Early efficacy and safety of statin therapy in Korean patients with hypercholesterolemia: Daegu and Gyeongbuk Statin Registry

Background/Aims@#To date, prospective data are limited on efficacy and safety profiles of statin therapy in Korean hypercholesterolemic patients. Hence, the aim of this study was to evaluate the practice patterns of statin therapy and its efficacy and safety through the prospective Daegu and Gyeongbuk statin registry. @*Methods@#Statin naïve patients who were prescribed statins according to the criteria of Korean Guidelines for Management of Dyslipidemia were enrolled. Clinical and laboratory evaluations were performed at baseline and at week 8, where the efficacy was assessed with the same guidelines. @*Results@#Of 908 patients, atorvastatin and rosuvastatin were most frequently prescribed statins (63.1% and 29.3%, respectively). High intensity statins (atorvastatin 40 mg or rosuvastatin 20 mg) were prescribed in 24.7% of all patients and in 79.5% of high and very high risk groups. The total and low density lipoprotein (LDL) cholesterol levels decreased from 203.7 ± 43.0 to 140.6 ± 28.6 mg/dL and 134.4 ± 35.7 to 79.5 ± 21.3 mg/dL, respectively. The achievement rate of the LDL target goal was 98.6% in low risk, 95.0% in moderate risk, 88.1% in high risk, and 42.1% in very high risk patients (59.7% in overall). There was no significant difference in the efficacy between atorvastatin and rosuvastatin. Adverse events were observed in 12.0% of patients and led to 1.4% of treatment cessation. @*Conclusions@#The efficacy of the usual starting dose of statins in daily practice was relatively insufficient for Korean hypercholesterolemic patients with high or very high risks. Short-term adverse events of statin therapy were not common in Korean patients with a low discontinuation rate.

The Implication of Cardiac Injury Score on In-hospital Mortality of Coronavirus Disease 2019

Background@#s: The severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has spread worldwide. Cardiac injury after SARS-CoV-2 infection is a major concern. The present study investigated impact of the biomarkers indicating cardiac injury in coronavirus disease 2019 (COVID-19) on patients' outcomes. @*Methods@#This study enrolled patients who were confirmed to have COVID-19 and admitted at a tertiary university referral hospital between February 19, 2020 and March 15, 2020. Cardiac injury was defined as an abnormality in one of the following result markers: 1) myocardial damage marker (creatine kinase-MB or troponin-I), 2) heart failure marker (N-terminal-pro B-type natriuretic peptide), and 3) electrical abnormality marker (electrocardiography). The relationship between each cardiac injury marker and mortality was evaluated. Survival analysis of mortality according to the scoring by numbers of cardiac injury markers was also performed. @*Results@#A total of 38 patients with COVID-19 were enrolled. Twenty-two patients (57.9%) had at least one of cardiac injury markers. The patients with cardiac injuries were older (69.6 ± 14.9 vs. 58.6 ± 13.9 years old, P = 0.026), and were more male (59.1% vs. 18.8%, P = 0.013).They showed lower initial oxygen saturation (92.8 vs. 97.1%, P = 0.002) and a trend toward higher mortality (27.3 vs. 6.3%, P = 0.099). The increased number of cardiac injury markers was significantly related to a higher incidence of in-hospital mortality which was also evidenced by Kaplan-Meier survival analysis (P = 0.008). @*Conclusion@#The increased number of cardiac injury markers is related to in-hospital mortality in patients with COVID-19.

Accuracy of implantable loop recorders for detecting atrial tachyarrhythmias after atrial fibrillation catheter ablation

Background@#Implantable loop recorders (ILRs) can provide an enhanced possibility to detect atrial fibrillation (AF), but the accuracy, especially the positive predictive value (PPV), is controversial. This study aimed to evaluate the accuracy of ILRs for detecting AF through a comparison with Holter. @*Method and results@#Thirteen patients who underwent AF ablation were enrolled. ILRs were implanted in all patients, who were scheduled to have Holter monitorings after the procedure. The incidence of AF was compared between the two modalities and analyzed for any correlations. A total of 51 Holters (67,985.5 min) and concomitant ILRs were available for the comparison. The judgment of the presence of AF did not perfectly correlate between the ILR and Holter (Kappa = 0.866, P < 0.001). In the ILR data, the sensitivity of detecting AF on the Holter was 81.6% (95% confidence interval [CI] 0.812–0.820; P < 0.001). The specificity was 99.9% (95% CI 0.998–0.999; P < 0.001). When the ILR detected AF, the PPV was 99.5% (95% CI 0.994–0.995), but the ILR did not detect AF, and the negative predictive value was 94.2% (95% CI 0.941–0.944). A separate analysis of AF/atrial tachycardia (AT) showed that the AT detection rate of the ILR was 2.3%. @*Conclusion@#The ILR had a low false positive value and high PPV for AF events. However, it was limited in identifying AT.

Effect of carvedilol on premature ventricular complexes originating from the ventricular outflow tract

Background@#Carvedilol is one of the most effective beta-blockers in reducing ventricular tachyarrhythmias and mortality in patients with heart failure. One of the possible antiarrhythmic mechanisms of carvedilol is the suppression of store overload-induced Ca2+ release, especially for the triggered activity. @*Objectives@#Premature ventricular complex (PVC) originating from the ventricular outflow tract (OT) is the most common form of idiopathic PVC, and its main mechanism is related to triggered activity. We evaluate the efficacy of carvedilol to suppress the OT PVC. @*Methods@#The electronic medical records at our hospital were screened to identify OT PVC patients treated with carvedilol. Clinical, electrocardiographic, and Holter monitoring studies were reviewed. @*Results@#A total of 25 patients who underwent Holter monitoring before and after carvedilol administration were found and enrolled. The mean age of the patients was 54.9 ± 13.9 years, and the mean dose of carvedilol was 18.2 ± 10.2 mg (sustained release formulation, 8/16/32 mg). The 24-h burden of PVC in 18 (72%) of 25 patients was significantly reduced from 12.2 ± 9.7% to 4.4 ± 6.7% (P = 0.006). In seven patients, the burden of PVC was changed from 7.1 ± 6.1% to 9.8 ± 8.4% (P = 0.061). There was no difference in age, carvedilol dose, duration of treatment, ventricular function, and left atrial size between responding and non-responding groups. @*Conclusion@#In this retrospective pilot study, treatment with carvedilol showed PVC suppression in 72% of patients. Now, we are conducting a prospective, randomized, multicenter study to evaluate the effect of carvedilol on OT PVC (Clinical trial registration: FOREVER trial, Clinical-Trials.gov: NCT03587558).

Optical Coherence Tomography: Defined Plaque Erosion after Removal of a Coronary Guidewire

No abstract available.

Clinical Outcomes in Patients with Deferred Coronary Lesions according to Disease Severity Assessed by Fractional Flow Reserve

Data on the clinical outcomes in deferred coronary lesions according to functional severity have been limited. This study evaluated the clinical outcomes of deferred lesions according to fractional flow reserve (FFR) grade using Korean FFR registry data. Among 1,294 patients and 1,628 lesions in Korean FFR registry, 665 patients with 781 deferred lesions were included in this study. All participants were consecutively categorized into 4 groups according to FFR; group 1: ≥ 0.96 (n = 56), group 2: 0.86–0.95 (n = 330), group 3: 0.81–0.85 (n = 170), and group 4: ≤ 0.80 (n = 99). Primary endpoint was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction, and target vessel revascularization. The median follow-up period was 2.1 years. During follow-up, the incidence of MACE in groups 1–4 was 1.8%, 7.6%, 8.8%, and 13.1%, respectively. Compared to group 1, the cumulative rate by Kaplan-Meier analysis of MACE was not different for groups 2 and 3. However, group 4 had higher cumulative rate of MACE compared to group 1 (log-rank P = 0.013). In the multivariate Cox hazard models, only FFR (hazard ratio [HR], 0.95; P = 0.005) was independently associated with MACE among all participants. In contrast, previous history of percutaneous coronary intervention (HR, 2.37; P = 0.023) and diagnosis of acute coronary syndrome (ACS) (HR, 2.35; P = 0.015), but not FFR, were independent predictors for MACE in subjects with non-ischemic (FFR ≥ 0.81) deferred coronary lesions. Compared to subjects with ischemic deferred lesions, clinical outcomes in subjects with non-ischemic deferred lesions according to functional severity are favorable. However, longer-term follow-up may be necessary.

Angiographically minimal but functionally significant coronary lesion confirmed by optical coherence tomography

No abstract available.

Circadian Rhythm of Hospital Death: Difference Between the Intensive Care Unit and General Room

BACKGROUND AND OBJECTIVES: The purpose was to record the time at which biological phenomena stop in different hospital wards and determine regular patterns in times of death, as well as any associated factors. SUBJECTS AND METHODS: A total of 6,517 inpatients at the Keimyung University Dongsan Medical Center who died between January 2006 and December 2012 were retrospectively enrolled. A comparative analysis was conducted for the mortality distribution between the intensive care unit (ICU) and general wards (GW). RESULTS: A total of 3,198 (49%) died in the ICU and 3,319 (51%) in the GW. The ICU showed an increase in mortality over the most recent 3 years. There was no difference in monthly or daily pattern. ICU mortality peaked at 14:00 to 16:00 hours (9.2%) and 20:00 to 22:00 hours (9.1%), and GW mortality peaked at 06:00 to 08:00 hours (9.6%) and 10:00 to 12:00 hours (9.4%), with a significant statistical difference between the two wards (p=0.03). Patients with diseases of the circulatory system died most often in the ICU (28.3%), whereas those with neoplasms had the highest mortality rate in the GW (77.7%) (p<0.01). CONCLUSIONS: Some differences between the ICU and GW may be accounted for by a preserved circadian rhythm that was affected by disease distribution, hospital room environment, and use of various drugs.

An Intra-procedural Stent Thrombosis in a Prasugrel Resistant Patient Treated with Ticagrelor / 계명의대학술지

Stent thromboses due to multifactorial causes including hypercoagulable conditions and high on treatment platelet reactivity (HTPR), which means a low response to anti-platelet therapy, especially clopidogrel. Prasugrel is a third generation thienopyridine and inactive pro-drug requiring metabolic activation in vivo, which improves the rate of HTPR with clopidogrel. This drug is mostly effective, with a potent, fast, and consistent anti-platelet action, but rare cases of inadequate platelet inhibition with prasugrel have been reported. Here we describe the case of a 47-year-old man who presented with a recurrent acute myocardial infarction and ST during an intravascular ultrasound pullback and was resistant to prasugrel, was successfully treated with ticagrelor.

Recurrent Embolic Stroke due to Atrial Septal Defect without Pulmonary Hypertension

No abstract available.

Outcome of Percutaneous Coronary Intervention with Intra-Aortic Balloon Pump in Patients with Cardiogenic Shock / 대한내과학회지

BACKGROUND/AIMS: The mortality of hospitalized patients undergoing treatment with an intra-aortic balloon pump (IABP) due to cardiogenic shock is well known as quite high. The aim of this study was to evaluate the outcome of percutaneous coronary intervention (PCI) with an IABP in patients with acute coronary syndrome (ACS) and cardiogenic shock and identify the predictors of in-hospital mortality. METHODS: 134 patients who underwent PCI with IABP due to ACS complicated by cardiogenic shock were consecutively enrolled. Outcomes were obtained and analyzed during hospitalization and after 1 year. RESULTS: The incidence of all-cause mortality was 35.8% (in-hospital mortality, 34.3%; 1-year mortality, 1.5%). The nonsurvival group exhibited higher peak levels of creatine kinase MB; lower ejection fractions; and higher incidences of ST elevation myocardial infarction, ventricular arrhythmia, and use of an assistive device than did the survival group. Aging (hazard ratio 2.839; 95% confidence interval 1.408-5.723; p = 0.004), the use of a temporary pacemaker (2.035; 1.114-3.720; 0.021), the use of a mechanical ventilator (4.376; 1.852-10.341; 0.001), and the performance of cardiopulmonary resuscitation (CPR) (2.219; 1.017-4.839; 0.045) were independent predictors for in-hospital mortality. However, out-of-hospital mortality among in-hospital survivors was not affected by predictors of in-hospital mortality. CONCLUSIONS: The incidence of in-hospital mortality was high, as expected in patients undergoing PCI with IABP due to ACS with cardiogenic shock. Aging, CPR, and additional procedures such as pacemaker use and mechanical ventilation were predictors of in-hospital mortality. However, the patients who were successfully discharged after the complex procedure showed acceptable 1-year outcomes.

Positive Peri-Stent Vascular Remodeling and Late-Acquired Incomplete Stent Apposition in Intravascular Ultrasound (IVUS) after Drug-Eluting Stent Implantation / 계명의대학술지

The peri-stent vascular changes after 2nd generation drug-eluting stent (2G DES) implantation have not been fully investigated compare to 1st generation DES (1G DES). From March 2003 to October 2010, patients receiving percutaneous coronary intervention (PCI) with either 1G or 2G DES were retrospectively included. All patients underwent intravascular ultrasound (IVUS) at post-procedure and 8-12 months after PCI. A total of 281 patients (1G DES: 201 patients with 217 lesions and 2G DES: 80 patients with 88 lesions) were enrolled. The incidence of positive peri-stent vascular remodeling (PPVR) and late-acquired incomplete stent apposition (LAISA) were investigated by IVUS images. Major adverse cardiac events (MACE) up to 3 years were also evaluated. The lesion and the stent length were shorter, and the stent size was larger in the 2G DES group. The incidences of PPVR and LAISA were lower in the 2G DES group before and after propensity score matching. However, the incidence of 3-year MACE were not different between the two groups. Independent predictors for PPVR or LAISA were stent length and 1G DES implantation. These results suggested that biocompatible stent system in 2G DES might have reduced peri-stent vascular changes.

Atrial Septal Defect with Normal Pulmonary Arterial Pressure in Adult Cyanotic Patient

A 22-year-old male presented with recurrent stroke, central cyanosis, and dyspnea. Transesophageal echocardiography and cardiac catheterization revealed bidirectional shunt flow through atrial septal defect (ASD) without pulmonary arterial hypertension. The orifice of inferior vena cava facing towards ASD opening led partially right to left shunt resulting in cyanosis with normal pulmonary arterial pressure.

Long-term outcomes of intravascular ultrasound-guided implantation of bare metal stents versus drug-eluting stents in primary percutaneous coronary intervention

BACKGROUND/AIMS: While drug-eluting stents (DESs) have shown favorable outcomes in ST-segment elevation myocardial infarction (STEMI) compared to bare metal stents (BMSs), there are concerns about the risk of stent thrombosis (ST) with DESs. Because intravascular ultrasound (IVUS) guidance may help optimize stent placement and improve outcomes in percutaneous coronary intervention (PCI) patients, we evaluated the impact of IVUS-guided BMS versus DES implantation on long-term outcomes in primary PCI. METHODS: In all, 239 STEMI patients received DES (n = 172) or BMS (n = 67) under IVUS guidance in primary PCI. The 3-year incidence of major adverse cardiac events (MACEs) including death, myocardial infarction (MI), target vessel revascularization (TVR), and ST was evaluated. RESULTS: There was no difference in all cause mortality or MI. However, the incidence of TVR was 23.9% with BMS versus 9.3% with DES (p = 0.005). Thus, the number of MACEs was significantly lower with DES (11.0% vs. 29.9%; p = 0.001). The incidence of definite or probable ST was not different (1.5% vs. 2.3%; p = 1.0). IVUS-guided DES implantation (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.08 to 0.78; p = 0.017), stent length (HR, 1.03; 95% CI, 1.00 to 1.06; p = 0.046), and multivessel disease (HR, 3.01; 95% CI, 1.11 to 8.15; p = 0.030) were independent predictors of MACE. CONCLUSIONS: In patients treated with primary PCI under IVUS guidance, the use of DES reduced the incidence of 3-year TVR versus BMS. However, all cause mortality and MI were similar between the groups. The incidence of ST was low in both groups.

Efficacy and safety of antiplatelet-combination therapy after drug-eluting stent implantation

BACKGROUND/AIMS: Combination single-pill therapy can improve cost-effectiveness in a typical medical therapy. However, there is a little evidence about the efficacy and tolerability of combination single-pill antiplatelet therapy after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS: From June to November 2012, in total, 142 patients who met the following criteria were enrolled: at least 18 years old; successful PCI with DES at least 3 months earlier; and regular medication of aspirin and clopidogrel with no side effects. After VerifyNow P2Y12 and aspirin assays, the combination single pill of aspirin and clopidogrel was given and laboratory tests were repeated 6 weeks later. RESULTS: At baseline, the incidence of aspirin resistance, defined as aspirin reaction unit (ARU) > or = 550, was 9.2%, that of clopidogrel resistance, defined as P2Y12 reaction unit (PRU) > or = 230, was 46.5%, and that of percent inhibition of PRU < 20% was 32.4%. At follow-up, the incidence of resistance by ARU value was 7.0%, 50.0% by PRU value, and 35.9% by percentage inhibition of PRU, respectively. The mean values of ARU (431.5 +/- 63.6 vs. 439.8 +/- 55.2; p = 0.216) and PRU (227.5 +/- 71.4 vs. 223.3 +/- 76.0; p = 0.350) were not significantly different before versus after antiplatelet-combination single-pill therapy. Five adverse events (3.5%) were observed during the study period. CONCLUSIONS: Combination single-pill antiplatelet therapy, which may reduce daily pill burden for patients after PCI with DES, demonstrated similar efficacy to separate dual-pill antiplatelet therapy.

Long-term outcomes of simple crossover stenting from the left main to the left anterior descending coronary artery

BACKGROUND/AIMS: Although complex bifurcation stenting in patients with non-left main (LM) bifurcation lesions has not yielded better clinical outcomes than simpler procedures, the utility of complex bifurcation stenting to treat LM bifurcation lesions has not yet been adequately explored. METHODS: In the present study, patients who underwent LM-to-left anterior descending (LAD) coronary artery simple crossover stenting to treat significant de novo distal LM or ostial LAD disease, in the absence of angiographically significant ostial left circumflex (LCX) coronary artery disease, were consecutively enrolled. The frequencies of 3-year major adverse cardiovascular events (MACEs; cardiac death, myocardial infarction, and target lesion revascularization), were analyzed. RESULTS: Of 105 eligible consecutive patients, only 12 (11.4%) required additional procedures to treat ostial LCX disease after main vessel stenting. The mean percentage diameter of ostial LCX stenosis increased from 22.5% +/- 15.2% to 32.3% +/- 16.3% (p < 0.001) after LM-to-LAD simple crossover stenting. The 3-year incidence of MACEs was 9.7% (cardiac death 2.2%; myocardial infarction 2.2%; target lesion revascularization 8.6%), and that of stent thrombosis 1.1%. Of seven cases (7.5%) requiring restenosis, pure ostial LCX-related repeat revascularization was required by only two. CONCLUSIONS: Simple crossover LM-to-LAD stenting without opening of a strut on the LCX ostium was associated with acceptable long-term clinical outcomes.

Characteristics of Function-Anatomy Mismatch in Patients with Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Coronary lesions with mismatched functional and anatomical significance are not uncommon. We assessed the accuracy and predictors of mismatch between fractional flow reserve (FFR) and quantitative coronary angiography (QCA) analyses in patients with coronary lesions. SUBJECTS AND METHODS: A total of 643 lesions with pre-interventional FFR and QCA measurements were consecutively enrolled and divided into four groups using FFR or =50% as cutoffs for functional and anatomical significance, respectively. Accordingly, FFR >0.80 and DS > or =50%, and FFR < or =0.80 and DS <50% defined false-positive (FP) and false-negative (FN) lesions, respectively. RESULTS: Overall, 40.4% (260/643) of the lesions were mismatched, and 51.7% (218/414) and 18.3% (42/229) were FP and FN lesions, respectively. In a multivariate analysis, independent predictors of FP were non-left anterior descending artery location {odds ratio (OR), 0.36; 95% confidence interval (CI), 0.28-0.56; p<0.001}, shorter lesion length (OR, 0.96; 95% CI, 0.95-0.98; p<0.001), multi-vessel disease (OR, 0.47; 95% CI, 0.30-0.75; p=0.001), and larger minimal lumen diameter by QCA (OR, 2.88; 95% CI,1.65-5.00; p<0.001). Independent predictors of FN were multi-vessel disease (OR, 1.82; 95% CI, 1.24-5.27; p=0.048), aging (OR, 0.96; 95% CI, 0.93-0.99; p=0.034), smoking (OR, 0.36; 95% CI, 0.14-0.93; p=0.034), and smaller reference vessel diameter by QCA (OR, 0.30; 95% CI, 0.10-0.87; p=0.026). CONCLUSION: A mismatch between FFR and angiographic lesion severity is not rare in patients with coronary artery disease; therefore, an angiography-guided evaluation could under- or over-estimate lesion severity in specific lesion subsets.

Stent Distortion Complicated by Intravascular Ultrasound Catheter Entrapment During Pullback Interrogation / 대한내과학회지

Entrapment of an intravascular ultrasound (IVUS) catheter during coronary intervention is rare, but can cause serious complications. Retrieval of an entrapped catheter can also lead to adverse results for implanted stents. We report a case in which the sheath tip at the guidewire exit port was entrapped and caused stent distortion during a post-stent IVUS procedure with automatic pullback.

Spontaneous coronary artery dissection diagnosed by intravascular ultrasound and followed up by cardiac computed tomography

No abstract available.

Impact of Home-Based Exercise Training with Wireless Monitoring on Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Recent studies have suggested a favorable effect of cardiac rehabilitation (CR) on patients with cardiovascular disease. This study aimed to evaluate the impact of home-based exercise training with wireless monitoring on acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). A total of 55 ACS patients undergoing PCI were randomly divided into home based exercise training with wireless monitoring cardiac rehabilitation (CR, n = 26) and usual care (UC, n = 29). Exercise capacity and quality of life (QOL) were evaluated at baseline and after 12 weeks. Change of metabolic equivalent of the tasks, maximal exercise time and QOL were significantly increased (+2.47 vs +1.43, P = 0.021; +169.68 vs +88.31 sec, P = 0.012; and +4.81 vs +0.89, P = 0.022, respectively), and the change of submaximal rate pressure product, and of submaximal rate of perceived exertion were significantly decreased (-28.24 vs -16.21, P = 0.013; and -1.92 vs -1.62, P = 0.018, respectively) in the CR group compared to the UC group after 12 weeks. CR using home-based exercise training with wireless monitoring led to improvement of exercise capacity and QOL relative to conventional care in ACS patients undergoing PCI. Our findings suggest that early scheduled CR may be considered in ACS patients undergoing PCI.