Clinical efficacy of angiotensin receptor-neprilysin inhibitor in de novo heart failure with reduced ejection fraction

Background/Aims@#We aimed to analyze the efficacy of angiotensin receptor-neprilysin inhibitor (ARNI) by the disease course of heart failure (HF). @*Methods@#We evaluated 227 patients with HF in a multi-center retrospective cohort that included those with left ventricular ejection fraction (LVEF) ≤ 40% undergoing ARNI treatment. The patients were divided into patients with newly diagnosed HF with ARNI treatment initiated within 6 months of diagnosis (de novo HF group) and those who were diagnosed or admitted for HF exacerbation for more than 6 months prior to initiation of ARNI treatment (prior HF group). The primary outcome was a composite of cardiovascular death and worsening HF, including hospitalization or an emergency visit for HF aggravation within 12 months. @*Results@#No significant differences in baseline characteristics were reported between the de novo and prior HF groups. The prior HF group was significantly associated with a higher primary outcome (23.9 vs. 9.4%) than the de novo HF group (adjusted hazard ratio 2.52, 95% confidence interval 1.06–5.96, p = 0.036), although on a higher initial dose. The de novo HF group showed better LVEF improvement after 1 year (12.0% vs 7.4%, p = 0.010). Further, the discontinuation rate of diuretics after 1 year was numerically higher in the de novo group than the prior HF group (34.4 vs 18.5%, p = 0.064). @*Conclusions@#The de novo HF group had a lower risk of the primary composite outcome than the prior HF group in patients with reduced ejection fraction who were treated with ARNI.

Temporal Trend of the Incidence and Characteristics of Renal Infarction:Korean Nationwide Population Study

Background@#Large-scale studies about epidemiologic characteristics of renal infarction (RI) are few. In this study, we aimed to analyze the incidence and prevalence of RI with comorbidities in the South Korean population. @*Methods@#We investigated the medical history of the entire South Korean adult population between 2013 and 2019 using the National Health Insurance Service database (n = 51,849,591 in 2019). Diagnosis of RI comorbidities were confirmed with International Classification of Disease, Tenth Revision, Clinical Modification codes. Epidemiologic characteristics, distribution of comorbidities according to etiologic mechanisms, and trend of antithrombotic agents were estimated. @*Results@#During the 7-years, 10,496 patients were newly diagnosed with RI. The incidence rate increased from 2.68 to 3.06 per 100,000 person-years during the study period.The incidence rate of RI increased with age peaking in the 70s with 1.41 times male predominance. The most common comorbidity was hypertension, followed by dyslipidemia and diabetes mellitus. Regarding etiologic risk factor distribution, high embolic risk group, renovascular disease group, and hypercoagulable state group accounted for 16.6%, 29.1%, and 13.7% on average, respectively. For the antithrombotic treatment of RI, the prescription of antiplatelet agent gradually decreased from 17.0% to 13.0% while that of anticoagulation agent was maintained around 35%. The proportion of non-vitamin K antagonist oral anticoagulants remarkably increased from only 1.4% to 17.6%. @*Conclusion@#Considering the progressively increasing incidence of RI and high prevalence of coexisting risk factors, constant efforts to raise awareness of the disease are necessary. The current epidemiologic investigation of RI would be the stepping-stone to establishing future studies about clinical outcomes and optimal treatment strategies.

Comparison of Clinical Outcomes of Long Stent Implantation with First- and Second-Generation Drug-Eluting Stents Following Rotational Atherectomy

Objective@#Rotational atherectomy (RA) and newly developed second-generation drug-eluting stent (DES) support the strategy of longer stent deployment in comparison to short stent implantations in the past. However, studies analyzing the outcome of patients who received long stent implantation following RA are few in number. The present study compared the clinical outcomes of patients with the coronary arterial disease (CAD) who underwent RA with long stent implantation using first- and second-generation DES. @*Methods@#A retrospective cohort study was performed at the single center from March 2003 to October 2019. Eighty-seven patients with CAD who underwent RA with ≥32 mm long stent implantation were enrolled in the study and divided into two groups according to the type of DES. As a primary endpoint, the cumulative 2-year incidence of major adverse cardiac events (MACE) including death, myocardial infarction (MI), target vessel revascularization, and stent thrombosis (ST) was compared by DES type. Adjusted interaction between the type of stent and clinical variables was estimated to determine the predictor variables of MACE. @*Results@#The second-generation DES group was associated with a shorter procedure duration and more common usage of intravascular ultrasound in procedural characteristics. In the second-generation DES group, a trend toward a lower rate of MI and ST existed. All-cause mortality and cardiovascular mortality were not significantly different. When combined with MACE, we could identify a significant reduction in the second-generation DES group. @*Conclusion@#In comparison to the first-generation DES group, the second-generation DES group was associated with a lower rate of MACE for 2 years in patients who underwent RA with long stent implantation.

Factors Associated with Low Awareness of Heart Failure in the General Population of Korea

Background and Objectives@#Factors associated with low heart failure (HF) awareness have not been well-evaluated. This study was conducted to find out which demographic features would be associated with low HF awareness in the general population of Korea. @*Methods@#A telephone interview was conducted with 1,032 adults (58 years and 50.6% were male) across the country. Based on answer to 15 questions about HF, we scored from 0 to 15 points (mean, 7.53±2.75; median, 8; interquartile range, 6–9). A score of <8 was defined as low HF awareness, and a score of ≥8 was defined as high HF awareness. @*Results@#A total of 478 subjects (46.3%) had low HF awareness. HF awareness scores were 5.18±1.85 and 9.55±1.50 in subjects of low and high HF awareness groups, respectively. Subjects with low HF awareness were older, more female-dominant, more diabetic, lower educational and house hold income levels, and more frequently living in rural areas, compared to those with high HF awareness (p<0.05 for each). In multivariable logistic regression analyses, older age (≥67 years: odds ratio [OR], 1.61; 95% confidence interval [CI], 1.16–2.19; p=0.004), female sex (OR, 1.33; 95% CI, 1.02–1.73; p=0.034) and low educational level (high school graduate or less vs. college graduate: OR, 2.38; 95% CI, 1.75–3.22; p<0.001) were significantly associated with low HF awareness even after controlling for potential confounders. @*Conclusions@#Older age, female sex, and lower level of education were independently associated with low HF awareness in the general Korean population. More attention and education are needed for these vulnerable groups to improve HF awareness.

Awareness and attitude on international emergency medicine: a resident survey

OBJECTIVE: International emergency medicine (IEM) is a rapidly growing field in emergency medicine (EM). However, there are few studies of the interest and attitude of EM residents on this subject in Korea. The aim of this study was to assess the awareness of IEM and determine feasibility of adoption as an EM residency program. METHODS: A structured on/off-line survey was distributed to all current first to third grade EM residents in Korea (year 2016–2017). Ninety-two hospitals with residency programs and 463 residents were identified as potential survey candidates. The survey consisted of 20 questionnaires including binary yes/no and multiple choice questions. RESULTS: The response rate was 37.1% (172/463). The proportion of residents who have interest in IEM was 62.8% (108/172); 76.2% (131/172) respondents answered that they wanted to participate in IEM/global health activities during their residency. Approximately two thirds (68.6%, 118/172) reported that they plan to participate in any IEM activity even after graduation. More than half (56.4%, 97/172) agreed that the inclusion of IEM/global health training in their residency might be necessary and it may help them to guide their future careers after their training (68.6%, 118/172). A total of 144 respondents (83.7%) indicated lack of time during their residency mostly, absence of an IEM program (47.1%, 81/172), and lack of information on IEM (31.4%, 54/172). CONCLUSION: IEM is of interest to Korean EM residents. On the other hand, formal education and training offered to residents is limited in Korea. Korean Society of Emergency Medicine should start discussions on how to adopt a global IEM agenda, and reflect on a resident training program.

Relationship between Serum Leptin Levels and Atherosclerosis in Type 2 Diabetes Patients

OBJECTIVE: Many studies have suggested that leptin is a possible cause of atherosclerosis and is proposed as a cardiovascular risk factor in obese patients. Several studies have shown that serum leptin is associated with pulse wave velocity (PWV) and carotid intima-media thickness (IMT). But the relevance of serum leptin levels for predicting incident cardiovascular disease is less clear. In this study, we investigated the relationship between serum leptin levels and aortic PWV, carotid IMT in type 2 diabetes (T2DM) patients. METHODS: Patients with end-stage renal disease or advanced atherosclerosis, systemic infection were excluded. A total of 116 patients (60 male/56 female; age, 59+/-14 years) were included. Serum leptin levels, aortic PWV and carotid IMT were measured. RESULTS: Aortic PWV was significantly associated with age (r=0.28, P<0.005). Carotid IMT was significantly related to age (r=0.46, P<0.001), low density lipoprotein (LDL) cholesterol (r=0.22, P<0.05), lipoprotein (a) (r=0.23, P<0.05) and estimated glomerular filteration rate (r=-0.348, P<0.01). There was no correlation between leptin and aortic PWV or carotid IMT. In multivariate analyses, aortic PWV was associated with age (P=0.007). Carotid IMT was significantly related to age (P<0.001), LDL cholesterol (P=0.01). CONCLUSION: Serum leptin was not associated with aortic PWV or carotid IMT in T2DM patients.

A Case of Pulmonary Sclerosing Hemangioma with an Increased Size and Chest Discomfort on 10 Years' Follow-up

Pulmonary sclerosing hemangioma is a relatively rare neoplasm of the lung with polymorphic histologic features of 2 unifying cellular components including surface cuboidal cells and interstitial round cells. Pulmonary sclerosing hemangioma typically occurs in middle aged women with asymptomatic, peripheral, solitary, well-circumscribed lesions. Although it is pathologically benign, it reveals size growing and chest symptom. We here report a case of pulmonary sclerosing hemangioma in a 72-year-old woman. She presented chest discomfort. A chest radiography and a chest computed tomography scan showed growing size from 3.2x3.1 cm to 6.0x5.3 cm in left upper lung during 10 years' follow-up period. Surgical resection of lung revealed a distinct constellation of findings including 2 epithelial cell types, surface cells, and round cells, which form 4 architectural patterns, papillary, sclerotic, solid, and hemorrhagic. She was diagnosed as pulmonary sclerosing hemangioma and chest discomfort disappeared.

Spontaneous Renal Hematoma Caused by Hypertension with Left Ventricular Hypertrophy

Spontaneous renal hematoma is rare. We report a 43-year-old man presented with sudden left flank pain and severe hypertension. Renal hematoma was confirmed on computed tomography. Renal angiography showed no active bleeding or vascular malformation. Echocardiography showed severe concentric left ventricular hypertrophy. Hypertension was the only cause for the condition. Symptoms and size of the hematoma decreased on antihypertensive medication and conservative treatment. Severe hypertension might have a role for developing renal hematoma.

The Clinical Characteristics, Therapeutic Outcome and Prognostic Factors for Invasive Pulmonary Aspergillosis: A Single-Center Experience and Review of the Literature / 대한의진균학회지

BACKGROUND: Despite advances in microbiological diagnosis and effective antifungal treatment, invasive pulmonary aspergillosis (IPA) is a still major cause of mortality in immunocompromised patients. OBJECTIVE: The aim of this study is to analyze clinical characteristics, treatment outcome and prognostic factors for IPA. METHODS: Between May 2003 and March 2011, we retrospectively studied all patients with IPA in our facility. RESULTS: A total 37 cases were identified. Hematologic malignancies were the leading underlying disease for 27 (27/37, 73.0%) patients. Neutropenic period between the onset of neutropenia and the diagnosis of IPA was 15.0 days. The most common symptom was fever (35/37, 94.6%). The principal findings of chest computed tomography (CT) were segmental or air space consolidation (17/37, 45.9%) followed by halo sign (13/37, 35.1%), and ground-glass attenuation (11/37, 29.7%). Amphotericin B was the initial treatment for 36 (36/37, 97.3%) patients. Voriconazole was subsequently substituted for Amphotericin B in 25 (35/36, 97.2%) patients. The 30-day mortality rate was 24.3% (9/37). The 30-day mortality rate was associated with a failure to recover from neutropenia (p=0.048) or persistent fever during treatment (p=0.003). Two patients were lost to follow-up. Overall mortality was 62.9% (22/35). CONCLUSION: IPA remains a serious condition with failure to recover from neutropenia or persistent fever during treatment associated with a high 30-day mortality rate.

The clinical features of drug-induced liver injury observed through liver biopsy: focus on relevancy to autoimmune hepatitis

BACKGROUND/AIMS: Accurate diagnosis of drug-induced liver injury (DILI) is difficult without considering the possibility of underlying diseases, especially autoimmune hepatitis (AIH). We investigated the clinical patterns in patients with a history of medication, liver-function abnormalities, and in whom liver biopsy was conducted, focusing on accompaniment by AIH. METHODS: The clinical, serologic, and histologic findings of 29 patients were compared and analyzed. The patients were aged 46.2+/-12.8 years (mean+/-SD), and 72.4% of patient were female. The most common symptom and causal drug were jaundice (58.6%) and herbal medications (55.2%), respectively. RESULTS: Aspartate aminotransferase (AST), alanine aminotransferase, total bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase levels were 662.2+/-574.8 U/L, 905.4+/-794.9 U/L, 12.9+/-10.8 mg/dL, 195.8+/-123.3 U/L, and 255.3+/-280.8 U/L, respectively. According to serologic and histologic findings, 21 cases were diagnosed with DILI and 8 with AIH. The AIH group exhibited significantly higher AST levels (537.1+/-519.1 vs. 1043.3+/-600.5 U/L), globulin levels (2.7+/-0.4 vs. 3.3+/-0.5 g/dL), and prothrombin time (12.9+/-2.4 vs. 15.2+/-3.9 s; P<0.05). Antinuclear antibody was positive in 7 of 21 cases of DILI and all 8 cases of AIH (P=0.002). The simplified AIH score was 3.7+/-0.9 in the DILI group and 6.5+/-0.9 in the AIH group (P<0.001). CONCLUSIONS: Accurate diagnosis is necessary for patients with a history of medication and visits for liver-function abnormalities; in particular, the possibility of AIH should be considered.

Diagnosis of a Malignant Tumor in a Patient with an Adnexal Mass Using Endoscopic Ultrasound Elastography

Elastography is an imaging modality for the evaluation of tissue stiffness, which has been used for the analysis of superficial organs, such as those of the breast and prostate. The measurement of tissue elasticity has been reported to be useful for the diagnosis and differentiation of tumors, which are stiffer than normal tissues. Endoscopic ultrasonography elastography (EUS-EG) is a promising imaging technique with a high accuracy for the differential diagnosis of solid pancreatic tumors. However, to date EUS-EG has not been used to provide complementary information for biologic behavior of adenxal mass. We report our experience of EUS-EG in a patient with adnexal mass.

Comparison of the Efficacy and Safety between Transradial and Transfemoral Percutaneous Coronary Intervention in Patients with Ischemic Heart Disease

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of transradial percutaneous coronary intervention (TRI) compared with transfemoral percutaneous coronary intervention (TFI) in patients with ischemic heart disease. METHODS: We reviewed retrospectively the medical records including imaging data of the patients with ischemic heart disease who underwent TRI or TFI from January 2007 to December 2009 in Soonchunhyang University Seoul Hospital. We compared major adverse cardiac and cerebrovascular events (MACCEs) including death, myocardial infarction, revascularization, stent thrombosis, and cerebrovascular accident during follow-up period. We also compared procedure related vascular complications including hematoma, arteriovenous fistula, pseudoaneurysm, and infection. RESULTS: Total number of patients was 347 (256 patients of TRI and 91 patients of TFI). There were no significant differences in the rate of MACCEs between two groups. There were significantly less procedure-related vascular complications in TRI group (3.1% vs. 11.0%, P=0.010). CONCLUSION: TRI is as effective as TFI with no difference in the rate of MACCEs in patients with ischemic heart disease. TRI is superior to TFI in safety with reduction of vascular complications.