Association of physical activity with the risk of major adverse cardiac and cerebrovascular events and mortality in patients with concomitant atrial fibrillation and coronary artery disease

Background@#Although regular physical activity benefits cardiovascular health, there is a concern that intense exer‑ cise is linked to the promotion of atrial fibrillation (AF) and coronary plaque rupture. However, the impact of physical activity on the outcomes of patients with concomitant AF and coronary artery disease (CAD) remains unclear. This study aimed to evaluate the association with clinical outcomes according to the level of physical activity in patients with concomitant AF and CAD. @*Methods@#We assessed 551 patients with AF and CAD (mean age, 67.1 ± 9.8 years) who completed a self-reported questionnaire for physical activity from 2015 to 2020 in a single tertiary-care hospital. Physical activity levels were con‑ verted into metabolic equivalent of task (MET) per week and categorized to correspond with multiple public health recommendations. We examined the association between physical activity, all-cause mortality, and major adverse cardiac and cerebrovascular events (MACCE). @*Results@#The risks of all-cause mortality (P for linear trend = 0.017) and MACCE (P for linear trend = 0.05) appeared inverse trend with a greater level of physical activity. Compared with inactive patients, patients who met the recom‑ mended target range of physical activity (500–1,000 MET-min/week: unadjusted hazard ratio [HR] = 0.58, 95% confi‑ dence interval [CI] = 0.36–0.99) and highly active patients who exceeded the minimum recommended level (≥ 1,000 MET-min/week: unadjusted HR = 0.47, 95% CI = 0.25–0.88) had a lower risk of all-cause mortality in the unadjusted model; however, these associations did not remain significant after adjusting for the model. There was no evidence of increased risk of all-cause mortality and MACCE at levels of physical activity above the recommended target range, even with vigorous-intensity physical activity exceeding the recommended target range. @*Conclusions@#There appears to be an inverse trend between physical activity levels and all-cause mortality and MACCE in patients with concomitant AF and CAD. No excess risk of mortality or MACCE was found at exercise levels above the recommended target range. Further large-scale studies are warranted to create an improved evidence base concerning the effects of physical activity in patients with AF and CAD.

Impact of Statin Treatment Intensity after Endovascular Revascularization on Lower Extremity Peripheral Artery Disease

Purpose@#Only a few Asian studies have discussed the impact of statin intensity on clinical outcomes in patients with peripheral artery disease (PAD). We aimed to investigate the clinical impact of statin intensity in patients with PAD after endovascular revascularization. @*Materials and Methods@#From April 2009 to June 2019, 376 patients with lower extremity PAD treated with endovascular revascularization were enrolled. They were classified into three groups according to statin intensity: no-statin, low-to-moderate intensity (LMI), and high-intensity (HI). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE). @*Results@#During the 40-month follow-up, MACE occurred less frequently in the HI and LMI groups than the no-statin group (11.4% vs. 16.0% vs. 39%, p<0.001). In adjusted Cox models, the HI group had the fewest MACE [hazard ratio (HR): 0.447; 95% confidence interval (CI): 0.244–0.834; p=0.018] and MALE (HR: 0.360; 95% CI: 0.129–1.006; p=0.051) events, while the LMI group had fewer MACE (HR: 0.571; 95% CI: 0.326–1.0; p=0.050) events than the no-statin group. HI statin therapy was associated with better outcomes in terms of MALE (HR: 0.432; 95% CI: 0.223–0.837; p=0.003) than LMI statin therapy after inverse probability treatment weighting analysis. @*Conclusion@#HI and LMI statin use is associated with a significant reduction in MACE events than no-statin use. HI statin use was associated with better MALE outcomes than no-statin or LMI statin use.

Early surgical intervention for unusually located cardiac fibroelastomas / 영남의대학술지

Papillary fibroelastomas are the second most common primary cardiac tumor in adults. Over 80% of fibroelastomas occur on the cardiac valves, usually on the left side of the heart, while the remaining lesions are typically scattered throughout the atria and ventricles. Although the optimal timing for surgery is controversial and depends on tumor size and location, prompt surgical resection is warranted in patients at high risk of embolism. A tumor on the cardiac valve can be removed using the slicing excision technique without leaflet injury. Here we present two cases of papillary fibroelastomas occurring on the ventricular surface of the aortic valve and in the right ventricle.

Clinical Impact of Beta Blockers in Patients with Myocardial Infarction from the Korean National Health Insurance Database

Background and Objectives@#Whether beta blockers favorably impact the clinical outcome in patients with acute myocardial infarction (AMI) remains in debate. We investigated the impact of beta blocker on major clinical outcomes during 2 years after percutaneous coronary intervention (PCI) in patients with AMI. @*Methods@#All patients with the first AMI treated with PCI for the period of 2005 to 2014 from the Korean National Health Insurance Service claims database were enrolled. We defined the regular user as medication possession ratio (MPR) ≥80% and non-user as MPR=0%. We compared the occurrence of all cause death, myocardial infarction (MI) and stroke according to adherence of beta-blockers. A 1:1 propensity score-matching was conducted to adjust for between-group differences. @*Results@#We identified a total 81,752 patients with met eligible criteria. At discharge, 63,885 (78%) patients were prescribed beta blockers. For 2 years follow up period, regular users were 53,991 (66%) patients, non-users were 10,991 (13%). In the propensity score matched population, regular use of beta blocker was associated with a 36% reduced risk of composite adverse events (all death, MI or stroke) (hazard ratio [HR], 0.636; 95% confidence interval [CI], 0.555–0.728; p<0.001). Compared to no use of beta blocker, regular use significantly reduced all death (HR, 0.736; 95% CI, 0.668–0.812; p<0.001), MI (HR, 0.729; 95% CI, 0.611–0.803; p<0.001) and stroke (HR, 0.717; 95% CI, 0.650–0.791; p<0.001). @*Conclusions@#Prescription of beta blocker in patients with AMI after PCI was sequentially increased. Continuous regular use of beta blocker for 2 years after AMI reduced major adverse events compared to no use of beta blocker.

The Role of Glucagon-Like Peptide 1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors in Reducing Cardiovascular Events in Patients with Type 2 Diabetes

The prevalence of type 2 diabetes mellitus (T2DM), which is associated with cardiovascular morbidity and mortality, is increasing worldwide. Although there have been advances in diabetes treatments that reduce microvascular complications (nephropathy, neuropathy, retinopathy), many clinical studies have found that conventional oral hypoglycemic agents and glucose control alone failed to reduce cardiovascular disease. Thus, incretin-based therapies including glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT-2Is) represent a new area of research, and may serve as novel therapeutics for treating hyperglycemia and modifying other cardiovascular risk factors. Recently, it has been confirmed that several drugs in these classes, including canagliflozin, empagliflozin, semaglutide, and liraglutide, are safe and possess cardioprotective effects. We review the most recent cardiovascular outcome trials on GLP-1RAs and SGLT-2Is, and discuss their implications for treating patients with T2DM in terms of protective effects against cardiovascular disease.

Effect of Cardiac Rehabilitation on Outcomes in Patients with ST-Elevation Myocardial Infarction

PURPOSE: Whether cardiac rehabilitation (CR) improves clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) has not been thoroughly evaluated. Moreover, few studies have sought to identify patients who would benefit most from CR among STEMI patients. MATERIALS AND METHODS: Consecutively, 265 STEMI patients who underwent primary PCI with implantation of DESs and follow-up angiography were examined. Seventy-six patients (30%) who received CR were assigned to the CR+ group. Another 178 patients (70%) who did not participate in CR were assigned to the CR− group. Second generation DESs were implanted in 238 (94%) patients. RESULTS: Major adverse cardiovascular events (MACEs), including death, myocardial infarction, and revascularization, were compared. The CR+ group tended to have lower MACE than the CR− group at 3 years, although the difference was not statistically significant (9.9% vs. 18.3%, hazard ratio=0.54, p=0.138). Subgroup analysis revealed a significant interaction according to CR and preprocedural thrombolysis in myocardial infarction (TIMI) flow (p value for interaction=0.011). In patients with low preprocedural TIMI flow (TIMI flow ≤1, n=161), those in the CR+ group had significantly lower MACE than those in the CR− group (p=0.005), whereas MACE was not different among patients with higher TIMI flow (TIMI flow ≥2, n=93). CONCLUSION: CR including exercise training was associated with lower MACE, particularly in patients with lower preprocedural TIMI flow during primary PCI for STEMI in the current DES era.

Prevalence and Clinical Outcomes of Asymptomatic Carotid Artery Stenosis in Patients Undergoing Concurrent Coronary and Carotid Angiography

PURPOSE: The prevalence and clinical outcomes of asymptomatic carotid artery stenosis (CAS) in patients with coronary artery disease (CAD) have not been thoroughly studied. We examined the prevalence and predictors of asymptomatic CAS detected by carotid angiography and determined the impact of concomitant CAS on prognosis in patients undergoing coronary angiography (CAG) due to CAD. MATERIALS AND METHODS: Between January 2013 and July 2015, 395 patients who underwent carotid digital subtraction angiography to screen for CAS during CAG were analyzed. The presence of CAS was defined as angiographically significant stenosis (≥50%). Major adverse cardiac and cerebrovascular event (MACCE) rates were compared between patients with and without CAS. MACCEs included a composite of cardiac death, cerebrovascular death, acute myocardial infarction, and stroke. RESULTS: Of the 395 patients, 101 (25.5%) patients had significant CAS. The independent predictors of CAS were age, male sex, hypertension, diabetes, and multi-vessel disease. In patients with CAD, the presence of CAS was as an independent predictor for MACCEs after adjusting for confounding factors (hazard ratio 2.47, 95% confidence interval 1.16–5.24, p=0.018). CONCLUSION: Asymptomatic CAS was documented in up to 25% of patients with CAD. The presence of CAS in patients with CAD was associated with a higher rate of MACCEs. Therefore, detection of CAS by carotid angiography during CAG may be important for risk stratification for CAD patients, particularly those with multi-vessel disease.

A Case of Multiple Venous Thrombosis as the First Manifestation of Lupus Nephritis / 대한신장학회지

Kidney involvement in systemic lupus erythematosus (SLE) is common. The incidence of venous thrombosis in SLE ranges from 5-15%, and venous thrombosis in lupus nephritis associated with nephritic syndrome or antiphospholipid antibody syndrome is reported in 30-35%. Lupus nephritis with nephrotic syndrome is not infrequently encountered at the point of diagnosis of SLE, but venous thrombosis as the first manifestation of SLE is rare. Herein we present our clinical experience with a case of multiple venous thrombosis with nephrotic-range proteinuria as the first manifestation of lupus nephritis.

A Phase II Trial of Paclitaxel, 5-fluorouracil (5-FU) and Cisplatin in Patients with Metastatic or Recurrent Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We wanted to assess the effectiveness and safety of combination chemotherapy with paclitaxel, 5-fluorouracil (5-FU) and cisplatin for treating advanced gastric cancer. MATERIALS AND METHODS: Patients with metastatic or recurrent gastric cancer were entered into this study. Paclitaxel at a dose of 135 mg/m2 on day 1, 5-FU 1 g/m2/ day in a 24 hour continuous infusion from day 1 to day 4 and cisplatin 60 mg/m2 on day 1 were administered. This regimen was repeated every 3 weeks. RESULTS: A total of 34 patients were enrolled in this study. Among them, 33 patients were finally evaluable for their response. 17 (51.5%) patients had a partial response (95% CI: 26.0~77.0%). The median duration of overall survival was 13.2 months. Grade 3 or 4 neutropenia and thrombocytopenia were observed in 15.2% and 1.1% of all the cycles, respectively. Grade 3 stomatitis and neurotoxicity were observed in 20.6% and 1.1% of all patients, respectively. Grade 4 non-hematologic toxicity was not observed. CONCLUSIONS: The regimen of paclitaxel, 5-FU and cisplatin demonstrated activity and accepatable toxicity for treating metastatic gastric cancer.

A Patient with Jejunal Mucinous Adenocarcinoma Metastatic to the Stomach Presenting with Submucosal Tumors in the Stomach and Jejunum / 대한소화기내시경학회지

The small bowel is the least common site for cancer to arise. Only approximately 1% of all gastrointestinal neoplasms arise in the small bowel. Mucinous adenocarcinoma is diagnosed when the amount of extracellular mucin in a tumor is over 50%. Because it is a very rare disease, there is little data available concerning its incidence, most common site of origin, and common sites of metastasis. There are no case reports describing primary mucinous adenocarcinoma of the jejunum in Korea. We report a case of jejunal mucinous adenocarcinoma metastatic to the stomach presenting as a submucosal tumor.

An Adult Case of Small Bowel Intussusception Caused by Hemangioma Presenting with Intestinal Bleeding / 대한소화기학회지

Intussusception is primarily a disease of children, and is relatively rare in adults. Unlike childhood intussusception, adult intussusception has an identifiable leading lesion such as malignant or benign neoplasm. However, intussusception caused by hemangioma is very rare. There were few cases of small bowel intussusception caused by hemangioma in adults, but those reports were presented with abdominal pain. This report describes a 65-year-old female who suffered from small bowel intussusception caused by hemangioma presenting with intestinal bleeding. Upper gastrointestinal endoscopy and colonoscopy were performed, but bleeding focus was not found. Abdominal computed tomography showed the target sign of small bowel with a leading point of mass. This mass turned out to be a hemangioma after the small bowel resection. Therefore, small bowel intussusception by hemangioma should be also considered as a bleeding focus when an adult patient presented intestinal bleeding without bleeding focus in the stomach and colon. Herein we report a case of small bowel intussusception caused by hemangioma presenting with intestinal bleeding.