The impact of early cryoballoon ablation on clinical outcome in patients with atrial fibrillation: From the Korean cryoballoon ablation registry.

INTRODUCTION: Influence of early atrial fibrillation (AF) ablation, particularly cryoballoon ablation (CBA), on clinical outcome during long-term follow-up has not been clarified. The objective was to determine whether an early CBA (diagnosis-to-ablation of ≤6 months) strategy could affect freedom from AF recurrence after index CBA. METHODS: The study included 2605 patients from Korean CBA registry data with follow-up >12 months after de novo CBA. The primary outcome was recurrence of atrial tachyarrhythmias (ATs) of ≥30-s after a 3-month blanking period. RESULTS: Compared to patients in early CBA group, patients in late CBA group had higher prevalence of diabetes, congestive heart failure, and chronic kidney disease, and higher mean CHA2 DS2 -VAS score. During mean follow-up of >21 months, ATs recurrence was detected in 839 (32.2%) patients. The early CBA group showed a significantly lower 2-year recurrence rate of ATs than the late CBA group (26.1% vs. 31.7%, p = 0.043). In subgroup analysis, the early CBA group showed significantly higher 1-year and 2-year freedom from ATs recurrence than the late CBA group only in paroxysmal atrial fibrillation (PAF) patients in overall and propensity score matched cohorts. Multivariate analysis showed that early CBA was an independent factor for preventing ATs recurrence in PAF (hazard ratio: 0.637; 95% confidence intervals: 0.412-0.984). CONCLUSION: Early CBA strategy, resulting in significantly lower ATs recurrence during 2-year follow-up after index CBA, might be considered as an initial rhythm control therapy in patients with paroxysmal AF.

Long-term clinical impact of early recurrence of atrial tachyarrhythmia after cryoballoon ablation in patients with atrial fibrillation.

INTRODUCTION: The impact of early recurrence of atrial tachyarrhythmia (ERAT) within the 90-day blanking period on long-term outcomes in atrial fibrillation (AF) patients undergoing cryoballoon ablation (CBA) is controversial. This study aimed to assess the relationship between ERAT and late recurrence of atrial tachyarrhythmia (LRAT) post-CBA. METHODS: Utilizing data from a multicenter registry in Korea (May 2018 to June 2022), we analyzed the presence and timing of ERAT (<30, 30-60, and 60-90 days) and its association with LRAT risk after CBA. LRAT was defined as any recurrence of AF, atrial flutter, or atrial tachycardia lasting more than 30 s beyond the 90 days. RESULTS: Out of 2636 patients, 745 (28.2%) experienced ERAT post-CBA. Over an average follow-up period of 21.2 ± 10.3 months, LRAT was observed in 874 (33.1%) patients. Patients with ERAT had significantly lower 1-year LRAT freedom compared to those without ERAT (42.6% vs. 85.5%, p < .001). Multivariate analysis identified ERAT as a potential predictor of LRAT, with a hazard ratio (HR) of 3.98 (95% confidence interval [CI], 3.47-4.57). Significant associations were noted across all examined time frames (HR, 3.84; 95% CI, 3.32-4.45 in <30 days, HR, 5.53; 95% CI, 4.13-7.42 in 30-60 days, and HR, 4.29; 95% CI, 3.12-5.89 in 60-90 days). This finding was consistently observed across all types of AF. CONCLUSION: ERAT during the 90-day blanking period strongly predicts LRAT in AF patients undergoing CBA, indicating a need to reconsider the clinical significance of this period.

Association between body mass index and results of cryoballoon ablation in Korean patients with atrial fibrillation: an analysis from the Korean Heart Rhythm Society Cryoablation registry.

AIMS: Pulmonary vein isolation using cryoablation is effective and safe in patients with atrial fibrillation (AF). Although both obesity and underweight are associated with a higher risk for incident AF, there is limited data on the efficacy and safety following cryoablation according to body mass index (BMI) especially in Asians. METHODS AND RESULTS: Using the Korean Heart Rhythm Society Cryoablation registry, a multicentre registry of 12 tertiary hospitals, we analysed AF recurrence and procedure-related complications after cryoablation by BMI (kg/m2) groups (BMI < 18.5, underweight, UW; 18.5-23, normal, NW; 23-25, overweight, OW; 25-30, obese Ⅰ, OⅠ; ≥30, obese Ⅱ, OⅡ). A total of 2648 patients were included (median age 62.0 years; 76.7% men; 55.6% non-paroxysmal AF). Patients were categorized by BMI groups: 0.9% UW, 18.7% NW, 24.8% OW, 46.1% OI, and 9.4% OII. Underweight patients were the oldest and had least percentage of non-paroxysmal AF (33.3%). During a median follow-up of 1.7 years, atrial arrhythmia recurred in 874 (33.0%) patients (incidence rate, 18.9 per 100 person-years). After multivariable adjustment, the risk of AF recurrence was higher in UW group compared with NW group (adjusted hazard ratio, 95% confidence interval; 2.55, 1.18-5.50, P = 0.02). Procedure-related complications occurred in 123 (4.7%) patients, and the risk was higher for UW patients (odds ratio, 95% confidence interval; 2.90, 0.94-8.99, P = 0.07), mainly due to transient phrenic nerve palsy. CONCLUSION: Underweight patients showed a higher risk of AF recurrence after cryoablation compared with NW patients. Also, careful attention is needed on the occurrence of phrenic nerve palsy in UW patients.

Timing of critical isthmus from end of P wave and usefulness of activation mapping with window of interest from end to end of P wave in reentrant atrial tachycardia.

In activation mapping of reentrant atrial tachycardia (AT), there was no reference for window of interest (WOI). We examined the timing of a successful termination site from end of the P wave and attempted to determine whether the critical isthmus can be identified using activation mapping when WOI was set as end to end of the P wave. Forty patients with 54 reentrant AT who underwent 3D electroanatomic mapping and radiofrequency catheter ablation were evaluated retrospectively. The critical isthmus was defined as a successful termination site. We evaluate critical isthmus timing from end of the P wave and percentage of critical isthmus timing from end of the P wave to tachycardia cycle length. In 54 reentrant AT, Macro-reentry was identified in 46 (85.2%) and micro-reentry was identified in eight (14.8%). The timing of the critical isthmus site from end of the P wave was - 4.0 ± 31.1 ms (Macro-reentry vs. Micro-reentry; - 8.9 ± 29.4 ms vs. 24.0 ± 26.7 ms; P = 0.005). The percentage of critical isthmus timing from end of the P wave/tachycardia cycle length was - 1.4 ± 10.5% (Macro-reentry vs. Micro-reentry; - 3.1 ± 9.8% vs. 8.3 ± 9.3%, P = 0.004) The critical isthmus of reentrant AT is located within 10% backward and forward from end of the P wave to tachycardia cycle length. Setting the WOI from end to end of the P wave is useful for identification of the critical isthmus through activation mapping.

Association of High-Sensitivity Troponin I with Cardiac and Cerebrovascular Events in Patient after Ischemic Stroke.

INTRODUCTION: Early recognition and risk stratification of cardiovascular events are necessary in patients after ischemic stroke. Recent evidence suggests that elevated high-sensitive cardiac troponin is a predictor of mortality and vascular events. Therefore, we aimed to explore the prognostic role of high-sensitive cardiac troponin I (hs-TnI) on mortality and cardiovascular outcomes in patients after ischemic stroke. METHODS: From August 2014 to July 2017, 1,506 patients with acute ischemic stroke were pulled consecutively in a retrospective single-center registry. Of these, 1,019 patients were selected and classified into the elevated or non-elevated hs-TnI groups according to hs-TnI level of 99th percentile upper reference limit (URL) at the time of admission for ischemic stroke. The primary outcome was a major adverse cardiac and cerebrovascular event (MACCE) during follow-up. RESULTS: Among 1,019 patients, 708 patients were non-elevated hs-TnI group (<99th percentile URL of hs-TnI) and 311 patients were elevated hs-TnI group (≥99th percentile URL of hs-TnI). The median follow-up period was 22.5 (interquartile range 5.0-38.8) months. In a multivariable Cox regression model, the elevated hs-TnI group has a higher risk of MACCE (adjusted hazard ratio [HR]: 3.12; 95% confidence interval [CI]: 2.33-4.17; p < 0.01), all-cause mortality (adjusted HR: 4.15; 95% CI: 2.47-6.99; p < 0.01) and readmission caused by coronary revascularization (adjusted HR: 3.12; 95% CI: 1.41-6.90; p < 0.01), heart failure (adjusted HR: 2.76; 95% CI: 1.38-5.51; p < 0.01), and stroke (adjusted HR: 1.73; 95% CI: 1.07-2.78; p = 0.02) compared with the non-elevated hs-TnI group. CONCLUSIONS: Elevated hs-TnI is independently associated with higher mortality and cardiac and cerebrovascular events in patients with ischemic stroke and may serve as a valuable prognostic factor in management after ischemic stroke.

The association of cardiac troponin and cardiovascular events in patients with concomitant heart failure preserved ejection fraction and atrial fibrillation.

BACKGROUND: Limited data are available for risk stratification in patients with atrial fibrillation (AF) and combined heart failure with preserved ejection fraction (HFpEF). We aimed to explore the prognostic utility of high-sensitivity cardiac troponin I (hs-cTnI) in patients with newly detected AF and concomitant HFpEF. METHODS: From August 2014 to December 2016, 2,361 patients with newly detected AF were polled in a retrospective single-center registry. Of which, 634 patients were eligible for HFpEF diagnosis (HFA-PEFF score ≥ 5) and 165 patients were excluded with exclusion criteria. Finally, 469 patients are classified into elevated or non-elevated hs-cTnI groups based on the 99th percentile upper reference limit (URL). The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCE) during follow-up. RESULTS: In 469 patients, 295 were stratified into the non-elevated hs-cTnI group (< 99th percentile URL of hs-cTnI) and 174 were placed in the elevated hs-cTnI group (≥ 99th percentile URL of hs-cTnI). The median follow-up period was 24.2 (interquartile range, 7.5-38.6) months. During the follow-up period, 106 patients (22.6%) in the study population experienced MACCE. In a multivariable Cox regression model, the elevated hs-cTnI group had a higher incidence of MACCE (adjusted hazard ratio [HR], 1.54; 95% confidence interval [CI], 1.08-2.55; p = 0.03) and coronary revascularization-caused readmission (adjusted HR, 3.86; 95% CI, 1.39-15.09; p = 0.02) compared with the non-elevated hs-cTnI group. The incidence of heart failure-caused readmission tended to occur more frequently in the elevated hs-cTnI group (8.5% versus 15.5%; adjusted HR, 1.52; 95% CI, 0.86-2.67; p = 0.08). CONCLUSIONS: One-fifth of patients with AF and concomitant HFpEF experienced MACCE during follow-up, and elevated hs-cTnI was independently associated with higher risk of MACCE, as driven by heart failure and revascularization-caused readmission. This finding suggested that hs-cTnI may be a useful tool in individualized risk stratification of future cardiovascular events in patients with AF and concomitant HFpEF.

Edoxaban-based long-term antithrombotic therapy in patients with atrial fibrillation and stable coronary disease: Rationale and design of the randomized EPIC-CAD trial.

BACKGROUND: Anticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD. DESIGN: The EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA2DS2-VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization. RESULTS: As of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023. CONCLUSIONS: EPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD.

Blood pressure levels and cardiovascular risk according to age in patients with diabetes mellitus: a nationwide population-based cohort study.

BACKGROUND: Little is known about age-specific target blood pressure (BP) in hypertensive patients with diabetes mellitus (DM). The aim of this study was to determine the BP level at the lowest cardiovascular risk of hypertensive patients with DM according to age. METHODS: Using the Korean National Health Insurance Service database, we analyzed patients without cardiovascular disease diagnosed with both hypertension and DM from January 2002 to December 2011. Primary end-point was composite cardiovascular events including cardiovascular death, myocardial infarction and stroke. RESULTS: Of 241,148 study patients, 35,396 had cardiovascular events during a median follow-up period of 10 years. At the age of < 70 years, the risk of cardiovascular events was lower in patients with BP < 120/70 mmHg than in those with BP 130-139/80-89 mmHg. At the age of ≥ 70, however, there were no significant differences in the risk of cardiovascular events between patients with BP 130-139/80-89 mmHg and BP < 120/70 mmHg. The risk of cardiovascular events was similar between patients with BP 130-139/80-89 mmHg and BP 120-129/70-79 mmHg, and it was significantly higher in those with BP ≥ 140/90 mmHg than in those with BP 130-139/80-89 mmHg at all ages. CONCLUSIONS: In a cohort of hypertensive patients who had DM but no history of cardiovascular disease, lower BP was associated with lower risk of cardiovascular events especially at the age of < 70. However, low BP < 130-139/80-89 mmHg was not associated with decreased cardiovascular risk, it may be better to keep the BP of 130-139/80-89 mmHg at the age of ≥ 70.

Uric Acid and Risk of Atrial Fibrillation in the Korean General Population.

BACKGROUND: Increased serum uric acid is associated with prevalence and incidence of atrial fibrillation (AF), but there is a lack of studies on the association between serum uric acid and risk of AF in the general population. Methods and Results: We used the data from the Kangbuk Samsung Hospital health screening cohort recorded between 2002 and 2015. The primary outcome was incidence of AF diagnosed on 12-lead electrocardiography. We analyzed and compared the hazard ratios (HR) according to baseline serum uric acid quartiles. The present study involved 282,473 subjects without baseline AF. Mean follow-up was 5.4±3.6 years. During follow-up, AF was identified in 365 subjects (cumulative incidence, 0.13%). After multivariable adjustment, including that for C-reactive protein, the risk of AF was significantly higher in the upper 2 quartiles than in the lowest quartile in men (upper third quartile: adjusted HR, 1.53; 95% confidence interval [CI]: 1.11-2.89; highest quartile: HR, 1.60; 95% CI: 1.13-2.25). In women, even though AF incidence rate was very low (0.6 of 10,000 person-years), the risk of AF in the highest quartile was 6.93-fold that in the lowest quartile (95% CI: 1.53-31.29). CONCLUSIONS: Serum uric acid is significantly and positively associated with incident AF in the Korean general population.

Metabolic Syndrome and the Risk of New-Onset Atrial Fibrillation in Middle-Aged East Asian Men.

BACKGROUND: Although the prevalence of both atrial fibrillation (AF) and metabolic syndrome (MetS) has been increasing in East Asia, the association between them is uncertain.Methods and Results:A total of 24,741 middle-aged Korean men without baseline AF were enrolled in a health screening program from January 2003 to December 2008. Among them, 21,981 subjects were evaluated to determine the risk of AF based on baseline MetS status through December 2016. At every visit, the subjects were evaluated for AF using ECG. MetS was defined using the criteria of the International Diabetes Federation and was present in 2,529 subjects (11.5%). Mean (±standard deviation) age was 45.9±5.3 years. During a mean follow-up of 8.7 years, 168 subjects (0.8%) were diagnosed with AF. The age-adjusted and multivariate-adjusted hazard ratios (HR) for MetS with AF were 1.62 (P=0.02) and 1.57 (P=0.03), respectively. Among the components of MetS, central obesity (age-adjusted HR 1.62, P<0.01) and raised blood pressure (age-adjusted HR 1.43, P=0.02) were associated with an increased risk of AF. CONCLUSIONS: MetS is associated with an increased risk of AF in middle-aged East Asian men. Of the components of MetS, central obesity is the most potent risk factor for the development of AF in this population.

C-reactive protein and risk of atrial fibrillation in East Asians.

AIMS: Inflammation has been suggested to play a role in the pathogenesis of atrial fibrillation (AF). It is uncertain whether C-reactive protein, a robust inflammatory marker, is associated with AF incidence in Asians with lower levels of C-reactive protein compared with western population. This study aimed to determine the association between C-reactive protein and risk of AF in a large population of Koreans. METHODS AND RESULTS: A total of 402 946 Koreans were enrolled in a health screening programme from January 2002 to December 2013. Among them, 210 208 subjects were analysed during the mean follow-up of 4.59 years (1 062 513 person-years). Atrial fibrillation was identified by electrocardiography at every visits. Atrial fibrillation was identified in 561 subjects (0.1%) at baseline. The median (inter-quartile) baseline C-reactive protein levels were higher in subject with AF than in those without AF [0.9 mg/L (0.4-0.9) vs. 0.4 mg/L (0.2-1.0), P < 0.001]. Subjects in the highest quartile of C-reactive protein had more AF than those in the lowest quartile [adjusted odds ratio (OR) 2.02, 95% confidence interval (CI) 1.45-2.81; P< 0.001]. During a mean follow-up of 4.59 years, AF developed in 261 subjects (0.1%). The highest quartile of baseline C-reactive protein had a 1.68-fold (95% CI 1.06-2.67) increased risk of AF than the lowest quartile in multivariate Cox regression analysis. CONCLUSION: Baseline C-reactive protein levels are significantly associated with the prevalence of AF and the risk of AF in Korean populations even C-reactive protein concentrations are substantially lower than reported in white populations.

Role of Coronary Artery Calcium Scoring in Detection of Coronary Artery Disease according to Framingham Risk Score in Populations with Low to Intermediate Risks.

Current guidelines recommend that coronary artery calcium (CAC) screening should only be used for intermediate risk groups (Framingham risk score [FRS] of 10%-20%). The CAC distributions and coronary artery disease (CAD) prevalence in various FRS strata were determined. The benefit to lower risk populations of CAC score-based screening was also assessed. In total, 1,854 participants (aged 40-79 years) without history of CAD, stroke, or diabetes were enrolled. CAC scores of > 0, ≥ 100, and ≥ 300 were present in 33.8%, 8.2%, and 2.9% of the participants, respectively. The CAC scores rose significantly as the FRS grew more severe (P < 0.01). The total CAD prevalence was 6.1%. The occult CAD prevalence in the FRS ≤ 5%, 6%-10%, 11%-20%, and > 20% strata were 3.4%, 6.7%, 9.0%, and 11.6% (P < 0.001). In multivariate logistic regression analysis adjusting, not only the intermediate and high risk groups but also the low risk (FRS 6%-10%) group had significantly increased odds ratio for occult CAD compared to the very low-risk (FRS ≤ 5%) group (1.89 [95% confidence interval, CI, 1.09-3.29] in FRS 6%-10%; 2.48 [95% CI, 1.47-4.20] in FRS 11%-20%; and 3.10 [95% CI, 1.75-5.47] in FRS > 20%; P < 0.05). In conclusion, the yield of screening for significant CAC and occult CAD is low in the very low risk population but it rises in low and intermediate risk populations.

Complications of Cardiac Perforation and Lead Dislodgement with an MRI-Conditional Pacing Lead: a Korean Multi-Center Experience.

Medtronic CapSureFix MRI 5086 pacing lead (5086; Medtronic, Inc., Minneapolis, MN, USA) has been reported to be associated with increased cardiac perforation and lead dislodgement. This study aimed to compare the incidence of cardiac perforation and lead dislodgement within 30 days after pacemaker implantation between 5086 MRI lead and previous Medtronic CapSureFix Novus 5076 non-MRI pacing lead. This was a nationwide, multicenter retrospective study in which we compared the incidence of adverse events between 277 patients implanted with 5086 lead and 205 patients implanted with 5076 lead between March 2009 and September 2014. Cardiac perforation within 30 days of pacemaker implantation occurred in 4 patients (1.4%) with the 5086 lead and in no patient with the 5076 lead (P = 0.084). Lead dislodgement occurred in 8 patients (2.9%) with the 5086 lead and in 5 patients (2.4%) with the 5076 lead (P = 0.764). On multivariate logistic regression analysis, age was significantly associated with cardiac perforation. Congestive heart failure and implantation of right atrial (RA) lead at RA free wall or septum were significant factors for the incidence of lead dislodgement and lead revision. The incidence of cardiac perforation and lead dislodgement were not statistically different between the patients with 5086 lead and the patients with 5076 lead. However, careful attention for cardiac perforation may be needed when using the 5086 MRI lead, especially in elderly patients.

Real-World Outcomes of a Rhythm Control Strategy for Atrial Fibrillation Patients with Reduced Left Ventricular Ejection Fraction (<50%).

Background/Objectives: The effectiveness of a rhythm control strategy in patients with atrial fibrillation (AF) and reduced left ventricular ejection fraction (LVEF < 50%) in real-world practice remains uncertain. Our objective was to evaluate the real-world outcomes of a rhythm control strategy in patients with AF and reduced LVEF, focusing on changes in LV systolic function and brain natriuretic peptide (BNP) levels. Methods: The study retrospectively reviewed the medical records of 80 patients with concurrent AF and reduced LVEF who underwent rhythm control therapy between March 2015 and December 2021. Results: The patients had an average age of 63.6 years and an initial LVEF of 34.3%. Sinus rhythm was restored using anti-arrhythmic drugs (38, 47.5%) or electrical cardioversion (42, 52.5%). Over a follow-up period of 53.0 months, AF recurred in 65% of patients, with 57.7% undergoing catheter ablation. Significant improvements were noted in LVEF (from 34.3% to 55.1%, p < 0.001) and BNP levels (from 752 pg/mL to 72 pg/mL, p < 0.001) at the last follow-up. Nearly all patients (97.5%) continued with the rhythm control strategy during the follow-up period. Conclusions: In real-world settings, a rhythm control strategy proves to be feasible and effective for improving LVEF and reducing BNP levels in AF patients with reduced LVEF.

Perioperative management of patients with cardiac implantable electronic devices.

The use of cardiac implantable electronic devices (CIEDs) has increased significantly in recent years. Consequently, more patients with CIEDs will undergo surgery during their lifetime, and thus the involvement of anesthesiologists in the perioperative management of CIEDs is increasing. With ongoing advancements in technology, many types of CIEDs have been developed, including permanent pacemakers, leadless pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy-pacemakers/defibrillators, and implantable loop recorders. The functioning of CIEDs exposed to an electromagnetic field can be affected by electromagnetic interference, potential sources of which can be found in the operating room. Thus, to prevent potential adverse events caused by electromagnetic interference in the operating room, anesthesiologists must have knowledge of CIEDs and be able to identify each type. This review focuses on the perioperative management of patients with CIEDs, including indications for CIED implantation to determine the baseline cardiovascular status of patients; concerns associated with CIEDs before and during surgery; perioperative management of CIEDs, including magnet application and device reprogramming; and additional perioperative provisions for patients with CIEDs. As issues such as variations in programming capabilities and responses to magnet application according to device can be challenging, this review provides essential information for the safe perioperative management of patients with CIEDs.

Association of typical atrial flutter and cavotricuspid isthmus ablation on clinical recurrence after cryoballoon ablation for atrial fibrillation.

Typical atrial flutter commonly occurs in patients with atrial fibrillation (AF). Limited information exists regarding the effects of concurrent atrial flutter on the long-term outcomes of rhythm control. This study investigated the association between concurrent typical atrial flutter and cavotricuspid isthmus (CTI) ablation and the recurrence of atrial arrhythmia. The data were obtained from a multicenter registry of cryoballoon ablation for AF (n = 2,689). Patients who were screened for typical atrial flutter were included in the analysis (n = 1,907). All the patients with typical atrial flutter underwent CTI ablation. The primary endpoint was the late recurrence of atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia. Among the 1,907 patients, typical atrial flutter was detected in 493 patients (25.9%). Patients with concurrent atrial flutter had a lower incidence of persistent AF and a smaller size of the left atrium. Patients with atrial flutter had a significantly lower recurrence rate of atrial arrhythmia (19.7% vs. 29.9%, p < 0.001). In patients with atrial flutter, the recurrence rate of atrial tachycardia or atrial flutter was more frequent (7.3% vs. 4.7%, p = 0.028), but the recurrence rate of AF was significantly lower (17.0% vs. 29.4%, p < 0.001). Atrial flutter has been identified as an independent predictor of the primary endpoint (adjusted hazard ratio, 0.704; 95% confidence interval, 0.548-0.906; p = 0.006). Typical atrial flutter in patients with AF may serve as a positive marker of the recurrence of atrial arrhythmia, and performing CTI ablation in this population is associated with a reduced likelihood of AF recurrence. Performing routine screening and ablation procedures for coexisting atrial flutter may improve the clinical outcomes of AF.

Reduced lung function is independently associated with increased risk of type 2 diabetes in Korean men.

BACKGROUND: Reduced lung function is associated with incident insulin resistance and diabetes. The aim of this study was to assess the relationship between lung function and incident type 2 diabetes in Korean men. METHODS: This study included 9,220 men (mean age: 41.4 years) without type 2 diabetes at baseline who were followed for five years. Subjects were divided into four groups according to baseline forced vital capacity (FVC) (% predicted) and forced expiratory volume in one second (FEV1) (% predicted) quartiles. The incidence of type 2 diabetes at follow-up was compared according to FVC and FEV1 quartiles. RESULTS: The overall incidence of type 2 diabetes was 2.2%. Reduced lung function was significantly associated with the incidence of type 2 diabetes after adjusting for age, BMI, education, smoking, exercise, alcohol, and HOMA-IR. Both FVC and FEV1 were negatively associated with type 2 diabetes (P < 0.05). In non-obese subjects with BMI < 25, the lowest quartile of FVC and FEV1 had a significantly higher odds ratio for type 2 diabetes compared with the highest quartile after adjusting for age and BMI (2.15 [95% CI 1.02-4.57] and 2.19 [95% CI 1.09-4.42]). CONCLUSIONS: Reduced lung function is independently associated with the incidence of type 2 diabetes in Korean men.

Optimal office blood pressure levels in younger (<50 years old) Korean hypertensive patients: a nationwide cohort study in South Korea.

BACKGROUND: It is unclear what thresholds and targets of office blood pressure (BP) for treatment are appropriate in younger (<50 years old) hypertensive patients. Thus, the aim of this study was to evaluate associations of office BP levels with major cardiovascular events (MACEs) in these patients. METHODS: Using the Korean National Health Insurance Service database, data of 98 192 younger (<50 years old) hypertensive patients having BP measurements available without any history of cardiovascular events from 2002 to 2011 were extracted. This cohort study evaluated associations of BP levels (<120/<70, 120-129/70-79, 130-139/80-89, 140-149/90-99, and ≥150/≥100 mmHg) with MACEs. The study outcome was MACE, a composite of cardiovascular death, myocardial infarction, stroke, and heart failure. RESULTS: In all patients, those treated with antihypertensive medication accounted for 34.7% and those who achieved BP less than 130/80 mmHg accounted for 35.5%. During a mean follow-up of 9.5 ±â€Š2.8 years, 4918 (5%) MACEs were documented in our cohort. The risk of MACE was the lowest [adjusted hazard ratio: 0.77, 95% confidence interval (CI) 0.66-0.89] for those with BP level of less than 120/less than 70 mmHg. It was the highest (hazard ratio 2.0, 95% CI 1.83-2.19) for those with BP level of at least 150/at least 100 mmHg in comparison with those with BP level of 130-139/80-89 mmHg. These results were consistent for all age groups (20-29, 30-39, and 40-49 years) and both sexes. CONCLUSION: Elevated BP level from less than 120 mmHg/less than 70 mmHg is significantly correlated with an increased risk of MACE in younger (<50 years old) Korean hypertensive patients. Lowering BP to less than 120 mmHg/less than 70 mmHg is needed for these patients.

Effect of Sodium-Glucose Cotransporter Inhibitors on Major Adverse Cardiovascular Events and Hospitalization for Heart Failure in Patients With Type 2 Diabetes Mellitus and Atrial Fibrillation.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to lower cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus (T2DM) and high cardiovascular risks. Here, we aimed to evaluate the effect of SGLT2 inhibitors on major adverse cardiovascular events (MACE), a composite of cardiovascular mortality, myocardial infarction, or ischemic stroke and hospitalization for heart failure in patients with T2DM and atrial fibrillation (AF). Using the Korean National Health Insurance Service database, we identified 40,268 patients with T2DM and AF who were newly prescribed oral hypoglycemic drugs (2,977 patients with SGLT2 inhibitors and 37,291 patients without SGLT2 inhibitors) between 2014 and 2018. After 1: 4 propensity score matching, patients who received SGLT2 inhibitors (n = 2,958) and those who did not receive SGLT2 inhibitors (n = 10,691) were enrolled, and followed up until December 31, 2018. During a mean follow-up duration of 2.1 ± 1.4 years, the risk of major adverse cardiovascular events was similar between the 2 groups (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.76 to 1.21). There were no significant differences between the 2 groups for cardiovascular mortality, myocardial infarction, or ischemic stroke. However, patients who received SGLT2 inhibitors had significantly lower risks of hospitalization for heart failure (HR 0.70, 95% CI 0.53 to 0.93) and all-cause mortality (HR 0.74, 95% CI 0.56 to 0.98) than those who did not receive SGLT2 inhibitors. In conclusion, in this real-world cohort of Asian patients with T2DM and AF, use of SGLT2 inhibitors was associated with a lower risk of hospitalization for heart failure.