Analysis of the accuracy of automatic electrocardiogram interpretation in ST-segment elevation myocardial infarction

Objective@#This study aimed to analyze the association between the culprit artery and the diagnostic accuracy of automatic electrocardiogram (ECG) interpretation in patients with ST-segment elevation myocardial infarction (STEMI). @*Methods@#This single-centered, retrospective cohort study included adult patients with STEMI who visited the emergency department between January 2017 and December 2020. The primary endpoint was the association between the culprit artery occlusion and the misinterpretation of ECG, evaluated by the chi-square test or Fisher exact test. @*Results@#The rate of misinterpretation of the automated ECG for patients with STEMI was 26.5% (31/117 patients). There was no significant correlation between the ST segment change in the four involved leads (anteroseptal, lateral, inferior, and aVR) and the misinterpretation of ECG (all P > 0.05). Single culprit artery occlusion significantly affected the misinterpretation of ECG compared with multiple culprit artery occlusion (single vs. multiple, 27/86 [31.3%] vs. 4/31 [12.9%], P = 0.045). There was no association between culprit artery and the misinterpretation of ECG (P = 0.132). @*Conclusion@#Single culprit artery occlusion might increase misinterpretation of ECG compared with multiple culprit artery occlusions in the automatic interpretation of STEMI.

Clinical significance of high on-treatment platelet reactivity in patients with prolonged clopidogrel therapy

Background/Aims@#Prolonged dual antiplatelet therapy (DAPT) with aspirin and clopidogrel beyond 1 year has been shown to reduce ischemic events at the expense of increased bleeding. However, limited data are available on the clinical significance of platelet reactivity (PR) at 1 year. @*Methods@#We retrospectively identified 331 patients who underwent percutaneous coronary intervention (PCI) and assessed the on-clopidogrel PR using VerifyNow P2Y12 assay at 1 year in a single center. Two hundred eleven patients were on DAPT for > 1 year. The relationship between high on-treatment platelet reactivity (HPR) at 1 year and clinical outcomes beyond 1 year, as well as the longitudinal change in PR was analyzed. @*Results@#At 1 year, 135 (64%) patients showed HPR and 76 (36%) did not. There was a significant increase in ischemic endpoint events, including cardiovascular death, non-fatal myocardial infarction, and stroke/transient ischemic attack in patients with compared to without HPR at 1 year (hazard ratio [HR], 2.68; 95% confidence interval [CI], 1.06 to 6.77; p = 0.036). However, the incidence of any Bleeding Academic Research Consortium bleeding was significantly lower in the HPR group (HR, 0.11; 95% CI, 0.02 to 0.65; p = 0.015). In the longitudinal analysis, PR significantly decreased from post-load to 1 year after index PCI in the non-HPR group. Conversely, the HPR group showed high PR from baseline through 1 year. @*Conclusions@#HPR at 1 year may be a useful surrogate for predicting ischemic and bleeding events in patients on prolonged DAPT. Patients with and without HPR at 1 year showed different patterns of longitudinal change in PR.

Atrial Fibrillation as a Risk Factor for Major Adverse Cardiac and Cerebrovascular Events after Non-cardiac Surgery

No abstract available.

Unilateral versus Bilateral Groin Puncture for Atrial Fibrillation Ablation: Multi-Center Prospective Randomized Study

PURPOSE: Catheter ablation for atrial fibrillation (AF) requires heavy anticoagulation and uncomfortable post-procedural hemostasis. We compared patient satisfaction with and the safety of unilateral groin (UG) puncture-single trans-septal (ST) ablation with conventional bilateral groin (BG) puncture-double trans-septal (DT) ablation in paroxysmal AF patients. MATERIALS AND METHODS: We enrolled 222 patients with paroxysmal AF (59.4±10.7 years old) who were randomized in a 2:1 manner into UG-ST ablation (n=148) and BG-DT ablation (n=74) groups. If circumferential pulmonary vein isolation could not be achieved after three attempts of touch-up ablation in the UG-ST group, the patient was crossed over to BG-DT by performing a left groin puncture. RESULTS: Ten patients in the UG-ST group (6.8%) required crossover to the BG-DT approach. There were no significant differences in procedure time (p=0.144) and major complications rate (p>0.999) between the UG-ST and BG-DT groups. Access site pain (p=0.014), back pain (p=0.023), and total pain (p=0.015) scores were significantly lower for the UG-ST than BG-DT group as assessed by the Visual Analog Scale. Over 20.2±8.7 months of follow up, there was no difference in AF recurrence free-survival rates between the two groups (Log rank, p=0.984). CONCLUSION: UG-ST AF ablation is feasible and safe, and was found to significantly reduce post-procedural hemostasis-related discomfort, compared to the conventional DT approach, in patients with paroxysmal AF.

Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina and Its Prognostic Implications in 3,094 Consecutive Patients

BACKGROUND AND OBJECTIVES: Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population. METHODS: We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed. RESULTS: The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p 220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs. CONCLUSIONS: ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina and Its Prognostic Implications in 3,094 Consecutive Patients

BACKGROUND AND OBJECTIVES@#Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population.@*METHODS@#We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed.@*RESULTS@#The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p 220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs.@*CONCLUSIONS@#ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

Prognostic Value of Inferior Shift of P wave Axis after Catheter Ablation for Longstanding Persistent Atrial Fibrillation based on Dallas Lesion Set Including Anterior Line

BACKGROUND AND OBJECTIVES: Although an anterior linear ablation is an effective lesion set in radiofrequency catheter ablation (RFCA) for longstanding persistent atrial fibrillation (L-PeAF), its durability for bidirectional block (BDB) is only about 60% at repeat procedure. We hypothesized that changes in electrocardiogram (ECG) may predict an anterior line block state and the clinical outcome of L-PeAF ablation. SUBJECTS AND METHODS: We studied 304 L-PeAF patients (77% male, 60±10yrs), who consistently underwent RFCA Dallas lesion set (circumferential pulmonary vein isolation, posterior box lesion, and anterior line) protocol with subsequent comparison of pre-procedural and post-procedural P wave axes, and one year follow-up (n=205) sinus rhythm (SR) ECGs. RESULTS: 1. P wave axis shifted inferiorly at immediate post-procedure (p<0.001), and was independently correlated with BDB of anterior line (β=10.4, 95% confidence interval [CI] 2.79-17.94, p=0.008). 2. The degree of post-procedural inferior shift of P wave axis did not reflect clinical recurrence within one-year (n=205, p=0.923), potentially due to conduction recovery of an anterior line. However, among 160 patients without clinical recurrence within one-year, P wave axis at one-year ECG was independently associated with very late recurrence of AF after one-year (n=160, hazard ratio [HR] 0.98; 95% CI 0.97-0.99, p=0.001), during 45.6±16.7 months of follow-up. 3. Among 22 patients who underwent repeat procedures, P wave axis shift was more significant in patients with maintained BDB of an anterior line than in those without (p=0.015). CONCLUSION: An inferior shift of P wave axis reflects the achievement and the maintenance of an anterior line BDB, and is associated with better long-term clinical outcome after catheter ablation for L-PeAF based on Dallas lesion set.

Long-Term Prognosis of Patients with an Implantable Cardioverter-Defibrillator in Korea

PURPOSE: The objective of this study was to elucidate the long-term prognosis of patients with implantable cardioverter-defibrillators (ICDs) in Korea. MATERIALS AND METHODS: We enrolled 405 patients (age, 57.7±16.7 years; 311 men) who had undergone ICD implantation. The patients were divided into three groups: heart failure (HF) and ICD for primary (group 1, n=118) and secondary prevention (group 2, n=93) and non-HF (group 3, n=194). We compared appropriate and inappropriate ICD therapy delivery among the groups and between high- (heart rate ≥200 /min) and low-rate (<200 /min) ICD therapy zones. RESULTS: During the follow-up period (58.9±49.8 months), the annual appropriate ICD therapy rate was higher in group 2 (10.4%) than in groups 1 and 3 (6.1% and 5.9%, respectively, p<0.001). There were no significant differences in annual inappropriate ICD therapy rate among the three groups. In group 1, the annual appropriate ICD therapy rate was significantly lower in patients with a high-rate versus a low-rate therapy zone (4.5% and 9.6%, respectively, p=0.026). In group 3, the annual inappropriate ICD therapy rate was significantly lower in patients with a high-rate versus a low-rate therapy zone (3.1% and 4.0%, respectively, p=0.048). CONCLUSION: Appropriate ICD therapy rates are not low in Korean patients with ICD, relative to prior large-scale studies in Western countries. Appropriate and inappropriate ICD therapy could be reduced by a high-rate therapy zone in patients with HF and ICD for primary prevention, as well as non-HF patients, respectively.

Early Experience of Novel Oral Anticoagulants in Catheter Ablation for Atrial Fibrillation: Efficacy and Safety Comparison to Warfarin

PURPOSE: Compared with warfarin, novel oral anticoagulants (NOACs) are convenient to use, although they require a blanking period immediately before radiofrequency catheter ablation for atrial fibrillation (AF). We compared NOACs and uninterrupted warfarin in the peri-procedural period of AF ablation. MATERIALS AND METHODS: We compared 141 patients treated with peri-procedural NOACs (72% men; 58+/-11 years old; 71% with paroxysmal AF) and 281 age-, sex-, AF type-, and history of stroke-matched patients treated with uninterrupted warfarin. NOACs were stopped 24 hours before the procedure and restarted on the same procedure day after hemostasis was achieved. RESULTS: We found no difference in the CHA2DS2-VASc (p=0.376) and HAS-BLED scores (p=0.175) between the groups. The preprocedural anticoagulation duration was significantly shorter in the NOAC group (76.3+/-110.7 days) than in the warfarin group (274.7+/-582.7 days, p<0.001). The intra-procedural total heparin requirement was higher (p<0.001), although mean activated clotting time was shorter (350.0+/-25.0 s vs. 367.4+/-42.9 s, p<0.001), in the NOAC group than in the warfarin group. There was no significant difference in thromboembolic events (1.4% vs. 0%, p=0.111) or major bleeding (1.4% vs. 3.9%, p=0.235) between the NOAC and warfarin groups. Minor stroke occurred in two cases within 10 hours of the procedure (underlying CHA2DS2-VASc scores 0 and 1) in the NOAC group. CONCLUSION: Pre-procedural anticoagulation duration was shorter and intra-procedural heparin requirement was higher with NOAC than with uninterrupted warfarin during AF ablation. Although the peri-procedural thromboembolism and bleeding incidences did not differ, minor stroke occurred in two cases in the NOAC group.

Clinical significance of changes in the corrected QT interval in stress-induced cardiomyopathy

BACKGROUND/AIMS: Although transient changes in the electrocardiogram (ECG) of patients with stress-induced cardiomyopathy (SCMP) are common, there are little data about ECG changes in patients with SCMP and the clinical implications of these variations. METHODS: We investigated a total of 128 patients (age, 63.2 ± 15.4 years; female, 60.9%) diagnosed with SCMP. We compared the ECGs taken after SCMP diagnosis and during the recovery phase to those taken before SCMP diagnosis under baseline conditions. All patients were divided into two groups according to corrected QT (QTc) interval changes: recovered QTc group (QTc in SCMP > QTc in recovery phase, n = 77) and nonrecovered QTc group (QTc in SCMP ≤ QTc in recovery phase, n = 51). RESULTS: In comparison of baseline, SCMP, and recovery phase, we found the mean heart rate (81.5 ± 18.7, 96.8 ± 25.3, and 83.0 ± 19.4/min, respectively; p < 0.001), frequencies of ST segment elevation (0.0%, 8.6%, and 1.6%, p = 0.004), ST segment depression (0.0%, 6.3%, and 1.6%, p = 0.007), T wave inversion (4.4 %, 43.8%, and 61.7%, p < 0.001), and QTc (447.4 ± 35.3, 488.9 ± 67.1, and 468.0 ± 49.5, p < 0.001) showed significant changes. In-hospital mortality (9.1% vs. 25.5%, p = 0.012) and critical care (54.5% vs. 72.5%, p = 0.040) occurred more frequently in the nonrecovered QTc group than in recovered QTc group. CONCLUSIONS: The QTc can be prolonged in patients with SCMP. Short-term mortality was increased in patients where the QTc did not recover.

Impact of Coronary Artery Anatomy on Clinical Course and Prognosis in Apical Hypertrophic Cardiomyopathy: Analysis of Coronary Angiography and Computed Tomography

BACKGROUND AND OBJECTIVES: Apical hypertrophic cardiomyopathy (AHCM) is an uncommon variant of hypertrophic cardiomyopathy with a relatively benign course. However, the prognostic factors of AHCM-particularly those associated with coronary artery disease (CAD) and its anatomical subtypes-are not well known. SUBJECTS AND METHODS: We enrolled 98 consecutive patients with AHCM who underwent coronary angiography or coronary computed tomography scanning at two general hospitals in Korea from January 2002 to March 2012. Patient charts were reviewed for information regarding cardiovascular (CV) risk factors, symptoms, and occurrence of CV events and/or mortality. We also reviewed echocardiographic data and angiography records. RESULTS: The mean age at the time of enrollment was 61.45+/-9.78 years, with female patients comprising 38.6%. The proportions of mixed and pure types of AHCM were 34.4% and 65.6%, respectively. CAD was found in 31 (31.6%) patients. The mean follow-up period was 53.1+/-60.7 months. CV events occurred in 22.4% of patients, and the mortality rate was 5.1%. The mixed-type was more frequent in CV event group although this difference was not statistically significant (50% vs. 30%, p=0.097). The presence of CAD emerged as an independent risk factor for CV events in univariate and multivariate Cox regression analysis after adjusting for other CV risk factors. CONCLUSION: Coronary artery disease is an independent risk factor for CV events in AHCM patients. However, AHCM without CAD has a benign natural course, comparable with the general population.

Cardiovascular Events of Electrical Cardioversion Under Optimal Anticoagulation in Atrial Fibrillation: The Multicenter Analysis

PURPOSE: Electric cardioversion has been successfully used in terminating symptomatic atrial fibrillation (AF). Nevertheless, largescale study about the acute cardiovascular events following electrical cardioversion of AF is lacking. This study was performed to evaluate the incidence, risk factors, and clinical consequences of acute cardiovascular events following electrical cardioversion of AF. MATERIALS AND METHODS: The study enrolled 1100 AF patients (mean age 60+/-11 years) who received cardioversion at four tertiary hospitals. Hospitalizations for stroke/transient ischemic attack, major bleedings, and arrhythmic events during 30 days post electric cardioversion were assessed. RESULTS: The mean duration of anticoagulation before cardioversion was 95.8+/-51.6 days. The mean International Normalized Ratio at the time of cardioversion was 2.4+/-0.9. The antiarrhythmic drugs at the time of cardioversion were class I (45%), amiodarone (40%), beta-blocker (53%), calcium-channel blocker (21%), and other medication (11%). The success rate of terminating AF via cardioversion was 87% (n=947). Following cardioversion, 5 strokes and 5 major bleedings occurred. The history of stroke/transient ischemic attack (OR 6.23, 95% CI 1.69-22.90) and heart failure (OR 6.40, 95% CI 1.77-23.14) were among predictors of thromboembolic or bleeding events. Eight patients were hospitalized for bradyarrhythmia. These patients were more likely to have had a lower heart rate prior to the procedure (p=0.045). Consequently, 3 of these patients were implanted with a permanent pacemaker. CONCLUSION: Cardioversion appears as a safe procedure with a reasonably acceptable cardiovascular event rate. However, to prevent the cardiovascular events, several risk factors should be considered before cardioversion.

Amphetamine-Like Weight Reduction Drug Induced Acute Cardiomyopathy with Left Ventricular Thrombosis / 이화의대지

A 37-year-old female patient admitted due to dyspnea on exertion and peripheral edema. For one and a half years, the patient had been taking various drugs and supplements to reduce weight, including amphetamine-like drugs. The patient had no major cardiovascular risk factors except three pack-years of smoking. A chest computed tomography showed a 1.7 cm diameter, capsulated space-occupying lesion in the left ventricle (LV) and 2-dimensional echocardiography showed LV systolic dysfunction (Left ventricular ejection fraction [LVEF], 30%) with a mobile cystic mass (1.1x1.8 cm) that was attached to the LV apex, which was increased in size and number the next day, even with low dose low-molecular-weight heparin. With an increased dose of anticoagulation medication and heart failure management with diuretics and angiotensin receptor II blocker, LV dysfunction was recovered and the LV thrombus disappeared.

Emphysematous Pyelonephritis Caused by Citrobacter freundii in a Patient with Type 2 Diabetes and Neurogenic Bladder

Emphysematous pyelonephritis (EPN) is a rare, life-threatening complication of upper urinary tract infections that is characterized by the presence of gas in the renal parenchyma and perirenal space. It commonly occurs in diabetic patients. Escherichia coli are the most common causative organisms, with few reports implicating Citrobacter freundii as the etiologic agent in EPN. A 57-year-old woman with diabetes and neurogenic bladder visited at our department with confused mentality, myalgia, and general weakness. Further investigation revealed that the patient suffered from unilateral EPN with sepsis caused by C. freundii. The patient's condition was improved considerably with percutaneous drainage and use of intravenous antibiotics for several weeks. However, renal function eventually deteriorated to permanent renal failure, which required hemodialysis. In conclusion, C. freundii may be the causative pathogen of EPN in a patient with type 2 diabetes and neurogenic bladder.

Relation of Absolute or Relative Adiposity to Insulin Resistance, Retinol Binding Protein-4, Leptin, and Adiponectin in Type 2 Diabetes

BACKGROUND: Central fat mass (CFM) correlates with insulin resistance and increases the risk of type 2 diabetes and cardiovascular complications; however, peripheral fat mass (PFM) is associated with insulin sensitivity. The aim of this study was to investigate the relation of absolute and relative regional adiposity to insulin resistance index and adipokines in type 2 diabetes. METHODS: Total of 83 overweighted-Korean women with type 2 diabetes were enrolled, and rate constants for plasma glucose disappearance (KITT) and serum adipokines, such as retinol binding protein-4 (RBP4), leptin, and adiponectin, were measured. Using dual X-ray absorptiometry, trunk fat mass (in kilograms) was defined as CFM, sum of fat mass on the lower extremities (in kilograms) as PFM, and sum of CFM and PFM as total fat mass (TFM). PFM/TFM ratio, CFM/TFM ratio, and PFM/CFM ratio were defined as relative adiposity. RESULTS: Median age was 55.9 years, mean body mass index 27.2 kg/m2, and mean HbA1c level 7.12+/-0.84%. KITT was positively associated with PMF/TFM ratio, PMF/CFM ratio, and negatively with CFM/TFM ratio, but was not associated with TFM, PFM, or CFM. RBP4 levels also had a significant relationship with PMF/TFM ratio and PMF/CFM ratio. Adiponectin, leptin, and apolipoprotein A levels were related to absolute adiposity, while only adiponectin to relative adiposity. In correlation analysis, KITT in type 2 diabetes was positively related with HbA1c, fasting glucose, RBP4, and free fatty acid. CONCLUSION: These results suggest that increased relative amount of peripheral fat mass may aggravate insulin resistance in type 2 diabetes.

Primary Hyperparathyroidism with Ectopic Parathyroid Adenoma Detected by Both 99mTc-MIBI SPECT and Contrast-Enhanced Neck CT / 대한내과학회지

An ectopic parathyroid gland is a major cause of persistent and recurrent hyperparathyroidism. Surgical success depends on accurate preoperative localization of the parathyroid adenoma. We herein report the case of a 52-year-old male patient who suffered from primary hyperparathyroidism for several years. He initially presented with urinary frequency, hypercalcemia, and a ureter stone. Ultrasonography and a 99mTc-sestamibi scan were performed, but failed to localize the parathyroid lesion. Four years later, the patient revisited our hospital, complaining of general weakness, headache, dyspepsia, and recurrent urinary symptoms secondary to persistent primary hyperparathyroidism. In addition, renal function was decreased and severe osteoporosis was found. We performed a 99mTc-sestamibi scan with single photon emission computed tomography (99mTc-MIBI SPECT) and contrast-enhanced neck CT, and detected an ectopic parathyroid adenoma in the upper anterior mediastinum. In conclusion, the combination of both 99mTc-MIBI SPECT and neck CT could permit better preoperative parathyroid localization, especially for mediastinal adenomas.