Kwok-Fai Lam

The University of Hong Kong, Hong Kong, Hong Kong

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Publications (22)122.23 Total impact

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    ABSTRACT: Current risk schemes to predict ischemic stroke and intracranial hemorrhage (ICH) in atrial fibrillation (AF) are derived primarily using Caucasian population. To describe the risk of ischemic stroke and ICH in a large contemporary 'real world' cohort of Chinese AF patients in Hong Kong with detailed long-term follow-up. This was an observational study using a hospital-based cohort of Chinese patients with non-valvular AF. Among 9,727 patients with non-valvular AF (age 76.9±12.5 years, 52.1% female), 3,881 patients (39.9%) did not received anti-thrombotic therapy, whilst 3,934 patients (40.4%) were on aspirin; and 1,912 (19.7%) on warfarin. After a mean follow-up of 3.19 years, 847 (21.8%) patients without antithrombotic therapy developed ischemic strokes (annual risk 9.28% [95%CIs: 8.89-9.70%]). There was a progressively increase in annual risk of ischemic stroke with increasing CHADS2 and CHA2DS2VASc scores. The c-statistics revealed that CHA2DS2-VASc scores (0.525; 95%CI:0.509-0.541, P=0.017) was better than CHADS2 scores (0.506; 95%CI:0.490-0.522, P=0.584) in predicting ischemic stroke. The use of aspirin and warfarin were associated with reduced annual risk of ischemic stroke by 18.7% and 52.7%, respectively (P<0.05). The annual incidence of ICH in patients on aspirin and warfarin were 0.77%/year and 0.80%/year, respectively. The adjusted net-clinical-benefit favored warfarin over aspirin, or no therapy for almost all Chinese AF patients CHA2DS2-VASc score≥1. Chinese AF patients are at high risk of ischemic stroke. Analysis of the net-clinical-benefit favors the use of warfarin over aspirin or no therapy for stroke prevention in a broad range of Chinese AF patients.
    Heart rhythm: the official journal of the Heart Rhythm Society 04/2014; 11(8). DOI:10.1016/j.hrthm.2014.04.021 · 4.56 Impact Factor
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    ABSTRACT: Background Current risk schemes to predict ischemic stroke and intracranial hemorrhage (ICH) in atrial fibrillation (AF) are derived primarily using Caucasian population. Objective To describe the risk of ischemic stroke and ICH in a large contemporary ‘real world’ cohort of Chinese AF patients in Hong Kong with detailed long-term follow-up. Method This was an observational study using a hospital-based cohort of Chinese patients with non-valvular AF. Results Among 9,727 patients with non-valvular AF (age 76.9±12.5 years, 52.1% female), 3,881 patients (39.9%) did not received anti-thrombotic therapy, whilst 3,934 patients (40.4%) were on aspirin; and 1,912 (19.7%) on warfarin. After a mean follow-up of 3.19 years, 847 (21.8%) patients without antithrombotic therapy developed ischemic strokes (annual risk 9.28% [95%CIs: 8.89-9.70%]). There was a progressively increase in annual risk of ischemic stroke with increasing CHADS2 and CHA2DS2VASc scores. The c-statistics revealed that CHA2DS2-VASc scores (0.525; 95%CI:0.509-0.541, P=0.017) was better than CHADS2 scores (0.506; 95%CI:0.490-0.522, P=0.584) in predicting ischemic stroke. The use of aspirin and warfarin were associated with reduced annual risk of ischemic stroke by 18.7% and 52.7%, respectively (P<0.05). The annual incidence of ICH in patients on aspirin and warfarin were 0.77%/year and 0.80%/year, respectively. The adjusted net-clinical-benefit favored warfarin over aspirin, or no therapy for almost all Chinese AF patients CHA2DS2-VASc score≥1. Conclusion Chinese AF patients are at high risk of ischemic stroke. Analysis of the net-clinical-benefit favors the use of warfarin over aspirin or no therapy for stroke prevention in a broad range of Chinese AF patients.
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    ABSTRACT: Exercise capacity is reduced in patients with end-stage renal disease on maintenance home peritoneal dialysis therapy, although the potential mechanisms and clinical implications remain unclear. Cross-sectional study. 95 ambulatory prevalent and incident peritoneal dialysis patients in a well-established renal dialysis center (mean age, 58.26 ± 12.6 [SD] years; 63% men; mean duration of peritoneal dialysis therapy, 3.2 ± 4.1 years). Estimated volume status using spectral bioelectrical impedance, echocardiography-derived hemodynamic parameters. Exercise capacity measured as peak oxygen consumption using symptom-limiting treadmill exercise testing. Exercise capacity was reduced in 96% of patients and severely reduced in 65%. Extracellular to intracellular fluid volume ratio showed the strongest correlation with reduced exercise capacity (R = -0.63; P < 0.001) and was superior to age, pulmonary capillary wedge pressure (E:E' ratio), lean tissue mass index, and hemoglobin and albumin levels in predicting exercise intolerance. Relatively small sample size and echocardiogram that was performed only at rest. There was a strong relationship between body extracellular to intracellular fluid volume ratio and exercise capacity in peritoneal dialysis patients. These findings provide new evidence for a connection between fluid distribution, muscle mass, and exercise capacity. Therapeutic strategies targeting fluid status and muscle mass may improve the exercise capacity of patients on peritoneal dialysis therapy.
    American Journal of Kidney Diseases 07/2013; 62(5). DOI:10.1053/j.ajkd.2013.05.016 · 5.76 Impact Factor
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    ABSTRACT: Background Early identification of individuals who are at risk of developing atrial fibrillation (AF) and ischemic stroke may enable a closer surveillance and thus prompt initiation of oral anticoagulation for stroke prevention. Objective This study sought to investigate whether congestive heart failure, hypertension, age ≥ 75 years, diabetes, previous stroke (CHADS2) and CHA2DS2–vascular disease, age 65–74 years, sex category (CHA2DS2–VASc) scores can predict new-onset AF and/or ischemic stroke in patients presenting with arrhythmic symptoms. Methods and results We prospectively followed up 528 patients (68.5 ± 10.6 years, male 46.2 %) presented for assessment of arrhythmic symptoms but without any documented arrhythmia, including AF for development of new-onset AF and/or ischemic stroke. Their mean CHADS2 and CHA2DS2–VASc scores on presentation were 1.3 ± 1.3 and 2.3 ± 1.5, respectively. After 6.1 years, 89 patients (16.8 %, 2.77 per 100 patient-years) had documented AF, and 65 patients (12.3 %, 2.0 per 100 patient-years) suffered stroke. Both the CHADS2 (C statistic 0.63, 95 % confidence interval (CI) 0.58–0.67, P < 0.0001, optimal cutoff at 1) and CHA2DS2–VASc (C statistic 0.63, 95 % CI 0.59–0.67, P < 0.0001, optimal cutoff at 2) scores provided similar prediction for the new-onset AF. Similarly, CHADS2 (C statistic 0.69, 95 % CI 0.65–0.73, P < 0.0001, optimal cutoff at 2) and CHA2DS2–VASc (C statistic 0.69, 95 % CI 0.65–0.73, P < 0.0001, optimal cutoff at 2) have compatible efficacy for stroke prediction in this Chinese population. Conclusion The CHADS2 and CHA2DS2–VASc scores can be used in patients who presented with arrhythmic symptoms to identify those who are at risk with developing new-onset clinical AF and ischemic stroke for close clinical surveillance and early intervention.
    Journal of Interventional Cardiac Electrophysiology 06/2013; 37(1). DOI:10.1007/s10840-012-9776-0 · 1.55 Impact Factor
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    ABSTRACT: Long non-coding RNAs (lncRNAs) represent the leading edge of cancer research, and have been implicated in cancer biogenesis and prognosis. We aimed to identify lncRNA signatures that have prognostic values in glioblastoma multiforme (GBM). Using a lncRNA-mining approach, we performed lncRNA expression profiling in 213 GBM tumors from The Cancer Genome Atlas (TCGA), randomly divided into a training (n=107) and a testing set (n=106). We analyzed the associations between lncRNA signatures and clinical outcome in the training set, and validated the findings in the testing set. We also validated the identified lncRNA signature in another two independent GBM data sets from Gene Expression Omnibus (GEO), which contained specimens from 68 and 101 patients, respectively. We identified a set of six lncRNAs that were significantly associated with overall survival in the training set (P ≤ 0.01). Based on this six-lncRNA signature, the training-set patients could be classified into high-risk and low-risk subgroups with significantly different survival (HR =2.13, 95% CI = 1.38-3.29; P = 0.001). The prognostic value of this six-lncRNA signature was confirmed in the testing set and the two independent data sets. Further analysis revealed that the prognostic value of this signature was independent of age and O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status. The identification of the prognostic lncRNAs indicates the potential roles of lncRNAs in GBM pathogenesis. This six-lncRNA signature may have clinical implications in the subclassification of GBM.
    Neurobiology of Disease 05/2013; DOI:10.1016/j.nbd.2013.05.011 · 5.62 Impact Factor
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    ABSTRACT: OBJECTIVE Diabetes mellitus (DM) is a well-established risk factor for coronary artery disease. Nonetheless, it remains unclear whether DM contributes to sudden cardiac death in patients who survive myocardial infarction (MI). The objective of this study was to compare the incidence of sudden cardiac death post-MI in diabetic and nondiabetic patients with no residual myocardial ischemia.RESEARCH DESIGN AND METHODSA total of 610 consecutive post-MI patients referred to a cardiac rehabilitation program with negative exercise stress test were studied.RESULTSOf these, 236 patients had DM at baseline. Over a mean follow-up of 5 years, 67 patients with DM (28.4%) and 76 of 374 patients without DM (20.2%) had died with a hazard ratio (HR) of 1.74 (95% CI: 1.28-2.56; P < 0.001). Patients with DM also had a higher incidence of cardiac death (1.84 [1.16-3.21]; P = 0.01), principally due to a higher incidence of sudden cardiac death (2.14 [1.22-4.23]; P < 0.001). Multiple Cox regression analysis revealed that only DM (adjusted HR: 1.9 [95% CI: 1.04-3.40]; P = 0.04), left ventricular ejection fraction (LVEF) ≤30% (3.6 [1.46-8.75]; P < 0.01), and New York Heart Association functional class >II (4.2 [1.87-9.45]; P < 0.01) were independent predictors for sudden cardiac death. Among patients with DM, the 5-year sudden cardiac death rate did not differ significantly among those with LVEF ≤30%, LVEF 31-50%, or LVEF >50% (8.8 vs. 7.8 vs. 6.8%, respectively; P = 0.83).CONCLUSION Post-MI patients with DM, even in the absence of residual myocardial ischemia clinically, were at higher risk of sudden cardiac death than their non-DM counterparts.
    Diabetes care 08/2012; 35(12). DOI:10.2337/dc12-0118 · 7.74 Impact Factor
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    ABSTRACT: To investigate the relation between baseline frequency of premature atrial complexes (PACs) and new atrial fibrillation (AF) and adverse cardiovascular events. Four hundred and twenty-eight patients without AF or structural heart disease undergoing 24 h electrocardiography monitoring for palpitations, dizziness, or syncope were recruited. One hundred and seven patients with number of PACs at the top quartile (i.e. > 100PACs/day) were defined to have frequent PACs. After 6.1-year follow-up, 31 patients (29%) with frequent PACs developed AF compared with 29 patients (9%) with PACs ≤ 100/day (P< 0.01). Cox regression analysis revealed that frequent PACs [hazard ratio (HR): 3.22 (95% confidence interval (CI): 1.9-5.5; P< 0.001)], age >75 years (HR: 2.3; 95% CI: 1.3-3.9; P= 0.004), and coronary artery disease (HR: 2.5; 95% CI: 1.4-4.4; P= 0.002) were independent predictors for new AF. Concerning the composite endpoint (ischaemic stroke, heart failure, and death), patients with frequent PACs were more at risk than those without (34.5 vs. 19.3%) (HR: 1.95; 95% CI: 1.37-3.50; P= 0.001). Cox regression analysis showed that age >75 years (HR: 2.2; 95% CI: 1.47-3.41; P< 0.001), coronary artery disease (HR: 2.2, 95% CI: 1.42-3.44, P< 0.001), and frequent PACs (HR: 1.6; 95% CI: 1.04-2.44; P= 0.03) were independent predictors for the secondary composite endpoint. Frequent PACs predict new AF and adverse cardiovascular events.
    Europace 12/2011; 14(7):942-7. DOI:10.1093/europace/eur389 · 3.05 Impact Factor
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    ABSTRACT: Little is known about the efficacy of proton pump inhibitors compared with H(2) receptor antagonists in preventing adverse upper gastrointestinal complications in patients with acute coronary syndrome (ACS) or ST elevation myocardial infarction (STEMI) receiving aspirin, clopidogrel, and enoxaparin or thrombolytics. The objective of this study was to compare the efficacies of esomeprazole and famotidine in preventing gastrointestinal complications. A double-blind, randomized, controlled trial was performed in patients receiving a combination of aspirin, clopidogrel, and either enoxaparin or thrombolytics. Patients received either esomeprazole (20 mg nocte) or famotidine (40 mg nocte) orally for 4-52 weeks, depending on the duration of dual antiplatelet therapy. The primary end point was upper gastrointestinal bleeding (GIB), perforation, or obstruction from ulcer/erosion (http://www.clinicaltrials.gov NCT00683111). In all, 311 patients were recruited, with 163 and 148 patients in the esomeprazole and famotidine groups, respectively. Mean (s.d.) follow-up was 19.2 (17.6) and 17.6 (18.0) weeks, respectively. One (0.6%) patient in the esomeprazole group and 9 (6.1%) in the famotidine group reached the primary end point (log-rank test, P=0.0052, hazard ratio=0.095, 95% confidence interval: 0.005-0.504); all had upper GIB. In patients with ACS or STEMI, esomeprazole is superior to famotidine in preventing upper gastrointestinal complications related to aspirin, clopidogrel, and enoxaparin or thrombolytics.
    The American Journal of Gastroenterology 11/2011; 107(3):389-96. DOI:10.1038/ajg.2011.385 · 9.21 Impact Factor
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    ABSTRACT: Previous studies showed that esomeprazole does not interfere significantly with the platelet inhibitory effect of clopidogrel. It is unknown whether famotidine, a histamine 2 receptor antagonist, interacts with clopidogrel. This double-blind, randomized study aimed to compare the influence of esomeprazole and famotidine on the platelet inhibitory effect of clopidogrel. Patients with acute coronary syndrome or elective percutaneous coronary interventions treated with aspirin and clopidogrel cotherapy were randomized to receive esomeprazole 20 mg daily or famotidine 40 mg daily. Platelet reactivity units (PRUs) were measured at baseline and on day 28. The primary analysis involved the PRU values on day 28. There were 44 patients in the esomeprazole group and 44 in the famotidine group. The baseline PRUs of the 2 groups were comparable (esomeprazole vs famotidine, 229.1 ± 85.6 vs 220.4 ± 83.0, P = .63). The PRUs on day 28 were 242.6 ± 89.7 and 237.5 ± 79.2 in the groups receiving esomeprazole and famotidine, respectively (mean difference 5.1, 95% CI -30.8 to 41.0, P = .78). The platelet inhibitory effect of clopidogrel was not significantly different between patients receiving esomeprazole and those receiving famotidine. Neither esomeprazole nor famotidine reduced the platelet inhibitory effect of clopidogrel. (Clinicaltrial.gov Identifier NCT01062516).
    American heart journal 11/2011; 162(5):870-4. DOI:10.1016/j.ahj.2011.08.007 · 4.56 Impact Factor
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    ABSTRACT: To analyze the regular dental care behavior and prevalence of edentulism in adult Danes, reported in sequential cross-sectional oral health surveys by the application of a marginal approach to consider the possible clustering effect of birth cohorts. Data from four sequential cross-sectional surveys of non-institutionalized Danes conducted from 1975-2005 comprising 4330 respondents aged 15+ years in 9 birth cohorts were analyzed. The key study variables were seeking dental care on an annual basis (ADC) and edentulism. For the analysis of ADC, survey year, age, gender, socio-economic status (SES) group, denture-wearing, and school dental care (SDC) during childhood were considered. For the analysis of edentulism, only respondents aged 35+ years were included. Survey year, age, gender, SES group, ADC, and SDC during childhood were considered as the independent factors. To take into account the clustering effect of birth cohorts, marginal logistic regressions with an independent correlation structure in generalized estimating equations (GEE) were carried out, with PROC GENMOD in SAS software. The overall proportion of people seeking ADC increased from 58.8% in 1975 to 86.7% in 2005, while for respondents aged 35 years or older, the overall prevalence of edentulism (35+ years) decreased from 36.4% in 1975 to 5.0% in 2005. Females, respondents in the higher SES group, in more recent survey years, with no denture, and receiving SDC in all grades during childhood were associated with higher probability of seeking ADC regularly (P < 0.05). The interaction of SDC and age (P<0.0001) was significant. The probabilities of seeking ADC were even higher among subjects with SDC in all grades and aged 45 years or older. Females, older age group, respondents in earlier survey years, not seeking ADC, lower SES group, and not receiving SDC in all grades were associated with higher probability of being edentulous (P<0.05). With the use of GEE, the potential clustering effect of birth cohorts in sequential cross-sectional oral health survey data could be appropriately considered. The success of Danish dental health policy was demonstrated by a continued increase of regular dental visiting habits and tooth retention in adults because school dental care was provided to Danes in their childhood.
    BMC Oral Health 03/2011; 11:9. DOI:10.1186/1472-6831-11-9 · 1.15 Impact Factor
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    ABSTRACT: Patients with rheumatoid arthritis (RA) are prone to premature atherosclerosis. We hypothesize that depletion of circulating endothelial progenitor cells (EPC) related to RA can contribute to the development of atherosclerosis. We studied coronary calcifications by multidetector computed tomography and their relationship with different subtypes of circulating EPC in 70 patients with RA and 35 age- and sex-matched controls (mean age 54.1 +/- 10.2 yrs, 87% were women). The presence of coronary atherosclerosis was defined as an Agatston score > or = 10. Four subpopulations of EPC were determined by flow cytometry on the basis of surface expression of CD34, CD133, and KDR antigen: CD34+, CD34/KDR+, CD133+, and CD133/KDR+ EPC, respectively. Among those with RA, 15 patients (21%) had coronary atherosclerosis. The mean Agatston score was higher (61.8 +/- 201.7 vs 0.14 +/- 0.69; p = 0.01) and coronary atherosclerosis was more prevalent (21.4% vs 0%; p < 0.01) in patients with RA compared to controls. RA patients with coronary atherosclerosis were older (66.2 +/- 6.9 vs 51.5 +/- 16.2 yrs; p < 0.01), had higher prevalence of hypertension (46.7% vs 14.5%; p = 0.01), and had lower CD133/KDR+ (0.45% +/- 0.28% vs 0.89% +/- 0.81%; p < 0.01) and CD133+ EPC levels (0.74% +/- 0.39% vs 1.22% +/- 0.83%; p < 0.01), but similar CD34/KDR+ and CD34+ EPC levels (all p > 0.05) compared to those without. Multiple logistic regression revealed that older age (OR 1.25, 95% CI 1.10-1.41, p < 0.01) and lower CD133/KDR+ EPC (OR 0.07, 95% CI 0.00-0.97, p < 0.01) were independent predictors for coronary atherosclerosis in patients with RA. Our results demonstrated that RA patients with coronary atherosclerosis have significantly lower levels of CD133/KDR+ and CD133+ EPC than those without. In addition to older age, lower levels of circulating CD133/KDR+ EPC also predicted occurrence of coronary atherosclerosis in RA patients.
    The Journal of Rheumatology 03/2010; 37(3):529-35. DOI:10.3899/jrheum.090782 · 3.17 Impact Factor
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    ABSTRACT: Little is known about the efficacy of H(2)-receptor antagonists in preventing recurrence of aspirin-related peptic ulcers. We compared the efficacy of high-dose famotidine with that of pantoprazole in preventing recurrent symptomatic ulcers/erosions. We performed a randomized, double-blind, controlled trial of 160 patients with aspirin-related peptic ulcers/erosions, with or without a history of bleeding. Patients were given either famotidine (40 mg, morning and evening) or pantoprazole (20 mg in the morning and placebo in the evening). All patients continued to receive aspirin (80 mg daily). The primary end point was recurrent dyspeptic or bleeding ulcers/erosions within 48 weeks. A total of 130 patients (81.1%) completed the study; 13 of 65 patients in the famotidine group reached the primary end point (20.0%; 95% one-sided confidence interval [CI] for the risk difference, 0.1184-1.0) compared with 0 of 65 patients in the pantoprazole group (P < .0001, 95% one-sided CI for the risk difference, 0.1184-1.0). Gastrointestinal bleeding was significantly more common in the famotidine group than the pantoprazole group (7.7% [5/65] vs 0% [0/65]; 95% one-sided CI for the risk difference, 0.0226-1.0; P = .0289), as was recurrent dyspepsia caused by ulcers/erosions (12.3% [8/65] vs 0% [0/65]; 95% one-sided CI for the risk difference, 0.0560-1.0; P = .0031). No patients had ulcer perforation or obstruction. In patients with aspirin-related peptic ulcers/erosions, high-dose famotidine therapy is inferior to pantoprazole in preventing recurrent dyspeptic or bleeding ulcers/erosions.
    Gastroenterology 10/2009; 138(1):82-8. DOI:10.1053/j.gastro.2009.09.063 · 12.82 Impact Factor
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    ABSTRACT: To evaluate the prevalence and pattern of arterial calcification in patients with asymptomatic systemic lupus erythematosus (SLE) compared with control subjects. SLE patients are prone to adverse cardiovascular events; however, the underlying atherosclerotic process is unknown. Multidetector computed tomography (MDCT) measured arterial calcium score (CS) reflecting underlying atherosclerosis and is closely associated with cardiovascular events. Fifty age and sex matched SLE patients and controls were enrolled. All subjects underwent 64 slice MDCT scan to evaluate CS in coronary, carotid arteries and the aorta. As compared with controls, SLE patients had higher mean CS and prevalence of CS > 0 across all vascular beds. After adjustment for age and sex, SLE patient odds of having CS > 0 in any vascular bed was 33.6 (95% CI: 9.5-165.2) were higher versus patients in the control group, mainly due to more prevalent coronary calcification (OR 30.0, 95% CI: 6.7-203.8). In SLE patients, the most frequent vessel with CS > 0 was coronary (42%) followed by carotid artery (24%). Further, arterial calcification occurred early involving 40% of SLE patients at age < 40 years, with increasing prevalence as age advanced. Our study confirms that patients with SLE have significantly higher prevalence and extent of systemic arterial calcification compared with age and sex matched controls.
    The Journal of Rheumatology 09/2009; 36(10):2212-7. DOI:10.3899/jrheum.090312 · 3.17 Impact Factor
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    ABSTRACT: To compare the clinical efficacy of intravenous diltiazem, digoxin, and amiodarone for acute ventricular rate (VR) control in patients with acute symptomatic atrial fibrillation (AF) necessitating hospitalization. Randomized control trial. Acute emergency medical admission unit in a regional teaching hospital in Hong Kong. One hundred fifty adult patients with acute AF and rapid VR (>120 bpm). Patients were randomly assigned in 1:1:1 ratio to receive intravenous diltiazem, digoxin, or amiodarone for VR control. The primary end point was sustained VR control (<90 bpm) within 24 hours; the secondary end points included AF symptom improvement and length of hospitalization. At 24 hours, VR control was achieved in 119 of 150 patients (79%). The time to VR control was significantly shorter among patients in the diltiazem group (log-rank test, p < 0.0001) with the percentage of patients who achieved VR control being higher in the diltiazem group (90%) than the digoxin group (74%) and the amiodarone group (74%). The median time to VR control was significantly shorter in the diltiazem group (3 hours, 1-21 hours) compared with the digoxin (6 hours, 3-15 hours, p < 0.001) and amiodarone groups (7 hours, 1-18 hours, p = 0.003). Furthermore, patients in the diltiazem group persistently had the lowest mean VR after the first hour of drug administration compared with the other two groups (p < 0.05). The diltiazem group had the largest reduction in AF symptom frequency score and severity score (p < 0.0001). In addition, length of hospital stay was significantly shorter in the diltiazem group (3.9 +/- 1.6 days) compared with digoxin (4.7 +/- 2.1 days, p = 0.023) and amiodarone groups (4.7 +/- 2.2 days, p = 0.038). As compared with digoxin and amiodarone, intravenous diltiazem was safe and effective in achieving VR control to improve symptoms and to reduce hospital stay in patients with acute AF.
    Critical care medicine 07/2009; 37(7):2174-9; quiz 2180. DOI:10.1097/CCM.0b013e3181a02f56 · 6.15 Impact Factor
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    ABSTRACT: The major complication of aspirin and clopidogrel (A+C) co-therapy is upper gastrointestinal bleeding (UGIB). However, data are unavailable for real-life situations. Furthermore, the treatment effect of antisecretory agents is unknown. This cohort study aimed to determine the occurrence of UGIB. The treatment effect of H2-receptor antagonist (H2RA) and proton pump inhibitor (PPI) was also analyzed. The records of 987 consecutive patients on A+C co-therapy between January 2001 and September 2006 were analyzed. The follow-up ended on the dates of a first occurrence of UGIB, stopping A+C co-therapy, a change in the antisecretory class, death, or March 2007. After a follow-up of 5.8 +/- 6.5 months, UGIB occurred in 39 (4.0%) patients. PPI, H2RA and control were prescribed in 213, 287 and 487 patients respectively. After adjustment for age, dose of aspirin, previous UGIB and duration of treatment, the risk was marginally reduced by H2RA (OR = 0.43, 95% CI 0.18-0.91, p = 0.04) and significantly reduced by PPI (OR = 0.04, 95% CI 0.002-0.21, p = 0.002), as compared to control. The occurrence of UGIB associated with A+C co-therapy for a median of 5.8 months was 4.0%. Co-prescription with PPI was associated with a lower risk.
    Digestion 07/2008; 77(3-4):173-7. DOI:10.1159/000141264 · 2.03 Impact Factor
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    ABSTRACT: The combination of aspirin, clopidogrel, and enoxaparin (combination therapy) is the standard treatment for acute coronary syndrome but is associated with gastrointestinal bleeding. However, information in this area is scarce. This retrospective study aimed to determine the incidence of upper gastrointestinal bleeding in a real-life situation. The effect of proton pump inhibitor (PPI) treatment was also analyzed. From January 2002 to December 2006, all patients receiving combination therapy were analyzed. The end point was the occurrence of upper gastrointestinal bleeding during combination therapy or within 7 days of stopping enoxaparin. The patient group consisted of 666 patients (age 72.1 +/- 12.6 yr). Gastrointestinal bleeding occurred in 18 (2.7%) patients. The overall hospital mortality was 4.1% (27 patients). A cardiac event was the major cause (N = 24, 3.6%). Only one patient died of massive gastrointestinal bleeding (0.15%). Multiple logistic regression analysis demonstrated that previous peptic ulcer, cardiogenic shock, and the lack of PPI coprescription were significant risk factors for gastrointestinal bleeding. The age-adjusted odds ratio (95% confidence interval) for gastrointestinal bleeding was 5.07 (1.31-16.58) for previous peptic ulcer, 21.41 (2.56-146.68) for cardiogenic shock, and 0.068 (0.010-0.272) for the coprescription with a PPI. In real life, the incidence of gastrointestinal bleeding associated with the combination of aspirin, clopidogrel, and enoxaparin therapy was estimated to be 2.7%. Previous peptic ulcer disease or cardiogenic shock were significant independent risk factors. Coprescription with a PPI can significantly reduce the risk.
    The American Journal of Gastroenterology 05/2008; 103(4):865-71. DOI:10.1111/j.1572-0241.2007.01715.x · 9.21 Impact Factor
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    ABSTRACT: Patients with nonerosive reflux disease (NERD) have the lowest esophageal acid exposure profile compared with the other gastroesophageal reflux disease (GERD) groups. To compare lower esophageal acid exposure recordings 1 cm above the lower esophageal sphincter (LES) with those 6 cm above the LES as well as to determine the characteristics of esophageal acid exposure along the esophagus among the different GERD groups. Patients with classic heartburn symptoms were enrolled into the study. Patients were evaluated by a demographics questionnaire and the validated GERD Symptom Checklist. Upper endoscopy was performed to evaluate the presence of esophageal erosions and Barrett's esophagus (BE). Ambulatory pH testing was performed using a commercially available 4-sensor pH probe with sensors located 5 cm apart. The distal sensor was placed 1 cm above the LES. Sixty-four patients completed the study. Of those, 21 patients had NERD, 20 had erosive esophagitis (EE), and 23 had BE. All patient groups demonstrated greater esophageal acid exposure 1 cm above the LES than 6 cm above the LES. In NERD and EE, this phenomenon was primarily a result of a higher mean percentage of upright time with pH <4. Unlike patients with EE and BE, those with NERD had very little variation in esophageal acid exposure throughout the esophagus (total and supine). ALL GERD groups demonstrated significant greater esophageal acid exposure at the very distal portion of the esophagus, primarily as a result of short upright reflux events. Unlike erosive esophagitis and BE, NERD patients demonstrate a more homogenous acid distribution along the esophagus.
    The American Journal of Gastroenterology 11/2006; 101(11):2463-9. DOI:10.1111/j.1572-0241.2006.00944.x · 9.21 Impact Factor
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    ABSTRACT: The use of low-dose aspirin to prevent cardiovascular disease events is well established. However, the incidence and predictors of upper gastrointestinal bleeding (UGIB) with its use are unknown. We studied prospectively the incidence and outcome of peptic ulceration in low-dose aspirin users. A total of 991 patients with coronary artery disease (CAD) on low-dose aspirin were prospectively followed-up for two years for the occurrence and clinical features of first hospitalized episode of UGIB. UGIB had a bimodal presentation with 45% occurring within four months of aspirin initiation and had an overall prevalence of 1.5% per year. There was no UGIB-related death. Hypertension (OR = 4.6, 95%CI 1.5-14.7, P = 0.009), history of peptic ulceration (OR = 3.1, 95%CI 1.1-9.0, P = 0.039), tertiary education (OR = 3.08, 95%CI 1.1-9.0, P = 0.039) and higher lean body mass (P = 0.016) were independent factors associated with UGIB. Use of nitrate did not reduce UGIB. The incidence of UGIB in patients with CAD on long-term low-dose aspirin is low, but is accompanied with significant morbidity. With prolonged use of aspirin, UGIB continues to be a problem for those with risk factors and especially in patients with a history of peptic ulcers, in which UGIB tends to occur early after aspirin therapy.
    World Journal of Gastroenterology 06/2006; 12(18):2923-7. · 2.43 Impact Factor
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    ABSTRACT: Coronary stenting is associated with a high incidence of restenosis in patients with diabetes mellitus. Recent data suggest that diabetic patients treated with abciximab have a lower rate of target vessel revascularization (TVR). We sought to investigate whether abciximab can reduce in-stent restenosis after coronary stenting in diabetic patients. In this prospective double-blind trial, we randomly assigned 254 patients with type 2 diabetes mellitus undergoing nonurgent coronary stenting to receive abciximab with an initial heparin bolus of 50 U/kg (n = 128) or placebo with an initial heparin bolus of 70 U/kg (n = 126). All patients received aspirin and clopidogrel before the procedure. The primary endpoint was angiographic restenosis by quantitative coronary angiography at 6 months. The secondary endpoint was death, myocardial infarction (MI), or target lesion revascularization (TLR) at 6 months. The clinical, angiographic, and procedural characteristics were matched between the 2 groups. Angiographic follow-up was completed in 226 patients (90%). Angiographic restenosis occurred in 29.1% of the abciximab group, and 24% of the placebo group (p = 0.30). The rates of the secondary endpoint were similar between the 2 groups (23.4% in the abciximab group versus 22.2% in the placebo group; p = 0.88). TLR was performed on 36 (18.4%) lesions in 29 (23.4%) patients of the abciximab group, and 26 (13.6%) lesions in 23 (18.3%) patients of the placebo groups, respectively (p = 0.21 and 0.35, respectively). Abciximab does not reduce angiographic restenosis or TLR in type 2 diabetic patients undergoing nonurgent coronary stenting.
    The Journal of invasive cardiology 11/2005; 17(10):534-8. · 1.57 Impact Factor
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    Gastroenterology 04/2003; 124(4). DOI:10.1016/S0016-5085(03)80833-8 · 12.82 Impact Factor