Analysis of clinical risk factors of failed electrical cardioversion in patients with persistent atrial fibrillation or atrial flutter

Background@#Although rhythm control could be the best for symptomatic atrial fibrillation (AF), some patients fail to achieve sinus rhythm (SR). This study aimed to identify clinical risk factors of failed electrical cardioversion (ECV). @*Methods@#A total of 248 patients who received ECV for persistent AF or atrial flutter (AFL) were retrospectivelyreviewed. Patients were divided into three groups: Group 1 maintained SR for > 1 year, group 2 maintained SR ≤ 1 yearafter ECV, and group 3 failed ECV. SR maintenance was assessed using regular electrocardiography or Holter monitoring. @*Results@#Patients were divided into group 1 (73, 29%), group 2 (146, 59%), and group 3 (29, 12%). The mean ageof patients was 60 ± 10 years, and 197 (79%) were male. Age, sex, and baseline characteristics were similar amonggroups. However, increased cardiac size, digoxin use, heart failure (HF), and decreased left ventricular ejection frac‑ tion (LVEF) were more common in group 3. Univariate analysis of clinical risk factors for failed ECV was increasedcardiac size [hazard ratio (HR) 2.14 (95% confidence interval [CI], 1.06–4.34, p = 0.030)], digoxin use [HR 2.66 (95% CI, 1.15–6.14), p = 0.027], HF [HR 2.60 (95% CI, 1.32–5.09), p = 0.005], LVEF < 40% [HR 3.45 (95% CI, 1.00–11.85), p = 0.038], and decreased LVEF [HR 2.49 (95% CI, 1.18–5.25), p = 0.012]. Among them, HF showed clinical significance only by multivariate analysis [HR 3.01 (95% CI, 1.13–7.99), p = 0.027]. @*Conclusions@#Increased cardiac size, digoxin use, HF, LVEF < 40%, and decreased LVEF were related to failed ECV for persistent AF or AFL. Among these, HF was the most important risk factor. Further multi-center studies including greater number of participants are planned.

Preliminary study on diagnosis of acute scrotum usingpoint-of-care ultrasonography by novice emergency residents:a comparison with conventional ultrasonography

Objective@#The diagnostic accuracy of novice residents in evaluating the scrotal pathology by point-of-care (POC) ultrasonography(US) was compared with that by the conventional US to determine the level of experience required toachieve competency. @*Methods@#Three novice residents underwent a one-day training course on identifying scrotal pathologies using POC US.They performed POC US on patients with an acute scrotum to identify five pathological findings. The diagnosis was confirmedby conventional scrotal US. The sensitivity and specificity of POC US by novice residents were calculated, and thechanges in sensitivity and specificity over time were observed. @*Results@#Sixty-two patients were included; the overall sensitivity and specificity were 76.7% (95% confidence interval [CI],61.3%-88.2%) and 78.9% (95% CI, 54.4%-93.9%), respectively. Decreased blood flow in the testicle showed very goodspecificity (100%; 95% CI, 93.8%-100.0%). The sensitivity and accuracy were variable at first 18 scans of each resident,but increased after 18 scans and were maintained over time. @*Conclusion@#Although the diagnostic accuracy of novice residents in evaluating the scrotal pathology using POC US wasvariable at first, the accuracy improved over time, especially after 18 scans of each resident. Nevertheless, larger, longtermresearch is needed to confirm the results of this study.

Determinants and Clinical Outcomes of Extended Dual Antiplatelet Therapy over 3 Years after Drug-Eluting Stent Implantation: A Retrospective Analysis

Purpose@#Although current guidelines recommend the administration of dual antiplatelet therapy (DAPT) for up to 12 months after the implantation of a drug-eluting stent (DES), extended DAPT is frequently used in real-world practice. @*Materials and Methods@#From the Korean Multicenter Angioplasty Team registry, we identified a total of 1414 patients who used DAPT for >3 years after DES implantation (extended-DAPT group) and conducted a landmark analysis at 36 months after the index procedure. We evaluated the determinants for and long-term outcomes of extended DAPT and compared the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke, between the extended-DAPT group and the guideline-DAPT group [DAPT <1 year after DES implantation (n=1273)]. @*Results@#Multivariate analysis indicated the occurrence of acute coronary syndrome as the most significant clinical determinant of the use of extended DAPT. Bifurcation, stent diameter ≤3.0 mm, total stented length ≥28 mm, and use of first-generation DESs were also significant angiographic and procedural determinants. MACCE rates were similar between the extended-DAPT group and the guideline-DAPT group in crude analysis [hazard ratio (HR), 1.08; 95% confidence interval (CI), 0.69–1.68; p=0.739] and after propensity matching (HR, 1.22; 95% CI, 0.72–2.07; p=0.453). Major bleeding rates were comparable between the two groups. @*Conclusion@#In patients undergoing percutaneous coronary intervention, indefinite use of DAPT does not show superior outcomes to those of guideline-DAPT. Major bleeding rates are also similar.

The Effectiveness of Dexmedetomidine in Vacuum-Assisted Breast Biopsy Under Monitored Anesthesia Care / 고신대학교의과대학학술지

OBJECTIVES: Vacuum-assisted breast biopsy (VABB) is a widely used technique for the diagnosis of breast lesions. It is carried out with local anesthesia, but procedural pain and stress are still problematic. Dexmedetomidine is a α-2 receptor agonist that can sedate without significant respiratory depression. The study aimed to report the effectiveness of sedation with monitored anesthesia care (MAC) using dexmedetomidine in VABB. METHODS: This was a retrospective chart review of patients who received VABB under MAC with dexmedetomidine. Forty-seven patients during the period of February 2015 to July 2016 were included. We collected data on patient characteristics, infusion drug and dose, induction to incision time, anesthetic, operation, and recovery time and other complications and vital signs. RESULTS: The mean operating time was 50.1 ± 24.9 minutes, and the anesthetic time was 71.2 ± 28.3 minutes. The mean time from induction to incision was 17.0 ± 5.2 minutes, and the recovery time was 20.1 ± 10.3 minutes. None of the patients needed an advanced airway management. Further, none of them showed hemodynamic instability. CONCLUSIONS: VABB was successfully performed with MAC using dexmedetomidine, and there was no respiratory depression or hemodynamic instability.

The method to reduce the malposition rate via reposition of guidewire with ultrasound guidance in the central venous catheterization

OBJECTIVE: Malposition of central venous catheterization (CVC) may cause vascular related complications and catheter dysfunctions. The aim of this study was to reduce the malposition rate of CVC by repositioning the malposition after confirming the location of the guide-wire with ultrasound (US) guidance. METHODS: This research assessed the before study (group A) from January to December 2016 and after study (group B) from January to December 2017 in the emergency department. CVCs were performed using the anatomical landmark technique (group A) and US guided technique (group B). In group B, if the guided-wire was misplaced, it was drawn back and repositioned under US guidance. The final location of the catheter tip was confirmed by chest X-ray. The rate of malposition before and after repositioning of the two groups was compared. RESULTS: The subjects were group A (694 cases) and group B (619 cases) with a total of 1,313 patients. The rate of malposition before repositioning of the two groups were 16 cases (2.3%) and 13 cases (2.1%), respectively, and no statistically significant difference was observed (P>0.05). In group B, there were 10 cases (1.6%) of guidewire malposition that was identified and three cases (0.5%) of catheter malposition could not be identified under US examination. The malpositioned guidewires were all corrected by repositioning under ultrasound guidance. The rate of malposition after repositioning of the two groups were 2.3% (n=16) and 0.5% (n=3), respectively, and a statistically significant difference was observed (P=0.009). CONCLUSION: With US guidance, confirming the location and repositioning CVC guidewire can reduce the malposition rate in CVCs.

Does the direction of J-tip of the guide-wire influence the misplacement of subclavian catheterization?

OBJECTIVE: Central venous catheter (CVC) misplacement can result in incorrect readings of the central venous pressure, vascular erosion, and intravascular thrombosis. Several studies have examined the correlation between the guidewire J-tip direction and misplacement rate. This study examined whether the guidewire J-tip direction (cephalad vs. caudad) affects the misplacement rate in right subclavian venous catheterization. METHODS: This prospective randomized controlled study was conducted between February 2016 and February 2017. The subjects were divided into two groups (cephalad group vs. caudad group) and the misplacement rate was compared according to guidewire J-tip direction in each group. RESULTS: Of 100 patients, the cephalad and caudad groups contained 50 patients each. The age, sex, and operator experience were similar in the two groups. In the cephalad group, misplacement of CVC insertion into the ipsilateral internal jugular vein occurred in two cases. In the caudad group, misplacement of CVC insertion into the contralateral subclavian vein occurred in one case, with loop formation in the brachiocephalic trunk in one case. Guidewire J-tip direction showed no significant correlation with CVC misplacement. CONCLUSION: The guidewire J-tip direction does not influence the rate of misplacement.

The influence of the decision making time by using point-of-care creatinine in patients with acute abdomen

OBJECTIVE: Radio-contrast abdomino-pelvic computed tomography (APCT) is considered the gold standard diagnostic tool for an acute abdomen in the emergency department. On the other hand, APCT has a risk of contrast-induced nephropathy. Emergency physicians evaluate the creatinine (Cr) level prior to taking a APCT for the above reason but it takes time to evaluation the serum Cr level. This study hypothesized that Cr measured by a point-of-care test (POCT) can shorten the time to making clinically important decisions for patients with an acute abdomen. METHODS: This prospective randomized study was conducted between March 2017 and October 2017. The subjects were divided into two groups (Cr measured by laboratory vs. Cr measured by POCT). To analyze the clinical acceptability for creatinine, agreement was demonstrated graphically by Bland-Altman plots. This study compared the time to make a clinically important decision by physicians and the length of stay at the emergency department in both groups. RESULTS: A total of 76 patients were eligible for the study, 38 patients were assigned to each group. There was no statistically significant difference in the time to the first medical examination (P=0.222) and emergency department stay time (P=0.802). On the other hand, the time to recognition of the Cr level (P < 0.001), time to performing APCT (P < 0.001), time to decision making (P < 0.001), and time to initiation of treatment (P < 0.001) were shortened significantly in the point-of-care creatinine group. CONCLUSION: In this study, the POCT for creatinine can allow rapid decision making by shortening the time to performing the radio-contrast APCT than the laboratory for patients with an acute abdomen.

Effects of Coronary Artery Revascularization with a Polymer-Free Biolimus A9–Coated BioFreedom Stent Versus Bypass Surgery before Noncardiac Surgery

PURPOSE: The present study aimed to evaluate the efficacy and safety of polymer-free drug-coated BioFreedom stent implantation in comparison to coronary artery bypass graft (CABG) before major noncardiac surgery. MATERIALS AND METHODS: In a multicenter registry, 55 patients required revascularization before major noncardiac surgery that should not be delayed >6 months. Of them, 27 underwent BioFreedom stent implantation and 28 underwent CABG. Primary outcomes included rate of noncardiac surgery, time from revascularization to noncardiac surgery, and occurrence of composite outcomes (all-cause death, myocardial infarction, stent thrombosis, stroke, repeat revascularization, or major bleeding). RESULTS: The rate of major noncardiac surgery was significantly higher in the BioFreedom group (92.6%) than in the CABG group (64.3%; p=0.027). Time from revascularization to noncardiac surgery was significantly shorter in the BioFreedom group (38.0 days) than in the CABG group (73.0 days; p=0.042). During the hospitalization for revascularization period, the occurrence of primary outcomes did not differ between the groups. However, the BioFreedom group showed a shorter hospitalization period and lower total treatment cost than the CABG group. During the hospital stay for noncardiac surgery, the occurrence of composite outcome was not significantly different between groups (4% vs. 0%; p>0.999): stroke occurred in only 1 case, and there were no cases of death or stent thrombosis in the BioFreedom group. CONCLUSION: This study demonstrated that BioFreedom stenting as a revascularization strategy before major noncardiac surgery might be feasible and safe in selected patients with less severe coronary artery diseases.

Short-Long R-R Sequence Induced Implantable Cardioverter Defibrillator Shock by Dislodged Lead Even Having Normal Interrogation Parameter

Inappropriate shocks from an implantable cardioverter defibrillator (ICD) can cause potentially dangerous ventricular arrhythmias and impaired quality of life. We describe a case in which a dislodged lead caused inappropriate ICD shocks through simultaneous sensing of atrial and ventricular signals. Interestingly, repeated short-long R-R sequences were recorded, but ICD interrogation parameters were usually unchanged.

A Novel Visualization Method for Sleep Spindles Based on Source Localization of High Density EEG

Equivalent dipole source localization is a well-established approach to localizing the electrical activity in electroencephalogram (EEG). So far, source localization has been used primarily in localizing the epileptic source in human epileptic patients. Currently, source localization techniques have been applied to account for localizing epileptic source among the epileptic patients. Here, we present the first application of source localization in the field of sleep spindle in mouse brain. The spatial distribution of cortical potential was obtained by high density EEG and then the anterior and posterior sleep spindles were classified based on the K-mean clustering algorithm. To solve the forward problem, a realistic geometry brain model was produced based on boundary element method (BEM) using mouse MRI. Then, we applied four different source estimation algorithms (minimum norm, eLORETA, sLORETA, and LORETA) to estimate the spatial location of equivalent dipole source of sleep spindles. The estimated sources of anterior and posterior spindles were plotted in a cine-mode that revealed different topographic patterns of spindle propagation. The characterization of sleep spindles may be better be distinguished by our novel visualization method.

Long-term clinical outcome of acute myocardial infarction according to the early revascularization method: a comparison of primary percutaneous coronary interventions and fibrinolysis followed by routine invasive treatment / 영남의대학술지

BACKGROUND: This study was conducted to provide a comparison between the clinical outcomes of primary percutaneous coronary intervention (PCI) and that of fibrinolysis followed by routine invasive treatment in ST elevation myocardial infarction (STEMI). METHODS: A total of 184 consecutive STEMI patients who underwent primary PCI or fibrinolysis followed by a routine invasive therapy were enrolled from 2004 to 2011, and their major adverse cardiovascular events (MACEs) were compared. RESULTS: Among the 184 patients, 146 patients received primary PCI and 38 patients received fibrinolysis. The baseline clinical characteristics were similar between both groups, except for triglyceride level (68.1±66.62 vs. 141.6±154.3 mg/dL, p=0.007) and high density lipoprotein level (44.6±10.3 vs. 39.5±8.1 mg/dL, p=0.005). The initial creatine kinase-MB level was higher in the primary PCI group (71.5±114.2 vs. 35.9±59.9 ng/mL, p=0.010). The proportion of pre-thrombolysis in MI 0 to 2 flow lesions (92.9% vs. 73.0%, p < 0.001) was higher and glycoprotein IIb/IIIa inhibitors were administered more frequently in the primary PCI group. There was no difference in the 12-month clinical outcomes, including all-cause mortality (9.9% vs. 8.8%, p=0.896), cardiac death (7.8% vs. 5.9%, p=0.845), non-fatal MI (1.4% vs. 2.9%, p=0.539), target lesion revascularization (5.7% vs. 2.9%, p=0.517), and stroke (0% vs. 0%). The MACEs free survival rate was similar for both groups (odds ratio, 0.792; 95% confidence interval, 0.317–1.980; p=0.618). The clinical outcome of thrombolysis was not inferior, even when compared with primary PCI performed within 90 minutes. CONCLUSION: Early fibrinolysis with optimal antiplatelet and antithrombotic therapy followed by appropriate invasive procedure would be a comparable alternative to treatment of MI, especially in cases of shorter-symptom-to-door time.

Acute upper limb ischemia in a patient with newly diagnosed paroxysmal atrial fibrillation / 영남의대학술지

Acute limb ischemia (ALI) due to an embolism is associated with high mortality rate and poor prognosis, and early diagnosis with prompt revascularization is required to reduce the risk of limb amputation or even death. The etiologies of ALI are diverse, and it includes an embolism from the heart and thrombotic occlusion of the atherosclerotic native vessels, stents, or grafts. An uncommon cause of ALI is acute arterial thromboembolism, and atrial fibrillation (AF) is the single most important risk factors for systemic thromboembolism. It is important to correctly identify the source of ALI for secondary prevention, as it depends on the underlying cause. Percutaneous transluminal angioplasty (PTA) has been proven to be a safe and effective treatment for focal atherosclerotic and thrombotic occlusive diseases of the aorta and its major extremity branches. Herein, we report on a 77-year-old female patient with acute upper limb ischemia, treated by PTA using a catheter-guided thrombectomy. He was newly diagnosed with paroxysmal AF (PAF) while evaluation the cause of his acute arterial thromboembolism. We recommend that cardiologists always consider PAF as a possible diagnosis even in patients without any history of AF under ALI because it is possible to develop thromboembolism in clinical practice.

Long-term clinical outcome of acute myocardial infarction according to the early revascularization method: a comparison of primary percutaneous coronary interventions and fibrinolysis followed by routine invasive treatment / 영남의대학술지

BACKGROUND: This study was conducted to provide a comparison between the clinical outcomes of primary percutaneous coronary intervention (PCI) and that of fibrinolysis followed by routine invasive treatment in ST elevation myocardial infarction (STEMI).METHODS: A total of 184 consecutive STEMI patients who underwent primary PCI or fibrinolysis followed by a routine invasive therapy were enrolled from 2004 to 2011, and their major adverse cardiovascular events (MACEs) were compared.RESULTS: Among the 184 patients, 146 patients received primary PCI and 38 patients received fibrinolysis. The baseline clinical characteristics were similar between both groups, except for triglyceride level (68.1±66.62 vs. 141.6±154.3 mg/dL, p=0.007) and high density lipoprotein level (44.6±10.3 vs. 39.5±8.1 mg/dL, p=0.005). The initial creatine kinase-MB level was higher in the primary PCI group (71.5±114.2 vs. 35.9±59.9 ng/mL, p=0.010). The proportion of pre-thrombolysis in MI 0 to 2 flow lesions (92.9% vs. 73.0%, p < 0.001) was higher and glycoprotein IIb/IIIa inhibitors were administered more frequently in the primary PCI group. There was no difference in the 12-month clinical outcomes, including all-cause mortality (9.9% vs. 8.8%, p=0.896), cardiac death (7.8% vs. 5.9%, p=0.845), non-fatal MI (1.4% vs. 2.9%, p=0.539), target lesion revascularization (5.7% vs. 2.9%, p=0.517), and stroke (0% vs. 0%). The MACEs free survival rate was similar for both groups (odds ratio, 0.792; 95% confidence interval, 0.317–1.980; p=0.618). The clinical outcome of thrombolysis was not inferior, even when compared with primary PCI performed within 90 minutes.CONCLUSION: Early fibrinolysis with optimal antiplatelet and antithrombotic therapy followed by appropriate invasive procedure would be a comparable alternative to treatment of MI, especially in cases of shorter-symptom-to-door time.

Acute upper limb ischemia in a patient with newly diagnosed paroxysmal atrial fibrillation / 영남의대학술지

Acute limb ischemia (ALI) due to an embolism is associated with high mortality rate and poor prognosis, and early diagnosis with prompt revascularization is required to reduce the risk of limb amputation or even death. The etiologies of ALI are diverse, and it includes an embolism from the heart and thrombotic occlusion of the atherosclerotic native vessels, stents, or grafts. An uncommon cause of ALI is acute arterial thromboembolism, and atrial fibrillation (AF) is the single most important risk factors for systemic thromboembolism. It is important to correctly identify the source of ALI for secondary prevention, as it depends on the underlying cause. Percutaneous transluminal angioplasty (PTA) has been proven to be a safe and effective treatment for focal atherosclerotic and thrombotic occlusive diseases of the aorta and its major extremity branches. Herein, we report on a 77-year-old female patient with acute upper limb ischemia, treated by PTA using a catheter-guided thrombectomy. He was newly diagnosed with paroxysmal AF (PAF) while evaluation the cause of his acute arterial thromboembolism. We recommend that cardiologists always consider PAF as a possible diagnosis even in patients without any history of AF under ALI because it is possible to develop thromboembolism in clinical practice.

A Randomized Controlled Trial of Compression Rates during Cardiopulmonary Resuscitation

The objective of this study was to compare the efficacy of cardiopulmonary resuscitation (CPR) with 120 compressions per minute (CPM) to CPR with 100 CPM in patients with non-traumatic out-of-hospital cardiac arrest. We randomly assigned patients with non-traumatic out-of-hospital cardiac arrest into two groups upon arrival to the emergency department (ED). The patients received manual CPR either with 100 CPM (CPR-100 group) or 120 CPM (CPR-120 group). The primary outcome measure was sustained restoration of spontaneous circulation (ROSC). The secondary outcome measures were survival discharge from the hospital, one-month survival, and one-month survival with good functional status. Of 470 patients with cardiac arrest, 136 patients in the CPR-100 group and 156 patients in the CPR-120 group were included in the final analysis. A total of 69 patients (50.7%) in the CPR-100 group and 67 patients (42.9%) in the CPR-120 group had ROSC (absolute difference, 7.8% points; 95% confidence interval [CI], -3.7 to 19.2%; P = 0.183). The rates of survival discharge from the hospital, one-month survival, and one-month survival with good functional status were not different between the two groups (16.9% vs. 12.8%, P = 0.325; 12.5% vs. 6.4%, P = 0.073; 5.9% vs. 2.6%, P = 0.154, respectively). We did not find differences in the resuscitation outcomes between those who received CPR with 100 CPM and those with 120 CPM. However, a large trial is warranted, with adequate power to confirm a statistically non-significant trend toward superiority of CPR with 100 CPM. (Clinical Trial Registration Information: www.cris.nih.go.kr, cris.nih.go.kr number, KCT0000231)

Lower limb ischemia after bee sting / 영남의대학술지

Bee sting causes mild symptoms such as urticaria and localized pain, and severe symptoms including anaphylaxis, cardiovascular collapse, and death. We reported on a patient with arterial thrombotic occlusion and severe ischemia in the lower limb after multiple bee stings. The patient was stung 5 times and complained of pallor, pain, and coldness in the left toe, and did not have dorsalis pedis pulsation. Computed tomography angiography showed multiple thrombotic occlusion of the anterior and posterial tibial artery below the knee. Local thrombolytic therapy using urokinase was administered and the occluded arteries were successfully recanalized.

Impact of Angiotensin Converting Enzyme Inhibitor versus Angiotensin Receptor Blocker on Incidence of New-Onset Diabetes Mellitus in Asians

PURPOSE: Angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) are associated with a decreased incidence of new-onset diabetes mellitus (NODM). The aim of this study was to compare the protective effect of ACEI versus ARBs on NODM in an Asian population. MATERIALS AND METHODS: We investigated a total of 2817 patients who did not have diabetes mellitus from January 2004 to September 2009. To adjust for potential confounders, a propensity score matched (PSM) analysis was performed using a logistic regression model. The primary end-point was the cumulative incidence of NODM, which was defined as having a fasting blood glucose > or =126 mg/dL or HbA1c > or =6.5%. Multivariable cox-regression analysis was performed to determine the impact of ACEI versus ARB on the incidence of NODM. RESULTS: Mean follow-up duration was 1839+/-1019 days in all groups before baseline adjustment and 1864+/-1034 days in the PSM group. After PSM (C-statistics=0.731), a total 1024 patients (ACEI group, n=512 and ARB group, n=512) were enrolled for analysis and baseline characteristics were well balanced. After PSM, the cumulative incidence of NODM at 3 years was lower in the ACEI group than the ARB group (2.1% vs. 5.0%, p=0.012). In multivariate analysis, ACEI vs. ARB was an independent predictor of the lower incidence for NODM (odd ratio 0.37, confidence interval 0.17-0.79, p=0.010). CONCLUSION: In the present study, compared with ARB, chronic ACEI administration appeared to be associated with a lower incidence of NODM in a series of Asian cardiovascular patients.

Disaster Basic Physics and Disaster Paradigm / 한양의대학술지

Disasters are unpredictable and unavoidable. The definition of disaster is a serious disruption of the functioning of society, causing widespread human, material, or environmental losses that exceed the ability of affected society to cope using only its own resources. Disaster medicine is a discipline resulting from combination of emergency medicine and disaster management. The field of disaster medicine involves the study of subject matter from multiple medical disciplines, and disaster medicine presents unique ethical situations not seen in other areas of medicine. Disaster can be classified into two categories, natural disaster and manmade disaster, each type of disaster has its own characteristics. Disaster management has a cycle of 4 activities, preparedness, response, recovery, and prevention/mitigation. Disaster medicine specialists have a role in each part of this cycle. To achieve effective disaster response, the National Disaster Life Support Foundation suggests the DISASTER Paradigm(TM), which consists of detection, incident command, safety and security, assess hazards, support, triage and treatment, evacuation, and recovery.

Comparison of Full Lesion Coverage versus Spot Drug-Eluting Stent Implantation for Coronary Artery Stenoses

PURPOSE: The aim of this study was to evaluate and compare the long-term clinical outcomes of the spot drug-eluting stent (DES) implantation strategy, which is used to minimize implanted stent length and the number of stents, versus full lesion coverage for treatment of coronary artery stenoses. MATERIALS AND METHODS: We evaluated 1-year clinical outcomes of 1619 patients with stent implantation for a single coronary lesion. They were divided into two groups: those treated by full lesion coverage (n=1200) and those treated with the spot stenting strategy (n=419). The combined occurrence of 1-year target vessel failure (TVF), including cardiac death, target-vessel related myocardial infarction, or ischemia-driven target-vessel revascularization was evaluated. RESULTS: The spot DES implantation group had a shorter stent length (23.14+/-9.70 mm vs. 25.44+/-13.24 mm, respectively; p<0.001) and a fewer number of stents (1.09+/-0.30 vs. 1.16+/-0.41, respectively; p<0.001), even though the average lesion length was similar to the full lesion coverage group (21.36+/-10.30 mm vs. 20.58+/-10.97 mm, respectively; p=0.206). Spot DES implantation was superior to full DES coverage with respect to 1-year TVF (1.4% vs. 3.3%, p=0.044). Cox proportional hazard model analysis showed that the risk for 1-year TVF was almost 60% lower among patients who received spot DESs compared to those who received full DES coverage after adjustment for other risk factors (HR=0.40, 95% confidence interval=0.17-0.98; p=0.046). CONCLUSION: Minimizing stent length and the number of stents with overlapping by spot DES implantation may result in reduced rates of 1-year TVF, compared with full DES coverage.

Performance of Reperfusion Therapy and Hospital Mortality in ST-Elevation Myocardial Infarction Patients with Non-Chest Pain Complaints

PURPOSE: ST-elevation myocardial infarction (STEMI) patients may visit the emergency department (ED) complaining of sensations of pain other than the chest. We investigated our performance of reperfusion therapy for STEMI patients presenting with non-chest pains. MATERIALS AND METHODS: This was a retrospective observational cohort study. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were divided into a chest pain group and a non-chest pain group. Clinical differences between the two groups and the influence of presenting with non-chest pains on door-to-electrocardiograms (ECG) time, door-to-balloon time, and hospital mortality were evaluated. RESULTS: Of the 513 patients diagnosed with STEMI, 93 patients presented with non-chest pains. Patients in the non-chest pain group were older, more often female, and had a longer symptom onset to ED arrival time and higher Killip class than patients in the chest pain group. There was a statistically significant delay in door-to-ECG time (median, 2.0 min vs. 5.0 min; p<0.001) and door-to-balloon time (median, 57.5 min vs. 65.0 min; p<0.001) in patients without chest pain. In multivariate analysis, presenting with non-chest pains was an independent predictor for hospital mortality (odds ratio, 2.3; 95% confidence interval, 1.1-4.7). However, door-to-ECG time and door-to-balloon time were not factors related to hospital mortality. CONCLUSION: STEMI patients presenting without chest pain showed higher baseline risk and hospital mortality than patients presenting with chest pain. ECG acquisition and primary PCI was delayed for patients presenting with non-chest pains, but not influencing hospital mortality. Efforts to reduce pre-hospital time delay for these patients are necessary.