Publications by authors named "Soonil Kwon"

69 Publications

Association between exercise habits and stroke, heart failure, and mortality in Korean patients with incident atrial fibrillation: A nationwide population-based cohort study.

PLoS Med 2021 Jun 8;18(6):e1003659. Epub 2021 Jun 8.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.

Background: There is a paucity of information about cardiovascular outcomes related to exercise habit change after a new diagnosis of atrial fibrillation (AF). We investigated the association between exercise habits after a new AF diagnosis and ischemic stroke, heart failure (HF), and all-cause death.

Methods And Findings: This is a nationwide population-based cohort study using data from the Korea National Health Insurance Service. A retrospective analysis was performed for 66,692 patients with newly diagnosed AF between 2010 and 2016 who underwent 2 serial health examinations within 2 years before and after their AF diagnosis. Individuals were divided into 4 categories according to performance of regular exercise, which was investigated by a self-reported questionnaire in each health examination, before and after their AF diagnosis: persistent non-exercisers (30.5%), new exercisers (17.8%), exercise dropouts (17.4%), and exercise maintainers (34.2%). The primary outcomes were incidence of ischemic stroke, HF, and all-cause death. Differences in baseline characteristics among groups were balanced considering demographics, comorbidities, medications, lifestyle behaviors, and income status. The risks of the outcomes were computed by weighted Cox proportional hazards models with inverse probability of treatment weighting (IPTW) during a mean follow-up of 3.4 ± 2.0 years. The new exerciser and exercise maintainer groups were associated with a lower risk of HF compared to the persistent non-exerciser group: the hazard ratios (HRs) (95% CIs) were 0.95 (0.90-0.99) and 0.92 (0.88-0.96), respectively (p < 0.001). Also, performing exercise any time before or after AF diagnosis was associated with a lower risk of mortality compared to persistent non-exercising: the HR (95% CI) was 0.82 (0.73-0.91) for new exercisers, 0.83 (0.74-0.93) for exercise dropouts, and 0.61 (0.55-0.67) for exercise maintainers (p < 0.001). For ischemic stroke, the estimates of HRs were 10%-14% lower in patients of the exercise groups, yet differences were statistically insignificant (p = 0.057). Energy expenditure of 1,000-1,499 MET-min/wk (regular moderate exercise 170-240 min/wk) was consistently associated with a lower risk of each outcome based on a subgroup analysis of the new exerciser group. Study limitations include recall bias introduced due to the nature of the self-reported questionnaire and restricted external generalizability to other ethnic groups.

Conclusions: Initiating or continuing regular exercise after AF diagnosis was associated with lower risks of HF and mortality. The promotion of exercise might reduce the future risk of adverse outcomes in patients with AF.
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http://dx.doi.org/10.1371/journal.pmed.1003659DOI Listing
June 2021

Clinical Characteristics of Eyes Showing a Discrete Margin of Different Retinal Reflectivity.

Ophthalmic Surg Lasers Imaging Retina 2021 May 1;52(5):273-280. Epub 2021 May 1.

Background And Objective: To evaluate the clinical characteristics of discrete margins of different retinal reflectivity (DMDRR) in ultra-widefield fundus photography.

Patients And Methods: This DMDRR comprises a discrete border, with differing patterns of reflectivity on either side. Spectral-domain optical coherence tomography was performed on both the macula and the margin. The incidences of epiretinal membrane (ERM) and peripheral retinal pathologies of patients with a DMDRR (n = 36) were compared with a control group (n = 41).

Results: An ellipsoid zone (EZ) defect at the DMDRR was detected in 34 eyes (92.2%), and vitreous traction was detected in 20 eyes (55.6%). A significantly higher proportion of eyes in the DMDRR group had an ERM, retinal hole, and cystic retinal tuft compared with the control group ( = .022, = .010, and < .001, respectively).

Conclusions: The DMDRR indicates EZ disruption that may originate from vitreous traction. Meticulous observation for vitreoretinal interface diseases is mandatory for these patients. .
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http://dx.doi.org/10.3928/23258160-20210429-05DOI Listing
May 2021

Increased Risk of Atrial Fibrillation in Patients with Atopic Triad: A Nationwide Population-Based Study.

J Allergy Clin Immunol Pract 2021 May 22. Epub 2021 May 22.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.

Background: Despite a sharp increase in the global prevalence of allergy over the past decade, the relation between multiple atopic conditions and atrial fibrillation (AF) has not been fully elucidated.

Objective: To determine whether there is an association between atopic diseases and AF and to examine the effect of multiple atopic diseases on the incidence of AF.

Methods: This retrospective population-based study used the database from the 2009 National Health Insurance Services-Health Screening Cohort in Korea. A total of 6,748,564‬ subjects without a previous history of AF were included in the final analysis and observed until 2017. The atopic triad included asthma, allergic rhinitis, and atopic dermatitis. A total of 1,168,196‬ subjects (17.3%) with at least one atopic disease were classified as the atopic group. The primary outcome was new-onset AF.

Results: During a median 7.2 ± 1.0 years of follow-up, 136,253‬ subjects were given the new diagnosis of AF (30,300 in the atopic group and 105,953 in the nonatopic group). The incidence of AF was 3.63/1000 person-years in the atopic group and 2.64/1000 person-years in the nonatopic group. The risk for AF showed a positive correlation with the number of diseases in the atopic triad (adjusted hazard ratio [aHR], 95% confidence interval [CI]: one disease: aHR = 1.15, CI, 1.14-1.17; two diseases: aHR = 1.34, CI, 1.31-1.38; and three diseases: aHR = 1.35, CI, 1.11-1.66; P for trend < .001).

Conclusions: The atopic triad of asthma, allergic rhinitis, and atopic dermatitis was associated with an increased risk for AF. Moreover, multiple atopic conditions have a higher risk for AF.
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http://dx.doi.org/10.1016/j.jaip.2021.04.056DOI Listing
May 2021

Influence of mild non-foveal involving epiretinal membrane on visual quality in eyes with multifocal intraocular lens implantation.

Graefes Arch Clin Exp Ophthalmol 2021 May 8. Epub 2021 May 8.

Keye Eye Center, 326 Teheran-ro, Gangnam-gu, Seoul, Korea.

Purpose: To determine the influence of mild non-foveal involving epiretinal membrane (ERM) on visual outcome in eyes with multifocal intraocular lens (MIOL) implantation.

Methods: Patients with history of MIOL implantation were screened for the presence of ERM using spectral-domain optical coherence tomography (SD-OCT) at postoperative 6 months. Ninety-one eyes with mild non-foveal involving ERM and history of MIOL implantation were compared with 83 age-matched controls without ERM and history of MIOL implantation. The visual acuity (corrected and uncorrected) and visual quality (contrast sensitivity, Strehl ratio, area ratio, and higher-order aberrations; HOAs) of the eyes with mild non-foveal involving ERM were compared with the data of the age-matched control group.

Results: There was no difference in visual acuity between the groups at baseline and postoperative 6 months. The mild non-foveal involving ERM group showed significantly low contrast sensitivity at a visual angle of 4.0°, 2.5°, 1.0°, and 0.64° under scotopic conditions (P = .048, P = .025, P = .003, and P = .02, respectively) and 4.0°, 1.0°, and 0.64° under photopic conditions (P = .028, P = .002, and P = .001, respectively). The mean area ratio of the mild non-foveal involving ERM group was 45.13 ± 10.93, which was significantly lower than that of the control group, which measured 50.34 ± 12.66 (P = .044).

Conclusion: A mild non-foveal involving ERM has no effect on visual acuity, but it reduces visual quality in eyes with MIOL implantation. A thorough screening using SD-OCT is warranted for this condition when considering MIOL implantation.
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http://dx.doi.org/10.1007/s00417-021-05225-wDOI Listing
May 2021

Validation of Adhesive Single-Lead ECG Device Compared with Holter Monitoring among Non-Atrial Fibrillation Patients.

Sensors (Basel) 2021 Apr 30;21(9). Epub 2021 Apr 30.

Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.

There are few reports on head-to-head comparisons of electrocardiogram (ECG) monitoring between adhesive single-lead and Holter devices for arrhythmias other than atrial fibrillation (AF). This study aimed to compare 24 h ECG monitoring between the two devices in patients with general arrhythmia. Twenty-nine non-AF patients with a workup of pre-diagnosed arrhythmias or suspicious arrhythmic episodes were evaluated. Each participant wore both devices simultaneously, and the cardiac rhythm was monitored for 24 h. Selective ECG parameters were compared between the two devices. Two cardiologists independently compared the diagnoses of each device. The two most frequent monitoring indications were workup of premature atrial contractions (41.4%) and suspicious arrhythmia-related symptoms (37.9%). The single-lead device had a higher noise burden than the Holter device (0.04 ± 0.05% vs. 0.01 ± 0.01%, = 0.024). The number of total QRS complexes, ventricular ectopic beats, and supraventricular ectopic beats showed an excellent degree of agreement between the two devices (intraclass correlation coefficients = 0.991, 1.000, and 0.987, respectively). In addition, the minimum/average/maximum heart rates showed an excellent degree of agreement. The two cardiologists made coherent diagnoses for all 29 participants using both monitoring methods. In conclusion, the single-lead adhesive device could be an acceptable alternative for ambulatory ECG monitoring in patients with general arrhythmia.
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http://dx.doi.org/10.3390/s21093122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8124998PMC
April 2021

Longitudinal Patterns in Antithrombotic Therapy in Patients with Atrial Fibrillation after Percutaneous Coronary Intervention in the Non-Vitamin K Oral Anticoagulant Era: A Nationwide Population-Based Study.

J Clin Med 2021 Apr 4;10(7). Epub 2021 Apr 4.

Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea.

We investigated whether longitudinal patterns in antithrombotic therapy have changed after the introduction of non-vitamin K oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI). Using a claims database of the Korean AF population who underwent PCI between 2012 and 2016 ( = 18,691), we analyzed prescription records of oral anticoagulants (OACs) and antiplatelets at 3-month intervals over 2 years after PCI. The study population was stratified (pre-NOAC, transition, and NOAC era) using time-periods of NOAC introduction in Korea and an expansion of reimbursement for NOAC in AF as indicators. The overall rates of OAC were low at baseline (24.9%, 26.9%, and 35.2% in pre-NOAC, transition, and NOAC era, respectively), contrary to high rates of dual antiplatelet therapy (DAPT) (73.3%, 71.4%, and 63.6%). However, OAC prescription rates were increased at 1-year (18.5%, 22.5%, and 31.6%), and 2-year follow-up (17.8%, 24.2%, and 31.8%) from pre-NOAC to NOAC era. In NOAC era, 63.5% of baseline OAC prescriptions comprised NOAC, of which 96.4% included triple therapy with DAPT. Over 2 years, we observed increasing rates of double therapy with a single antiplatelet (18.3% and 20.0% at 1- and 2-year follow-up) and OAC monotherapy (2.7% and 8.9% at 1- and 2-year follow-up).
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http://dx.doi.org/10.3390/jcm10071505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8038511PMC
April 2021

Impact of Non-Vitamin K Antagonist Oral Anticoagulants on the Change of Antithrombotic Regimens in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention.

Korean Circ J 2021 May 25;51(5):409-422. Epub 2021 Jan 25.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.

Background And Objectives: Antithrombotic therapy after percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) has changed in recent years with new data from large randomized trials and updates to clinical guidelines. This study aimed to investigate the trends in periprocedural antithrombotic regimens in Korean patients with AF undergoing PCI with non-vitamin K antagonist oral anticoagulants (NOACs).

Methods: Using the claims database of the Health Insurance Review and Assessment during 2013-2018, 27,594 patients with AF undergoing PCI were identified. The annual prevalence of PCI and prescriptions of each antithrombotic agent, including antiplatelet agents and oral anticoagulants, within 30 days after PCI were investigated.

Results: During 2013-2018, the number of patients with AF undergoing PCI increased up to 1.3-fold (from 3,913 to 5,075 patients per year). After the introduction of NOACs, the proportion of dual antiplatelet therapy (DAPT) decreased from 71.9% to 49.8% but still occupied the largest proportion among antithrombotic regimens. Triple antithrombotic therapy (TAT) use increased from 25.4% to 46.0%, and NOAC has rapidly replaced warfarin as the oral anticoagulant of choice. TAT was preferred to DAPT for patients with CHA₂DS₂-VASc score ≥2. Among various factors, prior intracranial hemorrhage was the most powerful predictor of favoring DAPT use over TAT.

Conclusion: Since the introduction of NOACs, the patterns of periprocedural antithrombotic regimens have changed rapidly toward more use of TAT, specifically with NOAC-based regimen. Appropriate stroke prevention with oral anticoagulants is still underutilized in patients with AF undergoing PCI in Korea.
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http://dx.doi.org/10.4070/kcj.2020.0407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112178PMC
May 2021

Proton Pump Inhibitor Co-Therapy in Patients with Atrial Fibrillation Treated with Oral Anticoagulants and a Prior History of Upper Gastrointestinal Tract Bleeding.

Cardiovasc Drugs Ther 2021 Mar 17. Epub 2021 Mar 17.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.

Purpose: The risk of gastrointestinal bleeding (GIB) can be mitigated by proton pump inhibitor (PPI) co-therapy in patients with atrial fibrillation (AF) treated with anticoagulants. We aimed to evaluate the effect of PPIs on the risk of GIB in Asian patients with AF, treated with oral anticoagulants (OACs), and with a prior history of upper GIB.

Methods: Using a nationwide claims database, OAC-naïve patients with AF and a history of upper GIB before initiating OAC treatment between January 2010 and April 2018 were included. Patients were categorized into 10 groups according to the index OAC (warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban) and whether or not they received PPI co-therapy, and were followed up for incidence of major GIB.

Results: Among a total of 42,048 patients, 40% were prescribed PPIs as co-therapy with OACs. Over a median 0.6 years (interquartile ranges 0.2-1.7 years) of follow-up, rivaroxaban use without PPIs showed the highest crude incidence of major GIB (2.62 per 100 person-years), followed by the use of warfarin without a PPI (2.20 per 100 person-years). Compared to the patients without PPI use, PPI co-therapy was associated with a significantly lower risk of major GIB, by 40% and 36%, in the rivaroxaban and warfarin groups, respectively. In dabigatran, apixaban, and edoxaban users, PPI co-therapy did not show a significant reduction in the risk of major GIB.

Conclusion: Among patients with AF receiving anticoagulant treatment and with a prior history of upper GIB, PPI co-therapy was associated with a significant reduction in the risk of major GIB in patients treated with rivaroxaban and warfarin.
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http://dx.doi.org/10.1007/s10557-021-07170-6DOI Listing
March 2021

Motor Asymmetry and Interocular Retinal Thickness in Parkinson's Disease.

J Korean Med Sci 2021 Feb 8;36(6):e50. Epub 2021 Feb 8.

Department of Ophthalmology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.

Background: To analyze the relationship between interocular difference of retinal thickness and motor asymmetry in Parkinson's disease (PD).

Methods: Prospective case-control series analyzed 62 eyes of 31 patients with PD and 62 eyes of 31 age- and sex-matched control. Ophthalmologic examinations including optical coherence tomography (OCT) scans were performed in both groups, and in the patients with PD, motor function was evaluated on the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) to determine the clinically more affected side. Peripapillary retinal nerve fiber layer thickness (pRNFLT) and macular retinal thickness (mRT) were measured in both eyes, after which the interocular asymmetry of the OCT parameters was determined. Additionally, the more and less affected sides of the UPDRS-III were evaluated using Symmetric index.

Results: The average and quadrant pRNFLT and mRT values between the two groups were not different, but the interocular asymmetry of the average mRT and asymmetry index of retinal thickness (AIRT) of temporal mRT were significantly higher in the PD patients than in the controls ( = 0.026 and 0.044). The sum of UPDRS-III showed a discrepancy between the more and less affected sides ( = 0.002); the calculated Symmetric index was 0.21 ± 0.19, which suggested asymmetric motor symptoms. The Symmetric index of UPDRS-III showed significant relations for interocular asymmetry of superior mRT and AIRT of average mRT ( = 0.001 and 0.008).

Conclusion: In the PD patients, the interocular asymmetry of mRT was larger than in the controls, and the motor symptoms were asymmetric. Additionally, the interocular asymmetry of mRT showed a significant correlation with motor-symptom laterality.
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http://dx.doi.org/10.3346/jkms.2021.36.e50DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870420PMC
February 2021

Predictors of ischemic stroke for low-risk patients with atrial fibrillation: A matched case-control study.

Heart Rhythm 2021 May 19;18(5):702-708. Epub 2021 Jan 19.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Background: The predictors of ischemic stroke in "low-risk" patients with atrial fibrillation (AF) (CHADS-VASc score 0 in men or 1 in women) are debated.

Objective: This study aimed to investigate the factors associated with ischemic stroke in low-risk patients with AF. Imaging characteristics of their ischemic strokes were also evaluated.

Methods: This was a matched case-control study conducted at a single tertiary institution. We identified 44 patients with de novo ischemic stroke and incidentally found AF with a low-risk CHADS-VASc score. A 1:5 age- and sex-matched control group was selected for patients with AF and a low-risk CHADS-VASc score but without ischemic stroke and oral anticoagulant therapy. Conditional multivariate logistic regression analysis was performed to identify the predictors.

Results: There were no significant differences in age, sex, body mass index, comorbidities, left atrial size, and left ventricular ejection fraction. Smokers were more prevalent in the stroke group than in the nonstroke group (24 of 44 [54.5%] vs 22 of 220 [10.0%]; P < .001). Additionally, the mean white blood cell count was significantly higher in the stroke group (P = .019). In conditional univariate logistic regression analysis, smoking and white blood cell count were significant predictors of stroke. In multivariate analysis, smoking was the only significantly associated factor (matched odds ratio 9.10; 95% confidence interval 2.48-33.42). In the stroke group, 14 of 44 patients (31.8%) had multiple vascular territory infarcts.

Conclusion: Smoking was the predictor associated with ischemic stroke in patients with AF and a low-risk CHADS-VASc score.
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http://dx.doi.org/10.1016/j.hrthm.2021.01.016DOI Listing
May 2021

Cumulative burden of metabolic syndrome and its components on the risk of atrial fibrillation: a nationwide population-based study.

Cardiovasc Diabetol 2021 01 19;20(1):20. Epub 2021 Jan 19.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.

Background: The metabolic syndrome (MetS) and its components are associated with the development of atrial fibrillation (AF). However, the impact of time-burden of MetS on the risk of AF is unknown. We investigated the effect of the cumulative longitudinal burden of MetS on the development of AF.

Methods: We included 2 885 189 individuals without AF who underwent four annual health examinations during 2009-2013 from the database of the Korean national health insurance service. Metabolic burdens were evaluated in the following three ways: (1) cumulative number of MetS diagnosed at each health examination (0-4 times); (2) cumulative number of each MetS component diagnosed at each health examination (0-4 times per MetS component); and (3) cumulative number of total MetS components diagnosed at each health examination (0 to a maximum of 20). The risk of AF according to the metabolic burden was estimated using Cox proportional-hazards models.

Results: Of all individuals, 62.4%, 14.8%, 8.7%, 6.5%, and 7.6% met the MetS diagnostic criteria 0, 1, 2, 3, and 4 times, respectively. During a mean follow-up of 5.3 years, the risk of AF showed a positive association with the cumulative number of MetS diagnosed over four health examinations: adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of 1, 2, 3, and 4 times compared to 0 times were 1.18 (1.13-1.24), 1.31 (1.25-1.39), 1.46 (1.38-1.55), and 1.72 (1.63-1.82), respectively; P for trend < 0.001. All five components of MetS, when diagnosed repeatedly, were independently associated with an increased risk of AF: adjusted HR (95% CI) from 1.22 (1.15-1.29) for impaired fasting glucose to 1.96 (1.87-2.07) for elevated blood pressure. As metabolic components were accumulated from 0 to 20 counts, the risk of AF also gradually increased up to 3.1-fold (adjusted HR 3.11, 95% CI 2.52-3.83 in those with 20 cumulative components of MetS), however, recovery from MetS was linked to a decreased risk of AF.

Conclusions: Given the positive correlations between the cumulative metabolic burdens and the risk of incident AF, maximal effort to detect and correct metabolic derangements even before MetS development might be important to prevent AF and related cardiovascular diseases.
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http://dx.doi.org/10.1186/s12933-021-01215-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816376PMC
January 2021

Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and Prior Gastrointestinal Bleeding.

Stroke 2021 Jan 8;52(2):511-520. Epub 2021 Jan 8.

Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea (E.-K.C., S.O., G.Y.H.L.).

Background And Purpose: Limited data support the benefits of non-vitamin K oral anticoagulants (NOACs) among atrial fibrillation patients with prior gastrointestinal bleeding (GIB). We aimed to evaluate the effectiveness and safety of NOACs compared with those of warfarin among atrial fibrillation patients with prior GIB.

Methods: Oral anticoagulant-naive individuals with atrial fibrillation and prior GIB between January 2010 and April 2018 were identified from the Korean claims database. NOAC users were compared with warfarin users by balancing covariates using the inverse probability of treatment weighting method. The primary outcomes were ischemic stroke, major bleeding, and the composite outcome (combined ischemic stroke and major bleeding). Fatal events from each outcome were evaluated as secondary outcomes.

Results: A total of 42 048 patients were included (24 781 in the NOAC group and 17 267 in the warfarin group). The mean time from prior GIB to the initiation of oral anticoagulant was 3.1±2.6 years. After inverse probability of treatment weighting, baseline characteristics were balanced between the two groups (mean age, 72 years; men, 56.8%; and mean CHADS-VASc score, 3.7). Lower risks of ischemic stroke, major bleeding, and the composite outcome were associated with NOAC use than with warfarin use (weighted hazard ratio, 0.608 [95% CI, 0.543-0.680]; hazard ratio, 0.731 [95% CI, 0.642-0.832]; and hazard ratio, 0.661 [95% CI, 0.606-0.721], respectively). For all secondary outcomes, NOACs showed greater risk reductions compared with warfarin.

Conclusions: NOACs were associated with lower risks of ischemic stroke and major bleeding than warfarin among atrial fibrillation patients with prior GIB.
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http://dx.doi.org/10.1161/STROKEAHA.120.030761DOI Listing
January 2021

Increased atrial fibrillation risk in Parkinson's disease: A nationwide population-based study.

Ann Clin Transl Neurol 2021 01 3;8(1):238-246. Epub 2021 Jan 3.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.

Objective: Parkinson's disease (PD) is the second most common neurodegenerative disorder associated with various morbidities. Although the relationship between cardiovascular disease and PD has been studied, a paucity of information on PD and atrial fibrillation (AF) association exists. Thus, we aimed to investigate whether patients with PD have an increased risk of AF.

Methods: This study included 57,585 patients with newly diagnosed PD (≥40-year-old, mean age 69.7 years, men 40.2%) and without a history of AF from the Korean National Health Insurance Service (NHIS) database between 2010 and 2015. Furthermore, an equal number of age- and sex-matched subjects without PD were selected for comparison. The primary outcome was new-onset AF.

Results: During the mean follow-up period of 3.4 ± 1.8 years, AF was newly diagnosed in 3,665 patients. A significantly higher incidence rate of AF was noted among patients with PD than among patients without PD (10.75 and 7.86 per 1000 person-year, respectively). Multivariate Cox-regression analysis revealed that PD was an independent risk factor for AF (hazard ratio [HR]: 1.27, 95% confidence interval [CI]: 1.18-1.36). Furthermore, subgroup analyses revealed that AF risk was higher in the younger age subgroups, and compared with the non-PD group, the youngest PD group (age: 40-49 years) had a threefold increased risk of AF (HR: 3.06, 95% CI: 1.20-7.77).

Interpretation: Patients with PD, especially the younger age subgroups, have an increased risk of AF. Active surveillance and management of AF should be considered to prevent further complications.
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http://dx.doi.org/10.1002/acn3.51279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818085PMC
January 2021

Opportunities for Increased Nitrogen Use Efficiency in Wheat for Forage Use.

Plants (Basel) 2020 Dec 9;9(12). Epub 2020 Dec 9.

Grass Genomics, Noble Research Institute, LLC, 2510 Sam Noble Parkway, Ardmore, OK 73401, USA.

Wheat is a major cool-season forage crop in the southern United States. The objective of this study is to understand the effect of nitrogen (N) fertilization on wheat biomass yield, quality, nitrogen use efficiency (NUE), and nitrogen nutrition index (NNI). The experiments were conducted in a greenhouse and a hoop house in a split-plot design, with three replications. Twenty wheat cultivars/lines were evaluated at four N rates (0, 75, 150, and 300 mg N.kg soil) in the greenhouse and (0, 50, 100, and 200 mg N.kg soil) in the hoop house. In general, high-NUE lines had lower crude protein content than the low-NUE lines. None of the cultivars/lines reached a plateau for biomass production or crude protein at the highest N rate. The line × N rate interaction for NUE was not significant in the greenhouse ( = 0.854) but was highly significant in the hoop house ( 0.001). NNI had a negative correlation with NUE and biomass. NUE had strong positive correlations with shoot biomass and total biomass but low to moderate correlations with root biomass. NUE also had a strong positive correlation with N uptake efficiency. Lines with high NUE can be used in breeding programs to enhance NUE in wheat for forage use.
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http://dx.doi.org/10.3390/plants9121738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7764361PMC
December 2020

Relationship between dominant frequency, organization index, and left atrial size in patients with atrial fibrillation.

J Cardiovasc Electrophysiol 2020 12 1;31(12):3159-3165. Epub 2020 Nov 1.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.

Introduction: Frequency domain analysis is a methodology for quantifying the organization of atrial fibrillation (AF) pattern to understand the pathophysiology of the electrical mechanism. We aimed to investigate whether the dominant frequency (DF) and organization index (OI) can indicate left atrial (LA) dilatation in patients with AF.

Methods And Results: This observational, retrospective, single-center cohort study assessed 100 patients with persistent AF. The study population was divided into two groups based on an anterior-posterior LA dimension (LAD of 50 mm) measured by transthoracic echocardiography. The groups were one-to-one propensity score-matched. Frequency domain analysis was performed using signals at leads II and V1 on surface electrocardiogram to calculate the DF and OI. In all patients, the DF was shown to have an inverse relationship with LAD (R = -.369, p < .001 in lead II; R = -.330, p = .001 in lead V1), while the OI was directly associated with LAD (R = .234, p = .190 in lead II; R = .283, p = .004 in lead V1). However, no significant relationship between the signal amplitude and LAD was observed. Compared to patients with LAD ≤ 50 mm, those with LAD > 50 mm had a lower DF (5.057 ± 0.740 vs. 4.542 ± 0.898, p = .002) and higher OI (0.261 ± 0.104 vs. 0.322 ± 0.116, p = .007) in lead V1. These findings were consistent with those found in lead II.

Conclusion: Patients with persistent AF and a larger LA size had a significantly higher OI and lower DF than those with a smaller LA size. Atrial electrical properties of structural remodeling are associated with increased organization of atrial signals.
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http://dx.doi.org/10.1111/jce.14785DOI Listing
December 2020

Factors predicting final visual outcome in quiescent proliferative diabetic retinopathy.

Sci Rep 2020 10 14;10(1):17233. Epub 2020 Oct 14.

Department of Ophthalmology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang, 14068, Republic of Korea.

To investigate factors reflecting visual outcome and macular perfusion in quiescent proliferative diabetic retinopathy (PDR) patients after panretinal photocoagulation (PRP). We included 118 patients with quiescent PDR who had completed PRP. All participants had standardized interview to determine ocular history, smoking status, cardiovascular risk factors, and history of diabetic mellitus (DM). Foveal avascular zone (FAZ) area, retinal vessel density (VD) and vessel length density (VLD) were measured using optical coherence tomography angiography. VD was negatively correlated with hypertension, diabetic foot, HbA1c, and time after PRP (β =  - 0.181, P = 0.046; β =  - 0.231, P = 0.020; β =  - 0.244, P = 0.010; β =  - 0.278, P = 0.029). FAZ area of superficial capillary plexus and deep capillary plexus (DCP) was positively correlated with DM duration and diabetic foot (β = 0.178, P = 0.047; β = 0.293, P = 0.002; β = 0.252, P = 0.045; β = 0.304, P = 0.002). Macular perfusion state in patients with quiescent PDR was associated with diabetic foot, DM duration, HbA1c, and time after PRP. Of note, diabetic foot showed the strongest correlation with macular perfusion among various systemic factors. VLD, especially in DCP was associated with poor visual outcome.
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http://dx.doi.org/10.1038/s41598-020-74184-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566633PMC
October 2020

Association of physical activity with all-cause and cardiovascular mortality in 7666 adults with hypertrophic cardiomyopathy (HCM): more physical activity is better.

Br J Sports Med 2020 Sep 23. Epub 2020 Sep 23.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA

Objectives: Recommendations on physical activity (PA) for adults with hypertrophic cardiomyopathy (HCM) are not well established. We investigated the association of PA intensity with mortality in the general adult HCM population.

Methods: A nationwide population-based cohort of individuals with HCM who underwent health check-ups including questionnaires on PA levels were identified from the years 2009 to 2016 in the National Health Insurance Service database. Subjects who reported no PA at baseline were excluded. To estimate each individual's PA level, the PA score (PAS) was calculated based on the self-reported questionnaires, and the study population was categorised into three groups according to tertiles of PAS. The associations of PAS with all-cause and cardiovascular mortality were analysed.

Results: A total of 7666 participants (mean age 59.5 years, 29.9% were women) were followed up for a mean 5.3±2.0 years. All-cause and cardiovascular mortality progressively decreased from the lowest to the highest tertiles of PA intensity: 9.1% (4.7%), 8.9% (3.8%) and 6.4% (2.7%), respectively (=0.0144 and 0.0023, respectively). Of note, compared with the middle PA group, the highest PA group did not have an increased risk of all-cause and cardiovascular mortality (HR 0.78, (95% CI 0.63 to 0.95) and HR 0.75 (95% CI 0.54 to 1.03), respectively). All subgroup and sensitivity analyses consistently showed that all-cause and cardiovascular mortality did not increase with higher PA levels.

Conclusions: Moderate-to-vigorous-intensity PA, in a middle-aged population of patients with HCM, was associated with progressive reduction of all-cause and cardiovascular mortality. The impact of vigorous-intensity PA on a younger age group requires further investigation.
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http://dx.doi.org/10.1136/bjsports-2020-101987DOI Listing
September 2020

Deep-Net: A Lightweight CNN-Based Speech Emotion Recognition System Using Deep Frequency Features.

Sensors (Basel) 2020 Sep 12;20(18). Epub 2020 Sep 12.

Interaction Technology Laboratory, Department of Software, Sejong University, Seoul 05006, Korea.

Artificial intelligence (AI) and machine learning (ML) are employed to make systems smarter. Today, the speech emotion recognition (SER) system evaluates the emotional state of the speaker by investigating his/her speech signal. Emotion recognition is a challenging task for a machine. In addition, making it smarter so that the emotions are efficiently recognized by AI is equally challenging. The speech signal is quite hard to examine using signal processing methods because it consists of different frequencies and features that vary according to emotions, such as anger, fear, sadness, happiness, boredom, disgust, and surprise. Even though different algorithms are being developed for the SER, the success rates are very low according to the languages, the emotions, and the databases. In this paper, we propose a new lightweight effective SER model that has a low computational complexity and a high recognition accuracy. The suggested method uses the convolutional neural network (CNN) approach to learn the deep frequency features by using a plain rectangular filter with a modified pooling strategy that have more discriminative power for the SER. The proposed CNN model was trained on the extracted frequency features from the speech data and was then tested to predict the emotions. The proposed SER model was evaluated over two benchmarks, which included the interactive emotional dyadic motion capture (IEMOCAP) and the berlin emotional speech database (EMO-DB) speech datasets, and it obtained 77.01% and 92.02% recognition results. The experimental results demonstrated that the proposed CNN-based SER system can achieve a better recognition performance than the state-of-the-art SER systems.
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http://dx.doi.org/10.3390/s20185212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7570673PMC
September 2020

Non-vitamin K antagonist oral anticoagulants in very elderly east Asians with atrial fibrillation: A nationwide population-based study.

Am Heart J 2020 11 15;229:81-91. Epub 2020 Aug 15.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Background: The evidence of effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) among elderly East Asians is limited.

Objectives: We aimed to describe the effectiveness and safety outcomes associated with NOACs and warfarin among elderly Koreans aged ≥80 years.

Methods: Using the Korean Health Insurance Review and Assessment service database, patients with atrial fibrillation (AF) who were naïve to index oral anticoagulant between 2015 and 2017 were included in this study (20,573 for NOACs and 4086 for warfarin). Two treatment groups were balanced using the inverse probability of treatment weighting (IPTW) method. The clinical outcomes including ischemic stroke, major bleeding including intracranial hemorrhage (ICH) and gastrointestinal bleeding (GIB), and a composite of these outcomes were evaluated.

Results: Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio 0.74 [95% confidence interval 0.62-0.89]), and composite outcome (0.78 [0.69-0.90]). NOACs showed nonsignificant trends towards to lower risks of GIB and major bleeding than warfarin. The risk of ICH of NOAC group was comparable with the warfarin group. Among NOACs, apixaban and edoxaban showed better composite outcomes than warfarin. Among the clinical outcomes, only ischemic stroke and the composite outcome had a significant interaction with age subgroups (80-89 years and ≥90 years, P-for-interaction = .097 and .040, respectively).

Conclusion: NOACs were associated with lower risks of ischemic stroke and the composite outcome (ischemic stroke and major bleeding) compared to warfarin in elderly East Asians. Physicians should be more confident in prescribing NOACs to elderly East Asians with AF.
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http://dx.doi.org/10.1016/j.ahj.2020.08.006DOI Listing
November 2020

Differential risk of incident cancer in patients with heart failure: A nationwide population-based cohort study.

J Cardiol 2021 Mar 28;77(3):231-238. Epub 2020 Aug 28.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address:

Background: Heart failure (HF) and cancer are currently two leading causes of mortality, and sometimes coexist. However, the relationship between them is not completely elucidated. We aimed to investigate whether patients with HF are predisposed to cancer development using the large Korean National Health Insurance claims database.

Methods: This study included 128,441 HF patients without a history of cancer and 642,205 age- and sex-matched individuals with no history of cancer and HF between 1 January 2010 and 31 December 2015.

Results: During a median follow-up of 4.06 years, 11,808 patients from the HF group and 40,805 participants from the control were newly diagnosed with cancer (cumulative incidence, 9.2% vs. 6.4%, p < 0.0001). Patients with HF presented a higher risk for cancer development compared to controls in multivariable Cox analysis [hazard ratio (HR) 1.64, 95% confidence interval (CI) 1.61-1.68]. The increased risk was consistent for all site-specific cancers. To minimize potential surveillance bias, additional analysis was performed by eliminating participants who developed cancer within the initial 2 years of HF diagnosis (i.e. 2-year lag analysis). In the 2-year lag analysis, the higher risk of overall cancer remained significant in patients with HF (HR 1.09, 95% CI 1.05-1.13), although the association was weaker. Among the site-specific cancers, three types of cancer (lung, liver/biliary/pancreas, and hematologic malignancy) were consistently at higher risk in patients with HF. An exploratory analysis showed that patients with repeated HF hospitalization had a higher risk of cancer development compared to those without, in a pattern of stepwise increases across the three groups [controls vs. HF without re-hospitalization vs. HF with re-hospitalization ≥1; HR (95% CI), 1.00 (reference) vs. 1.55 (1.51-1.59) vs. 1.96 (1.89-2.03), respectively].

Conclusions: Cancer incidence is higher in patients with HF than the general population. Active surveillance of coexisting malignancy needs to be considered in these patients.
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http://dx.doi.org/10.1016/j.jjcc.2020.07.026DOI Listing
March 2021

Plant SNAREs SYP22 and SYP23 interact with Tobacco mosaic virus 126 kDa protein and SYP2s are required for normal local virus accumulation and spread.

Virology 2020 08 21;547:57-71. Epub 2020 Apr 21.

Noble Research Institute, LLC, Ardmore, OK, 73401, USA. Electronic address:

Viral proteins often interact with multiple host proteins during virus accumulation and spread. Identities and functions of all interacting host proteins are not known. Through a yeast two-hybrid screen an Arabidopsis thaliana Qa-SNARE protein [syntaxin of plants 23 (AtSYP23)], associated with pre-vacuolar compartment and vacuolar membrane fusion activities, interacted with Tobacco mosaic virus (TMV) 126 kDa protein, associated with virus accumulation and spread. In planta, AtSYP23 and AtSYP22 each fused with mCherry, co-localized with 126 kDa protein-GFP. Additionally, A. thaliana and Nicotiana benthamiana SYP2 proteins and 126 kDa protein interacted during bimolecular fluorescence complementation analysis. Decreased TMV accumulation in Arabidopsis plants lacking SYP23 and in N. benthamiana plants subjected to virus-induced gene silencing (VIGS) of SYP2 orthologs was observed. Diminished TMV accumulation during VIGS correlated with less intercellular virus spread. The inability to eliminate virus accumulation suggests that SYP2 proteins function redundantly for TMV accumulation, as for plant development.
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http://dx.doi.org/10.1016/j.virol.2020.04.002DOI Listing
August 2020

Contact Force-Guided Ablation Reduced Poor Contact Segments and Improved Acute Reconnection in Patients with Atrial Fibrillation.

J Atr Fibrillation 2020 Feb-Mar;12(5):2185. Epub 2020 Feb 28.

Division of Cardiology, Department of Internal Medicine, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea.

Background: There is a paucity of information regarding whether contact force (CF)-guided ablation improves the outcomes of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) by achieving more optimal contact. We sought to assess whether real time CF-guided ablation has an impact on ablation parameters and acute pulmonary vein reconnection (PVR).

Methods: Left or right PVs were randomized to either CF-guided or blinded groups, and the order of CF blindness: CF-guided left PV/CF-blinded right PV, CF-blinded left PV/CF-guided right PV, CF-guided right PV/CF-blinded left PV, and CF-blinded right PV/CF-guided left PV groups. We compared CF parameters and acute PVR between segments ablated by CF-guided and CF-blinded strategies.

Results: Sixty patients with drug refractory symptomatic AF were included (paroxysmal AF 73%). CF-guided segments did not show significant differences in CF parameters compared to CF-blinded segments. However, CF-guided segments showed fewer segments with mean CF value <5 g than CF-blinded segments (4.3% vs. 12.4%, p<0.001). Forty-two patients showed acute PVR in 92 segments (8.5%). CF-guided PV segments showed lower acute PVR rate than CF-blinded segments (5.9% vs. 11.1%, p=0.011).

Conclusions: CF-guided ablation could reduce acute PVR after PVI by decreasing the number of segments with poor contact rather than increasing the mean CF during ablation. Better contact guided by CF information might help in improving the results of PVI. Further investigation will be needed to identify the association between the difference in acute reconnection and the long-term outcomes.
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http://dx.doi.org/10.4022/jafib.2185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237089PMC
February 2020

De novo malignancy risk in patients undergoing the first percutaneous coronary intervention: A nationwide population-based cohort study.

Int J Cardiol 2020 08 29;313:25-31. Epub 2020 Apr 29.

Department of Internal medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address:

Background: Although percutaneous coronary intervention (PCI) has been the mainstay of revascularization strategy for significant coronary artery disease, future cancer risk after PCI has never been explored. We aimed to investigate the risk of incident cancer in patients undergoing PCI for the first time.

Methods: We studied 125,613 patients who underwent the first PCI between 2010 and 2015 without a prior history of cancer. For comparison, we selected 628,065 age- and sex-matched controls without any history of cancer or PCI who completed the assigned national health examination during the same period.

Results: During a median 4.56 years (interquartile range, 3.06-6.13 years), 8528 patients from the PCI group and 40,166 controls were newly diagnosed with cancer (incidence rate, 15.1 vs. 13.9 per 1000 person-years, p < 0.0001). Patients undergoing PCI presented a higher risk for cancer development than the controls in multivariable Cox analysis (adjusted HR [aHR] 1.06, 95% CI 1.04-1.09, p < 0.0001). To minimize potential surveillance bias, we performed 1-year lag analysis by eliminating participants who developed cancer within 1 year from the PCI. In this analysis, the increased risk of overall cancer in the PCI group became insignificant (aHR 1.02, 95% CI 0.99-1.05, p = 0.2017). Regarding site-specific cancers, however, the risk of lung and hematologic malignancies remained higher and the risk of gastrointestinal, liver/biliary/pancreas, thyroid, and breast cancers remained lower in the PCI group.

Conclusions: Differential future cancer risks were observed in patients undergoing PCI. The results suggest that specialized surveillance strategy might be warranted for this expanding population.
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http://dx.doi.org/10.1016/j.ijcard.2020.04.085DOI Listing
August 2020

Detection of Atrial Fibrillation Using a Ring-Type Wearable Device (CardioTracker) and Deep Learning Analysis of Photoplethysmography Signals: Prospective Observational Proof-of-Concept Study.

J Med Internet Res 2020 05 21;22(5):e16443. Epub 2020 May 21.

Department of Electrical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea.

Background: Continuous photoplethysmography (PPG) monitoring with a wearable device may aid the early detection of atrial fibrillation (AF).

Objective: We aimed to evaluate the diagnostic performance of a ring-type wearable device (CardioTracker, CART), which can detect AF using deep learning analysis of PPG signals.

Methods: Patients with persistent AF who underwent cardioversion were recruited prospectively. We recorded PPG signals at the finger with CART and a conventional pulse oximeter before and after cardioversion over a period of 15 min (each instrument). Cardiologists validated the PPG rhythms with simultaneous single-lead electrocardiography. The PPG data were transmitted to a smartphone wirelessly and analyzed with a deep learning algorithm. We also validated the deep learning algorithm in 20 healthy subjects with sinus rhythm (SR).

Results: In 100 study participants, CART generated a total of 13,038 30-s PPG samples (5850 for SR and 7188 for AF). Using the deep learning algorithm, the diagnostic accuracy, sensitivity, specificity, positive-predictive value, and negative-predictive value were 96.9%, 99.0%, 94.3%, 95.6%, and 98.7%, respectively. Although the diagnostic accuracy decreased with shorter sample lengths, the accuracy was maintained at 94.7% with 10-s measurements. For SR, the specificity decreased with higher variability of peak-to-peak intervals. However, for AF, CART maintained consistent sensitivity regardless of variability. Pulse rates had a lower impact on sensitivity than on specificity. The performance of CART was comparable to that of the conventional device when using a proper threshold. External validation showed that 94.99% (16,529/17,400) of the PPG samples from the control group were correctly identified with SR.

Conclusions: A ring-type wearable device with deep learning analysis of PPG signals could accurately diagnose AF without relying on electrocardiography. With this device, continuous monitoring for AF may be promising in high-risk populations.

Trial Registration: ClinicalTrials.gov NCT04023188; https://clinicaltrials.gov/ct2/show/NCT04023188.
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http://dx.doi.org/10.2196/16443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273241PMC
May 2020

Effectiveness and Safety of Direct Oral Anticoagulants in Relation to Temporal Changes in Their Use.

Circ Cardiovasc Qual Outcomes 2020 03 12;13(3):e005894. Epub 2020 Mar 12.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom (G.Y.H.L.).

Background Since the direct oral anticoagulants (DOAC) were introduced, oral anticoagulant (OAC) prescription patterns have rapidly changed in patients with atrial fibrillation (AF). We aimed to evaluate the evolving trends of OAC use in a large nationwide cohort and specifically examine the changes in patient profiles treated with warfarin or DOAC and whether the time trends in OAC use affected clinical outcomes. Methods and Results Using the Korean Health Insurance Review and Assessment database, we divided OAC naive patients with AF into 3 groups according to the enrollment period between January 2015 and December 2017 (n=35 353 in cohort 1, n=36 631 in cohort 2, and n=44 819 in cohort 3). DOAC use increased from 59% to 89%, whereas warfarin use has decreased from 41% to 11% during the study period. Patients treated with warfarin were increasingly younger from cohort 1 to cohort 3 (mean age 68-65 years, <0.001) with lower mean CHADS-VASc scores (3.3-2.9, <0.001), whereas those with DOAC did not show a significant difference in clinical characteristics over the study period. Warfarin group had improved clinical outcomes over time, reflecting dynamic changes in patient characteristics. Compared with warfarin group, unadjusted hazard ratios of composite outcome for DOAC group have changed over time (hazard ratio 0.77 [95% CI, 0.69-0.85] in cohort 1, hazard ratio 0.84 [95% CI, 0.73-0.97] in cohort 2, and hazard ratio 1.00 [95% CI, 0.78-1.25] in cohort 3). After propensity score weighting between warfarin and DOAC groups in each cohort, DOAC showed consistently lower risks of the composite outcome by approximately 23% to 25% compared with warfarin across 3 different periods. Conclusions In contemporary clinical practice, OAC prescription patterns and characteristics of patients treated warfarin or DOAC have dynamically changed. Despite these changes, DOAC showed a consistent better net clinical benefit compared with warfarin across different periods.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.005894DOI Listing
March 2020

A CNN-Assisted Enhanced Audio Signal Processing for Speech Emotion Recognition.

Sensors (Basel) 2019 Dec 28;20(1). Epub 2019 Dec 28.

Interaction Technology Laboratory, Department of Software, Sejong University, Seoul 05006, Korea.

Speech is the most significant mode of communication among human beings and a potential method for human-computer interaction (HCI) by using a microphone sensor. Quantifiable emotion recognition using these sensors from speech signals is an emerging area of research in HCI, which applies to multiple applications such as human-reboot interaction, virtual reality, behavior assessment, healthcare, and emergency call centers to determine the speaker's emotional state from an individual's speech. In this paper, we present major contributions for; (i) increasing the accuracy of speech emotion recognition (SER) compared to state of the art and (ii) reducing the computational complexity of the presented SER model. We propose an artificial intelligence-assisted deep stride convolutional neural network (DSCNN) architecture using the plain nets strategy to learn salient and discriminative features from spectrogram of speech signals that are enhanced in prior steps to perform better. Local hidden patterns are learned in convolutional layers with special strides to down-sample the feature maps rather than pooling layer and global discriminative features are learned in fully connected layers. A SoftMax classifier is used for the classification of emotions in speech. The proposed technique is evaluated on Interactive Emotional Dyadic Motion Capture (IEMOCAP) and Ryerson Audio-Visual Database of Emotional Speech and Song (RAVDESS) datasets to improve accuracy by 7.85% and 4.5%, respectively, with the model size reduced by 34.5 MB. It proves the effectiveness and significance of the proposed SER technique and reveals its applicability in real-world applications.
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http://dx.doi.org/10.3390/s20010183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982825PMC
December 2019

Effectiveness and Safety of Direct Oral Anticoagulant for Secondary Prevention in Asians with Atrial Fibrillation.

J Clin Med 2019 Dec 17;8(12). Epub 2019 Dec 17.

Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea.

We investigated the effectiveness and safety of direct oral anticoagulants (DOACs) for secondary prevention in patients with atrial fibrillation (AF), particularly focusing on subgroups of patients with severe, disabling, and recent stroke. Using the Korean National Health Insurance Service claims database between January 2010 and April 2018, we selected OAC-naïve patients with non-valvular AF and a history of stroke. Cumulative risks for recurrent stroke, major bleeding, composite outcome (recurrent stroke + major bleeding), and mortality were compared between DOAC and warfarin groups. Among 61,568 patients, 28,839 and 32,729 received warfarin and DOACs, respectively. Compared with warfarin, DOACs were associated with lower risks of recurrent stroke (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.62-0.72), major bleeding (HR 0.73, 95% CI 0.66-0.80), composite outcome (HR 0.69, 95% CI 0.65-0.73), and mortality. DOAC use resulted in a consistent trend of improved outcomes in the subgroups of patients with severe, disabling, and recent stroke. In conclusion, DOACs were associated with lower risks of recurrent stroke, major bleeding, composite clinical outcomes, and mortality in patients with AF and a history of stroke. These results were consistent across all types of DOACs and subgroups of patients with severe, disabling, and recent stroke.
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http://dx.doi.org/10.3390/jcm8122228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947173PMC
December 2019

Oral Anticoagulation in Asian Patients With Atrial Fibrillation and a History of Intracranial Hemorrhage.

Stroke 2020 02 9;51(2):416-423. Epub 2019 Dec 9.

From the Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O., G.Y.H.L.).

Background and Purpose- Warfarin is associated with a better net clinical benefit compared with no treatment in patients with nonvalvular atrial fibrillation (AF) and history of intracranial hemorrhage (ICH). There are limited data on nonvitamin K antagonist oral anticoagulants (NOACs) in these patients, especially in the Asian population. We aimed to compare the effectiveness and safety of NOACs to warfarin in a large-scale nationwide Asian population with AF and a history of ICH. Methods- Using the Korean Health Insurance Review and Assessment database from January 2010 to April 2018, we identified patients with oral anticoagulant naïve nonvalvular AF with a prior spontaneous ICH. For the comparisons, warfarin and NOAC groups were balanced using propensity score weighting. Ischemic stroke, ICH, composite outcome (ischemic stroke+ICH), fatal ischemic stroke, fatal ICH, death from composite outcome, and all-cause death were evaluated as clinical outcomes. Results- Among 5712 patients with AF with prior ICH, 2434 were treated with warfarin and 3278 were treated with NOAC. Baseline characteristics were well-balanced after propensity score weighting (mean age 72.5 years and CHADS-VASc score 4.0). Compared with warfarin, NOAC was associated with lower risks of ischemic stroke (hazard ratio [HR], 0.77 [95% CI, 0.61-0.97]), ICH (HR, 0.66 [95% CI, 0.47-0.92]), and composite outcome (HR, 0.73 [95% CI, 0.60-0.88]). NOAC was associated with lower risks of fatal stroke (HR, 0.54 [95% CI, 0.32-0.89]), death from composite outcome (HR, 0.53 [95% CI, 0.34-0.81]), and all-cause death (HR, 0.83 [95% CI, 0.69-0.99]) than warfarin. NOAC showed nonsignificant trends toward to reduce fatal ICH compared with warfarin (HR, 0.47 [95% CI, 0.20-1.03]). Conclusions- NOAC was associated with a significant lower risk of ICH and ischemic stroke compared with warfarin. NOAC might be a more effective and safer treatment option for Asian patients with nonvalvular AF and a prior history of ICH.
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http://dx.doi.org/10.1161/STROKEAHA.119.028030DOI Listing
February 2020

Fluctuating renal function and the risk of incident atrial fibrillation: a nationwide population-based study.

Sci Rep 2019 12 2;9(1):18055. Epub 2019 Dec 2.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom.

Although chronic kidney disease is known to increase the risk of atrial fibrillation (AF), the impact of the variability of renal function on the risk of incident AF is unknown. We aimed to evaluate the association between variability of renal function and the risk of developing AF among the general population. We evaluated a total of 3,551,249 adults who had three annual health check-ups provided by the National Health Insurance Service. The variability of renal function was defined as GFR-VIM, which is variability independent of the mean (VIM) of creatinine-based estimated glomerular filtration rate (eGFR). The study population was divided into four groups (Q1-4) based on the quartiles of GFR-VIM, and the risks of incident AF by each group were compared. During a mean of 3.2 ± 0.5 years follow-up, incident AF occurred in 15,008 (0.42%) subjects. The incidence rates of AF increased from Q1 to Q4 (0.98, 1.42, 1.27, and 1.63 per 1,000 person-years, respectively). Adjusting with multiple variables, Q4 showed an increased risk of incident AF compared to Q1 (hazard ratio (HR) 1.125, 95% confidence interval (CI) 1.071-1.181). Variability of serum creatinine or other definitions of variability showed consistent results. On subgroup analyses, Q4 in males or those with a decreasing trend of eGFR had significantly increased risks of incident AF compared to Q1 (HR 1.127, 95% CI 1.082-1.175; and HR 1.115, 95% CI 1.059-1.173, respectively). High variability of eGFR was associated with an increased risk of incident AF, particularly in males or those with decreasing trends of eGFR during follow-up.
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http://dx.doi.org/10.1038/s41598-019-54528-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889358PMC
December 2019