The advantage of the mini-electrode-equipped catheter for the radiofrequency ablation of paroxysmal supraventricular tachycardia.

INTRODUCTION: Novel ablation catheters equipped with mini-electrodes (ME) offer high resolution mapping for target tissue. This study aimed to evaluate the mapping performance and efficacy of ME catheters in radiofrequency ablation (RFA) of paroxysmal supraventricular tachycardias (PSVTs). METHODS: We prospectively enrolled 136 patients undergoing RFA of PSVT including 76 patients with atrioventricular nodal reentrant tachycardia (AVNRT) and 60 patients with atrioventricular reentrant tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome. Patients were randomized to the ME group (ablation using ME catheters) or the control group (ablation using conventional catheters). The number of ablation attempt and cumulative ablation time to ablation endpoints, which was defined as an emergence of junctional rhythm in AVNRT or accessory pathway (AP) block in AVRT/WPW syndromes were compared. RESULTS: During ablation procedures, discrete slow pathway or AP electrograms were found in 27 (39.7%) patients in the ME group and 13 (19.1%) patients in the control group. The primary study outcomes were significantly lower in the ME group (ablation attempt number: 2.0 [1-4] vs. 3.0 [2-7] in the ME and control group, p = .032; ablation time: 23.5 [5.0-111.5] vs. 64.5 [16.0-185.0] s, p = .013). According to the PSVT diagnosis, ablation time to junctional rhythm was significantly shorter in the ME group in AVNRT. In AVRT/WPW syndrome, both ablation attempt number and ablation time to AP block were nonsignificantly lower in the ME group. CONCLUSION: The novel ME catheter was advantageous for identifying pathway potentials and reducing initial ablation attempt number and ablation time to reach acute ablation endpoint for PSVTs (ClinicalTrials.gov number, NCT04215640).

Risk of infective endocarditis associated with invasive dental procedures in patients with cardiac rhythm devices.

AIMS: The incidence of infective endocarditis related to cardiac implantable electronic devices (CIEDs) has gradually increased. The risk associated with dental procedures in patients with CIED implantation and the need for prevention of infective endocarditis remain unclear. The present study investigated the incidence and risk of infective endocarditis associated with invasive dental procedures in patients with CIEDs. METHODS AND RESULTS: We analysed a nationwide population-based cohort of patients with CIEDs who underwent dental procedures. We performed a self-controlled case series analysis and evaluated the incidence rate ratio of infective endocarditis 3 months after dental procedures. Of a total of 62 019 patients who underwent CIED implantation, 32 536 patients underwent at least one dental procedure during follow-up, and the mean number of dental procedures was 3.4 per patient. They were 152 infections with an incidence of 445 per 100 000 person-years in the dental procedure period and 500 events at an incidence of 255 per 100 000 person-years in the non-dental procedure period. The CIED-related infective endocarditis in the dental procedure period occurred significantly more frequently than during non-dental procedure periods (odds ratio, 1.75; 95% confidence interval, 1.48-2.05; P < 0.001). The mean time interval from dental procedure to infective endocarditis was 59.6 ± 47.3 days. CONCLUSION: Invasive dental procedures are associated with an increased risk of infective endocarditis in those who underwent CIED implantation. Appropriate preventive therapy might be needed in these patients.

Is Routine Thromboprophylaxis Needed in Korean Patients Undergoing Unicompartmental Knee Arthroplasty?

This study was undertaken to determine the prevalence and the natural course of venous thromboembolism (VTE) without thromboprophylaxis to ascertain whether routine thromboprophylaxis is necessary following unicompartmental knee arthroplasty (UKA) in Korean patients. The medical records and multidetector row computed tomography (MDCT) imaging of the consecutive 77 UKAs in 70 patients were reviewed. In all patients, MDCTs were undertaken preoperatively and at 1-week after surgery, and VTE symptoms were evaluated. At postoperative 6-months, follow-up MDCTs were undertaken in all patients in whom VTEs were newly detected after surgery. VTE lesions were newly detected in 18 (26%) of the 70 patients. However, none of the patients complained of VTE-related symptoms and MDCT demonstrated that all VTEs were small and involved limited portion without lower leg edema or pleuroparenchymal complication. At the 6-month follow up MDCT, all types of VTEs were shown to be completely resolved, regardless of their location. All of the VTE lesions maintained an asymptomatic status for 6-month after surgery. VTE following UKA in Korean patients who do not receive thromboprophylaxis seems to occur frequently, but all of the VTEs are clinically insignificant and all VTEs are spontaneously regressed. Routine thromboprophylaxis or thrombolytic treatment in Korean patients undergoing UKA may not be necessary.

The Patient's Perception Does Not Differ Following Subvastus and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Simultaneous Bilateral Randomized Study.

This simultaneous bilateral randomized study investigated whether patients would perceive the difference between the subvastus approach (SVA) and the medial parapatellar approach (MPA) after total knee arthroplasty (TKA). In 50 patients scheduled to undergo same-day bilateral TKA, one knee was randomly assigned to SVA and the other to MPA. Patient-reported measures (pain, Western Ontario McMaster University Osteoarthritis Index score, and side preference) and physician-assessed measures (isokinetic muscle strength, range of motion, and Knee Society score) were compared. No differences were observed in the patient-reported measures and physician-assessed measures, with the exception of greater quadriceps strength at postoperative 1 week in knees that underwent SVA. Patients receiving contemporary perioperative management after same-day bilateral TKA do not perceive any difference between knees that underwent SVA or MPA.

Is High-Flexion Total Knee Arthroplasty a Valid Concept? Bilateral Comparison With Standard Total Knee Arthroplasty.

BACKGROUND: The purpose of this study was to determine whether the high-flexion total knee prosthesis significantly improves knee flexion in vivo. METHODS: Forty-four patients undergoing same-day bilateral total knee arthroplasty for primary osteoarthritis of both knees were randomized to receive a standard posterior-stabilized knee prosthesis (P.F.C. Sigma; DePuy Johnson & Johnson, Warsaw, IN) in one knee and a high-flexion concept posterior-stabilized knee prosthesis (LOSPA; Corentec, Inc, Seoul, Korea) in the other knee and were followed up for 2 years postoperatively. RESULTS: The mean postoperative range of motion was 128.8° (range, 100°-144°) in the LOSPA group and 128.5° (range, 100°-142°) in the P.F.C. Sigma group (P = .744). There were no significant differences in the postoperative mean Knee Society score and Western Ontario and McMaster Universities Osteoarthritis Index score between the LOSPA and P.F.C. Sigma groups (P = .839 and P = .972, respectively). CONCLUSION: Despite theoretical range of motion advantages of high-flexion prosthesis, there were no group differences with regard to range of motion, clinical outcomes, and the incidence of radiolucent lines at final follow-up assessment.

Semimembranosus Release for Medial Soft Tissue Balancing Does Not Weaken Knee Flexion Strength in Patients Undergoing Varus Total Knee Arthroplasty.

BACKGROUND: The sequential medial release technique including semimembranosus (semiM) release is effective and safe during varus total knee arthroplasty (TKA). However, there are concerns about weakening of knee flexion strength after semiM release. We determined whether semiM release to balance the medial soft tissue decreased knee flexion strength after TKA. METHODS: Fifty-nine consecutive varus knees undergoing TKA were prospectively enrolled. A 3-step sequential release protocol which consisted of release of (1) the deep medial collateral ligament (dMCL), (2) the semiM, and (3) the superficial medial collateral ligament based on medial tightness. Gap balancing was obtained after dMCL release in 31 knees. However, 28 knees required semiM release or more after dMCL release. Isometric muscle strength of the knee was compared 6 months postoperatively between the semiM release and semiM nonrelease groups. Knee stability and clinical outcomes were also compared. RESULTS: No differences in knee flexor or extensor peak torque were observed between the groups 6 months postoperatively (P = .322 and P = .383, respectively). No group difference was observed in medial joint opening angle on valgus stress radiographs (P = .327). No differences in the Knee Society or Western Ontario and McMaster Universities Osteoarthritis Index scores were detected between the groups (P = .840 and P = .682, respectively). CONCLUSION: These results demonstrate that semiM release as a sequential step to balance medial soft tissue in varus knees did not affect knee flexion strength after TKA.

Comparison of cruciate retaining and PCL sacrificing TKA with respect to medial and lateral gap differences in varus knees after medial release.

We aimed to clarify whether the increase in medial gap after medial release is influenced by the retention or sacrifice of posterior cruciate ligament (PCL) during navigation-assisted total knee arthroplasty. After matched pairs were done according to the equality of preoperative varus deformity and medial collateral laxity, 54 knees of each type were available for this study. In the PCL sacrificing group, the mediolateral gap difference significantly increased in both flexion and extension as the preoperative mechanical axis angle increased whereas in the cruciate retaining group, the mediolateral gap difference did not show this tendency. When preoperative mechanical axis angles were over 10.4° in extension and over 7.7° in flexion, the medial gap showed greater increases in PCL sacrificing groups than in cruciate retaining groups.

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.

Effect of growth pressure on the synthesis of vertically aligned carbon nanotubes and their growth termination.

When vertically aligned carbon nanotubes (VACNTs) are synthesized by thermal chemical vapor deposition (TCVD), their structural features such as height and density can be determined by TCVD growth conditions. In this study we investigated the effect of growth pressure on the structural features of VACNTs. Changes in growth pressure significantly affected the height, density, and crystalinity of synthesized VACNTs. In addition, we suggest that the growth termination of VACNTs could be due to the lack of carbon feedstock supply to the center of the VACNT film induced by the pressure-dependent adsorption of amorphous carbon at the edge of the VACNT film. In addition, the field emission characteristics of the VACNT film were carried out. The turn-on voltage of the VACNT film was 1.62 V/microm and the field enhancement factor (beta) was 2478. These results provide useful information for practical applications of VACNTs, such as field emission display and X-ray source.

Negative association between plasma aldosterone concentration/plasma renin activity and morning blood pressure surge in never-treated hypertensive patients.

Morning blood pressure (BP) surge (MS) has been known to be a predictor of cardiovascular events. Currently, few studies have evaluated the underlying mechanism underlying MS, which may include neurohormonal factors and the renin-angiotensin-aldosterone system (RAAS). This study aimed to examine plasma aldosterone concentration (PAC) and plasma renin activity (PRA) and BP parameters with or without MS in never-treated subjects with essential hypertension. This cross-sectional study included a total of 261 patients (mean age: 48.8 years; 60.5% male) with never-treated essential hypertension who were registered in a working group at The Catholic University of Korea. The patients were divided into the MS group, which was defined as having the highest quartile of morning BP increase from sleep (>31 mmHg; n = 66) and the non-MS group (≤31 mmHg; n = 195). We collected 24-h ambulatory BP, pulse wave velocity, ankle brachial index, PAC and PRA from all patients. The measured PAC and PRA were lower in the MS group than in the non-MS group (PAC: 9.0 ± 5.4 ng/dl versus 12.2 ± 8.7 ng/dl, p < 0.001; PRA: 1.7 ± 1.3 ng/ml/h versus 2.6 ± 3.6 ng/ml/h, p = 0.002). The MS group had greater variations in daytime, nighttime and 24-h systolic blood pressure (SBPs) than the non-MS group (24-h SBP: 15.6 ± 4.4 mm Hg for the non-MS group and 18.9 ± 4.9 mmHg for the MS group; p < 0.001 for each). It is generally accepted that the sympathetic nervous system plays a major role in the regulation of BP variability. Therefore, further studies on sympathetic nervous system activation in hypertensives with extreme MS are needed. MS in enrolled patients who were at relatively low risk in this study may be less affected by the RAAS.

Clinical outcomes with the use of sodium-glucose cotransporter-2 inhibitors in patients with atrial fibrillation and type 2 diabetes mellitus: a multi-centre, real-world cohort study.

AIMS: Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been shown to improve cardiovascular outcomes and reduce the incidence of atrial fibrillation (AF) in patients with type 2 diabetes mellitus (T2DM). We investigated the clinical outcomes with and without the use of SGLT2is in patients with T2DM and concomitant AF. METHODS AND RESULTS: We derived patient data from a clinical data warehouse constructed from the electronic medical records of seven medical centres. Data for 11 012 patients diagnosed with both AF and T2DM were analysed. New SGLT2i users were classified into the SGLT2i group and those who were not prescribed SGLT2is were classified into the control group. We performed a 1:2 propensity score (PS)-matching analysis. The primary endpoint was a composite of all-cause death or hospitalization due to heart failure (HF) events in 3 years. The PS-matched population consisted of 1115 patients in the SGLT2i group and 2050 patients in the control group. Incidence of the primary endpoint was significantly lower in the SGLT2i group [8.4 vs. 14.6%, hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.55-0.87]. Sodium-glucose cotransporter-2 inhibitors use was associated with significantly lower all-cause mortality (HR 0.43, 95% CI 0.29-0.67) and HF hospitalization (HR 0.77, 95% CI 0.59-0.99). Adverse renal events, defined as >50% increase in serum creatinine level or initiation of dialysis, occurred less often in the SGLT2i group (HR 0.50, 95% CI 0.38-0.66, P < 0.001). CONCLUSION: Use of SGLT2is in patients with T2DM and concomitant AF was associated with reduced mortality or HF hospitalization events.

In this multi-centre, registry-based analysis, the new use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in patients with atrial fibrillation and type 2 diabetes mellitus was associated with lower all-cause mortality or hospitalization due to heart failure (HF) events. All-cause mortality, HF hospitalization, ischaemic stroke, and composite renal outcomes, defined as >50% decline in renal function or new initiation of dialysis occurred significantly less in the SGLT2i new users, compared with the propensity score-matched controls. The difference in outcomes between the SGLT2i group and control group was more pronounced in patients with higher HbA1c at baseline and prior HF.

Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction in Patients With Type 2 Diabetes: A Population-Based Investigation.

Background Whether the early use of sodium-glucose cotransporter-2 (SGLT2) inhibitors have cardioprotective effects following acute myocardial infarction is unknown. Thus, we aimed to evaluate the association between the early initiation of SGLT2 inhibitors and cardiac event rates in patients with diabetes with acute myocardial infarction undergoing percutaneous coronary intervention. Methods and Results Based on the National Health Insurance claims data in South Korea, patients who received percutaneous coronary intervention for acute myocardial infarction between 2014 and 2018 were analyzed. Patients given SGLT2 inhibitors or other glucose-lowering drugs were matched based on a propensity score. The primary end point was a composite of all-cause mortality and hospitalizations for heart failure. Major adverse cardiac events (a composite of all-cause death, nonfatal myocardial infarction, and ischemic stroke) were compared as the secondary end point. After 1:2 propensity score matching, the SGLT2 inhibitors group (938 patients) and the no use of SGLT2 inhibitors group (1876 patients) were compared. During a median follow-up of 2.1 years, the early use of SGLT2 inhibitors was associated with lower risks of both the primary end point (9.8% versus 13.9%; adjusted hazard ratio [HR], 0.68 [95% CI, 0.54-0.87]; P=0.002) and secondary end point (9.1% versus 11.6%; adjusted HR, 0.77 [95% CI, 0.60-0.99]; P=0.04). All-cause mortality and hospitalizations for heart failure were also significantly lower in early users of SGLT2 inhibitors. Conclusions The early use of SGLT2 inhibitors in patients with diabetes treated with percutaneous coronary intervention for acute myocardial infarction was associated with a significantly lower risk of cardiovascular events, including all-cause mortality, hospitalizations for heart failure, and major adverse cardiac events.

An Artificial Intelligence Algorithm With 24-h Holter Monitoring for the Identification of Occult Atrial Fibrillation During Sinus Rhythm.

Background: Subclinical atrial fibrillation (AF) is one of the pathogeneses of embolic stroke. Detection of occult AF and providing proper anticoagulant treatment is an important way to prevent stroke recurrence. The purpose of this study was to determine whether an artificial intelligence (AI) model can assess occult AF using 24-h Holter monitoring during normal sinus rhythm. Methods: This study is a retrospective cohort study that included those who underwent Holter monitoring. The primary outcome was identifying patients with AF analyzed with an AI model using 24-h Holter monitoring without AF documentation. We trained the AI using a Holter monitor, including supraventricular ectopy (SVE) events (setting 1) and excluding SVE events (setting 2). Additionally, we performed comparisons using the SVE burden recorded in Holter annotation data. Results: The area under the receiver operating characteristics curve (AUROC) of setting 1 was 0.85 (0.83-0.87) and that of setting 2 was 0.84 (0.82-0.86). The AUROC of the SVE burden with Holter annotation data was 0.73. According to the diurnal period, the AUROCs for daytime were 0.83 (0.78-0.88) for setting 1 and 0.83 (0.78-0.88) for setting 2, respectively, while those for nighttime were 0.85 (0.82-0.88) for setting 1 and 0.85 (0.80-0.90) for setting 2. Conclusion: We have demonstrated that an AI can identify occult paroxysmal AF using 24-h continuous ambulatory Holter monitoring during sinus rhythm. The performance of our AI model outperformed the use of SVE burden in the Holter exam to identify paroxysmal AF. According to the diurnal period, nighttime recordings showed more favorable performance compared to daytime recordings.

Comorbidities and Antithrombotic Treatment Pattern in Patients With Atrial Fibrillation.

Objective: Non-vitamin K antagonist oral anticoagulants (NOACs) are proven alternatives to warfarin for preventing stroke in patients with non-valvular atrial fibrillation. We aimed to examine the treatment patterns and patient factors associated with the use of antiplatelet agents, warfarin, and NOACs in clinical practice. Methods: We conducted a retrospective cohort study using the Korean Health Insurance Review & Assessment Service database. Patients receiving antithrombotics were identified before and after the introduction of NOACs (from August 1, 2013 to December 30, 2014 and July 1, 2015 to November 30, 2016, respectively). Patients were included if they were aged ≥18 years, had an atrial fibrillation diagnosis, and had a CHA2DS2-VASc score ≥2. Treatment pattern was assessed by classifying patients into NOAC, warfarin, or antiplatelet users based on the first date of antithrombotic prescription. Clinical factors associated with the type of antithrombotics chosen were examined using logistic regression analyses. Results: We identified 129,465 and 196,243 patients before and after the introduction of NOACs, respectively. The proportion of antiplatelet users was 60.7 and 53.0% before and after the introduction of NOACs, respectively. The proportion of warfarin users was higher in patients with low HAS-BLED score, high CHA2DS2-VASc score, or stroke before the NOAC era. A similar trend was observed for NOAC and warfarin users after the introduction of NOAC. Compared with antiplatelets, warfarin and NOAC uses were significantly associated with CHA2DS2-VASc score and stroke, whereas presence of myocardial infarction (MI) and peripheral arterial disease were significantly associated with antiplatelets prescription. For comparisons between NOAC and warfarin, HAS-BLED and CHA2DS2-VASc scores showed significant associations with NOAC use, whereas comorbidities including MI were significantly associated with warfarin use. Conclusions: The treatment pattern of antithrombotics did not change with the introduction of NOACs. However, comorbidities served as an important factor in choosing treatment regardless of NOAC entry.

Drug Utilization Pattern of Oral Anticoagulants in Patients with Atrial Fibrillation: A Nationwide Population-Based Study in Korea.

INTRODUCTION: Treatment persistence for anticoagulant therapy is important in preventing thromboembolism in nonvalvular atrial fibrillation (NVAF) patients. Understanding drug utilization pattern and treatment changes in oral anticoagulant (OAC) users may facilite better NVAF management. Thus, our study aimed to examine OAC treatment patterns preceding events leading to switch or discontinuation and medication adherence in Korean NVAF patients. METHODS: We conducted a drug utilization study on all Korean patients with atrial fibrillation (AF) newly prescribed OACs between July 2015 and November 2016 using the national claims data. We assessed treatment changes such as switching and discontinuation from index OAC and relevant events preceding the change and examined patient characteristics as predictors of changes that occurred among OAC users. Medication adherence was compared among OAC users by calculating the medication possession ratio (MPR). RESULTS: A total of 48,389 NVAF patients were identified who initiated OACs within the study period. Most initiated nonvitamin K antagonist oral anticoagulants (NOACs) (22% apixaban, 24% dabigatran, 37% rivaroxaban), and 18% initiated warfarin. The frequency of switch to another OAC was 8.8% for apixaban, 16.1% for dabigatran, 6.6% for rivaroxaban, and 19.1% for warfarin. The frequency of discontinuation was lower for apixaban (22.9%), dabigatran (26.3%), and rivaroxaban (25.7%) than warfarin (31.6%). Compared to warfarin, NOAC users were less likely to switch treatment. Thromboembolic event was the most common clinical event preceding switch from warfarin to NOAC and from NOAC to warfarin. Discontinuation of OAC was often preceded by a bleeding event. Patients who initiated apixaban showed significantly higher mean MPR compared to those on dabigatran and warfarin. CONCLUSION: In real-world practice in Korea, we have observed treatment change to be common in OAC users. Our results indicate better medication adherence with NOACs than with warfarin. (ClinicalTrials.gov registration number NCT03572972).

Anticoagulants are drugs that thin blood with the purpose of preventing thromboembolic disease (e.g., stroke), which is a disease occurring when a blood clot forms or blocks vessel. Maintaining treatment for anticoagulation is important to prevent stroke in atrial fibrillation (AF) patients. To understand current drug usage pattern and treatment changes related to oral anticoagulants (OAC) we examined OAC treatment patterns and preceding events that led to drug switch or stop and medication maintenance by Korean AF patients.The study was conducted by utilizing the Korean national claims data from July 2015 to November 2016. All AF patients who newly started taking OAC were included in the analysis. In total, 48,389 patients were identified with most (83%) taking nonvitamin K antagonist oral anticoagulants (NOAC), which are newer generation blood thinners, including apixaban, dabigatran, and rivaroxaban, and 18% taking warfarin, the conventional blood thinner. Compared to warfarin, NOAC users were less likely to switch to other treatment. NOAC users discontinued the treatment less frequently than warfarin users. Thromboembolic events commonly preceded switch between OACs. Patients who stopped taking OACs were often confronted with a bleeding event before stopping treatment. Apixaban takers showed higher treatment persistence compared to dabigatran or warfarin users. In this study, we determined that treatment change is common in OAC-using patients. The results suggest that NOAC users may better adhere to treatment than warfarin users.

Single direct oral anticoagulant therapy in stable patients with atrial fibrillation beyond 1 year after coronary stent implantation.

OBJECTIVE: Optimal antithrombotic therapy in patients with atrial fibrillation (AF) beyond 1 year after coronary stent implantation has not been well established in the era of direct oral anticoagulant (DOAC). METHODS: Using Korean National Health Insurance Service data, we analysed 4294 patients with AF who were prescribed DOAC beyond 1 year after coronary stent implantation. Subjects were classified into the monotherapy group (DOAC single therapy, n=1221) or the combination therapy group (DOAC with an antiplatelet agent, n=3073). The primary ischaemic endpoint was defined as a composite of cardiovascular death, myocardial infarction, stroke or systemic thromboembolism. The secondary endpoints were all-cause death, major bleeding defined as a bleeding event requiring hospitalisation and net adverse clinical events. Propensity score matching was performed to balance baseline covariates. RESULTS: Among included patients, 94% had drug-eluting coronary stents. During a median follow-up of 19 (7-32) months, the monotherapy group had a similar risk of the primary ischaemic endpoint (HR 0.828, 95% CI 0.660 to 1.038) and all-cause death (HR 1.076, 95% CI 0.895 to 1.294) compared with the combination therapy group. Risk of major bleeding was lower in the monotherapy group (HR 0.690, 95% CI 0.481 to 0.989), which was mostly driven by reduced gastrointestinal bleeding (HR 0.562, 95% CI 0.358 to 0.883). There was no significant difference in net adverse clinical events between the two groups. CONCLUSIONS: DOAC monotherapy showed similar efficacy in preventing ischaemic events and was associated with lower major bleeding events compared with combination therapy in patients with AF beyond 1 year after coronary stent implantation.

Soluble receptor of advanced glycated endproducts is associated with plaque vulnerability in patients with acute myocardial infarction.

BACKGROUND: The roles of soluble and endogenous secretory receptors for advanced glycation endproducts (sRAGE and esRAGE, respectively) in plaque vulnerability are unknown in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: We enrolled 54 patients with AMI (27 patients had type 2 diabetes mellitus [DM]) who had undergone primary percutaneous coronary intervention, and 54 controls who were matched for age, gender and the presence of DM. Plasma levels of s/esRAGE and matrix metalloproteinase (MMP)-9 were measured at the time of coronary angiography. There were no significant differences in the baseline characteristics of the AMI and control groups, except for the C-reactive protein levels (CRP: 14.1 ± 14.2 mg/L vs. 3.7 ± 5.2 mg/L, P < 0.001). The plasma levels of MMP-9 (28.6 ± 21.4 vs. 14.3 ± 8.5 ng/ml P < 0.001) and sRAGE (0.61 ± 0.28 vs. 0.41 ± 0.17 ng/ml, P < 0.001) were higher in the AMI group than in the controls. In multivariate logistic regression analysis, the plasma levels of MMP-9 and sRAGE above the median (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.02-5.58; P = 0.044; OR, 2.47; 95%CI, 1.05-5.80; P = 0.039, respectively) were independent predictors of AMI, as well as being a current smoker (OR, 2.98; 95%CI, 1.18-7.55; P = 0.021) and CRP ≥ 3.0 mg/L (OR, 3.08; 95%CI, 1.25-7.59; P = 0.015). CONCLUSIONS: An elevated plasma level of sRAGE might be independently associated with plaque vulnerability, as well as MMP-9, in patients with AMI.

Prevalence of electrocardiographic findings suggestive of sudden cardiac death risk in 10,867 apparently healthy young Korean men.

BACKGROUND: The objective of this study was to determine the prevalence of electrocardiographic (ECG) findings suggestive of sudden cardiac death risk in apparently healthy young Korean men. METHODS: We administered questionnaires that elicited personal and family histories and performed ECGs on 10,867 male subjects (mean age, 20.9 years). The subjects with abnormal ECG findings underwent echocardiography, a treadmill test, Holter monitoring, a flecainide provocation test, or an electrophysiologic study (EPS) according to the ECG findings and histories. RESULTS: Of the subjects, 5.95% had left ventricular hypertrophy on ECG, but no subjects had hypertrophic cardiomyopathy by echocardiography. The percentage of subjects with a Brugada ECG pattern was 0.90%. We identified one subject with a positive result on the flecainide provocation test. The percentage of subjects with a preexcitation ECG was 0.17%. In two of the subjects, supraventricular tachycardia was induced in the EPS. Of the subjects, 0.05% had epsilon waves, but there were no subjects with arrhythmogenic right ventricular dysplasia/cardiomyopathy by echocardiography. The percentage of subjects with long QT intervals was 0.02%, but there were no arrhythmias on the treadmill test or Holter monitoring. CONCLUSIONS: The prevalence of a Brugada ECG pattern in apparently healthy young men is higher in Korea than other countries.

Evaluation of clinical and magnetic resonance imaging results after treatment with casting and bracing for the acutely injured posterior cruciate ligament.

PURPOSE: The purpose of this study was to evaluate the clinical and magnetic resonance imaging (MRI) outcomes of nonoperative management of acute, isolated posterior cruciate ligament (PCL) injuries. METHODS: From February 2001 to January 2008, 49 consecutive patients with acute (<4 weeks), isolated PCL injuries underwent nonoperative treatment with cast immobilization and PCL braces. Of these patients, 38 who satisfied our inclusion criteria and could be followed up for a minimum of 24 months (median, 51 months) were enrolled in our study. Functional outcomes were evaluated at follow-up with the Lysholm knee scoring system, Hospital for Special Surgery knee scoring system, and International Knee Documentation Committee subjective and objective knee scoring systems. PCL injury status on MRI was assessed using a different scale for initial and follow-up MRI. RESULTS: The grade of posterior instability was significantly improved from initial grades of I in 13 patients (34%) and II in 25 patients (66%) to follow-up grades of 0 in 3 patients (8%), I in 21 patients (55%), and II in 14 patients (37%) (P = .007). The mean side-to-side difference in posterior translation measured with the KT-1000 arthrometer (MEDmetric, San Diego, CA) was initially 6.7 mm and significantly improved to 5.2 mm at the latest follow-up (P < .001). At latest follow-up, the mean Lysholm knee score, Hospital for Special Surgery knee score, and International Knee Documentation Committee subjective score were 88, 91, and 83, respectively. The continuity of the PCL on follow-up MRI showed statistically less posterior instability on both physical examination (P = .010) and KT-1000 arthrometer testing (P = .003). CONCLUSIONS: Our active, nonoperative method of casting and bracing with attached tibial supporters, which was designed to prevent posterior displacement at the knee, yielded satisfactory functional and MRI results in the majority of patients at intermediate-term follow-up. The continuity of the PCL with low signal intensity on follow-up MRI was a predictable factor for a favorable prognosis in patients with acute PCL injuries. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Parasitic helminth cystatin inhibits DSS-induced intestinal inflammation via IL-10(+)F4/80(+) macrophage recruitment.

Many immune down-regulatory molecules have been isolated from parasites, including cystatin (cystain protease inhibitor). In a previous study, we isolated and characterized Type I cystatin (CsStefin-1) of the liver fluke, Clonorchis sinensis. To investigate whether the CsStefin-1 might be a new host immune modulator, we induced intestinal inflammation in mice by dextran sodium sulfate (DSS) and treated them with recombinant CsStefin-1 (rCsStefin-1). The disease activity index (DAI) increased in DSS only-treated mice. In contrast, the DAI value was significantly reduced in rCsStefin-1-treated mice than DSS only-treated mice. In addition, the colon length of DSS only-treated mice was shorter than that of rCsStefin-1 treated mice. The secretion levels of IFN-γ and TNF-α in the spleen and mesenteric lymph nodes (MLNs) were significantly increased by DSS treatment, but the level of TNF-α in MLNs was significantly decreased by rCsStefin-1 treatment. IL-10 production in both spleen and MLNs was significantly increased, and IL-10(+)F4/80(+) macrophage cells were significantly increased in the spleen and MLNs of rCsStefin-1 treated mice after DSS treatment. In conclusion, rCsStefin-1 could reduce the intestinal inflammation occurring after DSS treatment, these effects might be related with recruitment of IL-10 secreting macrophages.