Comparison of the Effects of High-intensity Statin Therapy with Moderate-Intensity Statin and Ezetimibe Combination Therapy on Major Adverse Cardiovascular Events in Patients with Acute Myocardial Infarction: a Nationwide Cohort Study.

OBJECTIVE: We compared the effects of high-intensity statin monotherapy versus moderate-intensity statin and ezetimibe combination therapy on major adverse cardiovascular events (MACE) in patients with acute myocardial infarction (AMI). METHODS: Using the Korean National Health Insurance Service database, we screened 82,941 patients with AMI who underwent percutaneous coronary intervention (PCI) between 2013 and 2016. Among them, we identified 9,908 patients treated with atorvastatin 40 mg (A40, n=4,041), atorvastatin 20 mg + ezetimibe 10 mg (A20+E10, n=233), rosuvastatin 20 mg (R20, n=5,251), or rosuvastatin 10 mg + ezetimibe 10 mg (R10+E10, n=383). The primary outcome was MACE, a composite of all-cause death, non-fatal myocardial infarction undergoing PCI, repeat revascularization, and ischemic stroke. Multivariable analyses were performed using the inverse probability of treatment weighting method. RESULTS: The incidence rate of MACE in the overall population was 42.97 cases per 1,000 person-years. There was no significant difference in the risk of composite outcomes of MACE between the groups. However, the R10+E10 group showed a higher risk of all-cause death (hazard ratio, 2.07; 95% confidence interval, 1.08-3.94) than the A40 group (reference group) in the weighted multivariable model. CONCLUSIONS: In this study, there was no significant difference in the composite outcome of MACE between high-intensity statin monotherapy and moderate-intensity statin and ezetimibe combination therapy.

Association between interarm blood pressure differences and diabetic retinopathy in patients with type 2 diabetes.

BACKGROUND: The effect of interarm blood pressure difference on the development of diabetic retinopathy, proteinuria and chronic kidney disease remains unknown. We investigated to determine the impact of interarm blood pressure difference on the prevalence of diabetic retinopathy, proteinuria and chronic kidney disease in patients with type 2 diabetes. METHODS: The study included 563 patients with diabetes, who were evaluated with a simultaneous bilateral blood pressure measurement. The cutoff values for interarm blood pressure difference were 5, 10 and 15 mmHg. Logistic regression analysis was used to explore the relation between interarm blood pressure difference and diabetic retinopathy, proteinuria and chronic kidney disease. RESULTS: Diabetic patients with systolic interarm blood pressure difference ⩾5, ⩾10 and ⩾15 mmHg showed an increased risk of diabetic retinopathy [adjusted odds ratio = 1.48 (95% confidence interval = 1.01-2.18), odds ratio = 1.80 (95% confidence interval = 0.99-3.22), odds ratio = 2.29 (95% confidence interval = 1.00-5.23)] after adjustment. There were significant associations between interarm blood pressure difference ⩾5 and ⩾10 mmHg and proteinuria [odds ratio = 1.68 (95% confidence interval = 1.15-2.44), 1.89 (95% confidence interval = 1.05-3.37)]. CONCLUSION: The association between interarm blood pressure difference and the presence of diabetic retinopathy emerged even for systolic interarm blood pressure difference ⩾5 mmHg without interaction of systolic blood pressure. Systolic interarm blood pressure difference should be considered a surrogate marker for vascular complication in patients with type 2 diabetes.

Ergonovine Stress Echocardiography for the Diagnosis of Vasospastic Angina and Its Prognostic Implications in 3,094 Consecutive Patients.

BACKGROUND AND OBJECTIVES: Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population. METHODS: We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed. RESULTS: The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p<0.001) at a median follow-up of 10.5 years. Cox regression survival analyses revealed that male sex, age, presence of diabetes, total cholesterol level of >220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs. CONCLUSIONS: ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

Repolarization Heterogeneity of Magnetocardiography Predicts Long-Term Prognosis in Patients with Acute Myocardial Infarction.

PURPOSE: Magnetocardiography (MCG) has been proposed as a noninvasive, diagnostic tool for risk-stratifying patients with acute myocardial infarction (AMI). This study evaluated whether MCG predicts long-term prognosis in AMI. MATERIALS AND METHODS: In 124 AMI patients (95 males, mean age 60±11 years), including 39 with ST-elevation myocardial infarction, a 64-channel MCG was performed within 2 days after AMI. During a mean follow-up period of 6.1 years, major adverse cardiac events (MACE) were evaluated. RESULTS: MACE occurred in 31 (25%) patients, including 20 revascularizations, 8 deaths, and 3 re-infarctions. Non-dipole patterns were observed at the end of the T wave in every patients. However, they were observed at T-peak in 77% (24/31) and 54% (50/93) of patients with and without MACE, respectively (p=0.03). Maximum current, field map angles, and distance dynamics were not different between groups. In the multivariate analysis, patients with non-dipole patterns at T-peak had increased age- and gender-adjusted hazard ratios for MACE (hazard ratio 2.89, 95% confidence interval 1.20-6.97, p=0.02) and lower cumulative MACE-free survival than those with dipole patterns (p=0.02). CONCLUSION: Non-dipole patterns at T-peak were more frequently observed in patients with MACE and were related to poor long-term prognosis. Thus, repolarization heterogeneity measured by MCG may be a useful predictor for AMI prognosis.

Percutaneous cardiopulmonary support-supported percutaneous coronary intervention: a single center experience.

BACKGROUND AND OBJECTIVES: Percutaneous cardiopulmonary support (PCPS) has proven to be a valuable technique in high-risk coronary patients undergoing percutaneous coronary intervention (PCI). However, there have been few studies on PCI associated with PCPS in Korea. We summarized our experience with PCPS-supported PCI. SUBJECTS AND METHODS: We retrospectively reviewed 19 patients with PCPS-supported PCI between August 2005 and June 2009. PCPS was used as an elective procedure for 10 patients with at least two of the following conditions: left-ventricular ejection fraction <35%, target vessel(s) supplying more than 50% of the viable myocardium, high risk surgical patients, and patients who refused coronary bypass surgery. In the remaining 9 patients PCPS was used as an emergency procedure, to stabilize and even resuscitate patients with acute myocardial infarction and cardiogenic shock, in order to attempt urgent PCI. RESULTS: Among the 19 patients who were treated with PCPS-supported PCI, 11 (57.9%) survived and 8 (42.1%) patients did not. ST elevation myocardial infarction with cardiogenic shock was more prevalent in the non-survivors than in the survivors (75% vs. 27.3%, p=0.04). The elective PCPS-supported PCI was practiced more frequently in the survivors than in the non-survivors (72.7% vs. 25%, p=0.04). In the analysis of the event-free survival curve between elective and emergency procedures, there was a significant difference in the survival rate (p=0.025). Among the survivors there were more patients with multi-vessel disease, but a lower Thrombolysis in Myocardial Infarction grade in the culprit lesions was detected in the non-survivors, before PCI. Although we studied high-risk patients, there was no procedure-related mortality. CONCLUSION: Our experience suggests that PCPS may be helpful in high risk patients treated with PCI, especially in elective cases. More aggressive and larger scale studies of PCPS should follow.

Gender-based differences in the management and prognosis of acute coronary syndrome in Korea.

PURPOSE: Gender-based differences exist in the characteristics, management, and prognosis of acute coronary syndrome (ACS). However, their impact on prognosis remains unclear. We aimed to identify factors causing these differences in Koreans. MATERIALS AND METHODS: We examined 6,636 ACS patients (66.2% males) visiting 72 Korean hospitals between April-2007 and December-2008. Gender-based differences in clinical demographics, therapy, and outcomes were analyzed over 6 months. RESULTS: Women were older than men [mean (standard deviation, SD) age, 67.6 (9.8) vs. 60.6 (11.2) years; p<0.001]; had higher rates of hypertension, diabetes mellitus, and lack of exercise (p<0.001 for all); and lower rates of obesity, familial history of cardiovascular disease (CVD), and smoking (p<0.05 for all). Atypical symptoms were more common in women (20.5% vs. 15.1% in men, p<0.001), whereas myocardial infarction with ST-segment elevation was less common (17.1% vs. 27.8%, p<0.001). Mean (SD) time lapse from symptom onset to arrival at hospital was longer in women [11.44 (18.19) vs. 8.26 (14.89) hours in men, p<0.001], as was the duration of hospitalization [7.58 (7.61) vs. 7.04 (7.72) days, p=0.007]. Fewer women underwent revascularization procedures, including thrombolytic therapy, balloon angioplasty, stent implantation, and coronary artery bypass grafting (79.4% vs. 83.3% men, p<0.001). No significant differences were observed in CVD-related death, recurrent ACS, stroke, refractory angina, or rehospitalization for angina. CONCLUSION: Female ACS patients were older than male subjects and had more atypical presentation. They arrived at the hospital later than men and had longer hospital stays, but less often required revascularization therapy. However, no gender-based differences were noted in ACS-related mortality and morbidity.

Pulmonary hypertension associated with use of phentermine.

Weight-control drugs (known as anorexigens) such as fenfluramine have been linked with pulmonary hypertension in previous reports. In our case, a 29 year old woman was admitted for shortness of breath and was diagnosed with pulmonary hypertension. Three months ago, she had been taking phentermine for five weeks. Other factors that might have contributed to the development of pulmonary hypertension were excluded. With treatment, her symptoms improved. This is the first case that can suggest a possible connection between phenermine single medication with pulmonary hypertension. Phentermine has been considered a relatively safe drug to treat obesity, and further investigation is needed to decide the safety and dosage of phentermine.

Constrictive Pericarditis Accompanied by Swine-Origin Influenza A (H1N1) Infection.

Swine-origin influenza A (H1N1) is caused by a new strain of the influenza virus. The disease has spread rapidly and was declared a pandemic in April, 2009. So far, however, there is a scarcity of information regarding the complications of swine influenza. A report of the disease in the winter of 2009 in the Southern Hemisphere found that the most common manifestations of influenza A virus infection are upper respiratory tract infection and pneumonia. Although there may be an association between fulminant myocarditis and Swine influenza, cardiovascular complications resulting from swine Influenza A infection are exceedingly rare. We report a case of acute constrictive pericarditis in a healthy subject infected by the swine-origin influenza A (H1N1) virus.