Korean Circulation Journal最新文献

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.

Background and objectives: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an under-recognized condition with high mortality if untreated. Tafamidis, a transthyretin stabilizer, reduces mortality and cardiovascular events in ATTR-CM, but data in Korean populations are limited. This study evaluated the impact of tafamidis on survival and disease progression in Korean ATTR-CM patients using strain analysis of the left ventricle (LV), right ventricle (RV) and left atrium (LA).

Methods: This multicenter, retrospective study included 77 patients with confirmed ATTR-CM between July 2010 and June 2024. Patients were grouped as untreated or treated with tafamidis 20 mg or 80 mg. Strain analysis was performed at baseline and follow-up. The primary outcome was a composite of all-cause mortality and worsening heart failure.

Results: Compared with the untreated group, the tafamidis 20 mg group had a lower risk of the composite outcome (hazard ratio [HR], 0.29; 95% confidence interval [CI], 0.12, 0.73), with similar benefit in the 80 mg group (HR, 0.23; 95% CI, 0.06, 0.83). LV global longitudinal strain showed no significant difference (p=0.904). In contrast, LA stiffness index (LASI) and RV-pulmonary circulation coupling index deteriorated markedly in the untreated group. Over a median follow-up of 17.5 months, LASI worsened by 43.2% in the untreated group, compared to 8.0% and 8.7% increases in the 20 mg and 80 mg groups. RV-pulmonary circulation coupling index decreased by 35.8% and 1.2%, but increased by 10.9%, respectively.

Conclusions: Tafamidis was associated with improved survival and slower disease progression in Korean ATTR-CM. LASI and RV-pulmonary circulation coupling index may serve as sensitive markers of treatment response.

Transposition of the great arteries (TGA) is a congenital heart defect (CHD) characterized by discordance between the ventricles and great arteries. The arterial switch operation generally provides excellent early and long-term outcomes in cases in which both great arteries are well developed. Furthermore, various surgical techniques, including the Rastelli procedure, réparation à l'étage ventriculaire (REV) procedure, and pulmonary root translocation have been introduced to improve the outcomes in patients with complex TGA accompanied by significant left ventricular (LV) outflow tract obstruction. A common feature of these 3 techniques is the intraventricular tunneling of the LV to the aorta through the ventricular septal defect while maintaining the original position of the aortic root. Recently, aortic root translocation (ART), which reconstructs the biventricular outflow tracts by repositioning the aortic root toward the pulmonary side, has been reevaluated as an alternative to conventional techniques. Early experiences with ART have reported technical challenges, in addition to high surgical mortality and morbidity rates. Nevertheless, with an increase in surgical experience, early outcomes comparable to those of non-ART procedures have been reported, along with improved long-term results. A key principle of ART is to preserve the integrity of the aortic root geometry. Various modifications have been introduced to achieve this. As a potential solution, we propose an aortic root reconstruction technique, which we briefly introduce here. Furthermore, ART has been applied in patients with complex congenitally corrected TGA, and we anticipate that this technique will facilitate safer and more feasible biventricular repair in patients with complex CHDs.

Background and objectives: This study aimed to evaluate the prognostic value of the vasoactive inotropic score (VIS) in patients with fulminant myocarditis according to the application of venoarterial-extracorporeal membrane oxygenation (VA-ECMO).

Methods: This study retrospectively analyzed 417 patients with biopsy-proven or clinically suspected fulminant myocarditis from 7 hospitals in Korea. The primary outcome was a composite of all-cause death, heart transplantation, or the use of left ventricular assist device (LVAD) at 1 year.

Results: The median VIS was 19.9, and 217 (52.0%) patients received VA-ECMO. The primary outcome occurred in 105 patients (26.7%). All-cause death, heart transplantation, and the implantation of LVAD occurred in 81 (20.7%), 30 (8.7%), and 1 (0.3%) patients, respectively. VIS was associated with the risk of the primary outcome in both patients treated with VA-ECMO (hazard ratio [HR], 1.017 for every 10-point increase; 95% confidence interval [CI], 1.007-1.028; p=0.001) and patients without VA-ECMO (HR, 1.128 for every 10-point increase; 95% CI, 1.079-1.179; p<0.001), but the effect was greater in patients without who did not receive VA-ECMO (interaction p<0.001). Furthermore, the predictive performance of VIS for the primary outcome was significantly lower in patients with VA-ECMO than in those without VA-ECMO (C-index, 0.555 vs. 0.780; p value for C-index comparison, 0.002).

Conclusions: In patients with fulminant myocarditis, the prognostic value of VIS was more prominent in patients without VA-ECMO than in patients with VA-ECMO. These findings suggest that the prognostic value of VIS is weakened under the influence of VA-ECMO.

Trial registration: ClinicalTrials.gov Identifier: NCT05933902.

Background and objectives: Heart failure with reduced ejection fraction (HFrEF) poses a significant burden on healthcare systems worldwide. We evaluated the real-world cost-effectiveness of angiotensin receptor-neprilysin inhibitor (ARNI) compared with traditional renin-angiotensin system (RAS) blockade in patients with HFrEF in the Korean setting.

Methods: A partitioned survival model was developed based on the PARADE-HF study, which evaluated the effectiveness of ARNI in Korean HFrEF patients using National Health Insurance claims data. The model estimated medical costs, hospitalizations, life-years, and quality-adjusted life-years (QALYs) over a lifetime. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER).

Results: The use of ARNI resulted in additional 0.54 life-years, 0.25 QALYs gained, fewer hospitalizations (25.91 vs. 26.40) per 1,000 person-years, and an added cost of $2,880 per patient. The ICER was $11,365/QALY for all patients and $9,421/QALY for elderly patients (≥75 years). At a $20,000/QALY threshold of the willingness to pay, cost-effectiveness probabilities were 68% in all patients and 88% in elderly patients.

Conclusions: In the real world, ARNI demonstrated superior cost-effectiveness compared with traditional RAS blockade in patients with HFrEF, with particularly pronounced benefits in elderly patients aged ≥75 years. The favorable cost-effectiveness profile, combined with significant reductions in mortality and hospitalization, supports the broader adoption of ARNI in clinical practice, especially for elderly patients despite concerns about tolerability in this population.

Background and objectives: This study aimed to assess clinical factors that predict long-term clinical outcomes in women who underwent invasive coronary angiography (ICA).

Methods: A total of 741 Korean women (mean age 63.9±9.3 years) who underwent ICA for suspected angina were selected from a nationwide registry database. The three-year incidence of composite major adverse cardiovascular events (MACEs) including cardiac death, acute coronary syndrome, stroke, and heart failure requiring hospitalization was assessed.

Results: Within 3 years of clinical follow-up, there were 42 MACEs (5.7%). Multiple Cox regression analysis identified tachycardia (heart rate ≥100 beats per minute: hazard ratio [HR], 4.04; 95% confidence interval [CI], 1.19-13.71; p=0.025), multi-vessel disease (HR, 2.08; 95% CI, 1.04-4.19; p=0.038), left ventricular hypertrophy (left ventricular mass index >95 g/m²: HR, 2.79; 95% CI, 1.37-5.65; p=0.004), and the use of diuretics (HR, 2.51; 95% CI, 1.10-5.76; p=0.029) as significant predictors of 3-year MACEs. For subjects with three of 4 these clinical factors, the risk of MACE increased by 11.79 times compared to subjects with 0-2 clinical factors (95% CI, 4.55-30.56; p<0.001).

Conclusions: In Korean women undergoing elective ICA, tachycardia, multi-vessel disease, left ventricular hypertrophy and the use of diuretics were associated with 3-year MACEs. These indicators should be considered in managing women with suspected angina.

Background and objectives: Malnutrition is common and is associated with poor clinical outcomes in clinically overt patients with heart failure and preserved ejection fraction (HFpEF). However, its prevalence and pathophysiologic and prognostic relevance remain unclear in early-stage HFpEF. This study sought to assess the association between malnutrition risk, exercise capacity, cardiac and peripheral reserve limitations, and clinical outcomes in patients with early HFpEF, defined as those without a history of HF hospitalization.

Methods: Patients with symptomatic HFpEF without previous HF hospitalization (n=341) underwent exercise stress echocardiography. Simultaneous expired gas analysis was conducted in 296 (87%) participants to measure peak oxygen consumption (VO₂). Nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI).

Results: At least mild malnutrition risk (GNRI ≤98) was identified in 125 patients with HFpEF (36.6%). Compared to HFpEF patients without malnutrition risk (n=216), those at risk (n=125) showed reduced exercise capacity (lower peak VO₂) and lower cardiac output and arteriovenous oxygen content difference during exercise. During a median follow-up of 435 days, 52 patients experienced a composite outcome of all-cause mortality or worsening HF events. Patients with malnutrition risk had a nearly 3-fold increased risk of this outcome compared to those without risk (hazard ratio, 3.07; 95% confidence interval, 1.73-5.44; p<0.001).

Conclusions: Malnutrition risk is common in early-stage HFpEF and correlates with exercise intolerance, reduced cardiac output and oxygen uptake, and worse outcomes. Further research is needed to determine management strategies.