Korean Circulation Journal最新文献

Background and objectives: The prognosis of unrevascularized non-culprit lesions (NCLs) and the benefits of non-culprit percutaneous coronary intervention (PCI) may depend on their functional significance and location in patients with acute myocardial infarction (AMI) and multivessel coronary disease (MVD). We investigated the differential outcomes of fractional flow reserve (FFR) versus angiography-guided PCI for NCL between the left anterior descending artery (LAD) and non-LAD arteries.

Methods: This was a prespecified post hoc analysis of the FRAME-AMI trial. The primary endpoint, a composite of time to death, myocardial infarction, or repeat revascularization, was matched between the two strategies according to the NCL location.

Results: Among 562 patients, the proportions of NCL in the LAD and non-LAD groups were 55.0% and 45.0%, respectively. PCI rates (82.2% vs. 78.3%; p=0.242) and the primary outcome (9.4% vs. 11.5%; p=0.421) were comparable between the two groups. In the non-culprit LAD group, FFR-guided PCI was associated with a lower rate of the primary outcome compared to angiography-guided PCI (5.7% vs. 14.3%, p=0.010). In the non-culprit non-LAD group, the outcome rate did not significantly differ between FFR- and angiography-guided PCI (7.4% vs. 14.5%, p=0.081). Nevertheless, the interaction between the non-culprit location and FFR- or angiography-guided PCI did not affect the primary outcome (p=0.667).

Conclusions: The NCL location did not affect the favorable outcomes of FFR-guided PCI over angiography-guided PCI in patients with AMI and MVD.

Background and objectives: Exercise intolerance is the most common symptom of patients with heart failure (HF), regardless of the phenotypes. We aim to investigate the determinants of exercise capacity in chronic stable HF with reduced, mildly reduced, preserved, and recovered ejection fraction (EF).

Methods: Ambulatory HF subjects were recruited for a combined cardiopulmonary exercise test and exercise stress echocardiography. Impaired exercise capacity was referred to a peak oxygen consumption of <14 mL/kg/min, and a relationship between minute ventilation and carbon dioxide production of >34 was defined as ventilatory inefficiency.

Results: Among 66 participants, there were 16 HF with reduced EF, 18 HF with mildly reduced EF, 12 HF preserved EF, and 20 HF recovered EF. Diastolic dysfunction indices were independently predictive of impaired exercise capacity (odds ratio [OR], 3.847; 95% confidence interval [CI], 1.369-10.810). Global longitudinal strain (GLS) at rest was independently correlated with ventilatory inefficiency (OR, 1.404; 95% CI, 1.050-1.877). Among the exercise indices, the peak medial E/e' to cardiac output (CO) ratio was independently associated with impaired exercise capacity (OR, 3.478; 95% CI, 1.313-9.214) and peak GLS was best related to ventilatory inefficiency (OR, 1.403; 95% CI, 1.076-1.828).

Conclusions: Among resting and exertional echocardiographic variables, the peak medial E/e' to CO ratio, a non-invasive assessment of exertional left ventricular filling pressure indexed to CO, was the major determinant of exercise capacity in patients with different HF phenotypes.

Background and objectives: Precise prediction of long-term outcomes in patients with chronic total occlusion (CTO) of the coronary artery is crucial for cardiovascular care. The recent development of advanced machine learning (ML) models has opened up new possibilities in medical prognostics. This study aimed to develop ML models and validate their performance in predicting long-term clinical outcomes in patients with CTO.

Methods: This study retrospectively analyzed 3,248 patients listed in the Asan Medical Center CTO Registry (2003-2018). Patients underwent coronary artery bypass grafting, percutaneous coronary intervention, or optimal medical therapy and were followed up for a median period of 5.3 years. The study population was randomly split into training (n=2,598) and test (n=650) sets. Three ML algorithms-namely, L2-penalized logistic regression, artificial neural networks, and CatBoost-were employed to develop a prognostic model for 5-year cardiac death (primary endpoint) as well as 5-year all-cause mortality and target vessel revascularization (TVR) (secondary endpoints). Model performance was assessed using area under the receiver operating characteristic curves (AUCs), and feature importance was evaluated using SHapley Additive exPlanations values.

Results: The three ML algorithms exhibited comparable performance in predicting 5-year cardiac death (AUC: 0.80). Additionally, these three ML algorithms successfully predicted 5-year all-cause mortality (AUC: 0.83-0.84) and TVR (AUC: 0.65-0.74), showing good predictive performance. Patient demographics and comorbidities, rather than treatment modality, were the leading predictors of outcomes.

Conclusions: The ML models are reliable in predicting 5-year clinical outcomes in patients with CTO, demonstrating their potential for clinical application.

Background and objectives: The 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines updated the definition of pulmonary hypertension (PH). This study aimed to evaluate implications of the new PH definition.

Methods: A retrospective analysis of a single-center right heart catheterization registry (April 2016-July 2023) was conducted. Patients were classified using the classic definition (mean pulmonary arterial pressure [mPAP] ≥25 mmHg, pulmonary vascular resistance [PVR] >3 Wood units [WU]) and the new definition (mPAP >20 mmHg, PVR >2 WU). The primary outcome was a composite of cardiovascular death or heart failure (HF) hospitalization over a maximum follow-up of 5 years.

Results: Among 314 patients (median age, 62.5 years; male, 50.3%), the new definition led to a 9.6% increase in diagnosis of pre-capillary PH (Pre-PH) and a 10.5% increase in combined pre- and post-capillary PH (Cpc-PH). Event discrimination was comparable between the 2 definitions, as assessed by the C-index and net reclassification improvement. Multivariable Cox regression, adjusted for age and sex, showed a lower risk of cardiovascular death or HF hospitalization under the new definition. Spline analyses indicated that risk increased from mPAP >20 mmHg and PVR >2 WU.

Conclusions: The new definition increased PH diagnoses, particularly in Pre-PH and Cpc-PH, while maintaining comparable discriminative performance. Improved 5-year event-free survival observed under the new definition may be partly attributable to the inclusion of patients with milder disease. Notably, the risk progressively increased beyond mPAP >20 mmHg and PVR >2 WU, reinforcing the prognostic significance of the new thresholds.

Background and objectives: An individualized approach is recommended for prescribing dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). Asian-DAPT (ADAPT) scores were developed to assess both ischemic and bleeding risks in Asian populations. This study aimed to validate the ADAPT scores for predicting ischemic and bleeding events in patients receiving DAPT.

Methods: Patients from the Multicenter Registry of KOrean PCI foR Endpoint Analysis registry were analyzed. The ADAPT scores, comprising the ischemic-ADAPT (I-ADAPT), bleeding-ADAPT (B-ADAPT), and Net-ADAPT scores, were calculated using clinical and angiographic parameters. Co-primary endpoints included ischemic outcomes (cardiovascular death, myocardial infarction, and stent thrombosis) and bleeding outcomes (major and minor bleeding).

Results: A total of 4,657 patients were included in analysis. The mean age was 63.8±11.1 years, and 72.3% were male. During a median follow-up of 368 days, ischemic outcomes occurred in 0.9% (43 patients), and bleeding outcomes in 0.9% (44 patients). The I-ADAPT and B-ADAPT scores had significant predictive values for ischemic outcomes (C-statistic = 0.672; 95% confidence interval [CI], 0.585-0.758; p<0.001) and bleeding outcomes (C-statistic = 0.715; 95% CI, 0.642-0.789; p<0.001), respectively. Regarding the Net-ADAPT score, patients with a score >0 were at a 1.7-fold higher risk of ischemic events, while those with a score of <0 had a 1.3-fold higher risk of bleeding events.

Conclusions: The ADAPT scores were validated for predicting ischemic and bleeding risks in patients receiving DAPT. This scoring system can aid in evaluating both ischemic and bleeding risks for East Asians, who exhibit unique risk profiles.

Background and objectives: Case volume and improved survival have been reported in several critical illnesses; however, the impact of case volume of targeted temperature management (TTM) on neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients remains unclear. This study aimed to determine whether TTM case volume is associated with neurologically intact survival in comatose OHCA patients.

Methods: This observational study included consecutive adult (≥18 years) OHCA survivors with TTM using data from the Nationwide OHCA Registry in South Korea between 2016 and 2021. TTM case volume was evaluated in 2 ways. First, TTM volume was included as a continuous variable in a restricted cubic spline analysis. Second, TTM case volume was categorized into tertiles (high: ≥17.0 cases/year, medium: 12.0-16.9, and low-volume: <12.0 cases/year), and multivariable logistic regression analysis using generalized estimating equations was performed on good neurologic outcomes (cerebral performance category 1-2) based on the low-volume center.

Results: Overall, 4,018 OHCA survivors treated with TTM were included. In spline analyses, the overall association was significant; non-linearity was not detected in the primary 3-knot model but was observed in sensitivity models with alternative knot placements (4-knot: p=0.005; p for non-linearity=0.045). Although coronary angiography was lower in the high-volume center, multivariable analysis showed that a high-volume TTM center was associated with a good neurological outcome (adjusted odds ratio, 1.45; 95% confidence interval, 1.16-1.81; p=0.001).

Conclusions: Higher TTM case volume was associated with better neurological outcome in comatose OHCA survivors and may reflect greater overall post-arrest care capability.

Based on epidemiological and genetic studies in recent decades, lipoprotein(a) (Lp(a)) has been accepted as a causal risk factor for atherosclerotic cardiovascular disease and aortic stenosis. Although inter-ethnic differences exist, Lp(a) level ≥50 mg/dL is commonly reported to indicate elevated cardiovascular risk. Blood Lp(a) levels are largely determined based on genetic background, and the kringle IV type 2 repeat variant is a major factor. Lp(a) is structurally similar to low-density lipoprotein (LDL) but also contains apolipoprotein(a) (apo(a)), which includes kringle domains associated with diverse effects depending on particles and individuals. The LDL-like property of Lp(a) and effect of apo(a) on vascular cells can promote atherosclerosis. Apo(a) competes with plasminogen and can inhibit the role of plasmin during fibrinolysis. Furthermore, oxidized phospholipids on apo(a) may induce oxidative stress to enhance atherosclerosis and can affect valve calcification. Trials on new therapeutics targeting Lp(a) RNA, including antisense oligonucleotide (e.g., pelacarsen), siRNAs (e.g., olpasiran, lepodisiran, and zerlasiran), and small molecules (e.g., muvalaplin), are under way. Depending on the study or dose, these agents lowered Lp(a) levels by 80-100% compared with the control; however, results of clinical outcomes have yet to be reported.