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BACKGROUND Hand grip strength (HGS) has been associated with cardiovascular events. However, the exact mechanism responsible for the inverse association between HGS and cardiovascular events has not been established. The aim of this study was to assess whether arterial stiffness mediates this association. METHODS We studied 1508 participants (age; 60 ± 5, men; 47.5%) from the Ansan cohort of the Korean Genome Epidemiology Study. Participants were assessed for various parameters of arterial stiffness as well as HGS. The augmentation index (AIx) and brachial-ankle pulse wave velocity (baPWV) were evaluated by using an applanation tonometer and automated waveform analyzer, respectively. Carotid intima medial thickness (IMT) was measured by B-mode ultrasonogram with a 7.5-MHz linear array transducer. HGS was evaluated using a Jamar dynamometer. RESULTS With increased grip strength, AIx decreased (r = 0.437, P

Background and Purpose: Cardiopulmonary coupling (CPC) analysis is an easily assessable method to evaluate sleep-disordered breathing (SDB); however, its prognostic impact in patients with acute ischemic stroke needs to be investigated. We performed a CPC analysis using Holter monitoring at the early stage of noncardioembolic ischemic stroke to investigate the prognostic effect of SDB on functional impairment at the 3-month follow-up. Methods: A total 615 patients with acute noncardioembolic ischemic stroke who underwent Holter monitoring within 30 days of stroke onset were enrolled from a multicenter, prospective, all-comer cohort. CPC analysis was conducted, and SDB was defined by the presence of narrow-band coupling during sleep time. We investigated the association between SDB and functional impairment at 3 months as measured by the modified Rankin Scale. Result: Narrow-band coupling was present in 191 (31.1%) of 615 patients (mean age 64.5±12.6 years). The narrow-band group showed a significantly higher rate of severe functional impairment (modified Rankin Scale score >2; 45.5% versus 12.9%, P P P P C -statistic=0.770). Conclusions: SDB assessed by CPC analysis at the early stage of ischemic stroke could predict severe and prolonged functional impairment at 3 months. CPC analysis using Holter monitoring can help predicting functional impairment in acute ischemic stroke.

PURPOSE A recent study has shown that quadriceps strength can be used to predict the level of exercise capacity in patients with coronary heart disease. We investigated whether the relationship between muscular strength and exercise capacity is also observed with handgrip strength (HGS). METHODS We studied 443 participants (61.8 ± 11.2 yr; 78% male) who underwent coronary intervention and participated in cardiac rehabilitation between 2015 and 2018. Logistic regression was used to assess the relationship between various clinical measures (HGS, age, sex, etc) with the distance walked on a 6-minute walk test (6MWT) and maximal oxygen uptake ((Equation is included in full-text article.)O2max). RESULTS Handgrip strength was related to distance walked on the 6MWT (r = 0.435, P < .001). It was the only predictor of all exercise capacity categories, and one of the strongest predictors of each exercise capacity category. An HGS of 26% of body weight predicted an achievement of a 200-m walk on the 6MWT (positive predictive value = 0.95). However, HGS

Introduction: Although statin therapy is strongly recommended in acute myocardial infarction (AMI) patients, there has been consistent concern regarding the development of new onset diabetes mellitus (NODM). Currently, there has been no data whether diabetogenic effect of statin is intensity dependent. In this study, we investigated the impact of different statin intensity on incidence of NODM up to 3 years. Methods: Among 13,104 AMI patients enrolled in the Korea AMI Registry (KAMIR) between November 2011 and May 2015, we enrolled the 5,906 patients without diabetes mellitus and successful percutaneous coronary intervention (PCI). There were 22.8% (1,349/5,906) of patients received high intensity stain and 76.0% (4,488/5,906) patients received moderate intensity, and only 1.2% (69/5,906) patients received low intensity statin. The incidence of NODM were investigated among three different intensity of statins up to 3 years. Results: At baseline, high intensity statin group showed higher baseline LDL cholesterol level, body mass index, and abdominal circumference compared to other groups. In Kaplan-Meier curve, the cumulative incidence of NODM was significantly higher in high intensity group than mild and moderate intensity group (7.8% vs. 1.5% vs. 5.9% respectively, Log rank p-value = 0.002, Figure 1A). The incremental diabetogenic tendency was observed in each individual statin in dose-dependant manner (Figure 1B). In Cox regression, the intensity of statin was statistically significant prognostic factor of NODM after adjusting age, and other metabolic variables, such as body mass index, abdominal circumstance, and level of serum triglyceride. Conclusions: Among the AMI patients underwent successful PCI, higher intensity statin was associated with higher incidence of NODM, showing the diabetogenic effect of statin intensity.

Background: In the present study, we aimed to compare the 12-month clinical outcomes of immediate versus staged complete revascularization in acute ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary percutaneous coronary intervention (PCI) with everolimus-eluting stents (EES). Method: A total of 248 patients were enrolled in a prospective, randomized, open-label, multicenter registry. Immediate complete revascularization was defined as simultaneous PCI of the culprit and non-culprit lesions during the index procedure (Immediate group). Staged complete revascularization was defined as PCI of non-culprit lesion as a separate staged procedure after the culprit lesion PCI (mean 4.4 days, interquartile range; 1 to 11.4, Staged group). The study end points were major adverse cardiovascular events (MACE; the composite of total death, recurrent myocardial infarction, and revascularization), and individual hard endpoints including cardiac death, stent thrombosis and stroke at 12 months clinical follow up. Results: Although the incidence of MACE was not significantly different between the two groups (11.6% vs. 7.5%, p = 0.313), the incidence of total death was higher in the immediate group than the staged group (9.7% vs. 2.8%, P=0.040). Despite the incidence of target lesion and vessel revascularization were similar, there was a trend toward higher incidence of TLR- MACE in the immediate group than the staged group (9.7% vs. 3.7%, p =0.086). There was no significant difference in the risk of in-hospital complications including transfusion, bleeding, acute renal failure or acute heart failure between the groups. Conclusion: For STEMI patients with multi-vessel disease undergoing primary PCI with drug-eluting stents, routine immediate complete revascularization should not be justified possibly due to higher event risks.

Background: Previous studies showed that the triple antiplatelet therapy (TAT) which is an addition of cilostazol on the top of conventional dual antiplatelet therapy (DAT, aspirin + clopidogrel) was associated with better clinical outcomes in ST-elevation MI (STEMI) patients as compared with DAPT but the optimal duration of TAT was not determined yet. Method: A total 985 patients underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DES) were prospectively enrolled in 14 medical centers in Korea. We randomly assigned patients into 3 groups of DAT (aspiring and clopidogrel) for 12 months, TAT (aspirin, clopidogrel and cilostazol) for 1month or 6months. The primary end point was 1-year major adverse cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction (MI), stroke or repeat revascularization. The secondary endpoints were the incidence of cardiac death, stent thrombosis, bleeding events and each component of primary end point. Results: The primary end point was not different among the 3 groups (8.4% in the DAT, 11.0% in the TAT for 1month, 11.3% in the TAT for 6 months, p=0.427). However, incidence of cardiac death was significantly higher in TAT groups (0.3% vs 2.5% vs 1.3%, respectively, p=0.047). Regarding in-hospital outcomes, higher bleeding events occurred in TAT groups than DAT group (0.3% vs 3.2% vs 1.9%, p=0.027) without significant difference in major bleeding. Conclusion: TAT strategy with cilostazol on the top of DAT did not associated with reduced incidence of 1-year MACE as compared with DAT but may be associated with increased cardiovascular death and bleeding risk. Whether routine additional use of cilostazol for STEMI patients would be beneficial need further studies with larger study population.

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

Background Sleep fragmentation and sleep apnea are common in patients with atrial fibrillation (AF). We investigated the impact of radio‐frequency catheter ablation (RFCA) on sleep quality in patients with paroxysmal AF and the effect of a change in sleep quality on recurrence of AF. Methods and Results Of 445 patients who underwent RFCA for paroxysmal AF between October 2007 and January 2017, we analyzed 225 patients who had a 24‐hour Holter test within 6 months before RFCA. Sleep quality was assessed by cardiopulmonary coupling analysis using 24‐hour Holter data. We compared cardiopulmonary coupling parameters (high‐frequency coupling, low‐frequency coupling, very‐low‐frequency coupling) before and after RFCA. Six months after RFCA, the high‐frequency coupling (marker of stable sleep) and very‐low‐frequency coupling (rapid eye movement/wake marker) was significantly increased (29.84%–36.15%; P P =0.002, respectively) while low‐frequency coupling (unstable sleep marker) was decreased (41.25%–32.13%; P Conclusions Sleep quality improved after RFCA in patients with paroxysmal AF. The recurrence rate was significantly lower in patients who had unstable sleep before RFCA. These results suggest that RFCA can influence sleep quality, and sleep quality assessment before RFCA may provide a risk marker for recurrence after RFCA in patients with paroxysmal AF.

Introduction: Stress-associated neurobiological activity is associated with future cardiovascular events. However, whether the linkage between brain emotional activity and complex plaque characteristics exists during the phase of acute plaque instability needs to be elucidated. Objectives: We aimed to prospectively estimate brain amygdalar activity (AmygA), arterial inflammation (AI) and macrophage hematopoiesis (HEMA) according to the presence of complex plaque characteristics in patients with acute myocardial infarction (AMI). Methods: In a total of 45 AMI patients (mean 60.0 years, 84.4% male), 18F FDG-PET/CT imaging was performed within 45 days of index episode. Total plaque burden was assessed using the SYNTAX score. The culprit plaque was considered complex, if there were two or more of the following morphologic features: thrombus, ulceration, plaque irregularity, and impaired flow (TIMI Results: Average SYNTAX score ranged by 16.3±8.4 and 12 (26.7%) patients had intermediate to high score (≥22). Complex culprit plaque and significant flow limitation were present in 34 (75.6%) and 33 (73.3%) patients, respectively. AmygA increased significantly in those who had higher SYNTAX score (≥22; target-to-background ratio [TBR]: 0.68±0.08 vs. 0.63±0.06; p=0.004), complex culprit plaques (TBR: 0.66±0.05 vs. 0.60±0.04; p Conclusions: AmygA was markedly enhanced in AMI patients with complex plaque characteristics. These findings suggest that AmygA closely associates with loco-regional disease activity at the level of coronary vasculature.

Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic vascular disease. However, there are limited data regarding the impact of Lp(a) levels on the incidence and severity of endothelium-dependent coronary vasomotor response.A total of 2416 patients without significant coronary artery lesion (50% stenosis) by coronary angiography and underwent acetylcholine (ACh) provocation test were enrolled and categorized according to their serum Lp(a) level into four quartile groups: less than 6.70, 6.70-13.30, 13.30-26.27, and more than 26.27 mg/dl. The aim of this study is to estimate the incidence and severity of endothelium-dependent positive ACh provocation test in each group; moreover, to access the incidence of major adverse cardiovascular events, the composite of total death, myocardial infarction, and de novo percutaneous coronary intervention were compared between the four groups up to 5 years.The group with higher Lp(a) had a higher incidence of coronary heart disease, myocardial infarction, and peripheral arterial disease history. However, there was no difference among the four groups as regards the incidence of positive ACh provocation test, spasm severity, spasm extent, and location. However, at up to 5 years of clinical follow-up, the higher-Lp(a) group showed higher total death, de novo percutaneous coronary intervention, recurrent angina, and total major adverse cardiovascular events compared with the lower-Lp(a) groups.In our study, there was no relationship between the elevated Lp(a) level and the vasospastic response to the intracoronary ACh provocation test; however, higher Lp(a) levels were associated with poor clinical outcomes up to 5 years.

We evaluated the effect of chronic exposure to air pollutants (APs) on coronary endothelial function and significant coronary artery spasm (CAS) as assessed by intracoronary acetylcholine (ACH) provocation test.A total of 6430 patients with typical or atypical chest pain who underwent intracoronary ACH provocation test were enrolled. We obtained data on APs from the Korean National Institute of Environmental Research (http://www.nier.go.kr/). APs are largely divided into two types: particulate matter with aerodynamic diameter of less than or equal to 10 µm in size (PM10) and gaseous pollutants such as nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone. The primary endpoint is the incidence of significant CAS and its associated parameters during ACH provocation test.The incidence of CAS was positively correlated with an exposure duration of PM10, whereas nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone were shown to be unrelated to CAS. During the ACH provocation test, as PM10 increased, the frequency of CAS was increased, and the incidence of transient ST-segment elevation was also increased. There was a trend toward higher incidence of spontaneous spasm as PM10 increased. The mean exposure level of PM10 was 51.3±25.4 µg/m. The CAS risk increased by 4% when the level of PM10 increased by 20 µg/m by an adjusted Cox regression analysis.CAS incidence is closely related to exposure to PMs but not to gaseous pollutants. Particularly, higher exposure concentrations and longer exposure duration of PM10 increased the risk of CAS. These important findings provide a plausible mechanism that links air pollution to vasospastic angina and provide new insights into environmental factors.

BACKGROUND The long-term clinical outcomes of coronary artery spasm (CAS) patients presented with acute myocardial infarction (AMI) compared to those who did not present with AMI has rarely been investigated. METHODS From November 2004 to May 2014, a total of 3360 patients who were confirmed as CAS by the acetylcholine (Ach) provocation test and without significant coronary lesion were retrospectively analyzed. AMI was an initial presentation in 34 patients [CAS-myocardial infarction (MI) group], and not in other 3326 patients (CAS group). The clinical outcomes up to 5 years were compared between the two groups. RESULTS Baseline characteristics and cardiovascular risk factors did not differ between the two groups, except the higher smoking rate in CAS-MI group (38.2 vs. 23.5%, P=0.046). During a mean follow-up period of 1211±583 days, the cumulative incidence of recurrent angina [hazard ratio (HR): 2.71; 95% confidence interval (CI): 1.20-6.13; P=0.016], MI (HR: 33.89; 95% CI: 8.76-131.1; P

Introduction: Grip strength has been associated with cardiovascular events. However, there have been no exact mechanisms explaining the association between grip strength and cardiovascular events. Hypothesis: The aim of this study was to assess whether arterial stiffness or endothelial function could mediate the association between grip strength and cardiovascular events. Methods: We studied 1508 participants (Age; 60 ± 7, Men; 47.5 %) from the Ansan cohort of the Korean Genome Epidemiology Study. Participants were assessed for grip strength, measured using a Jamar dynamometer. The central blood pressure, the augmentation index, and the pulse wave velocity were evaluated by using an applanation tonometer. Intima medial thickness was measured by B-mode ultrasonogram with a 7.5 MHz linear array transducer. Results: With increasing the grip strength, augmentation index decreased (r= -0.445, p Conclusions: Grip strength was inversely correlated with augmentation index. This result suggests that systemic arterial stiffness could mediate the association between grip strength and cardiovascular events.

Backgrounds: Chronic mental stress is a major risk factor of coronary artery disease, but there is a lack of direct mechanistic evidence between brain amygdala activity, a neural stress center, versus plaque vulnerability in acute coronary syndrome. In this study, we aimed to evaluate whether brain amygdala activity in AMI patients assessed by 18 F-FDG PET/CT could be associated with vascular inflammation in carotid beds and high-risk coronary plaque features evaluated by OCT. Methods and Results: In retrospective analysis, the patients who underwent 18 F-FDG PET/CT and CAG at Korea University Guro Hospital (Seoul, Korea). Among 1802 patients underwent 18 F-FDG PET/CT from October 1 2009 to 31 December 31 2015, 230 patients received CAG. After excluding 36 patients who had active cancer or brain disease, 198 were stratified according to degree of coronary severity by syntax score [none (n=159); mild to moderate (n=26); severe (n=13)]. Brain amygdalar activity on PET was quantified as target-to-background ratio (TBR) of standardized uptake value (amygdalar SUV max /temporal SUV mean ). The amygdalar TBR was significantly higher in patients with severe coronary disease rather than those without coronary stenosis or mild to moderate stenosis assessed by syntax score (P=0.03). Intriguingly, among 13 patients with severe CAD, the amygdalar TBR significantly increased in the 6 patients presented as AMI compared to non-MI patients (P=0.03). In following prospective study, we performed 18 F-FDG PET/CT in AMI patients underwent percutaneous coronary intervention within index admission period, and in patients with chronic stable angina (CSA) as control. The plaque morphology in non-culprit segment of infarct-related artery (IRA) was estimated by OCT in AMI patients. Brain amygdalar TBR was significantly higher in AMI patients compared to CSA patients (p Conclusions: The amygdalar activity assessed by 18 F-FDG PET/CT was significantly higher in patients with AMI than CSA. This amygdalar activity was related to vulnerable plaque characteristics of IRA. Our results suggest that brain emotional activity in ACS could contribute to plaque instability in pan-vascular beds.

Introduction: Exercise capacity is related to the prognosis of coronary heart disease (CHD). Recent study have shown that quadriceps strength can be used to predict exercise capacity levels in patients with CHD. Hypothesis: The aim of this study is to determine whether this relationship between muscular strength and exercise capacity is maintained in hand grip strength (HGS). Methods: We studied 310 participants (Age; 62.1 ± 11.5, Men; 77.4 %) who underwent coronary intervention and participated cardiac rehabilitation. Maximal HGS was expressed as absolute value (kg), and relative to bodyweight (%bodyweight). Logistic regression was used to assess the relationship of maximal HGS, age, sex, type of CHD, diabetes, hypertension, renal insufficiency, ejection fraction, body mass index, body weight, waist to hip ratio, and basal metabolic rate with distance walked on 6-minuite walk test (6MWT) and estimated metabolic equivalents (eMETs). Results: Maximal HGS was significantly related to distance walked on 6 MWT (r = 0.40 for %bodyweight, p < 0.001) and eMETs (r = 0.43 for %bodyweight, p < 0.001). Maximal HGS was the strongest predictor of exercise capacity in each distance walked on 6 MWT category. Receiver operating characteristics curves identified maximal HGS of 35.7, 42.0% bodyweight as the best predictive cut offs for 200, and 400 meters, respectively with positive predictive values of 0.64. They also identified HGS of 38.3, and 44.6% bodyweight as the best predictive cut offs for 6 and 8 eMETs, respectively with positive predictive values of 0.70. Conclusions: Maximal HGS is related with distance on 6 MWT and eMETs levels at exercise test in CHD patients. This result suggests that maximal HGS can be used to predict exercise capacity levels. Based on this result, prospective study investigating the association between HGS and clinical outcome of CHD is needed.

Statins therapy decrease both low-density lipoprotein cholesterol (LDL-C) levels and the risk of atherosclerotic cardiovascular disease (ASCVD) with considerable individual variability. Whether the amount of LDL-C lowering is a surrogate maker of statin responsiveness to ASCVD prevention has not been fully investigated. Among 2352 eligible patients with statin prescriptions in a cardiovascular center between January 2005 and February 2014, one-third of patients (33%) on statin therapy failed to achieve effective reductions in LDL-C (LDL-C level reduction of less than 15%). By using, propensity-score matched population (480 pairs, n = 960), the 5-year cumulative incidences of total major adverse cardiac events (MACE) were evaluated. The 5-year total MACE did not differ between normal cholesterol responders and non-responders (15.4% vs 16.1%, respectively; P = .860). In the subgroup analysis, male sex, older age, percutaneous coronary intervention, and heart failure were positive predictors, and dyslipidemia at the beginning of statin therapy was the only negative predictor of MACE in the 5-year follow-up (all P value < .05). However, cholesterol responsiveness after statin therapy did not influence the incidence of MACE (P = .860). The amount of LDL-C lowering did not predict beneficial effect on clinical outcomes of ASCVD after statin therapy. This result supports that given statin therapy, total ASCVD risk reduction should be tailored, which may not dependent to adherence to degree of LDL-C lowering or LDL-C goal based treatment.

Background: Critical limb ischemia (CLI) and coronary artery disease (CAD) are associated with a high risk of mortality and cardiovascular events. Also, CAD is well-known for its higher prevalence in CLI patients (pts). We evaluated long-term clinical outcomes of the strategy of routine coronary angiography and subsequent coronary revascularization, if clinically indicated, in patients with CLI who underwent percutaneous transluminal angioplasty (PTA). Methods: A total 674 consecutive CLI patients underwent PTA and coronary angiography. Coronary artery disease (CAD) was defined as angiographic stenosis ≥70 %. Patients were divided into two groups according to the presence of CAD (CAD group: 413 pts, Non-CAD group: 261 pts). To adjust for any potential confounders that could cause bias, propensity score matching (PSM) analysis was performed. Clinical outcomes were assessed in a follow-up of 5 years by Kaplan-Meier curved analysis. Results: After PSM analysis, two matched groups (160 pairs, n=320 pts) were generated and their baseline characteristics were balanced. During the 5-year clinical follow-up, there were no differences between the two group regarding mortality, myocardial infarction, strokes, peripheral revascularization, and target extremity surgery except that the coronary revascularization was higher in the CAD group than the non-CAD group [Table]. Conclusion: A strategy of routine coronary angiography and coronary revascularization may be a reasonable treatment option for patients who have high risk for severe CAD at least for 5 years. A randomized trial is needed to determine if this is the preferred strategy for CLI patients.

Background: Critical limb ischemia (CLI) and chronic kidney disease (CKD) are associated with poor outcomes. We assessed the 5-year clinical outcomes of CKD versus non-CKD patients (pts) with CLI who underwent peripheral transluminal angioplasty (PTA). Methods: A total 765 consecutive CLI pts underwent PTA were analyzed. CKD is defined as either kidney damage or estimating glomerular filtration rate (GFR) < 90 mL/min/m 2 . Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Patients (pts) were divided into two groups according to the presence of CKD (CKD group: 465 pts, non-CKD group: 300 pts). To adjust for any potential confounders that could cause bias, propensity score matching (PSM) analysis was performed. Five-year clinical outcomes were assessed by Kaplan-Meier curved analysis and log rank test. Results: The CKD stage of study populations showed that 42% had mild, 21% moderate, 3% severe, and 32% kidney failure or dialysis. After PSM analysis, two matched groups (226 pairs, n= 452 pts) were generated and their baseline characteristics were balanced. During the 5-year clinical follow-up, there were no differences in the incidence of myocardial infarction, strokes and coronary or peripheral revascularization between the two groups. However, the incidence of total death and the above the ankle amputation were higher in the CKD group than the non-CKD group [Table]. Conclusion: CKD pts with CLI had higher incidence of mortality and amputation rate at 5 years following standard PTA compared with non-CKD pts. Improved therapies and special care are needed for this high-risk group of patients.

Background: Thromboangiitis Obliterans (TAO), commonly Buerger’s disease, is associated with high risk of adverse outcomes, particularly higher amputation rate despite all the effort. The role of endovascular therapy (EVT) in TAO has been questioned owing to the technically challenging distal distribution of lesions and high rate of restenosis. Methods: Among 765 consecutive patients (pts) with significant peripheral artery disease (PAD) who underwent endovascular therapy (EVT) from Jan 2004 to June 2016, we identified 25 patients diagnosed as TAO with critical limb ischemia (CLI) who underwent EVT . Various clinical, coronary and peripheral angiographic characteristics and 5-year clinical outcomes were examined. Results: The prevalence of TAO among PAD pts undergoing EVT was 3.27% (23 males; 3.86% and 1.18% among total male and female, respectively). The mean age was 48.6 ± 16.8 (SD) and 23 (92%) had a history of smoking. Pts commonly presented with lower limb wounds, gangrene, claudication, diabetic foot and resting pain in deceasing order [N(%): 15(60), 11(44), 9(36), 5(20) and 1(4)], with 77.4% of limbs higher than Rutherford grade 2. A total 25 pts, 31 limbs and 81 lesions were treated with stent or balloon angioplasty [24 (29.6%) and 53 (65.4%) lesions, respectively], achieving clinical success in 73 (90.1%) lesions. Over half lesions were chronic total occlusions (56, 69.1%) and distributed peripherally (Table). Although nearly half patients underwent repeated procedures, limb salvage was achieved in most patients after 5 years. Conclusion: TAO is known for its poor prognosis in terms of limb salvage and peripherally located lower extremity lesions which are technically difficult to approach. Our experience with 25 patients with 81 lesions show promising long-term limb salvage outcomes following repetitive EVT with optimal medical therapy.

Background Epicardial adipose tissue ( EAT ) is known to play an important role in atrial fibrillation substrate remodeling; however, the influence of sex on the association between EAT and left atrial ( LA ) transport function has not been elucidated. Methods and Results Of the 514 patients who underwent an index atrial fibrillation ablation procedure, 123 postmenopausal women with no history of hormone replacement therapy and 123 men who were matched for age, body mass index, type of atrial fibrillation, and CHADS 2 score were enrolled. Before the procedure, LA volume, LA emptying fraction, and EAT volume were assessed using multislice computed tomography. Blood samples were obtained from a coronary sinus for analysis of serum adiponectin level before the ablation procedure. There were no differences in baseline demographics and laboratory findings between sexes. Compared with men, women had significantly less total EAT ( P P =0.022) but higher proportions of periatrial EAT to total EAT volume (P/T EAT ratio, P LA emptying fraction ( P =0.042), and lower LA voltage ( P =0.034). The ratio of periatrial to total EAT volume correlated significantly with LA emptying fraction and LA voltage in both sexes, whereas total EAT volume and serum adiponectin level did not. On multivariate analysis, increased LA volume and higher periatrial:total EAT volume ratio were independent predictors of decreased LA emptying fraction in both sexes. Conclusions Compared with matched men, postmenopausal women with atrial fibrillation had higher periatrial adiposity, which was independently correlated with decreased LA voltage and LA transport function.

Rationale: Macrophage accumulation in adipose tissue associates with insulin resistance and increased cardiovascular disease risk. We previously have shown that generation of reactive oxygen species and monocyte chemotactic factors after exposure of adipocytes to saturated fatty acids, such as palmitate, occurs via translocation of NADPH oxidase 4 into lipid rafts (LRs). The anti-inflammatory effects of apolipoprotein AI (apoAI) and high-density lipoprotein (HDL) on macrophages and endothelial cells seem to occur via cholesterol depletion of LRs. However, little is known concerning anti-inflammatory effects of HDL and apoAI on adipocytes. Objective: To determine whether apoAI and HDL inhibit inflammation in adipocytes and adipose tissue, and whether this is dependent on LRs. Methods and Results: In 3T3L-1 adipocytes, apoAI, HDL, and methyl-β-cyclodextrin inhibited chemotactic factor expression. ApoAI and HDL also disrupted LRs, reduced plasma membrane cholesterol content, inhibited NADPH oxidase 4 translocation into LRs, and reduced palmitate-induced reactive oxygen species generation and monocyte chemotactic factor expression. Silencing ATP-binding cassette A-1 abrogated the effect of apoAI, but not HDL, whereas silencing ATP-binding cassette G-1 or scavenger receptor B-1 abrogated the effect of HDL but not apoAI. In vivo, apoAI transgenic mice fed a high-fat, high-sucrose, cholesterol-containing diet showed reduced chemotactic factor and proinflammatory cytokine expression and reduced macrophage accumulation in adipose tissue. Conclusions: ApoAI and HDL have anti-inflammatory effects in adipocytes and adipose tissue similar to their effects in other cell types. These effects are consistent with disruption and removal of cholesterol from LRs, which are regulated by cholesterol transporters, such as ATP-binding cassette A-1, ATP-binding cassette G-1, and scavenger receptor B-1.

Background— Iatrogenic myocardial injury by radiofrequency catheter ablation (RFCA) releases proinflammatory substances from damaged myocardium, and these may contribute to endothelial dysfunction in systemic vascular structure. The aim of this study is to evaluate the effect of nonischemic myocardial damage on coronary microvascular function in patients undergoing atrial fibrillation (AF) ablation. Methods and Results— We included 49 patients who underwent AF ablation (paroxysmal AF=25, persistent AF=24) and 34 controls. Immediately before and after RFCA, index of microvascular resistance (IMR) was assessed at left anterior descending coronary artery, and blood samples were obtained for analyses of nitric oxide (NO), activated leukocyte cell adhesion molecule, and lipoprotein-associated phospholipase. Transthoracic echocardiography was performed at baseline, 1 day, 1 month, and 3 months after RFCA. Compared with baseline, IMR, activated leukocyte cell adhesion molecule, and lipoprotein-associated phospholipase increased and NO decreased after RFCA. In 36 subjects with increasing IMR, E/E′ ratio increased at 1 day and returned to baseline level at 3 months after RFCA. Changes in activated leukocyte cell adhesion molecule and lipoprotein-associated phospholipase between baseline and after RFCA were independently related to the increase in IMR. In 14 subjects (28.6%), arrhythmia recurred. Using a cutoff value of 9.3 mm Hg/s, sensitivity was 56.7% and specificity was 91.2% for IMR change in predicting AF recurrence ( P =0.028). Conclusions— Myocardial damage by RFCA provoked coronary microvascular dysfunction through systemic proinflammatory reaction that may contribute to transient diastolic dysfunction. This phenomenon may represent a mechanism for early recurrence of arrhythmia after RFCA. Clinical Trial Registration— URL: http://cris.nih.go.kr . Unique identifier: KCT0000030.

Background Coronary artery spasm ( CAS ) is a well‐known endothelial dysfunction, and a major cause of vasospastic angina ( VSA ). The renin–angiotensin system ( RAS ) is known to be closely associated with endothelial function. However, there are only a few studies that investigated the impact of RAS inhibitor on long‐term clinical outcomes in VSA patients. Methods and Results A total of 3349 patients with no significant coronary artery disease, diagnosed with CAS by acetylcholine provocation test were enrolled for this study. Significant CAS was defined as having ≥70% narrowing of the artery after incremental injections of 20, 50, and 100 μg of acetylcholine into the left coronary artery. Patients were divided into 2 groups according to whether the prescription included RAS inhibitor or not ( RAS inhibitor group: n=666, non‐ RAS inhibitor group; n=2683). To adjust for any potential confounders that could cause bias, propensity score matching ( PSM ) analysis was performed using a logistic regression model. After PSM analysis, 2 matched groups (524 pairs, n=1048 patients, C‐statistic=0.845) were generated and their baseline characteristics were balanced. During the 5‐year clinical follow‐up, the RAS inhibitor group showed a lower incidence of recurrent angina (8.7% versus 14.1%, P =0.027), total death (0.0% versus 1.3%, P =0.045), and total major adverse cardiovascular events (1.0% versus 4.1%, P =0.026) than the non‐ RAS inhibitor group. Conclusions Chronic RAS inhibitor therapy was associated with lower incidence of cardiovascular events in VSA patients in the 5‐year clinical follow‐up.

Background: It is unclear whether the routine follow up (FU) coronary angiography (CAG) regardless of patient’s symptoms after successful percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) in patients (pts) with dyslipidemia is beneficial or not. Methods: The study population consisted of 554 consecutive dyslipidemia pts underwent PCI with unrestricted utilization of DESs from January 2004 to May 2011. Routine FU CAG was performed between 6 to 9 months following index PCI and was decided by individual physician’s discretion. Rests of the pts were clinically followed and ischemic driven events were captured. Clinical events including mortality, myocardial infarction and clinically driven PCI before 9 months were excluded in both groups. Cumulative clinical outcomes up to 3 years were compared between the Routine CAG group (n=329 pts) and the Clinical FU group (n= 225 pts). To adjust potential confounders, a propensity score matched (PSM) analysis was performed using the logistic regression model. Results: After PSM analysis, 2 propensity-matched groups (165 pairs, n = 330 pts, C-statistic=0.718) were generated and, the baseline characteristics of the two groups were balanced. At 3 years, the incidence of repeat revascularization and major adverse cardiac events (MACEs) was higher in the Routine CAG group than the control group (Table). Conclusions: Despite the expected beneficial effects, routine FU CAG following index PCI with DESs in dyslipidemia pts was associated with higher incidence of repeat PCI and MACE up to 3 years.

Introduction: Current guidelines on lipid management emphasize LDL-C lowering >50% of baseline levels with intensive statin regimens in patients with coronary artery disease. However, whether this strategy is beneficial also in patients with very low LDL-C has not been proven. Furthermore, controversy remains on the optimal statin intensity for Asians in whom outcome data of lipid therapy are highly limited. Methods and Results: Totally, 3867 patients with chronic ischemic heart disease were initially screened. Among them, 393 subjects(age: 66 years; males: 68%) who showed baseline LDL-C During the mean follow-up of 3.8 years, 41 patients (10.4%) experienced MACE. The event-free survival was higher in patients receiving higher dose statins (Figure, p=0.03). In the univariate analysis, age (p=0.05), the % change of LDL-C (p=0.01), and the statin intensity (p=0.03) were associated with MACE. In the multivariate analysis, the statin intensity was found to be an only independent predictor of clinical outcome (p=0.05). Interestingly, the beneficial effect of statins became significant at the moderate-high dose. The predictive value of the % change of LDL-C was not significant after controlling other variables. Conclusions: Our study demonstrated that higher dose statins (at least moderate-high intensity) were more beneficial in Asian patients with chronic ischemic heart disease even if their LDL-C is

Background: It has been reported that a major cause of vasospastic angina is endothelial dysfunction of the coronary artery. However, it is controversial whether the uric acid level is associated with vasospastic angina, and can be a prognostic factor for vasospastic angina. Methods: A total 3828 patients (pts) underwent coronary angiography with acetylcholine (Ach) provocation test from Mar 2004 to Sep 2012 were enrolled. The definition of positive coronary artery spasm (CAS) was defined as transient luminal narrowing more than 70%. The uric acid level was categorized into 4 quartile groups; less than 3.8, 3.9~4.7, 4.8~5.7, and more than 5.8 mg/dL. Major adverse cardiovascular events (MACEs) defined as the composite of recurrent chest pain, cardiac death, myocardial infarction, and cerebrovascular accident were valuated up to 3 years. Results: The follow-up rate was the 61.1% (2340/3828). There was no difference in uric acid level between negative and positive CAS groups in female gender but in male gender, uric acid level was higher in negative CAS group (Table 1). However, when adjusted by age, the difference was disappeared (OR, 0.965; 95% CI, 0.898-1.037; P-value, 0.335). The incidence of MACE was 11.1% in male gender and 8.6% in female gender. In male gender, the serum uric acid level between the groups with and without MACE was similar but in female gender, the uric acid level was higher in the group with MACE. However, when adjusted by age, uric acid was not associated with MACE (Table 2). Conclusions: In our study, uric acid was neither the risk factor nor prognostic factor for 3-year clinical events in CAS patients regardless of gender.

Background: Although percutaneous transluminal angioplasty (PTA) is considered as an effective treatment strategy in patients (pts) with critical limb ischemia (CLI), below-the-knee (BTK) lesions with CLI is particularly challenging. This study sought to compare the 12-month outcomes following stenting versus standard plain old balloon angioplasty (POBA) alone in BTK lesions. Method: This study consisted of 339 consecutive lower extremity arterial disease pts (394 limbs, 1026 lesions included 716 BTK lesions) with BTK lesions from Sep 2004 to Dec 2013. All the enrolled pts were treated by stenting (bare metal stents, primary or provisional, 78 limbs in 73 pts) or POBA (316 limbs in 266 pts) with PTA. Procedural success, complications and clinical outcomes were compared between the two groups up to 12 months. To adjust potential confounders, a propensity score matched (PSM) analysis was performed using the logistic regression model. Results: After PSM analysis, 2 propensity-matched groups (56 pairs in pts, n= 112; 61 pairs in limbs, n=122, C-statistic=0.808) were generated, and the baseline & angiographic characteristics of the two groups were balanced. Procedural success, complication incidences were similar between the two groups. Six to 9-month CT or angiographic follow-up, there were similar incidence of binary restenosis, primary, and secondary patency. At 12 months, there were similar incidence of individual hard endpoints including mortality, myocardial infarction, limb salvage, and any extremity amputations except the target lesion and extremity revascularization. Repeat PTA incidence was higher in the stenting group than POBA group (table). Conclusion: Although the repeat PTA risk was increased with BTK stenting, other major individual clinical outcomes and limb salvage rates were similar between the POBA and stenting for the BTK lesions.

OBJECTIVE Healthy obese phenotype with favorable metabolic profiles is proposed. However, whether healthy obesity leads to target organ changes is controversial. We investigated the impact of a healthy obesity on cardiovascular structure and function. METHODS A total of 2540 participants without known cardiovascular disease were enrolled. According to BMI and the metabolic syndrome (MetS) component, the participants were divided into six groups: healthy (none of five MetS components) normal weight (BMI

Left ventricular hypertrophy (LVH) is associated with increased risk for vascular events and mortality. This study investigated 8-year clinical outcomes of hypertensive patients with LVH who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) compared with hypertensive patients without LVH. A total of 1704 consecutive hypertensive patients who underwent PCI from 2004 to 2014 were enrolled. We classified them into either the LVH group (n = 406) or the control group (without LVH, n = 1298). LVH was defined by LV mass index > 115 g/m2 in men and > 95 g/m2 in women. After propensity score matched (PSM) analysis, 2 PSM groups (366 pairs, n = 732, c-statistic = 0.629) were generated. For up to 8 years, the LVH group showed a higher incidence of cardiac death (4.4% vs 1.2%, log-rank P = .023, hazard ratio: 3.371, 95% confidence interval: 1.109–10.25; P = .032) compared with the control group. However, there were no significant differences between the 2 groups in the incidence of total death, myocardial infarction, revascularization, and major adverse cardiac events up to 8 years. LVH in hypertensive patients who underwent successful PCI with DES was associated with higher incidence of cardiac death up to 8 years of follow-up. More careful managements and clinical follow-up are needed and treatment strategies should specifically focus to target prevention and reversal of LVH in hypertensive patients.

A 55-year-old man with a previous history of cerebral infarct and hypertension presented to our cardiovascular center complaining of angina in November 2011. Chronic total occlusion in the proximal left anterior descending artery was identified by coronary angiography (Figure 1A). The patient subsequently underwent percutaneous coronary intervention. Wiring was done successfully with a tapered stiff wire (Conquest Pro 20; ASAHI INTECC). After multiple predilation, a single drug-eluting stent (3.0 × 18 mm) of an open-cell design and bioabsorbable polymer (Nobori; Terumo, Tokyo, Japan) was implanted using a 3.5-mm noncompliant balloon (inflation pressure, 24 atmospheric pressure; Quantum Maverick Balloon; Boston Scientific/Scimed, Maple Grove, MN) for application of final high-pressure postdilation (Figure 1B). The patient has been asymptomatic since percutaneous coronary intervention and on dual antiplatelet therapy. A 6-month scheduled angiographic follow-up demonstrated a structural misalignment at the stent implantation site with a change in focal aneurysm (Figure 1C). Digital subtraction imaging by StentBoost (Subtract; Philips Healthcare, Best, The Netherlands) was done under the suspicion of stent distortion, but the imaging was unclear to clarify the diagnosis (Figure 1D). To determine the precise configuration of the stent, we performed intravascular optical coherence tomography (OCT). Conventional 2-dimensional (2-D) OCT revealed a focal thrombus and 2 additional aneurysms …

To the Editor: We read with interest the work by Chen et al,1 which reported that triple antiplatelet therapy seems to be superior to dual antiplatelet therapy in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention with drug-eluting stents. Chen et al1 reported the mortality benefits of triple antiplatelet therapy obtained mainly within 30 days after STEMI, reflecting the importance of the addition of cilostazol to aspirin and clopidogrel before stenting. Meanwhile, …

Background: Cerebrovascular disease (CVD) can be an important future cardiovascular event. The impact of previous cerebrovascular disease (CVD) on the clinical characteristics and midterm outcomes of patients (pts) with acute myocardial infarction (AMI) has not been well described in Asian population. Methods: Data were analyzed from 8151 pts with AMI (either STEMI or NSTEMI) enrolled in Korea Acute Myocardial Infarction Registry (KAMIR) from 2005 to 2007. Results: Of 8151 pts, 552 pts (6.8%) had previous CVD. The pts with CVD were older (68.95 ± 10.11 vs 62.83 ± 12.74, P P P P P =0.003) at 8 months. The incidences of recurrent MI and repeat revascularization at 8 months were similar between the two groups. Conclusions: Pts with CVD showed more severe and worse clinical characteristics on admission and was associated with lower rates of PCI or thrombolysis. When we consider the poorer midterm clinical outcomes including higher mortality and MACE, in pts with prior CVD, more intensive and aggressive management for this particular subset of pts should be emphasized for better long-term clinical outcomes.

Background: Visceral adipose tissue is thought to confer increased cardiovascular risk through leukocyte infiltration and increased adipose macrophage activity. Previous positron emission tomography (PET) studies using fluorodeoxyglucose (FDG) demonstrated that increased FDG uptake could reflect the severity of inflammation in atherosclerotic plaque. We hypothesized that active atherosclerotic change in the major arteries would accompany increased inflammation within visceral fat and it could be detected in humans using combined FDG PET/computed tomography (CT). Methods: We observed 44 consecutive subjects with cardiovascular disease. For all of them, an one-hour PET/CT (from brain to foot) was performed after injection of FDG (370–555 MBq). FDG uptake in the aorta or its major branches was evaluated visually and semiquantitatively. Maximal standard uptake values (SUV) of the highest regions of interest were calculated in the subcutaneous fat and visceral fat area, separately. Results: Significant FDG uptake in the arterial wall was noted in 21 patients (plaque positive; PP group), all of whom have experienced acute cardiovascular events (acute coronary syndrome or ischemic stroke) within a week. The other 23 patients (plaque negative; PN group) had chronic stable angina or asymptomatic carotid stenosis. Visceral fat SUV was significantly higher as compared to subcutaneous fat SUV (0.49± 0.15 vs. 0.15± 0.05, p< 0.001) in PP group, whereas there was no significant difference in PN group (0.18± 0.07 vs. 0.16± 0.03, p= 0.622). When we compared two groups, PP group showed higher visceral fat SUV than PN group (p< 0.001). In terms of subcutaneous fat SUV, the results were similar in two groups (p= 0.773). Conclusions: We demonstrated that atherosclerotic plaque inflammation was associated with increased inflammation within visceral fat. Our results need to be confirmed by comparison with histologic or other imaging findings. Further evaluation to determine whether metabolic activity of visceral adipose tissue is a marker or mediator of vascular inflammation is also needed.

A 20-year-old male who had fallen from the third floor of a building after excessive alcohol intake presented to our emergency room. He complained of flank pain, and subsequent simple x-ray and pelvis computed tomography revealed a right acetabular fracture, which we decided to treat conservatively. There were no other major injuries. An abdominal computed tomography scan (Figure 1A and 1B) revealed bilateral multifocal renal infarction. An urgent technetium-labeled dimercaptosuccinic acid renal scan (Figure 1C and 1D) showed significantly reduced perfusion in both lower lobes of the kidney. An emergent renal angiogram showed normal right main renal artery (Figure 2A). The anomalous right inferior polar artery showed complete thrombotic occlusion (Figure 2B). We prudently pursued the percutaneous renal intervention because there were no …