Publications by authors named "In Whan Seong"

205 Publications

Multivessel versus IRA-only PCI in patients with NSTEMI and severe left ventricular systolic dysfunction.

PLoS One 2021 13;16(10):e0258525. Epub 2021 Oct 13.

Korea Institute of Toxicology, Daejeon, Republic of Korea.

Background: A substantial number of patients presenting with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease (MVD) have severe left ventricular systolic dysfunction (LVSD) (left ventricular ejection fraction (LVEF) less than 35%). But data are lacking regarding optimal percutaneous coronary intervention (PCI) strategy for these patients. The aim of this study was to compare the long-term outcomes of IRA (infarct-related artery)-only and multivessel PCI in patients with NSTEMI and MVD complicated by severe LVSD.

Methods: Among 13,104 patients enrolled in the PCI registry from November 2011 to December 2015, patients with NSTEMI and MVD with severe LVSD who underwent successful PCI were screened. The primary outcome was 3-year major adverse cardiovascular events (MACEs), defined as all-cause death, any myocardial infarction, stroke, and any revascularization.

Results: Overall, 228 patients were treated with IRA-only PCI (n = 104) or MV-PCI (n = 124). The MACE risk was significantly lower in the MV-PCI group than in the IRA-only PCI group (35.5% vs. 54.8%; hazard ratio [HR] 0.561; 95% confidence interval [CI] 0.378-0.832; p = 0.04). This result was mainly driven by a significantly lower risk of all-cause death (23.4% vs. 41.4%; hazard ratio [HR] 0.503; 95% confidence interval [CI] 0.314-0.806; p = 0.004). The results were consistent after multivariate regression, propensity-score matching, and inverse probability weighting to adjust for baseline differences.

Conclusions: Among patients with NSTEMI and MVD complicated with severe LVSD, multivessel PCI was associated with a significantly lower MACE risk. The findings may provide valuable information to physicians who are involved in decision-making for these patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258525PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8513855PMC
October 2021

Heart failure with mid-range ejection fraction and the effect of β-blockers after acute myocardial infarction.

Heart Vessels 2021 May 21. Epub 2021 May 21.

Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea.

There is currently an ongoing debate about the 'grey area' of heart failure with mid-range ejection fraction (HFmrEF). We evaluated characteristics, prognosis, and the effect of β-blockers on clinical outcomes in patients with HFmrEF after acute myocardial infarction (AMI). We included a total of 10,785 patients and divided them into three groups: EF 40-49% (HFmrEF; n = 2717; reference); EF < 40% (reduced EF [HFrEF]; n = 1194); and EF ≥ 50% (preserved EF [HFpEF]; n = 6874). The primary outcome was 2-year all-cause mortality. HFmrEF was intermediate between HFrEF and HFpEF for baseline characteristics. The risk of all-cause mortality was lower for HFmrEF patients compared to HFrEF patients (adjusted hazard ratio [HR] 0.710; 95% confidence interval [CI] 0.544-0.927; P = 0.012). However, HFmrEF patients tended to be at higher risk for 2-year all-cause mortality than HFpEF patients (adjusted HR 1.235; 95% CI 0.989-1.511; P = 0.090). β-blockers were associated with reductions in all-cause mortality for the entire cohort (adjusted HR 0.760; 95% CI 0.592-0.975; P = 0.031). β-blockers were effective in patients with HFrEF (adjusted HR 0.667; 95% CI 0.471-0.944; P = 0.022), tended to be effective in patients with HFmrEF (adjusted HR 0.665; 95% CI 0.426-1.038; P = 0.072), but not effective in patients with HFpEF (adjusted HR 0.852; 95% CI 0.548-1.326; P = 0.478; interaction P = 0.026). In conclusion, clinical profiles and prognosis of patients with post-AMI HFmrEF are largely intermediate between HFrEF and HFpEF. β-blockers reduced or tended to reduce 2-year all-cause mortality in patients with HFrEF or HFmrEF, respectively, but not those with HFpEF after AMI.
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http://dx.doi.org/10.1007/s00380-021-01876-1DOI Listing
May 2021

Association between nonalcoholic fatty liver disease and cardiovascular disease revealed after comprehensive control of metabolic risk factors: a nationwide population-based study in Korea.

Eur J Gastroenterol Hepatol 2021 Mar 12. Epub 2021 Mar 12.

Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon Department of Statistics, Kyungpook National University, Daegu Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.

Objectives: Previous epidemiological studies have limitations in revealing whether cardiovascular disease (CVD) incidence is mediated by interim occurrence of other metabolic diseases in otherwise healthy nonalcoholic fatty liver disease (NAFLD) patients.

Methods: The study population consisted of 334 280 healthy subjects who had had the National Health check-ups in South Korea from 2009 to 2014. The fatty liver index (FLI) was used to identify subjects with NAFLD. CVD was defined as occurrence of a composite of cardiovascular death, myocardial infarction, ischemic stroke, or coronary revascularization. The association between FLI and CVD incidence was analyzed using time-dependent Cox regression analyses.

Results: The study population was categorized into quartile groups according to FLI (range: Q1, 0-4.9; Q2, 5.0-12.5; Q3, 12.6-31.0; Q4, >31.0). The median follow-up duration was 5.4 years, during which subjects with higher FLIs experienced CVD more frequently than did those with lower FLIs [Q1, 215 (0.3%); Q2, 498 (0.6%); Q3, 753 (0.9%); Q4, 981 (1.2%); P < 0.001]. Adjustment of baseline characteristics revealed that a higher FLI was independently associated with an increased risk for CVD [hazard ratio between Q4 and Q1, 1.86; 95% confidence interval (CI), 1.59-2.17; P < 0.001]. The association between them remained statistically significant (hazard ratio between Q4 and Q1, 1.92; 95% CI, 1.63-2.25; P < 0.001) after further adjustment for the interim events (diabetes, hypertension, heart failure, and atrial fibrillation).

Conclusions: Otherwise healthy NAFLD patients progressed to develop CVD independently of the interim occurrence of other metabolic diseases, which emphasizes the importance of NAFLD as a potential therapeutic target for prevention of CVD.
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http://dx.doi.org/10.1097/MEG.0000000000002102DOI Listing
March 2021

Derivation and validation of a combined in-hospital mortality and bleeding risk model in acute myocardial infarction.

Int J Cardiol Heart Vasc 2021 Apr 22;33:100732. Epub 2021 Feb 22.

Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea.

Background: In the potent new antiplatelet era, it is important issue how to balance the ischemic risk and the bleeding risk. However, previous risk models have been developed separately for in-hospital mortality and major bleeding risk. Therefore, we aimed to develop and validate a novel combined model to predict the combined risk of in-hospital mortality and major bleeding at the same time for initial decision making in patients with acute myocardial infarction (AMI).

Methods: Variables from the Korean Acute Myocardial Infarction Registry (KAMIR) - National Institute of Health (NIH) database were used to derive (n = 8955) and validate (n = 3838) a multivariate logistic regression model. Major adverse cardiovascular events (MACEs) were defined as in-hospital death and major bleeding.

Results: Seven factors were associated with MACE in the model: age, Killip class, systolic blood pressure, heart rate, serum glucose, glomerular filtration rate, and initial diagnosis. The risk model discriminated well in the derivation (c-static = 0.80) and validation (c-static = 0.80) cohorts. The KAMIR-NIH risk score was developed from the model and corresponded well with observed MACEs: very low risk (0.9%), low risk (1.7%), moderate risk (4.2%), high risk (8.6%), and very high risk (23.3%). In patients with MACEs, a KAMIR-NIH risk score ≤ 10 was associated with high bleeding risk, whereas a KAMIR-NIH risk score > 10 was associated with high in-hospital mortality.

Conclusion: The KAMIR-NIH in-hospital MACEs model using baseline variables stratifies comprehensive risk for in-hospital mortality and major bleeding, and is useful for guiding initial decision making.
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http://dx.doi.org/10.1016/j.ijcha.2021.100732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907424PMC
April 2021

Association of baseline platelet count with all-cause mortality after acute myocardial infarction.

Eur Heart J Acute Cardiovasc Care 2020 May 14. Epub 2020 May 14.

Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, College of Medicine, Daejeon, Republic of Korea.

Background: We sought to evaluate baseline platelet count as a prognostic indicator in patients with acute myocardial infarction (AMI).

Methods: Data of 13,085 patients with AMI were retrieved from a prospective nationwide AMI registry from November 2011 to December 2015. Using Cox hazards models, cumulative risks for adverse outcomes were compared among patients with baseline platelet count of less than 150 K/µL (lowest quartile), 150 to 249 K/µL, 250 to 349 K/µL (reference) and equal to or greater than 350 K/µL (higher quartile). The primary outcome of interest was all-cause mortality. Secondary outcomes included myocardial infarction, re-hospitalisation for heart failure, and stroke.

Results: During a median follow-up of 2.1 years, a steep U-shaped association was observed for the occurrence of all-cause mortality (p for non-linearity <0.001). For stroke, a similar U-shaped curve was also seen (p for non-linearity = 0.095). After multiple adjustments, the lowest and higher quartiles of baseline platelet count were positively associated with all-cause mortality (adjusted hazard ratio: 2.120; 95% confidence interval: 1.345-3.341; p = 0.001, and adjusted hazard ratio: 1.642; 95% confidence interval: 0.957-2.817; p = 0.072, respectively). Similar results were observed in sensitivity analyses even after excluding patients with age ≥75 years or patients with heart failure.

Conclusions: In patients with AMI, baseline platelet count demonstrated a U-shaped association with an increased risk of all-cause mortality at two years. If validated, these findings suggest that baseline platelet count could serve as a preferred prognostic marker in AMI due to its low cost and universal availability.
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http://dx.doi.org/10.1177/2048872620925257DOI Listing
May 2020

New onset diabetes mellitus and cardiovascular events in Korean patients with acute myocardial infarction receiving high-intensity statins.

BMC Pharmacol Toxicol 2021 02 4;22(1):11. Epub 2021 Feb 4.

Wonkwang University School of Medicine, Iksan, Korea.

Background: High-intensity statin therapy is typically used in patients with acute myocardial infarction (AMI) for secondary prevention. However, there have been consistent concerns regarding its association with diabetes mellitus. We investigated the effect of high-intensity atorvastatin and rosuvastatin on new-onset diabetes mellitus (NODM) and cardiovascular outcomes over a 3-year follow-up period.

Methods: Data from the Korea Acute Myocardial Infarction Registry were collected from November 2011 to October 2015, and 13,104 patients with AMI were enrolled from major cardiovascular centers. Among them, 2221 patients without diabetes who had been administered with high-intensity atorvastatin (40-80 mg) and rosuvastatin (20 mg) were investigated. The atorvastatin and rosuvastatin groups were evaluated for the incidence of NODM and major adverse cardiac events (MACE) including death, myocardial infarction, and revascularization cases in the following 3 years.

Results: Baseline characteristics were comparable between the two groups. Event-free survival rate of NODM was not significantly different between the atorvastatin and rosuvastatin groups (92.5% vs. 90.8%, respectively; Log-rank P-value = 0.550). The event-free survival rate of MACE was also not significantly different between atorvastatin and rosuvastatin groups (89.0% vs. 89.6%, respectively; Log rank P-value = 0.662). Multivariate Cox analysis revealed that statin type was not a prognostic factor in the development of NODM and MACE.

Conclusions: Administering high-intensity atorvastatin and rosuvastatin in patients with AMI produced comparable effects on NODM and clinical outcomes, suggesting their clinical equivalence in secondary prevention.
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http://dx.doi.org/10.1186/s40360-021-00476-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863364PMC
February 2021

Gender differences in clinical outcomes of acute myocardial infarction undergoing percutaneous coronary intervention: insights from the KAMIR-NIH Registry.

J Geriatr Cardiol 2020 Nov;17(11):680-693

Division of Cardiology, Daejeon St. Mary's hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.

Background: There are numerous but conflicting data regarding gender differences in outcomes following percutaneous coronary intervention (PCI). Furthermore, gender differences in clinical outcomes with acute myocardial infarction (AMI) following PCI in Asian population remain uncertain because of the under-representation of Asian in previous trials.

Methods: A total of 13, 104 AMI patients from Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) between November 2011 and December 2015 were classified into male ( = 8021, 75.9%) and female ( = 2547, 24.1%). We compared the demographic, clinical and angiographic characteristics, 30-days and 1-year major adverse cardiac and cerebrovascular events (MACCE) in women with those in men after AMI by using propensity score (PS) matching.

Results: Compared with men, women were older, had more comorbidities and more often presented with non-ST segment elevation myocardial infarction (NSTEMI) and reduced left ventricular systolic function. Over the median follow-up of 363 days, gender differences in both 30-days and 1-year MACCE as well as thrombolysis in myocardial infarction minor bleeding risk were not observed in the PS matched population (30-days MACCE: 5.3% . 4.7%, log-rank = 0.494, HR = 1.126, 95% CI: 0.800-1.585; 1-year MACCE: 9.3% . 9.0%, log-rank = 0.803, HR = 1.032, 95% CI: 0.802-1.328; TIMI minor bleeding: 4.9% . 3.9%, log-rank = 0.215, HR = 1.255, 95% CI: 0.869-1.814).

Conclusions: Among Korean AMI population undergoing contemporary PCI, women, as compared with men, had different clinical and angiographic characteristics but showed similar 30-days and 1-year clinical outcomes. The risk of bleeding after PCI was comparable between men and women during one-year follow up.
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http://dx.doi.org/10.11909/j.issn.1671-5411.2020.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729180PMC
November 2020

Variation in treatment strategy for non-ST segment elevation myocardial infarction: A multilevel methodological approach.

Int J Cardiol 2021 04 2;328:35-39. Epub 2020 Dec 2.

Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea; School of Medicine, Kyungpook National University, Daegu, Republic of Korea.

Background: Variations by hospital and region in the selection of an early invasive strategy (EIS) after non-ST-segment elevation myocardial infarction (NSTEMI) in patients with high-risk criteria are unknown.

Methods: We evaluated the data of 7037 patients with NSTEMI from 20 hospitals of 3 regions from the Korean Acute Myocardial Infarction Registry-National Institute of Health database. We used hierarchical generalized linear mixed-models to estimate region- and hospital-level variation in the selection of an EIS after adjusting for patient-level high-risk criteria. We explored the variation using the median rate ratio (MRR), which estimates the relative difference in the risk ratios of two hypothetically identical patients at two different sites.

Results: An EIS was selected in 84.4% of patients. At the hospital level, the median selection rate was 80.4%. At the region level, the median selection rate was 74.9% in the east region, 81.3% in the north region, and 83.9% in the west region, respectively. After adjusting for patient-level covariates, we found significant hospital- (MRR 2.19, 95% confidence interval [CI]: 1.74-3.03) and region-level (MRR 1.88, 95%CI: 1.26-5.44) variation in the selection of an EIS. Among patient-level factors, male sex, ongoing chest pain, history of coronary artery disease or acute heart failure, and GRACE risk score > 140 were independently associated with the selection of an EIS.

Conclusions: We observed significant hospital- and region-level variation in the selection of an EIS after NSTEMI in high-risk patients. Quality improvement efforts are required to standardize decision making and to improve clinical outcomes.
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http://dx.doi.org/10.1016/j.ijcard.2020.11.059DOI Listing
April 2021

Clinical Implication of 'Obesity Paradox' in Elderly Patients With Acute Myocardial Infarction.

Heart Lung Circ 2021 Apr 1;30(4):481-488. Epub 2020 Oct 1.

Chonbuk National University Hospital, Jeonju, Republic of Korea.

Background: The clinical impact of body mass index (BMI), especially in the elderly with acute myocardial infarction (AMI), has not been sufficiently evaluated. The purpose of this study was to elucidate the clinical impact of BMI in very old patients (≥80 years) with AMI.

Methods: The study analysed 2,489 AMI patients aged ≥80 years from the Korea Acute Myocardial Infarction Registry and the Korea Working Group on Myocardial Infarction (KAMIR/KorMI) registries between November 2005 and March 2012. The study population was categorised into four groups based on their BMI: underweight (n=301), normal weight (n=1,150), overweight (n=890), and obese (n=148). The primary endpoint was major adverse cardiovascular event (MACE), a composite of cardiac death, myocardial infarction, target lesion revascularisation, and target vessel revascularisation.

Results: Baseline characteristics among the four groups were similar, except for hypertension (45.1 vs 58.4 vs 66.2 vs 69.9%, respectively; p<0.001) and diabetes (16.6 vs 23.6 vs 30.7 vs 35.1%, respectively; p<0.001). Coronary care unit length of stay was significantly different among the four groups during hospitalisation (5.3±5.9 vs 4.8±6.8 vs 4.2±4.0 vs 3.5±2.1 days; p=0.007). MACE (16.9 vs 14.9 vs 13.7 vs 8.8%; p=0.115) and cardiac death (10.3 vs 8.4 vs 7.9 vs 4.1%; p=0.043) less frequently occurred in the obese group than in other groups during the 1-year follow-up. A multivariate regression model showed obese status (BMI ≥27.5 kg/m) as an independent predictor of reduced MACE (hazard ratio [HR], 0.20; 95% confidence interval [CI], 0.06-0.69; p=0.010) along with reduced left ventricular ejection fraction (≤40%) as a predictor of increased MACE (HR,1.87; 95% CI, 1.31-2.68; p=0.001).

Conclusion: Body mass index in elderly patients with acute myocardial infarction was significantly associated with coronary care unit stay and clinical cardiovascular outcomes.
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http://dx.doi.org/10.1016/j.hlc.2020.08.013DOI Listing
April 2021

Intensity of Statin Treatment in Korean Patients with Acute Myocardial Infarction and Very Low LDL Cholesterol.

J Lipid Atheroscler 2019 Sep 2;8(2):208-220. Epub 2019 Jul 2.

Division of Cardiology, Gyungsang National University Hospital, Jinju, Korea.

Objective: Data on the intensity of statin therapy for patients with acute myocardial infarction (MI) and very low baseline low-density lipoprotein (LDL) cholesterol level are lacking. We sought to assess the impact of statin intensity in patients with acute MI and LDL cholesterol <70 mg/dL.

Methods: A total of 1,086 patients with acute MI and baseline LDL cholesterol <70 mg/dL from the Korea Acute Myocardial Infarction Registry-National Institute of Health database were divided into less intensive statin (expected LDL reduction <40%, n=302) and more intensive statin (expected LDL reduction ≥40%, n=784) groups. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs), a composite of cardiac death, MI, revascularization occurring at least 30 days after admission, and stroke, at 12 months.

Results: After 1:2 propensity matching, differences were not observed between less intensive (n=302) and more intensive statin (n=604) groups in incidence of cardiac death (0.3% vs. 0.3%) and hemorrhagic stroke (0.3% vs. 0.5%, =0.727) at 12 months. Compared with the less intensive statin group, the more intensive statin group showed lower target-vessel revascularization (4.6% vs. 1.8%, =0.027) and MACCE (11.6% vs. 7.0%, =0.021). Major bleeding was not different between less intensive and more intensive statin groups (1.0% vs. 2.6%, =0.118).

Conclusion: More intensive statin therapy was associated with significantly lower major adverse cardiovascular events in patients with acute MI and very low LDL cholesterol compared with less intensive statin therapy.
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http://dx.doi.org/10.12997/jla.2019.8.2.208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7379123PMC
September 2019

Optimal Revascularization Strategy in Non-ST-Segment-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease: Culprit-Only Versus One-Stage Versus Multistage Revascularization.

J Am Heart Assoc 2020 08 31;9(15):e016575. Epub 2020 Jul 31.

Department of Cardiology Wonkwang University Hospital Iksan Republic of Korea.

Background Few studies have investigated optimal revascularization strategies in non-ST-segment-elevation myocardial infarction with multivessel disease. We investigated 3-year clinical outcomes according to revascularization strategy in patients with non-ST-segment-elevation myocardial infarction and multivessel disease. Methods and Results This retrospective, observational, multicenter study included patients with non-ST-segment-elevation myocardial infarction and multivessel disease without cardiogenic shock. Data were analyzed at 3 years according to the percutaneous coronary intervention strategy: culprit-only revascularization (COR), 1-stage multivessel revascularization (MVR), and multistage MVR. The primary outcome was major adverse cardiac events (MACE: a composite of all-cause death, nonfatal spontaneous myocardial infarction, or any repeat revascularization). The COR group had a higher risk of MACE than those involving other strategies (COR versus 1-stage MVR; hazard ratio, 0.65; 95% CI, 0.54-0.77; <0.001; and COR versus multistage MVR; hazard ratio, 0.74; 95% CI, 0.57-0.97; =0.027). There was no significant difference in the incidence of MACE between 1-stage and multistage MVR (hazard ratio, 1.14; 95% CI, 0.86-1.51; =0.355). The results were consistent after multivariate regression, propensity score matching, inverse probability weighting, and Bayesian proportional hazards modeling. In subgroup analyses stratified by the Global Registry of Acute Coronary Events score, 1-stage MVR lowered the risk of MACE compared with multistage MVR in low-to-intermediate risk patients but not in patients at high risk. Conclusions MVR reduced 3-year MACE in patients with non-ST-segment-elevation myocardial infarction and multivessel disease compared with COR. However, 1-stage MVR was not superior to multistage MVR for reducing MACE except in low-to-intermediate risk patients.
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http://dx.doi.org/10.1161/JAHA.120.016575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792267PMC
August 2020

Radial Plus Ipsilateral Femoral Approach is Feasible in Percutaneous Interventions for Iliac Artery Chronic Total Occlusion.

Ann Vasc Surg 2021 Feb 10;71:257-263. Epub 2020 Jul 10.

Department of Cardiology, Chungnam National University School of Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.

Background: Compared with conventional bilateral femoral (BF) approach, radial plus ipsilateral femoral (RF) approach may be feasible in the percutaneous intervention for iliac artery chronic total occlusion (CTO).

Methods: We included patients who underwent iliac CTO intervention between August 2009 and July 2018 in a tertiary referral center in Korea.

Results: A total of 83 patients were enrolled in this study. Of them, 51 and 32 patients were categorized into RF and BF initial access groups, respectively. The overall success rates were 98.0% and 96.7% in RF and BF group, respectively, and the techniques were also similar including use of bilateral wiring, stent type and profile, and post balloon but longer procedure time in the BF group. Additional contralateral femoral access was needed in 6 patients for the treatment of contralateral lesions, distal embolization, and due to tortuous right subclavian artery. Periprocedural complications including vascular injury, iliac perforation, and distal embolization occurred similarly in both groups with numerically lower rate of periprocedural bleeding in the RF group (9.8%) than in the BF group (21.9%). Clinical follow-up at 6 months showed there were no difference in the rates of death, cardiovascular death, target-limb reintervention, and unplanned target limb amputation in both groups.

Conclusions: RF approach for iliac CTO intervention was related to similar technical success rate with acceptable periprocedural safety outcomes compared with conventional BF approach.
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http://dx.doi.org/10.1016/j.avsg.2020.07.005DOI Listing
February 2021

Blood Pressure at 6 Months After Acute Myocardial Infarction and Outcomes at 2 Years: The Perils Associated With Excessively Low Blood Pressures.

Can J Cardiol 2020 10 8;36(10):1641-1648. Epub 2020 Feb 8.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: This study aimed to determine the association between achieved blood pressure at 6-month follow-up and cardiovascular outcomes at 2 years in patients treated with β-blockers and renin-angiotensin-aldosterone blockers after acute myocardial infarction (AMI).

Methods: We analyzed data from 5503 patients enrolled in the national AMI registry. Patients with myocardial reinfarction (MrI), rehospitalization for heart failure (rHHF), or stroke before 6-month follow-up were excluded. Achieved blood pressures were categorized into 10-mm Hg increments. The primary outcome was all-cause death. The secondary outcome was a composite of all-cause death, MrI, and rHHF. Hazard ratios (HRs) were estimated with multivariable-adjusted Cox hazards models using 125- to 134-mm Hg systolic blood pressure (SBP) and 75- to 84-mm Hg diastolic blood pressure (DBP) subgroups as reference.

Results: After a median follow-up of 2.1 years, SBP < 115 mm Hg was associated with increased risks for all-cause death (adjusted HR: 2.202 [1.158-4.188]) and for a composite outcome (HR: 1.682 [1.075-2.630]). Likewise, DBP < 75 mm Hg tended to be associated with an increase in all-cause death (HR: 2.078 [0.998-4.327] for DBP of 65 to 74 mm Hg; HR: 2.610 [1.256-5.423] for DBP < 65 mm Hg). Even in patients <75 years, the risk of a composite outcome was increased for DBP < 65 mm Hg (HR: 2.492 [1.401-4.434]).

Conclusions: Low blood pressure achieved with β-blocker and renin-angiotensin-aldosterone blocker at 6 months was associated with an increased risk of all-cause mortality independently of confounding factors in patients with AMI. This finding suggests that caution should be taken for patients with AMI who use blood-pressure-lowering treatments.
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http://dx.doi.org/10.1016/j.cjca.2020.01.026DOI Listing
October 2020

Association of baseline platelet count with all-cause mortality after acute myocardial infarction.

Eur Heart J Acute Cardiovasc Care 2020 May 14:2048872620925257. Epub 2020 May 14.

Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, College of Medicine, Daejeon, Republic of Korea.

Background: We sought to evaluate baseline platelet count as a prognostic indicator in patients with acute myocardial infarction (AMI).

Methods: Data of 13,085 patients with AMI were retrieved from a prospective nationwide AMI registry from November 2011 to December 2015. Using Cox hazards models, cumulative risks for adverse outcomes were compared among patients with baseline platelet count of less than 150 K/µL (lowest quartile), 150 to 249 K/µL, 250 to 349 K/µL (reference) and equal to or greater than 350 K/µL (higher quartile). The primary outcome of interest was all-cause mortality. Secondary outcomes included myocardial infarction, re-hospitalisation for heart failure, and stroke.

Results: During a median follow-up of 2.1 years, a steep U-shaped association was observed for the occurrence of all-cause mortality ( for non-linearity <0.001). For stroke, a similar U-shaped curve was also seen ( for non-linearity = 0.095). After multiple adjustments, the lowest and higher quartiles of baseline platelet count were positively associated with all-cause mortality (adjusted hazard ratio: 2.120; 95% confidence interval: 1.345-3.341;  = 0.001, and adjusted hazard ratio: 1.642; 95% confidence interval: 0.957-2.817;  = 0.072, respectively). Similar results were observed in sensitivity analyses even after excluding patients with age ≥75 years or patients with heart failure.

Conclusions: In patients with AMI, baseline platelet count demonstrated a U-shaped association with an increased risk of all-cause mortality at two years. If validated, these findings suggest that baseline platelet count could serve as a preferred prognostic marker in AMI due to its low cost and universal availability.
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http://dx.doi.org/10.1177/2048872620925257DOI Listing
May 2020

Left atrial enlargement and its association with left atrial strain in university athletes participated in 2015 Gwangju Summer Universiade.

Eur Heart J Cardiovasc Imaging 2020 08;21(8):865-872

Department of Cardiology, Chonnam National University Medical School/Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea.

Aims: Intensive and repetitive athletic training may result in cardiac geometric changes, but the determinants of left atrial (LA) enlargement (LAE) has been poorly studied. We investigated incidence and determinants of LAE and its association with LA strains in highly trained university athletes.

Methods And Results: A total of 1073 athletes (451 females, 22.4 ± 2.4 years old) who were able to measure LA size, volume, and strains during 2015 Gwangju Summer Universiade were enrolled. LAE was defined as the increased LA volume index > 42 mL/m2. LA strains, reservoir, conduit, and contractile were measured by 2D speckle tracking method, and LA reservoir strain < 27.6% was considered as abnormal. LAE was developed in 205 athletes (19.1%). In univariate analysis, male [odds ratio (OR) = 1.679], Caucasian (OR = 1.746), non-African descent (OR = 1.804), body muscle mass (OR = 1.056), body fat mass (OR = 0.962), systolic blood pressure (OR = 1.012), heart rate (OR = 0.980), sports type with cardiovascular (CV) demand (OR = 1.474), training time (OR = 1.011), left ventricular (LV) global longitudinal strain (LVGLS, OR = 0.906), and LV stroke volume (LVSV, OR = 1.044) were significantly associated with LAE. In multivariate logistic regression analysis, heart rate (OR = 0.961) and sports type with CV demand (OR = 1.299), LVGLS (OR = 0.865) and LVSV (OR = 1.013) were independent determinants of LAE. Abnormal LA reservoir strain was noted in 56 athletes (5.2%), and the incidence of abnormal value was not different between two groups; 42 athletes (4.8%) in LAE vs. 14 (6.8%) in no LAE group (P = 0.293).

Conclusion: LAE was common in university athletes (19.1%) and associated with heart rate, sports type with CV demand, LVGLS, and LVSV. Although LAE was significantly associated with the lower LA reservoir strain, the incidence of abnormal value was very low (5.2%) and indifferent between LAE and no LAE group.
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http://dx.doi.org/10.1093/ehjci/jeaa084DOI Listing
August 2020

Higher fatty liver index is associated with increased risk of new onset heart failure in healthy adults: a nationwide population-based study in Korea.

BMC Cardiovasc Disord 2020 04 28;20(1):204. Epub 2020 Apr 28.

Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Korea.

Background: Heart failure (HF) is relatively common cardiovascular disease with high mortality and morbidity. Although it is associated with many cardiovascular risk factors, the association between nonalcoholic fatty liver disease (NAFLD), the most common chronic liver disease, and HF has not been evaluated in a large-scale cohort study. Thus, we evaluated the ability of the fatty liver Index (FLI), a surrogate marker of NAFLD, to predict the development of HF in healthy individuals.

Methods: We analyzed the association between the FLI and new-onset HF with multivariate Cox proportional-hazards models in 308,578 healthy persons without comorbidities who underwent the National Health check-ups in the republic of Korea from 2009 to 2014.

Results: A total of 2532 subjects (0.8%) were newly diagnosed with HF during the study period (a median of 5.4 years). We categorized our subjects into quartile groups according to FLI (Q1, 0-4.9; Q2, 5.0-12.5; Q3, 12.6-31.0; and Q4, > 31.0). The cumulative incidence of HF was significantly higher in the highest FLI group than in the lowest FLI group (Q1, 307 [0.4%] and Q4, 890 [1.2%]; P < 0.001). Adjusted hazard ratio (HRs) indicated that the highest FLI group was independently associated with an increased risk for HF (HR between Q4 and Q1, 2.709; 95% confidence interval = 2.380-3.085; P < 0.001). FLI was significantly associated with an increased risk of new-onset HF regardless of their baseline characteristics.

Conclusions: Higher FLI was independently associated with increased risk of HF in a healthy Korean population.
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http://dx.doi.org/10.1186/s12872-020-01444-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189566PMC
April 2020

A Close Relationship between Non-Alcoholic Fatty Liver Disease Marker and New-Onset Hypertension in Healthy Korean Adults.

Korean Circ J 2020 Aug 23;50(8):695-705. Epub 2020 Mar 23.

Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea.

Background And Objectives: Nonalcoholic fatty liver disease (NAFLD) is an excessive accumulation of fat into the liver as a result of increased inflammation and insulin resistance. Although there can be common pathogenic mechanisms for NAFLD and hypertension associated with the development of cardiovascular diseases, little data are showing the association between NAFLD and hypertension in a large-scale cohort study. Thus, we evaluated the ability of the fatty liver index (FLI), a surrogate marker of NAFLD, to predict the development of hypertension in healthy individuals.

Methods: We included 334,280 healthy individuals without known comorbidities who underwent the National Health check-ups in South Korea from 2009 to 2014. The association between the FLI and hypertension was analyzed using multivariate Cox proportional-hazards models.

Results: During a median of 5.2 years' follow-up, 24,678 subjects (7.4%) had new-onset hypertension. We categorized total subjects into quartile groups according to FLI (range: Q1, 0-4.9; Q2, 5.0-12.5; Q3, 12.6-31.0; and Q4, >31.0). The incidence of hypertension was higher in subjects with the highest FLI than in those with the lowest FLI (Q4, 9,968 [11.9%] vs. Q1, 2,277 [2.7%]; p<0.001). There was a significant correlation between the highest FLI and an increased risk of new-onset hypertension (adjusted hazard ratio between Q4 and Q1, 2.330; 95% confidence interval, 2.218-2.448; p<0.001). FLI was significantly associated with an increased risk of new-onset hypertension regardless of baseline characteristics.

Conclusions: Higher FLI was independently associated with increased risk of hypertension in a healthy Korean population.
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http://dx.doi.org/10.4070/kcj.2019.0379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390718PMC
August 2020

Additional postdilatation using noncompliant balloons after everolimus-eluting stent implantation: Results of the PRESS trial.

Clin Cardiol 2020 Jun 16;43(6):606-613. Epub 2020 Mar 16.

Department of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea.

Background: There are limited data on the clinical value of routine postdilatation using noncompliant balloons after contemporary drug-eluting stent implantation.

Hypothesis: Additional postdilatation using noncompliant balloons after everolimus-eluting stent implantation could provide better clinical outcomes.

Methods: We randomly assigned 1774 patients with coronary artery disease to undergo additional high-pressure postdilatation using noncompliant balloons and moderate-pressure dilatation using stent balloons after everolimus-eluting stent implantation. The primary endpoint was a composite of death, myocardial infarction (MI), stent thrombosis, and target vessel revascularization (TVR) 2 years after randomization.

Results: The study was discontinued early owing to slow enrollment. In total, 810 patients (406 patients in the high pressure group and 404 in the moderate pressure group) were finally enrolled. At 2 years, the primary endpoint occurred in 3.6% of patients in the high pressure group and in 4.4% of those in the moderate pressure group (P = .537). In addition, no significant differences were observed between the two groups in the occurrence of an individual end point of death (0.8% in the high pressure group vs 1.5% in the moderate group, P = .304), MI (0.2% vs 0.5%, P = .554), stent thrombosis (0% vs 0.2%, P = .316), or TVR (2.8% vs 2.6%, P = .880).

Conclusions: The strategy of routine postdilatation using noncompliant balloons after everolimus-eluting stent implantation did not provide incremental clinical benefits.
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http://dx.doi.org/10.1002/clc.23355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298980PMC
June 2020

One-Year Clinical Outcomes between Single- versus Multi-Staged PCI for ST Elevation Myocardial Infarction with Multi-Vessel Coronary Artery Disease: from Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH).

Korean Circ J 2020 Mar;50(3):220-233

Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.

Background And Objectives: Although complete revascularization is known superior to incomplete revascularization in ST elevation myocardial infarction (STEMI) patients with multi-vessel coronary artery disease (MVCD), there are no definite instructions on the optimal timing of non-culprit lesions percutaneous coronary intervention (PCI). We compared 1-year clinical outcomes between 2 different complete multi-vessel revascularization strategies.

Methods: From the Korea Acute Myocardial Infarction Registry-National Institute of Health, 606 patients with STEMI and MVCD who underwent complete revascularization were enrolled from November 2011 to December 2015. The patients were assigned to multi-vessel single-staged PCI (SS PCI) group (n=254) or multi-vessel multi-staged PCI (MS PCI) group (n=352). Propensity score matched 1-year clinical outcomes were compared between the groups.

Results: At one year, MS PCI showed a significantly lower rate of all-cause mortality (hazard ratio [HR], 0.42; 95% confidential interval [CI], 0.19-0.92; p=0.030) compared with SS PCI. In subgroup analysis, all-cause mortality increased in SS PCI with cardiogenic shock (HR, 4.60; 95% CI, 1.54-13.77; p=0.006), age ≥65 years (HR, 4.00; 95% CI, 1.67-9.58, p=0.002), Killip class III/IV (HR, 7.32; 95% CI, 1.68-31.87; p=0.008), and creatinine clearance ≤60 mL/min (HR, 2.81; 95% CI, 1.10-7.18; p=0.031). After propensity score-matching, MS PCI showed a significantly lower risk of major adverse cardiovascular event than SS PCI.

Conclusions: SS PCI was associated with worse clinical outcomes compared with MS PCI. MS PCI for non-infarct-related artery could be a better option for patients with STEMI and MVCD, especially high-risk patients.
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http://dx.doi.org/10.4070/kcj.2019.0176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043963PMC
March 2020

Role of Carotid Artery Stenting in Prevention of Stroke for Asymptomatic Carotid Stenosis: Bayesian Cross-Design and Network Meta-Analyses.

Korean Circ J 2020 Apr 6;50(4):330-342. Epub 2020 Jan 6.

Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea.

Background And Objectives: There is insufficient evidence regarding the optimal treatment for asymptomatic carotid stenosis.

Methods: Bayesian cross-design and network meta-analyses were performed to compare the safety and efficacy among carotid artery stenting (CAS), carotid endarterectomy (CEA), and medical treatment (MT). We identified 18 studies (4 randomized controlled trials [RCTs] and 14 nonrandomized, comparative studies [NRCSs]) comparing CAS with CEA, and 4 RCTs comparing CEA with MT from MEDLINE, Cochrane Library, and Embase databases.

Results: The risk for periprocedural stroke tended to increase in CAS, compared to CEA (odds ratio [OR], 1.86; 95% credible interval [CrI], 0.62-4.54). However, estimates for periprocedural myocardial infarction (MI) were quite heterogeneous in RCTs and NRCSs. Despite a trend of decreased risk with CAS in RCTs (OR, 0.70; 95% CrI, 0.27-1.24), the risk was similar in NRCSs (OR, 1.02; 95% CrI, 0.87-1.18). In indirect comparisons of MT and CAS, MT showed a tendency to have a higher risk for the composite of periprocedural death, stroke, MI, or nonperiprocedural ipsilateral stroke (OR, 1.30; 95% CrI, 0.74-2.73). Analyses of study characteristics showed that CEA-versus-MT studies took place about 10-year earlier than CEA-versus-CAS studies.

Conclusions: A similar risk for periprocedural MI between CEA and CAS in NRCSs suggested that concerns about periprocedural MI accompanied by CEA might not matter in real-world practice when preoperative evaluation and management are working. Maybe the benefits of CAS over MT have been overestimated considering advances in medical therapy within10-year gap between CEA-versus-MT and CEA-versus-CAS studies.
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http://dx.doi.org/10.4070/kcj.2019.0125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7067609PMC
April 2020

Clinical Impact of Atypical Chest Pain and Diabetes Mellitus in Patients with Acute Myocardial Infarction from Prospective KAMIR-NIH Registry.

J Clin Med 2020 Feb 12;9(2). Epub 2020 Feb 12.

Department of Internal Medicine, Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea.

Atypical chest pain and diabetic autonomic neuropathy attract less clinical attention, leading to underdiagnosis and delayed treatment. To evaluate the long-term clinical impact of atypical chest pain and diabetes mellitus (DM), we categorized 11,159 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into four groups (atypical DM, atypical non-DM, typical DM, and typical non-DM). The primary endpoint was defined as patient-oriented composite endpoint (POCE) at 2 years including all-cause death, any myocardial infarction (MI), and any revascularization. Patients with atypical chest pain showed higher 2-year mortality than those with typical chest pain in both DM (29.5% vs. 11.4%, < 0.0001) and non-DM (20.4% vs. 6.3%, < 0.0001) groups. The atypical DM group had the highest risks of POCE (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.48-2.10), all-cause death (HR 2.23, 95% CI 1.80-2.76) and any MI (HR 2.34, 95% CI 1.51-3.64) in the adjusted model. In conclusion, atypical chest pain was significantly associated with mortality in patients with AMI. Among four groups, the atypical DM group showed the worst clinical outcomes at 2 years. Application of rapid rule in/out AMI protocols would be beneficial to improve clinical outcomes.
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http://dx.doi.org/10.3390/jcm9020505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7074023PMC
February 2020

Practical guidance for P2Y12 inhibitors in acute myocardial infarction undergoing percutaneous coronary intervention.

Eur Heart J Cardiovasc Pharmacother 2021 Mar;7(2):112-124

Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea.

Aims: Potent P2Y12 inhibitors for dual antiplatelet therapy (DAPT) is crucial for managing acute myocardial infarction; however, the selection of drugs is based on limited clinical information such as age and body weight. The current study sought to develop and validate a new risk scoring system that can be used to guide the selection of potent P2Y12 inhibitors by balancing ischaemic benefit and bleeding risk.

Methods And Results: Derivation cohort of 10 687 patients who participated in the Korea Acute Myocardial Infarction Registry-National Institutes of Health study was used to construct a new scoring system. We combined the ischaemic and bleeding models to establish a simple clinical prediction score. Among the low score group (n = 1764), the observed bleeding risk (8.7% vs. 4.4%, P < 0.001) due to potent P2Y12 inhibitors exceeded ischaemic benefit (1.3% vs. 2.2%, P = 0.185) during 12 months. Conversely, the high score group (n = 1898) showed an overall benefit from taking potent P2Y12 inhibitors from the standpoint of observed ischaemic (17.1% vs. 8.6%, P < 0.001) and bleeding events (10.1% vs. 6.8%, P = 0.073). The performance of ischaemic [integrated area under the curve (iAUC) = 0.809] and bleeding model (iAUC = 0.655) was deemed to be acceptable.

Conclusion: The new scoring system is a useful clinical tool for guiding DAPT by balancing ischaemic benefit and bleeding risk, especially among Asian populations. Further validation studies with other cohorts will be required to verify that the new system meets the needs of real clinical practice.
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http://dx.doi.org/10.1093/ehjcvp/pvaa005DOI Listing
March 2021

Ticagrelor versus clopidogrel in acute myocardial infarction patients with multivessel disease; From Korea Acute Myocardial Infarction Registry-National Institute of Health.

J Cardiol 2020 05 16;75(5):478-484. Epub 2019 Dec 16.

Wonkwang University Hospital, Iksan, South Korea.

Background: The clinical efficacy of ticagrelor is questionable in East Asian populations. Patients with acute myocardial infarction (AMI) with multivessel disease (MVD) are considered as high risk patients who might benefit from ticagrelor treatment. The purpose of this study is to compare the clinical effect of ticagrelor and clopidogrel in AMI patients with MVD in Korea.

Methods And Results: A total of 2275 patients between November 2011 and June 2015, diagnosed with AMI with MVD after successful percutaneous coronary intervention who were registered in the Korea Acute Myocardial Infarction Registry - National Institute of Health (KAMIR-NIH) were enrolled. Patients were divided into ticagrelor (n = 837) and clopidogrel group (n = 1438). The primary endpoint was major adverse cardiac events (MACE) defined as cardiac death, non-fatal MI, target vessel revascularization, or ischemic stroke during 2 years of clinical follow-up. Secondary endpoints were thrombolysis in myocardial infarction (TIMI) major or minor bleeding, net clinical event composed of MACE and TIMI major bleeding, any repeated percutaneous coronary intervention, heart failure requiring re-hospitalization, and stent thrombosis. After propensity score matching analysis, the primary endpoint was lower in ticagrelor group compared to the clopidogrel group (8.6 % vs. 11.9 %; HR: 0.68; 95 % CI: 0.50-0.94; p = 0.018). The risk of TIMI major or minor bleeding was higher in the ticagrelor group (10.8 % vs. 4.8 %; HR: 2.51; 95 % CI: 1.68-3.76; p < 0.001). The net clinical event was similar between ticagrelor and clopidogrel group (11.3 % vs. 13.6 %; HR 0.82; 95 % CI: 0.60-1.11; p = 0.195).

Conclusion: Ticagrelor significantly reduced the risk of MACE than clopidogrel for AMI patients with MVD in Korea. However, the risk of TIMI major or minor bleeding was higher and the net clinical benefit was similar. Further large-scale multi-center randomized clinical trials are needed to clarify the proper use dual antiplatelet therapy in East Asian populations.
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http://dx.doi.org/10.1016/j.jjcc.2019.11.003DOI Listing
May 2020

Clopidogrel versus Aspirin after Dual Antiplatelet Therapy in Acute Myocardial Infarction Patients Undergoing Drug-Eluting Stenting.

Korean Circ J 2020 Feb 11;50(2):120-129. Epub 2019 Oct 11.

Department of Cardiology, Kyungsang National University Hospital, Jinju, Korea.

Background And Objectives: There is a paucity of data regarding the benefit of clopidogrel monotherapy after dual antiplatelet therapy (DAPT) in patients treated with drug-eluting stents (DES). This study compared outcome between clopidogrel versus aspirin as monotherapy after DES for acute myocardial infarction (MI).

Methods: From Korea Acute Myocardial Infarction Registry-National Institute of Health database, 1,819 patients treated with DES who were switched to monotherapy with clopidogrel (n=534) or aspirin (n=1,285) after uneventful 12-month DAPT were analyzed. The primary endpoint was net adverse clinical events (NACE), defined as a composite of death from any cause, MI, repeat percutaneous coronary intervention (PCI), stent thrombosis, ischemic stroke, or major bleeding during the period from 12 to 24 months.

Results: After adjustment using inverse probability of treatment weighting, patients who received clopidogrel, compared with those treated with aspirin, had a similar incidence of NACE (0.7% and 0.7%; hazard ratio, 1.06; 95% confidence interval, 0.31-3.60; p=0.923). The 2 groups had similar rates of death from any cause (0.1% in each group, p=0.789), MI (0.3% and 0.1%, respectively; p=0.226), repeat PCI (0.1% and 0.3%, respectively; p=0.548), stent thrombosis (0.1% and 0%, respectively; p=0.121), major bleeding (0.2% in each group, p=0.974), and major adverse cardiovascular and cerebrovascular events (0.5% in each group, p=0.924).

Conclusions: Monotherapy with clopidogrel, compared to aspirin, after DAPT showed similar clinical outcomes in patients with acute MI treated with DES.
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http://dx.doi.org/10.4070/kcj.2019.0166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6974667PMC
February 2020

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

Korean J Intern Med 2020 01 28;35(1):119-132. Epub 2019 Nov 28.

Division of Cardiology, Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Korea.

Background/aims: Minimising total ischemic time (TIT) is important for improving clinical outcomes in patients with ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention (PCI). TIT has not shown a significant improvement due to persistent pre-hospital delay. This study aimed to investigate the risk factors associated with pre-hospital delay.

Methods: Individuals enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health between 2011 and 2015 were included in this study. The study population was analyzed according to the symptom-to-door time (STDT; within 60 or > 60 minutes), and according to the type of hospital visit (emergency medical services [EMS], non-PCI center, or PCI center).

Results: A total of 4,874 patients were included in the analysis, of whom 28.4% arrived at the hospital within 60 minutes of symptom-onset. Old age (> 65 years), female gender, and renewed ischemia were independent predictors of delayed STDT. Utilising EMS was the only factor shown to reduce STDT within 60 minutes, even when cardiogenic shock was evident. The overall frequency of EMS utilisation was low (21.7%). Female gender was associated with not utilising EMS, whereas cardiogenic shock, previous myocardial infarction, familial history of ischemic heart disease, and off-hour visits were associated with utilising EMS.

Conclusion: Factors associated with delayed STDT and not utilising EMS could be targets for preventive intervention to improve STDT and TIT.
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http://dx.doi.org/10.3904/kjim.2019.123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960059PMC
January 2020

Improvement of Left Ventricular Ejection Fraction and Pulmonary Hypertension Are Significant Prognostic Factors in Heart Failure with Reduced Ejection Fraction Patients.

J Cardiovasc Imaging 2019 Oct;27(4):257-265

Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.

Background: We evaluated long-term prognosis according to improvement of pulmonary hypertension (PH) and left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF) and PH.

Methods: We included all consecutive patients with HFrEF and PH who had a baseline and follow-up echocardiographic examinations from September 2011 to March 2017. PH was defined as maximal velocity of tricuspid regurgitation (TR Vmax) over 3.0 m/s, and LVEF improvement was defined as LVEF change ≥ 15% from the baseline echocardiography. Primary outcome was 5-year major adverse cardio-cerebrovascular events (MACCE).

Results: We analyzed 271 patients. Mean LVEF was 28±8% and TR Vmax was 3.4±0.4 m/s. On follow-up, 183 (68%) showed improvement of LVEF, and 165 (61%) demonstrated improvement of PH. We classified patients into 4 groups according to improvement of PH and LVEF; group 1 (both improvement, 134 patients), group 2 (PH improvement only, 31 patients), group 3 (LVEF improvement only, 49 patients) and group 4 (no improvement, 57 patients). Group 4 had older age, higher incidence of myocardial infarction and aggravation of pre-existing HF. During the follow-up (31±20 months), 27% died and 40.8% experienced MACCE. Group 4 had the worst survival (HR=4.332, 95% CI=2.396-7.833, p<0.001), and group 3 had increased MACCE rate (HR=2.030, 95% CI=1.060-3.888, p=0.033) compared with group 1. Group 2 had similar long-term clinical events (HR=1.085, 95% CI=0.458-2.571, p=0.853) to group 1.

Conclusions: In patients with HFrEF and PH, persistence of PH and no LVEF improvement was associated with the worst long-term outcome.
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http://dx.doi.org/10.4250/jcvi.2019.27.e36DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795568PMC
October 2019

Dual antiplatelet therapy beyond 12 months versus for 12 months after drug-eluting stents for acute myocardial infarction.

J Cardiol 2020 01 24;75(1):66-73. Epub 2019 Sep 24.

Kyungsang National University Hospital, Jinju, Republic of Korea.

Background: The optimal duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome remains uncertain. This study investigated the benefit of DAPT beyond 12 months after drug-eluting stents (DES) for acute myocardial infarction (MI).

Methods: From Korea Acute Myocardial Infarction Registry-National Institute of Health database, 6199 patients treated with DAPT for 12 months after DES (second-generation DES 98%) without ischemic or bleeding events were analyzed. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), a composite of death from any cause, MI, or ischemic stroke during the period from 12 to 24 months.

Results: After adjustment using inverse probability of treatment weighting, patients who received DAPT beyond 12 months (n=4795), compared to patients treated with 12-month DAPT (n=1404), had a similar incidence of MACCE (1.3% vs. 1.0%, HR: 1.32, 95% CI: 0.71-2.45, p=0.378). The 2 groups did not differ significantly in the rates of death (0.1% vs. 0.1%), MI (0.8% vs.0.6%), stent thrombosis (0.1% vs. 0.2%), ischemic stroke (0.4% vs. 0.2%), and major bleeding (0.1% vs. 0.1%). The rate of net adverse clinical events was 1.4% with DAPT beyond 12 months and 1.1% with 12-month DAPT (p=0.466).

Conclusions: DAPT beyond 12 months, as compared with 12-month DAPT, in real-world patients with acute MI treated predominantly with second-generation DES did not reduce the risk of MACCE. The rates of major bleeding and net adverse clinical events did not differ significantly between the 2 treatments.
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http://dx.doi.org/10.1016/j.jjcc.2019.06.006DOI Listing
January 2020

Comparison of Two-Year Outcomes of Acute Myocardial Infarction Caused by Coronary Artery Spasm Versus that Caused by Coronary Atherosclerosis.

Am J Cardiol 2019 11 23;124(10):1493-1500. Epub 2019 Aug 23.

Chonnam National University Hospital, Gwangju, South Korea.

The study compared the 2-year outcomes of patients diagnosed with acute myocardial infarction (AMI) triggered by coronary artery atherosclerosis and AMI caused by coronary artery spasm. A total of 36,797 patients in the Korea AMI Registry were grouped into 2 categories-(1) AMI due to coronary artery spasm without stenotic lesion (CAS-AMI, n = 484); and (2) AMI induced by coronary artery atherosclerosis (CAA-AMI, n = 36,313). The major clinical outcomes of the 2 groups were compared over a 2-year clinical follow-up period. Major adverse cardiac events (MACE) were defined as the composite of total death, nonfatal myocardial infarction, and repeat revascularization. The incidence of MACE (7.1% vs 11.1%; p = 0.007) and repeat revascularization (0.4% vs 4.2%; p <0.001) in the CAS-AMI group were significantly lower than in the CAA-AMI group at 2 years. However, the incidence of total death and nonfatal myocardial infarction was similar in both the groups. Aborted cardiac arrest was strongly associated with 2-year mortality in the CAS-AMI group (hazard ratios 13.5, 95% confidence interval 5.34 to 34.15, p <0.001) The incidence of MACE in CAS-AMI patients was significantly lower than in the CAA-AMI group of patients up to 2 years due to the relatively lower rate of repeat revascularization in CAS-AMI patients. However, the incidence of total death or nonfatal myocardial infarction in CAS-AMI patients was not different from that of patients with CAA-AMI.
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http://dx.doi.org/10.1016/j.amjcard.2019.08.019DOI Listing
November 2019

Association between non-alcoholic fatty liver disease and risk of new-onset atrial fibrillation in healthy adults.

Liver Int 2020 02 22;40(2):338-346. Epub 2019 Sep 22.

Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University, Chungnam National University Hospital, Daejeon, Korea.

Background & Aims: Previous studies demonstrated conflicting results regarding the association between non-alcoholic fatty liver disease (NAFLD) and atrial fibrillation (AF). The statistical power was not sufficient because of modest sample sizes of these studies. We analysed a large population-based cohort to evaluate the association between NAFLD and AF.

Methods: We evaluated 334 280 healthy individuals without comorbidities who underwent National Health check-ups in South Korea from 2009 to 2014. NAFLD was defined by a surrogate marker, the fatty liver index (FLI). The association between FLI and AF incidence was analysed using multivariate Cox proportional hazards regression models.

Results: During a median follow-up of 5.3 years, 1415 subjects (0.4%) were newly diagnosed with AF. Subjects were categorized into quartile groups according to FLI (range: Q1, 0-4.9; Q2, 5.0-12.5; Q3, 12.6-31.0; Q4, >31.0). The cumulative incidence of AF was significantly higher in subjects with higher FLIs than in those with lower FLIs (Q1, 167 [0.2%]; Q2, 281 [0.3%]; Q3, 470 [0.6%]; Q4, 497 [0.6%]; P < .001). Adjusted hazard ratios (HRs) indicated that a higher FLI was independently associated with an increased risk for AF (HR between Q4 and Q1, 1.35; 95% confidence interval [CI], 1.11-1.63; P = .002). After further adjustment for the interim events (diabetes, hypertension, heart failure and myocardial infarction), this association remained statistically significant (HR between Q4 and Q1, 1.55; 95% CI, 1.19-2.03; P = .001).

Conclusions: NAFLD, assessed by FLI, was independently associated with increased risk for AF in healthy Korean population. Moreover, NAFLD itself predisposes to AF independently of the interim events.
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http://dx.doi.org/10.1111/liv.14236DOI Listing
February 2020

Usefulness of Calculation of Cardiovascular Risk Factors to Predict Outcomes in Patients With Acute Myocardial Infarction.

Am J Cardiol 2019 09 25;124(6):857-863. Epub 2019 Jun 25.

Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea; School of Medicine, Kyungpook National University, Daegu, Republic of Korea.

Cardiovascular risk factors contribute differently to short-term prognosis of acute myocardial infarction (AMI); hypertension and diabetes increase adverse outcomes, whereas hyperlipidemia, smoking, and obesity seem to paradoxically decrease these in post-MI patients. We aimed to investigate whether a simple calculation of conventional risk factors, PARADOCS (Pressure of ARtery elevAtion, Diabetes, Obesity, Cholesterol, Smoking) score, would improve the ability to predict major adverse cardiac and cerebrovascular events (MACCEs) in post-MI patients. Between November 2011 and December 2015, 13,104 patients with diagnosis of AMI were analyzed in this study from Korean AMI Registry - National Institute of Health database. PARADOCS score was calculated as follows: (number of nonparadoxical risk factors - number of paradoxical risk factors) + 3 where nonparadoxical risk factors are hypertension and diabetes, and paradoxical risk factors are hyperlipidemia, smoking, and obesity. PARADOCS score was significantly greater in patients with 1-year MACCEs compared with those without MACCEs (3.43 ± 1.03 vs 2.88 ± 1.11, p <0.001). In Cox proportional hazards model, PARADOCS score was an independent predictor of 1-year MACCEs (hazards ratio 1.23, 95% confidence interval 1.16 to 1.30; p <0.001) after adjusting for confounding variables. In Kaplan-Meier survival curve, patients with greater PARADOCS score had worse clinical outcome. In conclusion, although it needs more validation, a simple calculation of risk factors, PARADOCS score, could provide useful prognostic information of MI patients to clinicians.
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http://dx.doi.org/10.1016/j.amjcard.2019.06.010DOI Listing
September 2019
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