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.

Left Ventricular End-Systolic Volume Can Predict 1-Year Hierarchical Clinical Composite End Point in Patients with Cardiac Resynchronization Therapy

PURPOSE: This study aimed to elucidate which echocardiographic criteria at three time points, for cardiac resynchronization therapy (CRT) response, are accurate in discriminating the hierarchical clinical composite end point (HCCEP). MATERIALS AND METHODS: We included 120 patients (age, 66.1±12.6 years; men, 54.2%) who underwent CRT implantation for heart failure (HF). Echocardiography was performed before and at 3, 6, and 12 months after CRT implantation. The 1-year HCCEP included all-cause mortality, hospitalization for HF, and New York Heart Association functional class for 12 months. CRT response criteria were decrease in left ventricular (LV) end-systolic volume (LVESV) >15%, decrease in LV end-diastolic volume >15%, absolute increase in LV ejection fraction (LVEF) ≥5%, relative increase in LVEF ≥15%, and decrease in mitral regurgitation ≥1 grade. Temporal changes in CRT response rates, accuracy of CRT response criteria at each time and cutoff value for the discrimination of improvement in HCCEP, and agreements with improvement in HCCEP were analyzed. RESULTS: HCCEP improvement rates were 65.8% in total group. In nonischemic group, CRT response rates according to all echocardiographic criteria significantly increased with time. In ischemic group, CRT response rate did not significantly change with time. In total group, ΔLVESV at 6 months (ΔLVESV6) had the most significant accuracy for the discrimination of HCCEP (area under the curve=0.781). The optimal cutoff value of ΔLVESV6 was 13.5% (sensitivity=0.719, specificity=0.719). ΔLVESV6 had fair agreement with HCCEP (κ=0.391, p < 0.001). CONCLUSION: ΔLVESV6 is the most useful echocardiographic CRT response criterion for the prediction of 1-year HCCEP.

CHA₂DS₂-VASc Score in the Prediction of Ischemic Stroke in Patients after Radiofrequency Catheter Ablation of Typical Atrial Flutter

PURPOSE: Despite undergoing successful catheter ablation of typical atrial flutter (AFL), patients remain at increased risk for ischemic stroke. However, data on risk prediction tools for the development of stroke after AFL ablation are lacking. This study investigates whether CHA₂DS₂-VASc score is useful for predicting ischemic stroke after successful ablation of typical AFL. MATERIALS AND METHODS: A total of 293 patients (236 men, mean age 56.1±13.5 years) who underwent successful radiofrequency catheter ablation for typical AFL were included in this study. The clinical end point was occurrence of ischemic stroke during follow-up after AFL ablation. RESULTS: During the follow-up period (60.8±45.9 months), ischemic stroke occurred in 18 (6%) patients at a median of 34 months (interquartile range, 13–65 months). CHA₂DS₂-VASc score [hazard ratio 2.104; 95% confidence interval (CI), 1.624–2.726; p < 0.001] was an independent predictor for the occurrence of stroke after AFL ablation. The area under the receiver operating characteristic curve for CHA₂DS₂-VASc score was 0.798 (95% CI, 0.691–0.904). The CHA₂DS₂-VASc score could be used to stratify patients into two groups with different incidences of ischemic stroke (1.6% vs. 14.4%, p < 0.001) at a cutoff value of 2. CONCLUSION: CHA₂DS₂-VASc score is useful in a prediction model for the risk of stroke after catheter ablation of typical AFL.

Predictors of Sick Sinus Syndrome in Patients after Successful Radiofrequency Catheter Ablation of Atrial Flutter

PURPOSE: The identification of sick sinus syndrome (SSS) in patients with atrial flutter (AFL) is difficult before the termination of AFL. This study investigated the patient characteristics used in predicting a high risk of SSS after AFL ablation. MATERIALS AND METHODS: Out of 339 consecutive patients who had undergone radiofrequency ablation for AFL from 1991 to 2012, 27 (8%) had SSS (SSS group). We compared the clinical characteristics of patients with and without SSS (n=312, no-SSS group). RESULTS: The SSS group was more likely to have a lower body mass index (SSS: 22.5+/-3.2; no-SSS: 24.0+/-3.0 kg/m2; p=0.02), a history of atrial septal defects (ASD; SSS: 19%; no-SSS: 6%; p=0.01), a history of coronary artery bypass graft surgery (CABG; SSS: 11%; no-SSS: 2%; p=0.002), and a longer flutter cycle length (CL; SSS: 262.3+/-39.2; no-SSS: 243.0+/-40; p=0.02) than the no-SSS group. In multivariate analysis, a history of ASD [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.2-11.4, p=0.02] and CABG (7.1, 95% CI 1.5-32.8, p=0.01) as well as longer flutter CL (1.1, 95% CI 1.0-1.2, p=0.04) were independent risk factors for SSS. CONCLUSION: A history of ASD and CABG as well as longer flutter CL increased the risk of SSS after AFL ablation. While half of the patients with SSS after AFL ablation experienced transient SSS, heart failure was associated with irreversible SSS.

A Favorable Treatment Response of Erlotinib in Lung Adenocarcinoma with Concomitant Activating EGFR Mutation and ROS1 Rearrangement / 이화의대지

The rearrangement of c-ros oncogene 1 (ROS1) has been recently identified as an important molecular target in non small cell lung cancer (NSCLC). ROS1 rearrangement and epidermal growth factor receptor (EGFR) mutation were mutually exclusive each other in previous studies, and the clinical implication of co-existence of the two genetic alterations has not been determined. We report a case of 46-year-old female never-smoker NSCLC patient whose tumor harbored ROS1 rearrangement and EGFR mutation concomitantly. She had undergone curative surgery for stage IIIA NSCLC, and the recurrence in left pleura and brain occurred at 2 years after the surgery. She received several lines of chemotherapy including docetaxel plus carboplatin, erlotinib, pemetrexed, and gemcitabine. Erlotinib therapy showed a favorable treatment response with progression-free survival of 9.5 months and partial response of tumor on radiologic evaluations. This case represents a successful erlotinib treatment in a NSCLC patient with concurrent ROS1 rearrangement and EGFR mutation.

Aortic Valve Replacement after Previous Coronary Artery Bypass Grafting with Patent Internal Mammary Artery / 이화의대지

With the aging population, more patients who have undergone previous coronary artery bypass grafting (CABG) are surviving long enough to require subsequent aortic valve replacement (AVR). Conventional redo AVR after prior CABG involves resternotomy, dissection and clamping of the patent bypass graft vessel. Favorable results have been reported for AVR following previous CABG; however, the problems of this procedure includes that injury to the patent bypass grafts can result in catastrophic complications. Increasing patient age and comorbidities may increase operative mortality, less invasive percutaneous aortic valve intervention has advanced. However, because there are no sufficient data comparing transcatheter aortic valve intervention with surgical AVR, currently, the surgical approach should still be consider as the standard of treatment for AVR following previous CABG. We report a patient in whom successful conventional AVR was underwent after previous CABG with patent left internal mammary artery.

Esophageal Involvement of Pemphigus Vulgaris Associated with Upper Gastrointestinal Bleeding

Esophageal involvement of pemphigus vulgaris is rare, and when present, the most common presenting symptoms reported in the medical literature are odynophagia and dysphagia. Here, we present two cases of pemphigus vulgaris presenting with upper gastrointestinal hemorrhage because of esophageal involvement of the disease. In case 1, a 41-year-old female patient with a prior diagnosis of pemphigus vulgaris presented with hematemesis. Esophagogastroduodenoscopy showed diffuse mucosal exfoliation and oozing bleeding of the oropharynx and esophagus. The patient recovered after the administration of high-dose corticosteroids and immunosuppressants. In case 2, a 30-year-old female patient with known pemphigus vulgaris also presented with hematemesis, showing similar endoscopic findings to the first case. She also responded to the same treatment. Esophageal involvement of pemphigus vulgaris responds to high-dose corticosteroids and immunosuppressants. Thus, in patients with pemphigus vulgaris with signs or symptoms of upper gastrointestinal bleeding, an early endoscopy for the evaluation of esophageal involvement is beneficial.

Successful emergency transcatheter aortic valve implantation / 영남의대학술지

Despite the necessity of surgical aortic valve replacement, many patients with symptomatic severe aortic stenosis (AS) cannot undergo surgery because of their severe comorbidities. In these high-risk patients, percutaneous transcatheter aortic valve implantation (TAVI) can be safely accomplished. However, no study has shown that TAVI can be performed for patients with severe AS accompanied by acute decompensated heart failure. In this case report, 1 patient presented a case of severe pulmonary hypertension with decompensated heart failure after diagnosis with severe AS, and was successfully treated via emergency TAVI. Without any invasive treatment, acute decompensated heart failure with severe pulmonary hypertension is common in patients with severe AS, and it can increase mortality rates. In conclusion, TAVI can be considered one of the treatment options for severe as presented as acute decompensated heart failure patients with pulmonary hypertension.

A Nationwide Survey of Inhalant Allergens Sensitization and Levels of Indoor Major Allergens in Korea

PURPOSE: The higher prevalence of respiratory allergic disease may be due to increased exposure to inhalation allergens. We conducted a survey of allergic diseases in autumn and winter with detection of major indoor allergens in major cities in Korea. METHODS: We enrolled 110 subjects from the fourth Korea National Health and Nutrition Examination Survey with stratified, cluster, and systematic sampling procedures. All participants answered a health questionnaire as well as underwent a skin prick test (SPT) and ImmunoCAP for 11 indoor major allergens. We also measured the levels of 5 major allergens (Der f 1, Der p 1, Can f 1, Bla g 1, and Asp f 1) in fine indoor dust from the houses of 60 subjects with a 2-site ELISA. RESULTS: The prevalence of allergic rhinitis and asthma were 25.5% and 7.3%, respectively. The most common sensitized allergens identified by SPT and ImmunoCAP were Dermatophagoides farinae (40.9%, 36.8%), followed by cockroach (23.6%, 19.5%), mugwort (13.6%, 22.9%), oak (9.1%, 22.9%), Japanese hop (9.1%, 8.6%), and dog dander (8.2%, 6.9%). There was a modest discrepancy between SPT and ImmunoCAP. Der f 1 and Der p 1 were detected in 91.7% and 45.0% of the enrolled houses, respectively. Der f 1 indicated high concentrations in all specific provinces in Korea; however, Der p 1 measured high only in the south. Dog dander allergens were present in 71.7% of houses; however, Bla g 1 was present in only 11.7% of houses and Asp f 1 was not detected in any houses. CONCLUSIONS: The most important inhalant allergens in Korea are house dust mites followed by cockroach, mugwort, oak, Japanese hop, and dog dander in indoor environment, in which The dominant species of house dust mites were different according to region.

Columnar variant of papillary carcinoma in the thyroglossal duct cyst with progression to lung metastasis / 영남의대학술지

Thyroglossal duct cyst (TGDC) carcinoma generally shows a favorable prognosis. If metastasis is present latently, it may not threaten the patient's life immediately. It has been shown, however, that larger than 1 cm papillary carcinoma (PC), level VI metastasis to the lymph node (LN), which is the nearest to the thyroid, independently predicts a worse prognosis. In the case presented herein, a 61-year-old female patient was diagnosed with an about 3 cm PC in the TGDC, particularly the columnar variant subtype, one of the aggressive variants. She had occult papillary thyroid microcarcinoma, but no LN metastasis. Even though she underwent the Sistrunk procedure and total thyroidectomy with central compartment neck dissection followed by high-dose radioactive iodine remnant ablation, however, the cancer cells spread to level IV neck LN, and finally to the lung. Therefore, when a patient is diagnosed with an aggressive histologic variant of PC in the TGDC, even without LN metastasis, the invasive surgical approach and close postoperative surveillance are necessary, with consideration of the risk of disease progression. Therefore, if it is possible to stratify the risk for patients, higher-risk patients can be offered a more invasive therapeutic approach.

Cytomegalovirus Colitis with Colon Perforation and Lower Gastrointestinal Bleeding in a Immunocompetent Patient / 이화의대지

Cytomegalovirus (CMV) infection in immunocompromised patients is associated with significant morbidity, mortality, and adverse clinical outcome. However, CMV infection in immunocompetent patients has been considered to have subclinical and self-limited course, and does not require treatment. We reports a case of CMV colitis, presented with colon perforation and lower gastrointestinal bleeding in a immunocompetent 31-year-old young male. After conservative treatment, colonoscopy revealed multiple ulcers in transverse colon. CMV colitis was confirmed by microscopic findings and immunohistochemistry. After successful treatment with ganciclovir, the patient improved without invasive procedure.

Effectiveness Analysis Through Enzyme-Linked Immunosorbent Assay Examination of Antibody After Pandemic H1N1 2009 Influenza Vaccination

BACKGROUND: A pandemic influenza outbreak started in 2009 by the number of patients discharged each year. But the result of H1N1 influenza vaccination is maintained for research and less state. The purpose of this study was to measure the antibody titers after H1N1 influenza vaccination toestimate demands of different standard vaccination in patients with chronic diseases and elderly patients. METHODS: From March 2010 to February 2011, we retrospectively reviewed the medical records of 55 patients admitted to a tertiary hospital. The H1N1 virus antibody titer of each patient was measured through enzyme-linked immunosorbent assay. Titers were measured post vaccination on day 1 and at 1, 3 and 6 months. RESULTS: A total of 55 patients were enrolled in this study. The comorbidities looked at were malignancy, cardiovascular disease, diabetes mellitus, renal disease, cerebrovascular disease, hematologic disease and infectious disease. Five patients (9.1%) had no comorbidities. Patients in their 50's had the highest positive response rate (58.3%). The antibody titers at 1 month after vaccination were not associated with the number of comorbidities. The ratio of positive response increased gradually at baseline (16.4%) to 1 month (47.8%). After 6 months, there remained no positive response. CONCLUSION: The H1N1 antibodies were unstable as the values of the titer changed at follow-up (1 month, 3 months, and 6 months). The positive response rates of those in their 50's and those who had chronic diseases were higher than others. The positive response rates showed that the ability to generate antibodies did not decrease with age or disease conditions.

The Case of Isolated Double Atrial Septum with Persistent Interatrial Space

Double atrial septum is very rare atrial septal malformation which has double layered atrial septum with persistent interatrial space between the two atria. Clinically, most cases of this anomaly are asymptomatic unless manifest as thromboembolic complications, such as stroke, or transient ischemic attack, that thrombus may be originated from this interatrial space. We report a case of a 69-year-old man who was diagnosed with isolated double atrial septum by transthoracic echocardiography.