A Retrospective Clinical Evaluation of an Artificial Intelligence Screening Method for Early Detection of STEMI in the Emergency Department

Background@#Rapid revascularization is the key to better patient outcomes in ST-elevation myocardial infarction (STEMI). Direct activation of cardiac catheterization laboratory (CCL) using artificial intelligence (AI) interpretation of initial electrocardiography (ECG) might help reduce door-to-balloon (D2B) time. To prove that this approach is feasible and beneficial, we assessed the non-inferiority of such a process over conventional evaluation and estimated its clinical benefits, including a reduction in D2B time, medical cost, and 1-year mortality. @*Methods@#This is a single-center retrospective study of emergency department (ED) patients suspected of having STEMI from January 2021 to June 2021. Quantitative ECG (QCG™), a comprehensive cardiovascular evaluation system, was used for screening. The non-inferiority of the AI-driven CCL activation over joint clinical evaluation by emergency physicians and cardiologists was tested using a 5% non-inferiority margin. @*Results@#Eighty patients (STEMI, 54 patients [67.5%]) were analyzed. The area under the curve of QCG score was 0.947. Binned at 50 (binary QCG), the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 98.1% (95% confidence interval [CI], 94.6%, 100.0%), 76.9% (95% CI, 60.7%, 93.1%), 89.8% (95% CI, 82.1%, 97.5%) and 95.2% (95% CI, 86.1%, 100.0%), respectively. The difference in sensitivity and specificity between binary QCG and the joint clinical decision was 3.7% (95% CI, −3.5%, 10.9%) and 19.2% (95% CI, −4.7%, 43.1%), respectively, confirming the non-inferiority. The estimated median reduction in D2B time, evaluation cost, and the relative risk of 1-year mortality were 11.0 minutes (interquartile range [IQR], 7.3–20.0 minutes), 26,902.2 KRW (22.78 USD) per STEMI patient, and 12.39% (IQR, 7.51–22.54%), respectively. @*Conclusion@#AI-assisted CCL activation using initial ECG is feasible. If such a policy is implemented, it would be reasonable to expect some reduction in D2B time, medical cost, and 1-year mortality.

Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis

Purpose@#The purpose of this study was to compare the efficacy of low-dose steroid, highdose steroid, and low-dose steroid combined with hyaluronidase with respect to intra-articular injection therapy for adhesive capsulitis (AC) of the shoulder. @*Methods@#Thirty patients with primary AC in the initial stage were randomly assigned into three groups to receive ultrasound-guided intra-articular injections with 20 mg of triamcinolone acetonide (group A, n=10), 40 mg of triamcinolone acetonide (group B, n=10) and 20 mg of triamcinolone acetonide combined with hyaluronidase (group C, n=10). The outcome measures included a visual analogue scale (VAS), the Shoulder Disability Questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment. @*Results@#Among the 30 patients, one participant in group B dropped out; therefore, a total of 29 patients completed this study and were successfully injected. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF improved in all groups compared with the preinjection status, regardless of treatment or time point. In the comparison between groups, the SDQ and ISF showed significantly greater improvements in groups B and C than in group A. @*Conclusion@#The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.

Long-term Prognosis of Mild to Moderate Aortic Stenosis and Coronary Artery Disease

Background@#There is an incomplete understanding of the natural course of mild to moderate aortic stenosis (AS). We aimed to evaluate the natural course of patients with mild to moderate AS and its association with coronary artery disease (CAD). @*Methods@#We retrospectively analyzed 787 patients diagnosed with mild to moderate AS using echocardiography between 2004 and 2010. Cardiac death and aortic valve replacement (AVR) for AS were assessed. @*Results@#A median follow-up period was 92 months. Compared to the general population, patients with mild to moderate AS had a higher risk of cardiac death (hazard ratio [HR], 17.16; 95% confidence interval [CI], 13.65–21.59; P < 0.001). Established CAD was detected in 22.4% and associated with a significantly higher risk of cardiac mortality (adjusted HR, 1.62; 95% CI, 1.04–2.53; P = 0.033). The risk of cardiac death was lower when patients were taking statin (adjusted HR, 0.64; 95% CI, 0.41–0.98; P = 0.041), which was clear only after 7 years. Both patients with CAD and on statin tended to undergo more AVR, but the difference was not statistically significant (the presence of established CAD; adjusted HR, 1.63; 95% CI, 0.51–3.51; P = 0.214 and the use of statin; adjusted HR, 1.86; 95% CI, 0.76–4.58; P = 0.177). @*Conclusion@#Mild to moderate AS does not have a benign course. The presence of CAD and statin use may affect the long-term prognosis of patients with mild to moderate AS.

Long-term Prognosis of Mild to Moderate Aortic Stenosis and Coronary Artery Disease

Background@#There is an incomplete understanding of the natural course of mild to moderate aortic stenosis (AS). We aimed to evaluate the natural course of patients with mild to moderate AS and its association with coronary artery disease (CAD). @*Methods@#We retrospectively analyzed 787 patients diagnosed with mild to moderate AS using echocardiography between 2004 and 2010. Cardiac death and aortic valve replacement (AVR) for AS were assessed. @*Results@#A median follow-up period was 92 months. Compared to the general population, patients with mild to moderate AS had a higher risk of cardiac death (hazard ratio [HR], 17.16; 95% confidence interval [CI], 13.65–21.59; P < 0.001). Established CAD was detected in 22.4% and associated with a significantly higher risk of cardiac mortality (adjusted HR, 1.62; 95% CI, 1.04–2.53; P = 0.033). The risk of cardiac death was lower when patients were taking statin (adjusted HR, 0.64; 95% CI, 0.41–0.98; P = 0.041), which was clear only after 7 years. Both patients with CAD and on statin tended to undergo more AVR, but the difference was not statistically significant (the presence of established CAD; adjusted HR, 1.63; 95% CI, 0.51–3.51; P = 0.214 and the use of statin; adjusted HR, 1.86; 95% CI, 0.76–4.58; P = 0.177). @*Conclusion@#Mild to moderate AS does not have a benign course. The presence of CAD and statin use may affect the long-term prognosis of patients with mild to moderate AS.

Evaluation of Coronary Artery Calcium Progression in Asymptomatic Individuals with an Initial Score of Zero

BACKGROUND AND OBJECTIVES@#Coronary artery calcium (CAC) scoring in the asymptomatic population can improve cardiovascular risk prediction. We aimed to assess CAC progression and the impact of coronary risk factors on the CAC progression rate in asymptomatic Korean individuals with a baseline CAC score of zero.@*METHODS@#The study population was derived from the Korea Initiatives on Coronary Artery Calcification (KOICA) registry: a retrospective, single ethnicity, multicenter registry of asymptomatic individuals who underwent CAC scoring as a part of a health checkup. Individuals with at least two CAC scores and an initial score of zero were included. CAC progression was defined as [√CAC score (follow-up) −√CAC score (baseline)] ≥2.5. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was calculated.@*RESULTS@#Among 6,268 participants (mean age, 48.0±7.1 years; male, 80.5%), 719 (11.5%) experienced CAC progression during follow-up (median, 109 months; interquartile range, 78–208 months). The CAC progression rate was 0.3%, 1.9%, 4.3%, 8.6%, and 16.7% in years 1–5, respectively. The chance of CAC progression at 5 years was 13.1%, 22.0%, and 27.9% for individuals with a 10-year ASCVD risk of <5%, ≥5% but <7.5%, and ≥7.5%, respectively. A multivariable analysis revealed age, male sex, waist circumference, diabetes, and low-density lipoprotein cholesterol level as independently associated with annualized CAC progression (p<0.001, p=0.017, p=0.025, p=0.032, and p=0.003, respectively).@*CONCLUSIONS@#The probability of CAC progression is very low in Korean individuals with a CAC score of zero. However, the risk of CAC progression increases nonlinearly over time, and increases as the 10-year ASCVD risk increases.

Evaluation of Coronary Artery Calcium Progression in Asymptomatic Individuals with an Initial Score of Zero

BACKGROUND AND OBJECTIVES: Coronary artery calcium (CAC) scoring in the asymptomatic population can improve cardiovascular risk prediction. We aimed to assess CAC progression and the impact of coronary risk factors on the CAC progression rate in asymptomatic Korean individuals with a baseline CAC score of zero. METHODS: The study population was derived from the Korea Initiatives on Coronary Artery Calcification (KOICA) registry: a retrospective, single ethnicity, multicenter registry of asymptomatic individuals who underwent CAC scoring as a part of a health checkup. Individuals with at least two CAC scores and an initial score of zero were included. CAC progression was defined as [√CAC score (follow-up) − √CAC score (baseline)] ≥2.5. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was calculated. RESULTS: Among 6,268 participants (mean age, 48.0±7.1 years; male, 80.5%), 719 (11.5%) experienced CAC progression during follow-up (median, 109 months; interquartile range, 78–208 months). The CAC progression rate was 0.3%, 1.9%, 4.3%, 8.6%, and 16.7% in years 1–5, respectively. The chance of CAC progression at 5 years was 13.1%, 22.0%, and 27.9% for individuals with a 10-year ASCVD risk of <5%, ≥5% but <7.5%, and ≥7.5%, respectively. A multivariable analysis revealed age, male sex, waist circumference, diabetes, and low-density lipoprotein cholesterol level as independently associated with annualized CAC progression (p<0.001, p=0.017, p=0.025, p=0.032, and p=0.003, respectively). CONCLUSIONS: The probability of CAC progression is very low in Korean individuals with a CAC score of zero. However, the risk of CAC progression increases nonlinearly over time, and increases as the 10-year ASCVD risk increases.

Changes in electrocardiographic findings after closed thoracostomy in patients with spontaneous pneumothorax

OBJECTIVE: We aimed to describe electrocardiographic (ECG) findings in spontaneous pneumothorax patients before and after closed thoracostomy. METHODS: This is a retrospective study which included patients with spontaneous pneumothorax who presented to an emergency department of a tertiary urban hospital from February 2005 to March 2015. The primary outcome was a difference in ECG findings between before and after closed thoracostomy. We specifically investigated the following ECG elements: PR, QRS, QTc, axis, ST segments, and R waves in each lead. The secondary outcomes were change in ST segment in any lead and change in axis after closed thoracostomy. RESULTS: There were two ECG elements which showed statistically significant difference after thoracostomy. With right pneumothorax volume of greater than 80%, QTc and the R waves in aVF and V5 significantly changed after thoracostomy. With left pneumothorax volume between 31% and 80%, the ST segment in V2 and the R wave in V1 significantly changed after thoracostomy. However, majority of ECG elements did not show statistically significant alteration after thoracostomy. CONCLUSION: We found only minor changes in ECG after closed thoracostomy in spontaneous pneumothorax patients.

The interdependent complexity of disaster and Middle East Respiratory Syndrome / 한국역학회지

No abstract available.

A Study on the Statistical Method for the Target Component of a Glucose-lowering Functional Material in Extracts of Evening Primerose Seeds

BACKGROUND: The use of the extracts from evening primrose seeds as a health functional food has been gradually increased. Therefore, the monitoring and screening process has been considerably required for its quality control. OBJECTIVE: This study aimed to estimate the measurement uncertainty associated with determination of penta-o-galloyl β-D-glucose (PGG) in extracts from evening primrose seeds by high-performance liquid chromatography. METHODS: The sources of measurement uncertainty was expressed in accordance with mathematical/statistical theories of GUM & EURACHEM Guide. The expanded uncertainty was calculated by using the relative standard uncertainty between analytical result and sources of uncertainty in measurement (sample weight, final volume, extraction volume, standard solution, matrix and instrument etc). RESULTS: In the results of 95% confidence interval, the uncertainty in measurement was 10,253.34 ± 1,844.50 µg/kg (k = 2.0). CONCLUSION: In this study, it showed that the value of uncertainty in measurement for determination of PGG in extracts from evening primrose seeds by HPLC has about 18.0% influence on PGG contents of the analytical results. The results would be very useful for the monitoring and screening of evening primrose seeds marketed in Korea for its quality control as dietary supplement.

Celecoxib Does Not Attenuate the Antiplatelet Effects of Aspirin and Clopidogrel in Healthy Volunteers

BACKGROUND AND OBJECTIVES: The prevalence of arthritis, which is often treated with celecoxib, is high in patients with coronary artery disease. Furthermore, celecoxib has been reported to reduce restenosis after coronary stenting by inhibiting expression of the proto-oncogene Akt. A concern is that celecoxib increases thrombogenicity by inhibiting the synthesis of prostacyclin in endothelial cells. However, it is not known whether the administration of celecoxib will attenuate the antiplatelet effects of aspirin and clopidogrel, which are used after stenting. We addressed this gap in our knowledge. SUBJECTS AND METHODS: We recruited healthy volunteers (n=40) and randomized them into five subgroups (n=8 for each group: aspirin, celecoxib, aspirin+celecoxib, aspirin+clopidogrel, and aspirin+clopidogrel+celecoxib). Each subject received their medications for 6 days and blood samples were taken on day 0 and day 7. Celecoxib (200 mg twice a day), and/or aspirin (100 mg daily), and/or clopidogrel (75 mg daily) were administered. We compared platelet function among subgroups using light transmittance aggregometry and arachidonic acid metabolite assays. RESULTS: Celecoxib treatment alone did not significantly affect platelet aggregation. The reduction in adenosine diphosphase (ADP)-induced platelet aggregation by aspirin+clopidogrel was not affected by addition of celecoxib (31.3+/-6.9% vs. 32.4+/-12.2%, p=0.83). Inhibition of collagen-induced platelet aggregation by aspirin+clopidogrel was not affected by addition of celecoxib (47.6+/-13.4% vs. 51.6+/-3.7%, p=0.69). Drug-induced changes in prostacyclin and thromboxane levels did not differ among treatment groups. CONCLUSION: Celecoxib treatment does not interfere with the antiplatelet effects of aspirin or clopidogrel, suggesting that celecoxib can be safely administered in combination with dual antiplatelet therapy in patients with coronary stenting without increased thrombogenicity.

Overlooked or unrecognized pitfalls in noninvasive multi-detector computed tomography coronary angiography / 대한내과학회지

The prevalence of coronary artery disease is gradually increasing. The importance of accurate, early diagnosis and treatment has been emphasized repeatedly, given the possible fatal outcome of coronary artery disease, such as in acute myocardial infarction or heart failure. In order to detect patients at high risk of coronary artery disease, noninvasive multi-detector computed tomographic coronary angiography (CTCAG) has recently been introduced for clinical use. It has become popular thanks to its noninvasiveness and high negative predictive value. Most studies have focused on these advantages, while neglecting a number of flaws in multi-detector CTCAG. We present two cases of multi-detector CTCAG with false positive and false negative results. We would like to emphasize that the interpretation of the findings obtained with multi-detector CTCAG should depend on the clinical findings in the patient, along with other factors, such as the location or length of the lesion.

Non-cardiac Findings on 64-Slice Cardiac Multi-detector CT

BACKGROUND AND OBJECTIVES: Multi-detector CT (MDCT) is becoming more commonly used as a diagnostic tool for various cardiac diseases, and this modality can also incidentally detect a significant number of non-cardiac findings during cardiac work-ups. The objectives of this study were to evaluate the incidence of non-cardiac findings during cardiac MDCT and to compare them with chest CT. SUBJECTS AND METHODS: We enrolled 1,007 consecutive subjects (mean age: 49+/-10 years, males: 63%) who underwent both cardiac and chest CT (64-slice MDCT) as a part of a routine health check-up. The subjects were evaluated for the incidence of non-cardiac findings and the therapeutic consequences according to the CT protocols during the mid-term follow-up (average length of mid-term follow-up: 533+/-39 days). RESULTS: Eight hundred sixty incidental non-cardiac findings were identified in 627 patients (62%) with cardiac CT. Forty-three subjects (4%) had clinically significant lesions that required additional diagnostic work-up or radiological follow-up, and these lesions were 23 cases of non-calcified nodule, 2 cases of ground glass opacity, 6 cases of pneumonia, 1 case of active tuberculosis, 2 cases of focal bronchiolitis, 3 cases of arterial lesion, 1 case of liver cirrhosis and 5 cases of extra-pulmonary masses. Five subjects (0.5%), including 2 cases (0.2%) of malignancy, had therapeutic consequences during their follow-up. Compared with chest CT, 68% (40/59) of the significant intrathoracic lesions and 67% (4/6) of the intrathoracic lesions with therapeutic consequences were documented by cardiac CT. CONCLUSION: In the present study, 4% of the asymptomatic patients who underwent cardiac MDCT were found to have significant non-cardiac findings that required further work-up. To avoid missing a number of clinically important findings, physicians who analyze cardiac MDCT scans should carefully evaluate not only the heart, but all the other organs that are within the scan range.

A Unique Case of Transient Midventricular Ballooning: An Atypical Manifestation of Stress-Induced Cardiomyopathy Involving Both Ventricles

Stress-induced cardiomyopathy is characterized by reversible systolic dysfunction of the ventricles, usually involving the apical segments. It occurs more commonly in women and is frequently precipitated by emotional or physical stressors. Ever since the first report of typical stress-induced cardiomyopathy-usually known as Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome-was issued, variant forms of stress-induced cardiomyopathy have been reported. We describe a patient who presented with typical ischemic chest pain, but who was found to have an atypical form of stress-induced cardiomyopathy: midventricular ballooning syndrome involving both the left and right ventricles. Transthoracic echocardiography and computed tomography were used in this patient.

Comparison of Primary Prevention Strategies for Coronary Heart Disease in Asymptomatic Individuals: The National Cholesterol Education Program-Adult Treatment Panel III Guideline Versus the Screening for Heart Attack Prevention and Education Guideline

BACKGROUND AND OBJECTIVES: The National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP) III guideline has been widely accepted for the primary prevention of coronary heart disease (CHD). The coronary artery calcium score (CACS) has recently been recognized as an excellent predictor of CHD events, and a primary prevention strategy based on the CACS [the Screening for Heart Attack Prevention and Education (SHAPE) guideline] has been proposed. The purpose of this study was to explore how the guidelines function for asymptomatic South Korean individuals. SUBJECTS AND METHODS: We consecutively enrolled 2,079 asymptomatic subjects (age range for men: 45-75 years, age range for women: 55-75 years) who underwent CACS and coronary CT angiography (CCTA) as a part of a health check-up. We analyzed the differences of the target population for CHD prevention according to the 2 guidelines and we compared them in terms of the presence of occult CHD. RESULTS: Four-hundred eighteen (20%) individuals were recommended for pharmacotherapy according to the NCEP-ATP III and 371 (18%) were recommended for pharmacotherapy according to the SHAPE guideline (Cohen's kappa=0.36). According to the SHAPE guideline, more individuals with significant stenosis noted on the CCTA were categorized into the high or very high risk group (50% vs. 24%, respectively, p<0.001) and recommended for pharmacotherapy (53% vs. 28%%, respectively, p<0.001). However, 57 (43%) individuals with significant stenosis on the CCTA were not suitable for pharmacotherapy according to either the NCEP-ATP III or the SHAPE guideline. CONCLUSION: Comparing the NCEP-ATP III and the SHAPE guidelines, there were considerable differences for primary prevention in the target population. Although SHAPE might provide more accurate stratification in terms of the presence of occult CHD, a more precise risk stratification algorithm needs to be implemented for this population.