Implementation of National Health Policy for the Prevention and Control of Cardiovascular Disease in South Korea: Regional-Local Cardio-Cerebrovascular Center and Nationwide Registry

Cardiovascular disease (CVD) remains the leading cause of morbidity, mortality, and health care costs in South Korea. The prevalence of preventable and treatable risk factors for CVD such as obesity, hypercholesterolemia, and smoking has continued to increase, despite improvements management of hypertension. Active leadership, participation, and support of professional organizations and medical institutions in national cardiovascular registries and regional treatment network have proven to be effective models to reduce the global burden of CVD in the Europe and North America. Regional treatment network systems for ST-segment elevation myocardial infarction have established to coordinate percutaneous coronary intervention (PCI) treatment centers, non-PCI treatment centers, and emergency centers especially across the Europe. The Act on the Prevention and Management of Cardio-cerebrovascular Disease was enacted in South Korea in 2017 to establish the legal frameworks and a comprehensive plan for the prevention and management CVD and risk factors. To fully achieve the goal of a NationalHealth Plan for Cardiovascular Disease, it is necessary to embark on a nationwide registry project and to promote the regional acute treatment accessibility which can therefore play a key role in achieving the objectives of the 2017 Act. In this regard, the Korean Society of Cardiology advocates a national project for health promotion and cardiovascular prevention to improve cardiovascular outcomes, which includes the expansion and establishment of regional cardiocerebrovascular centers (CCVCs) and new local CCVCs.

Implementation of National Health Policy for the Prevention and Control of Cardiovascular Disease in South Korea: Regional-Local Cardio-Cerebrovascular Center and Nationwide Registry

Cardiovascular disease (CVD) remains the leading cause of morbidity, mortality, and health care costs in South Korea. The prevalence of preventable and treatable risk factors for CVD such as obesity, hypercholesterolemia, and smoking has continued to increase, despite improvements management of hypertension. Active leadership, participation, and support of professional organizations and medical institutions in national cardiovascular registries and regional treatment network have proven to be effective models to reduce the global burden of CVD in the Europe and North America. Regional treatment network systems for ST-segment elevation myocardial infarction have established to coordinate percutaneous coronary intervention (PCI) treatment centers, non-PCI treatment centers, and emergency centers especially across the Europe. The Act on the Prevention and Management of Cardio-cerebrovascular Disease was enacted in South Korea in 2017 to establish the legal frameworks and a comprehensive plan for the prevention and management CVD and risk factors. To fully achieve the goal of a NationalHealth Plan for Cardiovascular Disease, it is necessary to embark on a nationwide registry project and to promote the regional acute treatment accessibility which can therefore play a key role in achieving the objectives of the 2017 Act. In this regard, the Korean Society of Cardiology advocates a national project for health promotion and cardiovascular prevention to improve cardiovascular outcomes, which includes the expansion and establishment of regional cardiocerebrovascular centers (CCVCs) and new local CCVCs.

Prevalence and Clinical Characteristics of Asymptomatic Pyuria in Chronic Kidney Disease

BACKGROUND: Pyuria seems to be common in chronic kidney disease (CKD), irrespective of urinary tract infection (UTI). It has been hypothesized that sterile pyuria occurs in CKD because of chronic renal parenchymal inflammation. However, there are limited data on whether CKD increases the rate of pyuria or how pyuria in CKD should be interpreted. We investigated the prevalence and characteristics of asymptomatic pyuria (ASP) in CKD via urinary white blood cell (WBC) analysis.METHODS: Urine examination was performed for all stable hemodialysis (HD) and non-dialysis CKD patients of the outpatient clinic (total N=298). Patients with infection symptoms or recent history of antibiotic use were excluded. Urine culture and WBC analysis were performed when urinalysis revealed pyuria.RESULTS: The prevalence of ASP was 30.5% (24.1% in non-dialysis CKD and 51.4% in HD patients). Over 70% of the pyuria cases were sterile. The majority of urinary WBCs were neutrophils, even in sterile pyuria. However, the percentage of neutrophils was significantly lower in sterile pyuria. In multivariate logistic regression analysis, the degree of pyuria, percentage of neutrophils, and presence of urinary nitrites remained independently associated with sterile pyuria.CONCLUSIONS: The prevalence of ASP was higher in CKD patients and increased according to CKD stage. Most ASP in CKD was sterile. Ascertaining the number and distribution of urinary WBCs may be helpful for interpreting ASP in CKD.

A calpain inhibitor protects against fractalkine production in lipopolysaccharide-treated endothelial cells

BACKGROUND: Fractalkine (CX3CL1) is a chemokine with a unique CX3C motif and is produced by endothelial cells stimulated with lipopolysaccharide (LPS), tumor necrosis factor (TNF)-α, interleukin (IL)-1, and interferon-γ. There have been several reports that the caspase/calpain system is activated in endotoxemia, which leads to cellular apoptosis and acute inflammatory processes. We aimed to determine the role of the caspase/calpain system in cell viability and regulation of fractalkine production in LPS-treated endothelial cells. METHODS: Human umbilical vein endothelial cells (HUVECs) were stimulated with 0.01–100 μg/mL of LPS to determine cell viability. The changes of CX3CL1 expression were compared in control, LPS (1 μg/mL)-, IL-1α (1 μg/mL)-, and IL-1β (1 μg/mL)-treated HUVECs. Cell viability and CX3CL1 production were compared with 50 μM of inhibitors of caspase-1, caspase-3, caspase-9, and calpain in LPS-treated HUVECs. RESULTS: Cell viability was significantly decreased from 1 to 100 μg/mL of LPS. Cell viability was significantly restored with inhibitors of caspase-1, caspase-3, caspase-9, and calpain in LPS-treated HUVECs. The expression of CX3CL1 was highest in IL-1β-treated HUVECs. CX3CL1 production was highly inhibited with a calpain inhibitor and significantly decreased with the individual inhibitors of caspase-1, caspase-3, and caspase-9. CONCLUSION: The caspase/calpain system is an important modulator of cell viability and CX3CL1 production in LPS-treated endothelial cells.

Which dialysis unit blood pressure is the most accurate for predicting home blood pressure in patients undergoing hemodialysis?

BACKGROUND/AIMS: We investigated which dialysis unit blood pressure (BP) is the most useful for predicting home BP in patients undergoing hemodialysis (HD). METHODS: Patients undergoing HD who had been treated > 3 months were included in this study. Exclusion criteria were hospitalized patients with acute illness and changes in dry weight and anti-hypertensive drugs 2 weeks before the study. We used the dialysis unit BP recording data, such as pre-HD, intra-HD, post-HD, mean pre-HD, and post-HD (pre-post-HD), mean pre-HD, intra-HD, and post-HD (pre-intra-post-HD) BP. Home BP (the same period of dialysis unit BP) was monitored as a reference method during 2 weeks using the same automatic oscillometric device. Patients were asked to record their BP three times daily (wake up, between noon and 6:00 PM, and at bedtime). RESULTS: Significant differences were detected between home systolic blood pressure (SBP) and pre-HD, post-HD, and intra-HD SBP (p = 0.003, p = 0.001, p = 0.016, respectively). In contrast, no differences were observed between home SBP and pre-intra-post-HD and pre-post-HD SBP (p = 0.235, p = 0.307, respectively). Areas under the receiver operating characteristic curve for pre-intra-post-HD and prepost-HD SBP with 2-week home BP as the reference standard were 0.812 and 0.801, respectively. CONCLUSIONS: These results suggest that pre-intra-post-HD and pre-post-HD SBP had similar accuracy for predicting mean 2-week home SBP in HD patients. Therefore, pre-intra-post-HD and pre-post-HD SBP should be useful for predicting home SBP in HD patients if ambulatory or home BP measurements are unavailable.

Systematic Review of Treatment for Trapped Thrombus in Patent Foramen Ovale

BACKGROUND AND OBJECTIVES: Trapped thrombus in patent foramen ovale (PFO) is a rare complication of pulmonary embolism that may lead to tragic clinical events. The aim of this study was to identify the optimal treatment for different clinical situations in patients with trapped thrombus in a PFO by conducting a literature review. SUBJECTS AND METHODS: A PubMed database search was conducted from 1991 through 2015, and 194 patients (185 articles) with trapped thrombus in a PFO were identified. Patient characteristics, paradoxical embolic events, and factors affecting 60-day mortality were analyzed retrospectively. RESULTS: Among all patients, 112 (57.7%) were treated with surgery, 28 with thrombolysis, and 54 with anticoagulation alone. Dyspnea (79.4%), chest pain (33.0%), and syncope (17.5%) were the most common presenting symptoms. Pretreatment embolism was found in 37.6% of cases, and stroke (24.7%) was the most common event. Surgery was associated with fewer post-treatment embolic events than were other treatment options (p=0.044). In the multivariate analysis, initial shock or arrest, and thrombolysis were independent predictors of 60-day mortality. Thrombolysis was related with higher 60-day mortality compared with surgery in patients who had no initial shock or arrest. CONCLUSION: This systematic review showed that surgery was associated with a lower overall incidence of post-treatment embolic events and a lower 60-day mortality in patients with trapped thrombus in a PFO. In patients without initial shock or arrest, thrombolysis was related with a higher 60-day mortality compared with surgery.

What is the Role of Korean Society of Internal Medicine to Support the Optimal Patient Care under the Medical Insurance System? / 대한내과학회지

No abstract available.

Part 3. Advanced cardiac life support: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

No abstract available.

Consumption of an Excessive Amount of Ionic Beverage Can Trigger Adrenal Adenoma - Induced Severe Hypokalemic Rhabdomyolysis / 대한내과학회지

Rhabdomyolysis results from acute damage to skeletal muscles caused by various conditions, of which hypokalemia is a recognized but rare example. Although primary aldosteronism may cause severe hypokalemia leading to rhabdomyolysis, the potassium level of such patients can be within the normal range. Hypokalemia is most frequently triggered when these patients are exposed to an additional insult, such as diuretic stress. Similarly, overzealous consumption of ionic beverages with osmotic diuretic effects can cause hypokalemia. Here, we describe a patient with an aldosterone-secreting adrenal adenoma, who presented with acute rhabdomyolysis secondary to severe hypokalemia triggered by consumption of a large volume of ionic beverage for 3 weeks.

A Case of Bilateral Renal Infarction of Unknown Cause in a Previously Healthy Young Male

We report a rare case of bilateral renal infarction resulting in acute renal failure in a previously healthy 26-year-old soldier. The patient presented with an abdominal pain and bilateral costovertebral angle tenderness. Laboratory studies showed elevated serum creatinine, mild leukocytosis, and increased lactate dehydrogenase. Contrast-enhanced computed tomography showed multiple perfusion defects in both kidneys with wedge-shaped infarction in right kidney. Kidney biopsy performed in the left kidney revealed microinfarction. Comprehensive work-up did not reveal any specific causes or risk factors except smoking, and the infarction was considered to be idiopathic. He emphasized that he received extremely strenuous military training several days before he came to the hospital. He was treated with low molecular weight heparin with significant improvement in renal function. Further studies are needed for the characterization of idiopathic renal infarction in previously healthy individuals and evaluating the mechanisms including strenuous physical activity on the renal blood flow.

Myocardial Contrast Echocardiography for the Detection of Coronary Artery Disease in Patients with Global Hypokinesis Admitted for First-Onset Acute Heart Failure: Pilot Study

BACKGROUND: The non-invasive differentiation of ischemic and nonischemic acute heart failure (AHF) not resulting from acute myocardial infarction is difficult and has therapeutic and prognostic implications. The aim of this study was to assess whether resting myocardial contrast echocardiography (MCE) can detect coronary artery disease (CAD) in patients with decreased left ventricular (LV) systolic function and global hypokinesis presenting with AHF. METHODS: Twenty-one consecutive patients underwent low-power real-time MCE based on color-coded pulse inversion Doppler. Standard apical LV views were acquired during contrast IV infusion of Definity(R). Following transient microbubbles destruction, the contrast replenishment rate (beta), reflecting myocardial blood flow velocity, was derived by plotting signal intensity vs. time and fitting data to the exponential function: y (t) = A (1 - e(-beta(t-t0))) + C. RESULTS: Of the 21 (mean age 56.6 +/- 13.6 years) patients, 5 (23.8%) demonstrated flow-limiting CAD (> 70% of luminal diameter narrowing). The mean +/- standard deviation of LV ejection fraction was 29.6 +/- 8.6%. Quantitative MCE analysis was feasible in 258 of 378 segments (68.3%). There were no significant difference in "beta" and "Abeta" in patients without and with CAD (0.48 +/- 0.27 vs. 0.45 +/- 0.25, p = 0.453 for beta and 2.99 +/- 2.23 vs. 3.68 +/- 3.13, p = 0.059 for Abeta, respectively). No contrast-related side effects were reported. CONCLUSION: Resting quantitative MCE analysis in patients with AHF was feasible, however, the parameters did not aid in detecting of CAD.

Acquired Long QT Syndrome Manifesting with Torsades de Pointes in a Patient with Panhypopituitarism due to Radiotherapy

We describe a 64-year-old male patient with panhypopituitarism who experienced polymorphic ventricular tachycardia (VT) associated with long QT intervals. The panhypopituitarism developed as a sequelae of radiation therapy administered 20 years prior to his current presentation and was recently aggravated by urinary tract infection with sepsis. In this case, polymorphic VT was resistant to conventional therapy (including magnesium infusion), and QT prolongation and T wave inversion were normalized after the administration of steroid and thyroid hormones. Thyroid hormone is generally known to be associated with torsades de pointes (TdP), but steroid or other hormones may also provoke TdP. Hormonal disorders should be considered as a cause of polymorphic VT with long QT intervals. Some arrhythmias can be life-threatening, and they can be prevented with supplementation of the insufficient hormone.

Reversible dilated cardiomyopathy caused by idiopathic hypoparathyroidism

Dilated cardiomyopathy (DCM) is usually an idiopathic disease with a poor prognosis. Hypocalcemia is a rare and reversible cause of DCM. Here, we report a 50-year-old female with DCM, induced by idiopathic hypoparathyroidism, that improved after treatment with calcium.

Medical Management of Acute Kidney Injury, Mainly Focused on Preventable Diseases / 대한내과학회지

Acute kidney injury (AKI) severity predicts adverse outcomes, such as requirement for renal replacement therapy, length of hospital stay, and mortality. In addition, the widespread use of the RIFLE (risk, injury, failure, loss of kidney function, end-stage kidney disease) and AKI classification systems has shown that even small changes in glomerular filtration rate are associated with increased mortality. Furthermore, AKI contributes to dysfunction of other organs, such as heart, lung, brain, and liver. Consequently, primary/secondary prevention and early diagnosis of AKI are of central clinical importance. Herein, I briefly reviewed the established medical management of AKI, mainly focused on preventable diseases.

Role of Intravenous Sodium Bicarbonate and Oral N-acetylcysteine in Radiocontrast-Induced Nephropathy / 대한내과학회지

No abstract available.

Role of IL-1alpha in Cisplatin-Induced Acute Renal Failure in Mice

BACKGROUND/AIMS: For unknown reasons, caspase-1 -/- mice, protected against cisplatin-induced acute renal failure (ARF), are deficient in interleukin (IL)-1alpha. We thus asked whether IL-1alpha deficiency underlies the mechanism of protection against cisplatin-induced ARF in these mice. METHODS: Cisplatin (30 mg/kg) was injected intraperitoneally into wild-type C57BL/6 mice to produce a cisplatin-induced model of ARF. IL-1alpha was measured in control vehicle- and cisplatin-treated wild-type animals. We also examined whether IL-1alpha -/- mice were similarly protected against cisplatin-induced ARF. Additionally, infiltration of CD11b- and CD49b-positive cells, as markers of macrophages, natural killer, and natural killer T cells (pan-NK cells), was investigated in wild-type and IL-1alpha -/- mice. RESULTS: Compared with vehicle-treated mice, renal IL-1alpha increased in cisplatin-treated wild-type mice beginning on day 1. IL-1alpha -/- mice were shown to be protected against cisplatin-induced ARF. No significant difference in the infiltration of neutrophils or CD11b- and CD49b-positive cells were observed between wild-type and IL-1alpha -/- mice. CONCLUSIONS: Mice deficient in IL-1alpha are protected against cisplatin-induced ARF. The lack of IL-1alpha may explain, at least in part, the protection against cisplatin-induced ARF observed in caspase-1 -/- mice. Investigation of the protective mechanism (s) in IL-1alpha -/- mice in cisplatin-induced ARF merits further study.

Clinical Significance of Acute Kidney Injury in Patients with Colistin Treatment / 대한신장학회지

PURPOSE: Colistin (colistimethate sodium) became available for clinical use in 1959 and was used until the early 1980s to treat infections caused by Gram-negative rods. It was abandoned during the last two decades mainly due to its significant nephrotoxicity. However, the emergence of multidrug-resistant (MDR) bacteria such as Pseudomonas aeruginosa and Acinetobacter baumanii has resulted in significantly increased use of intravenous colistin. This study was designed to investigate the incidence and risk factors of acute kidney injury (AKI) associated with intravenous colistin (colistimethate sodium) treatment. METHODS: We retrospectively collected the data from patients who were admitted to Chung-Ang University Hospital and treated with colistin from May 2007 to June 2009. Among these, we excluded the patients with baseline glomerular filtration rate (GFR) less than 15 ml/min/1.73m2. AKI was defined as an increase of creatinine more than 150% from the baseline, according to RIFLE criteria. RESULTS: A total of 92 patients met the inclusion criteria and were included in the analysis. AKI occurred in 43 (47%) of the 92 patients. The cumulative doses (2.51+/-1.89 vs. 1.75+/-1.35 g, p=0.032) of colistin were significantly greater in the AKI group than in the normal kidney function (NKF) group. Serum creatinine level showed a significant increase in the AKI group, from day 3 (1.6+/-1.1 vs. 0.9+/-0.5 mg/dL, p=0.001) to day 90 (2.1+/-1.9 vs. 0.7+/-0.2 mg/dL, p=0.033). Furthermore, the occurrence of AKI at day 3 was a significant predictor of shorter survival (Log rank test p=0.031). CONCLUSION: AKI was a relatively common side effect of colistin. The cumulative dose was critical, rather than the daily dose or duration of treatment. Early acute kidney injury may predict shorter cumulative survival in patients undergoing colistin treatment.

Isolated Pancreatic Tuberculosis in a Patient with End-Stage Renal Disease / 대한신장학회지

Tuberculosis (Tb) is a common disease in the developing world and its incidence is slowly increasing in developed countries, where a resurgence has occurred subsequent to the acquired immunodeficiency syndrome epidemic. In addition, patients with end-stage renal disease who are on maintenance hemodialysis carry a high risk for Tb; reported incidence varies from 6-16 times that of the general population. Extrapulmonary Tb constitutes a major part of Tb in dialysis patients. Isolated pancreatic Tb is a very rare occurrence in the setting of extrapulmonary Tb. It usually occurs as a complication of miliary Tb in immunodeficient individuals, particularly those with human immunodeficiency virus infection. There is no isolated pancreatic Tb in patients with end-stage renal disease. We recently experienced a case of isolated pancreatic Tb diagnosed by acid fast bacilli culture, Tb polymerase chain reaction from ultrasound-guided fine needle aspiration, and an excellent response after anti-Tb treatment in a 72-year-old patient with end-stage renal disease.

The Effects of Low Sodium Dialysate in Hemodialysis Patients / 대한신장학회지

PURPOSE: Hypertension is a common problem in maintenance hemodialysis (HD) patients. We assessed the effects of low sodium dialysate on changes of blood pressure in maintenance HD patients. METHODS: Forty HD patients were enrolled in this cross-over study. All the patients underwent nine consecutive HD sessions with the dialysate contained 138 mEq/L sodium (conventional sodium HD), then concentrations of sodium were switched to match the patients average pre-HD plasma sodium measured during the conventional sodium phase (135 mEq/L for patients with sodium levels less than 137, 137 for patients with sodium levels over 137). Dry weight and dialysis prescription were not modified during the six weeks of the study. RESULTS: There was a significant decrease in the interdialytic weight gain (2.4+/-0.9 kg vs. 2.0+/-0.7 kg, p<0.001) and the interdialytic thirsty in low sodium HD sessions compare to conventional sodium HD sessions. Pre-HD systolic and diastolic blood pressure (BP), post-dialysis systolic BP was similar in both periods of the study. The use of low sodium dialysate is associated with significantly lower systolic BP in patients with uncontrolled hypertension (n=10,157.1+/-3.6 mmHg vs. 148.0+/-9.4 mmHg, p=0.011), but not in those with controlled hypertension. Cardio-thoracic ratio was significant decrease in low sodium dialysate HD (0.53+/-0.08 vs. 0.51+/-0.07, p=0.002). The episodes of intradialytic hypotension and related symptoms were not more frequent in low sodium dialysate HD. CONCLUSION: Low dialysate sodium concentration based on predialysis sodium levels of patients could reduce the pre-HD systolic BP, interdialytic thirsty and interdialytic weight gain in maintenance HD patients.

Utility of B-Type Natriuretic Peptide for Predicting Perioperative Cardiovascular Events in Patients Without History of Cardiovascular Disease Undergoing Major Non-Cardiac Surgery

BACKGROUND AND OBJECTIVES: Patients without previous history of cardiac disease can be regarded as low-risk when undergoing major non-cardiac surgery. The aim of this study was to examine whether preoperative B-type natriuretic peptide (BNP) level predicted postoperative cardiac events in these patients. SUBJECTS AND METHODS: Preoperative BNP level was measured in 163 patients whose risk was considered low according to the Revised Cardiac Risk Index. Postoperative cardiac events, including death during hospitalization, myocardial injury, arrhythmia, cerebrovascular accidents and congestive heart failure were assessed. RESULTS: Postoperative cardiac events occurred in 8 patients (4.9%). Preoperative BNP levels were significantly higher among patients who experienced postoperative cardiac events, compared to those who did not (130.6+/-148.8 vs. 57.9+/-70.8 pg/mL, p=0.009). CONCLUSION: Preoperative BNP level may provide prognostic information in low-risk patients undergoing major non-cardiac surgery.