J-curve relationship between corrected QT interval and mortality in acute heart failure patients

BACKGROUND/AIMS

This study investigated the prognostic power of corrected QT (QTc) interval in patients with acute heart failure (AHF) according to sex.

METHODS

We analyzed multicenter Korean Acute Heart Failure registry with patients with AHF admitted from 2011 to 2014. Among them, we analyzed 4,990 patients who were followed up to 5 years. Regarding QTc interval based on 12 lead electrocardiogram, patients were classified into quartiles according to sex.

RESULTS

During follow-up with median 43.7 months, 2,243 (44.9%) patients died. The relationship between corrected QT interval and all-cause mortality followed a J-curve relationship. In Kaplan-Meier analysis, both sex had lowest mortality in the second QTc quartile. There were significant prognostic differences between the second and the fourth quartiles in male (log-rank p = 0.002), but not in female (log-rank p = 0.338). After adjusting covariates, the third (hazard ratio [HR], 1.185; 95% confidence interval [CI], 1.001 to 1.404; p = 0.049) and the fourth (HR, 1.404; 95% CI, 1.091 to 1.535; p = 0.003) quartiles demonstrated increased risk of mortality compared to the second quartile in male. In female, however, there was no significant difference across quartiles. QTc interval was associated with 5-year all-cause mortality in J-shape with nadir of 440 to 450 ms in male and 470 to 480 ms in female.

CONCLUSION

QTc interval was an independent predictor of overall death in male, but its significance decreased in female. The relationship between QTc interval and all-cause mortality was J-shaped in both sex.

Impact of Intensive Glucose Control in Patients with Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: 3-Year Clinical Outcomes

We investigated whether intensive glucose control after percutaneous coronary intervention (PCI) improves clinical outcomes in diabetic patients. From the Grand-DES registry, we analyzed 2576 diabetic patients (median age 66 years, male 65.6%) who underwent PCI and had at least 2 records of HbA1c during the follow-up. Patients were categorized according to the mean HbA1c (≥7% or <7%). Primary outcome was major adverse cardiovascular event (MACE), a composite of cardiac death, non-fatal myocardial infarction, and any revascularization. During a median follow-up of 33.6 months, MACE occurred in 335 (13.0%) patients. Intensive glucose control with follow-up mean HbA1c < 7.0% (42.2%; n = 1087) was not associated with lower risk of MACE, compared to control with mean HbA1c ≥ 7.0% (adjusted hazard ratio [aHR] [95% confidence interval] 1.06 [0.82–1.37], p = 0.672). In subgroup analysis, patients with sustained HbA1c of <7.0% throughout the follow-up were not associated with a lower risk of MACE compared to those with sustained HbA1c of ≥7.0% (aHR 1.15 [0.71–1.89], p = 0.566). More intensive glucose control with mean HbA1c ≤ 6.5% was not associated with lower risk of MACE, compared to loose control with a mean HbA1c ≥ 8.0% (aHR 1.15 [0.71–1.86], p = 0.583). Intensive glucose control after PCI was not associated with better clinical outcomes in diabetic patients undergoing PCI than lenient control.

Characteristics, Outcomes, and Treatment of Heart Failure With Improved Ejection Fraction

Background

Many patients with heart failure (HF) with reduced ejection fraction (HFrEF) experience improvement or recovery of left ventricular ejection fraction (LVEF). Data on clinical characteristics, outcomes, and medical therapy in patients with HF with improved ejection fraction (HFiEF) are scarce.

Methods and Results

Of 5625 consecutive patients hospitalized for acute HF in the KorAHF (Registry [Prospective Cohort] for Heart Failure in Korea) study, 5103 patients had baseline echocardiography and 2302 patients had follow‐up echocardiography at 12 months. HF phenotypes were defined as persistent HFrEF (LVEF ≤40% at baseline and at 1‐year follow‐up), HFiEF (LVEF ≤40% at baseline and improved up to 40% at 1‐year follow‐up), HF with midrange ejection fraction (LVEF between 40% and <50%), and HF with preserved ejection fraction (LVEF ≥50%). The primary outcome was 4‐year all‐cause mortality from the time of HFiEF diagnosis. Among 1509 HFrEF patients who had echocardiography 1 year after index hospitalization, 720 (31.3%) were diagnosed as having HFiEF. Younger age, female sex, de novo HF, hypertension, atrial fibrillation, and β‐blocker use were positive predictors and diabetes mellitus and ischemic heart disease were negative predictors of HFiEF. During 4‐year follow‐up, patients with HFiEF showed lower mortality than those with persistent HFrEF in univariate, multivariate, and propensity‐score–matched analyses. β‐Blockers, but not renin–angiotensin system inhibitors or mineralocorticoid receptor antagonists, were associated with a reduced all‐cause mortality risk (hazard ratio: 0.59; 95% CI, 0.40–0.87; P=0.007). Benefits for outcome seemed similar among patients receiving low‐ or high‐dose β‐blockers (log‐rank, P=0.304).

Conclusions

HFiEF is a distinct HF phenotype with better clinical outcomes than other phenotypes. The use of β‐blockers may be beneficial for these patients.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01389843.

Diagnostic Utility and Pathogenic Role of Circulating MicroRNAs in Vasospastic Angina

We investigated the diagnostic value and pathophysiological role of circulating microRNA (miR) in vasospastic angina (VA). We enrolled patients who underwent coronary angiography for chest pain to explore the miR’s diagnostic utility. In addition, we investigated the role of miRs in regulating endothelial nitric oxide synthase (eNOS) expression in human coronary artery endothelial cells (hCAECs). Among the 121 patients, 46 were diagnosed with VA (VA group), 26 with insignificant coronary lesions (ICL group), and 49 with atherothrombotic angina (AA group). The VA group showed a significantly higher expression of miR-17-5p, miR-92a-3p, and miR-126-3p than the ICL group. In contrast, miR-221-3p and miR-222-3p were upregulated in the AA group compared to the VA group, and all levels of miR-17-5p, miR-92a-3p, miR-126-3p, miR-145-5p, miR-221-3p, and miR-222-3p differed between the AA group and the ICL group. In the hCAECs, transfection with mimics (pre-miR) of miR-17-5p, miR-92a-3p, and miR-126-3p was associated with eNOS suppression. Additionally, transfection with inhibitors (anti-miR) of miR-92a-3p significantly rescued the eNOS suppression induced by lipopolysaccharide. In conclusion, the circulating miRs not only proved to have diagnostic utility, but also contributed to pathogenesis by eNOS regulation.

Impact of diabetes mellitus on mortality in patients with acute heart failure: a prospective cohort study

Background

Although more than one-third of the patients with acute heart failure (AHF) have diabetes mellitus (DM), it is unclear if DM has an adverse impact on clinical outcomes. This study compared the outcomes in patients hospitalized for AHF stratified by DM and left ventricular ejection fraction (LVEF).

Methods

The Korean Acute Heart Failure registry prospectively enrolled and followed 5625 patients from March 2011 to February 2019. The primary endpoints were in-hospital and overall all-cause mortality. We evaluated the impact of DM on these endpoints according to HF subtypes and glycemic control.

Results

During a median follow-up of 3.5 years, there were 235 (4.4%) in-hospital mortalities and 2500 (46.3%) overall mortalities. DM was significantly associated with increased overall mortality after adjusting for potential confounders (adjusted hazard ratio [HR] 1.11, 95% confidence interval [CI] 1.03–1.22). In the subgroup analysis, DM was associated with higher a risk of overall mortality in heart failure with reduced ejection fraction (HFrEF) only (adjusted HR 1.14, 95% CI 1.02–1.27). Inadequate glycemic control (HbA1c ≥ 7.0% within 1 year after discharge) was significantly associated with a higher risk of overall mortality compared with adequate glycemic control (HbA1c < 7.0%) (44.0% vs. 36.8%, log-rank p = 0.016).

Conclusions

DM is associated with a higher risk of overall mortality in AHF, especially HFrEF. Well-controlled diabetes (HbA1c < 7.0%) is associated with a lower risk of overall mortality compared to uncontrolled diabetes.

Trial registration ClinicalTrial.gov, NCT01389843. Registered July 6, 2011. https://clinicaltrials.gov/ct2/show/NCT01389843

β-Blockers and 1-Year Postdischarge Mortality for Heart Failure and Reduced Ejection Fraction and Slow Discharge Heart Rate

Background

Many hospitalized patients with heart failure and reduced ejection fraction (HFrEF) have a slow heart rate at discharge, and the effect of β‐blockers may be reduced in those patients. We sought to examine the variable effect of β‐blockers on clinical outcomes according to the discharge heart rate of hospitalized HFrEF patients.

Methods and Results

The KorAHF (Korean Acute Heart Failure) registry consecutively enrolled 5625 patients hospitalized for acute heart failure. In this analysis, we included patients with HFrEF (left ventricular ejection fraction ≤40%). Slow heart rate was defined as <70 beats per minute regardless of the use of β‐blockers. The primary outcome was 1‐year all‐cause postdischarge death according to heart rate. Among 2932 patients with HFrEF, 840 (29%) had a slow heart rate and 56% received β‐blockers at discharge. Patients with slow heart rates were older and had lower 1‐year mortality than those with high heart rates (P<0.001). A significant interaction between discharge heart rate and β‐blocker use was observed (P<0.001 for interaction). When stratified, only patients without a β‐blocker prescription and with a high heart rate showed higher 1‐year mortality. In a Cox‐proportional hazards regression analysis, β‐blocker prescription at discharge was associated with 24% reduced risk for 1‐year mortality in patients with high heart rates (hazard ratio: 0.76; 95% CI, 0.61–0.95) but not in those with slow heart rates (hazard ratio: 1.02; 95% CI, 0.68–1.55).

Conclusions

Many patients with acute heart failure have slow discharge heart rates, and β‐blockers may have a limited effect on HFrEF and slow discharge heart rate.

Clinical Trial Registration

URL: http://www.clinicaltrial.gov. Unique identifier: NCT01389843.

Guideline-directed medical therapy in elderly patients with heart failure with reduced ejection fraction: a cohort study

OBJECTIVES AND DESIGN

Guideline-directed medical therapy (GDMT) with renin-angiotensin system (RAS) inhibitors and beta-blockers has improved survival in patients with heart failure with reduced ejection fraction (HFrEF). As clinical trials usually do not include very old patients, it is unknown whether the results from clinical trials are applicable to elderly patients with HF. This study was performed to investigate the clinical characteristics and treatment strategies for elderly patients with HFrEF in a large prospective cohort.

SETTING

The Korean Acute Heart Failure (KorAHF) registry consecutively enrolled 5625 patients hospitalised for acute HF from 10 tertiary university hospitals in Korea.

PARTICIPANTS

In this study, 2045 patients with HFrEF who were aged 65 years or older were included from the KorAHF registry.

PRIMARY OUTCOME MEASUREMENT

All-cause mortality data were obtained from medical records, national insurance data or national death records.

RESULTS

Both beta-blockers and RAS inhibitors were used in 892 (43.8%) patients (GDMT group), beta-blockers only in 228 (11.1%) patients, RAS inhibitors only in 642 (31.5%) patients and neither beta-blockers nor RAS inhibitors in 283 (13.6%) patients (no GDMT group). With increasing age, the GDMT rate decreased, which was mainly attributed to the decreased prescription of beta-blockers. In multivariate analysis, GDMT was associated with a 53% reduced risk of all-cause mortality (HR 0.47, 95% CI 0.39 to 0.57) compared with no GDMT. Use of beta-blockers only (HR 0.57, 95% CI 0.45 to 0.73) and RAS inhibitors only (HR 0.58, 95% CI 0.48 to 0.71) was also associated with reduced risk. In a subgroup of very elderly patients (aged ≥80 years), the GDMT group had the lowest mortality.

CONCLUSIONS

GDMT was associated with reduced 3-year all-cause mortality in elderly and very elderly HFrEF patients.

TRIAL REGISTRATION NUMBER

NCT01389843.

Admission Hyperglycemia as a Predictor of Mortality in Acute Heart Failure: Comparison between the Diabetics and Non-Diabetics

Background: To investigate the impact of admission hyperglycemia (HGL) on in-hospital death (IHD) and 1-year mortality in acute heart failure (AHF) patients with or without diabetes mellitus (DM). Methods: Among 5625 AHF patients enrolled in a nationwide registry, 5541 patients were divided into four groups based on the presence of admission HGL and diabetes mellitus (DM). Admission HGL was defined as admission glucose level > 200 mg/dL. IHD and 1-year mortality were compared. Results: IHD developed in 269 patients (4.9%), and 1-year death developed in 1220 patients (22.2%). DM was a significant predictor of 1-year death (24.8% in DM vs. 20.5% in non-DM, p < 0.001), but not for IHD. Interestingly, admission HGL was a significant predictor of both IHD (7.6% vs. 4.2%, p < 0.001) and 1-year death (26.2% vs. 21.3%, p = 0.001). Admission HGL was a significant predictor of IHD in both DM and non-DM group, whereas admission HGL was a significant predictor of 1-year death only in non-DM (27.8% vs. 19.9%, p = 0.003), but not in DM group. In multivariate analysis, admission HGL was an independent predictor of 1-year mortality in non-DM patients (HR 1.32, 95% CI 1.03–1.69, p = 0.030). Conclusion: Admission HGL was a significant predictor of IHD and 1-year death in patients with AHF, whereas DM was only a predictor of 1-year death. Admission HGL was an independent predictor of 1-year mortality in non-DM patients with AHF, but not in DM patients. Careful monitoring and intensive medical therapy should be considered in AHF patients with admission HGL, regardless of DM.

Blood pressure and heart failure

Background

Hypertension is a leading cause of cardiovascular disease, stroke, and death. It affects a substantial proportion of the population worldwide, and remains underdiagnosed and undertreated.

Body

Long-standing high blood pressure leads to left ventricular hypertrophy and diastolic dysfunction that cause an increase in myocardial rigidity, which renders the myocardium less compliant to changes in the preload, afterload, and sympathetic tone. Adequate blood pressure control must be achieved in patients with hypertension to prevent progression to overt heart failure. Controlling blood pressure is also important in patients with established heart failure, especially among those with preserved ejection fractions. However, aggressive blood pressure lowering can cause adverse outcomes, because a reverse J-curve association may exist between the blood pressure and the outcomes of patients with heart failure. Little robust evidence exists regarding the optimal blood pressure target for patients with heart failure, but a value near 130/80 mmHg seems to be adequate according to the current guidelines.

Conclusion

Prospective studies are required to further investigate the optimal blood pressure target for patients with heart failure.

NFATc1+CD31+CD45- circulating multipotent stem cells derived from human endocardium and their therapeutic potential

Many studies have shown the existence of cardiac stem cells in the myocardium and epicardial progenitor cells in the epicardium. However, the characteristics of stem cells in the endocardium has not been fully elucidated. In this study, we investigated the origin of newly identified cells in the blood and their therapeutic potential. The new population of cells, identified from human peripheral blood, was quite different from previously reported stem cells. These newly identified cells, which we named Circulating Multipotent Stem (CiMS) cells, were multipotent, and therefore differentiated into multiple lineages in vitro and in vivo. In order to determine the origin of these cells, we collected peripheral blood from a group of patients who underwent bone marrow, liver, heart, or kidney transplantation. We identified the endocardium as the origin of these cells because the Short Tandem Repeat profile of CiMS cells from the recipient had changed from the recipient's profile to the donor's profile after heart transplantation. CiMS cells significantly increased after stimuli to the endocardium, such as catheter ablation for arrhythmia or acute myocardial infarction. CiMS cells circulate in human peripheral blood and are easily obtainable, suggesting that these cells could be a promising tool for cell therapy.

The Effect of Door-to-Diuretic Time on Clinical Outcomes in Patients With Acute Heart Failure

OBJECTIVES

This study sought to examine the impact of door-to-diuretic (D2D) time on mortality in patients with acute heart failure (AHF) who were presenting to an emergency department (ED).

BACKGROUND

Most patients with AHF present with congestion. Early decongestion with diuretic agents could improve their clinical outcomes.

METHODS

The Korea Acute Heart Failure registry enrolled 5,625 consecutive patients hospitalized for AHF. For this analysis, the study included patients who received intravenous diuretic agents within 24 h after ED arrival. Early and delayed groups were defined as D2D time ≤60 min and D2D time >60 min, respectively. The primary outcomes were in-hospital death and post-discharge death at 1 month and 1 year on the basis of D2D time.

RESULTS

A total of 2,761 patients met the inclusion criteria. The median D2D time was 128 min (interquartile range: 63 to 243 min), and 663 (24%) patients belonged to the early group. The baseline characteristics were similar between the groups. The rate of in-hospital death did not differ between the groups (5.0% vs. 5.1%; p > 0.999), nor did the post-discharge 1-month (4.0% vs. 3.0%; log-rank p = 0.246) and 1-year (20.6% vs. 19.3%; log-rank p = 0.458) mortality rates. Get With the Guidelines-Heart Failure risk score was calculated for each patient. In multivariate analyses with adjustment for Get With the Guidelines-Heart Failure risk score and other significant clinical covariates and propensity-matched analyses, D2D time was not associated with clinical outcomes.

CONCLUSIONS

The D2D time was not associated with clinical outcomes in a large prospective cohort of patients with AHF who were presenting to an ED. (Registry [Prospective Cohort] for Heart Failure in Korea [KorAHF]; NCT01389843).

Postpartum women’s experience of abuse in childhood, postnatal depression, and thoughts of self-harm

Background

Postnatal depression threatens the health of both mothers and babies. To improve maternal and child health in Seoul, South Korea, a nurse home visitation program for pregnant women and new mothers and babies has been implemented since 2013.

Methods

Cross-sectional data collected from 9,124 mothers while they were visiting a public health center for prenatal services or a nurse was visiting their home within 6 weeks after birth between 2014 and 2018 were analyzed. Mothers were asked whether they had experienced physical, emotional, or sexual abuse in their childhood. Postnatal depression and thoughts of self-harm were measured using the Edinburgh Postnatal Depression Scale (EPDS). Postnatal depression was defined as a total EPDS score of 13 or higher; thoughts of self-harm were defined as a response of “yes, quite often,” “sometimes,” or “hardly ever” to the corresponding item, excluding the response of “never".

Results

Overall, 3.2% of mothers had experienced child abuse; 8.1% experienced postnatal depression and 5.4% reported thoughts of self-harm. Postnatal depression was more common in mothers who had experienced child abuse than among those who had not (24.2% vs. 7.6%). A similar pattern was found for thoughts of self-harm (21.1% vs. 4.9%, respectively). When controlling for mothers’ age, economic status, history of receiving treatment for mental health problems, and other factors, having experienced child abuse was associated with a 2.73-fold increase in the odds of postnatal depression (odds ratio, 2.02-3.70) and a 3.58-fold increase in the odds of thoughts of self-harm (odds ratio, 2.58-4.96).

Conclusions

Mothers should be screened for having experienced child abuse when providing public health perinatal care to improve mothers’ mental health and parenting practices and to promote their children’s growth and development.

Key messages

Child abuse may have a lifelong negative effect on victims, and the effect extends to the next generation’s health and development. Public health policy and interventions to prevent child abuse are needed to tackle health inequality beginning in early childhood.

P313ADGRL2 is an essential surface molecule for cardiac lineage specification and heart development

Background

Specific surface markers that enable monitoring of cell subsets would be valuable for establishing the conditions under which pluripotent stem cells (PSCs) differentiate into cardiac progenitor cells (CPCs) and cardiomyocytes (CMCs).

Methods and results

To verify whether a specific marker is expressed during heart development, we assessed its expression using the CLARITY technique. After immersion in a solution with a refractive index matching that of the CLARITY hybrid, the mouse embryo became transparent. After immunostaining the cleared embryo sample, Adgrl2 was exclusively observed in cardiac cells expressing α-SA at embryonic day E9.5 and E10.5. Our clarified 3D images and movies show that four chambers of the heart are fully developed at E10.5 but not at E9.5. At E9.5, Adgrl2 is observed at the ventricle and atrium, while Adgrl2 is present in all chambers of the heart at E10.5. Next, we performed LacZ (β-Gal) staining in heterozygous Adgrl2 KO embryos to evaluate Adgrl2 expression. As a result, LacZ staining showed that Adgrl2 was predominantly expressed in the heart during the embryonic developmental stage. Adgrl2 knockout in mice was embryonically lethal because of severe heart, but not vascular, defects. To examine the use of Adgrl2 as a bona fide CPC marker during heart development, we tracked Adgrl2 expression during early embryonic development. The heart of Adgrl2−/− embryos at E10.5 exhibited occlusion of the RV, and the expression levels of Gata4 and Nkx2.5 were not as high as those in wild-type and Adgrl2+/− embryos. Interestingly, the heart of Adgrl2−/− embryos, unlike those of wild-type and Adgrl2+/− embryos between E13.5 and E15.5 had a single ventricle revealing a ventricular septal defect. The specific expression pattern of Adgrl2 in PSC-derived cardiac lineage cells as well as in embryonic heart, adult mice, and human heart tissues.

Conclusion

We demonstrate that Adgrl2 plays a pivotal and functional role across all strata of the cardiomyogenic lineage, as early as the precursor stage of heart development. These findings shed light on heart development and regeneration.

Acknowledgement/Funding

Grants from “Strategic Center of Cell and Bio Therapy” (grant number: HI17C2085) and “Korea Research-Driven Hospital” (HI14C1277)

P3479Sequential stimulation and inhibition of lysophosphatidic acid receptor 4 are critical for cardiac differentiation and repair

Background

The clinical application of cell therapy to repair the damaged heart needs to understand the precise differentiation process of stem cells and the characteristics of cardiac progenitor cells.

Purpose

We examined the cardiac-specific markers that expressed on the cell surface and determined their functional significance during cardiac differentiation.

Methods and results

We screened cell-surface expressing proteins on cardiac progenitor cells at differentiation day 3 compared to undifferentiated pluripotent stem cells (PSCs). Among candidates, we identified lysophosphatidic acid receptor 4 (LPAR4) that is a G protein-coupled receptor. During in vitro differentiation of mouse PSCs toward cardiac cells, LPAR4 expression peaked for 3–5 days and then and declined immediately. Also in vivo, LPAR4 was specifically expressed in the early stage of heart development in embryos and disappeared completely in adults, suggesting that stimulatory signal of LPAR4 at an early stage should be shut off for further progression of differentiation. We next have identified the LPAR4 downstream signaling molecule, p38MAPK, by comparing PSCs and LPAR4 knockdown PSCs. In both mouse and human PSCs, ODP (LPAR4 specific agonist) followed by p38MAPK blocker (SB203580) treatment significantly increased cardiac differentiation efficiency. Furthermore, we investigated whether LPAR4 is the maker for adult cardiac progenitor cells. We found that LPAR4-positive cells were rarely present in normal adult mouse hearts, but LPAR4-positive cells were increased when the heart was damaged. LPAR4-positive cells from adult hearts differentiated into cardiomyocytes. After myocardial infarction (MI), the sequential stimulation and inhibition of LPAR4 with ODP and p38MAPK blocker resulted in the reduction of infarct size and improvement of left ventricular dysfunction.

Conclusion

We demonstrated that LPAR4 is a cardiac progenitor-specific marker and its functional significance during cardiac differentiation and regeneration. Our findings provide a new insight in cell-free cardiac repair by the modulation of progenitor-specific downstream signaling.

Acknowledgement/Funding

Grants from “Strategic Center of Cell and Bio Therapy” (grant number: HI17C2085) and “Korea Research-Driven Hospital” (HI14C1277)

Guideline-directed therapy at discharge in patients with heart failure and atrial fibrillation

Objectives

This study evaluated the relationship between guideline adherence for recommended therapy on discharge and relevant 60-day and 1-year clinical outcomes in patients with acute heart failure (HF) with reduced ejection fraction and atrial fibrillation (AF).

Methods

Of 5625 acute patients with HF in the Korean Acute Heart Failure registry, 986 patients with HF and documented AF were analysed. Guideline adherence scores were calculated for the prescription of ACE inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists and anticoagulants.

Results

In patients with HF with AF, there was a significant trend of reduced 60-day and 1-year mortality rates and the composite end point with guideline adherence. According to the Cox proportion hazard model, poor adherence was associated with a significantly higher risk of 60-day mortality (HR 4.75; 95% CI 1.77 to 12.74) and the composite end point (HR 2.36; 95% CI 1.33 to 4.18) compared with good adherence. Furthermore, poor adherence was associated with a significantly higher risk of 1-year mortality compared with moderate (HR 1.64; 95% CI 1.15 to 2.33) and good adherence (HR 2.34; 95% CI 1.39 to 3.97) and with a higher risk of the 1-year composite end point compared with good adherence (HR 1.58; 95% CI 1.07 to 2.33).

Conclusion

Better adherence to guidelines was associated with better 60-day and 1-year prognoses in patients with HF with AF.

Artificial intelligence algorithm for predicting mortality of patients with acute heart failure

Aims

This study aimed to develop and validate deep-learning-based artificial intelligence algorithm for predicting mortality of AHF (DAHF).

Methods and results

12,654 dataset from 2165 patients with AHF in two hospitals were used as train data for DAHF development, and 4759 dataset from 4759 patients with AHF in 10 hospitals enrolled to the Korean AHF registry were used as performance test data. The endpoints were in-hospital, 12-month, and 36-month mortality. We compared the DAHF performance with the Get with the Guidelines–Heart Failure (GWTG-HF) score, Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score, and other machine-learning models by using the test data. Area under the receiver operating characteristic curve of the DAHF were 0.880 (95% confidence interval, 0.876–0.884) for predicting in-hospital mortality; these results significantly outperformed those of the GWTG-HF (0.728 [0.720–0.737]) and other machine-learning models. For predicting 12- and 36-month endpoints, DAHF (0.782 and 0.813) significantly outperformed MAGGIC score (0.718 and 0.729). During the 36-month follow-up, the high-risk group, defined by the DAHF, had a significantly higher mortality rate than the low-risk group(p<0.001).

Conclusion

DAHF predicted the in-hospital and long-term mortality of patients with AHF more accurately than the existing risk scores and other machine-learning models.

Predictive value of a fragmented QRS complex in diagnosing patients with myocardial ischemia

Background

A fragmented QRS complex (fQRS) is caused by conduction abnormalities of the ventricle secondary to myocardial ischemia and/or scar in patients with myocardial infarction. However, the implications of the fQRS in the development of coronary artery disease with myocardial ischemia in those without a scar remain unknown.

Methods

We studied electrocardiograms (ECGs) obtained from 150 patients (60.5 ± 8.5 years, 102 men) with myocardial ischemia, which was confirmed by performing both, a nuclear exercise stress test and coronary angiography. We also studied ECGs obtained from 601 patients (58.5 ± 10.0 years, 315 men) who showed a negative nuclear exercise stress test (control group). Patients in whom the nuclear exercise stress test showed a myocardial scar were excluded.

Results

An fQRS was more commonly observed in patients with myocardial ischemia (n = 48, 32.0%) than in the control group (n = 133, 22.1%) (P = 0.011). The sensitivity, specificity, positive, and negative predictive values of fQRS in diagnosing myocardial ischemia were 32.0, 77.9, 26.5, and 82.1%, respectively. The fQRS (odds ratio 1.580, 95% confidence interval 1.020‐2.446, P = 0.040) was an independent predictor of myocardial ischemia after adjusting for age, sex, current smoking habits, ST‐T changes on ECG, as well as histories of hypertension, diabetes, and dyslipidemia. Moreover, the fQRS showed an incremental prognostic value over conventional risk factors (χ² = 5, P = 0.032) and over a combination of conventional factors and ST‐T changes (χ² = 9, P = 0.014).

Conclusions

The fQRS is a moderately sensitive and independent predictor of myocardial ischemia.

The incremental economic burden of heart failure: A population-based investigation from South Korea

Background

The prevalence of heart failure (HF) and its economic burden are increasing with age of the South Korean population. This study aimed to assess the economic impact of HF from the societal perspective.

Methods

A prevalence-based, incremental cost-of-patient study was performed to estimate the cost ratio between patients with HF and those without HF based on the claims database of the national health insurance in South Korea. We defined adult HF patients as those aged ≥19 years who had at least one insurance claim record with a primary or secondary diagnosis of HF. Age- and gender-matched controls were defined using a 1:4 greedy matching method. Costs were estimated by including medical costs for insurance-covered and non-covered services, transportation costs, caregiver’s cost, and time costs of patients. The ratio of costs between patients with HF and those without HF was adjusted for age, gender, and type of universal health security program in the multivariate regression model.

Results

The average annual per-capita cost was estimated to be $6,601 for patients with HF (n = 14,252), which is about 3.38 (95% confidence interval [CI]: 3.31–3.46) times higher than that for patients without HF (n = 1,116,882) and 1.64 (95% CI: 1.59–1.70) times higher than that for the age- and gender-matched patients without HF (n = 57,008). In the multivariate regression model, the annual per-capita total costs were 1.98-fold (95% CI: 1.94–2.02) statistically higher for patients with HF than for patients without HF after adjustment for age, gender, and type of universal health security program.

Conclusions

This study demonstrates a significant incremental burden of HF. Given that the prevalence of HF is expected to increase with an increase in the aging population, the national economic burden is expected to be substantial in the future. Thus, greater emphasis on the prevention and treatment of HF is warranted.

Nutritional risk index as a predictor of mortality in acutely decompensated heart failure

BACKGROUND

We investigated the role of nutritional risk index (NRI) in predicting 1-year mortality in patients with acute decompensated heart failure (ADHF).

METHODS

Among 5,625 cohort patients enrolled in Korean Acute Heart Failure (KorAHF) Registry, a total of 5,265 patients who were possible to calculate NRI [NRI = (1.519 x serum albumin [g/dl]) + (41.7 x weight [kg]/ideal body weight [kg])] were enrolled. The patients were divided into 4 groups according to the NRI quartile; Q1 <89 (n = 1121, 69.9 ± 14.5 years, 632 males), Q2 89-95 (n = 1234, 69.7 ± 14.4 years, 677 males), Q3 95-100 (n = 1199, 68.8 ± 14.0 years, 849 males), Q4 >100 (n = 1711, 65.6 ± 14.5 years, 779 males). Primary end-point was all-cause mortality at 1-year clinical follow-up.

RESULTS

The 1-year mortality was significantly increased as the NRI quartile decreased, and the lowest NRI quartile was associated with the highest 1-year mortality (Q1: 27.5% vs. Q2: 20.9% vs. Q3: 12.9% vs. Q4: 8.7%, linear p <0.001). On Kaplan-Meier survival analysis, the significant inter-quartile difference was observed (p <0.001 for all). In multivariate analysis using Cox proportional hazard regression, the lowest NRI quartile was an independent predictor of 1-year mortality in patients with ADHF.

CONCLUSIONS

Poor nutritional status as assessed by NRI and quartile grading of NRI was associated with 1-year mortality in Korean patients with ADHF. The assessment of nutritional status by NRI may provide additional prognostic information and thus would be useful in the risk stratification of the patients with ADHF.

Comparison of Characteristics and 3-Year Outcomes in Patients With Acute Heart Failure With Preserved, Mid-Range, and Reduced Ejection Fraction

BACKGROUND

The clinical characteristics and outcomes of acute heart failure (AHF) according to left ventricular ejection fraction (LVEF) have not been fully elucidated, especially for patients with mid-range LVEF. We performed a comprehensive comparison of the epidemiology, patterns of in-hospital management, and clinical outcomes in AHF patients with different LVEF categories. Methods and Results: The Korean Acute Heart Failure (KorAHF) registry is a prospective multicenter cohort of hospitalized AHF patients in Korea. A total of 5,374 patients enrolled in the KorAHF registry were classified according to LVEF based on the 2016 ESC guidelines. More than half of the HF patients (58%) had reduced EF (HFrEF), 16% had mid-range EF (HFmrEF), and 25% had preserved EF (HFpEF). The HFmrEF patients showed intermediate epidemiological profiles between HFrEF and HFpEF and had a propensity to present as de-novo HF with ischemic etiology. Patients with lower LVEF had worse short-term outcomes, and the all-cause in-hospital mortality, including urgent heart transplantation, of HFrEF, HFmrEF, and HFpEF was 7.1%, 3.6%, and 3.0%, respectively. Overall, discharged AHF patients showed poor 3-year all-cause death up to 38%, which was comparable between LVEF subgroups (P=0.623).

CONCLUSIONS

Each LVEF subgroup of AHF patients was a heterogeneous population with diverse characteristics, which have a significant effect on the clinical outcomes. This finding suggested that focused phenotyping of AHF patients could help identify the optimal management strategy and develop novel effective therapies.

Risk prediction for 30-day heart failure-specific readmission or death after discharge: Data from the Korean Acute Heart Failure (KorAHF) registry

BACKGROUND

Identifying patients with acute heart failure (HF) at high risk for readmission or death after hospital discharge will enable the optimization of treatment and management. The objective of this study was to develop a risk score for 30-day HF-specific readmission or death in Korea.

METHODS

We analyzed the data from the Korean Acute Heart Failure (KorAHF) registry to develop a risk score. The model was derived from a multiple logistic regression analysis using a stepwise variable selection method. We also proposed a point-based risk score to predict the risk of 30-day HF-specific readmission or death by simply summing the scores assigned to each risk variable. Model performance was assessed using an area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, the net reclassification improvement (NRI), and the integrated discrimination improvement (IDI) index to evaluate discrimination, calibration, and reclassification, respectively.

RESULTS

Data from 4566 patients aged ≥40 years were included in the analysis. Among them, 446 (9.8%) had 30-day HF-specific readmission or death. The final model included 12 independent variables (age, New York Heart Association functional class, clinical history of hypertension, HF admission, chronic obstructive pulmonary disease, etiology of cardiomyopathy, systolic blood pressure, left ventricular ejection fraction, serum sodium, brain natriuretic peptide, N-terminal prohormone of brain natriuretic peptide at discharge, and prescription of β-blockers and angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists at discharge). The point risk score showed moderate discrimination (AUC of 0.710; 95% confidence interval, 0.685-0.735) and good calibration (χ²=8.540, p=0.3826).

CONCLUSIONS

The risk score for the prediction of the risk of 30-day HF-specific readmission or death after hospital discharge was developed using 12 predictors. It can be utilized to guide appropriate interventions or care strategies for patients with HF.

Imprinted gene Zinc finger protein 127 is a novel regulator of master pluripotency transcription factor, Oct4

Induced pluripotent stem cells (iPSCs) show great promise for replacing current stem cell therapies in the field of regenerative medicine. However, the original method for cellular reprogramming, involving four exogenous transcription factors, is characterized by low efficiency. Here, we focused on using epigenetic modifications to enhance the reprogramming efficiency. We hypothesized that there would be a new reprogramming factor involved in DNA demethylation, acting on the promoters of pluripotency-related genes. We screened proteins that bind to the methylated promoter of Oct4 and identified Zinc finger protein 127 (Zfp127), the functions of which have not yet been identified. We found that Zfp127 binds to the Oct4 promoter. Overexpression of Zfp127 in fibroblasts induced demethylation of the Oct4 promoter, thus enhancing Oct4 promoter activity and gene expression. These results demonstrate that Zfp127 is a novel regulator of Oct4, and may become a potent target to improve cellular reprogramming. [BMB Reports 2018; 51(5): 242-248].

Coronary artery bypass graft versus percutaneous coronary intervention in acute heart failure

Objective

Myocardial ischaemia is a leading cause of acute heart failure (AHF). However, optimal revascularisation strategies in AHF are unclear. We aimed to compare two revascularisation strategies, coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), in patients with AHF.

Methods

Among 5625 consecutive patients enrolled prospectively in the Korean Acute Heart Failure registry from March 2011 to February 2014, 717 patients who received CABG or PCI during the index hospitalisation for AHF were included in this analysis. We compared adverse outcomes (death, rehospitalisation for HF aggravation or cardiovascular causes, ischaemic stroke and a composite outcome of death and rehospitalisation for HF aggravation or cardiovascular causes) with the use of propensity score matching.

Results

For the propensity score-matched cohort with 190 patients, CABG had a lower risk of all-cause mortality than PCI (83 vs 147 deaths per 1000 patient-years; HR 0.57, 95% CI 0.34 to 0.96, p=0.033) during the median follow-up of 4 years. There was also a trend towards lower rates of rehospitalisation due to cardiovascular events or HF aggravation. Subgroup analysis revealed that the adverse outcomes were significantly lower in the CABG group than in PCI group, especially in patients with old age, three-vessel diseases, significant proximal left anterior descending artery disease and those without left main vessel disease or chronic total occlusion.

Conclusions

Compared with PCI, CABG is associated with significant lower all-cause mortality in patients with AHF. Further studies should evaluate proper revascularisation strategies in AHF.

Clinical trial registration

NCT01389843; Results.

Body fluid status assessment by bio-impedance analysis in patients presenting to the emergency department with dyspnea

BACKGROUND/AIMS

Fluid retention occurs in patients with heart failure, accounting for dyspnea. We investigated the diagnostic implication of body fluid status, assessed by bio-impedance analysis (BIA), in acute heart failure (AHF) among patients who presented with dyspnea.

METHODS

A total of 100 patients who presented with dyspnea and suspected with AHF were analyzed in this study. We enrolled 50 AHF and 50 non-AHF patients discriminated through echocardiographic analysis and Framingham criteria and were matched by age and sex. Body composition was analyzed using a multifrequency BIA.

RESULTS

AHF patients demonstrated higher extracellular water (ECW)/total body water (TBW) compared with non-AHF patients (0.412 ± 0.017 vs. 0.388 ± 0.023, p < 0.001). A significant difference of ECW/TBW between AHF patients and nonAHF patients was noted when the upper extremities, trunk, and lower extremities were analyzed (all p < 0.001, respectively). ECW/TBW was not different between patients with reduced ejection fraction (EF) and preserved EF along body compartments. The best cut-off value to predict AHF was > 0.412 at lower extremities with sensitivity and specificity of 0.780 and 0.960. The ECW/TBW of the lower extremities (ECW/TBWL) was correlated with log B-type natriuretic peptide (BNP) levels (r = 0.603, p < 0.001) and also improved the net reclassification improvement and integrated discriminated improvement when added to log BNP level. Multivariate analysis revealed that ECW/TBWL > 0.412 had an independent association with AHF patients (p = 0.011).

CONCLUSION

The ECW/TBWL was higher in patients with dyspnea caused by AHF than their counterparts and demonstrated an independent diagnostic implication. It may be a promising marker to diagnose AHF at bedside.

Gata6 in pluripotent stem cells enhance the potential to differentiate into cardiomyocytes

Pluripotent stem cell (PSC) variations can cause significant differences in the efficiency of cardiac differentiation. This process is unpredictable, as there is not an adequate indicator at the undifferentiated stage of the PSCs. We compared global gene expression profiles of two PSCs showing significant differences in cardiac differentiation potential. We identified 12 up-regulated genes related to heart development, and we found that 4 genes interacted with multiple genes. Among these genes, Gata6 is the only gene that was significantly induced at the early stage of differentiation of PSCs to cardiomyocytes. Gata6 knock-down in PSCs decreased the efficiency of cardiomyocyte production. In addition, we analyzed 6 mESC lines and 3 iPSC lines and confirmed that a positive correlation exists between Gata6 levels and efficiency of differentiation into cardiomyocytes. In conclusion, Gata6 could be utilized as a biomarker to select the best PSC lines to produce PSC-derived cardiomyocytes for therapeutic purposes. [BMB Reports 2018; 51(2): 85-91].

Reverse J-Curve Relationship Between On-Treatment Blood Pressure and Mortality in Patients With Heart Failure

OBJECTIVES

This study aimed to assess the relationship between on-treatment blood pressure (BP) and clinical outcomes of patients with heart failure (HF).

BACKGROUND

Lower BP has been reported to be related to increased mortality in various cardiovascular diseases. The optimal BP level for patients already experiencing HF is contentious.

METHODS

The Korean Acute Heart Failure registry prospectively enrolled a total of 5,625 consecutive patients hospitalized for acute HF in 10 tertiary university hospitals in Korea between March 2011 and February 2014. Clinical profiles including BP were collected at admission, discharge, and during outpatient follow-up. Mean on-treatment BP was calculated from BP at discharge and at each follow-up visit. We evaluated the effects of mean on-treatment BP on the clinical outcomes of patients.

RESULTS

Patients were followed up for a median 2.2 years. One-year mortality after discharge was 18.2%. The relationship between on-treatment BP and all-cause mortality followed a reversed J-curve relationship. A nonlinear, multivariable Cox proportional hazard model identified a nadir of systolic and diastolic BPs of 132.4/74.2 mm Hg in patients, for whom the mortality rate was lowest (p < 0.0001). The relationship with increased mortality above and below the reference BP was more definitive for diastolic BP and for HF with a preserved ejection fraction.

CONCLUSIONS

Systolic and diastolic BPs <130/70 mm Hg at discharge and during follow-up was associated with worse survival in HF patients. These data suggest that the lowest BP possible might not be an optimal target for HF patients. Further studies should establish a proper BP goal in HF patients. (Registry [Prospective Cohort] for Heart Failure in Korea [KorAHF]; NCT01389843).

Therapeutic Potential of a Novel Necrosis Inhibitor, 7-Amino-Indole, in Myocardial Ischemia-Reperfusion Injury

Supplemental Digital Content is available in the text.

Opening of mitochondrial permeability transition pore and Ca²⁺ overload are main contributors to myocardial ischemia–reperfusion injury, which paradoxically causes a wide variety of myocardial damage. We investigated the protective role of a novel necrosis inhibitor (NecroX-7; NecX) against myocardial ischemia–reperfusion injury using in vitro and in vivo models. H9C2 rat cardiomyoblasts and neonatal cardiomyocytes were exposed to hypoxia–reoxygenation stress after pre-treatment with NecX, vitamin C, a combination of vitamin C and E, N-acetylcysteine, an apoptosis inhibitor (Z-VAD-fmk), or cyclosporine A. The main mechanism of cell death after hypoxia–reoxygenation stress was not apoptosis but necrosis, which was prevented by NecX. Protective effect of NecX was based on its potent reactive oxygen species scavenging activity, especially on mitochondrial reactive oxygen species. NecX preserved mitochondrial membrane potential through prevention of Ca²⁺ influx and inhibition of mitochondrial permeability transition pore opening, which was more potent than that by cyclosporine A. Using Sprague-Dawley rats exposed to myocardial ischemia for 45 minutes followed by reperfusion, we compared therapeutic efficacies of NecX with cyclosporine A, vitamin C, a combination of vitamin C and E, and 5% dextrose, each administered 5 minutes before reperfusion. NecX markedly inhibited myocardial necrosis and reduced fibrotic area to a greater extent than did cyclosporine A and other treated groups. In addition, NecX preserved systolic function and prevented pathological dilatory remodeling of left ventricle. The novel necrosis inhibitor has a significant protective effect against myocardial ischemia–reperfusion injury through inhibition of mitochondrial permeability transition pore opening, indicating that it is a promising candidate for cardioprotective adjunctive measure on top of reperfusion therapy.

Predictors and Prognostic Value of Worsening Renal Function During Admission in HFpEF Versus HFrEF: Data From the KorAHF (Korean Acute Heart Failure) Registry

Background

Worsening renal function (WRF) is associated with adverse outcomes in patients with heart failure. We investigated the predictors and prognostic value of WRF during admission, in patients with preserved ejection fraction (HFpEF) versus those with reduced ejection fraction (HFrEF).

Methods and Results

A total of 5625 patients were enrolled in the KorAHF (Korean Acute Heart Failure) registry. WRF was defined as an absolute increase in creatinine of ≥0.3 mg/dL. Transient WRF was defined as recovery of creatinine at discharge, whereas persistent WRF was indicated by a nonrecovered creatinine level. HFpEF and HFrEF were defined as a left ventricle ejection fraction ≥50% and ≤40%, respectively. Among the total population, WRF occurred in 3101 patients (55.1%). By heart failure subgroup, WRF occurred more frequently in HFrEF (57.0% versus 51.3%; P<0.001 in HFrEF and HFpEF). Prevalence of WRF increased as creatinine clearance decreased in both heart failure subgroups. Among various predictors of WRF, chronic renal failure was the strongest predictor. WRF was an independent predictor of adverse in‐hospital outcomes (HFrEF: odds ratio; 2.75; 95% confidence interval, 1.50–5.02; P=0.001; HFpEF: odds ratio, 9.48; 95% confidence interval, 1.19–75.89; P=0.034) and 1‐year mortality (HFrEF: hazard ratio, 1.41; 95% confidence interval, 1.12–1.78; P=0.004 versus HFpEF: hazard ratio, 1.72; 95% confidence interval, 1.23–2.42; P=0.002). Transient WRF was a risk factor for 1‐year mortality, whereas persistent WRF had no additive risk compared to transient WRF.

Conclusions

In patients with acute heart failure patients, WRF is an independent predictor of adverse in‐hospital and follow‐up outcomes in both HFrEF and HFpEF, though with a different effect size.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01389843.

Identification of Adult Mesodermal Progenitor Cells and Hierarchy in Atherosclerotic Vascular Calcification

The nature of calcifying progenitor cells remains elusive. In this study, we investigated the developmental hierarchy and dynamics of progenitor cells. In vitro and in vivo reconstitution assays demonstrated that Sca-1+/PDGFRα- cells in the bone marrow (BM) are the ancestors of Sca-1+/PDGFRα+ cells. Cells of CD29 + Sca-1+/PDGFRα- lineage in the BM showed both hematopoietic potential with osteoclastic differentiation ability as well as mesenchymal stem cell-like properties with osteoblastic differentiation potential. Clonally-isolated BM-derived artery-infiltrated Sca-1+/PDGFRα- cells maintained osteoblastic/osteoclastic bipotency but lost hematopoietic activity. In hypercholesterolemic apolipoprotein-E-deficient (Apoe-/-) mice, the mobilization from BM to peripheral circulation, followed by migration into atherosclerotic plaques of Sca-1+/PDGFRα- cells, but not Sca-1+/PDGFRα+ cells, were significantly decreased, and Interleukin-1β (IL-1β) and Interleukin-5 (IL-5) mediated this response. Here, we demonstrated that Sca-1+/PDGFRα- cells are mesodermal progenitor cells in adults, and the dynamics of progenitor cells were regulated by atherosclerosis-related humoral factors. These results may contribute to better understanding of vascular homeostasis and assist in the development of novel therapies for atherosclerosis. Stem Cells 2018;36:1075-1096.

Recurrent Obturator Hernia as a Cause of Nonspecific Abdominal Pain: A Case Report

Many patients visit the emergency department (ED) with abdominal pain. Sometimes, physicians are faced with diagnostic challenges, particularly for older patients. We recently had an elderly female patient who visited the ED several times with non-specific abdominal pain caused by an unusual hernia. One year before, an 81-year-old female visited our ED complaining of abdominal pain radiating to the right inguinal/femoral area. An incarcerated obturator hernia was found on an abdomino-pelvic computed tomography (CT) scan, and she underwent a laparoscopic hernioplasty. However, 1 year later, she revisited complaining of abdominal pain similar to the previous episode. Eventually, the diagnosis of recurrent obturator hernia was made, and a second operation was performed. An obturator hernia may be the cause of non-specific abdominal pain and small bowel obstruction in elderly emaciated females. Recognising the clinical signs and characteristics of this disease is necessary for a prompt diagnosis and treatment.

Hyponatraemia and its prognosis in acute heart failure is related to right ventricular dysfunction

OBJECTIVES

Hyponatraemia is a well-known predictor of clinical outcomes in heart failure (HF). However, the mechanism remains poorly understood. Previous reports suggest that hyponatraemia is related to right HF. We sought to evaluate the association between right ventricular (RV) dysfunction and hyponatraemia, and the impact of this relationship on the prognosis of patients with acute heart failure (AHF).

METHODS

This is a nested case-control study of the Korean Acute Heart Failure registry. Among 2935 AHF patients enrolled prospectively and consecutively at four tertiary hospitals in Korea from 2011 to 2014, 116 patients with severe persistent hyponatraemia, defined as serum sodium level <130 mmol/L at admission and <135 mmol/L before discharge, were matched with 232 controls, based on propensity scores for hyponatraemia. RV function was assessed with fractional area change (FAC) by echocardiography.

RESULTS

RV dysfunction (FAC <35%) was more prevalent in patients with severe persistent hyponatraemia than in those without (81.0% vs 33.6%, p<0.001). Hyponatraemia was strongly associated with RV dysfunction (adjusted OR 8.00, 95% CI 4.50 to 14.22, p<0.001), but not with left ventricular dysfunction (adjusted OR 1.21, 95% CI 0.74 to 1.50, p=0.308). RV dysfunction was an independent predictor of all-cause mortality, after adjustment for hyponatraemia (adjusted HR 2.20, 95% CI 1.53 to 3.15, p<0.001), while hyponatraemia was not (adjusted HR 1.33, 95% CI 0.94 to 1.87, p=0.108).

CONCLUSIONS

In patients with AHF, hyponatraemia was more common with RV dysfunction. RV dysfunction, rather than hyponatraemia, was more significantly related with patients' prognosis. Thus, the utility of RV dysfunction instead of hyponatraemia per se should be considered in HF risk models.

TRIAL REGISTRATION NUMBER

Korean Acute Heart Failure registry NCT01389843; Results.

EphrinB1 promotes cancer cell migration and invasion through the interaction with RhoGDI1

Eph receptors and their corresponding ephrin ligands have been associated with regulating cell–cell adhesion and motility, and thus have a critical role in various biological processes including tissue morphogenesis and homeostasis, as well as pathogenesis of several diseases. Aberrant regulation of Eph/ephrin signaling pathways is implicated in tumor progression of various human cancers. Here, we show that a Rho family GTPase regulator, Rho guanine nucleotide dissociation inhibitor 1 (RhoGDI1), can interact with ephrinB1, and this interaction is enhanced upon binding the extracellular domain of the cognate EphB2 receptor. Deletion mutagenesis revealed that amino acids 327–334 of the ephrinB1 intracellular domain are critical for the interaction with RhoGDI1. Stimulation with an EphB2 extracellular domain-Fc fusion protein (EphB2-Fc) induces RhoA activation and enhances the motility as well as invasiveness of wild-type ephrinB1-expressing cells. These Eph-Fc-induced effects were markedly diminished in cells expressing the mutant ephrinB1 construct (Δ327–334) that is ineffective at interacting with RhoGDI1. Furthermore, ephrinB1 depletion by siRNA suppresses EphB2-Fc-induced RhoA activation, and reduces motility and invasiveness of the SW480 and Hs578T human cancer cell lines. Our study connects the interaction between RhoGDI1 and ephrinB1 to the promotion of cancer cell behavior associated with tumor progression. This interaction may represent a therapeutic target in cancers that express ephrinB1.

Outcomes of de novo and acute decompensated heart failure patients according to ejection fraction

Objective

There are conflicting results among previous studies regarding the prognosis of heart failure with preserved ejection fraction (HFpEF) compared with heart failure with reduced ejection fraction (HFrEF). This study aimed to compare the outcomes of patients with de novo acute heart failure (AHF) or acute decompensated HF (ADHF) according to HFpEF (EF≥50%), or HFrEF (EF<40%) and to define the prognosis of patients with HF with mid-range EF (HFmrEF, 40≤EF<50%).

Methods

Between March 2011 and February 2014, 5625 consecutive patients with AHF were recruited from 10 university hospitals. A total of 5414 (96.2%) patients with EF data were enrolled, which consisted of 2867 (53.0%) patients with de novo and 2547 (47.0%) with ADHF. Each of the enrolled group was stratified by EF.

Results

In de novo, all-cause death rates were not significantly different between HFpEF and HFrEF (HFpEF vs HFrEF, 206/744 (27.7%) vs 438/1631 (26.9%), HRadj 1.15, 95% CI 0.96 to 1.38, p=0.14). However, among patients with ADHF, HFrEF had a significantly higher mortality rate compared with HFpEF (HFpEF vs HFrEF, 245/613 (40.0%) vs 694/1551 (44.7%), HRadj 1.25, 95% CI 1.06 to 1.47, p=0.007). Also, in ADHF, HFmrEF was associated with a significantly lower mortality rate within 1 year compared with HFrEF (HFmrEF vs HFrEF, 88/383 (23.0%) vs 430/1551 (27.7%), HRadj 1.31, 95% CI 1.03 to 1.65, p=0.03), but a significantly higher mortality rate after 1 year compared with HFpEF (HFmrEF vs HFpEF, 83/295 (28.1%) vs 101/469 (21.5%), HRadj 0.70, 95% CI 0.52 to 0.96, p=0.02).

Conclusions

HFpEF may indicate a better prognosis compared with HFrEF in ADHF, but not in de novo AHF. For patients with ADHF, the prognosis associated with HFmrEF was similar to that of HFpEF within the first year following hospitalisation and similar to HFrEF 1  year after hospitalisation.

Impact of a Telehealth Program With Voice Recognition Technology in Patients With Chronic Heart Failure: Feasibility Study

Background

Despite the advances in the diagnosis and treatment of heart failure (HF), the current hospital-oriented framework for HF management does not appear to be sufficient to maintain the stability of HF patients in the long term. The importance of self-care management is increasingly being emphasized as a promising long-term treatment strategy for patients with chronic HF.

Objective

The objective of this study was to evaluate whether a new information communication technology (ICT)–based telehealth program with voice recognition technology could improve clinical or laboratory outcomes in HF patients.

Methods

In this prospective single-arm pilot study, we recruited 31 consecutive patients with chronic HF who were referred to our institute. An ICT-based telehealth program with voice recognition technology was developed and used by patients with HF for 12 weeks. Patients were educated on the use of this program via mobile phone, landline, or the Internet for the purpose of improving communication and data collection. Using these systems, we collected comprehensive data elements related to the risk of HF self-care management such as weight, diet, exercise, medication adherence, overall symptom change, and home blood pressure. The study endpoints were the changes observed in urine sodium concentration (uNa), Minnesota Living with Heart Failure (MLHFQ) scores, 6-min walk test, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as surrogate markers for appropriate HF management.

Results

Among the 31 enrolled patients, 27 (87%) patients completed the study, and 10 (10/27, 37%) showed good adherence to ICT-based telehealth program with voice recognition technology, which was defined as the use of the program for 100 times or more during the study period. Nearly three-fourths of the patients had been hospitalized at least once because of HF before the enrollment (20/27, 74%); 14 patients had 1, 2 patients had 2, and 4 patients had 3 or more previous HF hospitalizations. In the total study population, there was no significant interval change in laboratory and functional outcome variables after 12 weeks of ICT-based telehealth program. In patients with good adherence to ICT-based telehealth program, there was a significant improvement in the mean uNa (103.1 to 78.1; P=.01) but not in those without (85.4 to 96.9; P=.49). Similarly, a marginal improvement in MLHFQ scores was only observed in patients with good adherence (27.5 to 21.4; P=.08) but not in their counterparts (19.0 to 19.7; P=.73). The mean 6-min walk distance and NT-proBNP were not significantly increased in patients regardless of their adherence.

Conclusions

Short-term application of ICT-based telehealth program with voice recognition technology showed the potential to improve uNa values and MLHFQ scores in HF patients, suggesting that better control of sodium intake and greater quality of life can be achieved by this program.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. 
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Acute endophthalmitis after cataract surgery: 164 consecutive cases treated at a referral center in South Korea

PurposeTo identify prognostic factors in patients referred with endophthalmitis after cataract surgery, and to evaluate the efficacy of primary vitrectomy as an initial management.MethodsOver an eight-year study period, we retrospectively reviewed the medical records of 164 patients who were referred with endophthalmitis following cataract surgery. Treatment generally conformed to standard guidelines, although primary vitrectomy was performed in several eyes with a visual acuity of hand motion or better, depending on the patient's status. Using multivariate analysis, we analyzed outcomes to determine the effect on final visual outcome.ResultsA final visual acuity of ≥20/40 was achieved in 92/164 (56.1%) cases after treatment. Bacterial cultures showed bacterial growth in 89/164 cases (54.3%). Among the various baseline characteristics, old age (P=0.028), poor visual acuity at presentation (P=0.004), gram-negative bacterial infection (P=0.030), and short time between cataract surgery and signs of endophthalmitis (P=0.021) were associated with poor visual outcome. The visual outcome showed no significant difference, in terms of initial treatment feature, between the primary vitrectomy with intraocular antibiotics injection (IOAI) and IOAI-only groups. However, reintervention was significantly less frequent in the primary vitrectomy group than in the IOAI group (12.5 and 32.7%, respectively; P=0.002).ConclusionOld age, poor visual acuity at presentation, type of cultured organism (gram-negative bacteria), and early onset of endophthalmitis after cataract surgery were significantly related to poor visual outcome after endophthalmitis treatment. Primary vitrectomy may decrease the need for reintervention to control infection, although the treatment showed no benefits with regard to visual outcome.

Clinical Characteristics and Outcome of Acute Heart Failure in Korea: Results from the Korean Acute Heart Failure Registry (KorAHF)

Background and Objectives

The burden of heart failure has increased in Korea. This registry aims to evaluate demographics, clinical characteristics, management, and long-term outcomes in patients hospitalized for acute heart failure (AHF).

Subjects and Methods

We prospectively enrolled a total of 5625 consecutive subjects hospitalized for AHF in one of 10 tertiary university hospitals from March 2011 to February 2014. Descriptive statistics were used to determine the baseline characteristics of the study population and to compare them with those from other registries.

Results

The mean age was 68.5±14.5 years, 53.2% were male, and 52.2% had de novo heart failure. The mean systolic and diastolic blood pressures were 131.2±30.3 mmHg and 78.6±18.8 mmHg at admission, respectively. The left ventricular ejection fraction was ≤40% in 60.5% of patients. Ischemia was the most frequent etiology (37.6%) and aggravating factor (26.3%). Angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and aldosterone antagonists were prescribed in 68.8%, 52.2%, and 46.6% of the patients at discharge, respectively. Compared with the previous registry performed in Korea a decade ago, extracorporeal membrane oxygenation (ECMO) and heart transplantation have been performed more frequently (ECMO 0.8% vs. 2.8%, heart transplantation 0.3% vs. 1.2%), and in-hospital mortality decreased from 7.6% to 4.8%. However, the total cost of hospital care increased by 40%, and one-year follow-up mortality remained high.

Conclusion

While the quality of acute clinical care and AHF-related outcomes have improved over the last decade, the long-term prognosis of heart failure is still poor in Korea. Therefore, additional research is needed to improve long-term outcomes and implement cost-effective care.

Clinical implications of serum galactomannan measurement in patients with acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. Recently, non-invasive techniques have been introduced for diagnosis of invasive fungal disease. The purpose of this study is to evaluate the diagnostic significance of serum galactomannan measurement in patients with AIFR.

METHODOLOGY

We conducted a retrospective case-control study of 28 patients with AIFR and 36 fungus ball (FB) patients. We evaluated clinical, laboratory, and pathologic findings along with disease course.

RESULTS

In 28 patients with AIFR, there were 21 cases of invasive aspergillosis (IA) and 7 cases of invasive mucormycosis (IM). The control group was comprised of 36 patients with FB. The three-group analysis showed a statistically significant difference among the groups. At the cut-off value of 0.48, the sensitivity and specificity were 71.4% and 93.0%, respectively. Comparison of mean serum galactomannan levels in 5 non-survivors and 9 survivors at initial measurement showed no significant difference, but that became significantly different 1 week later. Statistical analysis showed that the levels of serum galactomannan decreased significantly according to the measurement-point in within survivor-group analysis. The difference in between survivor-groups analysis was also significant.

CONCLUSION

Serum galactomannan measurement seems useful for early diagnosis and discrimination of fungal species in patients with AIFR. In addition, clinical outcomes may be related to the levels and patterns of serum galactomannan, especially in IA. The appropriate measurement of galactomannan might be helpful in treating the patients at high risk for AIFR.

Pharmacokinetics and safety of a single dose of the novel necrosis inhibitor LC28-0126 in healthy male subjects

AIMS

A novel necrosis inhibitor, LC28-0126, is expected to have a cellular protective effect from ischaemic reperfusion injury in acute myocardial infarction. The objective of this study was to investigate the safety, tolerability and pharmacokinetics of LC28-0126 after a single intravenous administration in healthy male subjects.

METHODS

The study was a dose-block-randomized, double-blind, placebo-controlled, single ascending dose, first-in-human trial. Subjects were randomly assigned to receive 0.3, 1, 3, 10, 25, 50, 100 or 200 mg of LC28-0126. LC28-0126 was infused for 30 min and 5 min in cohorts 1 and 2, respectively. An interim analysis to assess the tolerability and pharmacokinetics was conducted in each dose group. Blood samples were taken to determine plasma LC28-0126 concentrations from predose to 48 or 144 h postdose, and urine samples were taken from predose to 48 or 72 h postdose.

RESULTS

Overall, 89 subjects were randomly assigned to the dose groups of the two cohorts. LC28-0126 was well tolerated, and no serious adverse events were reported. LC28-0126 showed rapid disposition in the distribution phase. Overall, the fraction of unchanged LC28-0126 excreted during the 48 or 72 h after administration was below 5%. The systemic exposure of LC28-0126 tends to be increased in a dose-proportional manner in the dose range of 0.3-200 mg.

CONCLUSIONS

A single intravenous dose of LC28-0126 was safe and well tolerated up to 200 mg. Furthermore, LC28-0126 demonstrated a predictable pharmacokinetic profile after a single intravenous infusion of doses ranging from 0.3 to 200 mg.