6.3%) were classified as LVDD. Patients with LVDD had significantly higher LV mass index (LVMI) (mean 121.72 ± 23.28g/m2 vs 116.62 ± 24.66g/m2 in iDF vs 102.50 ± 22.89g/m2 in nDF, p = 0.003); higher left atrial volume index (LAVI) (mean 41.24 ± 10.28ml/m2 vs 30.55 ± 10.07ml/m2 in iDF vs 25.75 ± 6.30ml/m2 in nDF, p Among these 111 patients, 10 patients (9%) reported MACE at 2 years. The risk of 2-year MACE is elevated in both indeterminate diastolic function[hazards ratio (HR) 3.80, p = 0.023] and LVDD (HR 37.78, p = 0.002). BMI (HR 1.25, p = 0.004), and systolic blood pressure (HR 1.07, p Conclusions LVDD and indeterminate diastolic function were correlated with increased MACE at 2 years. BMI and systolic blood pressure were predictors of increased risk of MACE at 2 years. Further investigation with larger sample size is warranted.

Background: Little is known regarding the impact of socioeconomic factors on the use of evidence-based therapies and outcomes in patients with heart failure with reduced ejection fraction across Asia. Methods: We investigated the association of both patient-level (household income, education levels) and country-level (regional income level by World Bank classification, income disparity by Gini index) socioeconomic indicators on use of guideline-directed therapy and clinical outcomes (composite of 1-year mortality or HF hospitalization, quality of life) in the prospective multinational ASIAN-HF study (Asian Sudden Cardiac Death in Heart Failure). Results: Among 4540 patients (mean age: 60±13 years, 23% women) with heart failure with reduced ejection fraction, 39% lived in low-income regions; 34% in regions with high-income disparity (Gini ≥42.8%); 64.4% had low monthly household income (P interaction Conclusions: These findings highlight the importance of socioeconomic determinants among patients with heart failure in Asia and suggest that attention should be paid to address disparities in access to care among the poor and less educated, including those from wealthy regions. Registration: URL: https://clinicaltrials.gov ; Unique Identifier: NCT01633398.

Background Because of a nonresponse to aspirin (aspirin resistance), patients with acute coronary syndrome (ACS) are at increased risk of developing recurrent event. The in vitro platelet function tests have potential limitations, making them unsuitable for the detection of aspirin resistance. We investigated whether miR‐19b‐1‐5p could be utilized as a biomarker for aspirin resistance and future major adverse cardio‐cerebrovascular (MACCE) events in patients with ACS. Methods and Results In this cohort study, patients with ACS were enrolled from multiple tertiary hospitals in Christchurch, Hong Kong, Sarawak, and Singapore between 2011 and 2015. MiR‐19b‐1‐5p expression was measured from buffy coat of patients with ACS (n=945) by reverse transcription quantitative polymerase chain reaction. Platelet function was determined by Multiplate aggregometry testing. MACCE was collected over a mean follow‐up time of 1.01±0.43 years. Low miR‐19b‐1‐5p expression was found to be related to aspirin resistance as could be observed from sustained platelet aggregation in the presence of aspirin (‐Log‐miR‐19b‐1‐5p, [unstandardized beta, 44.50; 95% CI, 2.20–86.80; P P P =0.01) on the risk of MACCE. Conclusions Lower miR‐19b‐1‐5p expression was found to be associated with sustained platelet aggregation on aspirin, and a higher risk of MACCE in patients with ACS. Therefore, miR‐19b‐1‐5p could be a suitable marker for aspirin resistance and might predict recurrence of MACCE in patients with ACS.

Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y(12) inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y(12) inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy. Asian Pacific Society of Cardiology (APSC); Abbott VascularAbbott Laboratories; AmgenAmgen; AstraZenecaAstraZeneca; BayerBayer AG; Roche Diagnostics; Daiichi SankyoDaiichi Sankyo Company Limited This work was funded through the Asian Pacific Society of Cardiology (APSC) with unrestricted educational grants from Abbott Vascular, Amgen, AstraZeneca, Bayer and Roche Diagnostics. JWCT reports honoraria from AstraZeneca, Bayer, Amgen, Medtronic, Abbott Vascular, Biosensors, Alvimedica, Boehringer Ingelheim and Pfizer; research and educational grants from Medtronic, Biosensors, Biotronik, Philips, Amgen, AstraZeneca, Roche, Otsuka, Terumo and Abbott Vascular; and consulting fees from Elixir and CSL Behring; and is on the European Cardiology Review editorial board; this did not influence peer review. JA reports honoraria from AstraZeneca, Daiichi Sankyo, Bayer and Sanofi; and grants/grants pending from Daiichi Sankyo. DPC reports consulting fees from APSC; support for travel to meetings for the study or otherwise from APSC; grants/grants pending from Roche Diagnostics; payment for development of educational presentations including service on speakers' bureaus from AstraZeneca. JD reports honoraria from Bayer and Pfizer. CTC reports honoraria from Abbott Vascular, AstraZeneca, Boston Scientific, Biotronik, Biosensors, Medtronic; consulting and ad boards from AstraZeneca, Boston Scientific; and research and educational support from AstraZeneca, Eli Lilly. AH reports consulting fee or honorarium from AstraZeneca. MC reports consulting fee or honorarium from AstraZeneca. AYYF reports honoraria and educational support from AstraZeneca. BK reports consulting fee or honorarium from AstraZeneca, Abbott, IE Menarini, Daiichi Sankyo, Sanovel and ARIS. UB reports honoraria from Amgen and AstraZeneca. All other authors have no conflicts of interest to declare.

Routine coagulation tests do not enable rapid, accurate determination of direct oral anticoagulant (DOAC) therapy. The ecarin clotting assay (ECA), performed on the ClotPro viscoelastic testing device, may enable sensitive and specific detection of dabigatran. We assessed the association between trough plasma dabigatran concentration and clotting time (CT) in the ClotPro ECA, in patients with non-valvular atrial fibrillation (NVAF). Each patient provided a single venous blood sample, ∼1 hour before dabigatran dosing. The study included 118 patients, of whom 64 were receiving dabigatran 110 mg twice daily and 54 were receiving 150 mg twice daily. ECA CT was moderately correlated with trough plasma dabigatran concentration ( r = 0.80, p < 0.001). Slight trends toward increased plasma dabigatran concentration and prolonged ECA CT were apparent with 150 mg versus the 110 mg dose (differences not statistically significant). Individuals with creatinine clearance below 50 mL/minute had significantly higher plasma dabigatran concentrations and significantly prolonged ECA CT versus those with creatinine clearance ≥50 mL/minute. In conclusion, this preliminary study has demonstrated that CT in the ClotPro ECA reflects the plasma concentration of dabigatran in patients with NVAF. The ECA could potentially be used to assess the impact of dabigatran on a patient’s coagulation status.

Sarawak General Hospital, which is the only public access tertiary referral center in Sarawak State for all clinical specialties, was designated a hybrid hospital to treat both COVID-19 and non-COVID-19 patients. During the initial surge of patients admitted with COVID-19, there was also a corresponding increase in health-care workers (HCWs) detected with COVID-19 infection. The latter being isolated, and the large number of staff members that had come into contact with COVID-19 being quarantined from work, placed further strain on the health-care services. The staff mass screening strategy was a policy decision made by the hospital in response to infection among HCWs, and it aimed to reduce in-hospital transmission (particularly among asymptomatic staff), mitigate workforce depletion due to quarantining, and protect the health-care workforce. In this study, we assessed the detection rate of COVID-19 infection from staff mass testing over a five-week period, and described our experience of adopting this surveillance screening strategy alongside ongoing contact tracing and symptomatic screening strategies. Although it was thought that such periodic staff surveillance might be helpful in protecting the health-care workforce within a short period, the long-term implications, especially in settings with limited resources, is significant and therefore explored in this paper. Our findings might provide an evidence-based reference for the future planning of an optimal strategy with the least compromise in care for a larger proportion of non-COVID-19 patients amid efforts against COVID-19 in a large nonCOVID-designated hospital with hybrid status.

Background Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes, compared to those without diabetes. The complexity of previous 2009 ASE/EACVI algorithms makes diastolic function (DF) assessment challenging. Hence, prognostic value of LVDD estimates in clinical setting is not well-established. Objective To evaluate the impact of 2016 recommendations in estimates of LVDD and predicting cardiovascular outcomes in patients with diabetes and hypertension. Materials and methods A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients were clinically NYHA Class I, had no prior adverse cardiac events, and had preserved left ventricular (LV) ejection fraction on echocardiography at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LVDD. Both 2009 and 2016 algorithms were applied in DF assessment. All patients follow-up at 1 year to assess clinical outcomes. Results There were 65 (58.6%) female patients. Mean age was 59.86 (7.45); mean duration of diabetes was 10.5 (5.41). 55 (50.5%) patients had LV hypertrophy on echocardiography. Prevalence of LVDD (14.4% vs 55.0%) and elevated LV filling pressure (9.0% vs 26.1%) were lower with 2016 compared with 2009 recommendations. Prevalence of indeterminate DF was 18.0% and 12.6% according to 2016 and 2009 recommendations respectively. Concordance between 2016 and 2009 recommendations was fair (k=0.29, p None out of 45 patients who were diagnosed with indeterminate and normal DF according to 2016 and LVDD with 2009 algorithms developed MACE at 1 year. Out of 12 patients diagnosed with LVDD based on both 2016 and 2009 recommendations, 4 patients developed MACE at 1 year. 2016 recommendations showed better accuracy (sensitivity=80.0%; specificity=88.68%) than 2009 recommendations (sensitivity=80.0%; specificity= 45.28%) in predicting MACE at 1 year. Conclusions The application of 2016 recommendations results in lower prevalence of LVDD. The 2016 criteria detect more advanced cases and predict 1 year cardiovascular outcomes better. Further studies are warranted to investigate the prognostic impact of this criteria. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH), Ministry of Health Malaysia

BACKGROUND: Reports on healthcare worker antibody response to COVID-19 infection are scarce. We aim to determine the COVID-19 antibody prevalence among healthcare workers in a cardiology centre and the relationship between case definition criteria with the COVID-19 antibody result. METHODS: Convenience sampling was applied. Healthcare workers in Sarawak Heart Centre (SHC) cardiology, radiology, and emergency unit were recruited. A survey form on clinical symptoms and close contact history was distributed. HEALGEN COVID-19 IgG/IgM rapid test was performed using serum/ whole blood specimen. Staff with positive COVID-19 antibody results were referred to the infectious disease specialist for assessment. RESULTS: A total of 310 staff were screened. 220(71%) were female, and the mean age was 36±7.7 years old. 46(14.8%) staff reported having clinical symptoms at some stage from the end of January 2020 to the time of this surveillance. Number of staff who had a history of overseas travel, close contact with confirmed COVID-19 patients, or had visited places with identified COVID-19 clusters were 4(1.3%), 24(7.7%) and 24(7.7%) respectively. There were 14 staff (4.5%) with positive tests positive, 2 for IgM, and 12 for IgG. All those with positive antibody were subsequently tested negative with RT-PCR test. The history of having clinical symptoms and exposure to COVID-19 cluster area were independently associated with a positive IgG result. CONCLUSION: The application of COVID-19 antibody serology rapid tests could determine true exposure of staff to the infection and allow us to reassess existing measures of infection control within the hospital.

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 ; 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 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 The PIONEER-HF trial has demonstrated the safety of Sacubitril-Valsartan initiation during acute decompensated heart failure (ADHF) compared to Enalapril. The efficacy outcome was also addressed by the surrogate end point of reduction in NT-proBNP. However, the safety and efficacy of Sacubitril-Valsartan initiation during ADHF compared to initiation after ADHF was unknown. Objectives (1) To compare the safety and efficacy of Sacubitril-Valsartan initiation during ADHF(inpatient) to initiation after ADHF(outpatient). (2) To explore the echocardiogram parameters associated with Sacubitril-Valsartan initiation during ADHF(inpatient) versus after ADHF(outpatient). Methods We enrolled patients diagnosed with heart failure with reduced ejection fraction (HFrEF) initiated on Sacubitril-Valsartan from February 2017 to December 2018. The baseline characteristics, echocardiogram parameters (changes in LVEF and positive remodeling), composite safety outcomes (hypotension, interruption of Sacubitril-Valsartan and worsening of renal function), and efficacy outcomes (cardiac death, readmission for heart failure) were compared. Results Thirty-seven patients were identified out of which 21 patients started Entresto after ADHF (outpatient group) and 16 patients during ADHF (inpatient group). The median follow-up duration was 196 days (IQR: 105 to 328days). The baseline characteristics were similar between the 2 groups. Outpatient groups achieved a significantly higher maximally tolerable dose of Sacubitril-Valsartan compared to inpatient group (median 400mg/day versus 200mg/day, p = 0.008) despite a similar starting dose (median 100mg/day versus 100mg/day, p = 0.127). The composite efficacy outcomes were similar between the 2 groups (4.8% versus 18.8%, p = 0.296). The composite safety outcome was similar between the groups (18.8% versus 4.8%, HR5.70 p = 0.054, 95%CI 0.967 to 33.60). Both groups achieved a significant improvement in LVEF after initiation of Sacubitril-Valsartan therapy: mean LVEF 23.44 ± 7.88% to 34.30 ± 13.88% (p = 0.001) in outpatient group; mean LVEF 22.99 ± 11.31% to 38.81 ± 13.91% (p = 0.002) in inpatient group. Reverse remodeling (reduction of LVESV≥15%) was similar between the 2 groups (61.9% versus 50.0%, p = 0.506). Conclusions Among patients with HFrEF in ADHF, initiation of Sacubitril-Valsartan therapy during or after ADHF led to similar safety and efficacy. Overall, there was a significant improvement in LVEF and positive remodeling of the LV regardless of the timing of initiation of therapy.

Warfarin is an anticoagulant indicated for patients who had undergone mechanical heart valve(s) replacement (MHVR). In these patients, time in therapeutic range (TTR) is important in predicting the bleeding and thrombotic risks.This study aimed to describe the anticoagulation control of warfarin using TTR in patients with MHVR in a tertiary health care referral Center.Data were collected retrospectively by reviewing clinical notes of outpatients who attended international normalized ratio (INR) clinics in November 2015. Patients who had MHVR and who took warfarin were included. The data collected were demographics, relevant laboratory investigations, and patients' prior medical history. TTR was calculated using Rosendaal and traditional methods.A total of 103 patients with MHVR were recruited. The mean age was 51.72 ± 13.97 years and 46.6% were male. A total of 54.4% had mitral valve replacement (MVR), whereas 26.2% had aortic valve replacement (AVR). The mean TTR calculated using the Rosendaal method was 57.1%. There was no significant difference among patients with AVR, MVR, and both valves (AMVR) in terms of TTR (AVR vs. MVR vs. AMVR, 62.94 ± 23.08, 54.12 ± 21.62, 57.63 ± 17.47; p = 0.213). The average dose of warfarin for all groups was approximately 3 mg/day. Moreover, MVR, AVR, and AMVR patients who had TTR (Rosendaal method) ≤60% were 58.9%, 37.0%, and 45.0%, respectively. Only 4.8% had minor bleeding, whereas none had stroke in the period of TTR determination.Despite a majority of patients having60% TTR, there were low incidences of bleeding and stroke events in this center. There were no factors found to be associated with INR control in this study.

Aim: Recurrent thrombotic events still occur despite dual antiplatelet therapy in patient's post percutaneous coronary intervention (PCI) could be attributed to high on-treatment platelet reactivity. Methods: A 44-year-old male, who had staged PCI to left anterior descending (LAD) 2 weeks after an anterior MI, with a drug-coated stent was readmitted with new anterior STEMI 35 days later. Coronary angiogram revealed mid-stent thrombus in situ. He had further uncomplicated PCI. Platelet function testing and genotyping showed clopidogrel high on-treatment platelet reactivity and CYP2C19*3/*17 genotype. Ticagrelor was commenced. Results & conclusion: This case study is the first reported in Malaysia to document a patient with a CYP2C19*3/*17 genotype presenting with a stent thrombosis after an uncomplicated index PCI procedure.

Aim Despite aspirin therapy, acute coronary syndrome (ACS) patients are at risk of developing re-events owing to the aspirin resistance. This study sought to explore the possibility of utilizing miR-19b-1-5p as a suitable biomarker for aspirin resistance and future major adverse cardio-cerebrovascular (MACCE) events in the ACS patients. Methods Buffy coat from ACS (n=945) patients was used to measure the miR-19b-1-5p expression by RT-qPCR and Platelets function was determined by Multiplate® aggregometry testing. Furthermore, MACCE was collected over a mean follow-up time of 1.01±0.43 years. Linear regression concerning the relationship between miR-19b-1-5p expression and Multiplate® data and cox regression concerning MACCE were used for the analysis, to be able to adjust for confounding. Results Low miR-19b-1-5p expression was found to be related to aspirin resistance as could be observed from sustained platelet aggregation in the presence of aspirin (-Log-miR-19b-1-5p, (B (95% CI); 41.51 (5.09–77.93); p Conclusions Lower miR-19b-1-5p expression was found to be associated with sustained platelet aggregation on aspirin, an increased leucocyte count and the risk of MACCE in ACS patients. Therefore, miR-19b-1-5p could be a suitable marker for aspirin resistance and might predict future MACCE in ACS patients.

BackgroundSex and gender differences in acute coronary syndrome (ACS) have been well studied in the western population. However, limited studies have examined the trends of these differences in a multi-ethnic Asian population.ObjectivesTo study the trends in sex and gender differences in ACS using the Malaysian NCVD-ACS Registry.MethodsData from 24 hospitals involving 35,232 ACS patients (79.44% men and 20.56% women) from 1st.Jan 2012 to 31st.Dec 2016 were analysed. Data were collected on demographic characteristics, coronary risk factors, anthropometrics, treatments and outcomes. Analyses were done for ACS as a whole and separately for ST-segment elevation myocardial infarction (STEMI), Non-STEMI and unstable angina. These were then compared to published data from March 2006 to February 2010 which included 13,591 ACS patients (75.8% men and 24.2% women).ResultsWomen were older and more likely to have diabetes mellitus, hypertension, dyslipidemia, previous heart failure and renal failure than men. Women remained less likely to receive aspirin, beta-blocker, angiotensin-converting enzyme inhibitor (ACE-I) and statin. Women were less likely to undergo angiography and percutaneous coronary intervention (PCI) despite an overall increase. In the STEMI cohort, despite a marked increase in presentation with Killip class IV, women were less likely to received primary PCI or fibrinolysis and had longer median door-to-needle and door-to-balloon time compared to men, although these had improved. Women had higher unadjusted in-hospital, 30-Day and 1-year mortality rates compared to men for the STEMI and NSTEMI cohorts. After multivariate adjustments, 1-year mortality remained significantly higher for women with STEMI (adjusted OR: 1.31 (1.09–1.57), pConclusionWomen continued to have longer system delays, receive less aggressive pharmacotherapies and invasive treatments with poorer outcome. There is an urgent need for increased effort from all stakeholders if we are to narrow this gap.

Introduction: Obstructive sleep apnea (OSA) is a known risk factor for cardiovascular mortality and morbidity. Patients with OSA can present with clinical syndromes of heart failure, but most of them have preserved left ventricular ejection fraction (HFpEF). In Malaysia, data regarding left ventricular (LV) diastolic dysfunction among OSA patients is limited. Objective: To determine the prevalence of LV diastolic dysfunction and factors associated with LV diastolic dysfunction among OSA patients on positive airway pressure (PAP) treatment. Method: Cross-sectional study analyzing 47 patients with OSA on PAP treatment at Sarawak General Hospital. All patients underwent transthoracic echocardiography (TTE) and serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was measured. Results: The mean age was 52.2±14.24 years, mean body mass index (BMI) 39.80±89.7 kg/m2, and mean apnea hypopnea index (AHI) 60.7±29.1. The mean LVEF was 66.2±8.0% and 15.6% had LV diastolic dysfunction. Most patients (14.9%) had grade II and 2.1% with grade III LV diastolic dysfunction. Among the patients with LV diastolic dysfunction, NT-proBNP was significantly elevated (>125pg/ml) in 87.5% of patients (p 125pg/ml had positive predictive value, negative predictive value, sensitivity and specificity of 70%, 97.3%, 87.5% and 92.3% respectively to diagnose LV diastolic dysfunction. Conclusion: The prevalence of LV diastolic dysnfunction in OSA patients was 15.6%. Elevated NT-proBNP level (>125 pg/ml) was a useful biomarker in the diagnosis of LV diastolic dysfunction among OSA patients.

The objectives of this study are to compare steady-state trough (Cmin,ss) and peak (Cmax,ss) concentrations of rivaroxaban between Asians and Caucasians and to evaluate the relationship between rivaroxaban concentrations and prothrombin time/international normalized ratio (PT/INR). Recruited patients were advised on the time to take rivaroxaban. Cmin,ss and PT/INR were taken when patients arrived. Cmax,ss and PT/INR were drawn between 2 and 4 h later after the patient took rivaroxaban with food. Thirty patients were included in the analyses: 57% (n = 17) males and 43% (n = 13) females, 77% (n = 23) on 20 mg and 23% (n = 7) on 15 mg. Median PTtrough and PTpeak are moderately correlated with Cmin,ss (r2 = 0.43) and Cmax,ss (r2 = 0.49), respectively. Patients on 15 mg have lower Cmin,ss and Cmax,ss versus Caucasians [12 ng/ml vs. 57 ng/ml (Cmin,ss); 87 ng/ml vs. 229 ng/ml (Cmax,ss), p

The global burden of cardiovascular diseases (CVDs) has been increasing steadily over the past two decades. Although the age-standardized CVD mortality rates have fallen, the number of deaths due to CVDs continues to rise, with 17.9 million deaths attributed to them in 2015.1 A 12.5% increase in CVD deaths was seen between 2005 and 2015, with approximately 85% attributed to ischaemic heart disease (IHD) and stroke alone.1 The World Health Organization (WHO) predicts this trend to continue, with cardiovascular disease mortality projected to increase by 6 million by 2030.

Diabetes mellitus is a multifactorial chronic disease with many possible contributing factors. Performing anomaly detection on datasets collected from large epidemiological diabetes studies has the potential to unearth previously unknown factors contributing to the pathogenesis of diabetes mellitus. This paper proposes a novel method for detecting anomalous blood glucose trajectories of individuals in a longitudinal diabetes dataset. We formulate the anomaly detection problem as the problem of discovering contextually homogeneous communities in diabetes similarity graphs, from which individuals exhibiting unexpected progression of blood glucose could then be identified. Specifically, we employ community detection and Bayesian techniques to identify communities with the highest degree of anomaly. Our results successfully pointed to individuals with contrasting blood glucose trajectories, even though they demonstrated highly similar social demographics and lifestyle characteristics. Domain expert evaluation supports the efficacy of our proposed method.

Platelet inhibition remains the core pharmacotherapy component in patients undergoing emergency or primary percutaneous coronary interventions (PCI). This can be achieved using a number of intravenous and oral preparations. Intravenous (iv) antiplatelets include various glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors and the only available intravenous P2Y12 inhibitor, cangrelor. Available oral agents include aspirin and various P2Y12 inhibitors or their analogues. These are usually used in combination with the intention to maintain dual antiplatelet therapy (DAPT) for a period of time (generally up to 12 months) after the index PCI procedure.

Visual Abstract, Highlights • Targeted profiling of ceramides identified a 12-ceramide plasma signature that predicted 12-month cardiovascular death, MI, and stroke in 2 prospective cohorts of AMI patients. • Among coronary artery bypass grafting patients, plasma ceramides were higher in those with recent AMI compared with those without recent acute MI. • Analysis of rat ischemic myocardium revealed a consistent increase in ceramide levels and overexpression of 3 enzymes in ceramide biosynthesis., Summary We identified a plasma signature of 11 C14 to C26 ceramides and 1 C16 dihydroceramide predictive of major adverse cardiovascular events in patients with acute myocardial infarction (AMI). Among patients undergoing coronary artery bypass surgery, those with recent AMI, compared with those without recent AMI, showed a significant increase in 5 of the signature’s 12 ceramides in plasma but not simultaneously-biopsied aortic tissue. In contrast, a rat AMI model, compared with sham control, showed a significant increase in myocardial concentrations of all 12 ceramides and up-regulation of 3 ceramide-producing enzymes, suggesting ischemic myocardium as a possible source of this ceramide signature.

Background: Patients undergoing elective percutaneous coronary intervention (PCI) with drug-eluting stents (DES) who have impaired clopidogrel response, have a higher risk of subsequent major adverse cardiovascular events (MACE). Aim of the study: To establish the relationship between CYP2C19 genotype, clopidogrel responsiveness and 1–year MACE. Materials & methods: Aspirin/clopidogrel responses were assessed with Multiplate Analyzer and CYP2C19*2 allele by SpartanRx. Results: A total of 42.0% carried ≥1 CYP2C19*2 allele. Prevalences of aspirin and clopidogrel high on-treatment platelet reactivity (HPR; local cutoffs: 300 AU*min for aspirin and 600 AU*min for clopidogrel) were 11.5% and 19.8% respectively. In multivariate ana­lysis, clopidogrel HPR was found to be an independent predictor for 1–year MACE (adj HR: 3.48, p = 0.022 ). Conclusion: Having clopidogrel HPR could be a potentially modifiable risk factor guided by phenotyping.

Background: Delayed enhancement cardiovascular magnetic resonance imaging (DeCMRI) has become the preferred method for viability assessment. It is well established that viable dysfunctional myocardium has the potential for functional recovery after revascularization. Objective: Our objective is to evaluate whether viability assessment by DeCMRI affects clinical outcome in daily clinical practice. Methodology:We retrospectively studied 132 consecutive patients (114 male, mean age 59 ± 10 years) with ischaemic cardiomyopathy (Mean LVEF: 29.1 ± 14%) who underwent CMRI viability testing from 1st Jan-31st Dec 2015 in our centre. Patientswere divided into 3 groups: Group A: Viable myocardium- optimal medical therapy only (38.6%); B: Viable myocardium- revascularization done (29.5%); and C: Nonviable myocardium (29.5%). Results: Mean age for groups A, B and C were 61.2, 58.3, 56.2 years respectively, p=0.048. The proportion of triple vessel disease in each of the groups were 56.1%, 54.5% and 38.5% (p=0.44); whereas left main involvement was 31.7%, 21.2% and 19.2% respectively (p=0.43). Majority of group C patients did not undergo revascularisation (90%). Group B had statistically significant EF improvement (5.5%, SD 11.9) compared to Group A (-0.6%, SD 6.7) and Group C (-1.2%, SD 9.8), p value 0.014. Mortality at 1 year was significantly higher in Group A compared to Group Band C (31.4%, 7.7% and 12.8% respectively, p=0.009). MACE rates were also increased in Group A compared to the other two groups (41.2%, 20.5% and 27.0%, p=0.09). Odds Ratio for MACE was 3.01 (95% Cl 1.22 - 7.45) for Group A vs B and 2.8 (95% Cl 1.1 - 6.9) for Group A vs C. Conclusion: Patients with viable myocardium who did not undergo revascularization (group A) had the worst prognosis, even when compared to those with non-viable myocardium; with significantly higher 1-year mortality. Although not statistically significant, there was also a trend towards higher MACE in these patients. These findings emphasize that patients with poor LV function but viable myocardium need to undergo revascularisation and that optimal medical therapy alone is not sufficient.

To develop a new graph-based anomaly detection system for discovering unexpected Type 2 Diabetes Mellitus (T2DM) progression patterns from a longitudinal cohort study. LIFECARE (Life Course Study in Cardiovascular Disease Epidemiology) study is a multinational longitudinal cohort study that aims at