Chern-En Chiang

National Yang Ming University, T’ai-pei, Taipei, Taiwan

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Publications (104)412.55 Total impact

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    ABSTRACT: Background: Atrial fibrillation (AF) can be managed with rhythm- or rate-control strategies. There are few data from routine clinical practice on the frequency with which each strategy is used and their correlates in terms of patients' clinical characteristics, AF control, and symptom burden. Methods: RealiseAF was an international, cross-sectional, observational survey of 11,198 patients with AF. The aim of this analysis was to describe patient profiles and symptoms according to the AF management strategy used. A multivariate logistic regression identified factors associated with AF management strategy at the end of the visit. Results: Among 10,497 eligible patients, 53.7% used a rate-control strategy, compared with 34.5% who used a rhythm-control strategy. In 11.8% of patients, no clear strategy was stated. The proportion of patients with AF-related symptoms (EHRA Class > = II) was 78.1% (n = 4396/5630) for those using a rate-control strategy vs. 67.8% for those using a rhythm-control strategy (p<0.001). Multivariate logistic regression analysis revealed that age <75 years or the paroxysmal or persistent form of AF favored the choice of a rhythm-control strategy. A change in strategy was infrequent, even in patients with European Heart Rhythm Association (EHRA) Class > = II. Conclusions: In the RealiseAF routine clinical practice survey, rate control was more commonly used than rhythm control, and a change in strategy was uncommon, even in symptomatic patients. In almost 12% of patients, no clear strategy was stated. Physician awareness regarding optimal management strategies for AF may be improved.
    Full-text · Article · Jan 2016 · PLoS ONE
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    ABSTRACT: Aim: Five multicentre, cross-sectional Centralized Pan-Regional Surveys on the Undertreatment of Hypercholesterolaemia (CEPHEUS) were conducted in 29 countries across Asia, Western Europe, Eastern Europe, the Middle East, and Africa. The surveys assessed the current use and efficacy of lipid-lowering drugs (LLDs) worldwide and identified possible patient and physician characteristics associated with failure to attain low-density lipoprotein cholesterol (LDL-C) goals. The aim of this analysis was to consolidate the global results from these surveys. Methods: The surveys involved patients aged ≥18 years who had been prescribed LLDs for at least 3 months without dose changes for at least 6 weeks. A single visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Cardiovascular risk profile and LDL-C goal attainment were assessed according to the 2004 updated US National Cholesterol Education Program Adult Treatment Panel III guidelines. Results: In total, 35 121 patients (mean age: 60.4 years) were included, and 90.3% had been prescribed statin monotherapy. Overall, only 49.4% of patients reached their recommended LDL-C level. LDL-C goals were attained in 54.8% (5084/9273) and 22.8% (3287/14 429) of patients were at high and very high cardiovascular risk, respectively. Factors associated with an increased likelihood of LDL-C goal attainment were lower baseline cardiovascular risk; presence of diabetes mellitus, hypertension, or history of cardiovascular disease; and treatment with simvastatin, atorvastatin, or rosuvastatin (vs. all other LLDs). Conclusion: LDL-C goal attainment in patients taking LLDs is suboptimal worldwide, particularly in patients at high and very high cardiovascular risk.
    No preview · Article · Dec 2015 · Journal of atherosclerosis and thrombosis
  • Chern-En Chiang · Kang-Ling Wang

    No preview · Article · Oct 2015 · Evidence-based medicine
  • Chern-En Chiang · Kang-Ling Wang · Shing-Jong Lin
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    ABSTRACT: Atrial fibrillation (AF) has become a major health burden in Asia. It is estimated that in year 2050 Asia will have 72 million AF patients, and 2.9 million among them will suffer from AF-associated stroke. Asian AF patients have similar cardiovascular co-morbidities as westerns, and the recently developed CHA2DS2-VASc score remains valid in predicting stroke risk in Asians, outperforming other scoring systems. There is little evidence supporting a role of aspirin in preventing AF-associated stroke in Asians. Warfarin is effective for the prevention of stroke in Asians, but is very difficult to use. Warfarin-induced bleeding events are more common in Asians. Four major clinical trials have been performed to test non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin in the stroke prevention in AF. Warfarin produced higher risk of major bleeding and intra-cranial haemorrhage in Asians compared with those in non-Asians, even though anticoagulation intensity was lower in Asians. All these trials consistently demonstrated that NOACs were superior or non-inferior to warfarin. The benefits of NOACs were especially robust in Asians. The relative risk reduction in most of the efficacy endpoints and the safety endpoints was numerically greater in Asians than in non-Asians. There was no evidence of increased risk of gastro-intestinal bleeding associated with NOACs in Asians. Unless in a few conditions when NOACs are contraindicated, NOACs are preferred medications in the stroke prevention for AF in Asians.
    No preview · Article · Oct 2015 · Europace
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    ABSTRACT: Atrial fibrillation (AF) is associated with cognitive decline and may contribute to an increased risk of dementia. The goal of the present study was to investigate whether statin use prevented non-vascular dementia in subjects with AF. Data from the National Health Insurance Research Database of Taiwan were used in this study. The study group comprised 51,253 AF subjects aged ≥60years who had received statin treatment. For each study patient, four age- and sex-matched AF subjects without statin exposure were selected as the control group (n=205,012). The risk of non-vascular dementia was compared between the statin and control groups. During the follow-up period, 17,201 patients experienced non-vascular dementia. The annual incidence of non-vascular dementia was lower in the statin group than in the control group (1.89% vs. 2.20%; p<0.001). Statin use exhibited a protective effect on the occurrence of non-vascular dementia, with an adjusted hazard ratio (HR) of 0.832 (95% confidence interval=0.801-0.864). Among statin types, the use of rosuvastatin was associated with the largest risk reduction (adjusted HR=0.661). Statin exposure duration was related inversely to the risk of non-vascular dementia. In this large-scale nationwide cohort study, statin use was associated with a lower risk of non-vascular dementia in AF. Use of more potent statin and longer exposure time may be associated with greater benefits. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    No preview · Article · Oct 2015 · International journal of cardiology
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    ABSTRACT: Background: Recent studies from Asia have suggested that the risk of ischemic stroke for patients with atrial fibrillation (AF) with a "low-risk" congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65 to 74, female (CHA2DS2-VASc) score of 0 (for males) or 1 (for females) might be higher than that for non-Asians. Objectives: This study hypothesized that the age threshold (65 years) used in the CHA2DS2-VASc system for initiating oral anticoagulants (OACs) might be lower in Taiwanese AF patients than in non-Asians. Methods: We used the National Health Insurance Research Database in Taiwan to study 186,570 nonanticoagulated AF patients. There were 9,416 males with a CHA2DS2-VASc score of 0 and 6,390 females with a CHA2DS2-VASc score of 1. Their risk of ischemic stroke was analyzed with stratification on the basis of age. Results: The annual risks of ischemic stroke for males (score 0) and females (score 1) were 1.15% and 1.12%, respectively, and continuously increased from younger to older age groups, with an increment in stroke risk evident for patients >50 years of age. At a cutoff of 50 years, patients could be further stratified into 2 subgroups with different stroke risks (>50 years of age: 1.78%/year; vs. <50 years of age: 0.53%/year). This observation was consistent for males (1.95%/year vs. 0.46%/year, respectively) and females (1.58%/year vs. 0.64%/year, respectively) with AF. In a subgroup analysis, the annual risks of ischemic stroke for males and females with AF 50 to 54 years of age were 1.47% and 1.07%, respectively. Conclusions: For Taiwanese patients 50 to 64 years of age, the annual stroke risk was 1.78%, which may exceed the threshold for OAC use for stroke prevention. The annual risk of ischemic stroke for AF patients <50 years of age was 0.53%, which was truly low-risk, and OACs could be omitted. Whether resetting the age threshold to 50 years could refine current clinical risk stratification for Asian AF patients deserves further study.
    No preview · Article · Sep 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Background: -Current American and European guidelines emphasized the importance of rate control treatments in treating atrial fibrillation (AF) with a Class I recommendation, although data about the survival benefits of rate control are lacking. The goal of the present study was to investigate whether patients receiving rate control drugs had a better prognosis compared to those without rate-control treatment. Methods and results: -This study used the "National Health Insurance Research Database" in Taiwan. There were 43,879, 18,466 and 38,898 AF patients enrolled in the groups of beta-blockers (BBs), calcium channel blockers (CCBs) and digoxin, respectively. The reference group consisted of 168,678 subjects who did not receive any rate-control drug. The clinical endpoint was all-cause mortality. During a follow-up of 4.9±3.7 years, mortality occurred in 88,263 patients (32.7%). After the adjustment for the baseline differences, the risk of mortality was lower in patients receiving BBs (adjusted hazard ratio [HR] = 0.76, 95% confidence interval [CI] = 0.74-0.78) and CCBs (adjusted HR = 0.93, 95% CI = 0.90-0.96) compared to those who did not receive rate-control medications. On the contrary, the digoxin group had a higher risk of mortality with an adjusted HR of 1.12 (95% CI = 1.10-1.14). The results were consistently observed in subgroup analyses and among the cohorts after propensity matching. Conclusions: -In this nationwide AF cohort, the risk of mortality was lower for patients receiving rate-control treatments with BBs or CCBs, and the use of BBs was associated with a largest risk reduction. Digoxin use was associated with greater mortality. Prospective randomized trials are necessary to confirm these findings.
    No preview · Article · Sep 2015 · Circulation
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    ABSTRACT: The use of vitamin K antagonists (VKAs), the cornerstone treatment for stroke prevention in patients with atrial fibrillation, is limited by the perceived risk of serious bleeding in Asia. Non-VKA oral anticoagulants (NOACs) are safer alternatives. Here, we evaluate performance differences of NOACs between Asians and non-Asians. We compared efficacy and safety of NOACs between patients enrolled in Asian and non-Asian countries using aggregative data from phase III clinical trials. The odds ratios (ORs [95% confidence interval]) were calculated by a random effects model. Comparing with VKAs, standard-dose NOACs reduced stroke or systemic embolism (OR=0.65 [0.52-0.83] versus 0.85 [0.77-0.93], P interaction= 0.045) more in Asians than in non-Asians and were safer in Asians than in non-Asians about major bleeding (OR=0.57 [0.44-0.74] versus 0.89 [0.76-1.04], P interaction=0.004), hemorrhagic stroke (OR=0.32 [0.19-0.52] versus 0.56 [0.44-0.70], P interaction=0.046) in particular, whereas gastrointestinal bleeding was significantly increased in non-Asians (OR=0.79 [0.48-1.32] versus 1.44 [1.12-1.85], P interaction=0.041). Generally, low-dose NOACs were safer than VKAs without heterogeneity in efficacy and safety between Asians and non-Asians, except for ischemic stroke, major, and gastrointestinal bleeding. Our findings suggest that standard-dose NOACs were more effective and safer in Asians than in non-Asians, whereas low-dose NOACs performed similarly in both populations. © 2015 The Authors.
    Preview · Article · Sep 2015 · Stroke
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    ABSTRACT: Both American and European guidelines recommended the use of CHA2DS2-VASc score, rather than CHADS2, for stroke risk stratification in atrial fibrillation (AF). However, the CHA2DS2-VASc score has not been proved to be better than CHADS2 for Asians in a large-scale study. We aimed to compare the accuracies of CHADS2 and CHA2DS2-VASc scores in predicting ischemic stroke in Chinese. This study used the "National Health Insurance Research Database" in Taiwan. A total of 186,570 AF patients without antithrombotic therapies were selected as the study cohort. The clinical endpoint was occurrence of ischemic stroke. During the follow-up of 3.4+3.7 years, 23,723 patients (12.7%) experienced ischemic stroke. The CHA2DS2-VASc score performed better than CHADS2 score in predicting ischemic stroke assessed by c-indexes (0.698 versus 0.659, p<0.0001). Among 25,286 patients with a CHADS2 score of 0, the CHA2DS2-VASc score ranged from 0-3 and the annual stroke rate ranged from 1.15% to 4.47%. Compared to patients with a CHA2DS2-VASc score of 0, the hazard ratio of ischemic stroke for patients with a CHA2DS2-VASc score of 3 was 3.998. Patients with a CHADS2 score of 0 were not necessarily 'low risk', and the annual stroke rate can be as high as 4.47% when they were further stratified by the CHA2DS2-VASc score. In contrast, patients with a CHA2DS2-VASc score of 0 had a truly low risk of ischemic stroke, with an annual stroke rate around 1.15%. The same as Caucasians, the CHA2DS2-VASc score should be used for stroke risk stratification in Asians. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · Aug 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
  • Hao-Min Cheng · Chern-En Chiang · Chen-Huan Chen
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    ABSTRACT: The prevalence rate of hypertension in Asian countries grows faster than in other parts of the world, where stroke exceeds coronary heart disease in causing morbidities and mortalities. The optimal management of hypertension is therefore an especially important task in Asia. In a transparent and rigorous guideline development process, the most updated information available on the management of hypertension was summarized in the 2015 Taiwan Society of Cardiology (TSOC)/Taiwan Hypertension Society (TSH) hypertension guideline. In contradiction with the ESH/ESH joint hypertension guidelines and the 2014 Joint National Committee (JNC) report, this updated guideline suggests some different blood pressure (BP) targets. In brief, the BP target is 150/90 mm Hg for very elderly patients (≥ 80 years), 130/80 mm Hg for patients with diabetes, coronary heart disease, proteinuric chronic kidney disease or those receiving antithrombotics for stroke prevention, and 140/90 mm Hg for all the other hypertension patients with or without the aforementioned comorbidities. To facilitate the adherence to the guideline, the following was proposed: mnemonics for lifestyle modifications: S-ABCDE (Sodium restriction, Alcohol limitation, Body weight reduction, Cigarette smoking cessation, Diet adaptation, and Exercise adoption), treatment algorithm: PROCEED (Previous experience, Risk factors, Organ damage, Contraindications or unfavorable conditions, Expert's or doctor's judgment, Expenses or cost, and Delivery and compliance issue), and medication adjustment algorithm: AT GOALs (Adherence, Timing of administration, Greater doses, Other classes of drugs, Alternative combination or single-pill combination, and Lifestyle modification + Laboratory tests). In particular, the effort of translating the concept of central BP into clinical practice may stand out from all other hypertension guidelines. In summary, our guidelines may deliver useful information and guidance to clinicians in managing hypertensive patients, including the approach to a more accurate diagnosis, treatment and adjustment algorithm, and evidence-based recommendations.
    No preview · Article · May 2015
  • Kang-Ling Wang · Shing-Jong Lin · Chern-En Chiang

    No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology (TSOC). There is new evidence regarding the management of hypertension, including randomized controlled trials, non-randomized trials, post-hoc analyses, subgroup analyses, retrospective studies, cohort studies, and registries. More recently, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) published joint hypertension guidelines in 2013. The panel members who were appointed to the Eighth Joint National Committee (JNC) also published the 2014 JNC report. Blood pressure (BP) targets have been changed; in particular, such targets have been loosened in high risk patients. The Executive Board members of TSOC and the Taiwan Hypertension Society (THS) aimed to review updated information about the management of hypertension to publish an updated hypertension guideline in Taiwan.
    Full-text · Article · Dec 2014 · Journal of the Chinese Medical Association
  • Gregory Y.H. Lip · Kang-Ling Wang · Chern-En Chiang
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    ABSTRACT: Non-vitamin K antagonist oral anticoagulants (NOACs) have changed the landscape for stroke prevention in atrial fibrillation (AF). Given the huge burden of AF in Asians, more attention to stroke prevention is clearly needed. Aiming to provide an overview and reappraisal of stroke prevention in Asians with AF, we searched MEDLINE for information on NOACs in Asians. In addition, abstracts from national and international cardiovascular meetings were studied to identify unpublished studies. In the 4 recent Phase 3 trials comparing NOACs to warfarin, a consistent pattern is evident. For efficacy endpoints in the comparison of NOACs vs warfarin, a significant reduction in stroke/systemic embolization was seen for dabigatran 150mg [HR 0.45 (0.28-0.72)], with non-significant trends seen for lower stroke/systemic embolization with other NOACs, except edoxaban 30mg. A similar pattern was seen for ischaemic stroke, with a significant reduction for dabigatran 150mg [HR 0.55 (0.32-0.950]. For haemorrhagic stroke, all NOAC regimes, except rivaroxaban 20mg, had significantly lower hazard ratios. No evidence of increased myocardial infarction was found for NOACs. All-cause mortality was significantly lowered amongst Asian patients on edoxaban 60mg compared to warfarin [HR 0.63 (0.40-0.98)] with non-significant trends to lower mortality with dabigatran 150mg, rivaroxaban and edoxaban 30mg. For safety endpoints, all the NOAC regimes, except rivaroxaban 20mg, significantly reduced major bleeding and 'all bleeding' events. Intracranial haemorrhage was consistently lowered by all NOACs. None of NOACs increased gastrointestinal bleeding. These information suggested that NOACs should be preferentially indicated for stroke prevention in Asians with AF. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    No preview · Article · Nov 2014 · International Journal of Cardiology
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    ABSTRACT: Background Saxagliptin was associated with an increased risk of hospitalization for heart failure (HHF) in diabetic patients with high cardiovascular risk. This study assessed the risk of HHF during an exposure to sitagliptin in general diabetic patients. Methods In Taiwan National Health Insurance research database, a study of the beneficiaries aged ≥ 45 years with diabetes treated with or without sitagliptin between March 2009 and July 2011 was conducted. Patients treated with sitagliptin were matched to patients never exposed to a dipeptidyl peptidase-4 (DPP-4) inhibitor by the propensity score methodology. The outcome measures were the first and the total number of HHF, and mortality for heart failure or all causes. Results A total of 8288 matched pairs of patients were analyzed. During a median of 1.5 years, the first event of HHF occurred in 339 patients with sitagliptin and 275 patients never exposed to a DPP-4 inhibitor (hazard ratio: 1.21, 95% confidence interval: 1.04–1.42, P = 0.017); all-cause mortality was similar (hazard ratio: 0.87, 95% confidence interval: 0.74–1.03, P = 0.109). The risk for HHF was proportional to exposure (hazard ratio: 1.09, 95% confidence interval: 1.06–1.11, P < 0.001 for every 10% increase in adherence to sitagliptin). Overall, there were 935 events of HHF, in which the association between the number of HHF and the adherence to sitagliptin was linear. The greatest total number of HHF occurred in the patients with the highest adherence. Conclusions The use of sitagliptin was associated with a higher risk of HHF but no excessive risk for mortality was observed.
    No preview · Article · Nov 2014 · International Journal of Cardiology
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    ABSTRACT: Background Digoxin and related cardiac glycoside have been used for almost 100 years in atrial fibrillation (AF). However, recent 2 analyses of the “AFFIRM” trial showed non-consistent results about the risk of mortality associated with digoxin use. The goal of the present study is to investigate the relationship between digoxin and the risk of ischemic stroke and mortality in Asians. Methods This study used the “National Health Insurance Research Database” in Taiwan. A total of 4,781 AF patients who did not receive any antithrombotic therapy were selected as the study population. Among the study population, 829 subjects (17.3%) received the digoxin treatment. The risks of ischemic stroke and mortality of patients with or without digoxin use were compared. Results The use of digoxin was associated with an increased risk of clinical events with an adjusted hazard ratio of 1.41 (95% CI =1.17-1.70) for ischemic stroke and 1.21 (95% CI =1.01-1.44) for all-cause mortality. In the subgroup analysis based on the coexistence with heart failure or not, digoxin was a risk factor of adverse events for patients without heart failure, but not for those with heart failure (interaction p<0.001 for either endpoint). Among AF patients without heart failure, the use of beta-blockers was associated with better survival with an adjusted hazard ratio of 0.48 (95% CI = 0.34-0.68). Conclusions Digoxin should be avoided for AF patients without heart failure since it was associated with an increased risk of clinical events. Beta-blockers may be a better choice for controlling ventricular rate.
    No preview · Article · Oct 2014 · The Canadian journal of cardiology
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    ABSTRACT: Background Most atrial fibrillation (AF) epidemiology described Western populations; there is a paucity of data from Chinese ethnicity. This study presented differences in patient characteristics and management strategies, and assessed the quality of life (QoL) and AF control in Taiwanese patients from RealiseAF. Methods RealiseAF enrolled 10,523 patients internationally, in which Taiwanese cohort accounts for 7.1%. Physicians were randomly selected from a global list. Patient characteristics, management and therapeutic strategies of AF, QoL measured by the EQ-5D questionnaire, and the control of AF (in sinus rhythm, or AF with a ventricular rate ≤80 beats per minute) evaluated by electrocardiography were assessed. Results Taiwanese patients were mostly outpatients (93.9%), older (70.2 ± 11.8 years), accompanied by more comorbidities, more frequently (51.7%) in permanent AF, and symptomatic (European Heart Rhythm Association score ≥II: 81.5%) compared with the non-Taiwanese cohort. A rhythm-control strategy was less preferable to rate-control than in non-Taiwanese cohort as well as the use of class I and III antiarrhythmic drugs (AADs); 85.2% of Taiwanese patients received AADs, among which beta-blockers were the most common (46.9%). QoL was compromised (Visual Analogue Scale: 70.3 ± 14.4; single index utility score: 0.81 ± 0.25) and only 48.6% of the Taiwanese patients had AF controlled. Conclusions AF complexity in the Taiwanese cohort was similar to or even greater than that in the non-Taiwanese cohort. The Taiwanese patients were highly symptomatic; QoL was impaired despite the widespread use of medications and AF control was unsatisfactory. There is an apparent unmet need in AF treatment in Chinese ethnicity.
    Full-text · Article · Sep 2014 · Journal of Cardiology
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    ABSTRACT: Aim: Withholding effective treatment is clinically prevalent. The CEntralized Pan-Asian survey on tHE Under-treatment of hypercholeSterolemia (CEPHEUS-PA) indicated suboptimal low-density lipoprotein cholesterol (LDL-C) goal attainment in Taiwan, which may be attributable to clinical inertia. We herein analyzed the Taiwanese cohort in the CEPHEUS-PA to identify key elements regarding clinical inertia and unsatisfactory LDL-C control. Methods: A questionnaire regarding the attitudes and perceptions for each physician and patient was included in the CEPHEUS-PA. Physicians completed the physician questionnaire before enrolling patients, who completed the patient questionnaire before the assessment. Results: The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guideline was used by 81.8% of physicians to establish the individual therapeutic targets; 50.2% of patients failed to take medications persistently. Regarding perceptions to hypercholesterolemia management, 75.9% of physicians were confident of having a sufficient number of patients at cholesterol targets; 80.2% and 65.9% of patients felt satisfied and motivated, respectively, but 46.0% had no strong feeling. The healthcare reimbursement policy used for treatment guidance was a significant determinant for LDL-C goal attainment (OR=0.32, 95% CI: 0.15-0.69, P=0.006) in addition to patient compliance. Low patient involvement indexed by having no strong feeling was associated with poor LDL-C control (OR=0.73, 95% CI: 0.56-0.95, P=0.020). Conclusions: The referenced healthcare reimbursement policy, poor patient compliance, and low patient involvement with hypercholesterolemia management were associated with failure of LDL-C control. Our findings highlight the need to overcome those barriers to improve the under-treatment of hypercholesterolemia.
    No preview · Article · Jun 2014 · Journal of atherosclerosis and thrombosis
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    ABSTRACT: Background: The impact of renal dysfunction has been investigated in patients with non-valvular atrial fibrillation (AF). The aim of this study was to assess its additive prognostic value in low thromboembolic risk AF patients with CHA2DS2-VASc score 0-1. Methods and results: A total of 617 non-valvular AF patients were enrolled and baseline serum creatinine was measured. Estimated glomerular filtration rate and estimated clearance of creatinine were calculated using the Modification of Diet in Renal Disease equation and Cockcroft-Gault formula, respectively. The primary endpoint was cardiovascular death and systemic thromboembolic events, including acute ischemic stroke, transient ischemic attack, and peripheral artery embolism. Of these, 338 individuals had clinical CHA2DS2-VASc score 0-1. Among these individuals, 23 patients had impaired renal function. During the follow-up period of 53.6±32.1 months, the annual composite outcome rate in AF patients with CHA2DS2-VASc score 0-1 was 0.40%/year. As compared with patients with preserved renal function, the annual composite outcome rate was significantly higher in patients with impaired renal function (2.92%/year vs. 0.21%/year, P<0.001). Moreover, on multivariate Cox regression analysis, renal dysfunction was the only risk predictor in these low-risk patients. Conclusions: Impaired renal function has an additive prognostic value for thromboembolic events and cardiovascular mortality in low-risk AF patients with CHA2DS2-VASc score 0-1.
    No preview · Article · Feb 2014 · Circulation Journal
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    ABSTRACT: Background The implementation of international guidelines for antithrombotic use in atrial fibrillation (AF) in routine practice is not well known, particularly, in some parts of the world, such as the Middle East and Africa. Aim To describe and analyse the use of antithrombotics in patients with AF in routine practice. Methods The RealiseAF international cross-sectional survey enrolled 10,523 patients (with at least one documented AF episode in the preceding 12 months) from 831 sites. Participating physicians were randomly selected from physician list forms. Results Mean age was 66.6 ± 12.2 years. In 47.4% of the patients with a CHADS2 score ≥ 2, oral anticoagulants were not prescribed. Patients who had a CHADS2 score ≥ 2, permanent or persistent AF, valvular heart disease, a stroke leading to hospitalization in the previous year or treatment by a cardiologist (rather than an internist) were most likely to receive oral anticoagulants. Patients aged ≥ 75 years and those with coronary heart disease; major bleeding leading to hospitalization in the previous year or a rhythm control strategy was least likely to receive oral anticoagulants. Appropriate antithrombotic treatment was prescribed in 66.7% of the patients with a CHADS2 score ≥ 2 in the Middle East/Africa, 55.3% in Europe, 43.9% in Latin America and 31.7% in Asia. Conclusion There is substantial deviation from international guidelines in antithrombotic use for AF in routine clinical practice, with overuse and underuse of antithrombotics in about 50% of the cases and important geographical differences. These findings emphasize the need for improved medical education worldwide and a better understanding of geographical disparities in the implementation of guidelines.
    Full-text · Article · Feb 2014 · Archives of cardiovascular diseases
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    ABSTRACT: Atrial fibrillation can be categorized into nonpermanent and permanent atrial fibrillation. There is less information on permanent than on nonpermanent atrial fibrillation patients. This analysis aimed to describe the characteristics and current management, including the proportion of patients with successful atrial fibrillation control, of these atrial fibrillation subsets in a large, geographically diverse contemporary sample. Data from RealiseAF, an international, observational, cross-sectional survey of 10,491 patients with atrial fibrillation, were used to characterize permanent atrial fibrillation (N = 4869) and nonpermanent atrial fibrillation (N = 5622) patients. Permanent atrial fibrillation patients were older, had a longer time since atrial fibrillation diagnosis, a higher symptom burden, and were more likely to be physically inactive. They also had a higher mean (SD) CHADS2 score (2.2 [1.3] vs. 1.7 [1.3], p<0.001), and a higher frequency of CHADS2 score ≥2 (67.3% vs. 53.0%, p<0.001) and comorbidities, most notably heart failure. Physicians indicated using a rate-control strategy in 84.2% of permanent atrial fibrillation patients (vs. 27.5% in nonpermanent atrial fibrillation). Only 50.2% (N = 2262/4508) of permanent atrial fibrillation patients were controlled. These patients had a longer time since atrial fibrillation diagnosis, a lower symptom burden, less obesity and physical inactivity, less severe heart failure, and fewer hospitalizations for acute heart failure than uncontrolled permanent atrial fibrillation patients, but with more arrhythmic events. The most frequent causes of hospitalization in the last 12 months were acute heart failure and stroke. Permanent atrial fibrillation is a high-risk subset of atrial fibrillation, representing half of all atrial fibrillation patients, yet rate control is only achieved in around half. Since control is associated with lower symptom burden and heart failure, adequate rate control is an important target for improving the management of permanent atrial fibrillation patients.
    Full-text · Article · Jan 2014 · PLoS ONE

Publication Stats

1k Citations
412.55 Total Impact Points

Institutions

  • 1993-2015
    • National Yang Ming University
      • • School of Medicine
      • • Institute of Clinical Medicine
      T’ai-pei, Taipei, Taiwan
  • 1994-2013
    • Taipei Veterans General Hospital
      • • Department of Medical Research and Education
      • • Cardiology Division
      • • Department of Medicine
      T’ai-pei, Taipei, Taiwan
  • 2004-2005
    • Fu Jen Catholic University
      • School of Medicine
      T’ai-pei, Taipei, Taiwan