Depression and Subclinical Coronary Atherosclerosis in Adults Without Clinical Coronary Artery Disease.

BACKGROUND: The relationship between depression and subclinical coronary atherosclerosis in asymptomatic individuals is not clear. We evaluated this relationship in a Korean population. METHODS AND RESULTS: We analyzed 3920 individuals (mean age 54.7±7.9 years and 2603 men [66.4%]) with no history of coronary artery disease who voluntarily underwent coronary computed tomographic angiography and screening for depression using the Beck Depression Inventory as part of a general health examination. The degree and extent of subclinical coronary atherosclerosis were evaluated by coronary computed tomographic angiography, and ≥50% diameter stenosis was defined as significant. Participants were categorized into groups of those with or without depression using the Beck Depression Inventory scores ≥16 as a cutoff value. Of the study participants, 272 (6.9%) had a Beck Depression Inventory score of 16 or higher. After adjustment for cardiovascular risk factors, depression was not significantly associated with any coronary plaque (adjusted odds ratio [OR], 1.05 [95% CI, 0.78-1.41]; P=0.746), calcified plaque (OR, 0.95 [95% CI, 0.71-1.29]; P=0.758), noncalcified plaque (OR, 1.31 [95% CI, 0.79-2.17]; P=0.305), mixed plaque (OR, 1.16 [95% CI, 0.60-2.23]; P=0.659), or significant coronary artery stenosis (OR, 1.22 [95% CI, 0.73-2.03]; P=0.450). In the propensity score-matched population (n=1318) as well, none of the coronary artery disease measures of subclinical coronary atherosclerosis were statistically significantly associated with depression (all P>0.05). CONCLUSIONS: In this large cross-sectional study with asymptomatic individuals undergoing coronary computed tomographic angiography and Beck Depression Inventory evaluation, depression was not associated with an increased risk of subclinical coronary atherosclerosis.

Differential Impact of Degree of Hypertension on Subclinical Coronary Atherosclerosis in Asymptomatic Subjects With and Without Diabetes Mellitus.

This study sought to evaluate the association between the degree of hypertension and subclinical coronary atherosclerosis in asymptomatic subjects with and without diabetes mellitus (DM). We retrospectively analyzed 7,352 asymptomatic subjects (mean age 52.8 ± 7.8 years; 4,689 [63.8%] men) with no history of coronary artery disease who voluntarily underwent coronary computed tomography angiography as part of a general health examination. The classification of hypertension was adapted from the American College of Cardiology and American Heart Association 2017 guideline. Subclinical coronary atherosclerosis was defined as the presence of coronary plaque by coronary computed tomography angiography. In subjects without DM (n = 6,598), after the adjustment for cardiovascular risk factors, subclinical coronary atherosclerosis was significantly associated with both stage 1 hypertension (adjusted odds ratio [aOR] 1.356; 95% confidence interval [CI], 1.167 to 1.575; p <0.001) and stage 2 hypertension (aOR, 1.614; 95% CI, 1.329 to 1.961; p <0.001) groups compared with the normal group. In contrast, in subjects with DM (n = 754), there was no statistical difference in the aOR of the stage 1 hypertension group for the presence of coronary plaque (aOR, 1.449; 95% CI, 0.982 to 2.136; p = 0.061). However, the stage 2 hypertension group had a significant association with subclinical coronary atherosclerosis (aOR, 2.067; 95% CI, 1.287 to 3.322; p = 0.003). In subjects without DM, both stages 1 and 2 hypertension were associated with subclinical coronary atherosclerosis. However, in subjects with DM, stage 2 hypertension was only associated with an increased risk of subclinical coronary atherosclerosis.

Prediction of the 10-year risk of atherosclerotic cardiovascular disease in the Korean population.

OBJECTIVES: Proper risk assessment is important for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, no validated risk prediction tools are currently in use in Korea. This study sought to develop a 10-year risk prediction model for incident ASCVD. METHODS: Using the National Sample Cohort of Korea, 325,934 subjects aged 20-80 years without previous ASCVD were enrolled. ASCVD was defined as a composite of cardiovascular death, myocardial infarction, and stroke. The Korean atherosclerotic cardiovas cular disease risk prediction (K-CVD) model was developed separately for men and women using the development dataset and validated in the validation dataset. Furthermore, the model performance was compared with the Framingham risk score (FRS) and pooled cohort equation (PCE). RESULTS: Over 10 years of follow-up, 4,367 ASCVD events occurred in the overall population. The predictors of ASCVD included in the model were age, smoking status, diabetes, systolic blood pressure, lipid profiles, urine protein, and lipid-lowering and blood pressure-lowering treatment. The K-CVD model had good discrimination and strong calibration in the validation dataset (time-dependent area under the curve=0.846; 95% confidence interval, 0.828 to 0.864; calibration χ2=4.73, goodness-of-fit p=0.32). Compared with our model, both FRS and PCE showed worse calibration, overestimating ASCVD risk in the Korean population. CONCLUSIONS: Through a nationwide cohort, we developed a model for 10-year ASCVD risk prediction in a contemporary Korean population. The K-CVD model showed excellent discrimination and calibration in Koreans. This population-based risk prediction tool would help to appropriately identify high-risk individuals and provide preventive interventions in the Korean population.

Comprehensive Prediction of Subclinical Coronary Atherosclerosis in Subjects Without Traditional Cardiovascular Risk Factors.

It is not uncommon for asymptomatic individuals without identified cardiovascular risk factors to present with atherosclerosis-related adverse events. We aimed to evaluate the predictors of subclinical coronary atherosclerosis in individuals without traditional cardiovascular risk factors. We analyzed 2,061 individuals without identified cardiovascular risk factors who voluntarily underwent coronary computed tomography angiography as part of a general health examination. Subclinical atherosclerosis was defined as the presence of any coronary plaque. Of 2,061 individuals, subclinical atherosclerosis was observed in 337 individuals (16.4%). Clinical variables, such as age, gender, body mass index (BMI), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C), were significantly associated with subclinical coronary atherosclerosis. The participants were randomly split into train and validation data sets. In the train set, a prediction model using 6 variables with optimal cutoffs (age >53 years for men and >55 years for women, gender, BMI >22 kg/m2, SBP >120 mm Hg, HDL-C <55 mg/100 ml, and LDL-C >130 mg/100 ml) was derived (area under the curve 0.780, 95% confidence interval 0.751 to 0.809, goodness-of-fit p = 0.693). In the validation set, this model performed well (area under the curve 0.792, 95% confidence interval 0.726 to 0.858, goodness-of-fit p = 0.073). In conclusion, together with nonmodifiable risk factors, such as age and gender, modifiable variables, such as BMI, SBP, LDL-C, and HDL-C, were shown to be associated with subclinical coronary atherosclerosis, even at currently acceptable levels. These results suggest that stricter control of BMI, blood pressure, and cholesterol might be helpful in the primary prevention of future coronary events.

Oral anticoagulants and concurrent rifampin administration in tuberculosis patients with non-valvular atrial fibrillation.

BACKGROUND: Evidence and guidelines for Non-vitamin K antagonist oral anticoagulants (NOACs) use when prescribing concurrent rifampin for tuberculosis treatment in patients with non-valvular atrial fibrillation (NVAF) are limited. METHODS: Using the Korean National Health Insurance Service database from January 2009 to December 2018, we performed a population-based retrospective cohort study to assess the net adverse clinical events (NACE), a composite of ischemic stroke or systemic embolism and major bleeding, of NOACs compared with warfarin among NVAF patients taking concurrent rifampin administration for tuberculosis treatment. After a propensity matching score (PSM) analysis, Cox proportional hazards regression was performed in matched cohorts to investigate the clinical outcomes. RESULTS: Of the 735 consecutive patients selected, 465 (63.3%) received warfarin and 270 (36.7%) received NOACs. Among 254 pairs of patients after PSM, the crude incidence rate of NACE was 25.6 in NOAC group and 32.8 per 100 person-years in warfarin group. There was no significant difference between NOAC and warfarin use in NACE (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.48-1.14; P = 0.172). Major bleeding was the main driver of NACE, and NOAC use was associated with a statistically significantly lower risk of major bleeding than that with warfarin use (HR, 0.63; 95% CI, 0.40-1.00; P = 0.0499). CONCLUSIONS: In our population-based study, there was no statically significant difference in the occurrence of NACE between NOAC and warfarin use. NOAC use may be associated with a lower risk of major bleeding than that with warfarin use.

Serum phosphorus and subclinical coronary atherosclerosis in asymptomatic subjects without kidney dysfunction.

BACKGROUND AND AIMS: There is limited data on the association between serum phosphorus concentration (SPC) and subclinical coronary atherosclerosis in low-risk asymptomatic subjects without kidney dysfunction. MATERIALS AND METHODS: We retrospectively analyzed 1,636 Korean individuals (mean age 52.6 ± 7.6 years; males: 712 (43.5%)) without traditional cardiovascular risk factors (CVRFs) and kidney dysfunction who voluntarily underwent coronary computed tomography angiography (CCTA) as part of a general health examination. Traditional CVRFs were defined as follows: systolic/diastolic blood pressure ≥ 140/90 mmHg, fasting blood glucose ≥ 126 mg/dL, hemoglobin A1c ≥ 6.5%, total cholesterol ≥ 240 mg/dL, low-density lipoprotein cholesterol ≥ 160 mg/dL, high-density lipoprotein cholesterol < 40 mg/dL, body mass index ≥ 25.0 kg/m2, currently smoking, and medical history of hypertension, diabetes, and hyperlipidemia. Study participants were stratified into tertiles according to their SPC levels (≤ 3.2, 3.3 - 3.6, and ≥ 3.7 mg/dL). RESULTS: 297 (18.2%) study participants had subclinical coronary atherosclerosis, characterized by any coronary plaque on CCTA. In multivariable regression analysis, the risk of subclinical coronary atherosclerosis increased in the second (odds ratio (OR): 1.629; 95% confidence interval (CI): 1.149 - 2.308; p = 0.006) and third (OR: 1.645; 95% CI: 1.093 - 2.476; p = 0.017) SPC tertiles compared to the first SPC tertile. In addition, the risk of calcified plaque increased in the second (OR: 1.605; 95% CI: 1.124 - 2.292; p = 0.009) and third (OR 1.790; 95% CI 1.179 - 2.716; p = 0.006) SPC tertiles. CONCLUSION: In low-risk asymptomatic Korean individuals without kidney dysfunction, a higher SPC level was an independent predictor of subclinical coronary atherosclerosis.

Marital Status and Subclinical Coronary Atherosclerosis in Asymptomatic Individuals.

Background Data are limited on the association between marital status and subclinical coronary atherosclerosis. This study investigated the influence of marital status on subclinical coronary atherosclerosis detected by coronary computed tomographic angiography in an asymptomatic population. Methods and Results This retrospective study analyzed 9288 asymptomatic individuals (mean age, 53.7±8.0 years; 6041 [65%] men) with no history of coronary artery disease who voluntarily underwent coronary computed tomographic angiography during a general health examination. Marital categories were married (n=8481) versus unmarried (n=807), comprising never married (n=195), divorced (n=183), separated (n=119), and widowed (n=310) individuals. The degree and extent of subclinical coronary atherosclerosis were evaluated by coronary computed tomographic angiography; ≥50% diameter stenosis was defined as significant. Logistic regression and propensity score matching analyses were used to determine the association between marital status and subclinical coronary atherosclerosis. After adjustment for cardiovascular risk factors, no significant differences were observed in the adjusted odds ratio (OR) of unmarried status for any coronary plaque (OR, 1.077; 95% CI, 0.899-1.291), calcified plaque (OR, 1.058; 95% CI, 0.881-1.271), noncalcified plaque (OR, 0.966; 95% CI, 0.691-1.351), mixed plaque (OR, 1.301; 95% CI, 0.884-1.917), and significant coronary artery stenosis (OR, 1.066; 95% CI, 0.771-1.474). Similarly, in the 2:1 propensity-score matched population (n=2398), no statistically significant differences were observed for the OR of marital status for any subclinical coronary atherosclerosis (P>0.05 for all). Conclusions In this large cross-sectional study, marital status was not associated with an increased risk of subclinical coronary atherosclerosis.

Lipoprotein(a) and subclinical coronary atherosclerosis in asymptomatic individuals.

BACKGROUND AND AIMS: There are limited data regarding the association between lipoprotein(a) (Lp[a]) and subclinical coronary atherosclerosis. This study investigated the association between Lp(a) and subclinical coronary atherosclerosis detected by coronary computed tomographic angiography (CCTA) in an asymptomatic population. METHODS: We retrospectively analyzed 7201 asymptomatic individuals (mean age 54.4 ± 7.9 years; 65.3% men with no prior history of coronary artery disease who voluntarily underwent CCTA as part of a general health examination). The degree and extent of subclinical coronary atherosclerosis were evaluated by CCTA. Study participants were stratified into quartiles according to their Lp(a) levels (<4.3, 4.3-8.9, 9.0-20.1, and ≥20.2 mg/dL). RESULTS: Of the study participants, any coronary plaque on CCTA was observed in 2557 (35.5%). Specifically, calcified, non-calcified, and mixed plaques were observed in 2411 (33.5%), 363 (5.0%) and 249 (3.5%) participants, respectively. After adjustment for the presence of cardiovascular risk factors, the fourth Lp(a) quartile was significantly associated with any coronary (odds ratio [OR] 1.212; 95% confidence interval [CI] 1.038-1.416), calcified (1.205, 95% CI 1.030-1.410), non-calcified (1.588, 95% CI 1.152-2.189), or mixed (1.674, 95% CI 1.172-2.391) plaque compared with the first Lp(a) quartile. In addition, 442 (6.1%) had significant coronary artery stenosis (≥50% diameter stenosis). The odds ratio for significant stenosis (1.537, 95% CI 1.153-2.048) was higher in the fourth quartile compared with the first quartile. CONCLUSIONS: In this large cross-sectional study with asymptomatic individuals undergoing CCTA, higher Lp(a) level was associated with subclinical coronary atherosclerosis.

Ticagrelor versus prasugrel in patients with acute myocardial infarction.

BACKGROUND: Ticagrelor and prasugrel are the mainstay of antithrombotic therapy for patients with acute myocardial infarction (MI). However, direct comparative data on clinical outcomes of potent P2Y12 inhibitors are limited, especially in East Asian populations. We aimed to evaluate the effect of ticagrelor versus prasugrel on clinical outcomes in patients with acute MI. METHODS: From the Korean nationwide National Health Insurance database, 10,797 patients with acute MI who received either ticagrelor or prasugrel in combination with aspirin after percutaneous coronary intervention (PCI) were enrolled. The primary outcome was net clinical benefit, defined as a composite of death, MI, stroke, or major bleeding. Secondary outcomes included the individual components of the primary outcome as effectiveness and safety measures. RESULTS: Among 10,797 patients, 9591 (88.8%) received ticagrelor and 1206 (11.2%) received prasugrel. During a median follow-up of 1.8 years, the primary outcome occurred in 1051 (16.6%) and 131 (14.4%) patients in the ticagrelor and prasugrel groups, respectively. In the propensity score matched cohort (n = 5979), the risk for the primary outcome was similar between the two groups (hazard ratio [HR] 0.949 for prasugrel; 95% confidence interval [CI]: 0.780-1.154). The risks for the composite of death, MI, or stroke (HR 0.938; 95% CI: 0.752-1.169) and major bleeding (HR 1.022; 95% CI: 0.709-1.472) were also comparable. CONCLUSIONS: In patients with acute MI undergoing PCI, ticagrelor and prasugrel appeared to have similar net clinical benefits. The risks for death, MI, or stroke and major bleeding were not significantly different between the two groups.

Frequency and Significance of Right Bundle Branch Block and Subclinical Coronary Atherosclerosis in Asymptomatic Individuals.

Limited data exist regarding the association between right bundle branch block (RBBB) and subclinical coronary atherosclerosis. This study investigated the influence of RBBB on subclinical coronary atherosclerosis detected by coronary computed tomographic angiography (CCTA) in an asymptomatic population. We retrospectively analyzed 7,205 asymptomatic individuals (mean age 54.4 ± 7.9 years and 4,695 men [65.2%]) with no prior history of coronary artery disease who voluntarily underwent CCTA and 12-lead electrocardiographic evaluation as part of a general health examination. The degree and extent of subclinical coronary atherosclerosis were evaluated by CCTA, and ≥50% diameter stenosis was defined as significant. The association between RBBB and subclinical coronary atherosclerosis was determined by logistic regression and propensity score matching analyses. Of study participants, 116 (1.6%) had RBBB. After adjustment for cardiovascular risk factors, there were no statistically significant differences in the adjusted odds ratios of RBBB for any atherosclerotic plaque (0.87, 95% confidence interval [CI] 0.57 to 1.32), calcified plaque (0.78, 95% CI 0.51 to 1.19), noncalcified plaque (1.44, 95% CI 0.77 to 2.69), mixed plaque (1.12, 95% CI 0.52 to 2.39), and significant coronary artery stenosis (0.92, 95% CI 0.48 to 1.74). Similarly, in the 5: 1 propensity score-matched population (n = 696), there were no statistically significant differences in the odds ratios for any subclinical coronary atherosclerosis between participants with and without RBBB (p for all >0.05). In conclusion, through this large cross-sectional study of asymptomatic individuals who underwent CCTA and electrocardiography evaluation, individuals with RBBB were not associated with an increased risk of subclinical coronary atherosclerosis compared with those without RBBB.

Cholesterol Control for Subclinical Coronary Atherosclerosis in Subjects Without Indication for Statin Therapy.

Low-risk individuals still experience adverse cardiac events. We sought to evaluate long-term cardiac events and predictors for subclinical coronary atherosclerosis in subjects without indication for statin therapy. We analyzed 3,272 individuals without indication for statin therapy who voluntarily underwent coronary computed tomography angiography as part of a general health examination. A cardiac event was defined as a composite of cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or late coronary revascularization. The prevalence of normal coronary arteries, nonobstructive coronary artery disease (CAD) (diameter stenosis < 50%), and obstructive CAD (diameter stenosis ≥50%) was 2,338 (71.5%), 809 (24.7%), and 125 (3.8%), respectively. During the follow-up period (median 5.3 [interquartile range, 4.3-6.3] years), the 6-year event-free survival rates were 99.2%±0.2% in subjects with normal coronary arteries, 98.2%±0.6% in those with nonobstructive CAD, and 90.2%±2.7% in those with obstructive CAD (log-rank p < 0.001). Multivariable regression analysis showed that low-density lipoprotein cholesterol (LDL-C, odds ratio [OR]: 1.012; 95% confidence interval (CI): 1.005-1.019) and high-density lipoprotein cholesterol (HDL-C, OR: 0.968; 95% CI: 0.952-0.984) levels were associated with subclinical obstructive CAD, together with age (OR: 1.080; 95% CI: 1.040-1.121) and male sex (OR: 3.102; 95% CI: 1.866-5.155) (all p < 0.05). In conclusion, LDL-C and HDL-C are significantly associated with the presence of subclinical obstructive CAD with a worse prognosis in subjects without indication for statin therapy. These findings suggest that stricter control of LDL-C and HDL-C levels may be necessary for primary prevention even in a relatively low-risk population.

Pre-existing depression in patients with coronary artery disease undergoing percutaneous coronary intervention.

The impact of pre-existing depression on mortality in individuals with established coronary artery disease (CAD) remains unclear. We evaluate the clinical implications of pre-existing depression in patients who underwent percutaneous coronary intervention (PCI). Based on National Health Insurance claims data in Korea, patients without a known history of CAD who underwent PCI between 2013 and 2017 were enrolled. The study population was divided into patients with angina (n = 50,256) or acute myocardial infarction (AMI; n = 40,049). The primary endpoint, defined as all-cause death, was compared between the non-depression and depression groups using propensity score matching analysis. After propensity score matching, there were 4262 and 2346 matched pairs of patients with angina and AMI, respectively. During the follow-up period, there was no significant difference in the incidence of all-cause death in the angina (hazard ratio [HR] of depression, 1.013; 95% confidence interval [CI] 0.893-1.151) and AMI (HR, 0.991; 95% CI 0.865-1.136) groups. However, angina patients less than 65 years of age with depression had higher all-cause mortality (HR, 1.769; 95% CI 1.240-2.525). In Korean patients undergoing PCI, pre-existing depression is not associated with poorer clinical outcomes. However, in younger patients with angina, depression is associated with higher all-cause mortality.

Association between nonalcoholic fatty liver disease and cardiovascular disease revealed after comprehensive control of metabolic risk factors: a nationwide population-based study in Korea.

OBJECTIVES: Previous epidemiological studies have limitations in revealing whether cardiovascular disease (CVD) incidence is mediated by interim occurrence of other metabolic diseases in otherwise healthy nonalcoholic fatty liver disease (NAFLD) patients. METHODS: The study population consisted of 334 280 healthy subjects who had had the National Health check-ups in South Korea from 2009 to 2014. The fatty liver index (FLI) was used to identify subjects with NAFLD. CVD was defined as occurrence of a composite of cardiovascular death, myocardial infarction, ischemic stroke, or coronary revascularization. The association between FLI and CVD incidence was analyzed using time-dependent Cox regression analyses. RESULTS: The study population was categorized into quartile groups according to FLI (range: Q1, 0-4.9; Q2, 5.0-12.5; Q3, 12.6-31.0; Q4, >31.0). The median follow-up duration was 5.4 years, during which subjects with higher FLIs experienced CVD more frequently than did those with lower FLIs [Q1, 215 (0.3%); Q2, 498 (0.6%); Q3, 753 (0.9%); Q4, 981 (1.2%); P < 0.001]. Adjustment of baseline characteristics revealed that a higher FLI was independently associated with an increased risk for CVD [hazard ratio between Q4 and Q1, 1.86; 95% confidence interval (CI), 1.59-2.17; P < 0.001]. The association between them remained statistically significant (hazard ratio between Q4 and Q1, 1.92; 95% CI, 1.63-2.25; P < 0.001) after further adjustment for the interim events (diabetes, hypertension, heart failure, and atrial fibrillation). CONCLUSIONS: Otherwise healthy NAFLD patients progressed to develop CVD independently of the interim occurrence of other metabolic diseases, which emphasizes the importance of NAFLD as a potential therapeutic target for prevention of CVD.

Comparison of new implantation of cardiac implantable electronic device between tertiary and non-tertiary hospitals: a Korean nationwide study.

This study compared the characteristics and mortality of new implantation of cardiac implantable electronic device (CIED) between tertiary and non-tertiary hospitals. From national health insurance claims data in Korea, 17,655 patients, who underwent first and new implantation of CIED between 2013 and 2017, were enrolled. Patients were categorized into the tertiary hospital group (n = 11,560) and non-tertiary hospital group (n = 6095). Clinical outcomes including in-hospital death and all-cause death were compared between the two groups using propensity-score matched analysis. Patients in non-tertiary hospitals were older and had more comorbidities than those in tertiary hospitals. The study population had a mean follow-up of 2.1 ± 1.2 years. In the propensity-score matched permanent pacemaker group (n = 5076 pairs), the incidence of in-hospital death (odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.43-1.32, p = 0.33) and all-cause death (hazard ratio [HR]: 0.92, 95% CI 0.81-1.05, p = 0.24) were not significantly different between tertiary and non-tertiary hospitals. These findings were consistently observed in the propensity-score matched implantable cardioverter-defibrillator group (n = 992 pairs, OR for in-hospital death: 1.76, 95% CI 0.51-6.02, p = 0.37; HR for all-cause death: 0.95, 95% CI 0.72-1.24, p = 0.70). In patients undergoing first and new implantation of CIED in Korea, mortality was not different between tertiary and non-tertiary hospitals.

Hospital-level variation in follow-up strategies after percutaneous coronary intervention, revealed in health claims data of Korea.

This study sought to determine hospital variation in the use of follow-up stress testing (FUST) and invasive coronary angiography (FUCAG) after percutaneous coronary intervention (PCI). The claims records of 150,580 Korean patients who received PCI in 128 hospitals between 2008 and 2015 were analyzed. Patient were considered to have undergone FUST and FUCAG, when these testings were performed within two years after discharge from the index hospitalization. Hierarchical generalized linear and frailty models were used to evaluate binary and time-to-event outcomes. Hospital-level risk-standardized FUCAG and FUST rates were highly variable across the hospitals (median, 0.41; interquartile range [IQR], 0.27-0.59; median, 0.22; IQR, 0.08-0.39, respectively). The performances of various models predicting the likelihood of FUCAG and FUST were compared, and the best performance was observed with the models adjusted for patient case mix and individual hospital effects as random effects (receiver operating characteristic curves, 0.72 for FUCAG; 0.82 for FUST). The intraclass correlation coefficients of the models (0.41 and 0.68, respectively) indicated that a considerable proportion of the observed variation was related to individual institutional effects. Higher hospital-level FUCAG and FUST rates were not preventive of death or myocardial infarction. Increased repeat revascularizations were observed in hospitals with higher FUCAG rates.

Right bundle branch block-type wide QRS complex tachycardia with a reversed R/S complex in lead V6: Development and validation of electrocardiographic differentiation criteria.

BACKGROUND: Differentiation of supraventricular tachycardia (SVT) with a right bundle branch block (RBBB) pattern from ventricular tachycardia (VT) is difficult, particularly when the R/S ratio in lead V6 is below 1.0. OBJECTIVE: We sought to investigate the electrocardiographic criteria for distinguishing between these arrhythmias. METHODS: We investigated electrocardiographic parameters from 111 consecutive patients who had RBBB pattern wide QRS complex tachycardia with a reversed R/S ratio in lead V6 (72 VTs, 39 SVTs). Diagnostic criteria from the previous algorithms were compared with our new criterion, the RS/QRS ratio, which was defined as the ratio of the interval from the onset of the QRS complex to the nadir of the S wave, divided by the QRS width in lead V6. The RS/QRS ratio was further tested in a prospective population (31 fascicular VTs, 29 SVTs). RESULTS: The diagnostic accuracy of previous criteria (Brugada algorithm, Vereckei algorithm, and R-wave peak time criterion) was only modest. However, the RS/QRS ratio in lead V6 was significantly lower in SVT than in VT (0.36 ± 0.04 vs 0.50 ± 0.08; P < .001). A cutoff value of the RS/QRS ratio >0.41 differentiated VT from SVT with a high diagnostic accuracy (sensitivity 97.2%; specificity 89.7%). When tested in a prospective population with fascicular VT, the diagnostic accuracy of the criteria was maintained (sensitivity 90.3%; specificity 86.2%). CONCLUSION: The RS/QRS ratio >0.41 in lead V6 is a simple and reliable index for distinguishing VT from SVT in RBBB pattern wide QRS complex tachycardia with a reversed R/S complex in lead V6. This criterion was particularly useful for the differential diagnosis of fascicular VT from RBBB pattern SVT.

Angiotensin-Converting Enzyme Inhibitor-based Versus Angiotensin Receptor Blocker-based Optimal Medical Therapy After Percutaneous Coronary Intervention: A Nationwide Cohort Study.

ABSTRACT: Optimal medical therapy (OMT) plays a crucial role in the secondary prevention of established coronary artery disease. The renin-angiotensin system (RAS) is an important target of OMT. However, there is limited evidence on whether there is any difference in the combined effect of OMT according to the classes of RAS blockade [angiotensin-converting enzyme inhibitor (ACEI) vs. angiotensin receptor blocker (ARB)]. Based on the nationwide National Health Insurance database in South Korea, 39,096 patients who received OMT after percutaneous coronary intervention between July 2013 and June 2017 were enrolled. Patients were stratified into either acute myocardial infarction (AMI) or angina cohort and analyzed according to the class of RAS blockade included in OMT at discharge (ACEI vs. ARB). The primary end point was all-cause mortality. The study population had a median follow-up of 2.3 years (interquartile range, 1.3-3.3 years). In the propensity score-matched AMI cohort (8219 pairs), the risk for all-cause mortality was significantly lower in patients with ACEI-based OMT than in those with ARB-based OMT (hazard ratio 0.83 of ACEI, 95% confidence interval 0.73-0.94, P = 0.003). However, in the propensity score-matched angina cohort (6693 pairs), the mortality risk was comparable, regardless of the class of RAS blockade (hazard ratio 1.13, 95 confidence interval 0.99-1.29, P = 0.08). In conclusion, in this nationwide cohort study involving patients receiving OMT after percutaneous coronary intervention, ACEI-based OMT was associated with a significantly lower risk of all-cause mortality in patients with AMI in comparison with ARB, but not in those with angina.

Beta-blockers provide a differential survival benefit in patients with coronary artery disease undergoing contemporary post-percutaneous coronary intervention management.

Beta-adrenergic receptor blockers are used in patients with coronary artery disease (CAD) to reduce the harmful effects of excessive adrenergic activation on the heart. However, there is limited evidence regarding the benefit of beta-blockers in the context of contemporary management following percutaneous coronary intervention (PCI). We used the nationwide South Korea National Health Insurance database to identify 87,980 patients with a diagnosis of either acute myocardial infarction (AMI; n = 38,246) or angina pectoris (n = 49,734) who underwent PCI between 2013 and 2017, and survived to be discharged from hospital. Beta-blockers were used in a higher proportion of patients with AMI (80.6%) than those with angina (58.9%). Over a median follow-up of 2.2 years (interquartile range 1.2-3.3 years) with the propensity-score matching analysis, the mortality risk was significantly lower in patients treated with a beta-blocker in the AMI group (HR: 0.78; 95% CI 0.69-0.87; p < 0.001). However, the mortality risk was comparable regardless of beta-blocker use (HR: 1.07; 95% CI 0.98-1.16; p = 0.10) in the angina group. The survival benefit associated with beta-blocker therapy was most significant in the first year after the AMI event.

Association of gamma-glutamyl transferase with subclinical coronary atherosclerosis and cardiac outcomes in non-alcoholics.

In an asymptomatic population, we determined the relationship between serum gamma-glutamyl transferase (GGT) and subclinical atherosclerosis, using coronary computed tomography angiography (CCTA). This was a retrospective observational cohort study which analyzed 5120 consecutive asymptomatic individuals with no prior history of coronary artery disease or significant alcohol intake who voluntarily underwent CCTA as part of a general health examination. All subjects were stratified into tertiles based on GGT levels. Degree and extent of subclinical coronary atherosclerosis were evaluated using CCTA. Cardiac events were a composite of all-cause death, myocardial infarction, unstable angina, and coronary revascularization. After adjustment for cardiovascular risk factors, there were no significant differences among GGT tertiles in terms of adjusted odds ratios for non-calcified and mixed plaques. The risk of any atherosclerotic and calcified plaques, significant stenosis, multi-vessel disease, and significant stenosis in the left main or proximal left anterior descending artery was higher in the third GGT tertile than in the first tertile (all p < 0.05). Over a median 5.4-year follow-up, the third GGT tertile had significant adjusted hazards ratios for cardiac events than did the first GGT tertile, even after stepwise adjustment for cardiovascular risk factors (all p < 0.01). In asymptomatic individuals, elevated GGT was independently associated with high-risk feature atherosclerosis and poorer cardiac outcomes.