Hemodynamic Changes in Chronic Liver Disease / 대한소화기학회지

Chronic liver disease causes hemodynamic changes in the body depending on the degree of progression. These hemodynamic changes begin with splanchnic vasodilation, with complications beginning to appear as the hyperdynamic changes occur. As chronic liver disease progresses, increased splanchnic vasodilation and hyperdynamic changes worsen portal hypertension and help cause or worsen chronic liver disease complications, such as ascites. Ultimately, the effective plasma volume and blood pressure decrease in the terminal stage.

The Busan Regional CardioCerebroVascular Center Project’s Experience Over a Decade in the Treatment of ST-segment Elevation Myocardial Infarction / 예방의학회지

Objectives@#The Regional CardioCerebroVascular Center (RCCVC) project was initiated to improve clinical outcomes for patients with acute myocardial infarction or stroke in non-capital areas of Korea. The purpose of this study was to evaluate the outcomes and issues identified by the Busan RCCVC project in the treatment of ST-segment elevation myocardial infarction (STEMI). @*Methods@#Among the patients who were registered in the Korean Registry of Acute Myocardial Infarction for the RCCVC project between 2007 and 2019, those who underwent percutaneous coronary intervention (PCI) for STEMI at the Busan RCCVC were selected, and their medical data were compared with a historical cohort. @*Results@#In total, 1161 patients were selected for the analysis. Ten years after the implementation of the Busan RCCVC project, the median door-to-balloon time was reduced from 86 (interquartile range [IQR], 64-116) to 54 (IQR, 44-61) minutes, and the median symptom-to-balloon time was reduced from 256 (IQR, 180-407) to 189 (IQR, 118-305) minutes (p<0.001). Inversely, the false-positive PCI team activation rate increased from 0.6% to 21.4% (p<0.001). However, the 1-year cardiovascular death and major adverse cardiac event rates did not change. Even after 10 years, approximately 75% of the patients had a symptom-to-balloon time over 120 minutes, and approximately 50% of the patients underwent inter-hospital transfer for primary PCI. @*Conclusions@#A decade after the implementation of the Busan RCCVC project, although time parameters for early reperfusion therapy for STEMI improved, at the cost of an increased false-positive PCI team activation rate, survival outcomes were unchanged.

Community-Based Pre-HospitalElectrocardiogram TransmissionProgram for Reducing Systemic TimeDelay in Acute ST-Segment ElevationMyocardial Infarction

Background and Objectives@#In acute ST-segment elevation myocardial infarction (STEMI),on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic timedelay to reperfusion and improve outcomes. However, it has not been adopted in communitybasedemergency transport system in Korea. @*Methods@#Busan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fireand Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECGtransmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated.Systemic time delay to reperfusion of STEMI patients in the program was compared with thatof 95 patients transported by 119 emergency medical system (EMS) before the program wasimplemented. @*Results@#During the study period, 289 ECG transmissions were made by 119 EMS personnel,executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as STsegmentelevation. Final diagnosis of STEMI was made in 20 patients who underwent primarypercutaneous coronary intervention. With the program, systemic time delay to reperfusion wassignificantly reduced (median [interquartile range; IQR], 76.0 [62.2–98.7] vs. 90.0 [75.0–112.0],p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0[34.0–69.5] vs. 58.0 [51.0–68.0], p=0.03). The proportion of patients with systemic time delayshorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission. @*Conclusions@#We developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions ofsystemic time delay and door-to-balloon time were observed. The expanded use of prehospitalECG transmission should be encouraged to realize the full potential of this program.

Part 4. Post-cardiac arrest care: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

No abstract available.

Comparison of Prolonged Atrial Electromechanical Delays with Different Definitions in the Discrimination of Patients with Non-Valvular Paroxysmal Atrial Fibrillation

BACKGROUND AND OBJECTIVES: Previous studies have evaluated atrial electromechanical delays (AEMDs) with a number of different definitions to discriminate patients with paroxysmal atrial fibrillation (PAF) from controls without PAF. However, their discriminative values for PAF have not previously been directly compared. SUBJECTS AND METHODS: A total of 65 PAF patients and 130 control subjects matched for age, sex, history of hypertension, and diabetes mellitus were selected. The AEMDi and AEMDp were defined as the time intervals from the initiation of the P wave on the surface electrocardiogram to the initiation and peak of the late diastolic transmitral inflow on pulsed wave Doppler images, respectively. The AEMDim and AEMDpm were defined as the time intervals from the initiation of the P wave on the surface electrocardiogram to the initiation and peak of the late diastolic lateral mitral annular motion on tissue Doppler images, respectively. RESULTS: There were no significant differences in the clinical characteristics between the two groups. All 4 AEMDs were consistently longer in the PAF group, and proven effective to differentiate the PAF patients from the controls. The AEMDi measurement had a larger area under the curve (AUC) than the other AEMDs, left atrial volume index, and P wave amplitude. However, the AEMDp, AEMDim, and AEMDpm measurements had AUCs similar to those of the left atrial volume index and P wave amplitude. CONCLUSION: The findings suggest that the AEMDi is better than the other AEMDs for the discrimination of PAF patients from the controls.

Association between Cardiac Troponin Level and Coronary Flow Reserve in Patients without Coronary Artery Disease: Insight from a Thermodilution Technique Using an Intracoronary Pressure Wire

BACKGROUND AND OBJECTIVES: Cardiac troponins are associated with increased mortality, even among patients with no coronary artery disease. Elevated cardiac troponin levels are frequently observed in patients without significant coronary lesions, although the mechanism underlying this finding is unclear. The aim of our study was to evaluate the association between the levels of cardiac troponin and coronary flow reserve (CFR). SUBJECTS AND METHODS: We evaluated serum cardiac troponin-I in 19 patients (9 female; age 61.9+/-10.9 year-old). All patients had an ejection fraction >40% and angiographically normal coronary arteries. Simultaneous measurements of fractional flow reserve (FFR), the index of microcirculatory resistance (IMR), and CFR measurements using an intracoronary temperature- and pressure-sensing guidewire under basal conditions and during maximal hyperemia were performed in three vessels: the left anterior descending artery (LAD), left circumflex artery (LCX) and right coronary artery (RCA). RESULTS: All patients were followed for a median of 13 months. FFR, IMR, and CFR measurements were performed successfully in all subjects. Mean CFRs of LAD, LCX, and RCA were 1.98+/-1.20, 2.75+/-2.11, and 4.44+/-2.51, respectively. Mean IMRs of LAD, LCX and RCA were 33.28+/-18.78, 29.11+/-26.70, and 30.55+/-23.65, respectively. There was a poor correlation between CFR and troponin-I values in each vessel. In selecting the lowest value of CFR in each patient as the corresponding value, the lowest CFR was not associated with troponin-I levels (r=-0.219, p=0.367). CONCLUSION: In patients without significant coronary lesions, the correlation between CFR and troponin-I level was not significant using a thermodilution technique. Further study of a larger population with longer-term follow-up may be needed to more fully understand microvascular dysfunction.

Native Aortic Valve Thrombosis Resembling Papillary Fibroelastoma

The differential diagnosis of cardiac mass is important in determining the therapeutic plan and avoiding unnecessary surgical intervention. Non-invasive imaging methods would be useful in the diagnosis of suspected cardiac mass, because they may provide earlier diagnosis and more accurate assessment of cardiac mass. Native aortic valve thrombosis is a rare disorder and difficult to differentiate from a tumor, and in particular, a papillary fibroelastoma. Thus, the clinical decision making with imaging modalities should be performed cautiously. We recently met a female patient who had a aortic valve mass resembling papillary fibroelastoma in normal native valve. The patient underwent a surgical resection and the pathologic finding showed an organized thrombus with no evidence of papillary fibroelastoma.

Early Experience of Busan-Ulsan Regional Cardiocerebrovascular Center Project in the Treatment of ST Elevation Myocardial Infarction / 대한내과학회지

BACKGROUND/AIMS: The purpose of this study was to compare changes in primary percutaneous coronary artery intervention (PCI) outcomes after starting the government-directed Busan-Ulsan Regional Cardiocerebrovascular Center Project. METHODS: Patients with ST segment elevation myocardial infarction (STEMI) who visited the Busan-Ulsan Regional Cardiocerebrovascular Center from 1 June 2009 to 30 May 2011 were selected. Their medical records were retrospectively reviewed. Clinical and survival outcomes before and after starting the project were compared. RESULTS: A total of 122 patients (mean age, 63 +/- 13 years; male, 74%) with STEMI were selected for analysis. There were no significant differences in patients' baseline characteristics. After starting the Busan-Ulsan Regional Cardiocerebrovascular Center Project, the door-to-balloon time decreased from 72 +/- 30 to 59 +/- 22 minutes (p = 0.011). The door-to-balloon time when the PCI team did not stay in the hospital also decreased from 80 +/- 30 to 62 +/- 12 minutes (p = 0.005). However, there was no significant change in the total ischemic time (339 +/- 293 vs. 304 +/- 287 minutes, p = 0.514), survival discharge rate (94% vs. 93%, p = 1.000), or 1-year survival rate (89% vs. 91%, p = 0.996). CONCLUSIONS: After starting the government-directed Busan-Ulsan Regional Cardiocerebrovascular Center Project, the door-to-balloon time was significantly reduced. However, the total ischemic time and short-term survival remained unchanged.

Cardiogenic Shock From Global Myocardial Ischemia Induced by Simultaneous Multivessel Coronary Spasm

Coronary artery spasm is an uncommon, but well recognized, etiology for acute myocardial infarction. However, cardiogenic shock with myocardial infarction resulting from simultaneous multiple coronary artery spasm has been rarely reported, and not in Korea. Recently, we experienced such a case in a 50-year-old Korean man without previous diagnosis of variant angina. The patient, hospitalized for blood sugar control, developed severe chest pain accompanying ST-segment elevation in multiple leads. The patient immediately received cardiac catheterization because of cardiogenic shock. Coronary angiogram revealed the severe and simultaneous spasm of three major epicardial arteries, which was promptly relieved by an intracoronary administration of isosorbide dinitrate. This case highlights the need to rule out the potential mechanism of coronary spasm even in the most severe episodes of acute coronary syndrome.

Factors Related to Prehospital Time Delay in Acute ST-Segment Elevation Myocardial Infarction

Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 +/- 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.

Analysis of Potential Cost-Savings After Introduction of Drug-Eluting Balloon Angioplasty for In-Stent Restenosis or Small Vessel Disease

BACKGROUND AND OBJECTIVES: The drug-eluting balloon (DEB) catheter system was developed to treat restenosis. Furthermore, DEB angioplasty has been shown to reduce restenosis risk when compared to drug-eluting stents (DES) in patients with in-stent restenosis (ISR) or small vessel disease (SVD). In addition, DEB angioplasty reduces costs due to fewer revascularizations and reduced clopidogrel treatment length. The objective of this study was to predict the expected cost-savings when DEB is substituted for DES in patients with ISR or SVD. SUBJECTS AND METHODS: The subjects included were patients treated by DES at Seoul National University Hospital from January 2006 to June 2009, with clinical data after percutaneous coronary intervention, were. A model was developed to allow the costs of DES and the calculated costs of DEB incurred by patients with ISR or SVD to be compared. The overall cost of DEB was calculated to be 1,256,150 won and the overall cost of DES was 2,102,500 won, and the cost of clopidogrel was 2,168 won. Expected repeat revascularizations within 12 months of DEB were calculated based on information provided by the Paclitaxel-Eluting PTCA-Balloon Catheter in Coronary Artery (PEPCAD) I and II trials. RESULTS: By substituting DEB for DES, total cost (including the cost of initial DEB treatment, the cost of repeat revascularization after DEB treatment, and the cost of clopidogrel treatment) was found to be 34% lower in ISR patients and 48% lower in SVD patients. CONCLUSION: DEB angioplasty will significantly reduce costs as compared to DES in ISR and in SVD patients.

Normal Ranges and Physiological Changes of Midwall Fractional Shortening in Healthy Korean Population

BACKGROUND AND OBJECTIVES: Left ventricular (LV) midwall fractional shortening (FSmw) reflects systolic function more accurately than LV endocardial fractional shortening (eFS) in patients with increased LV wall thickness. Although the normal reference ranges of LV-FSmw have been suggested in Western population studies, its reference values and age-related physiological changes in Eastern populations remain unknown. SUBJECTS AND METHODS: Conventional echocardiographic parameters, LV-FSmw, and stress-corrected LV-FSmw were assessed in 160 healthy and clinically normal subjects with a mean age of 45 (range, 11-72 years; 104 males, 56 women), all of whom were confirmed to be free of disease, based on laboratory investigations, clinical and physical examination findings and computed tomographic coronary angiographic examinations. RESULTS: LV-FSmw was higher in women compared to men. However, the differences were without statistical significance (18.2+/-1.5% for male gender and 19.4+/-2.5% for female gender, p=0.07). In contrast to LV-eFS that progressively increased with age (p=0.001), LV-FSmw and stress-corrected LV-FSmw was not influenced by changes in age (p=0.88 and 0.29, respectively). The results remained unchanged when analyses were performed adjusting for gender. CONCLUSION: The results of this study provide normal reference values for LV-FSmw and stress-corrected LV-FSmw and their natural physiological changes with advancing age. These measures can be used as reference standards for research on LV systolic function in the setting of pressure or volume overload.

A Giant Left Atrium in Rheumatic Mitral Stenosis

Enlargement of left atrium (LA) is not infrequently observed in patients with rheumatic mitral stenosis. We recently met a patient who had a giant LA associated with severe mitral stenosis. The right ventricle had almost collapsed due to compression by the LA. Mitral valve surgery was performed for mitral stenosis and the postoperative course was uneventful. Thus, we suggest that clinicians should not delay corrective surgery for severe mitral stenosis solely on account of a huge LA.