Laparoscopic iliopubic tract repair for asymptomatic contralateral occult inguinal hernia

PURPOSE

Metachronous contralateral inguinal hernia (MCIH) may occur after unilateral inguinal hernia (IH) repair, potentially as a result of occult IH (OIH). Contralateral OIH can be checked for during laparoscopic transabdominal hernioplasty for the treatment of unilateral IH. This study aims to assess the efficacy of laparoscopic iliopubic tract repair (IPTR) in treating contralateral OIH to reduce MCIH.

METHODS

The medical charts of 3165 patients aged > 18 years who underwent laparoscopic transabdominal hernioplasty for unilateral IH from January 2013 to December 2021 were retrospectively reviewed. The patients were categorized into two groups based on contralateral OIH presence: negative OIH (nOIH, 2657 patients) and OIH (508 patients). In cases of OIH, IPTR was performed, involving suturing of the iliopubic tract and transversalis fascia arch.

RESULTS

MCIH was indirect in 26 and direct in 4 patients in the nOIH group, and was direct in 3 patients in the OIH group. The incidence of indirect MCIH was higher in the nOIH group than in the OIH (1.0% [n = 26/2657] vs. 0.0% [n = 0/508], p = 0.048). There was no difference in postoperative complication rates, pain scores, return to daily life, or duration of hospitalization between the nOIH and OIH groups.

CONCLUSION

Laparoscopic IPTR for OIH treatment is an effective method for reducing the risk of indirect MCIH.

Clinical Outcome after Everolimus-Eluting Stent Implantation for Small Vessel Coronary Artery Disease: XIENCE Asia Small Vessel Study

There are limited data on outcomes after implantation of everolimus-eluting stents (EES) in East Asian patients with small vessel coronary lesions. A total of 1,600 patients treated with XIENCE EES (Abbott Vascular, CA, USA) were divided into the small vessel group treated with one ≤2.5 mm stent (n=119) and the non-small vessel group treated with one ≥2.75 mm stent (n=933). The primary end point was a patient-oriented composite outcome (POCO), a composite of all-cause death, myocardial infarction (MI), and any repeat revascularization at 12 months. The key secondary end point was a device-oriented composite outcome (DOCO), a composite of cardiovascular death, target-vessel MI, and target lesion revascularization at 12 months. The small vessel group was more often female, hypertensive, less likely to present with ST-elevation MI, and more often treated for the left circumflex artery, whereas the non-small vessel group more often had type B2/C lesions, underwent intravascular ultrasound, and received unfractionated heparin. In the propensity matched cohort, the mean stent diameter was 2.5±0.0 mm and 3.1±0.4 mm in the small and non-small vessel groups, respectively. Propensity-adjusted POCO at 12 months was 6.0% in the small vessel group and 4.3% in the non-small vessel group (p=0.558). There was no significant difference in DOCO at 12 months (small vessel group: 4.3% and non-small vessel group: 1.7%, p=0.270). Outcomes of XIENCE EES for small vessel disease were comparable to those for non-small vessel disease at 12-month clinical follow-up in real-world Korean patients.

Effectiveness of low-intensity atorvastatin 5 mg and ezetimibe 10 mg combination therapy compared with moderate-intensity atorvastatin 10 mg monotherapy: A randomized, double-blinded, multi-center, phase III study

BACKGROUND

We compared the efficacy and safety of low-intensity atorvastatin and ezetimibe combination therapy with moderate-intensity atorvastatin monotherapy in patients requiring cholesterol-lowering therapy.

METHODS

At 19 centers in Korea, 290 patients were randomized to 4 groups: atorvastatin 5 mg and ezetimibe 10 mg (A5E), ezetimibe 10 mg (E), atorvastatin 5 mg (A5), and atorvastatin 10 mg (A10). Clinical and laboratory examinations were performed at baseline, and at 4-week and 8-week follow-ups. The primary endpoint was percentage change from baseline in low-density lipoprotein (LDL) cholesterol levels at the 8-week follow-up. Secondary endpoints included percentage changes from baseline in additional lipid parameters.

RESULTS

Baseline characteristics were similar among the study groups. At the 8-week follow-up, percentage changes in LDL cholesterol levels were significantly greater in the A5E group (49.2%) than in the E (18.7%), A5 (27.9%), and A10 (36.4%) groups. Similar findings were observed regarding the percentage changes in total cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B levels. Triglyceride levels were also significantly decreased in the A5E group than in the E group, whereas high-density lipoprotein levels substantially increased in the A5E group than in the E group. In patients with low- and intermediate-cardiovascular risk, 93.3% achieved the target LDL cholesterol levels in the A5E group, 40.0% in the E group, 66.7% in the A5 group, and 92.9% in the A10 group. In addition, 31.4% of patients in the A5E group, 8.1% in E, 9.7% in A5, and 7.3% in the A10 group reached the target levels of both LDL cholesterol < 70 mg/dL and reduction of LDL ≥ 50% from baseline.

CONCLUSIONS

The addition of ezetimibe to low-intensity atorvastatin had a greater effect on lowering LDL cholesterol than moderate-intensity atorvastatin alone, offering an effective treatment option for cholesterol management, especially in patients with low and intermediate risks.

Impact of Atrial Fibrillation on Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI): The K-TAVI Registry

PURPOSE

The incidence and prognostic implications of atrial fibrillation (AF) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are controversial, especially for Korean patients. Furthermore, the pattern of antithrombotic therapy for these patients is unknown. The present study sought to identify the impact of AF on Korean patients undergoing TAVI and demonstrate the status of antithrombotic therapy for these patients.

MATERIALS AND METHODS

A total of 660 patients who underwent TAVI for severe AS were recruited from the nationwide K-TAVI registry in Korea. The enrolled patients were stratified into sinus rhythm (SR) and AF groups. The primary endpoint was all-cause death at 1-year.

RESULTS

AF was recorded in 135 patients [pre-existing AF 108 (16.4%) and new-onset AF 27 (4.1%)]. The rate of all-cause death at 1 year was significantly higher in patients with AF than in those with SR [16.2% vs. 6.4%, adjusted hazard ratio (HR): 2.207, 95% confidence interval (CI): 1.182-4.120, p=0.013], regardless of the onset timing of AF. The rate of new pacemaker insertion at 1 year was also significantly higher in patients with AF than in those with SR (14.0% vs. 5.5%, adjusted HR: 3.137, 95%CI: 1.621-6.071, p=0.001). Among AF patients, substantial number of patients received the combination of multiple antithrombotic agents (77.8%), and the most common combination was that of aspirin and clopidogrel (38.1%).

CONCLUSION

AF was an independent predictor of 1-year mortality and new pacemaker insertion in Korean patients undergoing TAVI.

Incidence, Relevant Patient Factors, and Clinical Outcomes of the Misdiagnosis of ST-Segment-Elevation Myocardial Infarction: Results From the Korea Acute Myocardial Infarction Registry

Background Data on the incidence, relevant patient factors, and clinical outcomes of the misdiagnosis of ST-segment-elevation myocardial infarction (STEMI) in the modern era of percutaneous coronary intervention are limited. Methods and Results Data from KAMIR (Korea Acute Myocardial Infarction Registry) between November 2011 and June 2020 were analyzed. Out of 28 470 patients with acute myocardial infarction, 11 796 were eventually diagnosed with STEMI following a coronary angiogram. They were classified into 2 groups: patients with an initial working diagnosis of STEMI before starting the initial treatment and patients with an initial working diagnosis of non-STEMI (misdiagnosed group). Out of 11 796 patients with a final diagnosis of STEMI, 165 (1.4%) were misdiagnosed. The door-to-angiography time in the misdiagnosed group was 5 times longer than that in the timely diagnosed group (median 220 [interquartile range {IQR}, 66-1177] versus 43 [IQR, 31-58] minutes; P<0.001). In a multivariable adjustments model, patients with a history of heart failure, atypical chest pain, anemia, or symptom-to-door time ≥4 hours had significantly higher odds, whereas those with systolic blood pressure <100 mm Hg or anterior ST elevation or left bundle-branch block on ECG had lower odds of STEMI misdiagnosis. For patients with culprit lesions in the left anterior descending artery (n=5838), the adjusted 1-year mortality risk for STEMI misdiagnosis was 1.84 (95% CI, 1.01-3.38). Conclusions Misdiagnosis of STEMI is not rare and is associated with a significant delay in coronary angiography, resulting in increased 1-year mortality for patients with culprit lesions in the left anterior descending artery.

Association between early rhythm control and the risk of dementia in patients with atrial fibrillation and prior history of stroke: a nationwide population-based study

Background

Patients with atrial fibrillation (AF) who experienced stroke before are at high risk for dementia. Although early rhythm control in patients with AF reduces the risk of stroke, there is a lack of evidence on whether early rhythm control reduces the risk of developing dementia in patients with new-onset AF and a history of prior stroke.

Purpose

To compare the risk of dementia between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke

Methods

Using the Korean nationwide claims database, we identified patients who were newly diagnosed as AF and had a history of prior stroke. Patients with prevalent dementia were excluded. Patients who received rhythm control therapy, including antiarrhythmic drug, direct current cardioversion, or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, otherwise as the usual care group. The inverse probability of treatment weighting method was used to balance baseline characteristics between the two groups. The incidence of all dementia, Alzheimer dementia, and vascular dementia were evaluated during follow-up.

Results

A total of 41,370 patients were included (mean age, 70±11 years; mean CHA2DS2-VASc score 5.3±1.6; 43% female); 10,213 were in the early rhythm control group and 31,157 in the usual care group. All patients received oral anticoagulants. During a median 2.7 years of follow-up, 6414 patients developed incident dementia (incidence rate, 4.9 per 100 person-years). Compared to usual care, early rhythm control was associated with lower risks of all dementia, Alzheimer dementia, and vascular dementia (weighted hazard ratio [95% confidence interval], 0.825 [0.776–0.876], 0.831 [0.774–0.893], and 0.800 [0.702–0.913], respectively, all p&lt;0.001) (Figure 1). The beneficial effect of early rhythm control on the risk of dementia were consistent regardless of the characteristics of prior stroke, for example, recent stroke within 6-month from their enrollment, disabling stroke that required continuous rehabilitation therapy, and severe stroke causing intensive care unit admission.

Conclusion

Early rhythm control within 1 year after AF diagnosis might be beneficial to prevent dementia in patients with incident AF and a history of stroke. To prevent progression of further cognitive dysfunction, early rhythm control should be considered in these patients.

Funding Acknowledgement

Type of funding sources: None.

Comparison of adhesive single-lead ECG device and Holter test for atrial fibrillation monitoring

Background

There is insufficient validation of diagnostic benefits of extended monitoring with an adhesive single-lead ECG device compared to Holter test for routine medical care of AF patients.

Purpose

The study aimed to compare AF detection rates between 72-hour monitoring using an adhesive single-lead ECG device (mobiCARE MC-100, Seers Technology, Republic of Korea) and 24-hour Holter test among AF patients at outpatient clinics.

Methods

A total of 200 AF patients indicated for Holter test at cardiology outpatient clinics enrolled in the study. Study participants equipped both Holter and MC-100 for the first 24 hours (Figure 1). After then, only MC-100 continued ECG monitoring for additional 48 hours. AF detection during the first 24 hours was compared between two devices. The diagnostic benefits of extended monitoring with MC-100 were evaluated.

Results

During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20.0%) patients (20 patients with paroxysmal and persistent AF each). Compared to 24-hour Holter, MC-100 increased AF detection rate by 1.5-fold (58/200; 29.0%) and 1.6-fold (64/200; 32.0%) with 48- and 72-hour monitoring, respectively (Figure 2A). With MC-100, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) for 24-, 48-, and 72-hour monitoring. Compared to 24-hour Holter, 72-hour monitoring with MC-100 increased the detection rate of paroxysmal AF by 2.2-fold (44/20). If only the episodes lasting over 30 seconds were counted as AF with MC-100, the detection rate of paroxysmal AF was decreased by 9.1% (Figure 2B).

Conclusion

Compared to Holter, AF detection rates could be improved with an adhesive single-lead device, especially for patients with paroxysmal AF. This device is expected to be useful for AF detection among patients whose conventional ECG tests were ineffective in documenting AF episodes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety)

The left atrial low-voltage area and persistent atrial fibrillation treated with pulmonary vein isolation alone

Background

There are limited data regarding the association between the burden of the left atrial low-voltage area (LVA) and the outcome of pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (PeAF).

Purpose

The study aimed to investigate the impact of the burden of LVA on the patients with PeAF treated with PVI alone.

Methods

Using a retrospective cohort of PeAF patients who underwent PVI alone, both clinical and the left atrial voltage mapping data were reviewed. LVA was defined as an area of ≤0.5 mV (bipolar) when mapped during sinus rhythm and ≤0.2 mV during AF. The high burden of LVA was defined as a case when the LVA constitutes ≥10% of the total left atrial body area. The patients were categorized into either the high or low burden groups. The recurrence of any atrial tachyarrhythmia was followed up, and multivariable Cox's regression analysis was performed.

Results

A total of 50 and 25 patients were investigated for the low burden (LVA&lt;10%) and high burden (LVA≥10%) groups, respectively. Compared to the low burden group, the high burden group had a significantly less male proportion (56.0% versus 78.0%), a higher CHA2DS2-VASc score (median 3 versus 2), more chronic kidney disease (16.0% versus 2.0%), and a higher burden of LVA (20±11% versus 5±3%). During the median follow-up of 9.5 (6.2–16.2)months, there were 30.0% and 48.0% ofrecurrences for the low and high burden groups, respectively. Compared to the low burden group, the high burden group was associated with higher risks of both early and late recurrences (HR [95% CI] =2.67 [1.15–6.18] and 2.08 [1.03–4.20], respectively) (Figure 1). The best cut-off of LVA to predict 2-year recurrence was 10.1% (Figure 2).

Conclusion

The high burden of LVA was significantly associated with an increased risk of recurrence among PeAF patients treated with PVI alone. Tailored ablation in addition to PVI would be needed to improve outcomes in patients with PeAF having a high burden of LVA.

Funding Acknowledgement

Type of funding sources: None.

A synergistic impact of early rhythm control and lifestyle modification on the risk of stroke in patients with new-onset atrial fibrillation: a Korean nationwide population-based cohort study

Background

Early rhythm control therapy and lifestyle modification have both been associated with a lower risk of stroke in patients with atrial fibrillation (AF). Although guidelines have emphasized integrated care for patients with AF to improve clinical outcomes, the synergistic impact of early rhythm control therapy and lifestyle modification on the risk of stroke is unclear.

Purpose

To evaluate the impact of the combination of early rhythm control therapy and lifestyle modification on the risk of stroke

Methods

Based on data from the Korean National Health Insurance Service database, we included patients with new-onset AF between January 2009 and December 2016. Based on questionnaires from health checks, patients with ≥2 healthy lifestyle behaviors among quitting smoking, abstaining from alcohol, and performing regular exercise were defined as “healthy lifestyle” group. Patients who received rhythm control therapy within 2-year after new-onset AF were defined as the early rhythm control group. With a two-by-two factorial design, patients were categorized into 4 groups as follows: (i) those without early rhythm control and healthy lifestyle (group 1); (ii) those with a healthy lifestyle but without early rhythm control (group 2); (iii) those with early rhythm control but without healthy lifestyle (group 3); and (iv) those with both early rhythm control and healthy lifestyle (group 4). The primary outcome was stroke.

Results

Among a total of 208,662 patients, 46,972, 110,479, 15,133, and 36,078 patients were included in group 1, 2, 3, and 4, respectively. For the early rhythm control group, the mean duration from AF diagnosis to rhythm control therapy was 27±76 days. During a median follow-up of 4.2 years, 9905 patients had an incident stroke (incidence rate, 10.6 per 100 person-years). After multivariable adjustment, compared to group 1, group 2 (healthy lifestyle only) and group 3 (early rhythm control only) were associated with a lower risk of stroke (HR and 95% CI: 0.769, 0.728–0.881, and 0.774, 0.703–0.852, respectively) (Figure 1). Group 4 with early rhythm control and a healthy lifestyle had the lowest risk of stroke among all groups (HR 0.575, 95% CI 0.536–0.617 compared to group 1) (Figure 1). After propensity score (PS) weighting for group 2 and 4, additional early rhythm control based on healthy lifestyle was associated with a lowered risk of stroke by 22% (Figure 2). After PS weighting between groups 3 and 4, additional lifestyle modification based on early rhythm control was associated with a lowered risk of stroke by 27% (Figure 2).

Conclusion

In this large-scale observational cohort study, early rhythm control therapy and healthy lifestyle behavior might reduce the risk of stroke in patients with new-onset AF, consistent with the results from recent randomized clinical trials. Furthermore, implementing both early rhythm control therapy and a healthy lifestyle could synergize stroke prevention in these populations.

Funding Acknowledgement

Type of funding sources: None.

Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: a systematic review and meta-analysis

Background

The concurrent use of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients may be associated with a lower risk of gastrointestinal bleeding (GIB), but evidence is still conflicting according to individual OACs.

Purpose

We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy.

Methods

A systematic search of PubMed, EMBASE, and Cochrane was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. We calculated pooled estimates of GIB risk by a random-effect meta-analysis and reported as odds ratios (OR) and 95% CI. Stratified analyses according to the origin of GIB, ethnic groups, individual OACs, and the presence of underlying GIB risk factors were performed.

Results

A total of 10 studies (1 randomized controlled study and 9 observational studies) and 1,970,931 patients who received OAC were included. OAC and PPI co-therapy were associated with a lower risk of total GIB, and major GIB; OR (95% CI) was 0.67 (0.62–0.74) for total GIB and 0.68 (0.63–0.75) for major GIB, respectively. Among total GIB, only the risk of upper GIB was lower with OAC and PPI co-therapy (OR 0.67, 95% CI 0.64–0.70). No difference in the lower risk of primary GIB outcomes of PPI co-therapy was observed between Asians and non-Asians (p-for-difference, total GIB=0.695, major GIB=0.748, respectively) and among individual OACs except for edoxaban. The protective effect of PPI on total GIB was more significant in high-risk patients, defined as those with concurrent medication of antiplatelets or non-steroidal anti-inflammatory drugs (OR 0.62, 95% CI 0.52–0.73) and presence of high bleeding risk factors such as previous GIB history, HAS-BLED score ≥3, or underlying gastrointestinal diseases. (OR 0.65, 95% CI 0.61–0.70).

Conclusion

In patients who receive OAC, the use of PPI co-therapy was associated with a lower risk of total GIB and major GIB irrespective of ethnic group and OAC type except for edoxaban. PPI co-therapy can be considered particularly in patients on concomitant NSAID and antiplatelet use or patients with high GIB risk factors.

Funding Acknowledgement

Type of funding sources: None.

Increased risk of atrial fibrillation in patients with uterine fibroids: a nationwide population-based study

Background

Uterine fibroid, the most common benign neoplasm of the uterus, is associated with an elevated risk of cardiovascular disease. The link between incident atrial fibrillation (AF) and the uterine fibroid is unclear because earlier studies focused primarily on the development of atherosclerosis and hypertension. We aimed to investigate the risk of AF in patients with uterine fibroid.

Methods

This is a retrospective cohort study using the Korean National Health Insurance Service database (NHIS). From 2009 to 2012, a total of 2,574,349 women (20 to 40 years old) who underwent general health examinations were included. Diagnosis of uterine fibroids and surgical treatment status was defined by the international classification of diseases, 10th revision codes, and procedural codes from the Korean NHIS. The primary outcome was newly diagnosed AF. The risk of AF according to the uterine fibroids and their surgical treatment status was evaluated using Cox proportional-hazard models.

Results

Of the total population, the mean age was 29.76±4.27 years, and 20,682 (0.8%) were identified to have uterine fibroid. Incident AF was identified in 3,868 patients (61 in the fibroid group, 3,807 in the control group) during a mean follow-up of 7.3±1.1 years. Patients of the uterine fibroid group showed a higher incidence of AF compared to the control group (0.41 and 0.20 per 1000 person-years, respectively, Figure 1). Multivariate Cox-regression analysis presented that uterine fibroid was an independent risk factor of AF: hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.16–1.93, p=0.002. Compared to the control group, uterine fibroid patients who underwent surgical treatment tend to show a lower risk for AF (HR 1.22, 95% CI 0.79–1.90) than patients without surgical treatment (HR 1.69, 95% CI 1.24–2.30), though statistical significance was indeterminate (Figure 2). After propensity score matching, patients of the uterine fibroid group showed higher risk of AF when compared to the control group (HR 1.77, 95% CI 1.32–2.63, p&lt;0.001), which was in line with our main results. The presence of uterine fibroid was consistently associated with higher risk of AF among all subgroups except for the stroke subgroup.

Conclusion

Patients with uterine fibroids are predisposed to an increased risk of AF compared to the control group. Careful monitoring of arrhythmia development would be warranted in patients of uterine fibroid and surgical treatment as it is associated with a modest risk decrement of incident AF.

Funding Acknowledgement

Type of funding sources: None.

Paradoxical association between lipid levels and incident atrial fibrillation according to statin usage

Background

In epidemiology studies, a higher level of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) is associated with a lower risk of atrial fibrillation (AF). Statin use might exert possible confounding effects in the paradoxical relationship; however, the inverse link between AF and cholesterol level that distinguishes statin users from non-users has not been evaluated.

Objective

We investigated the epidemiological relationships of TC–AF and LDL-C–AF in statin users and non-users, respectively.

Methods

From the Korean National Health Insurance Service database, we included 9,778,014 adults who underwent a health examination in 2009 and had no prior AF history. The levels of TC and LCL-C at the health exam were categorized in quartile (Q) and decile (D) values of the total study population. The study population was grouped into statin users and non-users, and TC–AF and LDL-C–AF relationships were evaluated.

Results

867,336 (8.9%) were on statin use among the total population. Statin users showed higher TC level (208.4±55.6 vs. 194.1±39.5 mg/dL, p&lt;0.001) and LDL-C level (123.0±102.2 vs. 121.3±226.3, p&lt;0.001) compared to non-users. Inverse associations of TC–AF and LCL-C–AF were observed; higher levels of TC and LDL-C were associated with a lower risk of AF. The hazard ratios (HR) and 95% confidence intervals (CI) were 0.797 (0.786–0.809) for the highest quartile of TC (Q4, TC ≥218) and 0.832 (0.82–0.843) for the highest quartile of LDL-C (Q4, LDL-C ≥135) when adjusted by age, sex, lifestyle behaviors, comorbidities, and low-income status. Statin users exhibited higher AF incidence rate than non-statin users, but the association in statin users generally tracked that seen among non-statin users demonstrating similar HR in Q4 of TC [0.812 (0.790–0.835) for statin users and 0.812 (0.798–0.826) for non-statin users] and LDL-C [0.842 (0.819–0.865) for statin users and 0.849 (0.835–0.863) for non-statin users].

Conclusion

The paradoxical relationship between lipid levels (TC and LDL-C) and incident AF remained consistent both in statin users and non-users. Further research is required to investigate an underlying mechanism for the cholesterol paradox of AF which still seems evident despite the pleiotropic effects of statin.

Funding Acknowledgement

Type of funding sources: None.

Fish oil supplements increase atrial fibrillation risk in healthy individuals: a population-based cohort study and Mendelian randomization analysis

Background

There is a paucity of information on the risk of atrial fibrillation (AF) in healthy individuals taking fish oil supplements.

Purpose

We aimed to investigate the epidemiologic and causal relationships between fish oil supplement intake and the long-term risk of AF.

Methods

From the population-based UK Biobank, we selected healthy individuals without a history of AF, other cardiac arrhythmias, or cardiovascular diseases, who were not taking lipid-lowering medications or dietary supplements other than fish oil. The 10-year risk of AF in Fish-Oil-Users vs. Non-Users was evaluated in the total population and propensity-score matched cohort. The causal relationship between n-3 polyunsaturated fatty acids (PUFA) and AF was evaluated using a two-sample summary-level Mendelian randomization analysis with fixed effects robust inverse-variance weighted method, using genetic instruments from previous studies genome-wide association studies for n-3 PUFA levels and AF, respectively.

Results

A total of 338,199 participants (aged 55.2±8.1, 44.3% men) were analysed. Of these, 35.0% (n=118,300) was taking fish oil supplements. The 10-year risk of AF was significantly higher in the Fish-Oil-Users than in the Non-Users (3.83% vs. 2.91%, adjusted hazard ratio [HR] 1.05, 95% CI [1.01–1.10], P=0.023). The result was consistent in the propensity-score matched cohort (propensity-score matched HR 1.06, 95% CI [1.00–1.12], P=0.043). The increased risk of AF by fish oil supplement was prominent in low-risk participants with healthy lifestyles. Among n-3 PUFA, the docosapentaenoic acid (DPA) showed significant causal estimates for the increased risk of AF (odds ratio [OR] 1.15, 95% CI [1.08–1.22], P&lt;0.001), while higher eicosapentaenoic acid (EPA) levels caused a decrease of AF risk (OR 0.85, 95% CI [0.80–0.90], P&lt;0.001).

Conclusion

Fish oil supplement intake significantly increased the long-term risk of AF in a healthy population. The causal effect of fish oil intake on the risk of AF may depend on the specific types of n-3 PUFA.

Funding Acknowledgement

Type of funding sources: None.

Impact of metabolic syndrome on the risk of ischemic stroke in non-anticoagulated atrial fibrillation patients having low CHA2DS2-VASc scores

Background

Metabolic syndrome (MetS) predisposes to a thromboembolic state. However, conflicting results have been reported on whether MetS confers an increased risk of ischemic stroke in atrial fibrillation (AF), especially in patients with low CHA2DS2-VASc score who are not indicated for oral anticoagulant therapy.

Purpose

We investigated the risk of ischemic stroke according to the presence of MetS, the number of MetS components (metabolic burden), and the individual metabolic components in non-anticoagulated AF patients with low CHA2DS2-VASc score.

Methods

A total of 76,015 oral anticoagulant-naïve AF patients with low CHA2DS2-VASc score (0,1 in male and 1 in female) were included from the Korean National Health Insurance Service database. The status of MetS and individual metabolic components were evaluated based on health examination data within two years of AF diagnosis. We estimated the risk of ischemic stroke according to MetS, metabolic burden, and an individual component of MetS using Cox proportional-hazards models.

Results

The mean age was 49.8±11.1 years and 52,388 (68.9%) were male. The average CHA2DS2-VASc score was 0.7±0.5 and MetS was prevalent among 21,570 (28.4%) of the study population. During a mean follow-up of 5.1 years, ischemic stroke was developed in 1,395 (1.84%) patients. MetS was associated with a higher risk of ischemic stroke after adjustment for age, sex, lifestyle behaviors, low income, and cardiovascular comorbidities: adjusted hazard ratio (aHR) 1.19, 95% confidence interval (CI) 1.06–1.33, p=0.002. A positive linear correlation was observed between metabolic burden and ischemic stroke risk. Patients with five MetS components showed the highest aHR of 1.55 (95% CI 1.14–2.11, Figure 1 and Figure 2), whereas those with a single MetS component had a marginal risk of ischemic stroke (aHR 1.18, 95% CI 0.99–1.41). Among individual metabolic components, elevated blood pressure and increased waist circumference was significantly associated with an increased risk of ischemic stroke: aHR (95% CI), 1.45 (1.30–1.62), p&lt;0.001, and 1.15 (1.03–1.30), p=0.016, respectively.

Conclusions

Among AF patients initially with CHA2DS2-VASc score 0 and 1 with no anticoagulation, the presence of MetS is associated with an increased risk of ischemic stroke. Given the linear incremental correlation between metabolic burden and ischemic stroke, special attention to the care of metabolic derangements is required in AF patients who are not indicated for anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation detection in ambulatory patients using a smart ring powered by deep learning analysis of continuous photoplethysmography monitoring

Background

Atrial fibrillation (AF) detection could be effective with photoplethysmography (PPG) signal monitoring by a wearable device.

Purpose

We aimed to validate the performance of AF detection among ambulatory patients who underwent electrical cardioversion for AF using a smart ring capable of continuous PPG monitoring and deep learning analysis.

Methods

In this prospective single-arm study, participants who underwent successful electrical cardioversion for AF were enrolled. The participants equipped a smart ring (CardioTracker, Sky Labs Inc., Seongnam, Republic of Korea) after the electrical cardioversion. The smart ring then continuously monitored PPG over 14 days to detect AF recurrence. The smart ring alarmed AF episodes based on deep learning analysis of PPG. The participants were asked to measure at least three daily ECGs using the smart ring to validate AF recurrence detected by PPG. All ECG snapshots were recorded along with lead I and saved with simultaneous PPG. ECG data were examined by the three cardiologists independently (SK, SRL, and EKC). The monitoring time, analyzable proportions of monitored signals, detection rates of AF episodes, and the diagnostic performance of PPG-based deep learning were evaluated. At the end of the monitoring, a survey on the use of the smart ring was performed.

Results

A total of 35 participants (mean age 58.9 years, male 74.3%) were enrolled. Figure 1 illustrates an example of PPG monitoring and PPG-ECG snapshots by the smart ring. The study participation period was a median of 14 days and the wearing time of the smart ring was a median of 9.2 days (IQR 7.1–11.5 days). Signal artifacts during daily activity decreased the analyzable proportions of monitored PPG by 68.5%. Irregular pulse episodes were detected by the smart ring in 29 (82.9%) participants after a median of 1 day from the cardioversion (Figure 2). A total of 2532 PPG-ECG snapshots were acquired and 1623 (64.1%) were interpretable by both the cardiologists (using ECG) and the deep learning analysis (using PPG). Comparing PPG by simultaneous ECG, the performance of AF detection by the smart ring was 98.7% for sensitivity, 97.8% for specificity, 2.2% for false positives, and 1.3% for false negatives (Figure 2). After using the smart ring, 76.9% of the participants responded that they had no discomfort in using the smart ring in daily activity and another 76.9% responded that it was helpful to monitor their disease.

Conclusion

Despite the signal artifacts during daily activity, AF detection with PPG monitoring by a smart ring could be effective for AF screening among ambulatory patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This work was supported by Sky Labs Inc, Seongnam, Republic of Korea, and by the grant No. 0320202040 from the Seoul National University Hospital Research Fund.

Impact of diabetes mellitus on periprocedural and 18-month clinical outcomes in Korean patients requiring rotational atherectomy: results from the ROCK Registry

BACKGROUND

Diabetes mellitus (diabetes) increases the risk of severe coronary artery calcification, which increases the complexity of percutaneous coronary intervention requiring rotational atherectomy (RA) by interfering with lesion preparation, and limiting final stent expansion.

OBJECTIVE

Investigate 30-day and 18-month clinical outcomes in patients with and without diabetes treated with percutaneous coronary intervention requiring RA.

DESIGN

Medical record review SETTING: Multicenter registry in South Korea PATIENTS AND METHODS: The ROtational atherectomy in Calcified lesions in Korea (ROCK) registry was a large, retrospective, multicenter study to assess RA treatment of severe coronary artery calcification.

MAIN OUTCOME MEASURES

The primary endpoint was target-vessel failure including cardiac death, target-vessel myocardial infarction, and target-vessel revascularization.

SAMPLE SIZE

540 patients followed for a median of 16.1 months.

RESULTS

Of the 540 patients, 305 had diabetes (56.5%). The diabetes group had a significantly higher frequency of multivessel disease; comorbidities such as hypertension, dyslipidemia, and chronic kidney disease; and lower ejection fraction of the left ventricle compared to the non-diabetes group (n=235). There were no significant differences in procedure success and complications observed between the two groups. Target vessel failure at 30 days between the diabetes and non-diabetes groups was not statistically significant in a multivariate Cox regression analysis (1.6% vs. 2.6%, adjusted hazard ratio [HR] 0.595, 95% confidence interval [CI] 0.154-2.300, P=.451). During an 18-month follow-up, the risk of target vessel failure was higher (12.5% vs. 8.9%) but the difference was not statistically significant (adjusted HR 1.393, 95% CI 0.782-2.482, P=.260).

CONCLUSIONS

Patients with diabetes have a risk of complications comparable to patients without diabetes, and 30-day and 18-month clinical outcomes are similar in severe coronary artery calcification requiring RA, despite having more comorbidities.

LIMITATIONS

Retrospective design. Sample size not based on power calculation.

CONFLICT OF INTEREST

None.

Predictors of recurrent acute myocardial infarction despite successful percutaneous coronary intervention

BACKGROUND/AIMS

Recurrent acute myocardial infarction (AMI) is an adverse cardiac event in patients with a first AMI. The predictors of recurrent AMI after the first AMI in patients who underwent successful percutaneous coronary intervention (PCI) have not been elucidated.

METHODS

We analyzed the data collected from 9,869 patients (63.2 ± 12.4 years, men:women = 7,446:2,423) who were enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health between November 2011 and October 2015, had suffered their first AMI and had received successful PCI during the index hospitalization. Multivariable logistic regression analysis was performed to identify the independent predictors of recurrent AMI following the first AMI.

RESULTS

The cumulative incidence of recurrent AMI after successful PCI was 3.6% (359/9,869). According to the multivariable logistic regression analysis, the significant predictive factors for recurrent AMI were diabetes mellitus, renal dysfunction, atypical chest pain, and multivessel disease.

CONCLUSION

In this Korean prospective cohort study, the independent predictors of recurrent AMI after successful PCI for the first AMI were diabetes mellitus, renal dysfunction, atypical chest pain, and multivessel disease.

Skin manifestations and clinical features of drug reaction with eosinophilia and systemic symptoms (DRESS): A retrospective multicenter study of 125 patients

BACKGROUND

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction generally accompanied by skin manifestations as the first and most frequent symptoms. However, skin manifestations and associated clinical features of DRESS have not been fully explored and evaluated.

OBJECTIVES

This study aimed to describe the skin manifestations of DRESS in detail and analyze their association with demographic characteristics and extra-cutaneous clinical features.

METHODS

We conducted this retrospective study on patients with DRESS diagnosed between September 2009 and August 2021 at three medical institutes and validated using the RegiSCAR score. Data regarding demographics, skin manifestations, and clinical characteristics were retrieved through thorough chart reviews.

RESULTS

Among 182 potential cases of DRESS, the validated 125 cases were analyzed. A widespread rash extending over more than 50% of the body surface area was observed in 122 patients (97.6%) and typical facial edema was experienced by 67 patients (53.6%). Polymorphous maculopapules were the most common rash morphology (106, 84.8%): specifically, exfoliative (59, 47.2%), urticarial (57, 45.6%), and purpuric forms (39, 31.2%) were common. Mucosal involvement was observed in 41 patients (32.8%). Patients with carboxamide antiepileptics (carbamazepine and oxcarbazepine) experienced more edema (P = .014) and typical facial edema than those with allopurinol (P = .021). The RegiSCAR score was higher in patients with purpura (P < .01).

CONCLUSIONS

Skin manifestations of DRESS exhibit a wide range of skin lesions and can vary according to the culprit drugs. Early suspicion and prompt intervention are needed to improve prognosis.

The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study

Funding Acknowledgements

Type of funding sources: None.

Background

Although the prevalence of atrial fibrillation (AF) is increasing worldwide, little is known about the exact risk factors of AF; and the disease"s association with socioeconomic status (SES) is under debate.

Purpose

This study aimed to examine the association between SES and the risk of AF in Korean patients with diabetes mellitus.

Methods

We studied 2,429,610 diabetic patients (mean age 56.9 years, female 40%) who underwent health check-ups from 2009 to 2012, using the National Health Insurance Service (NHIS) database of Korea. Subjects were categorized into 6 groups according to the number of times (0 through 5) entitled for medical aid (MA) recipient, within the past 5 years from the date of check-up. (Fig. 1)

Division of Medical Care Assistance in the Ministry of Health and Welfare selects the medical aid beneficiaries. The recipients should not have a reliable caregiver, nor their income be more than 40% of the standard median income.

Among the study population, 64,818 were classified as MA group: 10,697 in MA 1, 11,005 in MA 2, 12,431 in MA 3, 10,689 in MA 4, 19,996 in MA 5, respectively. The remaining 2,364,792 were never entitled to MA recipients within 5 years and were assigned to the non-MA group. The incidence rate and hazard ratio of AF were then calculated for each group.

Results

Risk factors for cardiovascular disease were measured at baseline. More current smokers were in MA 5 group (28.7% in MA 5, 26.7% in non-MA, 26.2% in MA 1, 23.8% in MA 2, 23% in MA 3, 23.2% in MA 4, respectively, p &lt; 0.001), while more heavy drinkers were in the non-MA group than among the MA groups (20.7% vs. 6.2–7.9%, p &lt; 0.001).

Hypertension and dyslipidemia were generally higher in MA groups than in the non-MA group (hypertension, 60.8–65.8% in MA groups vs. 54.8% in non-MA group; dyslipidemia, 44.1–54.9% in MA groups vs. 39.6% in non-MA group, all, p &lt; 0.001), and the non-MAs tended to do more physical activities (20.7% vs. 15.4–15.8%, p &lt; 0.001). Obese people with BMI≥30 were more in MA groups, especially in the MA 5, than in the non-MA group (7.5% in non-MA, 9.3%–9.7% in MA 1–4, and 12.2% in MA 5, all, p &lt; 0.001).

80,257 were newly identified as AF in the retrospective 5 years. All the MA groups showed a higher risk of AF than the non-MA group: hazard ratio (95% confidence interval [CI]) for each group, 1.44 (1.32–1.58) in MA 1, 1.58 (1.45–1.73) in MA 2, 1.52 (1.39–1.65) in MA 3, 1.53 (1.40–1.68) in MA 4, and 1.35 (1.24–1.45) in MA 5. Adjusting with multi-variables, the MA 5 showed 54% increased risk of AF compared to the non-MA group (HR, 1.54, [95% CI, 1.42–1.67]). (Fig. 2)

Conclusion

The risk of AF increased more than 50% in patients who needed medical aid 5 years in a row, and the risk also rose greatly in patients with only a short experience of socioeconomic hardship. Based on the findings, we need more attention to individuals with recent socioeconomic deprivation to provide timely management for AF and its complications. Abstract Figure. Fig. 1

Characterizing patients with newly diagnosed atrial fibrillation compared to those with established atrial fibrillation: data from the CODE-AF registry

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare

OnBehalf

CODE-AF investigator

Background/Introduction: The characteristic of atrial fibrillation (AF), such as the risk of complications, may differ depending on the time after diagnosis.

Purpose

This study aimed to compare the baseline characteristics according to the AF diagnosis duration using a large multicenter prospective registry: CODE-AF (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation).

Methods

A total of 10,021 patients with AF were enrolled between May 2016 to March 2021. We defined patients into two groups: the newly diagnosed (AF duration less than 3 months before enrollment) and the established (AF duration more than 3 months before enrollment) AF groups. We compared the baseline characteristics and the incidence of the composite outcomes (stroke, all-bleeding, heart failure and all-cause death) during follow-up period between the two groups. The survival analysis was performed using Kaplan-Meier curve analysis with validation by log-rank test.

Results

Among the 10,021 patients with AF (age 67.0 ±14.5 years, female 35.7%), patients with newly diagnosed AF were 2181, and those with established AF were 7840. Two groups did not differ between sex, weight, height, and body mass index. The newly diagnosed AF group was younger with higher tobacco and alcohol consumption compared to the established AF group. The established AF group had more comorbidities at the time of enrollment. Also, CHA2DS2-VASc score (2.36 ±1.64 vs. 2.68 ±1.67, p &lt;0.001) and HAS-BLED score (1.55 ±1.02vs. 1.86 ±1.06 p &lt;0.001) were both higher in established AF. The newly diagnosed AF group had a lower proportion of oral anticoagulation prescription (68.6% vs. 73.0%, p &lt;0.001), whereas prescription of non-vitamin K antagonist oral anticoagulants was higher compared to those with established AF (75.7% vs. 68.9%, p &lt;0.001) (Table). There was no significant difference in the event-free survival during the overall follow-up period on the composite outcomes. However, the newly diagnosed AF group showed a significantly higher risk of the composite outcomes within 90 days of enrollment than the established AF group (hazard ratio 2.01, 95% confidence interval 1.48 to 2.72) (Figure).

Conclusion

The newly diagnosed AF group showed different characteristics compared to the established AF group. Also, the composite clinical outcomes, including stroke, bleeding, heart failure, and all-cause death, had occurred more frequently during the early period after diagnosis in the newly diagnosed AF group. For the better clinical outcome of patients with newly diagnosed AF, structured assessment and comprehensive management is needed, especially during the early period after diagnosis. Abstract Figure.

Prognostic Value of Baseline Neutrophil-to-Lymphocyte Ratio Combined With Anemia in Patients With ST-Segment Elevation Myocardial Infarction: A Nationwide Prospective Cohort Study

Objective

Data pertaining to the prognostic value of the combination of high neutrophil-to-lymphocyte ratio (NLR) and anemia on admission in patients with ST-segment elevation myocardial infarction (STEMI) are limited. The objective of this study was to investigate the clinical value of baseline NLR in combination with anemia in predicting clinical outcomes after STEMI.

Methods

A total of 5,194 consecutive patients with STEMI within 12 hours of symptom onset from the Korea Acute Myocardial Infarction Registry-National Institute of Health database between 2011 and 2015 were categorized into 4 groups according to their NLR and hemoglobin levels: low NLR (<4) without anemia (n=2,722; reference group); high NLR (≥4) without anemia (n=1,527); low NLR with anemia (n=508); and high NLR with anemia (n=437). The co-primary outcomes were 180-day and 3-year all-cause mortality.

Results

Mortality rates significantly increased at the 3-year follow-up across the groups (3.3% vs. 5.4% vs. 16.5% vs. 21.7% for 180-day mortality and 5.3% vs. 9.0% vs. 23.8% vs. 33.4% for 3-year mortality; all p-trends <0.001). After adjusting for baseline covariates, the combination of high NLR and anemia was a significant predictor of 180-day mortality after STEMI with low NLR and no anemia as the reference (adjusted hazard ratio, 2.16; 95% confidence interval, 1.58–2.95; p<0.001). Similar findings were observed for the 3-year mortality.

Conclusions

This nationwide prospective cohort study showed that the combination of high NLR (≥4) and anemia is a strong predictor of all-cause mortality after STEMI.

Net clinical benefit of direct oral anticoagulants in very elderly and high bleeding risk patients with atrial fibrillation who are often excluded from oral anticoagulation therapy: a nationwide popul

Background

In the Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial, low-dose edoxaban (15mg once daily) showed better efficacy for stroke prevention and positive net clinical benefit compared to placebo in very elderly and high bleeding risk patients with atrial fibrillation (AF) who often excluded from oral anticoagulation (OAC) therapy. However, there are limited data to generalize the ELDERCARE-AF results into daily practice.

Purpose

To investigate the optimal OAC strategy for the best net clinical benefit in ELDERCARE-AF-like patients.

Methods

Using the Korean nationwide claims database, we included patients with incident non-valvular AF aged 80 years or older between 2014 and 2017. Among these, patients with one or more of the following criteria were finally included in the analysis: a low creatinine clearance (15 to 30 mL/min), a history of bleeding from a critical area or organ or gastrointestinal bleeding, low body weight (≤45kg), continuous use of nonsteroidal anti-inflammatory drugs, or current use of an antiplatelet drug. The risks of ischemic stroke, major bleeding, all-cause death, and composite clinical outcome (ischemic stroke+major bleeding+all-cause death) as a measure of net clinical outcome were evaluated during follow-up. The inverse probability of treatment weighting (IPTW) method was used to balance covariates between the groups.

Results

A total of 23,858 patients were finally included (no OAC, n=16,575; warfarin, n=2390; and direct oral anticoagulants (DOACs), n=4893, respectively). Among DOAC group, 69% used low-dose including rivaroxaban 15 mg once daily, dabigatran 110 mg twice daily, apixaban 2.5 mg twice daily, and edoxaban 30 mg once daily and 9% used very low dose including rivaroxaban 10 mg once daily and edoxaban 15 mg once daily (Figure). Median follow-up duration was 2 years (interquartile ranges, 1 to 3 years). Baseline characteristics were well-balanced after IPTW. Compared to the no OAC group, the DOAC group was associated with a lower risk of ischemic stroke (hazard ratio [HR], 95% confidence interval [CI]: 0.81, 0.68–0.95) and all-cause death (0.90, 0.85–0.95), and a higher risk of major bleeding (1.43, 1.20–1.69) (Figure). Patients treated with DOAC showed a lower risk of composite clinical outcome compared to those without OAC treatment (0.93, 0.88–0.98). Warfarin treatment did not reduce the risk of ischemic stroke (1.03, 0.85–1.23) and all-cause death (1.05, 0.99–1.12), but increased the risk of major bleeding (1.60, 1.32–1.92) and the composite clinical outcome (1.08, 1.02–1.15) compared to no OAC group.

Conclusion

In very elderly patients with non-valvular AF who had one or more frail components, DOACs which were currently prescribed in usual clinical practice showed better effectiveness and positive net clinical benefit compared to no OAC treatment. Compared to the latter, warfarin did not show benefit and possible harm.

Funding Acknowledgement

Type of funding sources: None.

Dual antithrombotic therapy on early clinical outcomes in patients with atrial fibrillation after percutaneous coronary intervention: a nationwide study in the era of NOAC

Background/Introduction

Recent evidence has confirmed low bleeding risk with double antithrombotic therapy, combining oral anticoagulant (OAC) and single platelet inhibitor, in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Among the Asian AF population, most of the patients received dual antiplatelet therapy (DAPT) without OACs, even after the introduction of non-vitamin K oral anticoagulants (NOACs).

Purpose

The current nationwide study assessed 3-month ischemic and bleeding risks of DAPT in comparison to triple antithrombotic therapy among the Korean AF population undergoing PCI.

Methods

We analyzed the claims records of 11,039 patients (mean age 70 years, 66.3% male, and mean CHA2DS2-VASc score 3.2) between 2013 to 2018. Patients were categorized into triple therapy group with vitamin K antagonists (VKAs-TT), or NOACs (NOACs-TT), and DAPT group according to the antithrombotic therapy after PCI. 3-month risks of ischemic stroke, non-fatal myocardial infarction, any in-hospital death, and major bleeding were compared between groups after baseline adjustment using inverse probability weighting.

Results

A total of 1,786, 1,997, and 7,256 patients were allocated to the VKAs-TT, NOACs-TT, and DAPT groups. The DAPT group had a higher prevalence of prior MI and coronary revascularization, but had lower thromboembolic and bleeding risks than the triple antithrombotic therapy groups (mean CHA2DS2-VASc score 3.8, 4.1, and 3.5; and mean HAS-BLED score 3.3, 3.4, and 3.1 for VKAs-TT, NOACs-TT, and DAPT groups, respectively). The NOACs-TT group was associated with a lower risk of ischemic stroke (hazard ratio [HR] 0.38, 95% confidence interval [CI] 0.20–0.70) and any in-hospital death (HR 0.70, 95% CI 0.49–0.98) compared with the VKAs-TT group. The DAPT group showed a lower risk of ischemic stroke (HR 0.41, 95% CI 0.27–0.63) and major bleeding (HR 0.55, 95% CI 0.37–0.84) than the VKAs-TT group, especially in patients without prior OAC treatment. The DAPT group showed a comparable ischemic risk against the NOACs-TT group, although the risk of major bleeding was lower in the DAPT group, especially among old age (HR 0.47, 95% CI 0.29–0.78) or OACs-naive patients (HR 0.50, 95% CI 0.29–0.86).

Conclusion

Among the Asian AF population, using short-term DAPT for 3-month after PCI was associated with a lower risk of bleeding without increasing ischemic risk compared to triple antithrombotic therapy with OAC. This may be a therapeutic option in very high bleeding risk patients who have had complex PCI necessitating focus on DAPT in the initial 3 month period.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by grant no 3020200200 from the Seoul National University Hospital Research Fund, by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety) (Project Number: 202013B14), and by the Korea National Research Foundation funded by the Ministry of Education, Science and Technology (grant 2020R1F1A106740). Figure 1Figure 2

Risk of dementia according to smoking cessation after newly diagnosed atrial fibrillation: a nationwide cohort study

Background

Incident atrial fibrillation (AF) is associated with an increased risk of dementia. There are limited data about the impact of smoking cessation after AF diagnosis on the risk of incident dementia.

Purpose

To evaluate the association between changes in smoking status after newly diagnosed AF and the risk of dementia.

Methods

Among patients with new-onset AF between 2010 and 2016, those who received a national health checkup exam within 2 years before and after the AF diagnosis were included. Patients who had prevalent dementia were excluded. Subjects were categorized into 4 groups according to the status of smoking before and after AF diagnosis: (1) never smoker; (2) ex-smoker; (3) quit-smoker after AF diagnosis; and (4) current smoker. The primary outcome was incident dementia during follow-up.

Results

A total of 126,252 patients were included (mean age 63, SD 12.0; men 62%; mean CHA2DS2-VASc 2.7). During a median 3 years of follow-up, dementia occurred in 5,925 patients (1.11 per 1000 person-years [1000PY]) (Alzheimer's dementia 1.5 per 1000 PY and vascular dementia 0.24 per 1000 PY, respectively). Never smokers, ex-smokers, quit-smokers, and current smokers were 52%, 27%, 7%, and 14% of the total study population, respectively. After multivariable adjustment, quit-smokers showed a higher risk of dementia than never smokers (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.03–1.32), but the risk was significantly decreased when compared to current smokers (HR 0.83, 95% CI 0.72–0.95). Alzheimer's dementia and vascular dementia showed consistent results as main (Figure).

Conclusion

All types of smoking were associated with a significantly higher risk of dementia in patients with new-onset AF. Smoking cessation after AF diagnosis showed a lower risk of dementia compared to patients smoking persistently. These findings may support the promotion of smoking cessation to lower the risk of dementia in patients with new-onset AF.

Funding Acknowledgement

Type of funding sources: None.

Clustering of healthy lifestyle behaviors is associated with a lower incidence of adverse events in patients with newly diagnosed atrial fibrillation: a nationwide cohort study

Background

Although unhealthy or healthy lifestyle behaviors tend to be clustered, studies on the risk of clinical outcomes depending on how the lifestyle behaviors are managed after atrial fibrillation (AF) diagnosis remain limited.

Purpose

We aimed to evaluate the association between a cluster of healthy lifestyle behaviors and the risk of adverse outcomes in patients with AF.

Methods

Using the Korean National Insurance Service database, patients who were newly diagnosed as nonvalvular AF between 2009 and 2016 and received national health screening examination within 2-year after AF diagnosis were included. A healthy lifestyle behavior score (HLS) was calculated by assigning 1 point each for “non-current” smoking, for non-drinking, and for performing regular exercise from the self-reported questionnaire in health screening examinations. The primary outcome was defined as major adverse cardiovascular events (MACE), including ischemic stroke, myocardial infarction, and hospitalization for heart failure. The secondary outcomes included individual components of the primary composite outcome and all-cause death.

Results

A total of 208,662 patients were included and 7.1%, 22.7%, 58.6%, and 11.6% were HLS 0, 1, 2, and 3 group, respectively. After multivariable adjustment, patients with HLS 1, 2, and 3 were associated with lower risks of MACE compared to those with HLS 0 (adjusted hazard ratio [95% confidence interval]: 0.788 [0.762–0.855], 0.654 [0.604–0.708], and 0.579 [0.527–0.636], respectively) (Figure). Increased number of healthy lifestyle behaviors were associated with lower risks of ischemic stroke, hospitalization for heart failure, and all-cause death. The risk reduction of healthy lifestyle combinations was consistently observed in various subgroups, regardless of CHA2DS2-VASc score and oral anticoagulant use.

Conclusion

Increased number of healthy lifestyle behaviors were significantly associated with lower MACE and all-cause death risks in patients with new-onset AF. These findings support the promotion of a healthy lifestyle to reduce the risk of adverse events in AF patients.

Funding Acknowledgement

Type of funding sources: None.

Risk of atrial fibrillation in young adults aged 20 to 39 years with isolated diastolic, isolated systolic, and systolic-diastolic hypertension: a nationwide population-based study

Background

There is limited evidence regarding the comparative risks of incident atrial fibrillation (AF) associated with stage 1 isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH), especially amongst young adults aged 20–39 years.

Purpose

To evaluate the association between early-stage of hypertension and AF in young adults aged 20–39 years.

Methods

From the Korean nationwide health screening database, 2,958,544 subjects aged 20–39 years who were not prescribed antihypertensive medication at the index examination in 2009 were included. Subjects were categorized into eight groups according to the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines: normal BP, elevated BP, stage 1 IDH, stage 1 ISH, stage 1 SDH, stage 2 IDH, stage 2 ISH, and stage 2 SDH. The primary outcome was new-onset AF during follow-up.

Results

During a median follow-up of 8.3 years, 7,347 subjects had incident AF (incidence rate, 0.3 per 1,000 person-years). Compared to the normal BP group, stage 1 IDH (adjusted hazard ratio [aHR], 1.160; 95% confidence interval [CI], 1.086–1.240) and stage 1 SDH (1.250; 1.165–1.341) were associated with higher risks of incident AF, but not stage 1 ISH. Stage 2 IDH, ISH, and SDH were associated with higher risks of incident AF by 24%, 37%, and 61%, respectively (Figure).

Conclusion

Among young adults, stage 1 IDH and SDH were associated with higher risks of incident AF compared to normal BP. The risk of incident AF with stage 2 IDH was similar to that of stage 1 SDH. Optimal BP control including diastolic BP is crucial for preventing new-onset AF, even amongst young adults.

Funding Acknowledgement

Type of funding sources: None.

Antithrombotic therapy for patients with atrial fibrillation and stable coronary artery disease of 1-year and 3-year after percutaneous coronary intervention: a nationwide population-based study

Background

In a recent trial, rivaroxaban monotherapy was noninferior for efficacy and superior for safety to rivaroxaban plus single antiplatelet therapy, as antithrombotic therapy for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, there are limited data regarding the comparative effectiveness and safety of oral anticoagulant (OAC) monotherapy versus OAC plus single antiplatelet therapy (SAPT) in real-world practice, especially after the introduction of direct oral anticoagulants (DOAC).

Purpose

To compare the effectiveness, safety, and net clinical benefit of OAC monotherapy to OAC plus SAPT in patients with AF and stable CAD of 1-year and 3-year after percutaneous coronary intervention (PCI) in a contemporary real-world observational cohort.

Methods

Using the Korean nationwide claims database, we included AF patients who underwent PCI from January 1, 2009 to February 28, 2019. Considering dynamic changes of antithrombotic therapy according to the period after receiving PCI, the index antithrombotic treatment was independently defined at the different time after receiving PCI and we conducted two cohort: 1-year and 3-year after PCI. In each cohort, the baseline characteristics of OAC monotherapy and OAC plus SAPT groups were balanced using inverse probability of treatment weighting (IPTW) methods. To assess clinical outcomes, ischemic stroke, myocardial infarction, major bleeding, and composite clinical outcomes of each outcome were analyzed.

Results

In cohort with 1-year after PCI, 678 patients with OAC monotherapy and 3159 patients with OAC plus SAPT were included. In cohort with 3-year after PCI, 1038 patients with OAC monotherapy and 2128 patients with OAC plus SAPT were enrolled. The baseline characteristics were well-balanced after IPTW between the two groups in both cohorts. Among total population, about 45% of patients prescribed DOAC as OAC treatment. Among patients with 1-year after PCI, OAC monotherapy and OAC plus SAPT showed comparable results for ischemic stroke, myocardial infarction, major bleeding, and composite clinical outcomes (Figure). In cohort with 3-year after PCI, OAC monotherapy and OAC plus SAPT showed comparable results for ischemic stroke and myocardial infarction, but OAC monotherapy was associated with a lower risk of the composite clinical outcome (hazard ratio [HR] 0.762, 95% confidence interval [CI] 0.607–0.950), mainly driven by reduction of major bleeding risk (HR 0.762, 95% CI 0.607–0.950) compared to OAC plus SAPT (Figure).

Conclusion

OAC monotherapy might be, at least, comparable choice for patients with AF and stable CAD compared to OAC plus SAPT. In patients with stable CAD more than 3-years after index PCI, OAC monotherapy could be better therapeutic choice to achieve less major bleeding and positive net clinical benefit.

Funding Acknowledgement

Type of funding sources: None.

Lower risk of stroke after alcohol abstinence in patients with incident atrial fibrillation: a nationwide population-based cohort study

Background

In a recent study, alcohol abstinence reduced the atrial fibrillation (AF) recurrence in patients with AF. However, the relationship between alcohol consumption and incident stroke in patients with AF per se remains unclear.

Purpose

To evaluate the association between alcohol consumption status (and its changes) after newly diagnosed AF and the risk of ischaemic stroke.

Methods

Using the Korean nationwide claims and health examination database, we included subjects who were newly diagnosed with AF between 2010 and 2016. Patients were categorized into three groups according to the status of alcohol consumption before and after AF diagnosis: non-drinkers; abstainers from alcohol after AF diagnosis; and current drinkers. The primary outcome was incident ischaemic stroke during follow-up.

Results

Among a total of 97,869 newly diagnosed AF patients, 51% were non-drinkers, 13% were abstainers, and 36% were current drinkers. After inverse probability of treatment weighting, baseline characteristics of three groups were well-balanced. Compared to current drinkers, abstainers and non-drinkers were associated with a lower risk of ischaemic stroke (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.77–0.96 for abstainers and HR 0.75, 95% CI 0.70–0.81 for non-drinkers, respectively). Amongst current drinkers, there was a dose-response relationship between the amount of alcohol consumption and the risk of ischaemic stroke.

Conclusion

Current alcohol consumption was associated with an increased risk of ischaemic stroke in patients with newly diagnosed AF, and alcohol abstinence after AF diagnosis could reduce the risk of ischaemic stroke. Lifestyle intervention, including attention to alcohol consumption, should be encouraged as a part of a comprehensive approach to AF management to improve clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Association between body mass index and the risk of atrial fibrillation and ischemic stroke according to age: a nationwide population-based cohort study

Background

Atrial fibrillation (AF) and ischemic stroke (IS) are two significant cardiovascular diseases that confer an enormous healthcare burden. A limited study comprehensively evaluated the association between full ranges of body mass index (BMI), including underweight, and AF or IS risks, especially in the different age subgroups.

Purpose

We investigated the association between BMI and AF and IS incidence according to the Korean population's age groups.

Methods

This was a nationwide population-based cohort study using data from the Korea National Health Insurance Service, including 9 194 477 healthy adults who underwent a medical examination in 2009. We stratified the study population into three age subgroups: age 20–39 (young, 33.1%), age 40–64 (middle-aged, 56.3%), and age over 65 years (elderly, 10.6%). In each age group, the individuals were categorized based on BMI (kg/m2) into underweight (&lt;18.5), normal (18.5 to &lt;23), overweight (23 to &lt;25), obese I (25 to &lt;30), and obese II (≥30). The first occurrences of AF and IS were followed up until December 31, 2018. According to BMI in each age group, the risks of AF and IS were analyzed by Cox proportional hazards regression with 95% confidence intervals (CI) by adjusting age, sex, lifestyle behaviors, and comorbidities.

Results

Overall, both underweight and higher BMI were associated with an increased risk of AF and stroke across all age groups. The increased risk of AF for patients with obese II was slightly accentuated compared to patients with normal BMI in the young population than elderly population (hazard ratio [HR] 1.78, 95% CI 1.63–1.94 for age 20–39 years; HR 1.55, 95% CI 1.48–1.61 for age ≥65 years, respectively). For underweight individuals, however, the increased risk of AF became more prominent in the elderly: HR and 95% CI was 1.12 (1.07–1.17) in the age over 65 years old, and 1.05 (0.94–1.16) in the age 20–39. Regarding IS, the young group presented a considerable increment in the magnitude of HRs in both underweight and higher BMI groups. However, the association between the BMI and stroke risk became attenuated in the elderly: HRs and 95% CI in underweight and obese II individuals were 1.10 (0.93–1.30) and 2.223 (1.99–2.49) in the age 20–39 group, whereas 0.97 (0.93–1.01) and 1.03 (0.98–1.08) in the age over 65 years old.

Conclusions

Underweight as well as obesity was associated with increased risks of AF and IS in the general population. In both AF and IS, the gradient of risks according to BMI was apparent at young ages; thus, maintaining normal body weight should be warranted in early life. An interplay of several factors other than BMI may contribute to ischemic stroke in the old ages, requiring integrated risk management in older patients.

Funding Acknowledgement

Type of funding sources: None.

Effect of smoking on clinical outcomes in patients receiving rotational atherectomy in calcified coronary lesions: from the ROCK Registry, South Korea

BACKGROUND

Tobacco smoking and its harmful health effects also increase economic burdens globally. Surprisingly, despite the detrimental health consequences of smoking, some studies have shown better survival among smokers compared with non-smokers, a phenomenon called "smoker's paradox". However, the impact of smoking status on clinical outcomes in severe calcified coronary artery disease (CAD) patients has yet to be reported.

OBJECTIVES

Investigate the impact of smoking on clinical outcomes in calcified CAD receiving rotational atherectomy (RA).

DESIGN

Retrospective review of medical records.

SETTING

Multicenter registry in South Korea.

PATIENTS AND METHODS

This multicenter registry included consecutive patients with calcified CAD who underwent RA at nine tertiary centers in Korea between January 2010 and October 2019.

MAIN OUTCOME MEASURES

Target-vessel failure (TVF) which included the composite of cardiac death, target-vessel myocardial infarction (TVMI), and target-vessel revascularization (TVR).

SAMPLE SIZE

583 lesions in 540 patients followed for a median of 16.1 months.

RESULTS

Lesions were divided into two groups: non-smokers (n=472, 81.0%) and smokers (n=111, 19.0%). TVF in the smoker group was significantly more frequent than in non-smoker group (log rank P=.016). The inverse probability of treatment weighting analysis also showed that smoking was significantly associated with a higher incidence of the primary outcome (HR: 1.617; 95% CI: 1.127-2.320; P=.009), cardiac death (HR 1.912; 95% CI: 1.105-3.311; P=.021), myocardial infarction (HR: 3.914; 95% CI: 1.884-8.132; P<.001), TVMI (HR: 3.234; 95% CI: 1.130-9.258; P=.029), and TVR (HR: 1.661; 95% CI: 1.043-2.643; P=.032). However, any bleeding was significantly observed less in the smokers.

CONCLUSION

Smoking is significantly associated with adverse clinical outcomes in CAD patients requiring RA.

LIMITATIONS

Retrospective design.

CONFLICTS OF INTEREST

None.

Off-label underdosed apixaban use in Asian patients with non-valvular atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

In Asian patients with atrial fibrillation (AF), off-label underdosed prescriptions of direct oral anticoagulants (DOACs) are common

Purpose

We aimed to compare the effectiveness and safety of off-label underdosed apixaban with on-label standard dose apixaban in Asian patients with AF.

Methods

Using the Korean nationwide claims database, we identified patients who prescribed apixaban and did not fulfill the dose reduction criteria of apixaban between January 2015 and December 2017. Multivariable Cox hazard regression model was performed and hazard ratios (HRs) for ischemic stroke, major bleeding (MB), all-cause death, and the composite clinical outcome were analyzed.

Results

Compared to patients prescribed on-label standard dose apixaban (n = 4,194), patients prescribed off-label underdosed apixaban (n = 2,890) were associated with higher risks of ischemic stroke (adjusted HR [aHR] 1.38, 95% confidence interval [CI] 1.06-1.81), all-cause death (aHR 1.19, 95% CI 1.01-1.39) and the composite clinical outcome (aHR 1.17, 95% CI 1.03-1.34), but with no significant differences in MB between the two groups (Figure). In patients without any dose reduction criteria, off-label underdosed apixaban use was associated with a significantly higher risk of ischemic stroke than on-label standard dose apixaban use (aHR 1.85, 95% 1.25-2.73); however, in patients who had single dose reduction criteria (age ≥80 years, serum creatinine ≥1.5mg/dL, or bodyweight ≤60 kg), off-label underdosed apixaban use did not show a significant overall benefit in the composite clinical outcome compared with on-label standard dose apixaban, but was associated with a higher risk of all-cause death (aHR 1.32, 95% CI 1.07-1.64).

Conclusion

Off-label underdosed apixaban use was associated with higher risks of ischemic stroke, all-cause death, and composite clinical outcome and comparable risk of MB compared with on-label standard dose apixaban use. Label-adherence of apixaban dosing should be emphasized to achieve the best clinical outcome for Asian patients with non-valvular AF, especially in those without any dose reduction criteria. Abstract Figure.

Hypertension burden and the risk of new-onset atrial fibrillation: a nationwide population-based study

Funding Acknowledgements

Type of funding sources: None.

Background

The association between the cumulative hypertension burden and the development of atrial fibrillation (AF) is unclear.

Purpose

We aimed to investigate the relationship between hypertension burden and the development of incident AF.

Methods and Results: Using the Korean National Health Insurance Service database, we identified 3,726,172 subjects who underwent four consecutive annual health checkups between 2009 and 2013, with no history of AF. During the median follow-up of 5.2 years, AF was newly diagnosed in 22,012 patients (0.59% of the total study population, 1.168 per 1,000 person-years). Using the BP values at each health checkup, we determined the burden of hypertension (systolic blood pressure [SBP] ≥130 mmHg or diastolic blood pressure [DBP] ≥80 mmHg), stratified as 0 to 4 per the hypertension criteria. The subjects were grouped according to hypertension burden scale 1 to 4: 20% (n = 742,806), 19% (n = 704,623), 19% (n = 713,258), 21% (n = 766,204), and 21% (n = 799,281). Compared to normal people, subjects with hypertension burdens of 1, 2, 3, and 4 were associated with an 8%, 18%, 26%, and 27% increased risk of incident AF, respectively. On semi-quantitative analyses with further stratification of stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg) and stage 2 (SBP ≥140 mmHg or DBP ≥90 mmHg) hypertension, the risk of AF increased with the hypertension burden by up to 71%.

Conclusions

Both a sustained exposure and the degree of increased blood pressure were associated with an increased risk of incident AF. Tailored blood pressure management should be emphasized to reduce the risk of AF. Abstract Figure.

Association between Body Mass Index and Clinical Outcomes of Peripheral Artery Disease after Endovascular Therapy: Data from K-VIS ELLA Registry

We investigated the association between body mass index and clinical outcomes of peripheral artery disease (PAD) after endovascular therapy (EVT). A total of 2914 PAD patients undergoing EVT were participated according to body mass index groups. Underweight was significantly associated with increased risk of major adverse cardiovascular events (MACE) (adjusted hazard ratio [HR], 1.540; 95% confidence interval [CI], 1.091–2.173) and major adverse limb events (MALE) (adjusted HR, 1.523; 95% CI, 1.066–2.177) compared with normal weight. Plus, overweight was associated with lower risk of MACE and not with MALE. However, obesity showed no significant association with MACE or MALE.

Background and Objectives

Few studies have investigated the obesity paradox in clinical outcomes of peripheral artery disease (PAD). We investigated the association between body mass index (BMI) and clinical outcomes in PAD patients undergoing endovascular therapy (EVT).

Methods

Patients (n=2,914) from the retrospective Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Disease registry were categorized according to BMI: underweight (<18.5 kg/m², n=204), normal weight (18.5–25 kg/m², n=1,818), overweight (25–30 kg/m², n=766), or obese (≥30 kg/m², n=126). Groups were compared for major adverse cardiovascular events (MACE) and major adverse limb events (MALE).

Results

The underweight and obese groups were older and had more frequent critical limb ischemia and infrapopliteal artery disease than the normal or overweight groups (all p<0.001). Hypertension and diabetes were more frequent and current smoking was less frequent in the overweight and obese groups than the underweight or normal weight groups (all p <0.001). The underweight group showed the higher rates of MACE and MALE at 3 years (17.2%, 15.7%) compared with the normal weight (10.8%, 11.7%), overweight (8.4%, 10.7%), or obese groups (8.7%, 14.3%) (log-rank p<0.001, p=0.015). In contrast, the risk of MACE was lower in the overweight than the normal weight group (adjusted hazard ratio, 0.706; 95% CI, 0.537–0.928).

Conclusions

In PAD patients undergoing EVT, underweight was an independent predictor for MACE and MALE, whereas MACE risk was lower for overweight than normal weight patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02748226

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

Inhibitory Effects of Aucklandia lappa Decne. Extract on Inflammatory and Oxidative Responses in LPS-Treated Macrophages

Aucklandia lappa Decne., known as “Mok-hyang” in Korea, has been used for the alleviation of abdominal pain, vomiting, diarrhea, and stress gastric ulcers in traditional oriental medicine. We investigated the anti-inflammatory and antioxidative effects of the ethanol extract of Aucklandia lappa Decne. (ALDE) in lipopolysaccharide (LPS)-stimulated RAW 264.7 cells. ALDE significantly inhibited the LPS-induced nitric oxide (NO) production and reduced inducible nitric oxide synthase (iNOS) expression in RAW 264.7 cells. The production of other proinflammatory mediators, including COX-2, interleukin (IL)-6, IL-1β, and tumor necrosis factor (TNF)-α, was reduced by ALDE in LPS-stimulated RAW 264.7 cells. The mechanism underlying the anti-inflammatory effects of ALDE was elucidated to be the suppression of LPS-induced nuclear translocation of p65, followed by the degradation of IκB and the inhibition of the phosphorylation of mitogen-activated protein kinases (MAPK). In addition, ALDE showed enhanced radical scavenging activity. The antioxidant effect of ALDE was caused by the enhanced expression of heme oxygenase (HO-1) via stabilization of the expression of the nuclear transcription factor E2-related factor 2 (Nrf2) pathway. Collectively, these results indicated that ALDE not only exerts anti-inflammatory effects via the suppression of the NF-κB and MAPK pathways but also has an antioxidative effect through the activation of the Nrf2/HO-1 pathway.

P1884Low lipid levels and high variability correlate with the risk of new-onset atrial fibrillation

Background

High levels of lipids and lipid variability are established risk factors for atherosclerotic cardiovascular disease. We investigated their roles in the development of atrial fibrillation (AF). This is the largest cohort study yet on the association between lipid levels and AF, and the first study on the association between lipid variability and AF.

Methods

A nationwide population-based cohort of 3,828,652 adults (mean age 43.9 years) from the Korean National Health Insurance Service database without prevalent AF, not on lipid-lowering medication, and with at least 3 measurements of each lipid parameter at 1–2 year intervals over a 4-year period were included. Total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were measured, and lipid variability was calculated using variability independent of mean. The cohort was divided into quartiles by baseline lipid levels and lipid variability, and followed up for incident AF.

Results

During median 3.4 years of follow-up, AF was newly diagnosed in 13,240 (0.35%). AF development was inversely associated with TC and LDL-C levels (for top vs. bottom quartile; TC, hazard ratio [HR] 0.76, 95% confidence interval [95% CI] 0.72–0.80); LDL-C, HR 0.78, 95% CI 0.74–0.82) in both sexes, and with TG levels in men (HR 0.85, 95% CI 0.80–0.90). Meanwhile, AF development was associated with higher LDL-C and HDL-C variability (for top vs. bottom quartile; LDL-C, HR 1.16, 95% CI 1.10–1.22; HDL-C, HR 1.08, 95% CI 1.03–1.14) in both sexes, and with TC variability in men (HR 1.16, 95% CI 1.10–1.22).

Conclusions

Lower cholesterol levels (TC, LDL-C) and higher cholesterol variability (LDL-C, HDL-C) were associated with higher risk for AF. Low TG levels and high TC variability were also associated with AF incidence in men. These findings support the “cholesterol paradox” in AF, and suggest that cholesterol variability is also a risk factor for AF development.

P4780Effectiveness and safety of non-vitamin k antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease

Background

Patients with atrial fibrillation (AF) often have concomitant valvular heart disease (VHD), especially in Asia. There are limited data on non-vitamin K antagonist oral anticoagulants (NOAC) impact on outcomes for stroke prevention and bleeding for these patients in real world clinical practice.

Purpose

To investigate the effectiveness and safety of NOACs compared with warfarin in patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHD.

Methods

We identified oral anticoagulants naive patients with AF and EHRA type 2 VHD from the Korean National Health Insurance Service database between 2014 and 2016 (n=2,671 taking warfarin; n=3,058 taking NOAC). Six clinical outcomes including ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding (GI), major bleeding, all-cause death, and their composite outcome and fatal clinical events (any events that led to death within 30-day of its occurrence) were evaluated. Inverse probability of treatment weighting (IPTW) method was used to balance covariates between the two groups.

Results

After weighted using 5% trimmed IPTW method (n=2371 taking warfarin; n=2792 taking NOAC), the mean age was 71.2 years, male was 57% and CHA2DS2-VASc score was 3.9. During a mean 1.4-year follow-up, weighted incidence rate of ischemic stroke, ICH, GI bleeding, and all-cause death were lower in the NOAC group than in the warfarin group. Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.53–0.96), GI bleeding (HR 0.50, 95% CI 0.35–0.72) and major bleeding (HR 0.61, 95% CI 0.45–0.80). Although NOAC and warfarin groups showed similar incidence rate of ICH, NOAC group was associated with a significantly lower risk of fatal ICH compared to warfarin group (HR 0.28, 95% CI 0.07–0.83). Overall, NOACs were associated with a lower risk of the composite outcome (HR 0.68, 95% CI 0.58–0.80). For an exploratory analysis, patients with EHRA type 1 VHD (n=366 taking warfarin; n=345 taking NOAC) was evaluated. In multivariable Cox regression analysis, NOAC group showed a comparable risk of ischemic stroke, ICH, all-cause death and composite outcome.

Clinical outcome in AF patients with VHD

Conclusion

In this nationwide Asian AF population with EHRA type 2 VHD, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin.

P3776Blood pressure variability and incidence of new-onset atrial fibrillation

Background

Visit-to-visit blood pressure (BP) variability is a known risk factor for stroke, but the association between BP variability and atrial fibrillation (AF) incidence is uncertain. We sought to evaluate the association between BP variability and incident AF.

Methods

We identified 8,063,922 subjects (mean age 48 years; 59% men) who had ≥3 health checkups provided by the Korean National Health Insurance Corporation between 2004 and 2010. Systolic and diastolic BP variability was defined as variability independence of the mean (VIM). VIM was divided into four groups and high variability of BP was defined as the highest quartile values. The primary end point was new-onset atrial fibrillation.

Results

During a mean 7 years of follow-up, 140,086 subjects were newly diagnosed with AF (2.53 per 1000 person-years). High variation in BP was associated with an increase in the risk of AF (SBP: hazard ratio [HR], 1.060; 95% confidence interval [CI], 1.044–1.075, DBP: HR, 1.066; 95% CI, 1.050–1.082) compared with subjects with lowest quartile of BP. Among subjects with high variation both in SBP and DBP, the risk of AF was 7.6% higher than subjects without high variation in SBP and DBP. The risk of high BP variation on new-onset AF was more obvious in high-risk patients. The association of high BP variability with AF was being stronger for high-risk subjects who were older (≥65 years), with diabetes, or with CKD compared with subjects who were younger, without diabetes, or without CKD.

Conclusions

Fluctuation in SBP and DBP was associated with higher incidence of AF, especially in high-risk subjects, independent of traditional AF risk factors.

P4782Direct comparison of dabigatran, apixaban, rivaroxaban and edoxaban for effectiveness and safety among patients with non-valvular atrial fibrillation

Background

Although the prescription of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation (AF) has been rapidly increasing in Asian countries since their introduction, limited evidence exists on the effectiveness and safety of warfarin and all 4 available NOACs from current clinical practice in the Asian population. We aimed to evaluate comparative effectiveness and safety of warfarin and all 4 available NOACs

Methods

We studied a retrospective observational cohort of oral anticoagulant (OAC) naïve non-valvular AF patients treated with warfarin or NOACs (rivaroxaban, dabigatran, apixaban, or edoxaban) from January 2015 to December 2017, based on the Korean Health Insurance Review and Assessment database. For the comparisons, warfarin to 4 NOACs and NOAC to NOAC comparison cohorts were balanced using inverse probability of treatment weighting (IPTW). Ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), major bleeding (MB) and a composite clinical outcome were evaluated.

Results

A total of 116,804 patients were included (25,420 with warfarin, 35,965 with rivaroxaban, 17,745 with dabigatran, 22,177 with apixaban, and 15,496 with edoxaban). Patients treated with warfarin were younger (mean age 67 years) compared to NOAC users (71 to 73 years) and had lower mean CHA2DS2-VASc score (3.18) than the NOAC groups (3.58 to 3.76). Among the NOAC users, patients prescribed apixaban were older (mean age 73 years) than other NOAC groups (71 to 72 years), had higher mean CHA2DS2-VASc score (3.76) than others (3.55 to 3.63) and higher burden of comorbidities. More than half of patients were prescribed reduced dose regimes. After IPTW, all baseline covariates were well balanced across 5 treatment groups. Compared with warfarin, all NOACs were associated with lower risks of ischemic stroke, ICH, GIB, MB and composite outcome (Figure A). Apixaban and edoxaban showed a lower rate of ischemic stroke compared with rivaroxaban and dabigatran (Figure B). Apixaban, dabigatran and edoxaban had a lower rate of GIB and MB compared with rivaroxaban. The composite clinical outcome was non-significantly different for apixaban vs edoxaban.

Conclusions

In this large contemporary observational Asian cohort, all 4 NOACs were associated with lower rates of ischemic stroke and major bleeding compared to warfarin. Differences in clinical outcomes between NOACs may give useful guidance for physicians to choose drugs to fit their particular patient clinical profile.

P4769Optimal rivaroxaban dose in Asian patients with atrial fibrillation and normal or mildly impaired renal function

Background

Although rivaroxaban 15 mg was only given to patients with creatinine clearance (CrCl) <50mL/min in the pivotal clinical trial, this dose has been commonly prescribed in Asian patients with non-valvular atrial fibrillation (AF) regardless of renal function. There is a paucity of information regarding the clinical outcomes of rivaroxaban 15 mg compared to rivaroxaban 20 mg in patients with CrCl ≥50mL/min. This study aimed to examine the effectiveness and safety of two doses of rivaroxaban in Asian patients with AF and CrCl ≥50mL/min.

Methods

Using the Korean National Health Insurance Service database, patients with AF and normal or mildly impaired renal function (CrCl ≥50mL/min) and naïve to rivaroxaban or warfarin were included from January 2014 to December 2016. Three separate 1:1 propensity score-matched cohorts were conducted: rivaroxaban 20 mg (R20) vs. warfarin (n=15,584), rivaroxaban 15 mg (R15) vs. warfarin (n=11,554), and R20 vs. R15 (n=10,392). Hazard ratios (HRs) for ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal (GI) bleeding, major bleeding, all-cause death, and composite clinical outcome were analyzed.

Results

Among the pooled total study population, mean age was 66.9±10.9 years, 62.2% were male, mean CHA2DS2-VASc score was 3.16±1.79, and mean CrCl was 83.6±42.0 mL/min (median 78.4 mL/min, IQR 67.7–91.0 mL/min). A substantial proportion (42.6%) of patients with CrCl ≥50 mL/min were prescribed off-label R15 for stroke prevention in the Korean AF population. Compared to warfarin, both R20 and R15 showed significantly lower risk for ischemic stroke, major bleeding (mainly through reduction of ICH), and all-cause death (Figure). Overall, both R20 and R15 had better results for the composite clinical outcome compared to warfarin (HR: 0.617, 95% CI: 0.550–0.691 for R20, and HR: 0.759, 95% CI: 0.675–0.853 for R15). Compared to off-label R15, on-label R20 showed a nonsignificant trend toward lower risks of ischemic stroke, hospitalization for GI bleeding, hospitalization for major bleeding, and all-cause death. Overall, on-label R20 had better results for the composite clinical outcome compared to off-label R15 in patients with CrCl ≥50 mL/min (HR: 0.852, 95% CI: 0.735–0.988). This benefit was consistently observed in patients aged ≥80 years and those <50 kg. In patients with CrCl 50–60 mL/min, R20 showed a nonsignificant trend toward a higher risk of hospitalization for major bleeding compared to R15 (HR: 1.828, 95% CI 0.994–3.452).

Conclusions

Among Asians with AF and CrCl ≥50mL/min, both R20 and R15 were associated with reduced risk of ischemic stroke, ICH, major bleeding, and all-cause death without significantly increased risk of GI bleeding compared with warfarin. In patients with CrCl ≥50mL/min, on-label R20 showed better results for the composite clinical outcome compared to off-label R15.

P664Impact of dynamic change in the status of metabolic syndrome associated with the risk of atrial fibrillation: a nationwide population-based study

Background/Introduction

Metabolic syndrome (MetS) is a well-known risk factor for new-onset atrial fibrillation (AF). However, there is a paucity of information on whether the change of MetS status has an impact on the risk of new-onset AF.

Objective

We aimed to evaluate the risk of AF according to the change of MetS status and to find whether components of metabolic syndrome control may affect AF risk.

Methods

A total of 7,565,531 subjects (≥20-year-old, mean age 47.2±13.7 years, male 55.6%) without prevalent AF who underwent 2 times of serial health checkup were identified from the Korean National Health Insurance Service. MetS was defined as having ≥3 of the following risk factors: increased waist circumference (ethnicity-specific, in Asian, ≥80 cm in women or ≥90 cm in men), increased triglycerides (≥150 mg/dL), decreased high-density lipoprotein-cholesterol level (<40 mg/dL in males, <50 mg/dL in females), increased blood pressure (≥130/85 mmHg), and increased fasting glucose level (≥100 mg/dL). Subjects stratified into four groups according to the change of MetS status during the follow-up period: 1,388,850 patients persistent MetS in the serial checkup (MM group), 608,158 in previous healthy but newly diagnosed MetS at 2nd checkup (HM group), 798,555 in the previous MetS but became healthy in 2nd checkup (MH group), and 4,769,968 patients without MetS in both (HH group). Incident AF was followed up till December 2017.

Results

Among those with MetS, 798,555 patients had improved to be healthy (10.6%). In those previous without MetS, 608,158 patients had newly diagnosed as MetS (8.0%) in 2nd checkup. During a mean follow-up of 7.9±0.9 years, incident AF was diagnosed in 135,600 patients (2.3 per 1000 person-year). MM, MH, and HM groups showed an increased risk of AF compared to HH group (Figure). Also, MH group showed a lower risk of AF compared to those with MM group. Regardless of the type of component that meets the MetS criteria, the risk of AF became different according to changing the number of MetS components. The risk of AF increased as the number of MetS components increased, whereas the risk of AF decreased as the number of MetS components decreased.

Risk of AF according to change of MetS

Conclusion

The risk of AF showed association with the dynamic change of MetS status and the variation in the number of MetS components. AF risk was reduced by the improvement in metabolic syndrome and each of MetS components.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Usefulness of Myocardial Longitudinal Strain in Prediction of Heart Failure in Patients with Successfully Reperfused Anterior Wall ST-segment Elevation Myocardial Infarction

Background and Objectives

Acute myocardial infarction-related heart failure (HF) is associated with poor outcome. This study was designed to investigate the usefulness of global longitudinal strain (GLS), global circumferential strain (GCS) and mean longitudinal strain of left anterior descending artery territory (LS_ant) measured by 2-dimensional speckle tracking echocardiography (2D STE) in prediction of acute anterior wall ST-segment elevation myocardial infarction (ant-STEMI)-related HF.

Methods

A total of 171 patients with ant-STEMI who underwent successful primary coronary intervention and had available 2D STE data were enrolled. Patients were divided into 3 groups: in-hospital HF, post-discharge HF, and no-HF groups.

Results

In-hospital and post-discharge HF developed in 39 (22.8%) and 13 (7.6%) of patients, respectively and 113 patients (69.6%) remained without HF. Multivariate analysis showed that GLS was the only factor significantly associated with the development of in-hospital HF. For post-discharge HF, LS_ant was the only independent predictor. Other echocardiographic or laboratory parameters did not show independent association with the development of ant-STEMI-related HF.

Conclusions

GLS is a powerful echocardiographic parameter related to development of in-hospital HF and LS_ant was significantly associated with post-discharge HF in patients with successfully reperfused ant-STEMI.

π and 4π Josephson Effects Mediated by a Dirac Semimetal

Cd_{3}As_{2} is a three-dimensional topological Dirac semimetal with connected Fermi-arc surface states. It has been suggested that topological superconductivity can be achieved in the nontrivial surface states of topological materials by utilizing the superconductor proximity effect. Here we report observations of both π and 4π periodic supercurrents in aluminum-Cd_{3}As_{2}-aluminum Josephson junctions. The π period is manifested by both the magnetic-field dependence of the critical supercurrent and the appearance of half-integer Shapiro steps in the ac Josephson effect. Our macroscopic theory suggests that the π period arises from interference between the induced bulk superconductivity and the induced Fermi-arc surface superconductivity. The 4π period is manifested by the missing first Shapiro steps and is expected for topological superconductivity.