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Aims Inflammation plays a role in the pathogenesis of atrial fibrillation (AF). Pericarditis enhanced atrial arrhythmogenesis, but the role of the pericardium remains unclear in AF. Activation of the toll-like receptor 4 (TLR4) by binding to lipopolysaccharide (LPS) promotes cardiac electrical remodelling. In this study, we hypothesized that pericarditis may induce atrial arrhythmogenesis via pericardium–myocardium interactions by TLR4 signalling. Methods and results Pericarditis was induced in rabbits by injecting LPS (1–2 mg/kg) into the pericardium. Conventional microelectrodes were used to record the action potentials of left atrial (LA) posterior walls (LAPWs) and LA appendages (LAAs) with and without attached pericardium in the control or pericarditis-induced rabbits. Cytokine array was used to measure the expression levels of proinflammatory cytokines in control and LPS-treated pericardium. Compared with the controls, the LPS-treated pericardium had higher expressions of IL-1α, IL-8, and MIP-1β. Rapid atrial pacing-induced burst firing in LPS-treated LAPWs and LAAs, and in control LAPWs (but not in LAAs). The incidence of pacing-induced spontaneous activity and burst firing was increased by LPS-treated pericardium but was attenuated by the control pericardium. Moreover, burst firing induced by LPS-treated pericardium was blocked upon administration of the TLR4 inhibitor, TAK-242 (100 ng/mL), ryanodine receptor inhibitor (ryanodine, 3 μM), or calmodulin kinase II inhibitor (KN-93, 1 μM). Conclusions Healthy and inflamed pericardium differently modulate LPS-induced atrial arrhythmogenesis. Targeting pericardium via TLR4 signalling may be a novel therapeutic strategy for AF.

This study aimed to investigate the cost-effectiveness of low-dose rivaroxaban plus aspirin versus aspirin alone for patients with stable cardiovascular diseases in the Taiwan setting. We constructed a Markov model to project the lifetime direct medical costs and quality-adjusted life-years of both therapies. Transitional probabilities were derived from the COMPASS trial, and the costs and utilities were obtained from the Taiwan National Health Insurance Database and published studies. One-way, scenario, subgroup, and probabilistic sensitivity analyses were performed to assess the uncertainty. Incremental cost-effectiveness ratio was presented as the outcome. The threshold of willingness-to-pay was set at US$76,368 (3 times the gross domestic product per capita of Taiwan). All analyses were operated by TreeAge 2019 and Microsoft Excel. The incremental cost-effectiveness ratios of rivaroxaban plus aspirin versus aspirin alone in the patients with stable cardiovascular diseases, coronary artery diseases, and peripheral artery diseases were US$83,459, US$69,852 and −US$13,823 per quality-adjusted life-year gained, respectively. The probabilistic sensitivity analyses showed that the probabilities of cost-effectiveness for the regimen with rivaroxaban among those with cardiovascular diseases and coronary artery diseases were 44.1% and 65.3% at US$76,368. Low-dose rivaroxaban plus aspirin is less likely to be a cost-effective alternative to aspirin in secondary prevention for the patients with stable cardiovascular diseases; however, among these patients, the regimen may have pharmacoeconomic incentives for the group merely having chronic coronary artery diseases from the Taiwan national payer’s perspective. The pharmacoeconomic incentives are influenced by the drug price, event treatment fees, and willingness-to-pay threshold.

Unplanned patient readmission (UPRA) is frequent and costly in healthcare settings. No indicators during hospitalization have been suggested to clinicians as useful for identifying patients at high risk of UPRA. This study aimed to create a prediction model for the early detection of 14-day UPRA of patients with pneumonia. We downloaded the data of patients with pneumonia as the primary disease (e.g., ICD-10:J12*-J18*) at three hospitals in Taiwan from 2016 to 2018. A total of 21,892 cases (1208 (6%) for UPRA) were collected. Two models, namely, artificial neural network (ANN) and convolutional neural network (CNN), were compared using the training (n = 15,324, ≅70%) and test (n = 6568, ≅30%) sets to verify the model accuracy. An app was developed for the prediction and classification of UPRA. We observed that (i) the 17 feature variables extracted in this study yielded a high area under the receiver operating characteristic curve of 0.75 using the ANN model and that (ii) the ANN exhibited better AUC (0.73) than the CNN (0.50), and (iii) a ready and available app for predicting UHA was developed. The app could help clinicians predict UPRA of patients with pneumonia at an early stage and enable them to formulate preparedness plans near or after patient discharge from hospitalization.

This study aimed to investigate the cost-effectiveness of low-dose rivaroxaban plus aspirin versus aspirin alone for patients with stable cardiovascular diseases in the Taiwan setting.We constructed a Markov model to project the lifetime direct medical costs and quality-adjusted life-years of both therapies. Transitional probabilities were derived from the COMPASS trial, and the costs and utilities were obtained from the Taiwan National Health Insurance Database and published studies. One-way, scenario, subgroup, and probabilistic sensitivity analyses were performed to assess the uncertainty. Incremental cost-effectiveness ratio was presented as the outcome. The threshold of willingness-to-pay was set at US$76,368 (3 times the gross domestic product per capita of Taiwan). All analyses were operated by TreeAge 2019 and Microsoft Excel.The incremental cost-effectiveness ratios of rivaroxaban plus aspirin versus aspirin alone in the patients with stable cardiovascular diseases, coronary artery diseases, and peripheral artery diseases were US$83,459, US$69,852 and -US$13,823 per quality-adjusted life-year gained, respectively. The probabilistic sensitivity analyses showed that the probabilities of cost-effectiveness for the regimen with rivaroxaban among those with cardiovascular diseases and coronary artery diseases were 44.1% and 65.3% at US$76,368.Low-dose rivaroxaban plus aspirin is less likely to be a cost-effective alternative to aspirin in secondary prevention for the patients with stable cardiovascular diseases; however, among these patients, the regimen may have pharmacoeconomic incentives for the group merely having chronic coronary artery diseases from the Taiwan national payer's perspective. The pharmacoeconomic incentives are influenced by the drug price, event treatment fees, and willingness-to-pay threshold.

Percutaneous angioplasty (PTA) for dysfunctional hemodialysis is usually performed by radiologists, but not cardiologists, in Taiwan, so that the radiation dose in patients and physicians are usually unknown and related studies are rare. In this study, we are pioneering an investigation into the radiation dose in percutaneous angioplasty for arteriovenous shunt assembling and the effect of RADPAD device, a lead-free surgical drape containing Bi and Ba, on the decrease of a radiation dose in the non-targeted organs of the patient and also the operator. The radiation dose in a typical digital subtraction angiography (DSA) by the PTA protocol under a fixed field of view (FOV), was measured with optically simulated luminescent dosimeters arranged in a PIXY RS-102 anthropomorphic phantom. The results indicate that there is a significant dose reduction at the hands (0.022±0.002 mGy before treatment vs. 0.014±0.001 mGy after treatment; P=0.021), but not at the lens (0.027±0.003 mGy before treatment vs. 0.018±0.001 mGy after treatment; P=0.058), and the gonads (0.026±0.003 mGy before treatment vs. 0.020±0.001 mGy after treatment; P=0.058), of the cardiologist/operator after treatment with the RADPAD drape. At the patient's abdomen, the dose significantly decreased from 1.597±0.104 mGy to 0.031±0.002 mGy (P In conclusion, the RADPAD drape significantly reduced radiation exposure to the patient during the PTA for the arteriovenous shunt assembling, which is suggested should be applied to the current cardiac catheterization.

Hypertension continues to be an important public health concern because of its associated morbidity, mortality, and economic impact on society. The aims of this study are to compare the secular changes in age-stratified hypertension prevalence, incidence, co-morbidity, and 3 years of cardiovascular outcome in Taiwan in the years 2005 and 2010.We enrolled hypertensive individuals from the datasets of the Longitudinal Health Insurance Database (LHID) in 2005 and 2010 in Taiwan separately. We analyzed the hypertension prevalence, incidence, medication treatment, and associated morbidities. The risks of cardiovascular and cerebrovascular events and all-causes mortalities among the hypertensive individuals were evaluated in 3 years of follow-up.There was an increased prevalence of hypertension but decreased incidence of hypertension in those over 65 from 2005 to 2010. Dyslipidemia was the highest rate of co-morbidity in 2005 and 2010. The most frequent categories of anti-hypertensive agents prescribed was 1 or 2 for both 2005 and 2010. Calcium channel blockers were the most common anti-hypertensive agents prescribed, followed by Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers. After 3 years of follow-up, the risks of coronary artery disease (CAD), cerebrovascular diseases (CVD) as well as death were less in 2010 than in 2005 in Taiwan.Our study showed that hypertension individuals had an increased prevalence, younger age, decreased incidence, increased medication treatment associated with decreased the CAD, CVD, and mortalities in 2010 compared to 2005 in Taiwan.

Background The incidence of infective endocarditis (IE) is high in dialysis patients. Limited data are available on the risk factors for IE and long-term outcome after IE in dialysis patients, especially in Asian populations. Methods We used Taiwan National Health Insurance Research Database to design a longitudinal cohort study. 68,426 ESRD patients who began dialysis between 1999 and 2007 were included. The follow-up period was from the start of dialysis to death, end of dialysis, or end of 2008. Cox proportional hazards models were used to identify the risk factors for IE. Results IE was diagnosed in 502 patients during follow-up (201.4 per 100,000person-years). Diabetes mellitus (DM), congestive heart failure (CHF), cerebro-vascular accident (CVA), and rheumatic heart disease (RHD) (HR: 3.07, 95% CI: 1.99–4.75) were associated with an increasing risk of development of IE. The cumulative incidence rate of IE in patients with RHD was 1.4, 2.2, and 3.9% at 1, 3, and 5years. In-hospital mortality was 23.5%. Cumulative survival rates post-IE were 54.3% at 1year and only 35.3% at 5years. Conclusion Dialysis patients had a higher risk of IE. Those who were older and had DM, CHF, CVA, or especially RHD were at a greater risk. Dialysis patients with IE also had high mortality.

The anti-inflammatory and vasodilating effects of three selected dietary organic sulfur compounds (OSC), including diallyl disulfide (DADS), dimethyl disulfide (DMDS), and propyl disulfide (PDS), from Allium species were investigated. In the anti-inflammatory activity assay, the three OSC demonstrated significant inhibition of nitric oxide (NO) and prostaglandin E2 (PGE2) production in LPS-induced RAW 264.7 cells. The expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX-2) in activated RAW 264.7 cells was inhibited by the three OSC, indicating that the three OSC prevented the LPS-induced inflammatory response in RAW 264.7 cells. For the vasodilative assay, the three OSC were ineffective in producing NO in SVEC4-10 cells, but they did enhance prostacyclin (PGI2) production. The expression of COX-2 in SVEC4-10 cells was activated by DADS and DMDS. Pretreatment of SVEC4-10 cells with the three OSC decreased ROS generation in H2O2-induced SVEC4-10 cells. In addition, the three OSC significantly inhibited angiotensin-I converting enzyme (ACE). The up-regulation of PGI2 production and COX-2 expression by DADS and DMDS and the reduction of ROS generation by DADS, DMDS, and PDS in SVEC4-10 cells contributed to the vasodilative effect of the three OSC. Collectively, these findings suggest that DADS, DMDS, and PDS are potential anti-inflammatory and vasodilative mediators.

Background Diabetes is associated with development of end-stage renal disease (ESRD) dialysis, but it is not clear whether ESRD dialysis is a risk factor for new-onset diabetes (NODM). Methods Using the Taiwan National Health Insurance Research Database, we designed two cohort studies to determine the association between dialysis and diabetes. Analysis 1 estimated the hazard ratios (HR) of ESRD dialysis in 20,585 patients with type 2 diabetes (T2DM) and 82,340 gender- and age- matched controls without diabetes. Analysis 2 estimated the HRs of NODM in 18,489 ESRD patients undergoing dialysis and 73,956 gender- and age- matched controls without ESRD dialysis. The follow-up period was from 2000 to date of endpoint, the date of death, or December 31, 2008. Cox proportional models were used to estimate the relative hazards. Results In analysis 1, the incidence of ESRD dialysis was higher in the T2DM cohort than in the non-diabetes cohort (6.78 vs. 0.61 per 1,000 person-years; HR: 7.97; 95%CI: 7.05-8.00). In analysis 2, the incidence of NODM was higher in the ESRD dialysis cohort than in the without-ESRD dialysis cohort (22.84 vs. 13.99 per 1,000 person-years; HR: 1.40; 95% CI: 1.34-1.47). Conclusions ESRD dialysis and diabetes were bidirectionally associated. The relationship between T2DM and incident ESRD dialysis was much stronger than between ESRD dialysis and NODM. Further studies are needed to determine the mechanism of ESRD dialysis-related NODM.

Stroke is a common cause of death worldwide, but about 30% of ischemic stroke (IS) patients have no identifiable contributing risk factors. Because peptic ulcer disease (PUD) and vascular events share some common risk factors, we conducted a population-based study to evaluate the association between PUD and IS. We followed up a representative sample of 1 million residents of Taiwan using the National Health Insurance Research Database from 1997 to 2011. We defined patients who received medications for PUD and had related diagnosis codes as the PUD group, and a reference group matched by age and sex was sampled from those who did not have PUD. We also collected data on medical history and monthly income. The events of IS occurred after enrollment were compared between the 2 groups. The data were analyzed using Cox proportional hazard models at the 2-tailed significant level of 0.05. The PUD group had higher income and prevalence of hypertension, diabetes mellitus (DM), heart disease, and hyperlipidemia. They also had a higher risk of developing IS with an adjusted hazard ratio of 1.31 (95% confidence interval: 1.20–1.41). Other independent risk factors included male sex, older age, lower income, and co-morbidity of hypertension, diabetes mellitus (DM), and heart disease. PUD is a risk factor for IS, independent of conventional risk factors such as male sex, older age, lower income, and co-morbidity of hypertension, DM, and heart disease. Prevention strategies taking into account PUD should be developed and evaluated.

Radial artery occlusion (RAO) occurs in 2% to 18% of patients after transradial access (TRA) cardiac catheterization. Using a kaolin-filled pad (QuikClot) reduces compression time during TRA and might reduce RAO. We examined the RAO risk with the kaolin-filled pad after TRA cardiac catheterization. This was a prospective cross-sectional study of 260 patients who underwent TRA cardiac catheterization in a cardiac ward of a Medical Center from 2012 to 2016. Patients were randomly assigned to 1 of 2 groups: the case group (n = 130) was postoperatively treated with a kaolin-filled pad, and the control group (n = 130) was treated with conventional hemostasis. Color duplex ultrasound was used to evaluate the 24-hour and 1-month postoperative radial artery flow velocity, diameter, patency, and RAO risk. RAO risk was not significantly different between the case and control groups after 24 hours (4.6% vs 5.4%, P = .776) or after 1 month (5.4% vs 6.1%, P = .789), regardless of whether it was a first TRA cardiac catheterization (after 24 hours [P = .153] or after 1month [P = .617], respectively) or a repeated TRA cardiac catheterization (after 24 hours [P = .754] or after 1month [P = .753], respectively). Using a kaolin-filled pad after TRA cardiac catheterization did not significantly reduce RAO risk compared with conventional hemostasis.

Background Atrial fibrillation (AF) is the most common sustained arrhythmia, and pulmonary veins (PVs) play a critical role in triggering AF. Angiotensin (Ang)-(1-7) regulates calcium (Ca2+) homeostasis and also plays a critical role in cardiovascular pathophysiology. However, the role of Ang-(1-7) in PV arrhythmogenesis remains unclear. Materials and methods Conventional microelectrodes, whole-cell patch-clamp, and the Fluo-3 fluorimetric ratio technique were used to record ionic currents and intracellular Ca2+ in isolated rabbit PV preparations, and in single isolated PV cardiomyocytes, before and after administration of Ang-(1-7). Results Ang (1-7) concentration-dependently (0.1, 1, 10, and 100 nM) decreased PV spontaneous electrical activity. Ang-(1-7) (100 nM) decreased the late-sodium (Na+), L-type Ca2+, and Na+-Ca2+ exchanger currents, but did not affect the voltage-dependent Na+ current in PV cardiomyocytes. In addition, Ang-(1-7) decreased intracellular Ca2+ transient and sarcoplasmic reticulum Ca2+ content in PV cardiomyocytes. A779 (a Mas receptor blocker, 3 μM), L-NAME (a NO synthesis inhibitor, 100 μM) or wortmannin (a specific PI3K inhibitor, 10 nM) attenuated the effects of Ang-(1-7) (100 nM) on PV spontaneous electric activity. Conclusion Ang-(1-7) regulates PV electrophysiological characteristics and Ca2+ homeostasis via Mas/PI3K/eNOS signaling pathway. This article is protected by copyright. All rights reserved.

The clinical effect of cisapride on QT intervals was prospectively studied.Consecutive adult patients were recruited in whom cisapride was indicated for gastroesophogeal reflux, gastric ulcer, duodenal ulcer, diabetic gastroparesis or chronic constipation refractory to laxatives. Exclusion criteria included disorders and medications affecting cardiac conduction, electrolyte homeostasis, drug clearance and membrane stability.Seventy-five patients were included and followed at 1 to 2 week intervals. Patients took cisapride 5 mg thrice daily for 1 to 4 weeks (lower dose stage), followed by 10 mg thrice daily for another 1 to 4 weeks (higher dose stage). Twelve-lead ECGs were performed before commencing cisapride (group B), at completion of the lower dose stage (group L) and at completion of the higher dose stage (group H).No patients experienced presyncope or syncope. Seventeen patients failing to comply, and 7 complaining of abdominal discomfort or diarrhea were excluded, leaving 51 participants. Group H's corrected QT interval (QTc) was longer than group B's by 13+/-15 ms (P0.001), and longer than group L's by 7+/-11 ms (P0.001). Group L's QTc was longer than group B's by 7+/-21 ms (P0.05). QT dispersion did not differ significantly among groups. Neither torsade de pointe nor ventricular tachycardia were noted in Holter monitoring of 33 patients during the higher dose stage.cisapride dose-dependently prolongs the QT interval. Further study is needed to examine the arrhythmogenicity of cisapride in higher doses and for longer durations.

To assess the therapeutic effect of melatonin on heat-induced acute lung inflammation and injury in rats. Heatstroke was induced by exposing anesthetized rats to heat stress (36 °C, 100 min). Rats were treated with vehicle or melatonin (0.2, 1, 5 mg/kg) by intravenous administration 100 min after the initiatioin of heatstroke and were allowed to recover at room temperature (26 °C). The acute lung injury was quantified by morphological examination and by determination of the volume of pleural exudates, the number of polymorphonuclear (PMN) cells, and the myeloperoxidase (MPO) activity. The concentrations of tumor necrosis factor, interleukin (IL)-1β, IL-6, and IL-10 in bronchoalveolar fluid (BALF) were measured by ELISA. Nitric oxide (NO) level was determined by Griess method. The levels of glutamate and lactate-to-pyruvate ratio were analyzed by CMA600 microdialysis analyzer. The concentrations of hydroxyl radicals were measured by a procedure based on the hydroxylation of sodium salicylates leading to the production of 2,3-dihydroxybenzoic acid (DHBA). Melatonin (1 and 5 mg/kg) significantly (i) prolonged the survival time of heartstroke rats (117 and 186 min vs 59 min); (ii) attenuated heatstroke-induced hyperthermia and hypotension; (iii) attenuated acute lung injury, including edema, neutrophil infiltration, and hemorrhage scores; (iv) down-regulated exudate volume, BALF PMN cell number, and MPO activity; (v) decreased the BALF levels of lung inflammation response cytokines like TNF-alpha, interleukin (IL)-1β, and IL-6 but further increased the level of an anti-inflammatory cytokine IL-10; (vi) reduced BALF levels of glutamate, lactate-to-pyruvate ratio, NO, 2,3-DHBA, and lactate dehydrogenase. Melatonin may improve the outcome of heatstroke in rats by attenuating acute lung inflammation and injury.

Aims Many issues regarding atrioventricular nodal re-entry (AVNR) remain unexplored; however, no stable animal model for the study of AVNR has yet been developed. Clinically, AVNR is found more commonly in adults than children. We attempt to characterize AV nodal functional properties and inducibility of AVNRT using rabbits of three different age groups since we hypothesize that the inducibility of AVNR may increase as the subject ages. Methods and results We evaluated the inducibility of AVNR and the functional characteristics of the AV node in 6-month-old (Group 1), 2-month-old (Group 2), and at 1-week-old (Group 3) rabbits using a well-established rabbit heart model. We found that the inducibility of AVNR was higher in the 2-month-old group, compared with the 1-week-old group (30%). There was no functional difference between the two older groups (6-month-old and 2-month-old groups), however the youngest group (Group 3) showed better AV nodal functional properties. Regarding the correlation between inducibility and nodal functional properties, subgroups with AVNR demonstrated a longer AH maximum (AHmax) compared with the non-re-entry group, although there is no difference in age-adjusted AHmax. Regarding the correlation between inducibility and nodal functional properties, for the 1-week-old rabbits, subgroups with AVNR demonstrated a shorter AH minimum compared with the non-re-entry group (39.0 vs. 61.0, P = 0.017). Conclusion Our results demonstrate that both 2-month-old and 6-month-old rabbits represent stable models for AVNR. Longer AH conduction time may lead to greater re-entry inducibility.

Although inducing mild hypothermia (32 °C) in animal models of cardiac arrest with highly attenuated cardiac and neurological injury, the protective effects of hypothermia molecular mechanisms were not fully elucidated, and thus, were examined here on the H9c2 rat ventricular myoblasts that underwent cell loss as well as apoptosis in conditions of simulated ischemia, represented by serum withdrawal plus hypoxia. The H9c2 cells apoptosis was evidenced by flow cytometry-, DNA fragmentation-, and caspase 3 activation-increased apoptotic cells (Annexin-V positive and propidium iodide negative). For the simulated ischemia, both cell loss and apoptosis of these cardiomyoblasts were associated with downregulated small molecular weight proteins (heat shock protein 20, heat shock protein 27, and α B-crystallin). Mild hypothermia significantly reduced the ischemia-induced apoptosis, small molecular weight proteins downregulation, and cell viability cut. Conclusively, hypothermia may inhibit simulated ischemia-induced apoptosis in cardiomyocytes by restoring normal small molecular weight proteins expression.

Objectives To examine whether the strengths of the associations between chronic diseases and overall choking differ from those of the associations between chronic diseases and only food-related choking. Design This cross-sectional study used nationwide multiple cause mortality files. Setting The USA. Participants Older adults aged 65 years or more died between 2009 and 2013. Main outcome measures Mortality ratio (observed/expected) of number of deaths from both causes (chronic diseases and choking) and 95% CIs. Results We identified 76543 deaths for which the death certificates report choking (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes W78, W79 and W80 combined) as a cause of death and only 4974 (6.5%) deaths were classified as food-related choking (ICD-10 code W79). Schizophrenia, Parkinson9s disease, Alzheimer9s disease and oral cancer are four chronic diseases that had significant associations with both overall and food-related choking. Stroke, larynx cancer and mood (affective) disorders had significant associations with overall choking, but not with food-related choking. Conclusions We suggest using overall choking instead of only food-related choking to better describe the associations between chronic diseases and choking.

Thrombomodulin is an endothelial glycoprotein that decreases thrombin activity and activates protein C. A recent study has shown that G-33A promoter mutation of the thrombomodulin gene occurs particularly in Asians. In this study, we analyzed the distribution of G-33A mutation in the promoter region of the thrombomodulin gene in the Chinese population and determined whether the mutation might be a risk for coronary artery disease (CAD). In addition, the influence of this mutation on plasma soluble thrombomodulin levels in patients with CAD was also examined. We studied 320 consecutive patients (mean age 63 years; 73% men) with CAD and 200 age- and sex-matched control subjects. Screening for thrombomodulin G-33A promoter mutation was conducted using polymerase chain reaction, single-strand conformation polymorphism, and direct deoxyribonucleic acid sequencing. The frequency of the G-33A mutation (GA+AA genotypes) was significantly higher in the CAD group (23.8% vs 15.5%, odds ratio [OR] 1.70, p = 0.031). Multiple logistic regression analysis showed that the mutation was an independent risk factor (OR 1.81, p = 0.016) for CAD, as was hypertension (OR 1.44, p = 0.040), diabetes mellitus (OR 2.50, p0.001), and smoking (OR 2.15, p0.001). In CAD patients with GG genotype, the soluble thrombomodulin level increased with the extent of CAD (36 +/- 15 vs 47 +/- 18 vs 55 +/- 36 ng/ml in 1-, 2-, or 3-vessel CAD, p0.001). However, in CAD patients with G-33A mutation, there was no difference between the levels of soluble thrombomodulin (39 +/- 17 vs 37 +/- 15 vs 42 +/- 18 ng/ml, p = NS) in 1-, 2-, or 3-vessel CAD. Our observations suggest that there is a significant association of the G-33A mutation in thrombomodulin gene with CAD, and this mutation may influence the soluble thrombomodulin levels in patients with CAD.

A 71-year-old woman presented with dyspnea on exertion for one year. On auscultation, a grade 3/6 systolic murmur was heard at the upper sternal border. Chest radiographs (Figure 1, A and B) revealed a huge calcified lesion …

A 66-year-old man, with a history of hypertension and dyslipidaemia, was seen in our outpatient department. After a myocardial infarction in 2009, percutaneous transarterial coronary angioplasty and stenting for proximal and distal stenoses of his left anterior descending coronary artery was done. When seen for follow-up, he complained of occasional dyspnoea on exertion. Physical examination showed Quincke’s sign, Traube’s sign, and Duroziez’s sign. Electrocardiogram showed evidence of left ventricular hypertrophy, and chest radiography showed that the apex of the heart was displaced down and to the left (fi gure). Echocardiography showed severe eccentric aortic regurgitation and moderate mitral regurgitation.

A 52-year-old man complained of dyspnea on exertion for 1 month. On auscultation, a grade 3/6 to-and-fro murmur was heard at the left lower sternal border and was well transmitted to the apex. Fig 1⇓ is the transesophageal echocardiographic image of this patient at that time. Figs 2⇓ and 3⇓ were produced by cardiac catheterization. There was no significant pressure gradient among aorta, subaortic chamber, and left ventricle. The patient underwent open-heart surgery several days later.Surgery revealed a …

Patient initials or identifier number A 53 years old woman without systemic disease presented to the emergency department because of several episodes of atypical chest pain and palpitations. ### Relevant clinical history and physical exam Her general physical examination showed decreased