Publications by authors named "Sung-Ho Her"

115 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

Percutaneous Transcatheter Closure of Iatrogenic Aorto-right Atrial Fistula Using the Amplatzer Duct Occluder.

Korean Circ J 2021 Sep;51(9):789-791

Department of Cardiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.

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http://dx.doi.org/10.4070/kcj.2021.0135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424451PMC
September 2021

Effect of smoking on clinical outcomes in patients receiving rotational atherectomy in calcified coronary lesions: from the ROCK Registry, South Korea.

Ann Saudi Med 2021 Jul-Aug;41(4):191-197. Epub 2021 Aug 22.

From the Department of Internal Medicine, Wonkwang University Hospital, Iksan, Jeollabuk-do, South Korea.

Background: Tobacco smoking and its harmful health effects also increase economic burdens globally. Surprisingly, despite the detrimental health consequences of smoking, some studies have shown better survival among smokers compared with non-smokers, a phenomenon called "smoker's paradox". However, the impact of smoking status on clinical outcomes in severe calcified coronary artery disease (CAD) patients has yet to be reported.

Objectives: Investigate the impact of smoking on clinical outcomes in calcified CAD receiving rotational atherectomy (RA).

Design: Retrospective review of medical records.

Setting: Multicenter registry in South Korea.

Patients And Methods: This multicenter registry included consecutive patients with calcified CAD who underwent RA at nine tertiary centers in Korea between January 2010 and October 2019.

Main Outcome Measures: Target-vessel failure (TVF) which included the composite of cardiac death, target-vessel myocardial infarction (TVMI), and target-vessel revascularization (TVR).

Sample Size: 583 lesions in 540 patients followed for a median of 16.1 months.

Results: Lesions were divided into two groups: non-smokers (n=472, 81.0%) and smokers (n=111, 19.0%). TVF in the smoker group was significantly more frequent than in non-smoker group (log rank =.016). The inverse probability of treatment weighting analysis also showed that smoking was significantly associated with a higher incidence of the primary outcome (HR: 1.617; 95% CI: 1.127-2.320; =.009), cardiac death (HR 1.912; 95% CI: 1.105-3.311; =.021), myocardial infarction (HR: 3.914; 95% CI: 1.884-8.132; <.001), TVMI (HR: 3.234; 95% CI: 1.130-9.258; =.029), and TVR (HR: 1.661; 95% CI: 1.043-2.643; =.032). However, any bleeding was significantly observed less in the smokers.

Conclusion: Smoking is significantly associated with adverse clinical outcomes in CAD patients requiring RA.

Limitations: Retrospective design.

Conflicts Of Interest: None.
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http://dx.doi.org/10.5144/0256-4947.2021.191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8380281PMC
September 2021

Effect of Significant Coronary Artery Stenosis on Prognosis in Patients with Vasospastic Angina: A Propensity Score-Matched Analysis.

J Clin Med 2021 Jul 28;10(15). Epub 2021 Jul 28.

Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul 06649, Korea.

Vasospastic angina (VA) is a functional disease of the coronary artery and occurs in an angiographically normal coronary artery. However, it may also occur with coronary artery stenosis. We investigated the effect of coronary artery stenosis on clinical outcomes in VA patients. Study data were obtained from a prospective multicenter registry that included patients who had symptoms of VA. Patients were classified into two groups according to presence of significant coronary artery stenosis. Among 1920 patients with VA, 189 patients were classified in the "significant stenosis" group. The one-year composite clinical events rate was significantly higher in the significant stenosis group than in the "no significant stenosis" group (5.8% vs. 1.4%, respectively; < 0.001). Additionally, the prevalence of ACS was significantly greater in the "significant stenosis" group (4.8% vs. 0.9%, respectively; < 0.001). After propensity score matching, the adverse effects of significant stenosis remained. In addition, significant stenosis was independently associated with a 6.67-fold increased risk of ACS in VA patients. In conclusion, significant coronary artery stenosis can increase the adverse clinical outcomes in VA patients at long-term follow-up. Clinicians should manage traditional risk factors associated with atherosclerosis and control vasospasm as well as reduce the burden of atherosclerosis.
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http://dx.doi.org/10.3390/jcm10153341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8347544PMC
July 2021

Clinical Outcome of Rotational Atherectomy in Calcified Lesions in Korea-ROCK Registry.

Medicina (Kaunas) 2021 Jul 7;57(7). Epub 2021 Jul 7.

Department of Cardiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.

: Data is still limited regarding clinical outcomes of rotational atherectomy (RA) after percutaneous coronary intervention. We sought to evaluate clinical outcomes of RA. This multi-center registry enrolled patients who underwent RA during PCI from nine tertiary centers in Korea between January 2010 and October 2019. The primary endpoint was target-vessel failure (TVF; the composite outcome of cardiac death, target-vessel spontaneous myocardial infarction, or target-vessel revascularization). : Of 540 patients (583 lesions), the mean patient age was 71.4 ± 0.4 years, 323 patients (59.8%) were men, and 305 patients (56.5%) had diabetes mellitus. Technical success rate was 96.4%. In-hospital major adverse cerebral and cardiac events occurred in 63 cases (10.8%). At 1.5 years, 72 (16.0%) of TVFs were occurred. We evaluated independent predictors of TVF, which included current smoker (hazard ratio (HR), 1.92; 95% confidence interval (CI), 1.17-3.16; = 0.01), chronic renal disease (HR, 1.87; 95% CI, 1.14-3.08; = 0.013), history of cerebrovascular attack (HR, 2.14; 95% CI, 1.24-3.68; = 0.006), left ventricle ejection fraction (HR, 0.98; 95% CI, 0.97-0.999; = 0.037), and left main disease (HR, 1.94; 95% CI, 1.11-3.37; = 0.019). From this registry, we demonstrated acceptable success rates, in-hospital and mid-term clinical outcomes of RA in the DES era.
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http://dx.doi.org/10.3390/medicina57070694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303478PMC
July 2021

Impact of chronic total occlusion lesions on clinical outcomes in patients receiving rotational atherectomy: results from the ROCK registry.

Heart Vessels 2021 Nov 10;36(11):1617-1625. Epub 2021 Apr 10.

Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea.

The aim of this study was to investigate the impact of chronic total occlusion (CTO) on clinical outcomes in patients with calcified coronary lesions receiving rotational atherectomy (RA). This multi-center registry enrolled consecutive patients with calcified coronary artery disease who underwent RA during percutaneous coronary intervention (PCI) from 9 tertiary centers in Korea between January 2010 and October 2019. The primary outcome was target-vessel failure (TVF) which included the composite of cardiac death, target-vessel myocardial infarction (TVMI), and target-vessel revascularization (TVR). A total of 583 lesions were enrolled in this registry and classified as CTO (n = 42 lesions, 7.2%) and non-CTO (n = 541 lesions, 92.8%). The CTO group consisted of younger patients who were more likely to have a history of previous percutaneous coronary intervention or coronary artery bypass graft surgery. The incidence of the primary outcome was 14.1% and 16.7% for the non-CTO group and CTO group, respectively. The primary outcomes observed in the two groups were not significantly different (log-rank p = 0.736). The 18-month clinical outcomes of the CTO group were comparable to those of the non-CTO group in multivariate analysis. About 7% of patients requiring RA have CTO lesions and these patients experience similar clinical outcomes compared with those having non-CTO lesions. Use of RA for CTO lesions was safe despite higher procedural complexity.
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http://dx.doi.org/10.1007/s00380-021-01849-4DOI Listing
November 2021

Smoking may be more harmful to vasospastic angina patients who take antiplatelet agents due to the interaction: Results of Korean prospective multi-center cohort.

PLoS One 2021 2;16(4):e0248386. Epub 2021 Apr 2.

Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.

Background: The interaction between smoking and the use of antiplatelet agents on the prognosis of vasospastic angina (VA) is rarely investigated.

Methods: VA-Korea is a nation-wide multi-center registry with prospective design (n = 1812). The primary endpoint was the composite occurrence of acute coronary syndrome (ACS), symptomatic arrhythmia, and cardiac death. Log-rank test and Cox proportional hazard model were for statistical analysis. Also, we conducted interaction analysis in both additive and multiplicative scales between smoking and antiplatelet agents among VA patients. For additive scale interaction, relative excess risk due to interaction (RERI) was calculated and for multiplicative scale interaction, the ratio of hazard ratio (HR) was calculated. All statistical analysis conducted by Stata Ver 16.1.

Results: Patients who were smoking and using antiplatelet agents had the highest incidence rate in the primary composite outcome. The incidence rate was 3.49 per 1,000 person-month (95% CI: 2.30-5.30, log-rank test for primary outcome p = 0.017) and HR of smoking and using antiplatelet agents was 1.66 (95%CI: 0.98-2.81). The adjusted RERI of smoking and using antiplatelet agents was 1.10 (p = 0.009), and the adjusted ratio of HR of smoking and using antiplatelet agents was 3.32 (p = 0.019). The current study observed the interaction between smoking and using antiplatelet agents in both additive and multiplicative scales.

Conclusions: Smoking was associated with higher rates of unfavorable clinical outcomes among VA patients taking antiplatelet agents. This suggested that VA patients, especially those using antiplatelet agents should quit smoking.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248386PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8018640PMC
September 2021

Admission serum potassium levels and prognosis of vasospastic angina.

Sci Rep 2021 Mar 11;11(1):5707. Epub 2021 Mar 11.

Department of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.

Hypokalemia is a common electrolyte disturbance and is related to poor prognosis in patients with cardiovascular disease. However, the role of hypokalemia in patients with vasospastic angina (VSA) has not yet been studied. The present study enrolled 1454 patients diagnosed with VSA according to ergonovine provocation test results and available admission serum potassium data. The primary outcome was a composite of cardiac death, acute coronary syndrome, and new-onset life-threatening arrhythmia. Based on a hypokalemia definition as serum potassium concentration ≤ 3.5 mEq/L, the hypokalaemia group included 70 patients (4.8%). The median potassium levels were 3.4 mEq/L [interquartile range (IQR) 3.3-3.5] in the hypokalemia group and 4.1 mEq/L (IQR 3.9-4.3) in the no-hypokalemia group. The median follow-up duration was 764 days. Primary outcomes occurred in seven patients (10.0%) in the hypokalemia group and 51 patients (3.7%) in the no-hypokalemia group. The Kaplan-Meier analysis showed a higher cumulative incidence of primary outcomes in the hypokalemia group compared to that in the no-hypokalemia group (log-rank P = 0.014). Multivariate Cox regression analysis also showed that hypokalemia was an independent predictor of primary outcomes. In conclusion, hypokalemia at admission was associated with adverse clinical outcomes in VSA.
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http://dx.doi.org/10.1038/s41598-021-84712-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952915PMC
March 2021

Prognostic Value of Estimated Glomerular Filtration Rate 3-6 Months after Percutaneous Coronary Intervention.

Cardiorenal Med 2021 17;11(1):77-86. Epub 2020 Dec 17.

Department of Cardiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.

Background: The prognostic significance of follow-up (f/u) renal function for patients undergoing percutaneous coronary intervention (PCI) remains unknown. This study sought to investigate the prognostic implications of f/u renal function in patients undergoing PCI.

Methods: A drug-eluting stent registry was used. We divided patients into 4 groups according to the change in the estimated glomerular filtration rate (eGFR) before PCI and 3-6 months after PCI. Patients with normal pre-PCI eGFR and f/u eGFR were assigned to group 1. Those with normal pre-PCI eGFR and abnormal f/u eGFR were assigned to group 2. Patients with abnormal pre-PCI eGFR and normal f/u eGFR were assigned to group 3. Patients with abnormal pre-PCI eGFR and f/u eGFR were allocated into group 4.

Results: A total of 4,899 PCI patients were enrolled. The death rate in group 1, 2, 3, and 4 at 3 years was 2, 11, 4, and 9%, respectively. This showed significant differences between groups, except between groups 2 and 4. The prognosis of a group with aggravation from normal renal function was worse than that of a group with recovery from abnormal renal function. A prediction model that combines clinical risk factors and f/u eGFR has more power for predicting clinical outcomes than a combination of clinical risk factors and pre-PCI eGFR.

Conclusion: Post-PCI eGFR was more accurate for predicting patient outcomes than pre-PCI eGFR.
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http://dx.doi.org/10.1159/000512817DOI Listing
October 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

Safety and Efficacy of Pitavastatin in Patients With Impaired Fasting Glucose and Hyperlipidemia: A Randomized, Open-labeled, Multicentered, Phase IV Study.

Clin Ther 2020 10 10;42(10):2036-2048. Epub 2020 Sep 10.

Yonsei University Severance Hospital, Seoul, South Korea. Electronic address:

Purpose: Although the role of high-intensity lipid-lowering therapy in cardiovascular protection has broadened, concerns still exist about new-onset diabetes mellitus (NODM), especially in vulnerable patients. This study aimed to compare the effect of high-dose (4 mg/d) and usual dose (2 mg/d) pitavastatin on glucose metabolism in patients with hyperlipidemia and impaired fasting glucose (IFG).

Methods: In this 12-month study, glucose tolerance and lipid-lowering efficacy of high-dose pitavastatin (4 mg [study group]) was compared with that of usual dose pitavastatin (2 mg [control group]) in patients with hyperlipidemia and IFG. The primary end point was the change of glycosylated hemoglobin (HbA) after 24 weeks of treatment. The secondary end points were as follows: (1) NODM within 1 year after treatment, (2) change of lipid parameters, (3) changes of adiponectin, and (4) change of blood glucose and insulin levels.

Findings: Of the total 417 patients screened, 313 patients with hypercholesterolemia and IFG were randomly assigned into groups. The mean (SD) change in HbA was 0.06% (0.20%) in the study group and 0.03% (0.22%) in the control group (P = 0.27). Within 1 year, 27 patients (12.3%) developed NODM, including 12 (10.6%) of 113 patients in the study group and 15 (14.2%) of 106 in the control group (P = 0.43). The study group had a significantly higher reduction of total cholesterol and LDL-C levels and a higher increase in apolipoprotein A1/apolipoprotein B ratio (0.68 [0.40] vs 0.51 [0.35], P < 0.01).

Implications: The high-dose pitavastatin therapy did not aggravate glucose metabolism compared with the usual dose therapy. Moreover, it had a better effect on cholesterol-lowering and apolipoprotein distribution in the patients with hyperlipidemia and IFG.
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http://dx.doi.org/10.1016/j.clinthera.2020.07.013DOI Listing
October 2020

Efficacy and Tolerability of Pitavastatin Versus Pitavastatin/Fenofibrate in High-risk Korean Patients with Mixed Dyslipidemia: A Multicenter, Randomized, Double-blinded, Parallel, Therapeutic Confirmatory Clinical Trial.

Clin Ther 2020 10 2;42(10):2021-2035.e3. Epub 2020 Sep 2.

Department of Internal Medicine, Seoul St. Mary's Hospital, Seoul, South Korea; College of Medicine, The Catholic University of Korea, Seoul, South Korea. Electronic address:

Purpose: Dyslipidemia is an important risk factor for cardiovascular disease (CVD). Statins are known to effectively reduce not only low-density lipoprotein cholesterol (LDL-C) level but also death and nonfatal myocardial infarction due to coronary heart disease. The risk for CVD from atherogenic dyslipidemia persists when elevated triglyceride (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels are not controlled with statin therapy. Therefore, statin/fenofibrate combination therapy is more effective in reducing CVD risk. Here, we assessed the efficacy and tolerability of pitavastatin/fenofibrate combination therapy in patients with mixed dyslipidemia and a high risk for CVD.

Methods: This multicenter, randomized, double-blind, parallel-group, therapeutic-confirmatory clinical trial evaluated the efficacy and tolerability of fixed-dose combination therapy with pitavastatin/fenofibrate 2/160 mg in Korean patients with a high risk for CVD and a controlled LDL-C level (<100 mg/dL) and a TG level of 150-500 mg/dL after a run-in period with pitavastatin 2 mg alone. In the 8-week main study, 347 eligible patients were randomly assigned to receive pitavastatin 2 mg with or without fenofibrate 160 mg after a run-in period. In the extension study, patients with controlled LDL-C and non-HDL-C (<130 mg/dL) levels were included after the completion of the main study. All participants in the extension study received the pitavastatin/fenofibrate combination therapy for 16 weeks for the assessment of the tolerability of long-term treatment.

Findings: The difference in the mean percentage change in non-HDL-C from baseline to week 8 between the combination therapy and monotherapy groups was -12.45% (95% CI, -17.18 to -7.72), and the combination therapy was associated with a greater reduction in non-HDL-C. The changes in lipid profile, including apolipoproteins, fibrinogen, and high-sensitivity C-reactive protein from baseline to weeks 4 and 8 were statistically significant with combination therapy compared to monotherapy at all time points. Furthermore, the rates of achievement of non-HDL-C and apolipoprotein B targets at week 8 in the combination therapy and monotherapy groups were 88.30% versus 77.98% (P = 0.0110) and 78.94% versus 68.45% (P = 0.0021), respectively. The combination therapy was well tolerated, with a safety profile similar to that of statin monotherapy.

Implications: In these Korean patients with mixed dyslipidemia and a high risk for CVD, combination therapy with pitavastatin/fenofibrate was associated with a greater reduction in non-HDL-C compared with that with pitavastatin monotherapy, and a significantly improvement in other lipid levels. Moreover, the combination therapy was well tolerated, with a safety profile similar to that of statin monotherapy. Therefore, pitavastatin/fenofibrate combination therapy could be effective and well tolerated in patients with mixed dyslipidemia. ClinicalTrials.gov identifier: NCT03618797.
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http://dx.doi.org/10.1016/j.clinthera.2020.08.002DOI Listing
October 2020

Technical Feasibility and Safety of Percutaneous Coronary Intervention for True Ostial Left Anterior Descending Artery-Chronic Total Occlusion.

Can J Cardiol 2021 03 20;37(3):458-466. Epub 2020 Aug 20.

Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Electronic address:

Background: Percutaneous coronary intervention (PCI) for true ostial left anterior descending artery (LAD)-chronic total occlusion (CTO) lesions poses technical challenges owing to its inherent anatomic features.

Methods: In total, 270 consecutive patients who underwent PCI for ostial LAD-CTO at 13 major cardiac centers in South Korea were included. Ostial LAD-CTO was strictly defined as a LAD-CTO lesion whose proximal cap was within 1 mm from the carina of the distal left main coronary artery (LMCA) bifurcation.

Results: Ostial LAD-CTOs were frequently accompanied by stumpless lesion entry (43.4%), whereas significant bending within the occluded segment was less frequent (14.4%). The overall technical success rate was 85.9%, and serious in-hospital adverse events occurred in 5.6%. The retrograde approach tended to contribute more frequently to success in patients with concomitant LMCA disease, stumpless CTO, interventional collaterals, and higher Japanese-CTO scores. Apparent dissection or hematoma requiring rescue procedure at the LMCA or left circumflex artery occurred in 14 patients (5.2%), with a higher tendency in patients who had LMCA disease (12.1% vs 4.2%) and stumpless entry (9.4% vs 2.0%) than in those without. Among patients who were successfully treated, with an average of 1.7 stents, target-vessel failure occurred in 23 patients (9.9%) during a median 3.3 years of follow-up.

Conclusions: In this first large-scale analysis of true ostial LAD-CTO, PCI was feasible with a high technical success rate and favourable mid-term outcomes. Clinically relevant inflow vessel injury can occur during PCI and should be an important technical consideration regarding safety.
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http://dx.doi.org/10.1016/j.cjca.2020.08.009DOI Listing
March 2021

Impact of Overweight/Obesity on Clinical Outcomes of Patient with Vasospastic Angina: From the Vasospastic Angina in Korea Registry.

Sci Rep 2020 03 18;10(1):4954. Epub 2020 Mar 18.

Division of Cardiology, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea.

Obesity is associated with a high risk of morbidity and mortality in the general population and is a major independent risk factor for cardiovascular disease. We sought to evaluate the effect of overweight/obesity on clinical outcomes of patients with vasospastic angina (VA) at 1-year follow-up. The VA-KOREA (Vasospastic Angina in Korea) registry was a cohort of 11 centers from 2010 to 2015. The primary endpoint was a composite of cardiac death (CD), new-onset arrhythmia, and acute coronary syndrome (ACS). Using the body mass index (BMI) cut-off for Asians, 517 patients with definite VA were divided into either an overweight/obese (BMI ≥ 23 kg/m) group (n = 378) or a normal weight (BMI 18.5-22.9 kg/m) group (n = 139). The overweight/obese group showed a significantly lower rate of the primary endpoint composite (2.4% vs 7.9%, p = 0.004) and ACS (0.8% vs 4.3%, p = 0.007) than the normal weight group in the crude population. Similarly, in propensity-score matched analysis, the overweight/obese group showed a significantly lower rate of the primary endpoint composite (2.3% vs 8.4%, p = 0.006) and ACS (1.1% vs 4.6%, p = 0.035) than the normal weight group. However, there were no significant differences in CD and new-onset arrhythmia between the two groups in both the crude and propensity-score matched population. Independent predictors of the primary endpoint were overweight/obesity and dyslipidemia. In patients with VA, the overweight/obese group was associated with a favorable 1-year primary endpoint and the difference was mainly driven by the lower rate of ACS compared with the normal weight group.
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http://dx.doi.org/10.1038/s41598-020-61947-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080840PMC
March 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

Effect of Fimasartan versus Valsartan and Olmesartan on Office and Ambulatory Blood Pressure in Korean Patients with Mild-to-Moderate Essential Hypertension: A Randomized, Double-Blind, Active Control, Three-Parallel Group, Forced Titration, Multicenter, Phase IV Study (Fimasartan Achieving Systolic Blood Pressure Target (FAST) Study).

Drug Des Devel Ther 2020 23;14:347-360. Epub 2020 Jan 23.

Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.

Purpose: Head-to-head comparison of the blood pressure (BP) lowering effect of fimasartan versus valsartan, with olmesartan as a reference, on office blood pressure and ambulatory BP.

Patients And Methods: Of the 369 randomly assigned patients in this study, 365 hypertensive patients were referred as the full analysis set and divided into 3 groups with a 3:3:1 ratio (fimasartan group: 155, valsartan group: 157, olmesartan group: 53). After the 2-week single-blind placebo run-in period, initial standard doses of 60-mg fimasartan, 80-mg valsartan, and 10-mg olmesartan were administered for 2 weeks, then forcibly up-titrated higher doses (fimasartan 120 mg, valsartan 160 mg, olmesartan 20 mg) were given for 4 weeks. ABP was measured before and after the 6-week treatment. Primary endpoint was reduction of sitting office systolic BP (SiSBP) of fimasartan compared to valsartan after 6 weeks. Secondary endpoints were reduction of sitting office diastolic BP (SiDBP) and 24 hrs, day-time, and night-time mean systolic and diastolic ABP (ASBP, ADBP) after 6 weeks.

Results: Patients' mean age was 58.34±7.68 years, and 289 patients were male (79.18%). After the 6-week treatment, SiSBP reduction of fimasartan and valsartan were -16.26±15.07 and -12.81±13.87 (p=0.0298) and SiDBP were -7.63±9.67 and -5.14±8.52 (p=0.0211). Reductions in 24 hrs mean ASBP were -15.22±13.33 and -9.45±12.37 (p=0.0009), and ADBPs were -8.74±7.55 and -5.98±7.85 (p=0.0140). Reductions of night-time ASBPs were -16.80±15.81 and -10.32±14.88 (p=0.0012), and those of night-time ADBPs were -8.89±9.93 and -5.55±9.70 (p=0.0152). Reduction of BP in olmesartan group did not demonstrate significant difference with fimasartan group in all end-points.

Conclusion: Fimasartan 120-mg treatment demonstrated superior efficacy in reduction of SiSBP, SiDBP, and 24 hrs ASBP and ADBP compared to valsartan 160 mg. Reduction of night-time ASBP from baseline was largest in fimasartan group, suggesting that fimasartan may be effective for recovering dipping pattern.

Nct Number: NCT02495324 (Fimasartan Achieving SBP Target (FAST) study).
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http://dx.doi.org/10.2147/DDDT.S231293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986172PMC
January 2021

Clinical impact of statin therapy on vasospastic angina: data from a Korea nation-wide cohort study.

Heart Vessels 2020 Aug 9;35(8):1051-1059. Epub 2020 Mar 9.

Department of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.

The effect of statin therapy on reducing adverse cardiovascular events in vasospastic angina (VSA) has been inconsistent. Therefore, we investigated the association between statin therapy and adverse cardiovascular events in a large, prospective VSA cohort. The Variant Angina Korea registry consecutively enrolled 2960 patients suspected VSA. Among them, we included 1713 patients who were diagnosed with VSA based on coronary provocation test. We divided the patients into the statin (n = 744) and no-statin group (n = 914) according to the medication prescribed at discharge. The primary outcome was a composite of cardiac death, acute coronary syndrome, and new-onset life-threatening arrhythmia during a 3-year follow-up period. The primary outcome occurred in 32 patients (4.3%) in the statin and 28 patients (3.1%) in the no-statin group. In Kaplan-Meier analysis before and after propensity score matching, there was no significant difference in the cumulative incidence of primary outcomes between both groups. Multivariate Cox regression analysis demonstrated that the focal type of VSA was independent predictor of primary outcomes, but statin therapy was not. Furthermore, the lack of benefit of statin therapy for primary outcomes was consistently observed across the statin intensity and spasm characteristics. In conclusion, the present study demonstrated that statin therapy did not reduce adverse cardiovascular events in patients with VSA.
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http://dx.doi.org/10.1007/s00380-020-01579-zDOI Listing
August 2020

Comparison of calcium-channel blockers for long-term clinical outcomes in patients with vasospastic angina.

Korean J Intern Med 2021 01 24;36(1):124-134. Epub 2020 Feb 24.

Department of Cardiovascular Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.

Background/aims: Calcium channel blockers (CCBs) are the most widely prescribed medication for patients with vasospastic angina (VA). However, few studies have compared the prognosis of VA patients who are prescribed different CCBs.

Methods: We enrolled 2,960 patients who received provocation test prospectively in 11 university hospitals in Korea. We divided 1,586 patients received four major CCBs into two groups: a first generation CCB (diltiazem and nifedipine) group and a second generation CCB (amlodipine and benidipine) group. Primary outcome was time to events of composite of death from any cause, acute coronary syndrome (ACS) and symptomatic arrhythmia during 3-year follow-up. We also compared the effect of each CCB on the control of angina symptoms.

Results: There was no difference of the primary outcome among the two groups with a cumulative incidence rate of 5.4%, 2.9%, and a person-month incidence rate of 2.33 and 1.26, respectively (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.25 to 1.17; p = 0.120, as reference with the 1st generation CCBs). The incidence of ACS was significantly lower in 2nd generation CCBs group with a person-month incidence rate of 1.66 vs. 0.35 (HR, 0.22; 95% CI, 0.05 to 0.89; p = 0.034). Use of benidipine showed a significant better control of angina symptom compared with diltiazem for 3 years (odds ratio, 0.17; 95% CI, 0.09 to 0.32; p < 0.0001 at 3rd year).

Conclusion: The first and second generation CCB groups did not differ in terms of composite outcome occurrence. However, the ACS incidence rate was significantly lower in the users of the 2nd generation CCBs.
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http://dx.doi.org/10.3904/kjim.2019.308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7820640PMC
January 2021

Clopidogrel plus Aspirin Use is Associated with Worse Long-Term Outcomes, but Aspirin Use Alone is Safe in Patients with Vasospastic Angina: Results from the VA-Korea Registry, A Prospective Multi-Center Cohort.

Sci Rep 2019 11 28;9(1):17783. Epub 2019 Nov 28.

Department of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.

Anti-platelet agents are commonly used in vasospastic angina (VA) patients with comorbidity like coronary artery disease. However, long-term clinical outcomes in the use of aspirin, clopidogrel or the two agents together have rarely been investigated in VA patients. In a prospective study, we enrolled 2960 patients who received coronary angiography and ergonovine provocation test at 11 university hospitals in Korea. Among them, 1838 patients were diagnosed either with definite (n = 680) or intermediate (n = 1212) VA, using the criteria of chest pain, ECG changes and ergonovine provocation test results. They were analyzed according to their use of aspirin, clopidogrel or both, or no anti-platelet agent at all. The primary outcome was time to composite events of death from any cause, acute coronary syndrome (ACS) and symptomatic arrhythmia during a 3-year follow-up. A primary composite outcome was significantly more common in the aspirin plus clopidogrel group, at 10.8% (14/130), as compared with the non-antiplatelet group, at 4.4% (44/1011), (hazard ratio [HR] 2.41, 95% confidence interval [CI], 1.32-4.40, p = 0.004). With regard to the person-time event rate, similar results were shown, with the highest rate in the aspirin plus clopidogrel user at 4.72/1000 person months (95% CI, 2.79-7.96, log-rank test for primary outcome p = 0.016). The person-time event of the ACS rate was also highest in that group, at 2.81 (95% CI, 1.46-5.40, log-rank test for ACS p = 0.116). Kaplan-Meier survival analysis demonstrated poor prognosis in primary outcomes and ACS in aspirin plus clopidogrel users (log-rank test, p = 0.005 and p = 0.0392, respectively). Cox-proportional hazard regression analysis, adjusting for age, sex, history of coronary heart disease, hypertension, diabetes, presence or not of definite spasm, use of calcium channel blocker, demonstrated that the use of aspirin plus clopidogrel is an independent risk for the primary outcome (HR 2.01, CI: 1.07-3.81, p = 0.031). The aspirin-alone group had a similar primary and individual event rate compared to the no-antiplatelet agent group (HR 0.96, CI, 0.59-1.55, p = 0.872). Smokers using aspirin plus clopidogrel had poorer outcomes than non-smokers, with HR 6.36 (CI 2.31-17.54, p = 0.045 for interaction). In conclusion, among VA patients, aspirin plus clopidogrel use is associated with a poor clinical outcome at 3 years, especially in ACS. Aspirin alone appears to be safe for use in those patients.
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http://dx.doi.org/10.1038/s41598-019-54390-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883054PMC
November 2019

Comparison between angiotensin-converting enzyme inhibitor and angiotensin receptor blocker after percutaneous coronary intervention.

Int J Cardiol 2020 05 9;306:35-41. Epub 2019 Nov 9.

Departments of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.

Background: The inhibitors for renin-angiotensin-aldosterone system (RAAS) have different mechanisms of action in coronary artery disease (CAD). This study sought to compare the clinical outcomes between angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) therapy in patients with CAD undergoing contemporary percutaneous coronary intervention (PCI).

Methods: Based on the National Health Insurance claims data in South Korea, patients aged 18 years or older who had undergone PCI between July 2011 and June 2015 were enrolled. The study participants were classified either as patients with acute myocardial infarction (AMI, n = 21,747) or angina (n = 28,708). And according to the post PCI discharge medications, patients were categorized into ACEI and ARB therapy groups. The primary endpoint was all-cause death, and the two groups were compared using a propensity-score matching analysis.

Results: The study population had a median follow-up of 2.2 years (interquartile range, 1.2-3.2). In the propensity-score matched AMI group (8341 pairs), the occurrence of all-cause death was significantly lower in the ACEI group than in the ARB group (hazard ratio [HR] of ACEI, 0.823; 95% confidence interval [CI]: 0.715-0.947; p = 0.006). In the propensity-score matched angina group (10,878 pairs), there was no difference in the incidence of the primary endpoint between the ACEI and ARB groups (HR of ACEI, 1.113; 95% CI: 0.986-1.257; p = 0.084).

Conclusions: In this nationwide Korean cohort study, ACEI therapy in patients with AMI and concomitant PCI showed a significant reduction in all-cause mortality rates when compared to that with ARB therapy.
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http://dx.doi.org/10.1016/j.ijcard.2019.11.086DOI Listing
May 2020

Correlation between internal pudendal artery stenosis and erectile dysfunction in patients with suspected coronary artery disease.

PLoS One 2019 12;14(11):e0225179. Epub 2019 Nov 12.

The Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Background: Stenoses of internal pudendal arteries (IPAs) appear to be related to erectile dysfunction (ED). Nevertheless, the correlation between the severity of ED and stenosis of the IPAs is not well established.

Objectives: To evaluate angiographic findings of IPAs in patients with suspected coronary artery disease (CAD) and to assess the correlation between the severity of ED and IPA stenosis.

Materials And Methods: Ninety-one patients who were scheduled for cardiac angiogram (CAG) because of suspected CAD participated. ED was assessed using the International Index of Erectile Function (IIEF) questionnaire. Erectile function (EF) domain scoring was used to assess the severity of ED: severe (EF score = 1-10); moderate (11-16); mild-moderate (17-21); mild (22-25); and no ED (26-30). Angiography was performed in bilateral common, internal iliac, and IPAs and the location and extent of stenoses were measured. We divided patients according to those with maximum stenosis of less than 50% (Group I) and those with more than 50% (Group II), regardless of direction.

Results: We diagnosed 88 patients (88/91, 96.70%) with ED. There was no correlation between increasing age and severity of ED (r = - 0.063, p = 0.555). There were 72 patients in Group I and 19 in Group II. In Group I, 62 patients were diagnosed with ED even though there was no stenosis. There was no significant correlation between the severity of ED and the extent of stenosis in IPAs (r = -0.118, p = 0.265).

Conclusions: There was no significant correlation between the severity of ED and the extent of stenosis of IPAs. We believe that this is because the progression of ED is induced by endothelial cell dysfunction, not by mechanical obstruction leading to blood flow reduction.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225179PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850695PMC
March 2020

Comparative effectiveness analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with chronic kidney disease and unprotected left main coronary artery disease.

EuroIntervention 2020 May;16(1):27-35

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

Aims: Outcomes according to the status of renal insufficiency have not been fully evaluated in left main coronary artery disease (LMCAD). In the present study therefore, we sought to evaluate clinical outcomes in patients with significant LMCAD stratified by the degree of renal insufficiency and the relative clinical outcomes after PCI and CABG stratified by the differential levels of renal function using data from the large multinational "all-comers" Interventional Research Incorporation Society-Left MAIN Revascularization (IRIS-MAIN) registry.

Methods And Results: Among 4,894 patients with LMCAD, renal insufficiency was graded according to the estimated glomerular filtration rate (eGFR). The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as death, myocardial infarction, stroke, or any revascularisation. The patients were stratified into three groups according to eGFR: 3,824 (78%) in group 1 (eGFR ≥60 ml·min-1·1.73 m2), 838 (17%) in group 2 (eGFR ≥30 and <60), and 232 (5%) in group 3 (eGFR <30). At two years, after adjustment, compared with group 1, the risk of MACCE was significantly higher in group 2 (hazard ratio [HR] 1.46, 95% confidence interval [CI]: 1.18-1.79) and in group 3 (HR 3.39, 95% CI: 2.61-4.40). The p interaction for MACCE across groups was 0.20. The adjusted risk of MACCE was similar between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in groups 1 and 2. However, PCI was associated with a significantly higher risk of MACCE compared to CABG (HR 1.88, 95% CI: 1.08-3.25) in group 3.

Conclusions: The degree of renal insufficiency was proportionately associated with unfavourable outcomes in patients with LMCAD. In group 3, PCI was associated with a higher risk of MACCE compared with CABG. Also, the effect of PCI versus CABG on MACCE was consistent, with PCI being associated with less bleeding and CABG being associated with less repeat revascularisation.
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http://dx.doi.org/10.4244/EIJ-D-18-01206DOI Listing
May 2020

Efficacy and Safety of Omega-3 Fatty Acids in Patients Treated with Statins for Residual Hypertriglyceridemia: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

Diabetes Metab J 2020 02 20;44(1):78-90. Epub 2019 Jun 20.

Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Cardiovascular risk remains increased despite optimal low density lipoprotein cholesterol (LDL-C) level induced by intensive statin therapy. Therefore, recent guidelines recommend non-high density lipoprotein cholesterol (non-HDL-C) as a secondary target for preventing cardiovascular events. The aim of this study was to assess the efficacy and tolerability of omega-3 fatty acids (OM3-FAs) in combination with atorvastatin compared to atorvastatin alone in patients with mixed dyslipidemia.

Methods: This randomized, double-blind, placebo-controlled, parallel-group, and phase III multicenter study included adults with fasting triglyceride (TG) levels ≥200 and <500 mg/dL and LDL-C levels <110 mg/dL. Eligible subjects were randomized to ATOMEGA (OM3-FAs 4,000 mg plus atorvastatin calcium 20 mg) or atorvastatin 20 mg plus placebo groups. The primary efficacy endpoints were the percent changes in TG and non-HDL-C levels from baseline at the end of treatment.

Results: After 8 weeks of treatment, the percent changes from baseline in TG (-29.8% vs. 3.6%, <0.001) and non-HDL-C (-10.1% vs. 4.9%, <0.001) levels were significantly greater in the ATOMEGA group (=97) than in the atorvastatin group (=103). Moreover, the proportion of total subjects reaching TG target of <200 mg/dL in the ATOMEGA group was significantly higher than that in the atorvastatin group (62.9% vs. 22.3%, <0.001). The incidence of adverse events did not differ between the two groups.

Conclusion: The addition of OM3-FAs to atorvastatin improved TG and non-HDL-C levels to a significant extent compared to atorvastatin alone in subjects with residual hypertriglyceridemia.
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http://dx.doi.org/10.4093/dmj.2018.0265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043989PMC
February 2020

Association between body mass index and 1-year outcome after acute myocardial infarction.

PLoS One 2019 14;14(6):e0217525. Epub 2019 Jun 14.

Chonbuk National University Hospital, Jeonju, Republic of Korea.

Objectives: Beneficial effects of overweight and obesity on mortality after acute myocardial infarction (AMI) have been described as "Body Mass Index (BMI) paradox". However, the effects of BMI is still on debate. We analyzed the association between BMI and 1-year clinical outcomes after AMI.

Methods: Among 13,104 AMI patients registered in Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) between November 2011 and December 2015, 10,568 patients who eligible for this study were classified into 3 groups according to BMI (Group 1; < 22 kg/m2, 22 ≤ Group 2 < 26 kg/m2, Group 3; ≥ 26 kg/m2). The primary end point was all cause death at 1 year.

Results: Over the median follow-up of 12 months, the event of primary end point occurred more frequently in the Group 1 patients than in the Group 3 patients (primary endpoint: adjusted hazard ratio [aHR], 1.537; 95% confidence interval [CI] 1.177 to 2.007, p = 0.002). Especially, cardiac death played a major role in this effect (aHR, 1.548; 95% confidence interval [CI] 1.128 to 2.124, p = 0.007).

Conclusions: Higher BMI appeared to be good prognostic factor on 1-year all cause death after AMI. This result suggests that higher BMI or obesity might confer a protective advantage over the life-quality after AMI.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217525PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570024PMC
February 2020

Randomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total Occlusion.

Circulation 2019 04;139(14):1674-1683

Toyohashi Heart Center, Aichi, Japan (E.T.).

Background: Procedural results for percutaneous coronary intervention (PCI) in coronary vessels with chronic total occlusion (CTO) have improved in recent years, and PCI strategies have moved toward more complete revascularization with more liberal use of CTO-PCI. However, evidence evaluating CTO-PCI is limited to observational studies and small clinical trials.

Methods: In this open-label, multicenter, randomized, noninferiority trial, PCI-eligible patients were assigned to receive either 1 of 2 strategies: PCI or no PCI for the qualifying de novo CTO lesion with the option for PCI of obstructive non-CTO lesions at the discretion of the operator. The primary end point was a composite of death, myocardial infarction, stroke, or any revascularization. Health-related quality of life was assessed at baseline and at 1, 6, 12, 24, and 36 months. Because of slow recruitment, the trial was stopped before completion of the 1284 planned enrollments.

Results: Between March 2010 and September 2016, 834 patients were randomly assigned to the CTO-PCI (n=417) or no CTO-PCI (n=398) strategy. Among the patients assigned to the no CTO-PCI strategy, 78 (19.6%) crossed over to receive staged CTO-PCI within 3 days of randomization. The overall CTO-PCI success rate was 90.6%. Serious nonfatal complications associated with CTO-PCI occurred in 3 patients (1 stroke, 1 cardiac tamponade, and 1 patient with recurrent episodes of ventricular tachyarrhythmia induced by intracoronary thrombus). Approximately half of the patients in each group underwent PCI for an average of 1.3 non-CTO lesions, resulting in a comparable residual SYNTAX score (Synergy Between PCI With TAXUS and Cardiac Surgery; 3.7±5.4 versus 4.0±5.9, P=0.42) confined to non-CTO vessels. During a median follow-up of 4.0 years (interquartile range, 2.4 to 5.1 years), there was no significant difference between the CTO-PCI and the no CTO-PCI strategies in the incidence of the primary end point (22.3% versus 22.4%, hazard ratio, 1.03; 95% CI, 0.77 to 1.37; P=0.86). Both CTO-PCI and no CTO-PCI strategy were associated with significant improvements but without between-group differences in disease-specific health status that was sustained through 36 months.

Conclusions: CTO-PCI was feasible with high success rates. There was no difference in the incidence of major adverse cardiovascular events with CTO-PCI versus no CTO-PCI, but the study was limited by low power for clinical end points and high crossover rates between groups.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01078051.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.031313DOI Listing
April 2019

Comparison of Spot versus Long Stenting for Femoropopliteal Artery Disease.

Ann Vasc Surg 2019 Jul 13;58:101-107. Epub 2019 Feb 13.

Division of Cardiology and Cardiovascular Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea. Electronic address:

Background: Optimal stenting strategy for long femoropopliteal artery lesions still remains undefined. Longer stent length has been shown to be associated with increased risk of restenosis. We sought to compare the efficacy of spot versus long stenting in the treatment of femoropopliteal artery disease.

Methods: This study was designed as a multicenter randomized controlled trial to compare immediate and mid-term outcomes of spot versus long primary stenting for femoropopliteal arterial lesions. A total of 125 patients were randomized 1:1 to spot stenting group (n = 59) or long stenting group (n = 66).

Results: All lesions were treated with self-expanding bare nitinol stents. Baseline clinical and lesion characteristics were similar between the 2 groups except for male gender and current smoker. The mean lesion length was 24.1 ± 8.8 cm. Technical success was achieved in all patients. The 1-year primary patency and TLR-free (target lesion revascularization) survival did not differ significantly between the 2 groups. However, the spot stenting group showed a trend toward higher primary patency (86.1% vs. 72.7%, P = 0.158) and TLR-free survival (94.2% vs. 82.5%, P = 0.120). The total stented length (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.00-1.01, P = 0.011) and age (HR 0.94, 95% CI 0.90-1.00, P = 0.035) were independent predictors of restenosis.

Conclusions: The spot stenting appears to be more favorable than the long stenting in terms of primary patency and TLR-free survival, although the difference was not statistically significant. The stented length was an independent predictor of restenosis.
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http://dx.doi.org/10.1016/j.avsg.2018.11.023DOI Listing
July 2019

Differential cutoff points and clinical impact of stent parameters of various drug-eluting stents for predicting major adverse clinical events: An individual patient data pooled analysis of seven stent-specific registries and 17,068 patients.

Int J Cardiol 2019 May 2;282:17-23. Epub 2019 Feb 2.

Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea. Electronic address:

Background: Stent parameters (length and diameter) are well-known risk factors for adverse outcomes after percutaneous coronary intervention (PCI) with stenting. This study aimed to investigate the differential cutoff criteria and clinical impact of the length and diameter of various drug-eluting stents (DES) for predicting major cardiovascular events.

Methods: Using patient-level data from seven stent-specific, prospective DES registries, we evaluated 17,068 patients who underwent PCI with either various contemporary DES or first-generation DES between July 2007 and July 2015: 3053 treated with cobalt-chromium everolimus-eluting stents (CoCr-EES), 2976 with platinum-chromium EES (PtCr-EES), 2888 with Resolute zotarolimus-eluting stents (Re-ZES), 782 with Biomatrix biolimus-eluting stents (Bi-BES), 1868 with Nobori BES (No-BES), 1934 with Xience Prime cobalt-chromium EES (Pr-CoCr-EES), and 3567 with first-generation sirolimus-eluting stents (SES). Two clinical outcomes were assessed: target-vessel failure (TVF; a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization [TVR]) and TVR.

Results: Stent length and stent diameter were important factors for predicting TVF or TVR in the entire cohort and in each DES cohort. For TVF risk prediction, the Youden index-based cutoff of stent length was highest with Bi-BES (45.0 mm) and lowest with No-BES (29.0 mm), and the cutoff of stent diameter was smallest with Pr-CoCr-EES (2.78 mm) and largest with No-BES (3.20 mm). For TVR risk prediction, the cutoff of stent length was the highest with PtCr-EES (48.0 mm) and the lowest with No-BES (29.0 mm), and the cutoff of stent diameter was smallest with CoCr-EES (2.72 mm) and largest with first-generation SES (3.30 mm). The 3-year TVF and TVR rates were substantially different according to the presence or absence of long lesions and small vessels determined using these cutoff points.

Conclusions: For contemporary PCI practice involving diverse types of DES, we identified differential cutoff points of stent length and diameter for predicting adverse clinical outcomes. The clinical impact of these stent parameters on outcomes and its magnitude varied according to different DES. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01186133.
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http://dx.doi.org/10.1016/j.ijcard.2019.01.108DOI Listing
May 2019

Impact of multi-vessel vasospastic angina on cardiovascular outcome.

Atherosclerosis 2019 02 23;281:107-113. Epub 2018 Dec 23.

Department of Cardiovascular Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea. Electronic address:

Background And Aims: Since clinical characteristics and prognosis of patients with multi-vessel vasospastic angina (VSA) are not clear, we investigated the nature and prognosis of multi-vessel VSA in Koreans.

Methods: Among 2960 patients enrolled in the VA-KOREA (Vasospastic Angina in Korea) registry, 104 definite multi-vessel VSA patients, 163 single vessel VSA patients and 737 non-VSA patients were identified using the intracoronary ergonovine provocation test.

Results: Multi-vessel VSA and single vessel VSA groups showed similar baseline characteristics and medical treatment on discharge, but different from the non-VSA group. The primary composite endpoint (cardiac death, acute coronary syndrome, and symptomatic new onset arrhythmia) over a 36-month follow-up period was significantly higher in the multi-vessel VSA group than in the single vessel VSA and non-VSA groups (8.7% vs. 1.8% and 1.1%, each log-rank p < 0.05, respectively). The rate of death and acute coronary syndrome of the multi-vessel VSA group was higher than in the single vessel VSA and non-VSA groups (5.8% vs. 1.2% and 0.9%, each log-rank p < 0.05, respectively). In addition, multi-vessel VSA was an independent predictor of the primary composite endpoint at 36 months (HR 8.5, 95% CI [2.6-27.2], p < 0.0001).

Conclusions: Patients with multi-vessel VSA had worse clinical outcomes than single vessel VSA and non-VSA groups, suggesting that the existence of multi-vessel VSA itself is highly prognostic.
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http://dx.doi.org/10.1016/j.atherosclerosis.2018.12.018DOI Listing
February 2019

Moderate-intensity versus high-intensity statin therapy in Korean patients with angina undergoing percutaneous coronary intervention with drug-eluting stents: A propensity-score matching analysis.

PLoS One 2018 7;13(12):e0207889. Epub 2018 Dec 7.

Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.

Objectives: It is unclear whether high-intensity statin therapy provides incremental clinical benefits over moderate-intensity statin therapy in Asian patients with angina. This study sought to compare the clinical outcomes of moderate- and high-intensity statin therapies in patients undergoing percutaneous coronary intervention (PCI) for angina in Korean patients.

Methods: Based on the national health insurance claims data in South Korea, patients aged 18 years or older without a known history of coronary artery disease, who underwent PCI with drug-eluting stents due to angina between 2011 and 2015, were enrolled. According to the intensity of statin therapy, patients were categorized into moderate-intensity statin therapy (n = 23,863) and high-intensity statin therapy (n = 9,073) groups. The primary endpoint, defined as a composite of all-cause death and myocardial infarction, was compared between the two groups using a propensity-score matching analysis.

Results: During the follow-up period (median, 2.0 years; interquartile range, 1.1-3.1), 1,572 patients had 1,367 deaths and 242 myocardial infarctions. After propensity-score matching, there were 8,939 matched pairs. There was no significant difference in the incidence of the primary endpoint between the two groups (adjusted hazard ratio of high-intensity statin therapy, 1.093; 95% confidence interval: 0.950-1.259; p = 0.212).

Conclusions: In Korean patients undergoing PCI with drug-eluting stents for angina, the high-intensity statin therapy did not provide additional clinical benefits over the moderate-intensity statin therapy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207889PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286068PMC
May 2019

Impact of diabetes mellitus in patients undergoing contemporary percutaneous coronary intervention: Results from a Korean nationwide study.

PLoS One 2018 10;13(12):e0208746. Epub 2018 Dec 10.

Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.

Objectives: Despite an obvious improvement in the treatment of coronary artery disease (CAD) and survival rate of patients with CAD during recent decades, diabetes mellitus (DM) is still considered a risk factor of adverse clinical outcomes in these patients. Therefore, we sought to evaluate the clinical implications of DM in patients with CAD who underwent contemporary percutaneous coronary intervention (PCI).

Methods: Based on the National Health Insurance claims data in South Korea, patients aged 18 years or older who had undergone PCI for the diagnosis of CAD between 2011 and 2015 were analyzed. Patients were classified into the DM (n = 26,872) and non-DM (n = 54,243) groups. The primary endpoint was all-cause mortality, and it was compared between the two groups via a propensity score matching analysis.

Results: The study population was categorized as patients with angina (n = 49,228) or acute myocardial infarction (AMI, n = 31,887). The study population had a median follow-up of 2.1 years (interquartile range, 1.1-3.2). After the propensity score matching analysis, 8,157 and 4,266 pairs of patients with angina and AMI were identified, respectively. In the matched angina group, the incidence of all-cause death was significantly higher in patients with DM (adjusted hazard ratio [aHR]: 1.30; 95% confidence interval [CI]: 1.16-1.47; p<0.001) than in those without DM. Moreover, in the matched AMI group, the incidence of all-cause death was significantly higher in patients with DM (aHR: 1.35; 95% CI: 1.19-1.53; p<0.001) than in those without DM.

Conclusions: In patients undergoing contemporary PCI in Korea, the presence of DM was associated with poorer clinical outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208746PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287858PMC
May 2019
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