Risk of age older than 65 years for 30-day cardiac complication may be comparable to low-to-moderate risk according to revised cardiac risk index in non-cardiac surgery.

Revised cardiac risk index (RCRI) is widely used for surgical patients without containing age as a risk factor. We investigated age older than 65 years with respect to low-to-moderate risk of RCRI. From January 2011 to June 2019, a total of 203,787 consecutive adult patients underwent non-cardiac surgery at our institution. After excluding high-risk patients defined as RCRI score > 2, we stratified the patients into four groups according to RCRI and age (A: age < 65 with RCRI < 2, [n = 148,288], B: age ≥ 65 with RCRI < 2, [n = 42,841], C: age < 65 with RCRI = 2, [n = 5,271], and D: age ≥ 65 with RCRI = 2, [n = 5,698]). Incidence of major cardiac complication defined as a composite of cardiac death, cardiac arrest and myocardial infarction was compared. After excluding 1,689 patients with high risk (defined as RCRI score > 2), 202,098 patients were enrolled. The incidence with 95% confidence interval of major cardiac complication for A, B, C, and D groups was 0.3% (0.2-0.3), 1.1% (1.0-1.2), 1.8% (1.6-1.8), and 3.1% (2.6-3.6), respectively. In a direct comparison between B and C groups, old patients with RCRI < 2 showed a significantly lower risk compared to younger patients with RCRI = 2 (odd ratio, 0.62; 95% confidence interval, 0.50-0.78; p < 0.001). In non-cardiac surgery, the risk of age older than 65 years was shown to be comparable with low-to-moderate risk according to RCRI.

Preoperative left atrial volume index may be associated with postoperative atrial fibrillation in non-cardiac surgery.

Background: Postoperative atrial fibrillation (POAF) is related to mortality after non-cardiac surgery. Left atrial volume index (LAVI) is known to be associated with prognosis and development of atrial fibrillation, but it has not been fully investigated in patients undergoing non-cardiac surgery. Materials and methods: A total of 203,787 consecutive adult patients underwent non-cardiac surgery at our institution between January 2011 and June 2019. After identifying those with available LAVI estimated during preoperative echocardiography, we divided them into those with LAVI higher and lower than 34 mL/m2. The primary outcome was incidence of POAF. Results: A total of 83,097 patients were enrolled in this study. The study patients were divided into the low (57,838 [69.6%]) and high (25,259 [30.4%]) LAVI groups. After an adjustment, higher LAVI was associated with increased incidence of POAF (5.1% vs. 8.1%; odds ratio [OR], 1.33; 95% confidence interval [CI], 1.25-1.41; p < 0.001). In 24,549 pairs of propensity-score-matched population, the result was similar (6.2% vs. 7.9%; OR, 1.30; 95% CI, 1.21-1.39; p < 0.001). The estimated threshold of LAVI associated with POAF was 36.4 mL/m2 with an area under the curve of 0.571. Subgroup analysis in non-thoracic and thoracic surgery showed that the association between preoperative LAVI and POAF significantly interacted with diastolic dysfunction (p for interaction < 0.001), and the observed association was valid in patients without diastolic dysfunction. Conclusion: Preoperative LAVI was shown to be associated with POAF in non-cardiac surgery. Our result needs verification in further studies.

Association between Mortality and Sequential Organ Failure Assessment Score during a Short Stay in the Intensive Care Unit after Non-Cardiac Surgery.

Background: The sequential organ failure assessment (SOFA) score has been validated in various clinical situations. However, it has not been investigated during a short stay in the intensive care unit (ICU). This study aimed to evaluate the association between the SOFA score and outcomes in patients who were monitored for less than one day after non-cardiac surgery. Methods: From a total of 203,787 consecutive adult patients who underwent non-cardiac surgery between January 2011 and June 2019, we selected 17,714 who were transferred to the ICU immediately after surgery and stayed for less than 24 h. Patients were divided according to quartile value and change between the initial and follow-up levels of SOFA score. Results: Three-year mortality tended to increase with a higher initial SOFA score (11.7%, 11.8%, 15.1%, and 17.8%, respectively). The patients were divided according to changes in the SOFA score at the midnight postoperative follow-up check: 16,176 (91.3%) in the stable group and 1538 (8.7%) in the worsened group. The worsened group showed significantly higher three-year mortality and complications (13.2% vs. 18.6%; HR [hazard ratio]: 1.236; 95% CI [confidence interval]: 1.108−1.402; p ≤ 0.0021 for three-year mortality and 3.8% vs. 9.1%; HR: 2.13; 95% CI: 1.73−2.60; p < 0.001 for acute kidney injury). Conclusions: The SOFA score during a short stay in the ICU after non-cardiac surgery showed an association with mortality. The change in SOFA score may need to be considered at discharge from the ICU.

Association Between Perioperative Adverse Cardiac Events and Mortality During One-Year Follow-Up After Noncardiac Surgery.

Background Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long-term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30-day postoperative period and we compared mortality according to PACE occurrence. Methods and Results From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30-day mortality, mortality during a 1-year follow-up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1-year mortality. After excluding 1203 patients with 30-day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74-2.09; P<0.001). Results were similar for 7839 pairs of propensity-score-matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44-1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel. Conclusions PACE as a composite outcome was associated with 1-year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.

Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Cancer: A Population-Based Cohort Study Using a Common Data Model.

Studies have reported conflicting results on the association between the use of renin-angiotensin-aldosterone system (RAAS) inhibitors and cancer development. We compared the incidence of cancer between patients using RAAS inhibitors and other antihypertensive drugs. This retrospective observational cohort study used data from seven hospitals in Korea that were converted for use in the Observational Medical Outcomes Partnership Common Data Model. A total of 166,071 patients on antihypertensive therapy across the databases of the seven hospitals were divided into two groups according to the use of RAAS inhibitors. The primary outcome was the occurrence of cancer. A total of 166,071 patients across the databases of the seven hospitals was included in the final analysis; 26,650 (16%) were in the RAAS inhibitors group and 139,421 (84%) in the other antihypertensive drugs group. The meta-analysis of the whole cohort showed a lower incidence of cancer occurrence in the RAAS inhibitor group (9.90 vs. 13.28 per 1000 person years; HR, 0.81; 95% confidence interval [CI], 0.75-0.88). After propensity-score matching, the RAAS inhibitor group consistently showed a lower incidence of cancer (9.90 vs. 13.28 per 1000 person years; HR, 0.86; 95% CI, 0.81-0.91). The patients using RAAS inhibitors showed a lower incidence of cancer compared with those using other antihypertensive drugs. These findings support the association between the use of RAAS inhibitors and cancer occurrence.

Prediction model for postoperative atrial fibrillation in non-cardiac surgery using machine learning.

Some patients with postoperative atrial fibrillation (POAF) after non-cardiac surgery need treatment, and a predictive model for these patients is clinically useful. Here, we developed a predictive model for POAF in non-cardiac surgery based on machine learning techniques. In a total of 201,864 patients who underwent non-cardiac surgery between January 2011 and June 2019 at our institution, 5,725 (2.8%) were treated for POAF. We used machine learning with an extreme gradient boosting algorithm to evaluate the effects of variables on POAF. Using the top five variables from this algorithm, we generated a predictive model for POAF and conducted an external validation. The top five variables selected for the POAF model were age, lung operation, operation duration, history of coronary artery disease, and hypertension. The optimal threshold of probability in this model was estimated to be 0.1, and the area under the receiver operating characteristic (AUROC) curve was 0.80 with a 95% confidence interval of 0.78-0.81. Accuracy of the model using the estimated threshold was 0.95, with sensitivity and specificity values of 0.28 and 0.97, respectively. In an external validation, the AUROC was 0.80 (0.78-0.81). The working predictive model for POAF requiring treatment in non-cardiac surgery based on machine learning techniques is provided online (https://sjshin.shinyapps.io/afib_predictor_0913/). The model needs further verification among other populations.

Association between Cardiologist Consultation and Mortality of Stable Patients with Elevated Cardiac Troponin at Admission.

Elevated cardiac troponin (cTn) showed associations with mortality even in stable patients, but management has not been established. We aimed to investigate whether consultation to cardiologists could reduce mortality of stable patients with cTn elevation at admission. We identified 1329 patients with elevated cTn level at hospitalization from outpatient clinic to any department other than cardiology or cardiac surgery between April 2010 and December 2018. The patients were divided into two groups according to cardiologist consultation at admission. For primary outcome, mortality during one year was compared in the crude and propensity-score-matched populations. In 1329 patients, 397 (29.9%) were consulted to cardiologists and 932 (70.1%) were not. Mortality during the first year was significantly lower in patients consulted to cardiologists compared with those who were not (9.8% vs. 14.2%; hazard ratio (HR), 0.50; 95% confidence interval (CI), 0.35-0.72; p < 0.001). After propensity-score matching, 324 patients were in the cardiologist consultation group and 560 patients were in the no cardiologist consultation group. One-year mortality was consistently lower in the cardiologist consultation group (10.5% vs. 14.6%; HR, 0.58; 95% CI, 0.39-0.86; p = 0.01). Cardiologist consultation may be associated with lower mortality in stable patients with cTn elevation at admission. Further studies are needed to identify effective management strategies for stable patients with elevated cTn.

The Charlson Comorbidity Index is associated with risk of 30-day mortality in patients with myocardial injury after non-cardiac surgery.

Myocardial injury after non-cardiac surgery (MINS) is a well-known and relevant indicator of early postoperative mortality, but factors related to increased mortality in MINS patients are as yet unknown. The Charlson Comorbidity Index (CCI) is widely used to classify various comorbid conditions and underlying diseases. Our study aimed to determine the prognostic value of CCI with regard to mortality of patients with MINS. This study comprises 5633 patients who had MINS as diagnosed by a rise of postoperative cardiac troponin I above the normal range (≥ 0.04 ng/mL) from January 2010 to June 2019. Patients were divided into two groups according to median weighted CCI score: low CCI (≤ 2) and high CCI (> 2) groups. The primary outcome was 30-day mortality after surgery, and secondary outcomes were 1-year and overall mortalities. Of the 5633 patients, 3428 (60.9%) were in the low CCI group (1.21 ± 0.84) and 2205 (39.1%) were in the high CCI group (4.17 ± 1.82). After propensity score matching, mortality during the first 30 days after surgery was significantly greater in the high CCI group than the low CCI group (9.4% vs. 6.0%, respectively; hazard ratio 1.56, 95% confidence interval 1.23-1.98, p < 0.001). A high CCI score was associated with increased 30-day mortality in patients with MINS, suggesting that the CCI may need to be considered when predicting outcomes of MINS patients.

Angiotensin converting enzyme inhibitors and incidence of lung cancer in a population based cohort of common data model in Korea.

Contradictory findings exist about association of angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) with lung cancer development. This was a retrospective observational cohort study that used data from 7 hospitals in Korea, converted to the Observational Medical Outcomes Partnership Common Data Model. The primary outcome was occurrence of lung cancer. A total of 207,794 patients across the 7 databases was included in the final analysis; 33,230 (16%) were prescribed ACEi and 174,564 (84%) were prescribed ARB. Crude analysis adjusted for sex and age showed higher incidence of lung cancer in the ACEi group compared to the ARB group (hazard ratio [HR], 1.46; 95% confidence rate [CI], 1.08-1.97). After propensity-score matching, 30,445 pairs were generated, and there was no difference in incidence of lung cancer between the two groups (HR, 0.93; 95% CI, 0.64-1.35). Patients prescribed ACEi showed no difference in incidence of lung cancer development compared to those using ARB. This finding provides evidence on the association between ACEi and occurrence of lung cancer.

What Is the Optimal Exercise Prescription for Patients With Dilated Cardiomyopathy in Cardiac Rehabilitation? A SYSTEMATIC REVIEW.

PURPOSE: Dilated cardiomyopathy (DCM) is 1 of the major causes of advanced heart failure. However, relatively little is known about the effects of exercise specifically in patients with DCM. This purpose of this literature review was to identify optimal exercise training programming for patients with DCM. METHODS: A systematic review was conducted by 3 clinical specialists and the level of evidence of each study was rated using Sackett's levels of evidence. Multiple databases (PubMed Central, EMBASE, and EBSCO) were searched with the inclusion criteria of articles published in English. RESULTS: A total of 4544 studies were identified using the search strategy, of which 4 were included in our systematic review. The exercise frequency of the reviewed studies ranged from 3 to 5 times/wk, and exercise intensity was prescribed within a range from 50% to 80% of oxygen uptake reserve. Exercise time was as high as 45 min by the final month of the exercise prescription. Exercise type was mainly aerobic exercise and resistance training. The average improvement of exercise capacity was 19.5% in reviewed articles. Quality of life also improved after intervention. CONCLUSIONS: According to this systematic review of the literature, data related to exercise therapy specifically for patients with DCM are scarce and exercise interventions in articles reviewed were prescribed differently using the FITT (frequency, intensity, time, and type) principle. Exercise intensity tailored to individual exercise capacity should be used for optimal exercise prescriptions that are safe and efficacious in patients with DCM.

Comparison of long-term clinical outcomes between revascularization versus medical treatment in patients with silent myocardial ischemia.

BACKGROUND: There have been limited and conflicting results regarding the prognostic impact of revascularization treatment on the long-term clinical outcomes of silent ischemia. The current study aimed to determine whether revascularization treatment compared with medical treatment (MT) alone reduces long-term risk of cardiac death of asymptomatic patients with objective evidence of inducible myocardial ischemia. METHODS: A total of 1473 consecutive asymptomatic patients with evidence of inducible myocardial ischemia were selected from a prospective institutional registry. All patients showed at least 1 epicardial coronary stenosis with ≥50% diameter stenosis in coronary angiography. Patients were classified according to their treatment strategies. The primary outcome was cardiac death up to 10 years. RESULTS: Among the total population, 709 patients (48.1%) received revascularization treatment including percutaneous coronary intervention (PCI, n = 558) or coronary artery bypass graft surgery (CABG, n = 151), with the remaining patients (764 patients, 51.9%) receiving MT alone. During the follow-up period, the revascularization treatment group showed a significantly lower risk of cardiac death compared with the MT alone group (25.4% vs. 33.7%, HR 0.624, 95%CI 0.498-0.781, p < 0.001). Among revascularized patients, patients with negative non-invasive stress test results after revascularization showed significantly lower risk of cardiac death compared to those with residual myocardial ischemia (8.9% vs. 18.7%, HR 0.406, 95% CI 0.175-0.942, p = 0.036). CONCLUSIONS: In patients with silent myocardial ischemia, revascularization treatment was associated with significantly lower long-term risk of cardiac death compared with the MT alone group. The current results support contemporary practice of ischemia-directed revascularization, even in patients with silent myocardial ischemia.

The Effect of Preoperative Cognitive Behavior and Exercise Therapy for a Patient With an Implanted Left Ventricular Assist Device in Korea.

Left ventricular assist devices (LVADs) are used in patients with progressive heart failure symptoms to provide circulatory support. Patients with LVADs are referred to inpatient cardiac rehabilitation to prevent postoperative complications and improve aerobic capacity and quality of life. Preoperative exercise therapy for cardiac patients is an emerging treatment modality, and several studies have reported that it improves postoperative outcomes, such as length of hospital stay and postoperative complications. This case report describes the benefits of preoperative cognitive behavioral and exercise therapy in a Korean patient undergoing LVAD implantation. LEVEL OF EVIDENCE: V.

Exercise therapy for an older patient with left ventricular assist device.

A left ventricular assist device (LVAD) is a mechanical circulation support implanted for patients with end-stage heart failure. It may be used either as a bridge to cardiac transplantation or as a destination therapy. The health of a 75-year-old man with a medical history of systolic heart failure worsened. Therefore, he was recommended to have implanted a LVAD (Thoratec Corp.) as a destination therapy. After the surgery, he was enrolled in patient cardiac rehabilitation for the improvement of dyspnea and exercise capacity. In results, there is an improvement on his exercise capacity and quality of life. For the first time in Korea, we reported a benefit of exercise therapy after being implanted with a LVAD.

Monitoring of unfractionated heparin using activated partial thromboplastin time: an assessment of the current nomogram and analysis according to age.

BACKGROUND: We frequently encounter high levels of activated partial thromboplastin time (aPTT) during heparin anticoagulation. The purpose of this study is, first, to investigate the rate of achieving and maintaining therapeutic aPTT in patients treated with heparin anticoagulation and second, to assess the adequacy the current nomogram. METHODS: We included 197 patients who underwent anticoagulation with unfractionated heparin (UFH) according to the standard nomogram between September 2008 and May 2010. The primary endpoints were the rate of achieving a therapeutic range (TR) at the first sample, 24 hours, or 48 hours. We also compared heparin nomograms according to age (<70 years vs ≥70 years). RESULTS: Of the 197 patients, 131 had heparin loading. In the heparin loading group, there were 19.1% (n=25), 69.5% (n=91), and 90.1% (n=18) achieving TR at the first aPTT, 24 hours, and 48 hours, respectively. The therapeutic aPTT proportion was 39.2%, and the rate of peak level above 90 seconds was 93.1%. Peak levels of aPTT were higher in the older age group than in the younger age group (202.3 ± 124.2 versus 152.0 ± 78.9, p=0.007). CONCLUSION: Our results indicate a high rate of achieving therapeutic aPTT at 24 hous and 48 hours, but a low success rate for maintenance within the TR. Most patients had supratherapeutic aPTT of more than 90 seconds. Therefore, the TR of aPTT that matches heparin levels of 0.3 to 0.7 IU/mL measured by antifactor Xa assay should be determined. If not, we should consider adopting a new heparin dosing nomogram.

Serum total bilirubin is inversely associated with brachial-ankle pulse wave velocity in men with hypertension.

Serum total bilirubin has been suggested to have the potential anti-inflammatory and antioxidant effects on the vasculature. This study was designed to investigate the association of bilirubin with brachial-ankle pulse wave velocity (baPWV), a marker of arterial stiffness and cardiovascular disease. Hypertensive male subjects (n = 2,361) were classified into groups according to the 50th, 75th, and 95th percentiles of baPWV value. Correlation and regression analysis were used to assess the relationship between baPWV and other variables. Hypertensive subjects with baPWV above the 50th, 75th, and 95th percentiles had a significantly lower bilirubin level than those with baPWV under them (0.97 ± 0.40 vs. 1.00 ± 0.41 mg/dl, P < 0.001; 0.95 ± 0.39 vs. 0.99 ± 0.41 mg/dl, P = 0.001; 0.92 ± 0.36 vs. 0.99 ± 0.42 mg/dl, P = 0.048, respectively). Bilirubin is inversely related to baPWV (R (2) = 0.0032, P = 0.003) and C-reactive protein (CRP) (correlation coefficient = -0.13, P < 0.001). A 0.1 mg/dl increase in bilirubin was associated with a 19, 20, and 34 % reduced odds ratio for baPWV above the 50th, 75th, and 95th percentiles, respectively [odds ratio (OR) 0.77 (95 % confidence interval (CI) 0.62-0.95), P = 0.015; OR 0.80 (95 % CI 0.64-0.99), P = 0.044; OR 0.68 (95 % CI 0.45-1.00), P = 0.048, respectively] after adjustment for several variables. This study demonstrates an independent inverse association between bilirubin and baPWV in hypertensive men. Additionally, reduced CRP may be one of mediators on the mechanisms how bilirubin reduces baPWV.

Efficacy and tolerability of a generic and a branded formulation of atorvastatin 20 mg/d in hypercholesterolemic Korean adults at high risk for cardiovascular disease: a multicenter, prospective, randomized, double-blind, double-dummy clinical trial.

BACKGROUND: The reduction in plasma LDL-C concentrations with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy has been reported to reduce cardiovascular risk and mortality in individuals with or without preexisting coronary artery disease and elevated LDL-C concentrations. Atorvastatin is a statin used for lowering LDL-C concentrations. A generic formulation of atorvastatin is being developed in Korea. This study was undertaken for the purposes of marketing the generic formulation. OBJECTIVE: This study was designed to compare the efficacy and tolerability of a generic formulation of atorvastatin 20 mg/d versus a branded formulation at the same dosage in hypercholesterolemic Korean adults at high risk for cardiovascular events. METHODS: This 8-week, multicenter, randomized, double-blind, double-dummy study was conducted at 10 clinical centers in Korea between September 2008 and May 2009. Male and female patients aged 20 to 85 years at high risk for cardiovascular events (defined as an elevated LDL-C concentration [≥100 mg/dL]) were enrolled. Eligible patients were randomly assigned to receive generic or branded atorvastatin 20 mg once daily for 8 weeks. The primary end point was the percentage change from baseline to 8 weeks in LDL-C concentration. Secondary end points were the percentage changes from baseline in total cholesterol (TC), triglycerides (TG), HDL-C, apolipoprotein (apo) A1 and B, and high-sensitivity C-reactive protein concentrations; small, dense LDL (sdLDL) fraction; and tolerability. Tolerability was assessed using physical examination, laboratory testing, and by recording adverse events (AEs) at each visit. An additional secondary end point was the proportion of patients who achieved an LDL-C goal of <100 mg/dL. RESULTS: A total of 244 patients were randomized to treatment, and 33 patients were withdrawn from the study (9 patients did not receive the study medication, 11 patients due to AEs, and 13 patients due to withdrawal of consent). A total of 211 patients completed the study (50.7% male; 100% Asian; mean [SD] age, 61.7 [9.2] years) (106 patients in the group that received Accepted for publication October 5, 2010. the generic formulation and 105 patients in the group that received the branded formulation). LDL-C concentrations were reduced from the baseline by 44% and 46% after 8 weeks of treatment with the generic and branded formulations, respectively (P = NS). The percentage changes from baseline to study end in HDL-C, TC, TG, apo A1, apo B, and hsCRP concentrations and sdLDL fraction the proportions of patients who achieved the LDL-C goal between the 2 groups did not reach statistical significance. The most commonly reported events were hepatobiliary laboratory abnormality (1.7%), general somatic discomfort (1.7%), and epigastric pain (0.8%) in the group that received the generic formulation, and myalgia (1.7%), epigastric pain (0.9%), and elevation of creatinine phosphokinase (0.9%) in the group that received the branded formulation. No serious AEs were reported in either group. CONCLUSIONS: After 8 weeks of treatment, the differences in the LDL-C-lowering effects between the generic and branded formulations of atorvastatin 20 mg/d did not reach statistical significance in these Korean patients at high risk for cardiovascular events. Both formulations were generally well tolerated.

The relationship between apolipoprotein E polymorphism, lipoprotein (a) and fatty liver disease.

BACKGROUND/AIMS: The apolipoprotein E (apo E) gene is known to affect plasma lipoprotein-lipid levels, and lipoprotein (a) [Lp(a)] is an atherogenic lipoprotein that is negatively correlated with triglyceride level. The purpose of this study was to investigate the relationship between the apo E genotype, plasma Lp(a) level, and fatty liver. METHODOLOGY: A cross-sectional study was performed on 711 subjects who were diagnosed as having fatty liver by ultrasonography and on 711 sex- and age-matched control subjects. Apo E genotype, plasma Lp(a) concentrations, and serum levels of total cholesterol, triglyceride, LDL-cholesterol, and HDL-cholesterol were measured. RESULTS: Fatty liver subjects were found to have significantly higher triglyceride, and lower HDL-cholesterol levels. According to the multivariate logistic regression analysis, the odds ratios for fatty liver were 2.254 (95% CI 1.697-2.993) for hypertriglyceridemia, 1.841 (95% CI 1.449-2.339) for a high LDL-cholesterol level, 1.509 (95% CI 1.112-2.046) for a low HDL-cholesterol level, and 0.364 (95% CI 0.194-0.684) for a high HDL-cholesterol level. The odds ratios of epsilon4 and a high plasma Lp(a) level for fatty liver were 0.631 (95% CI 0.468-0.850) and 0.607 (95% CI 0.470-0.784) respectively. CONCLUSIONS: Our results suggest that the epsilon4 allele of apo E and plasma Lp(a) concentration may be associated with the pathogenesis of fatty liver.

Correlation between levels of N-terminal pro-B-type natriuretic peptide and degrees of heart failure.

BACKGROUND: The N-terminal fragment of pro Brain Natriuretic Peptide (NT-pro BNP) is a neuro-hormone synthesized in the cardiac ventricles in response to increased wall tension. The purpose of this study was to assess the correlation between the NT-pro BNP levels and the New York Heart Association function class (NYHA Fc) of dyspnea and echocardiographic findings for the patients who visited our cardiology departments. METHODS: From October, 2002 to April, 2003, serum NT-pro BNP levels were measured in 348 patients who visited the Samsung Medical Center and the Jong Koo Lee Heart Clinic. RESULTS: The NT-pro BNP levels were increased with the progression of NYHA Fc of dyspnea (p < 0.001 by ANOVA), the increase in the systolic left ventricular internal dimension (p < 0.05), and the decrease in the ejection fraction (p < 0.01). For the NYHA Fc I patients, the NT-pro BNP levels were positively correlated with age (0 < 0.001) and left atrial size (p < 0.001). For the patients with ischemic heart disease, the NT-pro BNP levels were also positively correlated with the NYHA Fc (p < 0.001 by ANOVA). The NT-pro BNP levels were increased with the increase in the systolic (p < 0.001) and diastolic pressure (p = 0.017), the left ventricular internal dimension as well as the decrease in the ejection fraction (p < 0.001). The area under the receiver operating characteristic (ROC) curve for the NT-pro BNP levels was 0.994 (95% confidence interval, 0.979-0.999), and the most reliable cut-off level for the NT-pro BNP was 293.6 pg/mL. CONCLUSION: The NT-pro BNP levels were positively correlated with the NYHA Fc of dyspnea and the systolic dysfunction for the patients who visited our cardiology departments. A 300 pg/mL value for the NT-pro BNP cut-off point appears to be a sensitive level to differentiate dyspnea originating from an ailing heart or not for the patients who visited our cardiology departments.