Jung-Hoon Sung

Bleeding risk and major adverse events in patients with cancer on oral anticoagulation therapy

BACKGROUND The efficacy of oral anticoagulation therapy (OAT) has not been revealed in atrial fibrillation (AF) patients with newly diagnosed cancers. This study evaluated the thromboembolic and bleeding events in AF patients with malignancies according to OAT. METHODS AND RESULTS In 2168 consecutive non-valvular AF patients with newly diagnosed malignancies, we analyzed the composite endpoints including major adverse cardiac events (MACEs) and major bleeding. Based on a propensity score matching, two groups with 690 matched pairs were created. Patient baseline characteristics were comparable between the matched groups. During a follow-up period of 3.9 ± 2.8 years, 72 (10%) and 65 (9%) patients had MACEs in the propensity score-matched OAT + and OAT − groups, respectively (p = 0.461). There was no significant difference in the major bleeding (10% vs. 8%, p = 0.300) and composite endpoints (18% vs. 16%, p = 0.181) between OAT + and OAT − patients. During the first year after the cancer diagnosis, 66 (48%) MACEs, 52 (41%) major bleedings, and 116 (49%) composite end points of all events occurred. The optimal international normalized ratio (2.0 to 3.0) level was achieved in only 85 (12%) patients. However, 1 year after cancer diagnosis, OAT + patients with the target therapeutic range of ≥ 60% demonstrated better cumulative survival free of composite end point than OAT − patients (p = 0.026). CONCLUSION During the first year after the cancer diagnosis, OAT did not improve the composite end point because of poor INR control caused by cancer treatment. However, after 1 year after diagnosis of cancer, optimal anticoagulation significantly reduced the composite end point.

Comparison of two different doses of single bolus steroid injection to prevent atrial fibrillation recurrence after radiofrequency catheter ablation.

Purpose Steroids may play a role in preventing the early recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). However, optimal doses and route of steroid delivery have not yet been determined. This study evaluated the effect of two different doses of a single bolus injection of steroids on AF recurrence after RFCA. Materials and Methods Of 448 consecutive AF patients who underwent RFCA, a single steroid bolus was injected into 291 patients. A low-dose steroid group (n=113) received 100 mg of hydrocortisone and a moderate-dose steroid group (n=174) received 125 mg of methylprednisolone. We used propensity-score matching to select patients as follows: control (n=95), low-dose (n=95), and moderate-dose steroid groups (n=97). Results Pericarditis developed in 1 (1.1%) control patient, 2 (2.1%) low-dose patients and 0 moderate-dose patients. Maximum body temperature and C-reactive protein were significantly decreased in the moderate-dose steroid group compared to the other groups (p<0.01). The number of patients of early AF recurrence (≤3 months) did not differ among three groups. Early recurrence was 24 (25%) in the control, 24 (25%) in the low-dose and 25 (26%) in the medium-dose groups (p=0.99). Compared with control group, low-dose or moderate-dose steroid treatment did not effectively decrease mid-term (3-12 months) AF recurrence [22 (23%) vs. 23 (24%) vs. 18 (19%); p=0.12]. Conclusion A single injection of moderate-dose steroid decreased inflammation. However, single bolus injections of low-dose or moderate-dose steroids were not effective in preventing immediate, early or midterm AF recurrence after RFCA.

Multidetector computed tomography may be an adequate screening test to reduce periprocedural stroke in atrial fibrillation ablation: A multicenter propensity-matched analysis

BACKGROUND Whether routine transesophageal echocardiography (TEE) in addition to multidetector computed tomography (MDCT) has incremental value in preventing periprocedural stroke before atrial fibrillation (AF) ablation is unclear. OBJECTIVE The purpose of this study was to evaluate whether screening with MDCT is sufficient for preventing periprocedural stroke. METHODS From 4 tertiary centers, we enrolled 1147 patients (902 males, age 57 ± 11 years) with optimal anticoagulation and preserved left ventricular ejection function who had undergone MDCT and routine TEE (group 1, n = 678) or selective TEE (group 2, n = 469) as screening tests before AF ablation. Based on a propensity score analysis, 2 groups with 412 matched pairs were created. RESULTS Patient baseline characteristics were comparable between the matched groups. In group 1 (n = 412), thrombi were detected in 4 patients (1.0%) on TEE, and ablation was not performed. These patients also showed thrombi (n = 3) or blood stasis (n = 1) on MDCT. For thrombi detection, MDCT had sensitivity and negative predictive value of 100%. In group 2 (n = 412), thrombi were detected in 7 patients (1.7%) on MDCT. Of these patients , 2 (0.5%) also showed thrombi on TEE. Periprocedural stroke incidence did not differ between the groups (0.2% each, P = 1.0). CONCLUSION The incidence of periprocedural stroke was low and did not differ significantly between the group assigned to routine TEE vs selective TEE screening in AF patients undergoing anticoagulation therapy if the patients had conditions associated with low thrombus risk. Thus, preprocedural TEE may not be necessary before AF ablation in patients who have undergone preprocedural cardiac MDCT that shows no evidence of left atrial appendage thrombus.

Association of insulin resistance and coronary artery remodeling: an intravascular ultrasound study

BackgroundThere are few studies that investigated the correlation between insulin resistance (IR) and the coronary artery remodeling. The aim of the study is to investigate the association of IR measured by homeostasis model assessment of insulin resistance (HOMA-IR) and coronary artery remodeling evaluated by intravascular ultrasound (IVUS).MethodsA total of 298 consecutive patients who received percutaneous coronary interventions under IVUS guidance were retrospectively enrolled. The value of HOMA-IR more than 2.5 was considered as IR positive. Metabolic syndrome was classified according to NCEP ATP III guidelines. The remodeling index was defined as the ratio of the external elastic membrane (EEM) area at the lesion site to the EEM area at the proximal reference site.ResultsA total of 369 lesions were analyzed (161 lesions in HOMA-IR positive and 208 lesions in HOMA-IR negative). Remodeling index was significantly higher in the HOMA-IR positive group compared with the negative group (HOMA-IR positive vs. negative: 1.074 ± 0.109 vs. 1.042 ± 0.131, p = 0.013). There was a significant positive correlation between remodeling index and HOMA-IR (p = 0.010). Analysis of HOMA-IR according to remodeling groups showed increasing tendency of HOMA-IR, and it was statistically significant (p = 0.045). Multivariate analysis revealed that only HOMA-IR was an independent predictor of remodeling index (r = 0.166, p = 0.018).ConclusionIncreased IR estimated by HOMA-IR was significantly associated with a higher remodeling index and positive coronary artery remodeling.

Assessment of the efficacy and tolerability of clopidogrel napadisilate in Korean patients with coronary stenting: a multicenter, prospective, open-label, randomized trial.

Abstract Objective: Clopidogrel is indicated for the treatment and prevention of peripheral vascular, cerebrovascular, and coronary artery diseases. This clinical trial was designed to demonstrate that clopidogrel napadisilate (CN) is not inferior to clopidogrel bisulfate (CB) with respect to its effectiveness in inhibiting platelet aggregation. Methods: This 4 week multi-center, prospective, open-label, randomized trial was conducted at five clinical centers in South Korea. Patients were randomized into the 75 mg CN group or the 75 mg CB group. Platelet aggregation was assessed by the VerifyNow assay. The primary outcome was the difference of the percentage P2Y12 inhibition and the secondary outcome was the baseline and change in P2Y12 reaction units (PRU). Results: There was no significant difference in the percentage P2Y12 inhibition (CN vs. CB, 34.92 ± 21.33% vs. 30.43 ± 17.90%, p = 0.203). The mean difference of the percentage P2Y12 inhibition between groups was 4.49%, their two-sided 95% confidence interval was −2.45% to 11.44%, and the lower bound (−2.45%) was greater than the acceptable non-inferiority margin of −9.0%. The baseline PRU was 96.67 ± 76.76 in the CN group and 216.95 ± 68.86 in the CB group (p = 0.121), and the change in the PRU was −3.32 ± 51.71 in the CN group and 10.52 ± 43.31 in the CB group (p = 0.106). Four subjects experienced AEs (6.3%, 5 events) in the CN group and 7 subjects (11.11%, 13 events) in the CB group without statistical significance (p = 0.364). With respect to serious adverse events, 2 events were reported in 2 subjects, 1 in each group. Conclusion: Clopidogrel napadisilate was not inferior to clopidogrel bisulfate in terms of antiplatelet efficacy and tolerability, and there were no clinically significant adverse events.

An exaggerated blood pressure response to exercise is associated with subclinical myocardial dysfunction in normotensive individuals.

Objectives: An exaggerated blood pressure (BP) response to exercise is associated with adverse cardiovascular outcomes, even in normotensive individuals. The purpose of this study was to compare myocardial function between normotensive individuals with and without an exaggerated BP response. Methods: We evaluated global myocardial function using speckle tracking echocardiography in normotensive individuals. Two-dimensional speckle tracking echocardiography and a treadmill exercise test were performed simultaneously in 171 normotensive individuals (mean age: 48 ± 8 years; 97 men) without any structural heart disease. Results: Among 171 normotensive individuals, 19 (11%) exhibited an exaggerated BP response (≥200 mmHg for men and ≥190 mmHg for women) during the treadmill test. Conventional echocardiographic parameters were similar between the two groups. However, on strain analyses, the systolic and early diastolic global longitudinal strains of the left ventricle (LV) and left atrium were lower in individuals with an exaggerated BP response to exercise. The peak SBP during exercise was inversely related to systolic global longitudinal strain of the LV (r = –0.35, P < 0.01) and left atrium (r = –0.41, P < 0.01). On multivariate analyses, an exaggerated BP response to exercise was shown to be an independent determinant of reduced global longitudinal strain of the LV (&bgr; = –0.20, P < 0.05) and left atrium (&bgr; = –0.28, P < 0.05). Conclusion: Normotensive individuals with an exaggerated BP response to exercise exhibit impairment in longitudinal myocardial function. Even without apparent hypertension, an exaggerated BP response could cause repeated increases in afterload and result in subclinical myocardial dysfunction.

Traumatic aortic regurgitation combined with descending aortic pseudo-aneurysm secondary to blunt chest trauma : online article - case report

Rupture of the aorta is a relatively rare complication of blunt chest trauma, and traumatic rupture of the aortic valve is even rarer. Even though both result from blunt chest trauma, the causative mechanisms of aortic valve injury differ from those of descending aortic rupture. There are no previous reports in the literature of simultaneous injuries to both the descending aorta and the aortic valve. We report a case of a 70-year-old man who presented with traumatic aortic regurgitation combined with traumatic pseudoaneurysm of the aortic isthmus following blunt chest trauma, and its successful repair with a hybrid surgical strategy.

The type of sinus node dysfunction might predict the severity of atrial remodeling and clinical outcome after catheter ablation of atrial fibrillation

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Heart Rate Acceleration of a Subsidiary Pacemaker by β-Adrenergic Stimulation

Background and Objectives Recent evidence indicates that the membrane voltage and Ca2+ clocks jointly regulate sinoatrial node (SAN) automaticity. However, the mechanism of heart rhythm acceleration of the subsidiary pacemaker (SP) during β-adrenergic stimulation is still unknown. Here we tested the hypothesis that the heart rate acceleration of the SP by β-adrenergic stimulation involves synergistic interactions between both clock mechanisms. Subjects and Methods We performed optical mapping and pharmacological interventions in 15 isolated Langendorff-perfused canine right atriums (RA). The SP model was produced by ligation of the SAN artery at the mid portion of the sulcus terminalis. Results In the 6 RAs with an intact SAN, 1 µmol/L isoproterenol infusion increased the heart rate from 82±9 to 166±18 bpm (102%) with late diastolic Cai elevation (LDCAE) at the superior SAN. However, in the 6 SP models, the heart rate increased from 55±10 bpm to 106±11 bpm (92%, p=0.005) without LDCAE at the earliest activation site. The isoproterenol induced heart rate increase was reversed to 74±5 bpm (33% from baseline) by administering an infusion of the funny current blocker ZD 7288 (3 µmol/L, n=3), whereas, it was suppressed to 69±7 bpm (24% from baseline) by sarcoplasmic reticulum (SR) Ca2+ emptying with administering ryanodine (10 µmol/L) plus thapsigargin (200 nmol/L, n=3). The isoproterenol induced heart rate increase was completely abolished by combined treatment with funny current blocker and SR Ca2+ emptying (n=3). Conclusion Acceleration of the Ca2+ clock in the SP plays an important role in the heart rate acceleration during β-adrenergic stimulation, and this interacts synergistically with the voltage clock to increase the heart rate.

High Prevalence and Clinical Implication of Myocardial Bridging in Patients with Early Repolarization

Purpose Recent evidence suggests that early repolarization (ER) is related with myocardial ischemia. Compression of coronary artery by a myocardial bridging (MB) can be associated with clinical manifestations of myocardial ischemia. This study aimed to evaluate the associations of MB in patients with ER. Materials and Methods In consecutive patients (n=1303, age, 61±12 years) who had undergone coronary angiography, we assessed the prevalence and prognostic implication of MB in those with ER (n=142) and those without ER (n=1161). Results MB was observed in 54 (38%) and 196 (17%) patients in ER and no-ER groups (p<0.001). In multivariate analysis, MB was independently associated with ER (odd ratio: 2.9, 95% confidence interval: 1.98–4.24, p<0.001). Notched type ER was more frequently observed in MB involving the mid portion of left anterior descending coronary artery (LAD) (69.8% vs. 30.2%, p=0.03). Cardiac event was observed in nine (6.3%) and 22 (1.9%) subjects with and without ER, respectively. MB was more frequently observed in sudden death patients with ER (2 out of 9, 22%) than in those without ER (0 out of 22). Conclusion MB was independently associated with ER in patients without out structural heart disease who underwent coronary angiography. Notched type ER was closely related with MB involving the mid portion of the LAD. Among patients who had experienced cardiac events, a higher prevalence of MB was observed in patients with ER than those without ER. Further prospective studies on the prognosis of MB in ER patients are required.