Net clinical benefit of oral anticoagulants in Korean atrial fibrillation patients with low to intermediate stroke risk: A report from the Clinical Survey on Stroke Prevention in patients with Atrial Fibrillation (CS-SPAF).

Background: The balance of stroke risk reduction and potential bleeding risk associated with antithrombotic treatment (ATT) remains unclear in atrial fibrillation (AF) at non-gender CHA2DS2-VASc scores 0-1. A net clinical benefit (NCB) analysis of ATT may guide stroke prevention strategies in AF with non-gender CHA2DS2-VASc scores 0-1. Methods: This multi-center cohort study evaluated the clinical outcomes of treatment with a single antiplatelet (SAPT), vitamin K antagonist (VKA), and non-VKA oral anticoagulant (NOAC) in non-gender CHA2DS2-VASc score 0-1 and further stratified by biomarker-based ABCD score (Age [≥60 years], B-type natriuretic peptide [BNP] or N-terminal pro-BNP [≥300 pg/mL], creatinine clearance [<50 mL/min], and dimension of the left atrium [≥45 mm]). The primary outcome was the NCB of ATT, including composite thrombotic events (ischemic stroke, systemic embolism, and myocardial infarction) and major bleeding events. Results: We included 2465 patients (age 56.2 ± 9.5 years; female 27.0%) followed-up for 4.0 ± 2.8 years, of whom 661 (26.8%) were treated with SAPT; 423 (17.2%) with VKA; and 1040 (42.2%) with NOAC. With detailed risk stratification using the ABCD score, NOAC showed a significant positive NCB compared with the other ATTs (SAPT vs. NOAC, NCB 2.01, 95% confidence interval [CI] 0.37-4.66; VKA vs. NOAC, NCB 2.38, 95% CI 0.56-5.40) in ABCD score ≥1. ATT failed to show a positive NCB in patients with truly low stroke risk (ABCD score = 0). Conclusions: In the Korean AF cohort at non-gender CHA2DS2-VASc scores 0-1, NOAC showed significant NCB advantages over VKA or SAPT with ABCD score ≥1.

Post-PCI Risk Assessment by Inflammation Activity According to Disease Acuity and Time from Procedure.

BACKGROUND: High-sensitivity C-reactive protein (hs-CRP) has been proposed as an indicator of inflammation and cardiovascular risk. However, little is known of the comparative temporal profile of hs-CRP and its relation to outcomes according to the disease acuity. METHODS: We enrolled 4,263 East Asian patients who underwent percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) and stable disease. hs-CRP was measured at baseline and 1 month post-PCI. Major adverse cardiovascular events (MACE: the composite occurrence of death, myocardial infarction, or stroke) and major bleeding were followed up to 4 years. RESULT: The AMI group (n = 2,376; 55.7%) had higher hs-CRPbaseline than the non-AMI group (n = 1,887; 44.3%) (median: 1.5 vs. 1.0 mg/L; p < 0.001), which remained higher at 1 month post-PCI (median: 1.0 vs. 0.9 mg/L; p = 0.001). During 1 month, a high inflammatory-risk phenotype (upper tertile: hs-CRPbaseline ≥ 2.4 mg/L) was associated with a greater MACE in the AMI group (adjusted hazard ratio [HRadj]: 7.66; 95% confidence interval [CI]: 2.29-25.59; p < 0.001), but not in the non-AMI group (HRadj: 0.74; 95% CI: 0.12-4.40; p = 0.736). Between 1 month and 4 years, a high inflammatory-risk phenotype (upper tertile: hs-CRP1 month ≥ 1.6 mg/L) was associated with greater MACE compared to the other phenotype in both the AMI (HRadj: 2.40; 95% CI: 1.73-3.45; p < 0.001) and non-AMI groups (HRadj: 2.67; 95% CI: 1.80-3.94; p < 0.001). CONCLUSION: AMI patients have greater inflammation during the early and late phases than non-AMI patients. Risk phenotype of hs-CRPbaseline correlates with 1-month outcomes only in AMI patients. However, the prognostic implications of this risk phenotype appears similar during the late phase, irrespective of the disease acuity.

Validation of Biomarker-Based ABCD Score in Atrial Fibrillation Patients with a Non-Gender CHA2DS2-VASc Score 0-1: A Korean Multi-Center Cohort.

PURPOSE: Atrial fibrillation (AF) patients with low to intermediate risk, defined as non-gender CHA2DS2-VASc score of 0-1, are still at risk of stroke. This study verified the usefulness of ABCD score [age (≥60 years), B-type natriuretic peptide (BNP) or N-terminal pro-BNP (≥300 pg/mL), creatinine clearance (<50 mL/min/1.73 m²), and dimension of the left atrium (≥45 mm)] for stroke risk stratification in non-gender CHA2DS2-VASc score 0-1. MATERIALS AND METHODS: This multi-center cohort study retrospectively analyzed AF patients with non-gender CHA2DS2-VASc score 0-1. The primary endpoint was the incidence of stroke with or without antithrombotic therapy (ATT). An ABCD score was validated. RESULTS: Overall, 2694 patients [56.3±9.5 years; female, 726 (26.9%)] were followed-up for 4.0±2.8 years. The overall stroke rate was 0.84/100 person-years (P-Y), stratified as follows: 0.46/100 P-Y for an ABCD score of 0; 1.02/100 P-Y for an ABCD score ≥1. The ABCD score was superior to non-gender CHA2DS2-VASc score in the stroke risk stratification (C-index=0.618, p=0.015; net reclassification improvement=0.576, p=0.040; integrated differential improvement=0.033, p=0.066). ATT was prescribed in 2353 patients (86.5%), and the stroke rate was significantly lower in patients receiving non-vitamin K antagonist oral anticoagulant (NOAC) therapy and an ABCD score ≥1 than in those without ATT (0.44/100 P-Y vs. 1.55/100 P-Y; hazard ratio=0.26, 95% confidence interval 0.11-0.63, p=0.003). CONCLUSION: The biomarker-based ABCD score demonstrated improved stroke risk stratification in AF patients with non-gender CHA2DS2-VASc score 0-1. Furthermore, NOAC with an ABCD score ≥1 was associated with significantly lower stroke rate in AF patients with non-gender CHA2DS2-VASc score 0-1.

Initial Experience with Left Bundle Branch Area Pacing with Conventional Stylet-Driven Extendable Screw-In Leads and New Pre-Shaped Delivery Sheaths.

Until recently, left bundle branch area pacing (LBBAp) has mostly been performed using lumen-less fixed screw leads. There are limited data on LBBAp with conventional style-driven extendable screw-in (SDES) leads, particularly data performed by operators with no previous experience with LBBAp procedures. In total, 42 consecutive patients undergoing LBBAp using SDES leads and newly designed delivery sheaths (LBBAp group) were compared with those treated with conventional right ventricular pacing (RVp) for atrioventricular block (RVp group, n = 84) using propensity score matching (1:2 ratio). The LBBAp was successful in 83% (35/42) of patients, with satisfactory pacing thresholds (0.8 ± 0.2 V at 0.4 ms). In the LBBAp group, the mean paced-QRS duration obtained during RV apical pacing (173 ± 18 ms) was significantly reduced by LBBAp (116 ± 14 ms, p < 0.001). Compared with the RVp group, the LBBAp group showed more physiological pacing, suggested by a much narrower paced-QRS duration (116 ± 14 vs. 151 ± 21 ms, p < 0.001). The pacing threshold was comparable in both groups. The LBBAp group revealed stable pacing thresholds for 6.8 ± 4.8 months post-implant and no serious complications including lead dislodgement or septal perforation. The novel approach of LBBAp using SDES leads and the new dedicated pre-shaped delivery sheaths was effectively and safely performed, even by inexperienced operators with LBBAp procedures.

Target Low-Density Lipoprotein-Cholesterol and Secondary Prevention for Patients with Acute Myocardial Infarction: A Korean Nationwide Cohort Study.

Although lowering low-density lipoprotein cholesterol (LDL-C) levels following acute myocardial infarction (MI) is the cornerstone of secondary prevention, the attainment of recommended LDL-C goals remains suboptimal in real-world practice. We sought to investigate recurrent adverse events in post-MI patients. From the Korea Acute Myocardial Infarction-National Institutes of Health registry, a total of 5049 patients with both measurements of plasma LDL-C levels at index admission and at the one-year follow-up visit were identified. Patients who achieved an LDL-C reduction ≥ 50% from the index MI and an LDL-C level ≤ 70 mg/dL at follow-up were classified as target LDL-C achievers. The primary endpoint was a two-year major adverse cardiac and cerebrovascular event (MACCE), including cardiovascular mortality, recurrent MI, and ischemic stroke. Among the 5049 patients, 1114 (22.1%) patients achieved the target LDL-C level. During a median follow-up of 2.1 years, target LDL-C achievers showed a significantly lower incidence (2.2% vs. 3.5%, log-rank p = 0.022) and a reduced adjusted hazard of MACCE (0.63; p = 0.041). In patients with acute MI, achieving a target LDL-C level was associated with a lower incidence and a reduced hazard of recurrent clinical events. These results highlight the need to improve current practices for managing LDL-C levels in real-world settings.

Clinical Experience with Use of Remdesivir in the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2: a Case Series.

BACKGROUND: A novel antiviral agent, remdesivir (RDV), is a promising candidate treatment for coronavirus disease 2019 (COVID-19) in the absence of any proven therapy. MATERIALS AND METHODS: This retrospective case series included 10 patients with a clinically and laboratory confirmed diagnosis of severe COVID-19 pneumonia who had received RDV for 5 days (n = 5) or 10 days (n = 5) in the Phase III clinical trial of RDV (GS-US-540-5773) conducted by Gilead Sciences. The clinical and laboratory data for these patients were extracted. RESULTS: One patient in the 10-day group received RDV for only 5 days because of nausea and elevated liver transaminases. No patient had respiratory comorbidity. Seven patients had bilateral lesions and three had unilateral lesions on imaging. All patients had received other medications for COVID-19, including lopinavir/ritonavir and hydroxychloroquine, before administration of RDV. Five patients required supplemental oxygen and one required mechanical ventilation. All patients showed clinical and laboratory evidence of improvement. Half of the patients developed elevated liver transaminases and three had nausea. There were no adverse events exceeding grade 2. CONCLUSION: Our experience indicates that RDV could be a therapeutic option for COVID-19. A well-designed randomized controlled clinical trial is now needed to confirm the efficacy of RDV in patients with COVID-19.

Efficacy of dronedarone versus propafenone in the maintenance of sinus rhythm in patients with atrial fibrillation after electrical cardioversion.

PURPOSE: Our objective was to compare the efficacy of dronedarone and propafenone in maintaining sinus rhythm in patients with atrial fibrillation (AF) after electrical cardioversion. METHODS: In this single-center, open-label, randomized trial, we randomly assigned patients with AF after electrical cardioversion to receive dronedarone 400 mg BID or propafenone 150 mg TID. Follow-up clinical evaluations were conducted at 1, 2, 3, and 6 months of treatment. The primary end point was the time to the first recurrence of AF. FINDINGS: A total of 98 patients were enrolled (79 men; mean age, 59.2 years; n = 49 per group). The median times to first recurrence of AF were 31 days in the dronedarone group and 32 days in the propafenone group (P = 0.715). The median (interquartile range) ventricular rates at first recurrence of AF were 76.5 (67.3-86.5) beats/min in the dronedarone group and 83.0 (71.0-96.0) beats/min in the propafenone group (P = 0.059). IMPLICATIONS: Dronedarone and propafenone had similar efficacies in maintaining sinus rhythm in patients with AF after electrical cardioversion. The ventricular rate at the first recurrence of AF was numerically but not statistically significantly lower in the dronedarone group than in the propafenone group. ClinicalTrials.gov identifier: NCT01991119.

Torsional and cyclic fatigue resistances of glide path preparation instruments: G-file and PathFile.

This study aimed to compare cyclic fatigue and torsional resistances of glide path creating instruments with different tapers and tip sizes. Two sizes (G1 and G2) from G-File system and three sizes (PathFile #1, #2, and #3) from PathFile system were used for torsional resistance and cyclic fatigue resistance tests (n = 10). The torsional resistance was evaluated at 2-, 3-, 4-, 5-, and 6-mm from the file tip by plotting the torsional load changes until fracture by rotational loading of 2 rpm. The cyclic fatigue resistance was compared by measuring the number of cycles to failure. Data were analyzed statistically using one-way ANOVA and Duncan's post-hoc comparison. The length of the fractured file fragment was also measured. All fractured fragments were observed under a scanning electron microscope (SEM). Although G-2 file showed a lower torsional strength than PathFile #3 at 2- and 3-mm levels (p < 0.05), they had similar ultimate strengths at 4-, 5-, and 6-mm levels (p > 0.05). The smaller files of each brand had a significantly higher cyclic fatigue resistance than the bigger ones (p < 0.05). PathFile #1 and #2 had higher fatigue resistances than G-files (p < 0.05). While G-1 had a similar fatigue resistance as PathFile #3, G-2 showed the lowest and PathFile #1 showed the highest resistances among the tested groups (p < 0.05). The SEM examination showed typical appearances of cyclic fatigue and torsional fractures, regardless of the tested levels. Clinicians may consider the instruments' sizes for each clinical case in order to get efficient glide path with minimal risk of fracture.

Prognosis after implantation of cardioverter-defibrillators in Korean patients with Brugada syndrome.

PURPOSE: Our study aims to analyze prognosis after implantable cardioverter-defibrillator (ICD) implantation in Korean patients with Brugada syndrome (BrS). MATERIALS AND METHODS: This was a retrospective study of BrS patients implanted with an ICD at one of four centers in Korea between January 1998 and April 2012. Sixty-nine patients (68 males, 1 female) were implanted with an ICD based on aborted cardiac arrest (n=38, 55%), history of syncope (n=17, 25%), or induced ventricular tachyarrhythmia on electrophysiologic study in asymptomatic patients (n=14, 20%). A family history of sudden cardiac death and a spontaneous type 1 electrocardiography (ECG) were noted in 13 patients (19%) and 44 patients (64%), respectively. RESULTS: During a mean follow-up of 59±46 months, 4.6±5.5 appropriate shocks were delivered in 19 patients (28%). Fourteen patients (20%) experienced 5.2±8.0 inappropriate shocks caused by supraventricular arrhythmia, lead failure, or abnormal sensing. Six patients were admitted for cardiac causes during follow-up, but no cardiac deaths occurred. An episode of aborted cardiac arrest was a significant predictor of appropriate shock, and the composite of cardiac events in the Cox proportional hazard model [hazard ratio (95% confidence interval) was 11.34 (1.31-97.94) and 4.78 (1.41-16.22), respectively]. However, a spontaneous type 1 ECG was not a predictor of cardiac events. CONCLUSION: Appropriate shock (28%) and inappropriate shock (20%) were noted during a mean follow-up of 59±46 months in Korean BrS patients implanted with an ICD. An episode of aborted cardiac arrest was the most powerful predictor of cardiac events.

Risk factors between patients with lone and non-lone atrial fibrillation.

Clinical factors such as tall stature, lean body mass, obstructive sleep apnea, alcohol or caffeine, smoking, endurance sports, and genetic factors are proposed as risk factors for lone atrial fibrillation (LAF). The KORAF (KORean Atrial Fibrillation) study is a retrospective multicenter registry that enrolled 3,570 consecutive atrial fibrillation (AF) patients. Data on risk factors were available for 2,133 patients, of whom 398 (18.7%) were identified as having LAF. In univariate analysis, patients with LAF were more likely to be men (82.4% vs 59.8%, P < 0.001) and current smokers (25.9% vs 15.6%, P < 0.01), alcohol drinkers (55.3% vs 31.2%, P < 0.01) and frequent consumers of caffeinated beverages (> 2 cups/day) (31.7% vs 19.3%, P < 0.01), and have a family history of AF (9.0% vs 2.6%, P < 0.001) than the non-LAF patients. Multivariate analysis showed that male gender (OR, 2.30; 95% CI, 1.61-3.27, P < 0.01), family history of AF (OR, 3.12; 95% CI, 1.91-5.12, P < 0.01), current alcohol use (OR, 2.01; 95% CI, 1.46-2.76, P < 0.01), and frequent caffeinated beverage consumption (OR, 1.66; 95% CI, 1.20-2.29, P < 0.01) were independently associated with LAF. In Korean patients, LAF is more closely associated with male gender, family history of AF, current alcohol and frequent caffeinated beverage consumption than non-LAF.

Prevalence and clinical factors of anxiety and depression in neurally mediated and unexplained syncope.

PURPOSE: Several studies have demonstrated that psychiatric disorders such as anxiety, depression and panic attack are associated with syncope, especially vasovagal and unexplained syncope (US). The aim of this study was to compare the prevalence of anxiety and depression between patients with neurally mediated syncope (NMS) and US and to investigate the clinical factors associated with anxiety and depression. MATERIALS AND METHODS: Between January 2009 and March 2010, 383 patients with syncopal episodes completed a Hospital Anxiety and Depression Scale questionnaire to assess symptoms of anxiety and depression. Inclusion criteria were NMS and US. Exclusion criteria were cardiac syncope, orthostatic hypotension and other disorders mimicking syncope. After exclusion, 199 patients were included. RESULTS: There were 176 (88.4%) NMS patients and 23 (11.6%) US patients. The prevalence of abnormal anxiety and depression were not significantly different between the NMS and US groups (10.2% vs. 8.7%, p=0.99; 8.5% vs. 17.4%, p=0.24). Clinical factors associated with anxiety were female gender (p=0.01) and six or more recurrent syncopal episodes (p=0.01) by univariate analysis. The only factor associated with abnormal anxiety score (OR=20.26, 95% CI: 1.4-291.6, p=0.01) was more than six recurrent syncopal episodes, while a positive head-up tilt table testing response was inversely associated with abnormal depression score (OR=0.28, CI: 0.08-0.97, p=0.04) in the multiple logistic regression analysis. CONCLUSION: Anxiety was associated with frequent syncopal episodes. Thus, anxiety might be considered in the management of syncope patients.

Short- and long-term outcomes depending on electrical dyssynchrony markers in patients presenting with acute heart failure: clinical implication of the first-degree atrioventricular block and QRS prolongation from the Korean Heart Failure registry.

BACKGROUND: Prolongations of PR interval and QRS duration on 12-lead electrocardiogram are associated with atrioventricular and interventricular/intraventricular dyssynchrony, respectively. However, their clinical significance remains unclear in real-world heart failure (HF) population. We assessed whether the presence of first-degree atrioventricular block and/or QRS prolongation (≥120 ms) is associated with worse short- and long-term outcomes in patients with acute HF. METHODS: The Korean Heart Failure is a nationwide registry of 3,200 consecutive patients presenting with acute HF at 24 centers in South Korea between June 2004 and April 2009. We selected 1,986 patients with sinus rhythm and divided them into 4 groups depending on the presence of first-degree atrioventricular block and/or QRS prolongation; ED_Neither (n = 1,347), ED_PR (n = 217), ED_QRS (n = 329), and ED_Both (n = 93) groups, respectively. RESULTS: During the median follow-up of 18.2 months, overall death rate (17%, 22%, 20%, and 29%, P < .01) tended to rise with increasing number of electrical dyssynchrony markers. Patients in ED_Both group showed worst outcomes regarding the requirement of invasive managements during the index admission, in-hospital mortality, postdischarge death/rehospitalization, and cardiac device implantation. In time-dependent Cox regression analyses, presence of both PR >200 ms and QRS ≥120 ms was independently associated with in-hospital death (P < .01), postdischarge death/rehospitalization (P = .03), cardiac device implantation (P < .01), and overall death (P < .01). CONCLUSIONS: A combined analysis of electrical dyssynchrony markers (PR prolongation and QRS widening) might be useful for short- and long-term risk stratifications of patients with acute HF.

Predictors and clinical impact of inappropriate implantable cardioverter-defibrillator shocks in Korean patients.

Limited data are available on inappropriate shocks in Korean patients implanted with an implantable cardioverter-defibrillator (ICD). We investigated the impact of inappropriate shocks on clinical outcomes. This retrospective, single-center study included 148 patients treated between October 1999 and June 2011. The primary outcome was a composite event of all-cause mortality or hospitalization for any cardiac reason. The median follow-up duration was 29 months (interquartile range: 8 to 53). One or more inappropriate shocks occurred in 34 (23.0%) patients. A history of atrial fibrillation was the only independent predictor of inappropriate shock (hazard ratio [HR]: 4.16, 95% confidence interval [CI]: 1.89-9.15, P < 0.001). Atrial fibrillation was the most common cause of inappropriate shock (67.7%), followed by supraventricular tachycardia (23.5%), and abnormal sensing (8.8%). A composite event of all-cause mortality or hospitalizations for any cardiac reason during follow-up was not significantly different between patients with or without inappropriate shock (inappropriate shock vs no inappropriate shock: 35.3% vs 35.4%, adjusted HR: 1.06, 95% CI: 0.49-2.29, P = 0.877). Inappropriate shocks do not affect clinical outcomes in patients implanted with an ICD, although the incidence of inappropriate shocks is high.

Identification of vulnerable plaque in a stented coronary segment 17 years after implantation using optical coherence tomography.

A patient presented with exertional chest pain two months prior to admission. Coronary angiography revealed a subocclusive stenosis within the boundaries of the stent. Optical coherence tomography showed remarkable intimal growth inside the stent, which demonstrated a heterogeneous appearance including low-intensity areas. These findings were congruent with the morphology of fibroatheroma in the native coronary artery and suggested that new atherosclerotic progression of the intima within the stent had occurred over 17 years following bare metal stent implantation. To the best of our knowledge, this is one of the most delayed instances of a bare metal stent restenosis described in the medical literature.

The response of the vena cava to abdominal breathing.

BACKGROUND: Recently, abdominal-breathing or diaphragmatic-breathing methods have increased in popularity. Little is known how abdominal breathing affects the circulatory system. This study was designed to determine the impact of the respiratory pattern on central venous flow using echocardiography. METHODS: The superior vena cava (SVC) and inferior vena cava (IVC) were observed in people who had practiced abdominal breathing for at least 2 years, while they were breathing in three different techniques: slow respiration, slow respiration with inspiratory pause, or normal respiration. In addition, the observation during normal respiration was compared with that of a control group. RESULTS: The abdominal-breathing group consisted of 20 people with mean duration of training of 9.6 years. The respiratory collapsibility index of IVC during slow respiration with inspiratory pause was 62±19% compared with 48±19% during normal respiration (p=0.012) in the abdominal-breathing group. The abdominal-breathing group had a higher IVC collapsibility index compared to the control group during normal respiration (48±19% versus 26±12%, p<0.001), assuming a similar respiratory rate of about 10/min. Neither the size nor the minute flow of SVC differed among breathing patterns or between groups. CONCLUSIONS: The IVC of people who practice abdominal breathing has a greater degree of collapse than those of normal people, suggesting that abdominal-breathing exercise can positively affect venous return via IVC. For those who practice abdominal breathing, the collapsibility of the IVC is the best during slow respiration with inspiratory pause. The SVC did not seem to be affected by abdominal-breathing training.

Immunoglobulin G4-related periaortitis mimicking an intramural hematoma.

Immunoglobulin G4 (IgG4)-related sclerosing disease in the cardiovascular system is a recently proposed disease entity, which is still unfamiliar to most clinicians. We present a case of IgG4-related periaortitis of the ascending aorta mimicking an intramural hematoma in the computed tomography (CT) scan, which led to an unnecessary surgery. IgG4-related periaortitis needs to be considered in the differential diagnosis in a patient with thickened aortic wall because the disease should be treated medically in light of its good response to steroid therapy.