The Effects of Radiofrequency Catheter Ablation for Atrial Fibrillation on Right Ventricular Function.

BACKGROUND AND OBJECTIVE: The effects of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) on right ventricular (RV) function are not well known. METHODS: Patients who underwent RFCA for AF and underwent pre- and post-procedural echocardiography were enrolled consecutively. Fractional area change (FAC), RV free-wall longitudinal strain (RVFWSL), and RV 4-chamber strain including the ventricular septum (RV4CSL) were measured. Changes in FAC, RVFWSL, and RV4CSL before and after RFCA were compared among paroxysmal AF (PAF), persistent AF (PeAF), and long-standing persistent AF (LSPeAF) groups. RESULTS: A total of 164 participants (74 PAF, 47 PeAF, and 43 LSPeAF; age, 60.8 ± 9.8 years; men, 74.4%) was enrolled. The patients with PeAF and LSPeAF had worse RV4CSL (p<0.001) and RVFWSL (p<0.001) than those with PAF and reference values. Improvements in RVFWSL and RV4CSL after RFCA were significant in the PeAF group compared with the PAF and LSPeAF groups (ΔRV4CSL, 8.4% [5.1, 11.6] in PeAF vs. 1.0% [-1.0, 4.1] in PAF, 1.9% [-0.2, 4.4] in LSPeAF, p<0.001; ΔRVFWSL, 9.0% [6.9, 11.5] in PeAF vs. 0.9% [-1.4, 4.9] in PAF, 1.0% [-1.0, 3.6] in LSPeAF, p<0.001). In patients without recurrence, improvements in RVFWSL and RV4CSL after RFCA were significant in the PeAF group compared to the LSPeAF group. CONCLUSIONS: RV systolic function is more impaired in patients with PeAF and LSPeAF than in those with PAF. RV systolic function is more improved after RFCA in patients with PeAF than in those with PAF or LSPeAF.

Early menopause is associated with abnormal diastolic function and poor clinical outcomes in women with suspected angina.

Early identification of women at high risk for cardiovascular diseases (CVD), with subsequent monitoring, will allow for improved clinical outcomes and generally better quality of life. This study aimed to identify the associations between early menopause, abnormal diastolic function, and clinical outcomes. This retrospective study included 795 menopausal women from is a nationwide, multicenter, registry of patients with suspected angina visiting outpatient clinic. The patients into two groups: early and normal menopause (menopausal age ≤ 45 and > 45 years, respectively). If participants met > 50% of the diastolic function criteria, they were classified as having normal diastolic function. Multivariable-adjusted Cox models were used to test associations between menopausal age and clinical outcomes including the incidence of major adverse cardiovascular events (MACE), over a median follow-up period of 771 days. Early menopause was associated with increased waist circumference (p = 0.001), diabetes prevalence (p = 0.003), obstructive coronary artery disease (p = 0.005), abnormal diastolic function (p = 0.003) and greater incidences of MACE, acute coronary syndrome, and hospitalization for heart failure. In patients with abnormal diastolic function, early menopause increased MACE risk significantly, with no significant difference in normal diastolic function. These findings highlight early menopause and abnormal diastolic function as being potential risk markers in women for midlife CVD events.

Evaluation of GPT-4 for 10-year cardiovascular risk prediction: Insights from the UK Biobank and KoGES data.

Cardiovascular disease (CVD) remains a pressing global health concern. While traditional risk prediction methods such as the Framingham and American College of Cardiology/American Heart Association (ACC/AHA) risk scores have been widely used in the practice, artificial intelligence (AI), especially GPT-4, offers new opportunities. Utilizing large scale of multi-center data from 47,468 UK Biobank participants and 5,718 KoGES participants, this study quantitatively evaluated the predictive capabilities of GPT-4 in comparison with traditional models. Our results suggest that the GPT-based score showed commendably comparable performance in CVD prediction when compared to traditional models (AUROC on UKB: 0.725 for GPT-4, 0.733 for ACC/AHA, 0.728 for Framingham; KoGES: 0.664 for GPT-4, 0.674 for ACC/AHA, 0.675 for Framingham). Even with omission of certain variables, GPT-4's performance was robust, demonstrating its adaptability to data-scarce situations. In conclusion, this study emphasizes the promising role of GPT-4 in predicting CVD risks across varied ethnic datasets, pointing toward its expansive future applications in the medical practice.

Association Between Aortic Valve Sclerosis and Clonal Hematopoiesis of Indeterminate Potential.

Background: The mechanism and medical treatment target for degenerative aortic valve disease, including aortic stenosis, is not well studied. In this study, we investigated the effect of clonal hematopoiesis of indeterminate potential (CHIP) on the development of aortic valve sclerosis (AVS), a calcified aortic valve without significant stenosis. Methods: Participants with AVS (valves ≥2 mm thick, high echogenicity, and a peak transaortic velocity of <2.5 m/sec) and an age- and sex-matched control group were enrolled. Twenty-four CHIP genes with common variants in cardiovascular disease were used to generate a next-generation sequencing panel. The primary endpoint was the CHIP detection rate between the AVS and control groups. Inverse-probability treatment weighting (IPTW) analysis was performed to adjust for differences in baseline characteristics. Results: From April 2020 to April 2022, 187 participants (125 with AVS and 62 controls) were enrolled; the mean age was 72.6±8.5 yrs, and 54.5% were male. An average of 1.3 CHIP variants was observed. CHIP detection, defined by a variant allele frequency (VAF) of ≥0.5%, was similar between the groups. However, the AVS group had larger CHIP clones: 49 (39.2%) participants had a VAF of ≥1% (vs. 13 [21.0%] in the control group; P=0.020), and 25 (20.0%) had a VAF of ≥2% (vs. 4 [6.5%]; P=0.028). AVS is independently associated with a VAF of ≥1% (adjusted odds ratio: 2.44, 95% confidence interval: 1.11-5.36; P=0.027). This trend was concordant and clearer in the IPTW cohort. Conclusions: Participants with AVS more commonly had larger CHIP clones than age- and sex-matched controls. Further studies are warranted to identify causality between AVS and CHIP.

Impact of amlodipine on clinical outcomes for heart failure in patients with dilated cardiomyopathy: a Korean nationwide cohort study.

Introduction: Amlodipine, widely used as a first-line treatment for hypertension, has inconclusive clinical evidence regarding its efficacy in patients with heart failure. This retrospective cohort study aimed to investigate the clinical effectiveness of amlodipine treatment after hospitalization for heart failure in patients with dilated cardiomyopathy (DCMP). Methods: A total of 20,851 patients who were diagnosed with DCMP and admitted for heart failure between 2005 and 2016 according to Korean nationwide medical insurance service database were enrolled. Amlodipine use was defined as its prescription at the time of discharge and for at least 180 days within a year. The primary outcome was all-cause death, and the secondary outcome was heart failure rehospitalization during a 5-year period. The outcomes between patients who received amlodipine (n = 6,798) and those who did not (n = 14,053) were compared. Results: During the 5-year follow-up, the group treated with amlodipine exhibited a significantly lower risk of all-cause death and heart failure rehospitalization than the group not treated with amlodipine [all-cause death: adjusted hazard ratio (HR): 0.64, 95% confidence interval (CI): 0.59-0.70, p < 0.001; cardiovascular death: adjusted HR: 0.71, 95% CI: 0.62-0.81, p < 0.001; heart failure rehospitalization: adjusted HR: 0.92, 95% CI: 0.86-0.98, p = 0.006]. In a subgroup analysis, amlodipine had a significant impact on decreasing all-cause mortality in older adults, those with a higher systolic blood pressure, and those with a lower Charlson Comorbidity Index. Conclusion: In summary, amlodipine use after hospitalization for heart failure in patients with DCMP was associated with a lower risk of all-cause death and readmission for heart failure.

Relative importance of left atrial reservoir strain compared with components of the HFA-PEFF score: a cross-sectional study.

Background: The relative importance of left atrial reservoir strain (LASr) regarding the Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology (HFA-PEFF) score, a diagnostic tool for patients with heart failure with preserved ejection fraction (HFpEF), remains unclear. We aimed to identify the relative importance of LASr compared with variables associated with HFpEF and HFA-PEFF scores. Methods: Between August 2021 and July 2022, we obtained retrospective data from the participants visiting a single cardiovascular center with subjective symptoms of heart failure, such as dyspnea or chest discomfort. In total, 2,712 participants with sinus rhythm and ejection fraction of more than 50% were enrolled. Multivariable logistic regression analysis, random forest analysis, and supervised machine learning algorithms were performed to identify the relative importance of LASr to the HFA-PEFF score. Results: The average HFA-PEFF score was 2.4 ± 1.6 points. Two hundred and thirty-eight participants had 5 or 6 points. LASr showed a moderate correlation with the HFA-PEFF score (r = -0.50, p < 0.001). Impaired LASr < 25.2% was an independent variable affecting a high HFA-PEFF score with traditional diastolic function parameters and components of the HFA-PEFF diagnostic algorithm. The odds ratio (OR) [1.74, 95% confidence interval (CI) 1.23-2.47] for LASr was higher compared to that of left ventricular global longitudinal strain (OR 1.59, 95% CI 1.14-2.21), septal E/e' (OR 1.23, 95% CI 0.85-1.77), and relative wall thickness (OR 1.20, 95% CI 0.76-1.89). LASr was also a relatively more important variable in estimating a high HFA-PEFF score than TR-Vmax, septal E/e', septal e', left ventricular mass index, and relative wall thickness, the major echocardiographic components of the HFA-PEFF score. Conclusions: LASr is an important factor with components of the HFA-PEFF score and is a useful tool to assess patients with HFpEF. Clinical Trial Registration: URL: https://clinicaltrials.org. Unique identifiers: NCT05638230.

Impact of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction and Chronic Kidney Disease.

BACKGROUND: In the setting of acute myocardial infarction (AMI), there are no data regarding the benefits of intravascular ultrasound (IVUS) for chronic kidney disease (CKD) patients.Methods and Results: This study used data from the Korea Acute Myocardial Infarction Registry, a large, multicenter prospective cohort. We evaluated 1,759 patients with AMI and CKD, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, and patients were classified into 2 groups: with and without IVUS. The primary outcome was target lesion failure (TLF) at 3 years. The hazard ratio (HR) of TLF according to eGFR was also analyzed. A total of 1,759 patients with AMI and CKD who underwent IVUS-guided PCI (19.2%) had a significantly lower risk of TLF at 3 years (8.9% vs. 15.3%; HR 0.55; 95% confidence interval [CI]: 0.38 to 0.81; P=0.002) than those who underwent angiography-guided PCI, regardless of their eGFR and the presence of end-stage renal disease (ESRD). The results were consistent after confounder adjustment and inversed probability weighting. CONCLUSIONS: In patients with CKD and AMI who underwent PCI with 2nd-generation DES implantation, the use of IVUS guidance was associated with a significant reduction in 3-year TLF and showed consistently favorable outcomes regardless of eGFR and ESRD.

Gender disparities in prevalence by diagnostic criteria, treatment and mortality of newly diagnosed acute myocardial infarction in Korean adults.

Acute myocardial infarction (AMI) is highly prevalent and remains the leading cause of mortality. Particularly in women, under-recognition and management of AMI have been raised. The aim of this study was to investigate the long-term trends of prevalence, treatment methodologies, and mortality of AMI by gender. The subjects of this study were patients hospitalized for AMI according to the Korean National Health Insurance Claims Database from 2002 to 2018. Total 633,097 AMI patients were hospitalized, 40% women. The incidence of AMI has been increasing since 2011, with a lower incidence in women. Overall, 53.1% of patients underwent CAG, with a lower tendency in women than in men (39.8% vs. 62.3%). Furthermore, fewer women underwent PCI than men (77.5% vs. 85.8% in 2018, p < 0.0001). Of the 336,463 AMI patients undergoing CAG, women were undertreated with a lower prescription rate of beta-blockers or statins at discharge. When adjusted for age, women showed higher 7-day mortality but lower 1-year mortality relative to men. According to the Korean National Health Insurance Claims Database, women with AMI have been under-recognized, underdiagnosed, and undertreated in terms of revascularization or medical therapy for years suggesting that efforts to close the gender gap are necessary.

Prognostic value of preoperative left ventricular global longitudinal strain for predicting postoperative myocardial injury and mortality in patients undergoing major non-cardiac surgery (SOLOMON study).

BACKGROUND: The usefulness of preoperative measurement of left ventricular global longitudinal strain (LVGLS) for predicting prognosis in patients undergoing non-cardiac surgery has not been evaluated. We analyzed the prognostic value of LVGLS in predicting postoperative 30-day cardiovascular events and myocardial injury after non-cardiac surgery (MINS). METHODS: This prospective cohort study was conducted in two referral hospitals and included 871 patients who underwent non-cardiac surgery <1 month after preoperative echocardiography. Those with ejection fraction <40%, valvular heart disease, and regional wall motion abnormality were excluded. The co-primary endpoints were the (1) composite incidence of all-cause death, acute coronary syndrome (ACS), and MINS and (2) composite incidence of all-cause death and ACS. RESULTS: Among the 871 participants enrolled (mean age: 72.9 years; female: 60.8%), there were 43 cases of the primary endpoint (4.9%): 10 deaths, 3 ACS, and 37 MINS. Participants with impaired LVGLS (≤16.6%) had a higher incidence of the co-primary endpoints (log-rank P < 0.001 and 0.015) than those without. The result was similar after adjustment with clinical variables and preoperative troponin T levels (hazard ratio = 1.30, 95% confidence interval [CI] = 1.03-1.65; P = 0.027). In sequential Cox analysis and net reclassification index, LVGLS had an incremental value for predicting the co-primary endpoints after non-cardiac surgery. Among the 538 (61.8%) participants who underwent serial troponin assay, LVGLS predicted MINS independently from the traditional risk factors (odds ratio = 3.54, 95% CI = 1.70-7.36; P = 0.001). CONCLUSIONS: Preoperative LVGLS has an independent and incremental prognostic value in predicting early postoperative cardiovascular events and MINS. CLINICAL TRIAL REGISTRATION: URL: https://trialsearch.who.int/. Unique identifiers: KCT0005147.

Early Invasive Strategy Based on the Time of Symptom Onset of Non-ST-Segment Elevation Myocardial Infarction.

BACKGROUND: A limitation of the current guidelines regarding the timing of invasive coronary angiography for patients with non-ST-segment elevation acute coronary syndrome is the randomization time. To date, no study has reported the clinical outcomes of invasive strategy timing on the basis of the time of symptom onset. OBJECTIVES: The aim of this study was to investigate the effect of invasive strategy timing from the time of symptom onset on the 3-year clinical outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: Among 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health, 5,856 patients with NSTE myocardial infarction were evaluated. The patients were categorized according to symptom-to-catheter (StC) time (<48 or ≥48 hours). The primary outcome was 3-year all-cause mortality. RESULTS: Overall, 3,919 patients (66.9%) were classified into the StC time <48 hours group. This group had lower all-cause mortality than the group with StC time ≥48 hours (7.3% vs 13.4%; P < 0.001). The lower risk for all-cause mortality in the group with StC time <48 hours group was consistent in all subgroups. Notably, emergency medical service use (HR: 0.31; 95% CI: 0.19-0.52) showed a lower risk for all-cause mortality than no emergency medical service use (HR: 0.54; 95% CI: 0.46-0.65; P value for interaction = 0.008). CONCLUSIONS: An early invasive strategy on the basis of StC time was associated with a decreased risk for all-cause mortality in patients with NSTEMI. Because the study was based on a prospective registry, the results should be considered hypothesis generating, highlighting the need for further research. (iCReaT Study No. C110016).

Impact of intravascular ultrasound in acute myocardial infarction patients at high ischemic risk.

INTRODUCTION AND OBJECTIVES: Evidence for the role of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients at high ischemic risk of acute myocardial infarction (AMI) is lacking. This study aimed to investigate the long-term clinical impact of IVUS-guided PCI in patients at high ischemic risk of AMI. METHODS: Among 13 104 patients with AMI enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we selected 8890 patients who underwent successful PCI with second-generation drug-eluting stent implantation and classified them into 2 groups based on whether or not they were at high ischemic risk or not, defined as any of the following: number of stents implanted ≥ 3, 3 vessels treated, ≥ 3 lesions treated, total stent length> 60mm, left main PCI, diabetes mellitus, and chronic kidney disease. The primary outcome was target lesion failure including cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization at 3 years. RESULTS: In 4070 AMI patients at high ischemic risk, IVUS-guided PCI (21.6%) was associated with a significantly lower risk of target lesion failure at 3 years (6.7% vs 12.0%; HR, 0.54; 95%CI, 0.41-0.72; P <.001) than angiography-guided PCI. The results were consistent after confounder adjustment, inversed probability weighting, and propensity score matching. CONCLUSIONS: In patients at high ischemic risk of AMI who underwent PCI with second-generation drug-eluting stent implantation, use of IVUS guidance was associated with a significant reduction in 3-year target lesion failure. iCreaT study No. C110016.

Red cell distribution width as a prognosticator in patients with heart failure.

AIMS: Increased red cell distribution width (RDW) is a poor prognostic factor in patients with heart failure (HF). However, only a few large-scale studies have identified the clinical utility of RDW after adjusting for covariates affecting RDW. METHODS AND RESULTS: From January 2010 to April 2021, we retrospectively enrolled patients diagnosed with HF from three referral hospitals with available RDW data (taken within 3 months of HF diagnosis) using an integrated clinical data system. Patients with an ejection fraction (EF) < 50% or HFA-PEFF (Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology) score ≥ 2 without severe valvular heart disease or coronary revascularization were enrolled. The primary endpoint was all-cause mortality, and cardiovascular mortality was also collected. Multivariable Cox regression analysis and stabilized inverse probability of treatment weighting (IPTW) were used to identify any association between RDW and all-cause death by balancing covariates or compounding factors. The global χ2 score was calculated and discrimination analysis was performed to evaluate the incremental value of RDW in predicting prognosis. Among the 6599 participants enrolled in this study, 1256 (19.0%) cases of all-cause death occurred, and the median duration of follow-up was 887 (interquartile range 351-1589) days. Elevated RDW at the initial diagnosis was associated with poor prognosis [cumulative incidence: 819 (30.2%) vs. 437 (11.2%), relative risk 1.58, 95% confidence interval (CI) 1.51-1.67, log-rank P < 0.001]. Multivariable Cox analysis showed that elevated RDW was a poor prognostic factor for the primary endpoint [hazard ratio (HR) 1.11, 95% CI 1.06-1.16, P < 0.001], independent of clinical risk factors, N-terminal pro-brain natriuretic peptide (NT-proBNP), and EF, which was concordant with the stabilized IPTW (HR 1.29, 95% CI 1.10-1.49, P < 0.001). Adding RDW to model composed of traditional risk factors, NT-proBNP, and echocardiographic parameters showed incremental prognostic value for predicting poor prognosis (area under the receiver operating characteristic curve, 0.799-0.826; P < 0.001). CONCLUSIONS: Increased RDW at the time of diagnosis is associated with poor prognosis in patients with HF, independent of clinical risk factors, such as NT-proBNP, and echocardiographic parameters. Therefore, RDW may aid in the management of these patients beyond traditional risk factors.

Effects of radiofrequency catheter ablation for premature ventricular complexes originating from the right ventricular outflow tract on right ventricular function.

INTRODUCTION: This study aimed to elucidate the relationship between premature ventricular complexes (PVCs) and right ventricular (RV) dysfunction, and the effects of radiofrequency catheter ablation (RFCA) on RV function. METHODS: A total of 110 patients (age, 50.8 ± 14.4 years; 30 men) without structural heart disease who had undergone RFCA for RV outflow tract (RVOT) PVCs were retrospectively included. RV function was assessed using fractional area change (FAC) and global longitudinal strain (GLS) before and after RFCA. Clinical data were compared between the RV dysfunction (n = 63) and preserved RV function (n = 47) groups. The relationship between PVC burden and RV function was analyzed. Change in RV function before and after RFCA was compared between patients with successful and failed RFCA. RESULTS: PVC burden was significantly higher in the RV dysfunction group than in the preserved RV function group (p < .001). FAC and GLS were significantly worse in proportion to PVC burden (p < .001 and p < .001, respectively). The risk factor associated with RV dysfunction was PVC burden [odds ratio (95% confidence interval), 1.092 (1.052-1.134); p < .001]. Improvement in FAC (13.0 ± 8.7% and -2.5 ± 5.6%, respectively; p < .001) and GLS (-6.8 ± 5.7% and 2.1 ± 4.2%, respectively; p < .001) was significant in the patients with successful RFCA, compared to the patients in whom RFCA failed. CONCLUSIONS: Frequent RVOT PVCs are associated with RV dysfunction. RV dysfunction is reversible by successful RFCA.

Artificial Intelligence-Enabled ECG Algorithm for the Prediction of Coronary Artery Calcification.

Coronary artery calcium (CAC), which can be measured in various types of computed tomography (CT) examinations, is a hallmark of coronary artery atherosclerosis. However, despite the clinical value of CAC scores in predicting cardiovascular events, routine measurement of CAC scores is limited due to high cost, radiation exposure, and lack of widespread availability. It would be of great clinical significance if CAC could be predicted by electrocardiograms (ECGs), which are cost-effective and routinely performed during various medical checkups. We aimed to develop binary classification artificial intelligence (AI) models that predict CAC using only ECGs as input. Moreover, we aimed to address the generalizability of our model in different environments by externally validating our model on a dataset from a different institution. Among adult patients, standard 12-lead ECGs were extracted if measured within 60 days before or after the CAC scores, and labeled with the corresponding CAC scores. We constructed deep convolutional neural network models based on residual networks using only the raw waveforms of the ECGs as input, predicting CAC at different levels, namely CAC score ≥100, ≥400 and ≥1,000. Our AI models performed well in predicting CAC in the training and internal validation dataset [area under the receiver operating characteristics curve (AUROC) 0.753 ± 0.009, 0.802 ± 0.027, and 0.835 ± 0.024 for the CAC score ≥100, ≥400, and ≥1,000 model, respectively]. Our models also performed well in the external validation dataset (AUROC 0.718, 0.777 and 0.803 for the CAC score ≥100, ≥400, and ≥1,000 model, respectively), indicating that our model can generalize well to different but plausibly related populations. Model performance in terms of AUROC increased in the order of CAC score ≥100, ≥400, and ≥1,000 model, indicating that higher CAC scores might be associated with more prominent structural changes of the heart detected by the model. With our AI models, a substantial proportion of previously unrecognized CAC can be afforded with a risk stratification of CAC, enabling initiation of prophylactic therapy, and reducing the adverse consequences related to ischemic heart disease.

Role of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Optimizing Outcomes in Acute Myocardial Infarction.

Background The role of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) is still unclear in patients with acute myocardial infarction acute myocardial infarction. This study aimed to evaluate the long-term impact of IVUS-guided PCI in patients with acute myocardial infarction. Methods and Results Among a total of 13 104 patients with acute myocardial infarction, enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we selected patients who underwent PCI with second-generation drug-eluting stent implantation. The primary outcome was the risk of target lesion failure at 3 years. Among the study population, 1887 patients (21.0%) underwent IVUS-guidance, and 7120 patients (79.0%) underwent angiography-guidance for second-generation drug-eluting stent implantation. IVUS-guided PCI was associated with a significantly lower risk of target lesion failure at 3 years (4.8% versus 8.0%; hazard ratio [HR], 0.59; 95% CI, 0.47 to 0.73; P<0.001) compared with angiography-guided PCI. The difference was driven mainly by a lower risk of cardiac death and target vessel myocardial infarction. The results were consistent after confounder adjustment by multiple sensitivity analyses. Moreover, quartile analysis of volume of IVUS use showed that higher IVUS use was associated with a decreased risk of 3-year target lesion failure (adjusted HR, 0.58; 95% CI, 0.45 to 0.75; P<0.001 for quartile 1 versus 4; P<0.001 for trend comparison across all quartiles). Conclusions In patients with acute myocardial infarction who underwent PCI with second-generation drug-eluting stent implantation, the use of IVUS guidance was associated with a significant reduction in 3-year target lesion failure, mainly driven by hard end points, such as cardiac death and target vessel myocardial infarction.

Clinical Outcomes in Patients With Delayed Hospitalization for Non-ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Recently, the number of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) has reduced, whereas increased mortality was reported. A plausible explanation for increased mortality was prehospital delay because of patients' reticence of their symptoms. OBJECTIVES: The purpose of this study was to investigate the association between prehospital delay and clinical outcomes in patients with NSTEMI METHODS: Among 13,104 patients from the Korea-Acute-Myocardial-Infarction-Registry-National Institutes of Health, the authors evaluated 6,544 patients with NSTEMI. Study patients were categorized into 2 groups according to symptom-to-door (StD) time (<24 or ≥24 hours). The primary outcome was 3-year all-cause mortality, and the secondary outcome was 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure. RESULTS: Overall, 1,827 (27.9%) patients were classified into the StD time ≥24 hours group. The StD time ≥24 hours group had higher all-cause mortality (17.0% vs 10.5%; P < 0.001) and incidence of secondary outcomes (23.3% vs 15.7%; P < 0.001) than the StD time <24 hours group. The higher all-cause mortality in the StD time ≥24 hours group was observed consistently in the subgroup analysis regarding age, sex, atypical chest pain, dyspnea, Q-wave in electrocardiogram, use of emergency medical services, hypertension, diabetes mellitus, chronic kidney disease, left ventricle dysfunction, TIMI (Thrombolysis In Myocardial Infarction) flow, and the GRACE risk score. In the multivariable analysis, independent predictors of prehospital delay were the elderly, women, nonspecific symptoms such as atypical chest pain or dyspnea, diabetes, and no use of emergency medical services. CONCLUSIONS: Prehospital delay is associated with an increased risk of 3-year all-cause mortality in patients with NSTEMI. (iCReaT Study No. C110016).

Clinical Impact of Single and Dual Antiplatelet Therapy Beyond 12 Months on Ischemic Risk in Patients With Acute Myocardial Infarction.

Background: There is ongoing debate regarding the optimal antiplatelet strategy beyond 12 months in patients with acute myocardial infarction (AMI) who undergo successful percutaneous coronary intervention (PCI). This study therefore aimed to investigate the clinical outcomes of single (SAPT) vs. dual antiplatelet therapy (DAPT) beyond 12 months in patients with stable AMI and second-generation drug-eluting stent (DES) implantation. Methods: Of 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health database, we selected 4,604 patients who underwent PCI with second-generation DES and exhibited no adverse clinical events within 12 months; they were classified into SAPT (aspirin or clopidogrel) or DAPT (aspirin and clopidogrel) groups. The primary endpoints were major adverse cardiac and cerebrovascular events (MACCE), including the composite of all-cause death, myocardial infarction (MI), and stroke between 12 and 36 months. Results: The SAPT group (n = 1,862) was associated with a significantly lower risk of MACCE between 12 and 36 months [4.2 vs. 8.5%, hazard ratio (HR): 0.47, 95% confidence interval (CI): 0.37-0.61; p < 0.001] than the DAPT group (n = 2,742). The results were consistent after adjusting for confounders through multivariable and propensity score matching analysis. Moreover, in patients with complex features (defined as an unprotected left main PCI, implanted stent length of ≥38 mm, multivessel PCI, or ≥3 stents per patients), the SAPT group (n = 678) also demonstrated a significantly lower risk of MACCE between 12 and 36 months (4.9 vs. 9.9%, HR: 0.46, CI: 0.31-0.68, p < 0.001) than the DAPT group (n = 1,167). Conclusions: In patients with AMI who underwent successful PCI with second-generation DES and exhibited no adverse clinical events within 12 months, the use of SAPT was associated with a significantly lower MACCE between 12 and 36 months compared with the use of DAPT.

Usefulness of Diastolic Function Score as a Predictor of Long-Term Prognosis in Patients With Acute Myocardial Infarction.

Background: Left ventricular diastolic function (LVDF) evaluation using a combination of several echocardiographic parameters is an important predictor of adverse events in patients with acute myocardial infarction (AMI). To date, the clinical impact of each individual LVDF marker is well-known, but the clinical significance of the sum of the abnormal diastolic function markers and the long-term clinical outcome are not well-known. This study aimed to investigate the usefulness of LVDF score in predicting clinical outcomes of patients with AMI. Methods: LVDF scores were measured in a 2,030 patients with AMI who underwent successful percutaneous coronary intervention from 2012 to 2015. Four LVDF parameters (septal e' ≥ 7 cm/s, septal E/e' ≤ 15, TR velocity ≤ 2.8 m/s, and LAVI ≤ 34 ml/m2) were used for LVDF scoring. The presence of each abnormal LVDF parameter was scored as 1, and the total LVDF score ranged from 0 to 4. Mortality and hospitalization due to heart failure (HHF) in relation to LVDF score were evaluated. To compare the predictive ability of LVDF scores and left ventricular ejection fraction (LVEF) for mortality and HHF, receiver operating characteristic (ROC) curve and landmark analyses were performed. Results: Over the 3-year clinical follow-up, all-cause mortality occurred in 278 patients (13.7%), while 91 patients (4.5%) developed HHF. All-cause mortality and HHF significantly increased as LVDF scores increased (all-cause mortality-LVDF score 0: 2.3%, score 1: 8.8%, score 2: 16.7%, score 3: 31.8%, and score 4: 44.5%, p < 0.001; HHF-LVDF score 0: 0.6%, score 1: 1.8%, score 2: 6.3%, score 3: 10.3%, and score 4: 18.2%, p < 0.001). In multivariate analysis, a higher LVDF score was associated with significantly higher adjusted hazard ratios for all-cause mortality and HHF. In landmark analysis, LVDF score was a better predictor of long-term mortality than LVEF (area under the ROC curve: 0.739 vs. 0.640, p < 0.001). Conclusion: The present study demonstrated that LVDF score was a significant predictor of mortality and HHF in patients with AMI. LVDF scores are useful for risk stratification of patients with AMI; therefore, careful monitoring and management should be performed for patients with AMI with higher LVDF scores.

Impact of cardiovascular disease and risk factors on fatal outcomes in patients with COVID-19 according to age: a systematic review and meta-analysis.

OBJECTIVE: Previous studies that evaluated cardiovascular risk factors considered age as a potential confounder. We aimed to investigate the impact of cardiovascular disease (CVD) and its risk factors on fatal outcomes according to age in patients with COVID-19. METHODS: A systematic literature review and meta-analysis was performed on data collected from PubMed and Embase databases up to 11 June 2020. All observational studies (case series or cohort studies) that assessed in-hospital patients were included, except those involving the paediatric population. Prevalence rates of comorbid diseases and clinical outcomes were stratified by mean patient age in each study (ranges: <50 years, 50-60 years and ≥60 years). The primary outcome measure was a composite fatal outcome of severe COVID-19 or death. RESULTS: We included 51 studies with a total of 48 317 patients with confirmed COVID-19 infection. Overall, the relative risk of developing severe COVID-19 or death was significantly higher in patients with risk factors for CVD (hypertension: OR 2.50, 95% CI 2.15 to 2.90; diabetes: 2.25, 95% CI 1.89 to 2.69) and CVD (3.11, 95% 2.55 to 3.79). Younger patients had a lower prevalence of hypertension, diabetes and CVD compared with older patients; however, the relative risk of fatal outcomes was higher among the former. CONCLUSIONS: The results of the meta-analysis suggest that CVD and its risk factors (hypertension and diabetes) were closely related to fatal outcomes in COVID-19 for patients across all ages. Although young patients had lower prevalence rates of cardiovascular comorbidities than elderly patients, relative risk of fatal outcome in young patients with hypertension, diabetes and CVD was higher than in elderly patients. PROSPERO REGISTRATION NUMBER: CRD42020198152.