Tae-Min Rhee

Evaluation of the association between diabetic retinopathy and the incidence of atrial fibrillation: A nationwide population-based study.

BACKGROUND Atrial fibrillation (AF) is prevalent among type 2 diabetic patients. However, the association between diabetic retinopathy (DR) and AF is controversial. METHODS We included 40,500 patients with type 2 diabetes (≥40years, mean age 62±11years, 53% men) without AF from the Korean National Insurance Service-National Sample Cohort (2002-2007). Subjects were classified without DR (non-DR, n=30,178), with DR (DR, n=8920), and with proliferative DR (PDR, n=1402). RESULTS During a mean 5.9-year follow-up, 1261 (3.1%) patients were newly diagnosed as having AF (4.9, 6.0, and 8.3 per 1000 person-years in the non-DR, DR, and PDR groups, respectively). In multivariate Cox proportional hazard models, patients in the DR and PDR groups had a significantly higher risk of AF than those in the non-DR group (DR group: hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.00-1.30; PDR group: HR 1.46, 95% CI 1.13-1.87); p for trend <0.001). The risk of AF increased in patients with DR and end-stage renal disease (ESRD) (HR 2.39, 95% CI 1.31-3.96, p<0.001) and in those with PDR and ESRD (HR 3.59, 95% CI 1.96-5.97, p<0.001) compared to those without DR and ESRD. CONCLUSIONS The presence and severity of DR was significantly associated with the incidence of AF. Also, the presence of ESRD had an impact on the incidence of AF in patients with DR.

Chronic Kidney Disease in the Second-Generation Drug-Eluting Stent Era : Pooled Analysis of the Korean Multicenter Drug-Eluting Stent Registry

OBJECTIVES The purpose of this study was to evaluate the clinical impact of chronic kidney disease (CKD) on clinical outcomes in contemporary practice of percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DES). BACKGROUND Although second-generation DES have improved the safety and efficacy issues in PCI, data regarding the performance of second-generation DES in patients with CKD are still limited. METHODS We performed a patient-level pooled analysis on 12,426 patients undergoing PCI using second-generation DES from the Korean Multicenter Drug-Eluting Stent Registry. Endpoints were stent-oriented outcomes (target lesion failure [TLF]) and patient-oriented composite outcomes (POCO) during a median follow-up of 35 months. CKD patients were stratified by the estimated glomerular filtration rate (eGFR) from mild CKD to end-stage renal disease patients, and by the coexistence of diabetes mellitus (DM). RESULTS A total of 2,927 patients had CKD (23.6%), who showed a significantly higher risk of TLF (adjusted hazard ratio [HRadjust]: 1.50; 95% confidence interval [CI]: 1.21 to 1.86) and POCO (HRadjust 1.34; 95% CI: 1.17 to 1.55) compared to patients with preserved renal function. Stratified analysis by eGFR showed that TLF was not increased in the mild to moderate CKD, whereas severe CKD and dialysis-dependent patients showed significantly higher risk of TLF (HRadjust 2.44; 95% CI: 1.54 to 3.86; HRadjust 3.58; 95% CI: 2.52 to 5.08, respectively). The eGFR threshold of increased clinical events was 40 to 45 ml/min/1.73 m2. Among CKD patients, DM CKD patients showed a higher incidence of TLF compared to non-DM CKD patients (HRadjust: 1.82; 95% CI: 1.32 to 2.52), driven by the increase in target vessel-related events. CONCLUSIONS In the era of second-generation DES, CKD patients were at a significantly higher risk of clinical outcomes only in severe CKD and end-stage renal disease patients.

Comparison of outcomes after treatment of in-stent restenosis using newer generation drug-eluting stents versus drug-eluting balloon: Patient-level pooled analysis of Korean Multicenter in-Stent Restenosis Registry

BACKGROUND Studies comparing the drug-eluting balloon (DEB) with contemporary drug-eluting stent (DES) in the treatment of in-stent restenosis (ISR) have been scarce. We compared that the efficacy and safety of contemporary DES versus DEB in unselected, real world patients of ISR occurred in bare-metal stent or DES. METHODS Patient-level pooled analysis from nationwide multicenter registries was performed with 628 consecutive patients who underwent ISR treatment using 2nd or 3rd generation DES or DEB. Target lesion failure (TLF) and patient-oriented composite outcomes (POCO, composite of all-cause mortality, all-cause myocardial infarction, or any revascularization) at 1-year follow-up were compared between the DES and DEB groups. RESULTS A total of 628 patients with 697 ISR lesions were treated using newer generation DES (n=409) or DEB (n=219). About 55.1% presented with acute coronary syndrome, and 15.1% showed left ventricular dysfunction. The risks of TLF and POCO were significantly lower in the DES group, even after being adjusted by an inverse probability weighted model (TLF, 9.2% vs. 17.9%, HRadjust 0.22, 95% CI 0.11-0.47; POCO, 12.4% vs. 24.1%, HRadjust 0.25, 95% CI 0.13-0.48, all p-values<0.001), mainly driven by the significantly lower risk of target lesion revascularization (TLR) (7.6% vs. 13.0%, HRadjust 0.21, 95% CI 0.09-0.49, p<0.001). Treatment of ISR with DEB independently predicted TLF (HR 1.87, 95% CI 1.05-3.02, p=0.034) along with multi-vessel disease, chronic kidney disease, type B2 or C lesion, and number of treated lesion>1. CONCLUSIONS In unselected patients of ISR, clinical outcome at one year was mainly dependent on difference in TLR and found to be better with contemporary DES than DEB.

Cirrhosis is a risk factor for atrial fibrillation: A nationwide, population-based study

Information is lacking regarding whether cirrhosis is associated with atrial fibrillation development. We aimed to investigate the incidence and clinical significance of atrial fibrillation in cirrhotic patients.

Discrimination of stress (Takotsubo) cardiomyopathy from acute coronary syndrome with clinical risk factors and coronary evaluation in real-world clinical practice

BACKGROUND Diagnosing stress cardiomyopathy (SCMP) apart from acute coronary syndrome (ACS) is challenging since coronary evaluation is not always feasible in real-world clinical practice. We explored the current practice pattern of coronary evaluation in patients suspected to have SCMP and divulged the distinguishable features of SCMP from ACS. METHODS AND RESULTS From 2010 to 2015, only 219 out of 691 (32%) hospitalized patients suspected to have SCMP have received coronary evaluation in two tertiary hospitals. After the evaluation, 66 patients (30%) turned out to have ACS. Coronary evaluation was performed based on coronary risk factors, clinical presentations, and test results including electrocardiograms (ECG), cardiac biomarkers, and echocardiography. Whereas initial presentations, ECG changes, cardiac biomarkers, and regional wall motion abnormality patterns were not significantly different, multivariate logistic regression analysis showed that age (≥70years), diabetes, a history of percutaneous coronary intervention (PCI), and the absence of evident triggers were significant factors discriminating ACS from SCMP. A decision tree based on classification and regression analysis also revealed the consistent results. CONCLUSIONS Although it is hard to differentiate SCMP from ACS merely based on clinical features, a substantial proportion of patients suspected to have SCMP did not undergo coronary evaluation to exclude ACS in real-world clinical practice. Coronary evaluation should be more actively performed in patients with old age, prior PCI history, diabetes, and less evident trigger.

Association between adult height, myocardial infarction, heart failure, stroke and death: a Korean nationwide population-based study

Background The association between adult height and cardiovascular (CV) events and mortality has been suggested, albeit inconsistently. We sought to discover the comprehensive relationship between height, CV-related morbidity and all-cause death according to age. Methods We investigated the association between adult height and myocardial infarction (MI), heart failure (HF), stroke incidence and mortality in 16 528 128 Korean patients who underwent regular health check-ups (2005-08). Height was stratified by decile according to age (20-39 years, 40-59 years and ≥60 years) and gender. Results During a 9-year follow-up period, 590 346 participants died and 232 093 were admitted to hospital for MI, 201 411 for HF and 267 566 for stroke. An inverse relationship between height and MI, HF, stroke and all-cause death was observed in the overall cohort analysis. The association was unchanged after adjusting for CV risk and behavioural and adulthood socioeconomic factors. Both male and female sex showed an inverse relationship with height in adulthood, CV events and mortality. Adult height showed an inverse association in all CV events and mortality, especially in the older groups (≥40 years). In a subgroup analysis of body mass index, there was an inverse relationship between height, CV events and mortality in each group. Conclusions Shorter height in adulthood was strongly related to an increased risk of MI, HF, stroke and all-cause death. A suitable environment and appropriate nutrition early in life could influence adult height and eventually reduce the risk of CV events and mortality.

Increased Risk of Atrial Fibrillation and Thromboembolism in Patients with Severe Psoriasis: a Nationwide Population-based Study

Psoriasis increases the risk of atrial fibrillation (AF) and thromboembolic events (TE). There is limited information on the effect of psoriasis severity on AF and TE. In this study, psoriasis patients were enrolled from the Korean National Insurance Service-National Sample Cohort (2004–2008). Diagnosis and disease severity were determined from claims data. Newly diagnosed non-valvular AF and TE were identified during a 9.6-year follow-up. The effect of psoriasis severity on AF and TE was evaluated. We identified 13,385 psoriasis patients (1,947 with severe psoriasis). Severe psoriasis significantly increased the risk of AF (adjusted hazard ratio [HRadjust] 1.44 [95% confidence interval (CI) 1.14–1.82], p = 0.002) and TE (HRadjust 1.26 [95% CI 1.07–1.47], p = 0.005); mild psoriasis did not show any significant effects. Results were similar after propensity-score matching. Risk increments of AF and TE were prominent in patients with greater cardiovascular risk. A possible limitation of our study is that it has a retrospective design, and the effect of unmeasured confounders and risk of misclassification could bias the results. To conclude, our results showed that severe, but not mild, psoriasis significantly increased AF and TE risk. AF surveillance and active stroke prevention would be beneficial in such cases.

Proteinuria Detected by Urine Dipstick Test as a Risk Factor for Atrial Fibrillation: A Nationwide Population-Based Study

Proteinuria is one of the well-known risk factors for cardiovascular disease. However the impact of proteinuria on the incidence of atrial fibrillation (AF) is unclear. In this study, we investigated the association between proteinuria detected using urine dipstick test and the risk of AF. A total of 18,201,275 individuals were analyzed, who had no prior AF and had received biennial health checkups provided by the National Health Insurance Service between 2005 and 2008 in Korea. Incidences of AF were ascertained through the end of 2015. During a mean follow-up of 9.6 years, a total of 324,764 (1.8%) developed AF (1.86 per 1,000 person-years). In Cox regression models, proteinuria was associated with an increased risk of AF: adjusted HR and 95% CI of AF occurrence were 1.13 (1.10–1.16), 1.34 (1.31–1.38), 1.53 (1.48–1.58), 1.82 (1.71–1.94), and 1.86 (1.61–2.16) in individuals with trace, 1+, 2+, 3+, and 4+ proteinuria, respectively, compared with those without proteinuria. The result was consistent even after additional adjustment for estimated glomerular filtration rate. In addition, the risk of AF further increased or decreased according to the follow-up dipstick test results. Thus, proteinuria measured with a dipstick test might be considered a potent risk factor for AF development.

Deferred versus conventional stent implantation in patients with acute ST-segment elevation myocardial infarction: An updated meta-analysis of 10 studies

BACKGROUND We sought to evaluate safety and efficacy of the deferred stenting versus immediate stent implantation of infarct-related arteries in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS A meta-analysis using random-effects models were conducted. The primary outcome, major adverse cardiac events (MACE), was a composite of all-cause mortality, myocardial infarction (MI), any unplanned target vessel revascularization (TVR), and hospitalization due to cardiac cause. Periprocedural composite events were composed of acute re-occlusion, no-reflow/slow flow, or distal embolization. RESULTS Seven non-randomized registries and three randomized trials comparing outcomes of deferred versus immediate stenting in infarct-related arteries of 2281 STEMI patients were selected. Risk of MACE between deferred or immediate stenting did not differ significantly (rates, 12.8% vs 15.0%; pooled RR=0.68, 95% CI: 0.43-1.06; p=0.087; I2=26.8%). Deferred stenting was associated with significantly reduced risk of periprocedural composite events (rates, 5.3% vs 10.2%; pooled RR=0.36, 95% CI: 0.18-0.69; p=0.002; I2=68.0%) and flow abnormality in infarct-related arteries (rates, 3.8% vs 8.4%; pooled RR=0.29, 95% CI: 0.14-0.61; p=0.001; I2=58.1%). However, clinical outcomes including all-cause mortality, MI, or any unplanned TVR, were unaffected. Meta-regression indicated a significant relationship between prolonged total ischemic and reduced risk of MACE after deferred stenting (OR=0.994, 95% CI: 0.990-0.998; p=0.027; I2 residual 0.0%, adjusted R2=100.0%). CONCLUSIONS Although deferred stenting carried significantly lower risk of periprocedural composite events and abnormal flow in patients undergoing primary PCI for STEMI, such benefits had no impact on MACE, which did not differ significantly by timing of stent placement.

Predictors and Long-Term Clinical Outcome of Longitudinal Stent Deformation: Insights From Pooled Analysis of Korean Multicenter Drug-Eluting Stent Cohort

Background— There are limited data on the frequency of and factors associated with quantitative coronary angiography (QCA)–defined longitudinal stent deformation (LSD) in various contemporary drug-eluting stents platforms. This study sought to evaluate the predictors of LSD and its long-term clinical implication. Methods and Results— A patient-level pooled analysis was performed with 7350 lesions in 5871 patients treated with platinum-chromium–based everolimus-eluting stent (Promus Element), cobalt-chromium–based everolimus-eluting stent (Promus/Xience V), or cobalt-chromium–based zotarolimus-eluting stent (Endeavor Resolute). QCA was performed to analyze differences of stent length between immediate post-deployment and final post-procedure. Independent factors associated with LSD were identified. Clinical outcomes at 3 years were compared between those with and without QCA-based LSD. The frequency of QCA-based LSD was 1.12% (82 cases). Nine of these cases were angiographically overt. Left main or ostial lesion, bifurcation treatment with provisional side branch stenting or ballooning, additional downstream intervention of a distal lesion, intravascular ultrasound use, and adjunctive post-dilatation were independently associated with QCA-based LSD. The type of stent was not associated with QCA-based LSD. Rates of target lesion failure were nominally higher in lesions with QCA-based LSD than in those without (8.97% versus 5.88%; hazard ratio, 1.415; 95% confidence interval, 0.631–3.175; P=0.399). Conclusions— LSD is uncommon with contemporary drug-eluting stents, regardless of the type of stent platform. LSD is mainly associated with procedural factors, especially with additional downstream procedures which require the passage of devices through the stent. Careful manipulation of poststent imaging or procedural devices is required to prevent LSD. More data are needed to clarify the impact of LSD on clinical events.