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1.  APACHE II Score, Rather Than Cardiac Function, May Predict Poor Prognosis in Patients With Stress-Induced Cardiomyopathy 
While the disease course of stress-induced cardiomyopathy (SIC) is usually benign, it can be fatal. The prognostic factors to predict poorer outcome are not well established, however. We analyzed the Acute Physiology And Chronic Health Evaluation (APACHE) II score to assess its value for predicting poor prognosis in patients with SIC. Thirty-seven consecutive patients with SIC were followed prospectively during their hospitalization. Clinical factors, including APACHE II score, coronary angiogram, echocardiography and cardiac enzymes at presentation were analyzed. Of the 37 patients, 27 patients (73%) were women. The mean age was 66.1 ± 15.6 yr, and the most common presentation was chest pain (38%). Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% ± 9.3%, and the wall motion score index (WMSI) was 1.9 ± 0.3. Six patients (16%) expired during the follow-up period of hospitalization. Based on the analysis of characteristics and clinical factors, the only predictable variable in prognosis was APACHE II score. The patients with APACHE II score greater than 20 had tendency to expire than the others (P = 0.001). Based on present study, APACHE II score more than 20, rather than cardiac function, is associated with mortality in patients with SIC.
doi:10.3346/jkms.2012.27.1.52
PMCID: PMC3247775  PMID: 22219614
APACHE II Score; Cardiac Function; Stress-Induced Cardiomyopathy
2.  A Novel Risk Stratification Model for Patients with Non-ST Elevation Myocardial Infarction in the Korea Acute Myocardial Infarction Registry (KAMIR): Limitation of the TIMI Risk Scoring System 
Chonnam Medical Journal  2011;47(1):20-26.
The Thrombolysis in Myocardial Infarction (TIMI) risk score (TRS) has proven value in predicting prognosis in unstable angina/non ST-elevation myocardial infarction (NSTEMI) as well as in ST-elevation myocardial infarction. The TRS system has little implication, however, in the extent of myocardial damage in high-risk patients with NSTEMI. A total of 1621 patients (63.6±12.2 years; 1043 males) with NSTEMI were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR). We analyzed the risk for major adverse cardiac events (MACE) during a 6-month follow-up period. The TRS system showed good correlation with MACE for patients in the low and intermediate groups but had poor correlation when the high-risk group was included (p=0.128). The MACE rate was 3.8% for TRS 1, 9.4% for TRS 2, 10.7% for TRS 3, and 12.3% for TRS 4 (HR=1.29, p=0.026). Among the biomarkers and clinical risk factors, elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) (HR=2.61, p=0.001) and Killip class above III showed good correlation with MACE (HR=0.302, p<0.001). Therefore, we revised an alternative clinical scoring system by including these two variables that reflect left ventricular dysfunction: age > 65 years, history of ischemic heart disease, Killip class above III, and elevated pro-BNP levels above the 75th percentile. This modified scoring system, when tested for validity, showed good predictive value for MACE (HR=1.64, p<0.001). Compared with the traditional TRS, the novel alternative scoring system based on age, history of ischemic heart disease, Killip class, and NT-proBNP showed a better predictive value for 6-month MACE in high-risk patients with NSTEMI.
doi:10.4068/cmj.2011.47.1.20
PMCID: PMC3214861  PMID: 22111052
Angina, unstable; Mortality; Myocardial Infarction
3.  Relationship Between Obesity and N-Terminal Brain Natriuretic Peptide Level as a Prognostic Value After Acute Myocardial Infarction 
Korean Circulation Journal  2010;40(11):558-564.
Background and Objectives
Recently, the prognostic value of N-terminal brain natriuretic peptide (NT-proBNP) in acute coronary syndrome has been demonstrated in many studies. However, NT-proBNP levels are influenced by various factors such as sex, age, renal function, heart failure severity, and obesity. NT-proBNP concentrations tend to decrease with higher body mass index (BMI). The aim of this study was to examine the influence of obesity on NT-proBNP as a predictive prognostic factor in acute myocardial infarction (AMI) patients.
Subjects and Methods
Using data from the Korea Acute Myocardial Infarction Registry (January 2005 to September 2008), 2,736 AMI patients were included in this study. These patients were divided into men (n=1,972, 70%) and women (n=764, 30%), and were grouped according to their BMIs. Major adverse cardiac events (MACE) during 1 year clinical follow-up were evaluated.
Results
NT-proBNP was significantly higher in lower BMI (p<0.001). Mean NT-proBNP levels of each obesity group were 2,393±4,022 pg/mL in the lean group (n=875), 1,506±3,074 pg/mL in the overweight group (n=724) and 1,100±1,137 pg/mL in the obese group (n=1,137) (p<0.01). NT-proBNP was an independent prognostic factor of AMI in obese patients by multivariative analysis of independent risk factors of MACE (p=0.01).
Conclusion
NT-proBNP is lower in obese AMI patients than in non-obese AMI patients, but NT-proBNP is still of independent prognostic value in obese AMI patients.
doi:10.4070/kcj.2010.40.11.558
PMCID: PMC3008826  PMID: 21217932
Brain natriuretic peptide; Obesity; Myocardial infarction
4.  Clinical Effects of Hypertension on the Mortality of Patients with Acute Myocardial Infarction 
Journal of Korean Medical Science  2009;24(5):800-806.
The incidence of ischemic heart disease has been increased rapidly in Korea. However, the clinical effects of antecedent hypertension on acute myocardial infarction have not been identified. We assessed the relationship between antecedent hypertension and clinical outcomes in 7,784 patients with acute myocardial infarction in the Korea Acute Myocardial Infarction Registry during one-year follow-up. Diabetes mellitus, hyperlipidemia, cerebrovascular disease, heart failure, and peripheral artery disease were more prevalent in hypertensives (n=3,775) than nonhypertensives (n=4,009). During hospitalization, hypertensive patients suffered from acute renal failure, shock, and cerebrovascular event more frequently than in nonhypertensives. During follow-up of one-year, the incidence of major adverse cardiac events was higher in hypertensives. In multi-variate adjustment, old age, Killip class ≥III, left ventricular ejection fraction <45%, systolic blood pressure <90 mmHg on admission, post procedural TIMI flow grade ≤2, female sex, and history of hypertension were independent predictors for in-hospital mortality. However antecedent hypertension was not significantly associated with one-year mortality. Hypertension at the time of acute myocardial infarction is associated with an increased rate of in-hospital mortality.
doi:10.3346/jkms.2009.24.5.800
PMCID: PMC2752759  PMID: 19794974
Hypertension; Myocardial infarction; Mortality
5.  Impact of Smoking on Clinical Outcomes in Female Patients with Acute Myocardial Infarction 
Korean Circulation Journal  2015;45(1):22-27.
Background and Objectives
Cigarette smoking has been recognized as a prominent threat to women's health. We investigated the impact of smoking on clinical outcomes in Korean female patients after acute myocardial infarction (AMI).
Subjects and Methods
Out of the AMI patients who enrolled in the Korea AMI Registry, 4444 female patients were included in this study. Patients were divided into two groups-non-smoker and smoker-according to their current smoking status. We compared in-hospital mortality and major adverse cardiac events (MACE), including cardiac death, myocardial infarction, repeated percutaneous coronary intervention (PCI), or coronary artery bypass grafting during the one-year clinical follow-up period between two groups.
Results
The non-smoker group had more hypertension (HTN) and diabetes mellitus. The levels of total cholesterol, triglyceride, and low-density lipoprotein cholesterol were higher in the non-smoker group. However, in-hospital mortality was significantly higher in the smoker group (1.0% vs. 2.4%, p=0.002), and cardiac death during the 12-month clinical follow-up was significantly more frequent in the smoker group (2.2% vs. 4.5%, p=0.003). Total MACEs during the 12 months were higher in the smoker group (4.9% vs. 6.8%, p=0.014). Smoking and HTN were independent predictors of MACE {odds ratio (OR): 1.742, 95% confidence interval (CI): 1.010-3.000, p=0.046; OR: 1.573, 95% CI: 1.003-2.466, p=0.049, respectively}.
Conclusion
Female smokers with AMI showed significantly higher in-hospital mortality and MACE rates during the one-year clinical follow-up period.
doi:10.4070/kcj.2015.45.1.22
PMCID: PMC4310976  PMID: 25653700
Hospital mortality; Myocardial infarction; Female; Smoking
6.  The scientific achievements of the decades in Korean Acute Myocardial Infarction Registry 
The Korea Acute Myocardial Infarction Registry (KAMIR) was the first nationwide registry data collection designed to track outcomes of patients with acute myocardial infarction (AMI). These studies reflect the current therapeutic approaches and management for AMI in Korea. The results of KAMIR could help clinicians to predict the prognosis of their patients and identify better diagnostic and treatment tools to improve the quality of care. The KAMIR score was proposed to be a predictor of the prognosis of AMI patients. Triple antiplatelet therapy, consisting of aspirin, clopidogrel and cilostazol, was effective at preventing major adverse clinical outcomes. Drug-eluting stents were effective and safe in AMI patients with no increased risk of stent thrombosis. Statin therapy was effective in Korean AMI patients, including those with very low levels of low density cholesterol. The present review summarizes the 10-year scientific achievements of KAMIR from admission to outpatient care during long-term clinical follow-up.
doi:10.3904/kjim.2014.29.6.703
PMCID: PMC4219958  PMID: 25378967
Acute myocardial infarction; Prognosis; Therapeutics
7.  The Value of Assessing Myocardial Deformation at Recovery after Dobutamine Stress Echocardiography 
Background
The purpose of this study was to evaluate whether performing an assessment of myocardial deformation using speckle tracking imaging during the recovery period after dobutamine stress echocardiography (DSE) allows detection of significant coronary artery disease (CAD) in patients with chest discomfort.
Methods
DSE and coronary angiography were performed in 44 patients with chest discomfort. The mean global longitudinal peak systolic strain (GLS) was measured at rest, at low stress (dobutamine infusion rate of 10 µg/kg/min) and at recovery (5 min after cessation of dobutamine infusion) of DSE using automated function imaging with apical views. Fractional flow reserve (FFR) was also performed in patients with intermediate coronary stenosis. CAD was defined as having a ≥ 70% diameter stenosis on coronary angiography or as having a FFR < 0.8. Patients were divided two groups based on the absence or presence of CAD [CAD (-) group vs. CAD (+) group].
Results
There were no significant differences in the clinical characteristics and results of conventional echocardiography between the two groups. GLS at recovery was lower in the CAD (+) group than in the CAD (-) group (-18.0 ± 3.4% vs. -21.0 ± 1.9%, p = 0.003). The optimal cutoff of GLS at recovery for detection of CAD was -19% (sensitivity of 70.6%, specificity of 83.3%).
Conclusion
Assessment of GLS at recovery of DSE is a reliable and objective method for detection of CAD. This finding may suggest that systolic myocardial stunning remains even after recovery of wall motion abnormalities in patients with CAD.
doi:10.4250/jcu.2014.22.3.127
PMCID: PMC4192410  PMID: 25309689
Dobutamine; Stress echocardiography; Myocardial stunning; Speckle tracking imaging
8.  Characteristics, In-Hospital and Long-Term Clinical Outcomes of Nonagenarian Compared with Octogenarian Acute Myocardial Infarction Patients 
Journal of Korean Medical Science  2014;29(4):527-535.
We compared clinical characteristics, management, and clinical outcomes of nonagenarian acute myocardial infarction (AMI) patients (n=270, 92.3±2.3 yr old) with octogenarian AMI patients (n=2,145, 83.5±2.7 yr old) enrolled in Korean AMI Registry (KAMIR). Nonagenarians were less likely to have hypertension, diabetes and less likely to be prescribed with beta-blockers, statins, and glycoprotein IIb/IIIa inhibitors compared with octogenarians. Although percutaneous coronary intervention (PCI) was preferred in octogenarians than nonagenarians, the success rate of PCI between the two groups was comparable. In-hospital mortality, the composite of in-hospital adverse outcomes and one year mortality were higher in nonagenarians than in octogenarians. However, the composite of the one year major adverse cardiac events (MACEs) was comparable between the two groups without differences in MI or re-PCI rate. PCI improved 1-yr mortality (adjusted hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.36-0.69, P<0.001) and MACEs (adjusted HR, 0.47; 95% CI, 0.37-0.61, P<0.001) without significant complications both in nonagenarians and octogenarians. In conclusion, nonagenarians had similar 1-yr MACEs rates despite of higher in-hospital and 1-yr mortality compared with octogenarian AMI patients. PCI in nonagenarian AMI patients was associated to better 1-yr clinical outcomes.
Graphical Abstract
doi:10.3346/jkms.2014.29.4.527
PMCID: PMC3991796  PMID: 24753700
Aged, Eighty and over; Myocardial Infarction; Percutaneous Coronary Intervention
9.  Concomitant Impact of High-Sensitivity C-Reactive Protein and Renal Dysfunction in Patients with Acute Myocardial Infarction 
Yonsei Medical Journal  2013;55(1):132-140.
Purpose
The present study aimed to investigate the impact of high-sensitivity C-reactive protein (hs-CRP) and renal dysfunction on clinical outcomes in acute myocardial infarction (AMI) patients.
Materials and Methods
The study involved a retrospective cohort of 8332 patients admitted with AMI. The participants were divided into 4 groups according to the levels of estimated glomerular filtration rate (eGFR) and hs-CRP: group I, no renal dysfunction (eGFR ≥60 mL·min-1·1.73 m-2) with low hs-CRP (≤2.0 mg/dL); group II, no renal dysfunction with high hs-CRP; group III, renal dysfunction with low hs-CRP; and group IV, renal dysfunction with high hs-CRP. We compared major adverse cardiac events (MACE) over a 1-year follow-up period.
Results
The 4 groups demonstrated a graded association with increased MACE rates (group I, 8.8%; group II, 13.8%; group III, 18.6%; group IV, 30.1%; p<0.001). In a Cox proportional hazards model, mortality at 12 months increased in groups II, III, and IV compared with group I [hazard ratio (HR) 2.038, 95% confidence interval (CI) 1.450-2.863, p<0.001; HR 3.003, 95% CI 2.269-3.974, p<0.001; HR 5.087, 95% CI 3.755-6.891, p<0.001].
Conclusion
High hs-CRP, especially in association with renal dysfunction, is related to the occurrence of composite MACE, and indicates poor prognosis in AMI patients.
doi:10.3349/ymj.2014.55.1.132
PMCID: PMC3874927  PMID: 24339298
C-reactive protein; glomerular filtration rate; myocardial infarction
10.  One-Year Clinical Outcomes among Patients with Metabolic Syndrome and Acute Myocardial Infarction 
Korean Circulation Journal  2013;43(8):519-526.
Background and Objectives
Metabolic syndrome (MetS) is an important risk factor for cardiovascular disease. However, the clinical outcome of acute myocardial infarction (AMI) with MetS has not been well examined. The purpose of this study was to evaluate the clinical outcomes of AMI patients with MetS.
Subjects and Methods
We evaluated a total of 6352 AMI patients who had successful percutaneous coronary interventions and could be identified for MetS between 2005 and 2008 at 51 hospitals participating in the Korea Acute Myocardial Infarction Registry. They were divided into 2 groups according to the presence of MetS: the MetS group (n=2493, 39.2%) versus the Non-MetS group (n=3859, 60.8%). In addition, 4049 AMI patients with high levels of low density lipoprotein-cholesterol (LDL-C) (≥100 mg/dL) among them, were divided into the MetS group (n=1561, 38.6%) versus the Non-MetS group (n=2488, 61.4%).
Results
In the overall population, there was no significant difference in 12-month the major adverse cardiac events (MACE) rate between the 2 groups. However, the MetS group showed a significantly higher 12-month MACE rate in the high LDL-C population. Multivariate analysis showed that MetS was an independent prognostic factor for 12-month MACE {hazard ratio (HR) 1.607, 95% confidence interval (CI) 1.027 to 2.513, adjusted p=0.038} and for 12-month target vessel revascularization (HR 1.564, 95% CI 1.092 to 2.240, adjusted p=0.015) in the high LDL-C population.
Conclusion
MetS patients with AMI in the overall population showed no significant difference in 12-month clinical outcomes. However, in patients with higher LDL-C ≥100 mg/dL, they showed significantly worse clinical outcome than Non-MetS patients. Therefore, it is important to ascertain the presence of MetS in AMI patients, and more aggressive therapy should be strongly considered for AMI patient with MetS.
doi:10.4070/kcj.2013.43.8.519
PMCID: PMC3772296  PMID: 24044010
Metabolic syndrome; Myocardial infarction; Low density lipoprotein-cholesterol
11.  Percutaneous Coronary Intervention for Acute Myocardial Infarction in Elderly Patients with Renal Dysfunction: Results from the Korea Acute Myocardial Infarction Registry 
Journal of Korean Medical Science  2013;28(7):1027-1033.
This study aimed to evaluate the effects of percutaneous coronary intervention (PCI) on short- and long-term major adverse cardiac events (MACE) in elderly (>75 yr old) acute myocardial infarction (AMI) patients with renal dysfunction. As part of Korea AMI Registry (KAMIR), elderly patients with AMI and renal dysfunction (GFR<60 mL/min) received either medical (n=439) or PCI (n=1,019) therapy. Primary end point was in-hospital death. Secondary end point was MACE during a 1 month and 1 yr follow-up. PCI group showed a significantly lower incidence of in-hospital death (20.0% vs 14.3%, P=0.006). Short-term and long-term MACE rates were higher in medical therapy group (31.9% vs 19.0%; 57.7% vs 31.3%, P<0.001), and this difference was mainly attributed to cardiac death (29.3% vs 17.6%; 51.9% vs 25.0%, P<0.001). MACE-free survival time after adjustment was also higher in PCI group on short-term (hazard ratio, 0.67; confidence interval, 0.45-0.98; P=0.037) and long-term follow-up (hazard ratio, 0.61, confidence interval, 0.45-0.83; P=0.002). In elderly AMI patients with renal dysfunction, PCI therapy yields favorable in-hospital and short-term and long-term MACE-free survival.
doi:10.3346/jkms.2013.28.7.1027
PMCID: PMC3708073  PMID: 23853485
Acute Myocardial Infarction; Renal Dysfunction; Elderly; Percutaneous Coronary Intervention; Major Adverse Cardiac Event
12.  Changes in smoking behavior and adherence to preventive guidelines among smokers after a heart attack 
Objective
Risk factor modification is key to preventing subsequent cardiac events after a heart attack. This study was designed to investigate the disparity between preventive guidelines and clinical practice among smoking patients.
Methods
The study was carried out in smokers admitted with myocardial infarction (MI). A total of 275 patients who had been regularly followed for over one year after MI were randomly selected and enrolled in this study. We investigated changes in smoking behavior and the adherence rate to ACC/AHA Guidelines for secondary prevention in patients with coronary artery disease at the time of, and one year after, the index event.
Results
The study population consisted of 275 patients (97.1% males) with a mean age of 57.0 ± 11.2 years. Achievement of target goals at one year was as follows: smoking cessation, 52.3%; blood pressure, 83.9%; HbA1c, 32.7%; lipid profile, 65.5%; and body mass index (BMI), 50.6%. Over one year, 80% of the patients attempted to quit smoking; 27% of them re-started smoking within one month after discharge while 65% succeeded in cessation of smoking. At one year, only 52% of the patients overall had stopped smoking. From the multivariate logistic analysis including smoking patterns and clinical characteristics, the severity of coronary artery disease was the only independent predictor for smoking cessation (Relative risk (RR): 1.230; P = 0.022).
Conclusions
Only a small percentage of MI patients adhere to guidelines for secondary prevention and a sizable proportion fail to stop smoking. These findings underscore the need for an effective patient education system.
doi:10.3969/j.issn.1671-5411.2013.02.006
PMCID: PMC3708054  PMID: 23888174
Coronary artery disease; Myocardial infarction; Prevention; Smoking
13.  Takotsubo cardiomyopathy recurrence with left ventricular apical ballooning following isolated right ventricular involvement: A case report 
We report a case of Takotsubo cardiomyopathy, which involved the right ventricle at first presentation and demonstrated involvement of the left ventricle during recurrence. The patient was admitted to Kyung Hee University Hospital due to a left hip fracture, which was considered a result of physical stress. Complete recovery was confirmed by echocardiography prior to recurrence. The cause of the second event was surgery for the left hip fracture. Recurrence of Takotsubo cardiomyopathy at various cardiac locations provides evidence against the existing hypotheses that variants of Takotsubo cardiomyopathy are associated with anatomically different distributions of cardiac adrenergic receptors, the degree of stimulation by sympathetic activity and different susceptibilities to such sympathetic stimulation.
doi:10.3892/etm.2013.1112
PMCID: PMC3735877  PMID: 23935757
Takotsubo cardiomyopathy; apical ballooning syndrome; right ventricle
14.  New Horizons of Acute Myocardial Infarction: From the Korea Acute Myocardial Infarction Registry 
Journal of Korean Medical Science  2013;28(2):173-180.
As the first nationwide Korean prospective multicenter data collection registry, the Korea Acute Myocardial Infarction Registry (KAMIR) launched in November 2005. Through a number of innovative approaches, KAMIR suggested new horizons about acute myocardial infarction (AMI) which contains unique features of Asian patients from baseline characteristics to treatment strategy. Obesity paradox was existed in Korean AMI patients, whereas no gender differences among them. KAMIR score suggested new risk stratifying method with increased convenience and an enhanced accuracy for the prediction of adverse outcomes. Standard loading dose of clopidogrel was enough for Asian AMI patients. Triple antiplatelet therapy with aspirin, clopidogrel and cilostazol could improve clinical outcomes than dual antiplatelet therapy with aspirin and clopidogrel. Statin improved clinical outcomes even in AMI patients with very low LDL-C levels. The rate of percutaneous coronary intervention was higher and door-to-balloon time was shorter than the previous reports. Zotarolimus eluting stents as the 2nd generation drug-eluting stent (DES) was not superior to the 1st generation DES, in contrast to the western AMI studies. KAMIR made a cornerstone in the study of Korean AMI and expected to be new standards of care for AMI with the renewal of KAMIR design to overcome its pitfalls.
doi:10.3346/jkms.2013.28.2.173
PMCID: PMC3565126  PMID: 23399991
Acute Myocardial Infarction; ST-Elevation Myocardial Infarction; Non-ST-Elevation Myocardial Infarction
15.  Effect of Early Statin Treatment in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction 
Korean Circulation Journal  2013;43(2):100-109.
Background and Objectives
The benefit of early statin treatment following acute myocardial infarction (MI) complicated with cardiogenic shock (CS) has not been well studied. We sought to assess the effect of early statin therapy in patients with CS complicating acute MI.
Subjects and Methods
We studied 553 statin-naive patients with acute MI and CS (Killip class IV) who underwent revascularization therapy between November 2005 and January 2008 at 51 hospitals in the Korea Acute Myocardial Infarction Registry. Patients were divided into 2 groups: those who received statins during hospitalization (n=280) and those who did not (n=273). The influence of statin treatment on a 12-month clinical outcome was examined using a matched-pairs analysis (n=200 in each group) based on the propensity for receiving statin therapy during hospitalization.
Results
Before adjustment, patients receiving statin, compared to those not receiving statin, had a more favorable clinical profile, were less likely to suffer procedural complications, and more likely to receive adequate medical therapy. Patients receiving statin had lower unadjusted in-hospital mortality and composite rate of mortality, MI, and repeat revascularization at 12 months, which remained significantly lower after adjustment for patient risk, procedural characteristics, and treatment propensity.
Conclusion
In CS patients with acute MI undergoing revascularization therapy, early statin treatment initiated during hospitalization was associated with lower rates of in-hospital death and 12-month adverse cardiac events.
doi:10.4070/kcj.2013.43.2.100
PMCID: PMC3596656  PMID: 23508129
Angioplasty; Myocardial infarction; Shock
16.  Massive right coronary air embolism in the right coronary artery during left coronary angiography: A case report 
Coronary air embolism is one of the inadvertent complications of coronary angiography. We report a case of unexpected massive right coronary air embolism during left coronary angiography with a JL4 diagnostic catheter. This report demonstrates that air embolism may occur in the contralateral coronary artery and therefore complete air aspiration must be ensured during coronary angiography.
doi:10.3892/etm.2013.939
PMCID: PMC3627689  PMID: 23596473
air embolism
17.  Comparison of Drug-Eluting Stents in Acute Myocardial Infarction Patients with Chronic Kidney Disease 
Background/Aims
To determine which drug-eluting stents are more effective in acute myocardial infarction (MI) patients with chronic kidney disease (CKD).
Methods
This study included a total of 3,566 acute MI survivors with CKD from the Korea Acute Myocardial Infarction Registry who were treated with stenting and followed up for 12 months: 1,845 patients who received sirolimus-eluting stents (SES), 1,356 who received paclitaxel-eluting stents (PES), and 365 who received zotarolimus-eluting stents (ZES). CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 calculated by the modification of diet in renal disease method.
Results
At the 12-month follow-up, patients receiving ZES demonstrated a higher incidence (14.8%) of major adverse cardiac events (MACEs) compared to those receiving SES (10.1%) and PES (12%, p = 0.019). The ZES patients also had a higher incidence (3.9%) of target lesion revascularization (TLR) compared to those receiving SES (1.5%) and PES (2.4%, p = 0.011). After adjusting for confounding factors, ZES was associated with a higher incidence of MACE and TLR than SES (adjusted hazard ratio [HR], 0.623; 95% confidence interval [CI], 0.442 to 0.879; p = 0.007; adjusted HR, 0.350; 95% CI, 0.165 to 0.743; p = 0.006, respectively), and with a higher rate of TLR than PES (adjusted HR, 0.471; 95% CI, 0.223 to 0.997; p = 0.049).
Conclusions
Our findings suggest that ZES is less effective than SES and PES in terms of 12-month TLR, and has a higher incidence of MACE due to a higher TLR rate compared with SES, in acute MI patients with CKD.
doi:10.3904/kjim.2012.27.4.397
PMCID: PMC3529238  PMID: 23269880
Myocardial infarction; Renal insufficiency; Chronic; Stents
18.  Coronary Stents in Patients with ST-Elevation Myocardial Infarction and Chronic Kidney Disease Undergoing Primary Percutaneous Coronary Intervention 
Korean Circulation Journal  2012;42(12):830-838.
Background and Objectives
Chronic kidney disease (CKD) is associated with poor outcomes after percutaneous coronary intervention (PCI). We sought to compare different coronary stents used during primary PCI in patients with ST-elevation myocardial infarction (STEMI) and CKD.
Subjects and Methods
We selected 2408 consecutive STEMI patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) undergoing primary PCI and divided them into 5 groups based on the type of stent implanted: 1) bare metal stent (BMS), 2) paclitaxel-eluting stent (PES), 3) sirolimus-eluting stent (SES), 4) zotarolimus-eluting stent (ZES), or 5) everolimus-eluting stent (EES). The study endpoint was the number of major adverse cardiac events (MACE) at 12 months.
Results
There was no significant difference in the incidence of 12-month myocardial infarction, target lesion revascularization, or target vessel revascularization between stent groups; however, the overall rate of repeat revascularization differed significantly between groups. All-cause death differed significantly among the groups. The incidence of 12-month MACE in BMS, PES, SES, ZES, and EES was 8.3%, 9.8%, 8.6%, 5.5%, and 2.6%, respectively (p<0.001). Kaplan-Meier analysis did not show a significant differences in 12-month MACE-free survival among the groups (log-rank p=0.076). This finding remained the same after adjusting for multiple confounders (p=0.147).
Conclusion
Any of the 5 stents can be used to treat STEMI patients with CKD undergoing primary PCI; all have similar risk of 12-month MACE. This result is hypothesis-generating and warrants further evaluation with a long-term randomized study.
doi:10.4070/kcj.2012.42.12.830
PMCID: PMC3539049  PMID: 23323121
Myocardial infarction; Stents; Angioplasty; Kidney failure, chronic
19.  Safety and Efficacy of Overlapping Homogenous Drug-Eluting Stents in Patients with Acute Myocardial Infarction: Results from Korea Acute Myocardial Infarction Registry 
Journal of Korean Medical Science  2012;27(11):1339-1346.
The aim of this study was to compare safety and efficacy of 4 homogenous overlapping drug-eluting stents (DES) in acute myocardial infarction (AMI) patients. We selected 1,349 consecutive patients (62.1 ± 14.9 yr, 69.4% male) who received homogenous overlapping DESs in diffuse de novo coronary lesions from Korea Acute Myocardial Infarction Registry from April 2006 through September 2010. They were divided into 4 groups based on type of DES implanted - Paclitaxel (PES), Sirolimus (SES), Zotarolimus (ZES) and Everolimus (EES)-eluting stents. Primary endpoint was 12-month MACE. We also studied EES versus other DESs (PES + SES + ZES). Mean stent length was 26.2 ± 7.5 mm and mean stent diameter was 3.1 ± 0.4 mm. Average number of stents used per vessel was 2.2 ± 0.5. Incidence of major adverse cardiac events (MACE) in PES, SES, ZES, and EES groups were 9.5%, 9.2%, 7.5%, and 3.8%, respectively (P = 0.013). In EES group, overall MACE and repeat revascularization were lowest, and no incidence of stent thrombosis was observed. Non-fatal MI was highest in PES, almost similar in SES and EES with no incidence in ZES group (P = 0.044). Cox proportional hazard analysis revealed no differences in the incidence of primary endpoint (P = 0.409). This study shows no significant differences in 12-month MACE among 4 groups.
doi:10.3346/jkms.2012.27.11.1339
PMCID: PMC3492668  PMID: 23166415
Drug-Eluting Stents; Myocardial Infarction; Coronary Angioplasty
20.  Suboptimal medical care of patients with ST-Elevation Myocardial Infarction and Renal Insufficiency: results from the Korea acute Myocardial Infarction Registry 
BMC Nephrology  2012;13:110.
Background
The clinical outcomes of ST-segment elevation myocardial infarction (STEMI) are poor in patients with renal insufficiency. This study investigated changes in the likelihood that patients received optimal medical care throughout the entire process of myocardial infarction management, on the basis of their glomerular filtration rate (GFR).
Methods
This study analyzed 7,679 patients (age, 63 ± 13 years; men 73.6%) who had STEMI and were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to August 2008. The study subjects were divided into 5 groups corresponding to strata used to define chronic kidney disease stages.
Results
Patients with lower GFR were less likely to present with typical chest pain. The average symptom-to-door time, door-to-balloon time, and symptom-to-balloon time were longer with lower GFR than higher GFR. Primary reperfusion therapy was performed less frequently and the results of reperfusion therapy were poorer in patients with renal insufficiency; these patients were less likely to receive adjunctive medical treatment, such as treatment with aspirin, clopidogrel, β-blocker, angiotensin-converting enzyme (ACE) inhibitor/angiotensin-receptor blocker (ARB), or statin, during hospitalization and at discharge. Patients who received less intense medical therapy had worse clinical outcomes than those who received more intense medical therapy.
Conclusions
Patients with STEMI and renal insufficiency had less chance of receiving optimal medical care throughout the entire process of MI management, which may contribute to worse outcomes in these patients.
doi:10.1186/1471-2369-13-110
PMCID: PMC3467157  PMID: 22966970
Myocardial infarction; Optimal medical care; Renal function
21.  Impact of High-Normal Blood Pressure Measured in Emergency Room on Adverse Cardiac Events in Acute Myocardial Infarction 
Korean Circulation Journal  2012;42(5):304-310.
Background and Objectives
Prehypertension according to JNC7 is common and is associated with increased vascular mortality. The importance of management in high-normal blood pressure (BP) is underemphasized.
Subjects and Methods
We analyzed major adverse cardiac events (MACEs) in the Korea Acute Myocardial Infarction Registry in normal BP (group I) and high-normal BP (group II) patients.
Results
Among 14871 patients, 159 (61±12.3 years, 122 males) satisfied the study indication. Six-month and one-year clinical follow-up rate was 88.9% and 85.8%, respectively. Group I had 78 patients (60.9±12.4 years). Group II had 81 patients (61.6±12.5 years). Demographics of patients were not different between groups. Treatment strategy was not different. Initial Thrombolysis in Myocardial Infarction flow grade 0 was less frequent in group II (n=32, 47.1%) than in group I (n=16, 21.9%) (p=0.001). Successful intervention rate was not different between group II (93.8%) and group I (97.1%) (p=0.590). Six-month MACE occurred in 3 patients in group I (4.4%) and 10 in group II (15.6%) (p=0.031). Compared with normal BP, the odds ratio for patients with high-normal BP was 1.147 (p=0.045, 95% confidence interval 1.011-1.402) for 6-month MACE.
Conclusion
Even though high-normal BP patients had a better baseline clinical status, the prognosis was poorer than patients with normal BP. Therapeutic BP target goal for the patients with acute myocardial infarction should be <140/90 mm Hg, which is recommended in JNC7.
doi:10.4070/kcj.2012.42.5.304
PMCID: PMC3369961  PMID: 22701132
Blood pressure; Prognosis
22.  Prognostic Impact of Baseline High-Sensitivity C-Reactive Protein in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention Based on Body Mass Index 
Korean Circulation Journal  2012;42(3):164-172.
Background and Objectives
Serum high sensitivity C-reactive protein (hs-CRP) is a marker of inflammation and may lead to the development of atherosclerosis, adversely affecting mortality. The aim of this study was to evaluate the relationship between baseline hs-CRP level and 12-month clinical outcomes in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) according to their body mass index (BMI) status.
Subjects and Methods
Using data from the Korea Acute Myocardial Infarction Registry from November 2005 to September 2008, a total of 8174 consecutive AMI patients were studied. Cox proportional hazard model revealed that higher baseline levels of hs-CRP was associated with 12-month all-cause mortality (p=0.045). To further understand this association, patients were divided into 3 groups based on their body mass index: 1) overweight/obese, 2) normal weight, and 3) underweight patients. Then each group was stratified into quartiles based on their hs-CRP.
Results
In overweight/obese patients, Cox model showed significant association of hs-CRP with 12-month mortality when adjusted for age and gender (p<0.001), however, after adjustment with multiple covariates, mortality was highest in the 4th quartile {HR 2.382, (1.079-5.259), p=0.032} though statistically insignificant (p=0.172). We observed no significant association of serum hs-CRP with 12-month mortality in normal weight (p=0.681) and underweight (p=0.760) patients.
Conclusion
Higher baseline hs-CRP level (≥4.08 mg/dL) in overweight/obese AMI patients showed significant association with 12-month all-cause mortality independent of other prognostic markers.
doi:10.4070/kcj.2012.42.3.164
PMCID: PMC3318088  PMID: 22493611
C-reactive protein; Overweight; Obesity; Body mass index; Myocardial infarction
23.  Early Cardiac Valvular Changes in Ankylosing Spondylitis: A Transesophageal Echocardiography Study 
Background
This study was conducted to determine the early cardiac valvular changes in young male ankylosing spondylitis (AS) patients.
Methods
A total of 70 AS patients on treatment without clinical cardiac symptoms were divided into group I (< 10 years, n = 50) and group II (≥ 10 years, n = 20) depending on their disease duration after first diagnosis. Twenty-five healthy volunteers were selected as control subjects. All the subjects underwent transthoracic and transesophageal echocardiography, electrocardiography, and rheumatologic evaluation for AS patients.
Results
The thickness of both the aortic and mitral valve was more increased in AS patients than in controls. Aortic valve thickness over 1.3 mm could predict AS with a sensitivity of 73% and specificity of 76%. The prevalence of aortic valve thickening was higher in the AS group compared to the controls. The prevalence of aortic and mitral regurgitation was very low and there was no difference between the controls and the patients. The aortic valve thickening was related to longer disease duration, high blood pressure, disease activity and inflammatory markers.
Conclusion
Thickening of the aortic and mitral valve was observed without regurgitation in male AS patients early in the course of their disease without clinical cardiac manifestations. This subclinical change of aorto-mitral valve in early AS should be considered and followed up to determine its prognostic implication and evolution.
doi:10.4250/jcu.2012.20.1.30
PMCID: PMC3324725  PMID: 22509436
Ankylosing spondylitis; Cardiac valves; Echocardiography
24.  Culprit-Lesion-Only Versus Multivessel Revascularization Using Drug-Eluting Stents in Patients With ST-Segment Elevation Myocardial Infarction: A Korean Acute Myocardial Infarction Registry-Based Analysis 
Korean Circulation Journal  2011;41(12):718-725.
Background and Objectives
In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, complete revascularization (CR) for non-culprit lesions is not routinely recommended. The aim of this study was to compare the clinical outcomes of multivessel compared with infarct-related artery (IRA)-only revascularization in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI.
Subjects and Methods
From the Korean Acute Myocardial Infarction Registry (KAMIR) database, 1,094 STEMI patients with multivessel disease who underwent primary PCI with drug-eluting stents were enrolled in this study. The patients were divided into two groups: culprit-vessel-only revascularization (COR, n=827) group; multivessel revascularization, including non-IRA (MVR, n=267) group. The primary endpoint of this study included major adverse cardiac events (MACEs), such as death, myocardial infarction, or target or nontarget lesion revascularization at one year.
Results
There was no difference in clinical characteristics between the two groups. During the one-year follow-up, 102 (15.2%) patients in the COR group and 32 (14.2%) in the MVR group experienced at least one MACE (p=0.330). There were no differences between the two groups in terms of rates of death, myocardial infarction, or revascularization (2.1% vs. 2.0%, 0.7% vs. 0.8%, and 11.7% vs. 10.1%, respectively; p=0.822, 0.910, and 0.301, respectively). The MACE rate was higher in the incompletely revascularized patients than in the completely revascularized patients (15% vs. 9.5%, p=0.039), and the difference was attributable to a higher rate of nontarget vessel revascularization (8.6% vs. 1.8%, p=0.002).
Conclusion
Although multivessel angioplasty during primary PCI for STEMI did not reduce the MACE rate compared with culprit-vessel-only PCI, CR was associated with a lower rate of repeat revascularization after multivessel PCI.
doi:10.4070/kcj.2011.41.12.718
PMCID: PMC3257455  PMID: 22259602
Myocardial infarction; Coronary artery disease; Angioplasty
25.  Concomitant renal insufficiency and diabetes mellitus as prognostic factors for acute myocardial infarction 
Background
Diabetes mellitus and renal dysfunction are prognostic factors after acute myocardial infarction (AMI). However, few studies have assessed the effects of renal insufficiency in association with diabetes in the context of AMI. Here, we investigated the clinical outcomes according to the concomitance of renal dysfunction and diabetes mellitus in patients with AMI.
Methods
From November 2005 to August 2008, 9905 patients (63 ± 13 years; 70% men) with AMI were enrolled in a nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) and were categorized into 4 groups: Group I (n = 5700) had neither diabetes nor renal insufficiency (glomerular filtration rate [GFR] ≥ 60 ml/min/1.73 m2), Group II (n = 1730) had diabetes but no renal insufficiency, Group III (n = 1431) had no diabetes but renal insufficiency, and Group IV (n = 1044) had both diabetes and renal insufficiency. The primary endpoints were major adverse cardiac events (MACE), including a composite of all cause-of-death, myocardial infarction, target lesion revascularization, and coronary artery bypass graft after 1-year clinical follow-up.
Results
Primary endpoints occurred in 1804 (18.2%) patients. There were significant differences in composite MACE among the 4 groups (Group I, 12.5%; Group II, 15.7%; Group III, 30.5%; Group IV, 36.5%; p < 0.001). In a Cox proportional hazards model, after adjusting for multiple covariates, the 1-year mortality increased stepwise from Group III to IV as compared with Group I (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.34-2.86; p = 0.001; and HR, 2.42; 95% CI, 1.62-3.62; p < 0.001, respectively). However, Kaplan-Meier analysis showed no significant difference in probability of death at 1 year between Group III and IV (p = 0.288).
Conclusions
Renal insufficiency, especially in association with diabetes, is associated with the occurrence of composite MACE and indicates poor prognosis in patients with AMI. Categorization of patients with diabetes and/or renal insufficiency provides valuable information for early-risk stratification of AMI patients.
doi:10.1186/1475-2840-10-95
PMCID: PMC3225317  PMID: 22035298
acute myocardial infarction; diabetes mellitus; major adverse cardiac events; renal insufficiency

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