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Key Clinical Message: Transcatheter aortic valve implantation (TVAI) is a widely used treatment modality for severe aortic stenosis. The complication rates of the procedure have gradually decreased over time, owing to the improvements in procedural skills and development of TVAI devices. However, several rare but serious complications can still occur after TAVI. We recently encountered acute decompensated heart failure as a rare and fatal complication of TAVI and would like to share our experience. [ABSTRACT FROM AUTHOR]

Background: Patients with diabetes mellitus (DM) have a higher prevalence of heart failure (HF) than those without it. Approximately 40 % of HF patients have DM and they tend to have poorer outcomes than those without DM. This study evaluated the impact of insulin therapy on mortality among acute HF patients. Methods: A total of 1740 patients from the Korean Acute Heart Failure registry with DM were included in this study. The risk of all-cause mortality according to insulin therapy was assessed using the Cox proportional hazard models with inverse probability of treatment weighting to balance the clinical characteristics (pretreatment covariates) between the groups. Results: DM patients had been treated with either oral hypoglycemic agents (OHAs) alone (n = 620), insulin alone (n = 682), or insulin combined with OHAs (n = 438). The insulin alone group was associated with an increased mortality risk compared with the OHA alone group (HR = 1.41, 95 % CI 1.21–1.66]). Insulin therapy combined with OHAs also showed an increased mortality risk (HR = 1.29, 95 % CI 1.14–1.46) compared with the OHA alone group. Insulin therapy was consistently associated with increased mortality risk, regardless of the left ventricular ejection fraction (LVEF) or HF etiology. A significant increase in mortality was observed in patients with good glycemic control (HbA1c < 7.0 %) receiving insulin, whereas there was no significant association in patients with poor glycemic control (HbA1c ≥ 7.0%). Conclusions: Insulin therapy was found to be associated with increased mortality compared to OHAs. The insulin therapy was harmful especially in patients with low HbA1c levels which may suggest the necessity of specific management strategies and blood sugar targets when using insulin in patients with HF. [ABSTRACT FROM AUTHOR]

Variations by hospital and region in the selection of an early invasive strategy (EIS) after non–ST-segment elevation myocardial infarction (NSTEMI) in patients with high-risk criteria are unknown. We evaluated the data of 7037 patients with NSTEMI from 20 hospitals of 3 regions from the Korean Acute Myocardial Infarction Registry–National Institute of Health database. We used hierarchical generalized linear mixed-models to estimate region- and hospital-level variation in the selection of an EIS after adjusting for patient-level high-risk criteria. We explored the variation using the median rate ratio (MRR), which estimates the relative difference in the risk ratios of two hypothetically identical patients at two different sites. An EIS was selected in 84.4% of patients. At the hospital level, the median selection rate was 80.4%. At the region level, the median selection rate was 74.9% in the east region, 81.3% in the north region, and 83.9% in the west region, respectively. After adjusting for patient-level covariates, we found significant hospital- (MRR 2.19, 95% confidence interval [CI]: 1.74–3.03) and region-level (MRR 1.88, 95%CI: 1.26–5.44) variation in the selection of an EIS. Among patient-level factors, male sex, ongoing chest pain, history of coronary artery disease or acute heart failure, and GRACE risk score > 140 were independently associated with the selection of an EIS. We observed significant hospital- and region-level variation in the selection of an EIS after NSTEMI in high-risk patients. Quality improvement efforts are required to standardize decision making and to improve clinical outcomes. • There is significant hospital- and region-level variation in early invasive strategy selection. • An early conservative strategy is often chosen when an early invasive strategy would provide more benefit. • Site-level variation reflects that there is significant undertreatment for high-risk patients that could worsen clinical outcome. • Quality improvement efforts are required to standardize decision making and improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines have been slowly and inconsistently applied in clinical practice, and certain evidence-based, guideline-driven therapies for heart failure (HF) have been significantly underused. The purpose of this study was to survey guideline compliance and its effect on clinical outcomes in the treatment of systolic HF in Korea. Method and Results: The SUrvey of Guideline Adherence for Treatment of Systolic Heart Failure in Real World (SUGAR) trial was a multi-center, retrospective, observational study on subjects with systolic HF (ejection fraction <45%) admitted to 23 university hospitals. The guideline adherence indicator (GAI) was defined as a performance measure on the basis of 3 pharmacological classes: angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor II blocker (ARB), beta-blocker (BB), and aldosterone antagonist (AA). Based on the overall adherence percentage, subjects were divided into 2 groups: those with good guideline adherence (GAI ≥50%) and poor guideline adherence (GAI <50%). We included 1319 regional participants as representatives of the standard population from the Korean national census in 2008. Adherence to drugs at discharge was as follows: ACEI or ARB, 89.7%; BB, 69.2%; and AA, 65.9%. Overall, 82.7% of the patients had good guideline adherence. Overall mortality and re-hospitalization rates at 1 year were 6.2% and 37.4%, respectively. Survival analysis by log-rank test showed a significant difference in event-free survival rate of mortality (94.7% vs. 89.8%, p = 0.003) and re-hospitalization (62.3% vs. 56.4%, p = 0.041) between the good and poor guideline-adherence groups. Conclusions: Among patients with systolic HF in Korea, adherence to pharmacologic treatment guidelines as determined by performance measures, including prescription of ACEI/ARB and BB at discharge, was associated with improved clinical outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the value of a new Revised Cardiac Risk Index (RCRI) that includes consideration of QRS fragmentation (fQRS) as a predictor of cardiac events in patients undergoing noncardiac vascular surgery. Four hundred sixty-seven consecutive patients admitted for noncardiac vascular surgery were studied. Patients were allocated to RCRI 0, 1, 2, or ≥3 groups according to the sum of diabetes, renal insufficiency, and histories of ischemic heart disease, congestive heart failure, and cerebrovascular disease. They were then reallocated to fragmented RCRI (fRCRI) 0, 1, 2, or 3 groups after including a score of 1 or 0 corresponding to the presence or absence of fQRS. A major adverse cardiac event (MACE) was defined as a composite of death, myocardial infarction, congestive heart failure, and percutaneous coronary intervention before noncardiac vascular surgery. During index hospitalization, MACE developed in 38 patients (8.1%). fQRS was present in 169 (36.2%), and it was significantly greater in patients with MACE than in those without MACE (63.2% vs 34.3%, p <0.001). The proportions of RCRI 0, 1, 2, and 3 were 46.9% (n [ 219), 35.3% (n [ 165), 12.4% (n [ 58), and 5.4% (n [ 25), respectively. When fRCRI data were included, 28 patients (48.3%) in RCRI 2 were reclassified as fRCRI ≥3. By multivariate logistic regression analysis, fRCRI (odds ratio 1.529, 95% confidence interval 1.035 to 2.258, p [ 0.033) and a left ventricular ejection fraction <50% independently predicted in-hospital MACE. In conclusion, fRCRI is an independent predictor of in-hospital MACE in patients undergoing noncardiac vascular surgery. [ABSTRACT FROM AUTHOR]