Differences in coronary angiographic findings and outcomes between men and postmenopausal women with stable chest pain

BACKGROUND

Despite the significant increase in cardiovascular events in women after menopause, studies comparing postmenopausal women and men are scarce.

METHODS

We analyzed data from a nationwide, multicenter, prospective registry and enrolled 2412 patients with stable chest pain who underwent elective coronary angiography. Binary coronary artery disease (b-CAD) was defined as the ≥50% stenosis of epicardial coronary arteries, including the left main coronary artery.

RESULTS

Compared with the men, postmenopausal women were older (66.6 ± 8.5 vs. 59.5 ± 11.4 years) and had higher high-density lipoprotein cholesterol levels (49.0 ± 12.8 vs. 43.6 ± 11.6 mg/dl, P  < 0.01). The prevalence of diabetes did not differ significantly ( P  = 0.40), and smoking was more common in men than in postmenopausal women ( P  ≤ 0.01). At enrollment, b-CAD and revascularization were more common in men than in postmenopausal women (50.3% vs. 41.0% and 14.4% vs. 9.7%, respectively; both P  < 0.01). However, multivariate analyses revealed that revascularization [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.49-1.08] was not significantly related to sex and a similar result was found in age propensity-matched population (OR: 0.80; 95% CI: 0.52-1.24). During the follow-up period, the secondary composite cardiovascular outcomes were lower in postmenopausal women than in men (OR: 0.55; 95% CI: 0.31-0.98), also consistent with the result using the age propensity-mated population (OR: 0.33; 95% CI: 0.13-0.85).

CONCLUSION

Postmenopausal women experienced coronary revascularization comparable to those in men at enrollment, despite the average age of postmenopausal women was 7 years older than that of men.Postmenopausal women exhibit better clinical outcomes than those of men if optimal treatment is provided.

The Third Nationwide Korean Heart Failure III Registry (KorHF III): The Study Design Paper

With advancements in both pharmacologic and non-pharmacologic treatments, significant changes have occurred in heart failure (HF) management. The previous Korean HF registries, namely the Korea Heart Failure Registry (KorHF-registry) and Korean Acute Heart Failure Registry (KorAHF-registry), no longer accurately reflect contemporary acute heart failure (AHF) patients. Our objective is to assess contemporary AHF patients through a nationwide registry encompassing various aspects, such as clinical characteristics, management approaches, hospital course, and long-term outcomes of individuals hospitalized for AHF in Korea. This prospective observational multicenter cohort study (KorHF III) is organized by the Korean Society of Heart Failure. We aim to prospectively enroll 7,000 or more patients hospitalized for AHF at 47 tertiary hospitals in Korea starting from March 2018. Eligible patients exhibit signs and symptoms of HF and demonstrate either lung congestion or objective evidence of structural or functional cardiac abnormalities in echocardiography, or isolated right-sided HF. Patients will be followed up for up to 5 years after enrollment in the registry to evaluate long-term clinical outcomes. KorHF III represents the nationwide AHF registry that will elucidate the clinical characteristics, management strategies, and outcomes of contemporary AHF patients in Korea.

Trial Registration

ClinicalTrials.gov Identifier: NCT04329234.

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

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

Metabolic syndrome awareness in the general Korean population: results from a nationwide survey

BACKGROUND/AIMS

Metabolic syndrome (MetS) raises the risk of cardiovascular disease and type 2 diabetes. An awareness of MetS is vital for early detection and proactive management, which can mitigate the risks associated with MetS. Therefore, our study aimed to investigate the level of awareness of MetS among the Korean population.

METHODS

We conducted a nationwide survey between January and February 2023 among a representative sample of the Korean population using an online survey. Information regarding the awareness of MetS and its risk, the importance of lifestyle modification, and health behavior were collected. The question about the awareness of MetS was "How much do you think you know about MetS?" and there were five answers: 1) I know very well, 2) I know well, 3) I know a little, 4) I do not know, and 5) I have no idea. The high-awareness group was defined as those who answered that they knew very well or well.

RESULTS

Among 1,000 participants (mean age, 45.7 ± 13.2 yr), 29% were unaware of MetS, and only 20.8% had high awareness. The high-awareness group was significantly more knowledgeable about lifestyle modifications and demonstrated better health behaviors. After adjustment for possible confounding factors, younger age, low household income, and absence of comorbidity were independently associated with a lack of awareness regarding MetS.

CONCLUSION

The high-awareness group showed greater knowledge of the importance of lifestyle modifications and better health behaviors regarding MetS. The findings highlight the need for improved public education and awareness programs regarding MetS.

Development of an Artificial Soft Solid Gel Using Gelatin Material for High-Quality Ultrasound Diagnosis

For ultrasound diagnosis, a gel is applied to the skin. Ultrasound gel serves to block air exposure and match impedance between the skin and the probe, enhancing imaging efficiency. However, if use of the ultrasound gel exceeds a certain period of time, it may dry out and be exposed to air, causing impedance mismatch and reducing imaging resolution. In such cases, the use of a soft, solid gel proves advantageous, as it can be employed for an extended period without succumbing to the drying phenomenon and can be reused after disinfection. Its soft consistency ensures excellent skin adhesion. Our soft solid gel demonstrated approximately 1.2 times better performance than water, silicone, and traditional ultrasound gels. When comparing the dimensions of grayscale, dead zone, vertical, and horizontal regions, the measurements for the traditional ultrasound gel were 93.79 mm, 45.32 mm, 103.13 mm, 83.86 mm, and 83.86 mm, respectively. In contrast, the proposed soft solid gel exhibited dimensions of 105.64 mm, 34.48 mm, 141.1 mm, and 102.8 mm.

Physical Symptoms, Depressive Symptoms, and Quality of Life in Patients With Heart Failure: Cluster Analysis

BACKGROUND

Physical and psychological symptoms are prevalent in patients with heart failure (HF) and are associated with poor quality of life (QOL) and high hospitalization rates. Thus, it is critical to identify symptom clusters to better manage patients with high-risk symptom cluster(s) and to reduce adverse effects.

OBJECTIVE

The aims of this study were to identify clusters of physical HF symptoms (ie, dyspnea during daytime, dyspnea when lying down, fatigue, chest pain, edema, sleeping difficulty, and dizziness) and depressive symptoms and to examine their association with QOL in patients with HF.

METHODS

In this secondary analysis of a cross-sectional study, data on physical HF symptoms (Symptom Status Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and general QOL (European Quality of Scale-Visual Analog Scale) were collected. We identified clusters based on the physical HF symptoms and depressive symptoms using 2-step and k -means cluster analysis methods.

RESULTS

Chest pain was removed from the model because of the low importance value. Two clusters were revealed (cluster 1, severe symptom cluster, vs cluster 2, less severe symptom cluster) based on the 7 symptoms. In cluster 1, all of the 7 symptoms were more severe, and QOL was poorer than those in cluster 2 (all P s < .001). All the mean and median scores of the 7 symptoms in cluster 1 were higher than those in cluster 2.

CONCLUSIONS

Patients with HF were clearly divided into 2 clusters based on physical HF symptoms and depressive symptoms, which were associated with QOL. Clinicians should assess these symptoms to improve patient outcomes.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE)

BACKGROUND

Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women.

METHODS

Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD.

RESULTS

Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m²) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each).

CONCLUSIONS

In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Gender Difference of Blood Pressure Control Rate and Clinical Prognosis in Patients With Resistant Hypertension: Real-World Observation Study

BACKGROUND

There are several differences in the clinical course of hypertension due to the biological and social differences between men and women. Resistant hypertension is an advanced disease state, and significant gender difference could be expected, but much has not been revealed yet. The purpose of this study was to compare gender differences on the current status of blood pressure (BP) control and clinical prognosis in patients with resistant hypertension.

METHODS

This is a multicenter, retrospective cohort study using common data model databases of 3 tertiary hospitals in Korea. Total 4,926 patients with resistant hypertension were selected from January 2017 to December 2018. Occurrence of dialysis, heart failure (HF) hospitalization, myocardial infarction, stroke, dementia or all-cause mortality was followed up for 3 years.

RESULTS

Male patients with resistant hypertension were younger but had a higher cardiovascular risk than female patients. Prevalence of left ventricular hypertrophy and proteinuria was higher in men than in women. On-treatment diastolic BP was lower in women than in men and target BP achievement rate was higher in women than in men. During 3 years, the incidence of dialysis and myocardial infarction was higher in men, and the incidence of stroke and dementia was higher in women. After adjustment, male sex was an independent risk factor for HF hospitalization, myocardial infarction, and all-cause death.

CONCLUSION

In resistant hypertension, men were younger than women, but end-organ damage was more common and the risk of cardiovascular event was higher. More intensive cardiovascular prevention strategies may be required in male patients with resistant hypertension.

Obesity-related heart failure with preserved ejection fraction: diagnostic and therapeutic challenges

The prevalence of heart failure with preserved ejection fraction (HFpEF) has increased in recent decades. In particular, obesity-related HFpEF is a distinct and frequently encountered phenotype; however, its diagnosis is complex. Furthermore, the management of obesity-related HFpEF has not been established despite the introduction of promising drugs. This review summarizes the diagnostic challenges, pathophysiology, and therapeutic options for obesity-related HFpEF.

PRE-OPerative ECHOcardiograhy for prevention of cardiovascular events after non-cardiac surgery in intermediate- and high-risk patients: protocol for a low-interventional, mixed-cohort prospective study design (PREOP-ECHO)

Background

Cardiac evaluation using transthoracic echocardiography before noncardiac surgery is common in real-world practice. However, evidence supporting preoperative echocardiography is lacking. This study aims to evaluate the additional benefit of preoperative echocardiography in predicting postoperative cardiovascular events (CVE) in noncardiac surgery.

Methods

This study is designed as a multicenter, prospective study to assess the utility of preoperative echocardiography in patients undergoing intermediate- or high-risk noncardiac surgery. This trial comprises two studies: (1) a randomized controlled trial (RCT) for patients undergoing intermediate-risk surgery with fewer than three clinical risk factors from the revised cardiac risk index (intermediate-risk group) and (2) a prospective cohort study for patients undergoing intermediate-risk surgery with three or more clinical risk factors, or who undergo high-risk surgery regardless of the number of clinical risk factors (high-risk group). We hypothesize that the use of preoperative echocardiography will reduce postoperative CVEs in patients undergoing intermediate- to high-risk surgery through discovery of and further intervention for unexpected cardiac abnormalities before elective surgery. A total of 2330 and 2184 patients will be enrolled in the two studies. The primary endpoint is a composite of all-cause death; aborted sudden cardiac arrest; type I acute myocardial infarction; clinically diagnosed unstable angina; stress-induced cardiomyopathy; lethal arrhythmia, such as sustained ventricular tachycardia or ventricular fibrillation; and/or newly diagnosed or acutely decompensated heart failure within 30 days after surgery.

Discussion

This study will be the first large-scale prospective study examining the benefit of preoperative echocardiography in predicting postoperative CVE. The PREOP-ECHO trial will help doctors identify patients at risk of postoperative CVE using echocardiography and thereby reduce postoperative CVEs.

Trial registration

The Clinical Research Information Service KCT0006279 for RCT and KCT0006280 for prospective cohort study. Registered on June 21, 2021.

Awareness of cardiovascular disease among Korean women: Results from a nationwide survey

Women underestimate the risk of cardiovascular disease (CVD). It is essential to assess and raise awareness regarding CVD among women to reduce disease burden and mortality. Therefore, we investigated the awareness regarding CVD among Korean women. We conducted a nationwide survey between December 2020 and January 2021 among a representative sample of Korean women using random-digit-dialing telephonic interviews. We sought information regarding the awareness of CVD risk; recognition of symptoms and signs; and knowledge of the cause and prevention of and appropriate response to CVD. A total of 1,050 women (mean age, 60.2 ± 11.9 years) participated in the study. Approximately 52.0% of participants were unaware of CVD, and only 26% of participants had heard of CVD. Participants considered that compared to other diseases, CVD was not an important health issue for women, and few of them thought that cerebrovascular diseases and CVD were the leading causes of death (10.9% and 7.6%, respectively). After adjustment for possible confounding factors, age >70 years, rural residence, and educational attainment below college were independently associated with a lack of awareness regarding CVD. The awareness regarding CVD being the leading cause of death in women is low, and most women do not consider it an important health issue. Therefore, special attention must be paid to educate the public regarding CVD in women.

Cognitive Function of Recipients of Primary or Secondary Defibrillator Therapy: A Comparative Study Involving Nondefibrillator Patients With Systolic Heart Failure

BACKGROUND

The extent to which cognitive function differs between patients who receive implantable cardioverter-defibrillator (ICD) therapy and patients with heart failure (HF) who do not receive ICD therapy remains to be elucidated.

OBJECTIVES

The aim of this study was to compare the cognitive function between patients with primary or secondary ICDs and patients with HF without an ICD.

METHODS

This descriptive, comparative study included 116 patients who received ICDs and 74 patients with HF who did not receive ICDs. Patients underwent neuropsychological assessment for general cognition, memory, and executive function.

RESULTS

Immediate recall memory loss (18.9%) occurred more often in patients with HF without an ICD than in patients with primary (3.1%) and secondary (7.1%) ICDs (P = .018). After adjusting for age and education, delayed recall memory of patients with HF without ICDs was significantly worse than that of patients with primary ICDs (4.0 vs 6.5; P < .001), whereas delayed recall memory of patients with primary ICDs was better than that of patients with secondary ICDs (6.0 vs 6.5; P = .006). Executive function of patients with HF without ICDs was significantly worse than that of patients with primary (35 vs 58 seconds; P < .001) and secondary (28 vs 58 seconds; P = .0012) ICDs.

CONCLUSIONS

Patients with ICDs, regardless of primary or secondary indication, had less impairment of memory and executive function than patients with HF without ICDs, implying that ICD therapy did not interfere with cognitive performance. Cognitive screening as a part of routine care could be helpful for identifying impairment and implementing early cognitive training, especially in patients with HF.

Apparent treatment-resistant hypertension among ambulatory hypertensive patients: a cross-sectional study from 13 general hospitals

BACKGROUND/AIMS

To examine the prevalence and clinical characteristics of apparent treatment-resistant hypertension among ambulatory hypertensive patients.

METHODS

We enrolled adult ambulatory hypertensive patients at 13 well-qualified general hospitals in Korea from January to June 2012. Apparent resistant hypertension was defined as an elevated blood pressure > 140/90 mmHg with the use of three antihypertensive agents, including diuretics, or ≥ 4 antihypertensives, regardless of the blood pressure. Controlled hypertension was defined as a blood pressure within the target using three antihypertensives, including diuretics.

RESULTS

Among 16,915 hypertensive patients, 1,172 (6.9%) had controlled hypertension, and 1,514 (8.9%) had apparent treatment-resistant hypertension. Patients with apparent treatment-resistant hypertension had an earlier onset of hypertension (56.8 years vs. 58.8 years, p = 0.007) and higher body mass index (26.3 kg/m2 vs. 24.9 kg/m2, p < 0.001) than those with controlled hypertension. Drug compliance did not differ between groups. In the multivariable analysis, earlier onset of hypertension (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99; p < 0.001) and the presence of comorbidities (OR, 2.06; 95% CI, 1.27 to 3.35; p < 0.001), such as diabetes mellitus, ischemic heart disease, heart failure, and chronic kidney disease, were independent predictors. Among the patients with apparent treatment-resistant hypertension, only 5.2% were receiving ≥ 2 antihypertensives at maximally tolerated doses.

CONCLUSION

Apparent treatment-resistant hypertension prevalence is 8.9% among ambulatory hypertensive patients in Korea. An earlier onset of hypertension and the presence of comorbidities are independent predictors. Optimization of medical treatment may reduce the rate of apparent treatment-resistant hypertension.

Incremental value of QT interval for the prediction of obstructive coronary artery disease in patients with chest pain

Identification of obstructive coronary artery disease (OCAD) in patients with chest pain is a clinical challenge. The value of corrected QT interval (QTc) for the prediction of OCAD has yet to be established. We consecutively enrolled 1741 patients with suspected angina. The presence of obstructive OCAD was defined as ≥ 50% diameter stenosis by coronary angiography. The pre-test probability was evaluated by combining QTc prolongation with the CAD Consortium clinical score (CAD2) and the updated Diamond-Forrester (UDF) score. OCAD was detected in 661 patients (38.0%). QTc was longer in patients with OCAD compared with those without OCAD (444 ± 34 vs. 429 ± 28 ms, p < 0.001). QTc was increased by the severity of OCAD (P < 0.001). QTc prolongation was associated with OCAD (odds ratio (OR), 2.27; 95% confidence interval (CI), 1.81–2.85). With QTc, the C-statistics increased significantly from 0.68 (95% CI 0.66–0.71) to 0.76 (95% CI 0.74–0.78) in the CAD2 and from 0.64 (95% CI 0.62–0.67) to 0.74 (95% CI 0.72–0.77) in the UDF score, respectively. QT prolongation predicted the presence of OCAD and the QTc improved model performance to predict OCAD compared with CAD2 or UDF scores in patients with suspected angina.

Advance Directives and Factors Associated with the Completion in Patients with Heart Failure

Advance directive (AD) has been underutilized among patients with heart failure (HF). This study was performed to explore the ADs and examine factors associated with the completion of an AD survey in patients with HF. In a descriptive, correlational study, data on end-of-life values, treatment directives, and proxy (Korean-Advance Directive (K-AD) questionnaire) and factors associated with K-AD completion were collected among HF patients during outpatient visits. Of 67 patients (age, 67 years; male, 61.2%), 52.2% completed all or part of the K-AD. Among values, comfortable death was the most preferred (n = 15) followed by avoiding family burden (n = 6). In those completers, preferences for hospice care, cardiopulmonary resuscitation, ventilation support, and hemodialysis were 68.6%, 42.9%, 28.6%, and 28.6%, respectively. Female sex (odds ratio (OR) = 0.167), poorer HF prognosis (OR = 0.156), and better functional status (OR = 0.905) were associated with less likelihood of completing the AD survey. The findings suggest that in-depth AD discussion needs to be started earlier in patients with HF to facilitate completion of AD, especially in female patients. Future research should investigate if early discussion of ADs as part of advance care planning with integration into standard care of HF facilitates the documentation of ADs.

Factors Associated with Changes in Health Perception in Patients with Heart Failure

Determination of modifiable factors associated with changes in health perception can be beneficial for improvement in health perception and health-related quality of life. The purpose of this study was to examine if changes in physical symptoms, functional status, and depressive symptoms were associated with changes in health perception at three months and the mediator effect of physical symptoms. Data were collected at baseline and three months later (N = 65). Process Macro for SPSS was used to analyze the data. Only changes in depressive symptoms (p < .001) were associated with changes in physical symptoms. Then, only changes in physical symptoms (p = .026) were significantly associated with changes in health perception. Changes in physical symptoms played significant roles in changes in health perception directly and also through the mediator role. Clinicians and researchers need to assess and manage these two modifiable factors to improve health perception in this population.

Severe Periodontal Disease Increases Acute Myocardial Infarction and Stroke: A 10-Year Retrospective Follow-up Study

This study aimed to evaluate the causal association of periodontal disease with acute myocardial infarction (AMI) and stroke, after controlling for various confounders among the Korean population. A retrospective cohort study using the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) was performed during 2002 to 2015 (baseline: 2002 to 2005; follow-up: 2006 to 2015) in the Republic of Korea. A total of 298,128 participants with no history of AMI or stroke were followed up for 10 y. AMI and stroke were defined by a diagnosis using the International Classification of Diseases, 10th Revision (ICD-10) guideline. Periodontal condition was classified into 3 groups (healthy, moderate periodontal disease, severe periodontal disease [SPD]) using the combination of ICD codes, treatment codes in the NHIS, and recommendation of periodontal treatment by the dentists in HEALS. Various confounders, such as sociodemographic, behavioral, systemic, and oral health factors, including hypercholesterolemia, were considered. Multivariable Cox regression analysis was applied to estimate adjusted incidence rate ratio (adjusted hazard ratio [aHR]) based on person-year of periodontal condition for AMI, stroke, and nonfatal major adverse cardiovascular events (MACEs) encompassing AMI or stroke controlling for various confounders. Stratified analyses according to age group, sex, and toothbrushing frequency were also performed. After controlling for various confounders, participants with SPD compared with non-SPD participants had a higher incidence by 11% for AMI (aHR, 1.11; 95% confidence interval [CI], 1.02-1.20), by 3.5% for stroke (aHR, 1.035; 95% CI, 1.01-1.07), and by 4.1% for MACEs (aHR, 1.04; 95% CI, 1.01-1.07). The association of SPD with AMI and MACE was highly modified in females and adults aged 40 to 59 y. In the total Korean population, SPD increased total AMI events by 4.3%, total stroke events by 1.4%, and the total MACEs by 1.6%. Our data confirmed that SPD was causally associated with the new events of AMI and stroke.

Significant reduction in the density of premature ventricular complex with ß-blocker medication in fast rate-dependent premature ventricular complex

Background

There is little data regarding types of idiopathic premature ventricular complex (PVC) according to heart rate dependence.

Methods

One hundred and sixty-eight patients with idiopathic PVC were enrolled in this study. Evaluation of the number of PVCs and total ventricular beats, and the density of PVC was done using 24 h Holter monitoring. Patients were divided into groups as having: fast rate-dependent (Group I), slow rate-dependent (Group II), and heart rate-independent PVC (Group III) based on the relationship between the number of hourly PVC and hourly heart rate. After ß-blocker medication, 24 h Holter monitoring was repeated.

Results

Among the 168 subjects, 66 (39.3%) patients were in Group I, 18 (10.7%) in Group II, and 84 (50.0%) in Group III. There were no significant differences in the baseline number of PVCs and total ventricular beats, and the density of PVC among the three groups. The number of PVCs was significantly reduced in patients with Group I (14,030 ± 11,463 beats/day vs. 7401 ± 10,464 beats/day, p < 0.001), and total ventricular beat was significantly reduced in patients with Group I (109,223 ± 17,564 beats/day vs. 96,182 ± 15,594 beats/day, p < 0.001) and Group III (106,515 ± 13,468 beats/day vs. 97,995 ± 12,960 beats/day, p < 0.001) after ß-blocker medication. The density of PVC was significantly reduced only in patients of Group I (12.9 ± 10.3% vs. 7.4 ± 10.3%, p = 0.001) after ß-blocker medication.

Conclusions

The type of PVC according to the heart rate dependence should be considered when treating idiopathic PVC with ß-blockers.

Do advance directive attitudes and perceived susceptibility and end-of-life life-sustaining treatment preferences between patients with heart failure and cancer differ?

There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.

Effect of physical and psychocognitive function and perceived health status on 12-month adverse cardiac events among implantable cardioverter-defibrillator recipients

BACKGROUND

Post-implant recovery in patients with implantable cardioverter-defibrillators (ICDs) is often compromised because of reduced physical and psycho-cognitive function and poor health perception, leading to short event-free survival.

OBJECTIVES

To examine the effects of psychocognitive function, health perception, and ICD-related factors on 12-month cardiac events among ICD patients.

METHODS

Using a prospective study design, ICD patients underwent baseline assessment and were followed for 12 months to assess cardiac events.

RESULTS

Cardiac events occurred in 14 patients (18.9%) (N = 74: age, 58 years; primary ICDs, 45.9%). Time after ICD implant (odds ratio [OR] = 1.002; p = .028) and executive function (OR = 1.021; p = .027) were significant predictors of 12-month cardiac events, while other physical and psychological indices were not.

CONCLUSIONS

Reduced executive function and longer time after implant predicted the events. Healthcare professionals need to assess executive function and provide treatment and support to improve executive function.

Angiotensin receptor-neprilysin inhibitor for the treatment of heart failure: a review of recent evidence

Heart failure (HF) is a growing health concern in aging societies worldwide. Sacubitril/valsartan is changing the real-world treatment in the whole spectrum of HF. The beginning was the PARADIGM-HF trial published in 2014, which demonstrated the beneficial effects of inhibiting natriuretic peptide breakdown in combination with hindering the renin-angiotensin system in HF patients with a reduced ejection fraction. Subsequent large-scale randomized trials have evaluated angiotensin receptor-neprilysin inhibitor in HF patients with acute decompensation or with preserved ejection fraction. The post hoc analyses are being conducted as well. This review summarizes the recent evidence of sacubitril/ valsartan regarding patient-centered outcomes, based on randomized controlled trials and their associated studies.

Gender difference in the impact of Ischaemic heart disease on heart failure

BACKGROUND

Although the impact of ischaemic heart disease (IHD) on heart failure (HF) is evolving, there is uncertainty about the role of IHD in determining the risk of clinical outcomes by gender. This study evaluated the gender difference in the impact of IHD on long-term clinical outcomes in patients with heart failure reduced ejection fraction (HFrEF).

METHODS

Study data were obtained from a nationwide registry, which is a prospective multicentre cohort that included 3200 patients who were hospitalized for HF. A total of 1638 patients with HFrEF were classified by gender. The primary outcome was all-cause death during follow-up.

RESULTS

In total, 133 women (18.9%) died and 168 men (18.0%) died during the follow-up (median, 489 days). Women with HFrEF with IHD had a significantly lower cumulative survival rate than women without IHD at the long-term follow-up (74.8% vs 84.9%, log-rank P = .001). However, the survival rate was not different in men with HFrEF with IHD compared with men without IHD. A Cox regression analysis showed that IHD had a 1.43-fold increased risk for all-cause mortality independently in women after adjusting for confounding factors (odds ratio 1.43, 95% confidence interval 1.058-1.929, P = .020).

CONCLUSION

Ischaemic heart disease was an independent risk factor for long-term mortality in women with HFrEF. IHD should be actively evaluated in women with HF for predicting clinical outcomes and initiating appropriate treatment. Women with HF caused by IHD should be treated more meticulously to avoid a poor prognosis.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women's Chest Pain Registry

BACKGROUND/AIMS

Chest pain in patients with obstructive coronary artery disease (OCAD) is affected by several social factors. The gender-based differences in chest pain among Koreans have yet to be investigated.

METHODS

The study consecutively enrolled 1,549 patients (male/female, 514/1,035; 61 ± 11 years old) with suspected angina. The predictive factors for OCAD based on gender were evaluated.

RESULTS

Men experienced more squeezing type pain on the left side of chest, while women demonstrated more dull quality pain in the retrosternal and epigastric area. After adjustment for risk factors, pain in the retrosternal area (odds ratio [OR], 1.491; 95% confidence interval [CI], 1.178 to 1.887) and aggravation by exercise (OR, 2.235; 95% CI, 1.745 to 2.861) were positively associated with OCAD. In men, shorter duration (OR, 1.581; 95% CI, 1.086 to 2.303) and dyspnea (OR, 1.610; 95% CI, 1.040 to 2.490) increased the probability for OCAD, while left-sided chest pain suggested a low probability for OCAD (OR, 0.590; 95% CI, 0.388 to 0.897). In women, aggravation by emotional stress (OR, 0.348; 95% CI, 0.162 to 0.746) and dizziness (OR, 0.457; 95% CI, 0.246 to 0.849) decreased the probability for OCAD.

CONCLUSION

This is the first study to focus on gender differences in chest pain among Koreans with angina. Symptoms with high probability for OCAD were different between sexes. Our findings suggest that patient's medical history in pretest assessment for OCAD should be individualized considering gender.

Changes in the Physical Function and Psychological Distress from Pre-Implant to 1, 6, and 12 Months Post-Implant in Patients Undergoing Implantable Cardioverter Defibrillator Therapy

Recipients of implantable cardioverter-defibrillator (ICD) therapy in Western countries often experience distressful physical and psychological adjustments. Sociocultural influences on post-implant recovery are likely; however, evidence from other ethnic/cultural backgrounds is lacking. This study aimed to examine the changes in physical function and psychological distress (anxiety and depressive symptoms) from pre-implant to one, six, and 12 months post-implant in Korean patients undergoing ICD therapy. A total of 34 patients underwent pre- to post-implant longitudinal assessments of physical and psychological function using mixed modeling procedures. Physical function significantly declined from pre-implant to one month post-implant (B = -10.05, p = 0.004) and then nearly returned to the pre-implant level at six months post-implant (B = 8.34, p = 0.028). This level of improvement continued through 12 months post-implant. In psychological distress, significant improvements were observed from pre-implant to one month (anxiety (B = -1.20, p = 0.020) and in depressive symptoms (B = -1.15, p = 0.037)), which then plateaued without significant changes from one to 12 months. We concluded that physical function recovery occurred six months post-implant, but function remained poor until 12 months post-implant. Psychological distress improved one month post-implant and it was maintained. Clinicians must provide more intensive interventions to improve long-term physical function after ICD therapy.

Attitudes toward advance directives and prognosis in patients with heart failure: a pilot study

BACKGROUND/AIMS

Advance directives (ADs) in Korean patients with heart failure (HF) and the associations of attitude towards ADs and HF prognosis with ADs were initially assessed using the model of the Korean-Advance Directive (K-AD).

METHODS

Twenty-four patients with HF (age, 67.1 years; men, 58.3%; ejection fraction, 35.9%) participated. A pilot test to evaluate the feasibility of ADs and the possible associations of attitudes towards ADs and prognosis with end-of-life treatment preferences among patients with HF was conducted.

RESULTS

Fifteen patients (62.5%) completed the K-ADs. The major reason for incomplete K-AD was knowledge deficit. Patients valued "comfortable death" the most (45.4%), followed by "giving no burden to the family" (13.6%). Among treatment preferences, hospice care was preferred by the majority (66.7%), while cardiopulmonary resuscitation (CPR) was preferred by the minority (31.8%). Children (50.0%) were mostly appointed as a proxy, followed by the spouse (33.3%). More patients with moderately positive attitudes completed the K-ADs than their counterparts (70.0% vs. 57.1%). The 5-year survival rate was 69.2%; the patients who preferred CPR had a higher survival rate (70.6% vs. 68.5%) whereas those who preferred hospice care had a lower survival rate than their counterparts (70.7% vs. 75.2%).

CONCLUSION

The findings support the feasibility of the K-AD model, with a high acceptance rate in two-thirds of the sample. Further studies are warranted to investigate whether treatment preferences are associated with attitude towards ADs and/or HF prognosis using larger sample size.

P3453Gender difference in impact of ischemic heart disease on long-term outcome in patients with heart failure reduced ejection fraction

Background

Ischemic heart disease (IHD) is a major underlying etiology in patients with heart failure (HF). Although the impact of IHD on HF is evolving, there is a lack of understanding of how IHD affects long-term clinical outcomes and uncertainty about the role of IHD in determining the risk of clinical outcomes by gender.

Purpose

This study aims to evaluate the gender difference in impact of IHD on long-term clinical outcomes in patients with heart failure reduced ejection fraction (HFrEF).

Methods

Study data were obtained from the nationwide registry which is a prospective multicenter cohort and included patients who were hospitalized for HF composed of 3,200 patients. A total of 1,638 patients with HFrEF were classified into gender (women 704 and men 934). The primary outcome was all-cause death during follow-up and the composite clinical events of all-cause death and HF readmission during follow-up were also obtained. HF readmission was defined as re-hospitalization because of HF exacerbation.

Results

133 women (18.9%) were died and 168 men (18.0%) were died during follow-up (median 489 days; inter-quartile range, 162–947 days). As underlying cause of HF, IHD did not show significant difference between genders. Women with HFrEF combined with IHD had significantly lower cumulative survival rate than women without IHD at long-term follow-up (74.8% vs. 84.9%, Log Rank p=0.001, Figure 1). However, men with HFrEF combined with IHD had no significant difference in survival rate compared with men without IHD (79.3% vs. 83.8%, Log Rank p=0.067). After adjustment for confounding factors, Cox regression analysis showed that IHD had a 1.43-fold increased risk for all-cause mortality independently only in women. (odds ratio 1.43, 95% confidence interval 1.058–1.929, p=0.020). On the contrary to the death-free survival rates, there were significant differences in composite clinical events-free survival rates between patients with HFrEF combined with IHD and HFrEF without IHD in both genders.

Figure 1

Conclusions

IHD as predisposing cause of HF was an important risk factor for long-term mortality in women with HFrEF. Clinician need to aware of gender-based characteristics in patients with HF and should manage and monitor them appropriately and gender-specifically. Women with HF caused by IHD also should be treated more meticulously to avoid a poor prognosis.

Acknowledgement/Funding

None

Associations of Advance Directive Knowledge, Attitudes, and Barriers/Benefits With Preferences for Advance Treatment Directives Among Patients With Heart Failure and Their Caregivers

BACKGROUND

Patients with heart failure (HF) have not been considered as major beneficiaries of advance directives (ADs). We analyzed factors affecting the preferences for the adoption of ADs by patients with HF and their caregivers.

METHODS AND RESULTS

Seventy-one patient (mean age: 68 years)-caregiver (mean age: 55 years) dyads were enrolled during clinic visits for routine care at a single institution and completed questionnaires during in-person visits. Cohen's kappa coefficients and generalized estimating equation models were used to analyze the data. The agreement on dyadic perspectives for aggressive treatments was poor or fair, whereas agreement relative to hospice care was moderate (k = 0.42, 95% confidence interval = 0.087-0.754). Both patients and caregivers demonstrated poor knowledge of ADs and similar levels of perceived benefits and barriers to advance care planning. However, the caregivers had more positive attitudes toward ADs than patients. Patients and caregivers who were older and/or males had greater odds of preferring aggressive treatments and/or hospice care. Further, those with depressive symptoms had lower odds of preferring hospice care.

CONCLUSION

The dyadic agreement was moderately high only for hospice care preferences. Both patients and caregivers demonstrated knowledge of shortfalls regarding ADs. Timely AD discussions could increase dyadic agreement and enhance informed and shared decision-making regarding medical care.

Sex Differences in Long-Term Clinical Outcomes in Patients Hospitalized for Acute Heart Failure: A Report from the Korean Heart Failure Registry

Background: Although a better survival rate in women than in men has been reported in heart failure (HF) with reduced ejection fraction (HFrEF), the sex-specific prognosis has scarcely been addressed in HF with preserved EF (HFpEF). Thus, this study investigated the sex difference in clinical outcomes in patients with HFpEF, as well as in those with HFrEF. Materials and Methods: We studied clinical outcomes of 2,572 hospitalized patients due to HF (66.8 ± 14.4 years, 49.7% women) in the Korean Heart Failure Registry. Patients were divided into two groups by left ventricular EF (LVEF): HFpEF (LVEF ≥50%, n = 764) and HFrEF (LVEF <40%, n = 1,808) groups. Results: During a median follow-up of 1,121 days, there were 693 (28.7%) deaths and 1,073 (44.5%) composite events (death and HF readmission). There were no sex differences in the incidence of death or composite events during follow-up in both HFrEF and HFpEF groups (p > 0.05 for each). In 1:1 age-matched population (n = 1,005 in each sex), the long-term mortality was significantly lower in women than men in HFrEF group (p = 0.005), but not in HFpEF group (p = 0.786), while the incidences of composite events were similar between sex irrespective of LVEF (p > 0.05). However, there were no significant associations between sex and clinical outcomes in multivariable analysis (p > 0.05 for each). Conclusions: Sex per se was not the significant factor determining long-term clinical outcomes in HF patients regardless of the LVEF.

Fimasartan reduces clinic and home pulse pressure in elderly hypertensive patients: A K-MetS study

Background

Angiotensin II receptor blockers (ARBs) are recommended for treating patients with hypertension. However, comparative safety and efficacy of ARB use in elderly patients have not been well established. This study was designed to determine the efficacy of fimasartan, an ARB, in hypertensive elderly patients by measuring clinic and home blood pressures (BPs) and evaluating safety compared to nonelderly patients.

Method

In the K-MetS study, a nationwide prospective observational study of hypertensive patients on fimasartan, elderly patients (60 years and older) who were treated for 1 year with fimasartan were recruited. BP was evaluated in clinic and at home.

Results

Of the 6 399 enrolled patients, 2 363 were elderly (46.9% males, mean age 67.3 ± 5.7 years). Fimasartan reduced systolic and diastolic BP (SBP and DBP) in clinic from 144.1 ± 17.3 to 127.7 ± 12.9 mmHg and from 85.1 ± 10.4 to 76.8 ± 8.4 mmHg, respectively, (all p<0.0001) in 1 year. Similar results were found in home BPs. These BP changes were consistent with those in nonelderly patients. However, pulse pressure, a better predictor of cardiovascular events in the elderly, decreased more in elderly than in nonelderly patients by -8.2 ± 0.3 in elderly and -7.0 ± 0.2 mmHg (p<0.0001), respectively, after adjustment for confounding factors. Adverse events were reported in 1.6% of elderly hypertensives, independent of dose, which was consistent with results in nonelderly patients.

Conclusions

Fimasartan resulted in better pulse pressure reduction with similar BP reduction efficacy and safety in hypertensive elderly patients compared with nonelderly patients.

Predicted relationships between cognitive function, depressive symptoms, self-care adequacy, and health-related quality of life and major events among patients with heart failure

BACKGROUND

Cognitive decline, which often occurs in heart failure, is likely to decrease health-related quality of life and increase morbidity and mortality (major events), but it has been scantly addressed.

AIMS

To examine whether baseline cognitive domains of global cognition, memory and executive function predict baseline health-related quality of life and 15-month major events among patients with heart failure.

METHODS

This prospective study included 117 patients (mean age 65.5 ± 9.42 years; men 58.1%; New York Heart Association class III/IV 25.6%), who completed questionnaires, including neuropsychological testing for cognitive evaluation, depressive symptoms, self-care and health-related quality of life measures. Their 15-month major events were extracted from medical record reviews.

RESULTS

Approximately one-third of the sample had cognitive impairment. Forty-one patients (35.0%) experienced major events. Patients with major events had significantly worse memory (immediate recall memory 13.9 vs. 11.5, P=0.030; delayed recall memory 4.3 vs. 3.1, P=0.014) and reduced executive function (trail-making test A 28.1 vs. 38.0 seconds, P=0.031). After controlling for age, sex, heart failure severity and comorbidity, memory loss with depressive symptoms was associated with worse health-related quality of life, and odds ratios of experiencing major events increased only with reduced cognitive function in global cognition and executive function.

CONCLUSION

Cognitive function is an important factor for health-related quality of life and major events, and memory loss - worsened health-related quality of life and poor executive function was more likely to increase the risk of major events. Future studies should consider both cognitive function and depressive symptoms when designing heart failure interventions to improve patient outcomes.

Normal reference values of diastolic strain rate in healthy individuals: Chronological trends and the comparison according to genders

PURPOSE

Recently, the diastolic strain rate (DSR) utilizing speckle-tracking echocardiography has been proposed as a novel parameter for left ventricular diastolic function. We aimed to present normal reference data for those in a large-sized, selected group of healthy individuals.

METHODS

The current study was a part of the Normal echOcardiogRaphic Measurements in KoreAn popuLation (NORMAL), a prospective nationwide survey from 23 centers in Korea. We analyzed 447 subjects (age 48 ± 15 years, 234 females) without any history of cardiovascular disease and presented the early and late DSRs (SR_e and SR_a , respectively) in a total and gender-/age-specified groups.

RESULTS

Among the total subjects, the mean SR_e and SR_a were 1.6 ± 0.4 S^-1 and 0.8 ± 0.3 S^-1 , respectively. With increasing age, there were significant trends of decreasing SR_e and increasing SR_a . Although both gender groups showed comparable age, the female group presented significantly higher SR_e compared to male subjects with age of 20-59 years, which diminished after the age of 60 years. However, the SR_a was comparable between genders in all age groups. On multiple linear regression, age showed independent associations with both SR_e (β = -0.132, P = .010) and SR_a (β = 0.440, P < .001), whereas gender did not show any association with SR_e or SR_a .

CONCLUSION

We present normal reference data of a novel parameter, DSR, in a large-sized selected group with healthy Korean subjects. Additionally, we present significant age-related changes both in SR_e and SR_a without the impact of their gender.

Impact of Heart Rate Reduction with Maximal Tolerable Dose of Bisoprolol on Left Ventricular Reverse Remodeling

BACKGROUND

We aimed to evaluate effect of heart rate (HR) reduction on left ventricular reverse remodeling (LVRR) in Korean patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

Ambulatory patients with HFrEF, who had paired echocardiograms, N-terminal prohormone brain natriuretic peptide (NT-proBNP), and global assessment score (GAS) at baseline and 6-month (n = 157), were followed up on preset treatment schedule with bisoprolol.

RESULTS

The LVRR occurred in 49 patients (32%) at 6-month. In multivariable analysis, independent predictors associated with LVRR were use of anti-aldosterone agent (odds ratio [OR], 4.18; 95% confidence interval [CI], 1.80-9.71), young age (OR, 0.96; 95% CI, 0.92-0.99), high baseline HR (OR, 3.76; 95% CI, 1.40-10.10), and favorable baseline GAS (OR, 1.73; 95% CI, 1.06-2.81). Beneficial effect of bisoprolol, in terms of LVRR, NT-proBNP, and GAS, was remarkable in the high HR group (baseline HR ≥ 75 beats per minute [bpm]), which showed a large HR reduction.

CONCLUSION

High baseline HR (≥ 75 bpm) showed an association with LVRR and improvement of NT-proBNP and GAS in patients with HFrEF. This seems to be due to a large HR reduction after treatments with bisoprolol. Trial registry at www.ClinicalTrials.gov, NCT00749034.

Concomitant diastolic dysfunction further interferes with cognitive performance in moderate to severe systolic heart failure

Background

Studies of the relevance of cardiac functional markers to cognitive performance in heart failure (HF) have primarily focused on systolic markers. In this study, we examine whether concomitant diastolic dysfunction further interferes with cognitive performance in memory, attention, and executive function in patients with HF.

Methods and results

In this cross-sectional correlational study, 82 patients completed face-to-face interviews for neuropsychological testing for cognitive evaluation. Echocardiographic data were obtained from a review of medical records. Mild to moderate (ejection fraction [EF] ≥ 30%) and severe (EF < 30%) systolic dysfunction were present in 55 (67.1%) and 27 (32.9%) patients, respectively, while 21 (26.3%) had diastolic dysfunction (E/e′ > 15). Those patients who had severe systolic dysfunction had significantly lower attention scores (Digit Span Test [DST] backward, t = 2.62, p = 0.011), while those with concomitant severe diastolic dysfunction had significantly lower verbal fluency (t = 2.84, p = 0.006) and executive function (Korean-Trail Making Test Part B) (t = -2.14, p = 0.036) scores than those without severe diastolic dysfunction. After controlling for age and education, systolic patients with HF with concomitant severe diastolic dysfunction had worse cognitive performance in verbal fluency than those without severe diastolic dysfunction (F = 4.33, p = 0.041, partial eta = 0.057). Concomitant moderate to severe systolic and severe diastolic dysfunction further reduced verbal fluency (F = 8.42, p = 0.005, partial eta = 0.106).

Conclusions

Cognitive performance, particularly executive function, was worse in patients with HF with systolic dysfunction when diastolic dysfunction was concomitantly present. Routine monitoring of and surveillance for diastolic dysfunction and cognitive screening are warranted in the management of patients with HF.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

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

A multicenter cohort study of primary hypertension in Korea: study design and interim analysis of the Korean registry of target organ damage in hypertension (KorHR)

BACKGROUND

The Korean Registry of Target Organ Damage in Hypertension aims to evaluate the clinical characteristics and prevalence of subclinical target organ damage in Korean hypertensive patients.

METHOD

This is a prospective, observational, multicenter cohort study in which 23 university hospitals participated. Since May 2013, we have enrolled 1,318 consecutive hypertensive patients without known cardiovascular disease who met the following inclusion criteria: 1) age older than 30 years and 2) the first visit to the participating hospitals was within the last 5 years.

RESULTS

The mean age was 52 ± 12 years; 62.1% were male, and 41.3% were incident hypertensives. Patients with diabetes mellitus accounted for 7.8% of the population and 43.8% had hyperlipidemia or were on statins at baseline. The mean office blood pressures were 152 ± 20/96 ± 14 mmHg for incident hypertensive patients and 129 ± 13/78 ± 10 mmHg for patients on treatment. Patients with electrocardiographic and echocardiographic left ventricular hypertrophy accounted for 18.9 and 25.6%, respectively. The mean brachial-ankle pulse wave velocity (PWV) was 1564 ± 293 m/s and 19.5% had PWV values of more than 1750 cm/s. Patients with microalbuminuria and chronic kidney disease accounted for 21 and 4%, respectively. The first prescribed class of antihypertensive medications was angiotensin converting enzyme inhibitors in 2.9%, angiotensin receptor blockers (ARBs) in 57.5%, diuretics in 7.6%, calcium channel blockers (CCBs) in 61.0%, beta blockers in 17.3%, and fixed dose combination pill in 27.8%.

CONCLUSION

Our interim analysis shows that subclinical target organ damage in hypertension is considerably present for incident or treated hypertensive patients. CCBs and ARBs were the most commonly prescribed classes of antihypertensive medications and fixed dose combination pills were actively used in Korea.

TRIAL REGISTRATION

NCT01861080. Registered 16 May 2013.

Torsades de Pointes associated with QT prolongation after catheter ablation of paroxysmal atrial fibrillation

A 79-year-old woman who underwent catheter ablation for paroxysmal atrial fibrillation presented with Torsades de Pointes (TdP). Aggravation of prolonged QT interval which is most likely due to neural modulation by catheter ablation, played major role in the initiation of TdP. The patient was successfully treated with isoproterenol during acute stage and discharged after stabilization without implantation of permanent pacemaker or implantable cardioverter defibrillator.

Practical management of peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy that causes systolic heart failure (HF) in previously healthy young women. Despite latest remarkable achievement, unifying pathophysiologic mechanism is not well established. Considering close temporal relationship to pregnancy, the recent prolactin theory is promising. Abnormal short form of 16-kDa prolactin may be produced in the oxidative stress milieu, show anti-angiogenic effect and damage cardiovascular structure in late pregnancy. Future study is needed to determine whether abnormal prolactin system is useful as a biomarker for diagnosis and therapy of PPCM. Diagnosis is made based on the finding of left ventricular systolic dysfunction after excluding other causes of HF. A multidisciplinary team approach is essential for acute HF, antepartum, labor and postpartum care. Recovery from left ventricular dysfunction is critical for prognosis. As PPCM can recur and cause serious clinical events, subsequent pregnancy is not recommended. This review focuses on the practical management of PPCM.

Normal 2-Dimensional Strain Values of the Left Ventricle: A Substudy of the Normal Echocardiographic Measurements in Korean Population Study

Background

It is important to understand the distribution of 2-dimensional strain values in normal population. We performed a multicenter trial to measure normal echocardiographic values in the Korean population.

Methods

This was a substudy of the Normal echOcardiogRaphic Measurements in KoreAn popuLation (NORMAL) study. Echocardiographic specialists measured frequently used echocardiographic indices in healthy people according to a standardized method at 23 different university hospitals. The strain values were analyzed from digitally stored images.

Results

Of a total of 1003 healthy participants in NORMAL study, 2-dimensional strain values were measured in 501 subjects (265 females, mean age 47 ± 15 years old) with echocardiographic images only by GE echocardiographic machines. Interventricular septal thickness, left ventricular (LV) posterior wall thickness, systolic and diastolic LV dimensions, and LV ejection fraction were 7.5 ± 1.0 mm, 7.4 ± 1.0 mm, 29.9 ± 2.8 mm, 48.9 ± 3.6 mm, and 62 ± 4%, respectively. LV longitudinal systolic strain (LS) values of apical 4-chamber (A4C) view, apical 3-chamber (A3C) view, apical 2-chamber (A2C) view, and LV global LS (LVGLS) were −20.1 ± 2.3, −19.9 ± 2.7, −21.2 ± 2.6, and −20.4 ± 2.2%, respectively. LV longitudinal systolic strain rate (LVLSR) values of the A4C view, A3C view, A2C view, and LV global LSR (LVGLSR) were −1.18 ± 0.18, −1.20 ± 0.21, −1.25 ± 0.21, and −1.21 ± 0.21^−s, respectively. Females had lower LVGLS (−21.2 ± 2.2% vs. −19.5 ± 1.9%, p < 0.001) and LVGLSR (−1.25 ± 0.18^−s vs. −1.17 ± 0.15^−s, p < 0.001) values than males.

Conclusion

We measured LV longitudinal strain and strain rate values in the normal Korean population. Since considerable gender differences were observed, normal echocardiographic cutoff values should be differentially applied based on sex.

A Randomized, Double-blind, Multicenter, Phase III Study to Evaluate the Efficacy and Safety of Fimasartan/Amlodipine Combined Therapy Versus Fimasartan Monotherapy in Patients With Essential Hypertension Unresponsive to Fimasartan Monotherapy

PURPOSE

The goal of this study was to evaluate whether the blood pressure-lowering efficacy of fimasartan/amlodipine combination therapy was superior to that of fimasartan monotherapy after 8 weeks of treatment in patients with hypertension who had failed to respond adequately to fimasartan monotherapy.

METHODS

This trial was a randomized, double-blind, multicenter, Phase III clinical study. Patients who failed to respond after 4 weeks of treatment with 60 mg daily of fimasartan (sitting systolic blood pressure [SiSBP]) ≥140 mm Hg) were randomized to receive either daily fimasartan 60 mg or fimasartan/amlodipine 60 mg/10 mg. The primary efficacy end point was the change in SiSBP from baseline to week 8. Secondary end points included the change in SiSBP from baseline to week 4, the changes in sitting diastolic blood pressure from baseline to weeks 4 and 8, and the response rate (SiSBP <140 mm Hg or decrease in SiSBP ≥20 mm Hg) or control rate (SiSBP <140 mm Hg) at week 8. Treatment-emergent adverse events were also assessed.

FINDINGS

Of 143 patients randomized to treatment, 137 patients who had available efficacy data were analyzed. The mean age of patients was 59.1 (8.9) years, and 100 (73.0%) were male. Baseline SiSBP and sitting diastolic blood pressure were 150.6 (9.2) mm Hg and 91.7 (8.6) mm Hg, respectively. In the fimasartan/amlodipine combination group, a greater reduction in SiSBP from baseline to week 8 was observed compared with the fimasartan group (7.8 [13.3] mm Hg in the fimasartan group vs 20.5 [14.6] mm Hg in the fimasartan/amlodipine group; P < 0.0001). This reduction was observed after 4 weeks. The mean SiSBP changes from baseline to week 4 were 8.1 (15.8) mm Hg in the fimasartan group and 20.1 (14.7) mm Hg in the fimasartan/amlodipine group (P < 0.0001). At week 8, the response rate was significantly higher in the fimasartan/amlodipine (82.1%) group than in the fimasartan (32.9%) group (P < 0.0001). The control rate at week 8 was also higher in the fimasartan/amlodipine (79.1%) group than in the fimasartan (31.4%) group (P < 0.0001). Adverse drug reactions were observed in 9 patients (6.3%), with no significant differences between treatment groups. There were no serious adverse events associated with the study drugs.

IMPLICATIONS

Fimasartan/amlodipine combination therapy exhibited superior efficacy in reducing blood pressure, with no increase in adverse drug reactions, compared with fimasartan monotherapy. ClinicalTrials.gov identifier: NCT02152306.