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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: Speckle tracking-derived global longitudinal strain (GLS) of left ventricle is a potent prognostic marker for patients with ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to investigate the difference of prognostic impact of GLS between anterior and nonanterior myocardial infarction. Methods: This study included 686 patients who underwent primary percutaneous coronary intervention for their first STEMI between November 2007 and April 2012. Differences in the prognostic impact of GLS between anterior MI group and nonanterior MI group were evaluated. The composite of all-cause mortality and hospitalization for heart failure in 2 years was investigated for outcome. Results: During the follow-up period, 77 (11.2%) adverse events occurred. The anterior and nonanterior MI groups included 339 and 347 patients, respectively. Among patients with anterior MI, GLS significantly predicted 2-year outcome in an adjusted model (adjusted hazard ratio [HR] 1.186; 95% confidence interval [CI] 1.071-1.314, P = 0.001), whereas the association between GLS and mortality was weaker in the nonanterior MI group (adjusted HR 0.977; 95% CI 0.884-1.081, P = 0.657). The interaction between the infarction territory and GLS was significant (P for interaction = 0.018), indicating that GLS was a more sensitive predictor of mortality in patients with anterior MI than that in those with nonanterior MI. Conclusions: Speckle tracking-derived GLS of left ventricle more sensitively predicted clinical outcome in patients with anterior MI than in those with nonanterior MI. [ABSTRACT FROM AUTHOR]

Purpose A new antihypertensive drug that selectively blocks angiotensin II receptor type 1, fimasartan, has a potent and rapidly acting antihypertensive effect. We investigated the antihypertensive effects of fimasartan 60 and 120 mg and its safety in comparison to 8 mg of candesartan. Methods This clinical trial is a multicenter, randomized, double-blind, active comparator, and parallel group study. Three hundred sixty-two individuals were screened, and 290 patients aged 19 to 75 years with mild to moderate hypertension (diastolic blood pressure [DBP], 90–110 mm Hg) were randomly assigned to 60 to 120 mg/d of fimasartan or 8 mg/d of candesartan after a 2-week placebo run-in period. Treatments were administered for 12 weeks without dosage adjustment. The primary end point was the differences in DBP changes at week 12. Findings After 12 weeks of treatment, DBP and systolic blood pressure (SBP) decreased significantly in all 3 groups. The decrease in DBP at week 12 was larger but not statistically significant in the fimasartan 60 mg compared with the candesartan 8 mg group with a mean (SD) difference of 1.72 (8.32) mm Hg (95% CI, −0.71 to 4.15 mm Hg; P = 0.17). The lower margin of the CI (−0.71 mm Hg) exceeded the noninferiority margin (−3.5 mm Hg). The DBP-lowering effect of fimasartan 120 mg was also nonsignificantly larger than candesartan 8 mg (difference, 1.58 [8.27] mm Hg; P = 0.20). The decrease in SBP was also nonsignificantly larger in the fimasartan 60 mg group compared with the candesartan 8 mg group (difference, 3.50 [12.63] mm Hg; P = .06). The SBP-lowering effect of fimasartan 120 mg was statistically larger than candesartan 8 mg (difference, 4.98 [13.99] mm Hg; P = .02). Response rate (DBP <90 mm Hg or DBP lowering >10 mm Hg at week 12) was also nonsignificantly greater in both fimasartan groups (Fimasartan 60 mg, 81%; fimasartan 120 mg, 72%; candesartan 8 mg, 71%). The safety profile of the fimasartan 60 mg and 120 mg was similar to candesartan 8 mg, with a slightly higher, but statistically not significant, incidence of hepatic enzyme elevation in fimasartan 120 mg. Implications The antihypertensive effect of fimasartan, a newly available angiotensin II receptor type 1 blocker, is comparable, although not superior, to candesartan with a good safety profile. ClinicalTrials.gov identifier: NCT01135212. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the association between serum high-sensitivity C-reactive protein (hs-CRP) and incident hypertension. Study subjects were 452 Koreans who were enrolled in a cohort study. Log-transformed hs-CRP (odds ratio, 1.89; 95% confidence interval, 1.05-3.39; p = 0.035) was an independent predictor of incident hypertension. Inclusion of hs-CRP showed significant increase in the area under the curve from 0.697 to 0.720 ( p = 0.042), the net reclassification improvement (0.394, p < 0.001) and integrated discrimination improvement (0.0111, p = 0.045). The hs-CRP added incremental value to the combination of systolic blood pressure and conventional risk factors in predicting incident hypertension. [ABSTRACT FROM AUTHOR]

Imaging modalities for percutaneous coronary intervention (PCI), such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT), have increased in the current PCI era. However, their clinical benefits in acute myocardial infarction (AMI) have not been fully elucidated. This study investigated the long-term outcomes of image-guided PCI in patients with AMI using data from the Korean Acute Myocardial Infarction Registry. A total of 9,271 patients with AMI, who underwent PCI with second-generation drug-eluting stents between November 2011 and December 2015, were retrospectively examined, and target lesion failure (TLF) at 3 years (defined as the composite of cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization) was evaluated. From the registry, 2,134 patients (23.0%) underwent image-guided PCI (IVUS-guided: n = 1,919 [20.6%]; OCT-guided: n = 215 patients [2.3%]). Based on propensity score matching, image-guided PCI was associated with a significant reduction in TLF (hazard ratio: 0.76; 95% confidence interval: 0.59–0.98, p = 0.035). In addition, the TLF incidence in the OCT-guided PCI group was comparable to that in the IVUS-guided PCI group (5.3% vs 4.7%, p = 0.903). Image-guided PCI, including IVUS and OCT, is associated with favorable clinical outcomes in patients with AMI at 3 years post-intervention. Additionally, OCT-guided PCI is not inferior to IVUS-guided PCI in patients with AMI. [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]

The authors performed this study to investigate the efficacy and safety of a rosuvastatin (RSV)/amlodipine (AML) polypill compared with those of atorvastatin (ATV)/AML polypill. We included 259 patients from 21 institutions in Korea. Patients were randomly assigned to 1 of 3 treatment groups: RSV 10 mg/AML 5 mg, RSV 20 mg/AML 5 mg, or ATV 20 mg /AML 5 mg. The primary endpoint was the efficacy of the RSV 10.20 mg/AML 5 mg via percentage changes in LDL‐C after 8 weeks of treatment, compared with the ATV 20 mg /AML 5 mg. There was a significant difference in the mean percentage change of LDL‐C at 8 weeks between the RSV 10 mg/AML 5 mg and the ATV 20 mg/AML 5 mg (full analysis set [FAS]: −7.08%, 95% CI: −11.79 to −2.38, p =.0034, per‐protocol analysis set [PPS]: −6.97%, 95% CI: −11.76 to −2.19, p =.0046). Also, there was a significant difference in the mean percentage change of LDL‐C at 8 weeks between the RSV 20 mg/AML 5 mg and the ATV 20 mg/AML 5 mg (FAS: −10.13%, 95% CI: −15.41 to −4.84, p =.0002, PPS: −10.96%, 95% CI: −15.98 to −5.93, p <.0001). There was no significant difference in the adverse events rates between RSV 10 mg/AML 5 mg, RSV 20 mg/AML 5 mg, and ATV 20 mg/AML 5 mg. In conclusion, while maintaining safety, RSV 10 mg/AML 5 mg and the RSV 20 mg/AML 5 mg more effectively reduced LDL‐C compared with the ATV 20 mg /AML 5 mg (Clinical trial: NCT03951207). [ABSTRACT FROM AUTHOR]

We investigated if elevated cardiac troponin I (cTnI) serum levels before non-cardiac surgery were predictors of postoperative cardiac events in patients with end stage renal disease (ESRD) undergoing dialysis. In total, 703 consecutive patients with ESRD undergoing dialysis who underwent non-cardiac surgery were enrolled. Preoperative cTnI serum levels were measured at least once in all patients. The primary endpoint was defined as a composite of cardiac death, myocardial infarction (MI), and pulmonary edema during hospitalization or within 30 days after surgery in patients with a hospitalization longer than 30 days after surgery. Postoperative cardiac events occurred in 48 (6.8%) out of 703 patients (cardiac death 1, MI 18, and pulmonary edema 33). Diabetes mellitus (DM), previous ischemic heart disease, and congestive heart failure were more common in patients with postoperative cardiac events. Peak cTnI serum levels were higher in patients with postoperative cardiac event (180 ± 420 ng/L vs. 80 ± 190 ng/L, p = 0.008), and also elevated peak cTnI levels > 45 ng/L were more common in patients with postoperative cardiac events (66.8% vs. 30.5%, p < 0.001). Multivariate logistic regression analysis showed that DM (odds ratio [OR] 2.509, 95% confidence interval [CI] 1.178–5.345, p = 0.017) and serum peak cTnI levels ≥ 45 ng/L (OR 3.167, 95% CI 1.557–6.444, p = 0.001) were independent predictors for the primary outcome of cardiac death/MI/pulmonary edema. Moreover, cTnI levels ≥ 45 ng/L had an incremental prognostic value to the revised cardiac risk index (RCRI) (Chi-square = 23, p < 0.001), and to the combined RCRI and left ventricular ejection fraction (Chi-square = 12, p = 0.001). Elevated preoperative cTnI levels are predictors of postoperative cardiac events including cardiac death, MI, and pulmonary edema in patients with ESRD undergoing non-cardiac surgery. [ABSTRACT FROM AUTHOR]

There is insufficient information on the relationship between the N-terminal pro-brain natriuretic peptide (NT-proBNP) level and collateral circulation (CC) formation after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction. We analyzed 857 patients who underwent primary PCI. The serum NT-proBNP levels were measured on the day of admission, and the CC was scored according to Rentrop's classification. Log-transformed NT-proBNP levels were significantly higher in patients with good CC compared to those with poor CC (6.13 ± 2.01 pg/mL versus 5.48 ± 1.97 pg/mL, p < 0.001). The optimum cutoff value of log NT-proBNP for predicting CC was 6.04 pg/mL. Log NT-proBNP ≥ 6.04 pg/mL (odds ratio 2.23; 95% confidence interval 1.51–3.30; p < 0.001) was an independent predictor of good CC. CC development was higher in patients with a pre-TIMI flow of 0 or 1 than those with a pre-TIMI flow of 2 or 3 (22.6% versus 8.8%, p = 0.001). The incidence of left ventricular (LV) dysfunction (< 50%) was greater in patients with a pre-TIMI flow of 0 or 1 (49.8% versus 35.5%, p < 0.001). The release of NT-proBNP was greater in patients with LV dysfunction (34.3% versus 15.6%, p < 0.001). The incidence of good CC was greater in patients with log NT-proBNP levels ≥ 6.04 pg/ml (16.8% versus 26.2%, p = 0.003). The association between NT-proBNP and collateral formation was not influenced by pre-TIMI flow and LV function. NT-proBNP appears to reflect the degree of collateral formation in the early phase of STEMI and might have a new role as a useful surrogate biomarker for collateral formation in patients undergoing primary PCI. [ABSTRACT FROM AUTHOR]

Abstract: Background: We investigated the association between meteorological parameters and hospital admissions for acute myocardial infarction (AMI) in a temperate and continental climate, Korea. Methods: From the Korean AMI Registry, 2136 Koreans admitted for AMI in four university hospitals in Daegu city from November 2005 to October 2007 were included in this study. We calculated the incidences of AMI per season, per month, and per day-of-week. The meteorological parameters, including air temperature, relative humidity, wind speed, sunshine duration, and a thermo-hydrological index, were provided by the database of the Korea Meteorological Administration. Generalized additive Poisson models were used. Results: Seasonal variations were noted for AMI, characterized by winter peak and summer trough (p <0.001). Monthly occurrence rate of AMI was highest in January and lowest in October (p <0.001). There were significant associations between hospital admissions and meteorological parameters including air temperature, relative humidity, and sunshine duration after controlling for effects of day-of-week, season, and holidays (p <0.05). These associations were stronger in females and the younger age (<65 years) (p <0.01). Conclusions: The incidence of AMI shows seasonal and monthly variations. Meteorological parameters have a significant influence on the occurrence of AMI, particularly in females and the younger age. [ABSTRACT FROM AUTHOR]

We developed and assessed whether a novel neutrophil-to-hemoglobin and lymphocyte (NHL) score would improve the ability to predict clinical outcome compared with neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) in acute myocardial infarction (AMI). We examined 13,072 AMI patients from the Korean AMI Registry–National Institute of Health database. NHL score was calculated as follows: NHL score (U) = N/(Hb × L), where N, Hb, and L are baseline blood neutrophil, hemoglobin, and lymphocyte count. The primary outcome was the occurrence of major adverse cerebrocardiovascular events (MACCEs) at 2 years. The NLR, SII, and NHL score were independent predictors of 2-year MACCEs. The area under the curve of the NHL score (0.637) for predicting 2-year MACCEs was significantly higher compared with those of SII (0.589) and NLR (0.607). The NHL score significantly improved the reclassification and integrated discrimination compared with NLR (p < 0.0001) and SII (p < 0.0001). A high NHL score (≥ 0.35 U) was an independent predictor of 2-year MACCEs (adjusted hazard ratio, 1.41; 95% confidence interval, 1.29–1.55; p < 0.001). The NHL score could be a novel model for predicting long-term MACCEs in patients with AMI. [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]

This study sought to determine hospital variation in the use of follow-up stress testing (FUST) and invasive coronary angiography (FUCAG) after percutaneous coronary intervention (PCI). The claims records of 150,580 Korean patients who received PCI in 128 hospitals between 2008 and 2015 were analyzed. Patient were considered to have undergone FUST and FUCAG, when these testings were performed within two years after discharge from the index hospitalization. Hierarchical generalized linear and frailty models were used to evaluate binary and time-to-event outcomes. Hospital-level risk-standardized FUCAG and FUST rates were highly variable across the hospitals (median, 0.41; interquartile range [IQR], 0.27–0.59; median, 0.22; IQR, 0.08–0.39, respectively). The performances of various models predicting the likelihood of FUCAG and FUST were compared, and the best performance was observed with the models adjusted for patient case mix and individual hospital effects as random effects (receiver operating characteristic curves, 0.72 for FUCAG; 0.82 for FUST). The intraclass correlation coefficients of the models (0.41 and 0.68, respectively) indicated that a considerable proportion of the observed variation was related to individual institutional effects. Higher hospital-level FUCAG and FUST rates were not preventive of death or myocardial infarction. Increased repeat revascularizations were observed in hospitals with higher FUCAG rates. [ABSTRACT FROM AUTHOR]

We developed and assessed whether a novel neutrophil-to-hemoglobin and lymphocyte (NHL) score would improve the ability to predict clinical outcome compared with neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) in acute myocardial infarction (AMI). We examined 13,072 AMI patients from the Korean AMI Registry–National Institute of Health database. NHL score was calculated as follows: NHL score (U) = N/(Hb × L), where N, Hb, and L are baseline blood neutrophil, hemoglobin, and lymphocyte count. The primary outcome was the occurrence of major adverse cerebrocardiovascular events (MACCEs) at 2 years. The NLR, SII, and NHL score were independent predictors of 2-year MACCEs. The area under the curve of the NHL score (0.637) for predicting 2-year MACCEs was significantly higher compared with those of SII (0.589) and NLR (0.607). The NHL score significantly improved the reclassification and integrated discrimination compared with NLR (p < 0.0001) and SII (p < 0.0001). A high NHL score (≥ 0.35 U) was an independent predictor of 2-year MACCEs (adjusted hazard ratio, 1.41; 95% confidence interval, 1.29–1.55; p < 0.001). The NHL score could be a novel model for predicting long-term MACCEs in patients with AMI. [ABSTRACT FROM AUTHOR]

Background: This study investigates the impact of the occurrence of Osborn waves during therapeutic hypothermia (TH) on the recurrence of future fatal arrhythmias in patients resuscitated after sudden cardiac arrest (SCA). Methods: Of all survivors of out‐of‐hospital SCA, 100 consecutive patients (mean age, 52 ± 15 years; 80% men) who received TH were included in this study. Results: The most common first documented arrhythmia was ventricular fibrillation (VF) (77%), and ischemic heart disease (44%) and idiopathic VF (22%) were the most common causes of SCA in resuscitated patients. During TH, Osborn waves developed in 29 patients (29%). Osborn waves occurred more frequently in patients with Brugada syndrome. Patients with Osborn waves had lower in‐hospital (10.3% vs 26.8%; P =.072) and 1‐year death rates (20.7% vs 39.4%; P =.073) and better cerebral function (cerebral performance category scale, 2.0 ± 1.5 vs 2.7 ± 1.8; P =.053) than those without Osborn waves, although there was no statistical significance. Among 78 in‐hospital survivors, 31 (40%) underwent implantable cardioverter‐defibrillator (ICD) implantation. Appropriate ICD shocks from fatal arrhythmias were more frequent in patients who had Osborn waves than in those without Osborn waves (43% vs 6%; P =.032). Conclusions: Osborn waves during TH had no significant effect on the survival and cerebral function of patients resuscitated SCA. However, appropriate ICD shocks due to the recurrence of VF were more frequent in patients with Osborn waves during long‐term follow‐up. [ABSTRACT FROM AUTHOR]

Transthyretin familial amyloid polyneuropathy (TTR-FAP) is a life-threatening autosomal dominant disease caused by the deposition of amyloid fibrils composed of TTR proteins. Symptoms of this disease include progressive sensorimotor neuropathy, cardiomyopathy, and involvement of other organs. We described a pediatric case of extremely early onset TTR-FAP with a TTR Leu55Pro mutation. A 17-year-old boy began to suffer from lower limb weakness, gait disturbance, and decreased sensation from 14 years of age onward. He presented with hypertrophic cardiomyopathy, periorbital and scleral ecchymosis, anhidrosis, orthostatic intolerance, and gastrointestinal autonomic dysfunction including nausea, vomiting, and diarrhea alternating with constipation. The patient's older sister had developed similar gastrointestinal symptoms from 20 years of age onward and was diagnosed as having hypertrophic cardiomyopathy. The boy's biopsy results showed infiltrated amyloid deposition on subcutaneous fat tissue and endocardium. Genetic analysis of the TTR gene demonstrated that both the patient and his sister had a pathogenic mutation, c.224T > C (Leu55Pro). Both patients were prescribed tafamidis, a TTR stabilizing agent. Although a majority of TTR-FAPs occur during adulthood, it should be suspected, even in pediatric populations, when symmetric length dependent neuropathy occurs in conjunction with a family history of neuropathy, autonomic neuropathy, and/or cardiomyopathy. [ABSTRACT FROM AUTHOR]

Background Left cardiac sympathetic denervation (LCSD) has been underutilized in patients with hereditary ventricular arrhythmia syndromes such as congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). The purpose of this study was to investigate the safety and efficacy of video-assisted thoracoscopic (VATS) LCSD in such patients. Methods Fifteen patients (four men, 24.6 ± 10.5 years old) who underwent VATS-LCSD between November 2010 and January 2015 for hereditary ventricular arrhythmia syndromes at Kyungpook National University Hospital were enrolled in this study. The safety and efficacy of VATS-LCSD were evaluated by periprocedural epinephrine tests and assessing the development of complications and cardiac events during follow-up. Results Fourteen patients with LQTS and one patient with CPVT underwent VATS-LCSD. Six and one patients developed ventricular tachyarrhythmia during preprocedural and postprocedural epinephrine test, respectively (P = 0.063). No serious complications such as Horner syndrome, pneumothorax, or bleeding developed after LCSD. Mean hospital stay after VATS-LCSD was 3.7 ± 1.5 days. During a mean follow-up of 927 ± 350 days, one LQTS patient and one CPVT patient, neither of whom manifested tachyarrhythmia during post-LCSD epinephrine test, developed torsades de pointes and syncope, respectively. The annual event rates of six patients who were symptomatic during the period preceding LCSD decreased from 0.97 to 0.19 events/year (P = 0.045). Conclusions VATS-LCSD was a safe, and effective procedure for patients with hereditary ventricular tachycardia syndrome, with no serious adverse events and with short hospital stay. [ABSTRACT FROM AUTHOR]

Objectives: Some patients with suspected ST-segment elevation (STE) myocardial infarction (STEMI) show STE that does not fulfill the current criteria for STEMI. The purpose of this study was to investigate the characteristics and prognoses of patients with minimal STEMI. Methods: Between November 2007 and December 2011, 546 patients who underwent primary percutaneous coronary intervention (PCI) for STEMI were enrolled. Results: The minimal STE group had a higher proportion of women (30.2 vs. 21.0%, p = 0.031), better pre-PCI antegrade flow (Thrombolysis in Myocardial Infarction flow 2-3, 30.2 vs. 18.8%, p = 0.006) and better collateralization (Rentrop score 2-3, 27.4 vs. 18.1%, p = 0.024) compared to the definite STE group. Multivariate analysis showed that each of them were independent predictors for minimal STE. However, 1-year mortality of the minimal STE group did not differ from that of the definite STE group (7.1 vs. 9.3%, log-rank p = 0.315). Conclusions: Female gender, good collateral flow and good pre-PCI antegrade flow were independent predictors for minimal STE in patients with STEMI. However, minimal STE was not related to a good prognosis in patients with STEMI. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background Electrocardiogram (ECG) and signal-averaged ECG (SAECG) are important as diagnostic tools in arrhythmogenic right ventricular cardiomyopathy (ARVC). The aim of this study was to investigate changes in follow-up ECGs and SAECGs in patients with ARVC. Methods We collected 185 follow-up ECGs from 38 patients and 35 follow-up SAECGs from 18 patients during a mean follow-up period of 64 ± 36 months. Results On baseline ECG and SAECG, epsilon waves, T-wave inversion (TWI), and terminal activation delay (TAD) of QRS ≥55 ms in right precordial leads, and late potentials (LPs) were observed in six (16%), 11 (29%), 13 (34%), and 23 (68%) patients, respectively. During the follow-up period, 15 (39%) patients had 18 changes in ECG and/or SAECG features included in modified Task Force Criteria (TFC) of ARVC. Two patients developed new epsilon waves, and another two patients had dynamic epsilon waves. Newly developed TAD of QRS ≥55 ms was observed in two patients and disappeared in one patient. Eight patients, seven with and one without TWI in V1-V3 or beyond, showed dynamic changes. LP developed in three patients. One patient with dynamic change of TWI and another patient with dynamic change of epsilon wave and TAD of QRS ≥55 ms could not satisfy the modified TFC during follow-up. Conclusions Follow-up ECGs and SAECGs showed changes in 39% of patients with ARVC. Larger studies with a longer follow-up period are needed to investigate the clinical implications of changes in follow-up ECG and SAECG. [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]

Abstract: Background: The recanalization success rate of blunt and vague stump (stumpless) CTO lesions, especially those with a side branch arising from the occlusion, has been significantly lower than that of tapered stump CTO lesions. Intravascular ultrasound (IVUS) may be useful to identify the occlusion point and may facilitate the passage of guide-wires. We evaluated the clinical feasibility of the IVUS-guided wiring technique for stumpless CTO lesions. Methods: Thirty-one consecutive patients (7 women; mean age: 61.0±8.9years) with 32 lesions were enrolled. The IVUS catheter was introduced into the side branch and it was withdrawn from the side branch to find the entry point of the occlusion, trying to engage another stiffer guide-wire on the occlusion point with the help of real-time IVUS imaging. Results: The left anterior descending artery was the most common target-lesion location (22 lesions [69%]). CTO lesions were successfully reopened in 26 lesions (81%). IVUS guidance allowed confident navigation of the stiff guide-wires. The entry point could not be identified in one, and full guide-wire passage was impossible in 4 with the IVUS guidance; TIMI 3 flow could not be achieved even after stent deployment in 1. Although procedure-related complications developed in 8 lesions (25%), no events were serious. Emergent operation was not needed and death or fatal myocardial infarction did not develop during or after the procedures. Conclusions: The IVUS-guided wiring technique is useful and safe for the recanalization of stumpless CTO lesions and might be a valuable tool for the recanalization of complex CTO lesions. [Copyright &y& Elsevier]

Little is known about risk factors for 6-month major adverse cardiac events (MACEs) in 30-day survivors after acute myocardial infarction (AMI). We investigated predictors of 6-month MACE in 30-day survivors after MI from the Korea Acute Myocardial Infarction Registry (KAMIR). From November 2005 to January 2008, 9,706 patients (6,983 men, mean age 64.0 ± 12.4 years) who survived >30 days after AMI were analyzed. The primary end point was 6-month MACEs including death, MI, and revascularization. During 6-month follow-up, 317 patients (3.2%) had MACEs including 66 (0.6%) deaths, 23 (0.2%) recurrent MIs, and 218 (2.2%) revascularizations. In multivariate logistic regression analysis, factors reflecting demographics (body mass index), severity of left ventricular systolic dysfunction (Killip class >I, in-hospital cardiogenic shock, use of intra-aortic balloon pump), residual myocardial ischemia (previous coronary heart disease, multivessel disease), and electrical instability (ventricular tachycardia/ventricular fibrillation on admission) were independent predictors of 6-month MACEs after adjustment for clinical, angiographic, and procedural data. Plasma level of N-terminal pro–B-type natriuretic peptide provided an additional prognostic value predicting 6-month MACEs. In conclusion, this study provides useful prognostic information for clinicians to advise patients who have survived the acute phase of MI. More intensive management is needed in survivors after MI with these high-risk features. [Copyright &y& Elsevier]

Abstract: Background: The clinical manifestations of the Korean patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) are not well known. Methods: The clinical data of Korean patients who met the Task Force Criteria for ARVC were analyzed. Results: Thirty-seven patients (41.2±14.8 years old, 19 males) were diagnosed with ARVC. The commonest presenting symptoms were palpitations (30%), syncope/presyncope (30%) and no symptoms (30%). Four patients had a family history of premature sudden death or ARVC. Most patients with no symptoms were evaluated due to ECG abnormalities or asymptomatic ventricular arrhythmias. Ventricular tachycardia, ventricular fibrillation and frequent premature ventricular contractions only were observed in 35%, 5% and 24%, respectively. Wall motion abnormalities of the right and left ventricles were detected in 92% and 41%, respectively. Fatty or fibrofatty infiltration was observed in 26 of the 32 (81%) patients who underwent an endomyocardial biopsy. Two patients had signs of heart failure. Two patients with syncope/presyncope were diagnosed with vasovagal syncope and another was due to side effects from a medication. Most of the patients with ventricular arrhythmias were treated with β-blockers and/or amiodarone. Implantable cardioverter-defibrillators (ICDs) were implanted in 3 patients. During a mean follow-up of 27.4±26.5 months no syncope or sudden death developed except for in one patient with an ICD who suffered from recurrent shocks due to ventricular fibrillation. Conclusions: ARVC may be an important cause of syncope, ventricular arrhythmias, and ECG and wall motion abnormalities of the ventricles in Koreans. The Korean patients with ARVC exhibited various clinical manifestations. [Copyright &y& Elsevier]

Abstract: Brief exposure to cobalt chloride augmented vascular contractility. We hypothesized that endothelial dysfunction plays a role in the augmentation of aortic contractility, after brief exposure to cobalt chloride. Rat aortic ring preparations were mounted in organ baths, exposed to cobalt chloride (0.3–300μmol/L) for 30min, and then subjected to contractile agents or relaxants 1 and 5h after the end of exposure. Presence of cobalt chloride did not affect the contractile response to phenylephrine. Brief exposure to cobalt chloride, however, even at 5h after the end of exposure, not only augmented contractile responses to KCl or phenylephrine but also attenuated the relaxant response to acetylcholine. The mechanical denudation of endothelium or inhibition of endothelial nitric oxide synthase with 100μmol/L N ω -nitro-l-arginine methyl ester abolished the augmentation of contractile responses. Pre-treatment with 150units/mL of superoxide dismutase also abrogated the augmented contractile responses. Brief exposure to cobalt chloride did not affect the contractile response to phorbol dibutyrate in the presence or absence of calcium, or the expression of HSP70. In conclusion, endothelial dysfunction plays an important role in the augmentation of aortic contractility, after brief exposure to cobalt chloride. [Copyright &y& Elsevier]

Dyslipidemia is a major risk factor for development of atherosclerosis and cardiovascular disease (CVD). Effective lipid-lowering therapies has led to CVD risk reduction. This study evaluated the possible pharmacokinetic interactions between fenofibrate, a peroxisome proliferators-activated receptors α agonist, and pitavastatin, a 3-hydoxy-3-methylglutaryl-coenzyme A reductase inhibitor, in healthy Korean subjects. The study design was an open-label, randomized, multiple-dose, three-period, and six-sequence crossover study with a 10-day washout in 24 healthy volunteers. It had three treatments: 160 mg of micronized fenofibrate once daily for 5 days; 2 mg of pitavastatin once daily for 5 days; and 160 mg of micronized fenofibrate with 2 mg of pitavastatin for 5 days. Serial blood samples were collected at scheduled intervals for up to 48 h after the last dose in each period to determine the steady-state pharmacokinetics of both drugs. Plasma concentrations of fenofibric acid and pitavastatin were measured using a validated high-performance liquid chromatography with the tandem mass spectrometry method. A total of 24 subjects completed the study. Pitavastatin, when co-administered with micronized fenofibrate, had no effect on the Cmax,ss and AUCτ,ss of fenofibric acid. The Cmax,ss and AUCτ,ss of pitavastatin were increased by 36% and 12%, respectively, when co-administered with fenofibrate. Combined treatment with pitavastatin and micronized fenofibrate was generally well tolerated without serious adverse events. Our results demonstrated no clinically significant pharmacokinetic interactions between micronized fenofibrate and pitavastatin when 160 mg of micronized fenofibrate and 2 mg of pitavastatin are co-administered. The treatments were well tolerated during the study, with no serious adverse events. [ABSTRACT FROM AUTHOR]

Abstract: A twenty-year old male presented with diffuse limb muscle weakness and exertional dyspnea since childhood. The diagnosis of nemaline myopathy was given based on the muscle pathology findings that revealed nemaline rods on light and electron microscopy and discovery of a novel mutation, E239K, in ACTA1. Incidentally, the patient had hypertrophic cardiomyopathy (HCM) as shown by echocardiography. In nemaline myopathy, a few cases of HCM have been reported, albeit rarely and always fatal, but only one patient had ACTA1 mutation. This present report describes an infantile onset of nemaline myopathy with a milder clinical course and non-fatal HCM as compared with previous cases, showing clinical diversity in skeletal and cardiac manifestations of conditions associated with ACTA1 mutations. [Copyright &y& Elsevier]