Outcomes of Direct Oral Anticoagulants in Patients With Mitral Stenosis.

BACKGROUND: Patients with mitral stenosis and atrial fibrillation (AF) require anticoagulation for stroke prevention. Thus far, all studies on direct oral anticoagulants (DOACs) have excluded patients with moderate to severe mitral stenosis. OBJECTIVES: The aim of this study was to validate the efficacy of DOACs in patients with mitral stenosis. METHODS: The study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea, and it included patients who were diagnosed with mitral stenosis and AF and either were prescribed DOACs for off-label use or received conventional treatment with warfarin. The primary efficacy endpoint was ischemic strokes or systemic embolisms, and the safety outcome was intracranial hemorrhage. RESULTS: A total of 2,230 patients (mean age 69.7 ± 10.5 years; 682 [30.6%] males) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group (adjusted hazard ratio for DOAC: 0.28; 95% confidence interval: 0.18 to 0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC group and 0.93% of the warfarin group (adjusted hazard ratio for DOAC: 0.53; 95% confidence interval: 0.22 to 1.26). CONCLUSIONS: In patients with AF accompanied with mitral stenosis, DOAC use is promising and hypothesis generating in preventing thromboembolism. Our results need to be replicated in a randomized trial.

Utility of acute arrhythmia termination as an ablation endpoint for induced atrial tachyarrhythmia after complete pulmonary vein isolation during catheter ablation for persistent atrial fibrillation.

PURPOSE: The presence of inducible atrial tachyarrhythmia after pulmonary vein isolation (PVI) during radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF) may indicate the necessity of further substrate modification, but the optimal ablation endpoint is unknown. We sought to assess the impact of procedural termination of inducible atrial tachyarrhythmia after PVI in comparison with continued atrial tachyarrhythmia after PVI. METHODS: Among patients who underwent RFCA for persistent AF, we enrolled 93 patients who were in sinus rhythm after PVI and had inducible atrial tachyarrhythmia and 157 patients with continued atrial tachyarrhythmia after PVI. The impact of acute arrhythmia termination during further substrate modification on recurrence was compared between the two groups. RESULTS: Acute termination was achieved in 51 (54.8%) patients in the induced arrhythmia group and 61 (38.9%) in the continued arrhythmia group. During a mean 35.8 months, acute termination did not significantly reduce arrhythmia recurrence in the induced arrhythmia group (HR 0.712, 95% CI 0.400-1.266, p = 0.247), while it was associated with improved outcome in the continued arrhythmia group (HR 0.590, 95% CI 0.355-0.979, p = 0.038). Acute termination of either induced atrial tachycardia (AT) or induced AF was not associated with improved procedure outcome. Among the continued arrhythmia group, the benefit of acute termination was statistically significant in AT (HR 0.329, 95% CI 0.108-0.997, p = 0.039), but not in AF (HR 0.704, 95% CI 0.396-1.253, p = 0.233) after PVI. CONCLUSIONS: Acute termination of induced rhythm is not a reliable ablation endpoint during substrate modification in patients with inducible arrhythmia after PVI.

Clinical implications of combined glucose intolerance in treatment-naïve hypertensive patients.

BACKGROUND: This study is the first study to evaluate clinical significance of combined glucose intolerance (CGI) in treatment-naïve hypertensive patients. METHODS: We compared the results of demographic, anthropometric, clinical, laboratory examinations, echocardiography, arterial stiffness, central blood pressure (BP) and ambulatory BP monitoring (ABPM) between the groups according to fasting blood sugar (FBS), postprandial 2 hour blood glucose (PP2) and gender in treatment-naïve hypertensive patients. A total of 376 concecutively-eligible patients were categorized as follows: (1) normal glucose tolerance (NGT); FBS<100 mg/dL and PP2 < 140 (2) isolated glucose intolerance (IGI); 100≤FBS<126 or 140≤PP2 < 200, but not both 100≤FBS<126 and 140≤PP2 < 200 (3) CGI; both 100≤FBS<126 and 140≤PP2 < 200. RESULTS: Males were divided into NGT (n = 58, 33.1%), IGI (n = 88, 50.3%), CGI (n = 29, 16.6%) and females were divided into NGT (n = 59, 43.1%), IGI (n = 48, 35%), CGI (n = 30, 21.9%). In males multivariate analyses revealed that mitral average E/Ea (IGI vs CGI, p = 0.022), brachial-ankle pulse wave velocity baPWV(Rt.) (IGI vs CGI, p = 0.026), baPWV(Lt.) (IGI vs CGI, p = 0.018), office systolic BP (SBP) (NGT vs. CGI, p = 0.005; IGI vs. CGI, p = 0.001), office diastolic BP (DBP) (NGT vs. CGI, p = 0.034; IGI vs. CGI, p = 0.019), night-time SBP (NGT vs. CGI, p = 0.049; IGI vs. CGI, p = 0.018) were significantly higher in the CGI group than in the NGT or IGI group. However, there were no significant differences between the female groups. CONCLUSIONS: Treatment-naïve hypertensive males with CGI revealed subclinical diastolic dysfunction, arterial stiffness, and BPs.

Relationship between airflow obstruction and coronary atherosclerosis in asymptomatic individuals: evaluation by coronary CT angiography.

Airflow obstruction is associated with increased cardiovascular morbidity and mortality. However, the causal mechanisms linking airflow obstruction with higher incidence of cardiovascular events remain elusive. We evaluated the relationship between airflow obstruction, a key feature of chronic obstructive pulmonary disease (COPD), and prevalence, extent, and severity of coronary atherosclerosis in a large cohort of asymptomatic subjects. Participants were recruited from those undergoing spirometry and coronary computed tomography angiography (CCTA) as part of a general health evaluation from March 2009 to February 2011. Subjects were required to be over 40 years of age with no known CAD. Airflow obstruction was defined as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) < 70%. Obstructive CAD, as measured by CCTA, was defined as maximum intra-luminal stenosis ≥ 50%. Participants with airflow obstruction or normal lung function were compared in terms of obstructive CAD prevalence, the extent and severity of coronary atherosclerosis; including coronary artery calcium score (CACS), atheroma burden score (ABS), atheroma burden obstructive score (ABOS), segment involvement score (SIS), and segment stenosis score (SSS). A total of 1888 subjects were eligible for study inclusion. Compared with participants with normal lung function, those exhibiting airflow obstruction were more likely to have obstructive CAD (p = 0.002). Airflow obstruction was associated with higher CACS (p = 0.043), ABS (p = 0.002), ABOS (p = 0.017), SIS (p = 0.003), and SSS (p = 0.002). Multivariable analyses adjusted for conventional cardiovascular risk factors revealed that airflow obstruction was independently associated with presence of CAD (odds ratio 1.673, confidence intervals [CI] 1.002-2.789, p = 0.048). In this asymptomatic population, the presence of airflow obstruction was associated with a greater prevalence, extent, and severity of coronary atherosclerosis and was seen to be an independent predictor of the presence of CAD.

Impact of Postprocedural TIMI Flow on Long-Term Clinical Outcomes in Patients with Acute Myocardial Infarction.

This study aimed to evaluate the clinical prognostic implications of postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow in acute myocardial infarction patients. A total of 2796 ST-elevation myocardial infarction (STEMI) and 1720 non ST-elevation myocardial infarction (NSTEMI) patients treated in 8 hospitals affiliated with the Catholic University of Korea and Chonnam National University Hospital were analyzed. The study populations were divided according to the final TIMI flow. The primary outcome were the major adverse cardiac events (MACE), defined as a composite of cardiac deaths (CD), nonfatal myocardial infarctions (MI), and target lesion revascularization (TLR). Over a median follow-up of 3.3 years (minimum 2 to maximum 5 years), MACE and CD occurred more frequently in STEMI patients with TIMI ≤ 2 group than those with TIMI 3 (MACE: adjusted hazard ratio [aHR], 1.962; 95% confidence interval [CI] 1.513 to 2.546, P < 0.001, CD: aHR, 3.154, CI 2.308 to 4.309, P < 0.001). However, there was no significant difference between the two subgroups in NSTEMI (aHR, 0.932; 95% CI 0.586 to 1.484, P = 0.087). In STEMI patients, good postprocedural TIMI flow after PCI was associated with favorable clinical outcomes. And the effect of poor TIMI flow in STEMI was on death, not the components of MACE. Meanwhile, postprocedural TIMI flow had no effect on long-term outcomes in NSTEMI patients.

Underdevelopment of Left Atrial Appendage.

A patient was admitted for catheter ablation of atrial fibrillation. Cardiac computed tomography and transesophageal echocardiography revealed the absence of the left atrial appendage. However, the right atrial appendage looked normal and the level of pro B-natriuretic peptide was within normal limits. Successful catheter ablation was performed without any procedural complications and the sinus rhythm was appropriately maintained for 10 months with an antiarrhythmic drug.

Differences between Korea and Japan in Physician Decision Making Regarding Permanent Pacemaker Implantation.

BACKGROUND AND OBJECTIVES: The number of permanent pacemakers (PPMs) implanted in patients in Japan and Korea differs significantly. We aimed to investigate the differences in decision making processes of implanting a PPM. MATERIALS AND METHODS: Our survey included 15 clinical case scenarios based on the 2008 AHA/ACC/HRS guidelines for device-based therapy of cardiac rhythm abnormalities (class unspecified). Members of the Korean and Japanese Societies of Cardiology were asked to rate each scenario according to a 5-point scale and to indicate their decisions for or against implantation. RESULTS: Eighty-nine Korean physicians and 192 Japanese physicians replied to the questionnaire. For the case scenarios in which there was a class I indication for PPM implantation, the decision to implant a PPM did not differ significantly between the two physician groups. However, the Japanese physicians were significantly more likely than the Korean physicians to choose implantation in class IIa scenarios (48% vs. 37%, p<0.001), class IIb scenarios (40% vs. 19%, p<0.001), and class III scenarios (36% vs. 18%, p<0.001). These results did not change when the cases were categorized based on disease entity, such as sinus node dysfunction and conduction abnormality. CONCLUSION: Korean physicians are less likely than Japanese physicians to favor a PPM implantation when considering a variety of clinical case scenarios, which probably contributes to the relatively small number of PPMs implanted in patients in Korea as compared with those in Japan.

Achievement of successful pulmonary vein isolation: methods of adenosine testing and incremental benefit of exit block.

PURPOSE: Several approaches were tried to achieve complete pulmonary vein isolation (PVI). The aims of this study were to (1) compare adenosine-induced PV conduction and exit conduction, (2) determine the adequate adenosine dose, and (3) investigate the correlation of dormant conduction and recurrence of atrial fibrillation (AF). METHODS: A total of 378 consecutive patients who underwent PVI from June 2012 to April 2015 were prospectively included (the de novo procedure in 318 (84.1 %) and a redo procedure in 60 (15.9 %)). After the exit block was assessed, 20 mg adenosine was injected into the left atrium. If dormant conduction was observed, 12 and 6 mg of adenosine were injected sequentially. RESULTS: Exit conduction during PV pacing was observed in 34 patients (9 %), and dormant conduction was observed in 92 patients (24.3 %). Among them, 74 (80.4 %, 74/92) demonstrated dormant conduction without exit conduction and 16 (47.1 %, 16/34) showed exit conduction without dormant conduction. The 20-mg dose of adenosine had an additive yield in patients with dormant conduction, compared to that of 12 mg (93 %, 86/92) or 6 mg (80 %, 74/92). There was no significant difference in the recurrence rate regarding dormant conduction. The pattern of prevalence of reconnected origin during the redo procedure was similar to that of dormant conduction during the index procedure. CONCLUSIONS: There was a discrepancy between adenosine-induced PVI and exit block. Therefore, exit block test has additional value to verify latent incomplete PVI in conjunction with adenosine test. Furthermore, high-dose adenosine had an additive yield. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov/ct2/show/NCT01932112.

Visualization of the Critical Isthmus by Tracking Delayed Potential in Edited Windows for Scar-Related Ventricular Tachycardia.

BACKGROUND AND OBJECTIVES: Identifying the critical isthmus of slow conduction is crucial for successful treatment of scar-related ventricular tachycardia. Current 3D mapping is not designed for tracking the critical isthmus and may lead to a risk of extensive ablation. We edited the algorithm to track the delayed potential in order to visualize the isthmus and compared the edited map with a conventional map. SUBJECTS AND METHODS: We marked every point that showed delayed potential with blue color. After substrate mapping, we edited to reset the annotation from true ventricular potential to delayed potential and then changed the window of interest from the conventional zone (early, 50-60%; late, 40-50% from peak of QRS) to the edited zone (early, 80-90%; late, 10-20%) for every blue point. Finally, we compared the propagation maps before and after editing. RESULTS: We analyzed five scar-related ventricular tachycardia cases. In the propagation maps, the resetting map showed the critical isthmus and entrance and exit sites of tachycardia that showed figure 8 reentry. However, conventional maps only showed the earliest ventricular activation sites and searched for focal tachycardia. All of the tachycardia cases were terminated by ablating the area around the isthmus. CONCLUSION: Identifying the channel and direction of the critical isthmus by a new editing method to track delayed potential is essential in scar-related tachycardia.

Randomized Comparison of Continuous Versus Intermittent Heparin Infusion During Catheter Ablation of Atrial Fibrillation.

OBJECTIVES: This study tested the hypothesis that continuous heparin infusions would be favorable for maintaining heparin concentrations during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). BACKGROUND: Heparin infusions are essential for RFCA of AF. There is a paucity of data on the details for the optimal heparin infusion during RFCA of AF. METHODS: A total of 333 patients undergoing AF ablation were consecutively enrolled and randomized to intermittent or continuous heparin infusion. A heparin bolus of 100 U/kg was injected just prior to transseptal puncture. The heparin concentration necessary to maintain an optimal activated clotting time (ACT) (300 to 400 s) was determined and checked every 30 min during the procedure. The primary endpoint of the study was the frequency of the maintenance of an optimal intraprocedural ACT. RESULTS: The frequency of an optimal ACT in the continuous group was significantly higher than that in the intermittent group (64.0% vs. 57.6%, respectively, p < 0.01), whereas the total heparin level was significantly lower in the continuous group (13,162 ± 4,634 U vs. 15,837 ± 5,243 U, respectively, p < 0.01). The standard deviation of the ACT was significantly smaller in the continuous group than in the intermittent group (49 ± 30 vs. 33 ± 18, respectively, p < 0.01). Ninety-six patients had new oral anticoagulants (NOACs) before the procedure, and an optimal ACT at the first ACT check was less frequent than in patients taking warfarin (12.5% vs. 59.1%, respectively, p < 0.01). There were no significant differences in periprocedural bleeding or thromboembolic complications between the groups. CONCLUSIONS: During AF ablation, a continuous heparin infusion was superior to an intermittent heparin infusion for maintaining an optimal ACT range. (Randomized Comparison of Continuous and Intermittent Heparin Infusion During Catheter Ablation of Atrial Fibrillation [COHERE]; NCT01935557).

Benefit of implantable cardioverter-defibrillator therapy after generator replacement in patients with Brugada syndrome.

BACKGROUND: An implantable cardioverter-defibrillator (ICD) is the only proven effective therapeutic strategy for patients with Brugada syndrome (BS). However, it is controversial whether the device should be replaced even in patients who had never experienced appropriate ICD therapy until the time of generator replacement. METHODS AND RESULTS: This was a nationwide, multicenter retrospective study that enrolled patients who were diagnosed with BS and had an ICD implantation between January 1998 and April 2014. Appropriate ICD therapies administered for ventricular tachyarrhythmia were evaluated during follow-up. A total of 117 patients (age 43 ± 12 years, male 115 [98.3%]) were enrolled, and the mean follow-up duration was 6.0 ± 4.1 years. Thirty-seven (31.6%) patients had experienced appropriate ICD therapy during follow-up. Of all patients, 46 underwent replacement of the device. After the first generator replacement, the incidence of appropriate ICD therapy remained as high as 65.2% in patients who previously experienced appropriate ICD therapy before generator replacement. In 30 patients who did not experience any cardiac events until the first generator change, two (8.7%) had an episode of appropriate ICD therapy afterwards. CONCLUSIONS: No episode of ICD therapy before generator replacement could not guarantee a safe clinical course. ICD generator replacement should be considered even in patients without ICD therapy before.

Long-term outcomes of remote magnetic navigation for ablation of supraventricular tachycardias.

BACKGROUND: Little is known about the long-term outcomes of catheter ablation of supraventricular tachycardia (SVT) using remote magnetic navigation system (RMN). METHODS: One hundred twenty patients underwent catheter ablation of SVTs with RMN (Niobe, Stereotaxis, USA): atrioventricular nodal re-entrant tachycardia (AVNRT; n = 59), atrioventricular re-entrant tachycardia (AVRT; n = 45), and focal atrial tachycardia (AT, n = 16). The outcome of AVRT with right free wall accessory pathway was compared with those of a group of 26 consecutive patients undergoing manual ablation. RESULTS: Mean follow-up period was 2.2 ± 1.4 years. Overall arrhythmia-free survival was 86%; AVRT (77%), AVNRT (96%), and focal AT (71%). After the learning period (initial 50 cases), procedural outcomes had improved for AVRT and AVNRT (91% in overall group, 90% in AVRT group, 100% in AVNRT group, and 68% in focal AT group). The recurrence-free rate was higher for the free wall accessory pathways than those of the other sites (92 vs. 73%, log-rank P = 0.06). Furthermore, when it is confined for the right free wall accessory pathway, RMN showed excellent long-term outcome (7/7, 100 %) compared to the results of manual approach (18/26, 69.2%, log-rank P = 0.07). CONCLUSIONS: RMN showed favorable long-term outcomes for the ablation of SVT. In our experience, RMN-guided ablation may be associated with a higher success rate as compared to manual ablation when treating right-sided free wall pathways.

Epidemiology and outcomes in out-of-hospital cardiac arrest: a report from the NEDIS-based cardiac arrest registry in Korea.

Sudden cardiac death (SCD) is a significant issue affecting national health policies. The National Emergency Department Information System for Cardiac Arrest (NEDIS-CA) consortium managed a prospective registry of out-of-hospital cardiac arrest (OHCA) at the emergency department (ED) level. We analyzed the NEDIS-CA data from 29 participating hospitals from January 2008 to July 2009. The primary outcomes were incidence of OHCA and final survival outcomes at discharge. Factors influencing survival outcomes were assessed as secondary outcomes. The implementation of advanced emergency management (drugs, endotracheal intubation) and post-cardiac arrest care (therapeutic hypothermia, coronary intervention) was also investigated. A total of 4,156 resuscitation-attempted OHCAs were included, of which 401 (9.6%) patients survived to discharge and 79 (1.9%) were discharged with good neurologic outcomes. During the study period, there were 1,662,470 ED visits in participant hospitals; therefore, the estimated number of resuscitation-attempted CAs was 1 per 400 ED visits (0.25%). Factors improving survival outcomes included younger age, witnessed collapse, onset in a public place, a shockable rhythm in the pre-hospital setting, and applied advanced resuscitation care. We found that active advanced multidisciplinary resuscitation efforts influenced improvement in the survival rate. Resuscitation by public witnesses improved the short-term outcomes (return of spontaneous circulation, survival admission) but did not increase the survival to discharge rate. Strategies are required to reinforce the chain of survival and high-quality cardiopulmonary resuscitation in Korea.

Paced QRS axis as a predictor of pacing-induced left ventricular dysfunction.

PURPOSE: The selection of the optimal right ventricular (RV) pacing site remains unclear. We hypothesized that a normal paced QRS axis would provide a physiological ventricular activation and lead to a better long-term outcome. METHODS: We evaluated 187 patients who underwent a permanent pacemaker implantation and were dependent on RV pacing. The pacing sites were classified as the apex and non-apex according to the chest radiography. A paced QRS axis was defined as that between -30° and 90°. Preservation of the left ventricular (LV) systolic function was defined as that with a <10 % decrease in the ejection fraction after the pacemaker implantation. RESULTS: The median follow-up period was 5.8 years (interquartile 3.9-9.0). Radiographically, the RV leads were located in the apex (n = 148, 79 %) or non-apex (n = 39, 21 %). In the electrocardiogram, normal paced and abnormal paced QRS axes were observed in 28 patients (15 %) and 159 patients (85 %), respectively. The LV ejection fraction was decreased in the patients with an abnormal paced QRS axis (-10 ± 10 %, P < 0.001), but not in those with a normal axis (0 ± 6 %, P = 0.80). The electrocardiographic determinant differentiated a preserved LV function (95 % vs. 35 %, log-rank P = 0.04). Among the patients with radiographically non-apical pacing, a normal paced QRS axis was an additional meaningful predictor of a preserved LV function after the pacemaker implantation (95 % vs. 24 %, log-rank P = 0.002). CONCLUSION: Compared with the radiographic method, a normal paced QRS axis was associated with a preserved LV function.

Impact of left anterior line on left atrial appendage contractility in patients who underwent catheter ablation for chronic atrial fibrillation.

BACKGROUND: Left anterior line (LAL) has been used as a substitute for mitral isthmus line for catheter ablation of chronic atrial fibrillation (AF). However, it results in left anterolateral conduction delay and might affect left atrial (LA) contractility. We aimed to investigate whether LAL decreases LA appendage function. METHODS: This study included 46 patients (30 men, mean age 58 ± 9 years, group 1) with persistent AF who underwent catheter ablation including LAL. Thirty patients with paroxysmal AF who received no additional LA ablation were compared as control group (21 males, mean age 56 ± 8 years, group 2). Transthoracic and transesophageal echocardiography with Doppler tissue imaging was performed in sinus rhythm before and after the ablation. We compared the following variables: (1) E/A ratio of the mitral flow velocity, (2) ratio of early mitral inflow and mitral septal annulus velocity (E/Em), (3) peak velocity of appendage outflow (ApVmax), and (4) time delay from QRS onset to appendage outflow (TDqa). RESULTS: LA diameter was significantly reduced after ablation in both groups. In group 1, parameters for diastolic function (E/A ratio, 1.7 ± 0.5 vs 2.0 ± 0.6, P = 0.197; E/Em, 11.7 ± 4.8 vs 11.6 ± 5.1, P = 0.883) and appendage flow (ApVmax, 55.2 ± 19.9 cm/s vs 50.3 ± 19.3 cm/s, P = 0.203; TDqa, -77.3 ± 30.1 ms vs -66.1 ± 60.8 ms, P = 0.265) did not change significantly after ablation. Changes of ApVmax and TDqa after ablation were not significantly different between two groups (P = 0.409 and P = 0.195, respectively). CONCLUSIONS: LAL ablation did not aggravate mitral flow pattern or change appendage outflow. LAL could be used without concern over worsening LA diastolic and appendage function.

Independent determinants for presence and degree of left ventricular systolic dyssynchrony in treatment-naive patients with hypertension.

OBJECTIVE: Prevalence of left ventricular systolic dyssynchrony (LVSD) is over 40% in treatment-naive patients with hypertension and it improves after chronic antihypertensive treatment. These findings might support the hypothesis that blood pressure (BP), BP-derived parameters, central BP, or arterial stiffness would contribute to LVSD. Therefore, we aimed to investigate possible factors associated with LVSD in treatment-naive patients with hypertension. METHODS: The study groups consisted of 266 treatment-naive hypertensive patients who underwent anthropometric, clinical, laboratory, echocardiographic, arterial stiffness, central blood pressure, and 24-h ambulatory blood pressure monitoring evaluations. Echocardiographic measurement was recorded as follows: peak systolic velocity (Sa, subclinical left ventricular systolic function), peak early diastolic and late diastolic velocity at the mitral annulus (Ea and Aa, respectively), mitral E/Ea ratio (subclinical left ventricular diastolic function), standard deviation of time from ECG Q to systolic peak velocity of 12 left ventricular segments (Ts-SD12), and maximal difference between peak systolic velocities of any 2 of the 12 segments (Ts-Max). A Ts-SD12 at least 33 or Ts-Max at least 100 ms was regarded as presence of LVSD. RESULTS: Patients were divided into those without LVSD (group 1, n = 151, 56.8%) and those with LVSD (group 2, n = 115, 43.2%). Group 2 had higher E/Ea and high-density lipoprotein and lower Sa and triglyceride than group 1. On multivariate analysis, Sa was independently and inversely associated with the presence of LVSD [odds ratio (OR) 0.67, 95% confidence interval (CI) 0.48-0.93, P = 0.018]. The linear relationship between variables and degree of LVSD showed that serum potassium levels, E/Ea, and Sa remained significant after multivariate analysis (potassium, ß = 0.199, P = 0.006; E/Ea, ß = 0.211, P = 0.017; Sa, ß = -0.301, P < 0.001 in Ts-SD12 and potassium, ß=0.187, P = 0.010; E/Ea, ß = 0.234, P = 0.008; Sa, ß = -0.322, P < 0.001 in Ts-Max, respectively). CONCLUSION: Subclinical left ventricular systolic function is independently associated with both the presence and degree of LVSD in treatment-naive hypertensive patients. Subclinical left ventricular diastolic function and serum potassium levels are independently associated with the degree of LVSD. However, arterial stiffness and BP parameters are not determinants.

Metabolically obese status with normal weight is associated with both the prevalence and severity of angiographic coronary artery disease.

OBJECTIVE: We evaluated prevalence and severity of angiographic coronary artery disease (CAD) according to groups by metabolically obese (MO) and/or weight status. MATERIAL/METHODS: Normal weight was defined as body mass index (BMI, kg/m²)<25 and obesity was defined as BMI≥25. The MO was determined using the National Cholesterol Education Program-Adult Treatment Panel III classification with Korean-specific cutoffs for abdominal obesity. Therefore, a total of 856 subjects were categorized as follows: (1) metabolically healthy and normal weight (MHNW); (2) metabolically obese but normal weight (MONW); (3) metabolically healthy but obese (MHO); and (4) metabolically abnormally obese (MAO). The presence of obstructive lesion≥50% of coronary artery was considered as an angiographic CAD and the Gensini scoring system was used for the severity. RESULTS: MONW or MO showed a higher prevalence of CAD than MHNW or non-MO after adjustment for age and sex, respectively (MONW, odds ratio [OR]=1.69, 95% confidence interval [CI]: 1.13-2.51 and MO, OR=1.44, 95% CI: 1.09-1.91). In subjects without diabetes mellitus (DM), MONW or MO showed a marginally higher prevalence of CAD (MONW, OR=1.58, 95% CI: 0.96-2.61 and MO, OR=1.41, 95% CI: 0.96-2.08). MONW was independently associated with a higher severity of angiographic CAD than MHNW after age, sex, glomerular filtration rate, smoking status, high sensitive C-reactive protein, and use of anti-platelet and anti-angina drugs (ß=0.118, P=0.005). And MO was associated with a higher severity of angiographic CAD than non-MO after adjustment for age and sex (ß=0.077, P=0.024). The above associations were also consistent in subjects without DM (MONW, ß=0.147, P=0.003 and MO, ß=0.129, P=0.005). CONCLUSIONS: MONW or MO is associated with both the prevalence and severity of angiographic CAD after adjustment for age and sex and MONW is independently associated with the severity of angiographic CAD irrespective of DM. Therefore, subjects with MO but normal weight (MONW) should be carefully examined for angiographic CAD.

Influence of nationwide policy on citizens' awareness and willingness to perform bystander cardiopulmonary resuscitation.

AIMS: Public awareness to cardiopulmonary resuscitation (CPR) and cardiac arrest is influenced by systemic factors including related policies and legislations in the community. Here, we describe and compare the results of the two nationwide CPR surveys in 2007 and 2011 examining public awareness and attitudes to bystander CPR in South Korea along with changes in nationwide CPR policies and systemic factors. METHODS: This population-based study used specially designed questionnaires via telephone surveys. We conducted bi-temporal surveys by stratified cluster sampling to assess the impact of age, gender, and geographic regions in 2007 (n=1029) and in 2011 (n=1000). Logistic regression analysis was performed to identify factors associated with willingness to perform bystander CPR. RESULTS: Public awareness of automated external defibrillators increased from 3.0% in 2007 to 32.6% in 2011. The proportion of the population that underwent CPR training within the previous 2 years increased significantly from 26.9% to 49.0%. The factors most related with intention of bystander CPR were male gender, younger age, CPR awareness, recent CPR training, and qualified CPR learning. In 2011, 75.8% of respondents were more willing to perform bystander CPR for stranger vs. 68.3% in 2007 (p=0.002). Additional dispatcher hands-only CPR increased this proportion (85.8%, p<0.001). However, bystander CPR experience rates remained unchanged (3.6-3.9%). CONCLUSION: Changes in nationwide CPR policies and systemic factors affected citizens' awareness and willingness to perform bystander CPR. Additionally, applied dispatcher hands-only CPR and publicity increased public willingness to perform bystander CPR.

A case of left ventricular noncompaction accompanying fasciculo-ventricular accessory pathway and atrial flutter.

Left ventricular hypertrabeculation/noncompaction (LVHT) is an uncommon type of genetic cardiomyopathy characterized by trabeculations and recesses within the ventricular myocardium. LVHT is associated with diastolic or systolic dysfunction, thromboembolic complications, and arrhythmias, including atrial fibrillation, ventricular arrhythmias, atrioventricular block and Wolff-Parkinson-White syndrome. Herein, we describe a patient who presented with heart failure and wide-complex tachycardia. Echocardiography showed LVHT accompanied with severe mitral regurgitation. The electrophysiologic study revealed a fasciculo-ventricular accessory pathway and atrial flutter (AFL). The AFL was successfully treated with catheter ablation.