Se Yong Jang

Left Ventricular Strain as Predictor of Chronic Aortic Regurgitation

Background It is not well known about the implication of left ventricular (LV) strain as a predictor for mortality in patients with chronic aortic regurgitation (AR). The purpose of this study was to investigate whether global longitudinal strain measured by two-dimensional speckle-tracking echocardiography could predict long-term outcome in patients with chronic AR. Methods This is a single center non-randomized retrospective observational study. The patients with chronic AR from January 2002 to December 2012 were retrospectively enrolled. Following patients were excluded; combined other significant valvular disease, previous heart surgery, aortic disease, congenital heart disease, acute AR and young age under 18 years old. Finally, 60 patients were analyzed and the LV global strain rate was measured on apical four chamber image (GS-4CH). Results During 64 months follow-up duration, 16 patients (26.7%) were deceased and 38 patients (63.3%) underwent aortic valve replacement (AVR). Deceased group was older (69 years old vs. 51 years old, p < 0.001) and had lower longitudinal strain (-12.05 ± 3.72% vs. -15.66 ± 4.35%, p = 0.005). Kaplan-Meier survival curve stratified by GS-4CH showed a trend of different event rate (log rank p = 0.001). On multivariate analysis by cox proportional hazard model adjusting for age, sex, body surface area, history of atrial fibrillation, blood urea nitrogen, LV dilatation, LV ejection fraction and AVR, decreased GS-4CH proved to be an independent predictor of mortality in patients with chronic AR (hazard ratio 1.313, 95% confidence interval 1.010-1.706, p = 0.042). Conclusion GS-4CH may be a useful predictor of mortality in patient with chronic AR.

Complication Rate of Transfemoral Endomyocardial Biopsy with Fluoroscopic and Two-dimensional Echocardiographic Guidance: A 10-Year Experience of 228 Consecutive Procedures

Endomyocardial biopsy (EMB) is one of the reliable methods for the diagnosis of various cardiac diseases. However, EMB can cause various complications. The purpose of this study is to evaluate the complication of transfemoral EMB with both fluoroscopic and two-dimensional (2-D) echocardiographic guidance. A total of 228 patients (148 men; 46.0±14.6 yr-old) who underwent EMB at Kyungpook National University Hospital from January 2002 to June 2012 were included. EMB was performed via the right femoral approach with the guidance of both echocardiography and fluoroscopy. Overall, EMB-related complications occurred in 21 patients (9.2%) including one case (0.4%) with cardiac tamponade requiring emergent pericardiocentesis, four cases (1.8%) with small pericardial effusion without pericardiocentesis, two cases (0.9%) with hemodynamically unstable ventricular tachycardia (VT), one case (0.4%) with nonsustained VT, one case (0.4%) with tricuspid regurgitation, twelve cases (5.3%) with right bundle branch block. There was no occurrence of either EMB-related death or cardiac surgery. Left ventricular ejection fraction was significantly lower (32.0±18.7% vs 42.0±19.1%, P=0.023) and left ventricular end-diastolic dimension was larger (60.0±10.0 mm vs 54.2±10.2 mm, P=0.013) in patients with EMB related complications than in those without. It is concluded that transfemoral EMB with fluoroscopic and 2-D echocardiographic guidance is a safe procedure with low complication rate.

Prognostic Value of Early Acute Kidney Injury After Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction

The pattern and prognostic impact of early acute kidney injury (AKI) after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction have not been well established. From November 2005 to November 2011, 971 post-myocardial infarction patients who underwent primary PCI were analyzed. Early AKI was defined using absolute change in serum creatinine (SCr; SCr <24 hours after primary PCI minus admission SCr) as follows: no early AKI (SCr change <0.3 mg/dl), mild early AKI (SCr change 0.3 to <0.5 mg/dl), moderate early AKI (SCr change 0.5 to <1.0 mg/dl), and severe early AKI (SCr change ≥1.0 mg/dl). One-year major adverse cardiac events were defined as death, nonfatal myocardial infarction, and revascularizations. Overall, 9.6% had early AKI, including 5.7% with mild, 2.5% with moderate, and 1.4% with severe early AKI. Diabetes mellitus (odds ratio 1.84, p = 0.042), the left ventricular ejection fraction (odds ratio 0.97, p = 0.042), and hemoglobin levels (odds ratio 0.84, p = 0.039) were independently associated with early AKI. Early AKI (adjusted hazard ratio 2.80, p = 0.005) was an independent predictor of 1-year major adverse cardiac events. The adjusted hazard ratios of 1-year major adverse cardiac events from the lowest (reference) to the highest quartile of early AKI were as follows: 1, 2.87 (p = 0.012), 3.22 (p = 0.021), and 5.83 (p = 0.004), respectively. In conclusion, early dynamic change in renal function after primary PCI can sensitively predict worse outcomes.

A new tool for the risk stratification of patients undergoing primary percutaneous coronary intervention with ST-segment elevation myocardial infarction: Bio-Clinical SYNTAX score

0.80 0.33–1.90 0.607 1.13 0.43–2.94 0.804 Killip class N1 1.06 0.49–2.27 0.891 0.91 0.40–2.04 0.808 Diabetes mellitus 0.78 0.34–1.80 0.562 0.62 0.24–1.61 0.329 Hyperlipidemia 0.58 0.22–1.54 0.275 0.60 0.22–1.65 0.320 Current smoking 0.89 0.39–2.02 0.774 0.71 0.30–1.70 0.443 Hemoglobin 0.83 0.67–1.02 0.078 0.83 0.67–1.03 0.096 Uric acid 1.14 0.98–1.33 0.082 1.13 0.95–1.35 0.166 Log hs-CRP 1.39 1.12–1.72 0.003 1.35 1.08–1.69 0.008 Log Bio-CSS 2.91 1.52–5.55 0.001 2.79 1.41–5.52 0.003 Beta-blockers 1.64 0.33–8.29 0.549 ACE-I/ARBs 0.37 0.09–1.48 0.159 Statins 0.49 0.17–1.44 0.197

Etiologies and Predictors of ST-Segment Elevation Myocardial Infarction

Background and Objectives Rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is essential for the appropriate management of patients. We investigated the prevalence, etiologies and predictors of false-positive diagnosis of STEMI and subsequent inappropriate catheterization laboratory activation in patients with presumptive diagnosis of STEMI. Subjects and Methods Four hundred fifty-five consecutive patients (62±13 years, 345 males) with presumptive diagnosis of STEMI between August 2008 and November 2010 were included. Results A false-positive diagnosis of STEMI was made in 34 patients (7.5%) with no indication of coronary artery lesion. Common causes for the false-positive diagnosis were coronary spasm in 10 patients, left ventricular hypertrophy in 5 patients, myocarditis in 4 patients, early repolarization in 3 patients, and previous myocardial infarction and stress-induced cardiomyopathy in 2 patients each. In multivariate logistic regression analysis, symptom-to-door time >12 hours {odds ratio (OR) 4.995, 95% confidence interval (CI) 1.384-18.030, p=0.014}, presenting symptom other than chest pain (OR 7.709, 95% CI 1.255-39.922, p=0.027), absence of Q wave (OR 9.082, CI 2.631-31.351, p<0.001) and absence of reciprocal changes on electrocardiography (ECG) (OR 17.987, CI 5.295-61.106, p<0.001) were independent predictors of false-positive diagnosis of STEMI. Conclusion In patients whom STEMI was planned for primary coronary intervention, the false-positive diagnosis of STEMI was not rare. Correct interpretation of ECGs and consideration of ST-segment elevation in conditions other than STEMI may reduce inappropriate catheterization laboratory activation.

Hyponatremia at discharge as a predictor of 12-month clinical outcomes in hospital survivors after acute myocardial infarction

Hyponatremia in the early phase of acute myocardial infarction (AMI) is a well-known predictor of poor prognosis. However, little is known about the clinical implication of sodium levels at discharge in hospital survivors after AMI. The study included 1290 consecutive patients (64xa0±xa012xa0years; 877 men) who survived the index hospitalization after AMI. We determined the 12-month mortality rates of these patients. Patients who died during the 12-month follow-up had lower sodium levels at discharge than those who had survived (137xa0±xa06 vs. 139xa0±xa04xa0mmol/L; Pxa0<xa00.014). Hyponatremia at discharge, defined as a serum sodium level ≤135xa0mmol/L, was present in 210 patients (16.3xa0%). In the Cox-proportional hazard model, hyponatremia at discharge (hazard ratio, 2.264; 95xa0% confidence interval, 1.119–4.579; Pxa0=xa00.023) was an independent predictor of 12-month mortality. Moreover, hyponatremia at discharge had an incremental prognostic value over conventional risk factors (χ2xa0=xa07, Pxa0=xa00.007), and conventional risk factors and log N-terminal Pro-B-type natriuretic peptide combined (χ2xa0=xa05, Pxa0=xa00.021). In the subgroup analysis, the 12-month mortality of patients with hyponatremia at discharge was significantly higher than in those without, irrespective of age, Killip class, left ventricular ejection fraction, percutaneous coronary intervention at index hospitalization, and prescription of diuretics at discharge. Hyponatremia at discharge is an independent predictor of 12-month mortality in hospital survivors after AMI.

Coronary Collaterals Function and Clinical Outcome Between Patients With Acute and Chronic Total Occlusion

OBJECTIVESnThis study sought to demonstrate how changes in the collateral function and its clinical significance before and after percutaneous coronary interventions (PCIs) are compared between patients with acute coronary syndrome and total or nearly total occlusions (ATOs) and chronic total occlusions (CTOs).nnnBACKGROUNDnThe functional relevance of the collateral circulation in patients with ATOs and CTOs has not been fully investigated.nnnMETHODSnThe pressure-derived collateral pressure index (CPI), myocardial fractional flow reserve (FFRmyo), and coronary fractional flow reserve (FFRcor) at maximum hyperemia induced by intravenous adenosine were evaluated in occluded vessels at baseline, after the PCI, and at 1 year in 23 ATO and 74 CTO patients.nnnRESULTSnThe FFRmyo and FFRcor were significantly lower, but the CPI was significantly higher in the CTO than ATOxa0patients at baseline and after the PCI. There were significant increases in the FFRmyo (pxa0< 0.001) and FFRcor (pxa0<xa00.001), whereas there was no significant change in the CPI immediately after the PCI in both ATO and CTO patients. In the CTO patients, a post-PCI FFRmyoxa0<0.90 (pxa0= 0.01) and post-PCI CPIxa0<0.25 (pxa0= 0.033) were independent predictors of the clinical outcome. Patients with a high post-PCI CPI had better clinical outcomes in CTO patients with a low post-PCI FFRmyo (log-rank pxa0= 0.009), but not a high post-PCI FFRmyo (log-rank pxa0= 0.492).nnnCONCLUSIONSnRecruitable coronary collateral flow did not regress completely immediately after the PCI both in patients with ATOs and CTOs. Despite good collaterals in CTO patients, aggressive efforts to reduce the ischemicxa0burdenxa0might improve the clinical outcome.

A New Revised Cardiac Risk Index Incorporating Fragmented QRS Complex as a Prognostic Marker in Patients Undergoing Noncardiac Vascular Surgery

The aim of this study was to investigate the value of a new Revised Cardiac Risk Index (RCRI) that includes consideration of QRS fragmentation (fQRS) as a predictor of cardiac events in patients undergoing noncardiac vascular surgery. Four hundred sixty-seven consecutive patients admitted for noncardiac vascular surgery were studied. Patients were allocated to RCRI 0, 1, 2, or ≥3 groups according to the sum of diabetes, renal insufficiency, and histories of ischemic heart disease, congestive heart failure, and cerebrovascular disease. They were then reallocated to fragmented RCRI (fRCRI) 0, 1, 2, or ≥3 groups after including a score of 1 or 0 corresponding to the presence or absence of fQRS. A major adverse cardiac event (MACE) was defined as a composite of death, myocardial infarction, congestive heart failure, and percutaneous coronary intervention before noncardiac vascular surgery. During index hospitalization, MACE developed in 38 patients (8.1%). fQRS was present in 169 (36.2%), and it was significantly greater in patients with MACE than in those without MACE (63.2% vs 34.3%, p <0.001). The proportions of RCRI 0, 1, 2, and ≥3 were 46.9% (n = 219), 35.3% (n = 165), 12.4% (n = 58), and 5.4% (n = 25), respectively. When fRCRI data were included, 28 patients (48.3%) in RCRI 2 were reclassified as fRCRI ≥3. By multivariate logistic regression analysis, fRCRI (odds ratio 1.529, 95% confidence interval 1.035 to 2.258, p = 0.033) and a left ventricular ejection fraction <50% independently predicted in-hospital MACE. In conclusion, fRCRI is an independent predictor of in-hospital MACE in patients undergoing noncardiac vascular surgery.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. u2028The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Difference in the Prognostic Impact of Left Ventricular Global Longitudinal Strain between Anterior and Nonanterior Myocardial Infarction.

Speckle tracking–derived global longitudinal strain (GLS) of left ventricle is a potent prognostic marker for patients with ST‐segment elevation myocardial infarction (STEMI). The purpose of this study was to investigate the difference of prognostic impact of GLS between anterior and nonanterior myocardial infarction.