Simultaneous Occurrence of ImmuneMediated Thrombocytopenia and Myocarditis After mRNA-1273COVID-19 Vaccination: A Case Report

With the global spread of severe acute respiratory syndrome coronavirus 2, several vaccines were developed; messenger RNA (mRNA) vaccines have recently been widely used worldwide. However, the incidence of myocarditis following mRNA vaccination is increasing;although the cause of myocarditis has not yet been clearly identified, it is presumed to be caused by a problem in the innate immune system. Immune-mediated thrombocytopenia (ITP) after vaccination is rare but has been reported and is also assumed to occur by the same mechanism. We report the first case of simultaneous myocarditis and ITP after mRNA vaccination. A 38-year-old woman presented with chest pain, mild dyspnea, and sweating after vaccination with mRNA-1273 vaccine (Moderna) 4 days prior to admission.Upon admission to the emergency department, cardiac enzymes were elevated; blood test performed 5 months ago showed normal platelet count, but severe thrombocytopenia was observed upon admission. After administration of intravenous immunoglobulin, the platelet count improved; subsequently, myocarditis was observed on endomyocardial biopsy. Thus, myocarditis and ITP were judged to have occurred simultaneously due to the expression of the innate immune system markers after mRNA vaccination. The patient was discharged on day 6 of admission.

J-curve relationship between corrected QT interval and mortality in acute heart failure patients

Background/Aims@#This study investigated the prognostic power of corrected QT (QTc) interval in patients with acute heart failure (AHF) according to sex. @*Methods@#We analyzed multicenter Korean Acute Heart Failure registry with patients with AHF admitted from 2011 to 2014. Among them, we analyzed 4,990 patients who were followed up to 5 years. Regarding QTc interval based on 12 lead electrocardiogram, patients were classified into quartiles according to sex. @*Results@#During follow-up with median 43.7 months, 2,243 (44.9%) patients died. The relationship between corrected QT interval and all-cause mortality followed a J-curve relationship. In Kaplan-Meier analysis, both sex had lowest mortality in the second QTc quartile. There were significant prognostic differences between the second and the fourth quartiles in male (log-rank p = 0.002), but not in female (log-rank p = 0.338). After adjusting covariates, the third (hazard ratio [HR], 1.185; 95% confidence interval [CI], 1.001 to 1.404; p = 0.049) and the fourth (HR, 1.404; 95% CI, 1.091 to 1.535; p = 0.003) quartiles demonstrated increased risk of mortality compared to the second quartile in male. In female, however, there was no significant difference across quartiles. QTc interval was associated with 5-year all-cause mortality in J-shape with nadir of 440 to 450 ms in male and 470 to 480 ms in female. @*Conclusions@#QTc interval was an independent predictor of overall death in male, but its significance decreased in female. The relationship between QTc interval and all-cause mortality was J-shaped in both sex.

Pre-hospital delay and emergency medical services in acute myocardial infarction

Background/Aims@#Minimising total ischemic time (TIT) is important for improving clinical outcomes in patients with ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention (PCI). TIT has not shown a significant improvement due to persistent pre-hospital delay. This study aimed to investigate the risk factors associated with pre-hospital delay. @*Methods@#Individuals enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health between 2011 and 2015 were included in this study. The study population was analyzed according to the symptom-to-door time (STDT; within 60 or > 60 minutes), and according to the type of hospital visit (emergency medical services [EMS], non-PCI center, or PCI center). @*Results@#A total of 4,874 patients were included in the analysis, of whom 28.4% arrived at the hospital within 60 minutes of symptom-onset. Old age (> 65 years), female gender, and renewed ischemia were independent predictors of delayed STDT. Utilising EMS was the only factor shown to reduce STDT within 60 minutes, even when cardiogenic shock was evident. The overall frequency of EMS utilisation was low (21.7%). Female gender was associated with not utilising EMS, whereas cardiogenic shock, previous myocardial infarction, familial history of ischemic heart disease, and off-hour visits were associated with utilising EMS. @*Conclusions@#Factors associated with delayed STDT and not utilising EMS could be targets for preventive intervention to improve STDT and TIT.

KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.

KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.

β-arrestin2 Affects Cardiac Progenitor Cell Survival through Cell Mobility and Tube Formation in Severe Hypoxia

BACKGROUND AND OBJECTIVES: β-arrestin2 (β-arr2) basically regulates multiple signaling pathways in mammalian cells by desensitization and internalization of G-protein coupled receptors (GPCRs). We investigated impacts of β-arr2 on survival, mobility, and tube formation of cardiac progenitor cells (CPCs) obtained from wild-type (WT) mouse (CPC-WT), and β-arr2 knock-out (KO) mouse (CPC-KO) cultured in presence or absence of serum and oxygen as non-canonical roles in GPCR system. METHODS: CPCs were cultured in Dulbecco's Modified Eagle Medium/Nutrient Mixture F-12 -based media containing fetal bovine serum and growth factors. Survival of 2 types of CPCs in hypoxia and/or serum deprivation was measured by fluorescence-activated cell sorting. Wound healing ability, and tube formation ability on Matrigel of 2 kinds of CPCs were compared in normoxic and hypoxic cultures. Protein expression related to survival and mobility were measured with the Western blot for each culture conditions. RESULT: CPC-KO showed significantly worse mobility in the wound healing assay and in tube formation on Matrigel especially in hypoxic culture than did the CPC-WT. Also, CPC-KO showed significantly higher apoptosis fraction in both normoxic and hypoxic cultures than did the CPC-WT. Expression of proteins associated with cell survival and mobility, e.g., protein kinase B (Akt), β-catenin, and glycogen synthase kinase-3β (GSK-3β) was significantly worse in CPC-KO. CONCLUSIONS: The CPC-KO had significantly worse cell mobility, tube formation ability, and survival than the CPC-WT, especially in the hypoxic cultures. Apparently, β-arr2 is important on CPC survival by means of mobility and tube formation in myocardial ischemia.

Impact of Heart Rate Reduction with Maximal Tolerable Dose of Bisoprolol on Left Ventricular Reverse Remodeling

BACKGROUND: We aimed to evaluate effect of heart rate (HR) reduction on left ventricular reverse remodeling (LVRR) in Korean patients with heart failure with reduced ejection fraction (HFrEF). METHODS: Ambulatory patients with HFrEF, who had paired echocardiograms, N-terminal prohormone brain natriuretic peptide (NT-proBNP), and global assessment score (GAS) at baseline and 6-month (n = 157), were followed up on preset treatment schedule with bisoprolol. RESULTS: The LVRR occurred in 49 patients (32%) at 6-month. In multivariable analysis, independent predictors associated with LVRR were use of anti-aldosterone agent (odds ratio [OR], 4.18; 95% confidence interval [CI], 1.80–9.71), young age (OR, 0.96; 95% CI, 0.92–0.99), high baseline HR (OR, 3.76; 95% CI, 1.40–10.10), and favorable baseline GAS (OR, 1.73; 95% CI, 1.06–2.81). Beneficial effect of bisoprolol, in terms of LVRR, NT-proBNP, and GAS, was remarkable in the high HR group (baseline HR ≥ 75 beats per minute [bpm]), which showed a large HR reduction. CONCLUSION: High baseline HR (≥ 75 bpm) showed an association with LVRR and improvement of NT-proBNP and GAS in patients with HFrEF. This seems to be due to a large HR reduction after treatments with bisoprolol. Trial registry at www.ClinicalTrials.gov, NCT00749034.

β-arrestin2 Affects Cardiac Progenitor Cell Survival through Cell Mobility and Tube Formation in Severe Hypoxia

BACKGROUND AND OBJECTIVES@#β-arrestin2 (β-arr2) basically regulates multiple signaling pathways in mammalian cells by desensitization and internalization of G-protein coupled receptors (GPCRs). We investigated impacts of β-arr2 on survival, mobility, and tube formation of cardiac progenitor cells (CPCs) obtained from wild-type (WT) mouse (CPC-WT), and β-arr2 knock-out (KO) mouse (CPC-KO) cultured in presence or absence of serum and oxygen as non-canonical roles in GPCR system.@*METHODS@#CPCs were cultured in Dulbecco's Modified Eagle Medium/Nutrient Mixture F-12 -based media containing fetal bovine serum and growth factors. Survival of 2 types of CPCs in hypoxia and/or serum deprivation was measured by fluorescence-activated cell sorting. Wound healing ability, and tube formation ability on Matrigel of 2 kinds of CPCs were compared in normoxic and hypoxic cultures. Protein expression related to survival and mobility were measured with the Western blot for each culture conditions.RESULT: CPC-KO showed significantly worse mobility in the wound healing assay and in tube formation on Matrigel especially in hypoxic culture than did the CPC-WT. Also, CPC-KO showed significantly higher apoptosis fraction in both normoxic and hypoxic cultures than did the CPC-WT. Expression of proteins associated with cell survival and mobility, e.g., protein kinase B (Akt), β-catenin, and glycogen synthase kinase-3β (GSK-3β) was significantly worse in CPC-KO.@*CONCLUSIONS@#The CPC-KO had significantly worse cell mobility, tube formation ability, and survival than the CPC-WT, especially in the hypoxic cultures. Apparently, β-arr2 is important on CPC survival by means of mobility and tube formation in myocardial ischemia.

Clinical Characteristics and Outcome of Acute Heart Failure in Korea: Results from the Korean Acute Heart Failure Registry (KorAHF)

BACKGROUND AND OBJECTIVES: The burden of heart failure has increased in Korea. This registry aims to evaluate demographics, clinical characteristics, management, and long-term outcomes in patients hospitalized for acute heart failure (AHF). SUBJECTS AND METHODS: We prospectively enrolled a total of 5625 consecutive subjects hospitalized for AHF in one of 10 tertiary university hospitals from March 2011 to February 2014. Descriptive statistics were used to determine the baseline characteristics of the study population and to compare them with those from other registries. RESULTS: The mean age was 68.5±14.5 years, 53.2% were male, and 52.2% had de novo heart failure. The mean systolic and diastolic blood pressures were 131.2±30.3 mmHg and 78.6±18.8 mmHg at admission, respectively. The left ventricular ejection fraction was ≤40% in 60.5% of patients. Ischemia was the most frequent etiology (37.6%) and aggravating factor (26.3%). Angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and aldosterone antagonists were prescribed in 68.8%, 52.2%, and 46.6% of the patients at discharge, respectively. Compared with the previous registry performed in Korea a decade ago, extracorporeal membrane oxygenation (ECMO) and heart transplantation have been performed more frequently (ECMO 0.8% vs. 2.8%, heart transplantation 0.3% vs. 1.2%), and in-hospital mortality decreased from 7.6% to 4.8%. However, the total cost of hospital care increased by 40%, and one-year follow-up mortality remained high. CONCLUSION: While the quality of acute clinical care and AHF-related outcomes have improved over the last decade, the long-term prognosis of heart failure is still poor in Korea. Therefore, additional research is needed to improve long-term outcomes and implement cost-effective care.

Repeated isolated bilateral coronary ostial stenosis related to the syphilitic aortitis

No abstract available.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. 
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Successfully Managed Aortic Aneurysm by Endovascular Treatment and Sequential Surgical Replacement in a Patient with Chronic Consumptive Coagulopathy / 대한내과학회지

Aortic aneurysm-induced chronic consumptive coagulopathy is a very rare complication but can be a source of critical complications and mortality. A 72-year-old man presented with a rapidly expanding descending thoracic aortic aneurysm with a penetrating ulcer and an infrarenal abdominal aortic aneurysm complicated by chronic coagulopathy. We were aware of the bleeding risk during surgical replacement based on the patient's chronic coagulopathy status and successfully performed endovascular repair of the thoracic aortic aneurysm with a penetrating ulcer. Platelet transfusion, antiplatelet agents, and proteinase inhibitors improved the coagulopathy. A delayed type Ib endoleak developed, and the coagulopathy recurred 2 months later when the patient presented with purpura of both lower legs. We successfully managed the condition by elective surgical replacement of the entire aorta after improving the coagulopathy with platelet replacement and administration of proteinase inhibitors.

Abdominal and Pericardial Fat in Patients with and without Coronary Artery Disease: Computed Tomography Study

OBJECTIVE: There has been a limited investigation looking into the correlation between pericardial fat and abdominal fat with coronary artery disease (CAD) as measured by coronary computed tomographic angiography (CCTA). We proposed that the volume of pericardial fat is larger in patients with CAD than in patients without CAD, and sought to determine which abdominal adiposity index best correlated with pericardial fat volume. METHODS: Participants were examined using CCTA between October 2007 and January 2008. All participants had no previous history of CAD. Pericardial adipose tissue (PAT) volume, abdominal total adipose tissue volume, abdominal subcutaneous adipose tissue volume, and abdominal visceral adipose tissue (AVAT) volume were measured using CCTA. RESULTS: Fifty patients (26.5%) demonstrated CAD, and 139 patients did not demonstrate CAD by CCTA. PAT volume in patients with CAD was larger than that of patients without CAD (173.2+/-64.2 cm3 vs. 147.6+/-50.4 cm3, p<0.01). However, indices of abdominal adiposity were not significantly different between the two groups. Using multivariable analysis, independent predictors of CAD were PAT volume (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.00-1.02, p=0.04), coronary artery calcium score (OR 1.01, 95% CI 1.00-1.01, p<0.01), and typical chest pain (OR 4.88, 95% CI 1.47-16.21, p=0.01). AVAT volume showed a linear correlation with PAT volume. CONCLUSION: PAT volume was an independent predictor of CAD as measured by CCTA. PAT volume was also well correlated with the AVAT volume among the indices of abdominal adiposity.

Acute Profound Thrombocytopenia after Using Abciximab for No-Reflow during Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Glycoprotein IIb/IIIa antagonists are well established for their effectiveness in improving clinical outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention. Acute profound thrombocytopenia is a rare complication of abciximab. We present a case which was managed successfully for the rare complication of acute profound thrombocytopenia after using abciximab and an intra-aortic balloon pump for the treatment of a no-reflow phenomenon and consecutive cardiogenic shock during primary percutaneous coronary intervention.

A Rare Combination of the Left Circumflex Coronary Artery Fistula Connecting a Dilated Coronary Sinus with Persistent Left Superior Vena Cava and Multiple Arteriovenous Fistulae

Coronary artery fistula (CAF) is an abnormal communication between an epicardial coronary artery and a cardiac chamber, major vessel or other vascular structures. This report presents a rare case of CAF in which a dilated left main trunk and proximal circumflex coronary artery are connected to a dilated coronary sinus. There were also two other fistulae and persistent left superior vena cava. The coronary fistula was managed conservatively.

Percutaneous Retrieval of an Embolized Central Venous Chemoport in a Patient With Colon Cancer

The central access device is commonly used as a route of chemotherapuetic agents in patients with malignant diseases for its convenient and safety for insertion. This report describes a case of 66-year-old man with colon cancer who suffered a rare complication in which a chemoport embolized into the inferior vena cava and it was successfully retrieved by a percutaneous approach using a goose neck snare.

A Case of Severe Aortic Valve Regurgitation Caused by an Ascending Aortic Aneurysm in a Young Patient With Autosomal Dominant Polycystic Kidney Disease and Normal Renal Function

Aortic aneurysm is one several well-known cardiovascular complications in patients with autosomal dominant polycystic kidney disease (ADPCKD). Commonly affected site of aortic aneurysm and its related dissection in ADPCKD is abdominal aorta. Long standing hypertension, haemodialysis, old age are closely related with discovering of aortic aneurysm and dissection in ADPCKD. However, thoracic aortic aneurysms and its related severe aortic regurgitations (ARs) are rare in younger patients suffering from ADPCKD, especially ones who have normal renal function. Here, we report a case involving a 27-year-old Asian male patient with severe AR due to an ascending aneurysm of the thoracic aorta associated with ADPCKD. The patient had normal renal function without Marfan's habitus. The AR and thoracic aortic aneurysm were corrected surgically.

Protective Effects of Peroxiredoxin on Hydrogen Peroxide Induced Oxidative Stress and Apoptosis in Cardiomyocytes

BACKGROUND AND OBJECTIVES: The redox system is an important anti-oxidative system composed of thioredoxin, thioredoxin reductase, and peroxiredoxin (PRx). The fine details of PRx expression and its protective effects in various cells in cardiovascular tissue under oxidative stress created by hydrogen peroxide have not been fully elucidated. SUBJECTS AND METHODS: Oxidative stress was induced by adding hydrogen peroxide at 0.25 mM for 2 hours to rat neonatal cardiomyocytes (rCMCs), rat vascular smooth muscle cells (rVSMCs), and human umbilical vein endothelial cells (HUVECs). Apoptosis was quantified by flow cytometry and the expression patterns of the six PRx isoforms were evaluated by western blotting in the three cell lines after hydrogen peroxide stimulation. Apoptosis and the cell survival signal pathway were evaluated by PRx1 gene delivery using lentiviral vector in hydrogen peroxide stimulated rCMCs versus green fluorescence protein gene delivery. RESULTS: Hydrogen peroxide induced 25% apoptosis in rCMCs. Furthermore, the PRx1 and 5 isoforms were found to be overexpressed in hydrogen peroxide treated rCMCs, and PRx1 overexpression by gene delivery was found to reduce hydrogen peroxide induced rCMCs apoptosis significantly. In addition, this effect was found to originate from cell survival pathway modification. CONCLUSION: Hydrogen peroxide induced significant oxidative stress in rCMCs, rVSMCs, and HUVECs, and PRx1 overexpression using a lentiviral vector system significantly reduced hydrogen peroxide induced rCMCs apoptosis by upregulation of cell survival signals and downregulation of apoptotic signals. These findings suggest that PRx1 could be used as a treatment strategy for myocardial salvage in conditions of oxidative stress.

Usefulness of Home Blood Pressure Reflected Anti-hypertensive Treatment and the Evolution of Blood Pressure Profiles

BACKGROUND: It is still unclear how self-measured home blood pressure (BP) evolves over time in treated hypertensive patients, and the usefulness of home BP based treatment is under debate. METHODS: The patients whose anti-hypertensive medications had not been changed at least 6 months were enrolled. They measured home BP at enrollment and at study end. The patients were classified into controlled hypertension (CH), hypertension with white coat effect (WCH), hypertension with reverse white coat effect (RWCH), and uncontrolled hypertension (UH), based on their clinic and home BP. Their home BP profiles were reflected in the patients' treatments, instead of relying solely on clinic BP. RESULTS: Ninety patients (mean age, 56.5 +/- 9.9; male, 57.8%) were analyzed and mean follow-up duration was 34.1 +/- 3.6 months. CH, WCH, RWCH, and UH patients were 33.3% (30 patients), 37.8% (34 patients), 5.6% (5 patients), and 23.3% (21 patients), respectively at enrollment. Almost all CH and WCH patients remained in normal range of home BP whereas about half of RWCH and UH patients moved to CH or WCH. As a result, the proportion of RWCH and UH decreased at the end of follow-up. Overall clinic and home BP reduced significantly in all groups. Clinic BP declined significantly in WCH and UH, whereas home BP declined significantly in RWCH and UH. That means the BP profiles shifted toward more reasonable states. CONCLUSIONS: BP profiles shifted toward more reasonable states after home BP based adjustment of anti-hypertensive medication. Measurement of home BP might be beneficial in anti-hypertensive treatment.

Serum Thioredoxin 1 Level Has Close Relation with Myocardial Damage Amount in Acute Myocardial Infarction Patients

Thioredoxin-1 (Trx-1) is one of important anti-oxidative molecules to overcome the oxidative stress. The aim of the present study is to investigate the clinical relationship between serum concentration of Trx-1 on the pre-percutaneous coronary intervention (prePCI) and myocardial damage amount in the patients with acute myocardial infarction with the culprit lesion in only the left anterior descending artery on coronary angiography (n = 100). Initial value of creatine kinase (CK) was 368.3 +/- 531.4 U/L, and MB isoenzyme of CK (CK-MB) level was 22.92 +/- 33.8 ng/mL, and cardiac specific troponin T (cTnT) level was 0.61 +/- 1.6 ng/mL. Positive correlations were observed between prePCI Trx-1 level and initial CK (P = 0.005, r = 0.281), and cTnT (P < 0.001, r = 0.453), peak CK (P = 0.001, r = 0.316) in all patients, but the statistical relation was observed only in ST segment elevation myocardial infarction (STEMI) patients (P = 0.008, r = 0.329 for initial CK, P = 0.001, r = 0.498 for initial cTnT, P = 0.005, r = 0.349 for peak CK), not in Non-STEMI patients. Conclusively, we consider prePCI serum Trx-1 as a predictor for myocardial damage amount in patients with STEMI.