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Background: NT-pro B-type natriuretic peptide (NT-proBNP) is a powerful prognostic factor for acute heart failure. We investigated whether NT-proBNP levels differ based on the type of heart failure present., Methods: Using the Korean Acute Heart Failure Registry, a prospective, multicenter cohort, we categorized patients into two groups: de novo heart failure (DNHF, n = 1617) and acute decompensated chronic heart failure (ADHF, n = 1212). NT-proBNP levels were measured on admission. The primary outcome was all-cause mortality, and the secondary outcomes were re-hospitalization for heart failure and a composite of all-cause mortality or re-hospitalization for heart failure at 90 days and 1 year., Results: NT-proBNP levels were significantly lower in patients with DNHF than in those with ADHF (median 4213 vs. 5523 ng/L, p < 0.001). Compared to patients with DNHF, patients with ADHF had a significantly worse prognosis for 1-year all-cause mortality (adjusted hazard ratio (HR) = 1.46 [95% confidence interval (CI) = 1.07-1.98], p = 0.017). A higher NT-proBNP level was associated with higher 1-year all-cause mortality for both heart failure types (adjusted HR = 2.00, p = 0.002 in ADHF; adjusted HR = 2.41, p = 0.003 in DNHF). However, all-cause mortality risk was always higher in patients with ADHF than in those with DNHF for any given NT-proBNP level., Conclusion: NT-proBNP levels are an important prognostic factor for both DNHF and ADHF. Notably, patients with ADHF had consistently higher risks than those with DNHF with the same NT-proBNP level for 1-year all-cause mortality., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Variations by hospital and region in the selection of an early invasive strategy (EIS) after non-ST-segment elevation myocardial infarction (NSTEMI) in patients with high-risk criteria are unknown., Methods: We evaluated the data of 7037 patients with NSTEMI from 20 hospitals of 3 regions from the Korean Acute Myocardial Infarction Registry-National Institute of Health database. We used hierarchical generalized linear mixed-models to estimate region- and hospital-level variation in the selection of an EIS after adjusting for patient-level high-risk criteria. We explored the variation using the median rate ratio (MRR), which estimates the relative difference in the risk ratios of two hypothetically identical patients at two different sites., Results: An EIS was selected in 84.4% of patients. At the hospital level, the median selection rate was 80.4%. At the region level, the median selection rate was 74.9% in the east region, 81.3% in the north region, and 83.9% in the west region, respectively. After adjusting for patient-level covariates, we found significant hospital- (MRR 2.19, 95% confidence interval [CI]: 1.74-3.03) and region-level (MRR 1.88, 95%CI: 1.26-5.44) variation in the selection of an EIS. Among patient-level factors, male sex, ongoing chest pain, history of coronary artery disease or acute heart failure, and GRACE risk score > 140 were independently associated with the selection of an EIS., Conclusions: We observed significant hospital- and region-level variation in the selection of an EIS after NSTEMI in high-risk patients. Quality improvement efforts are required to standardize decision making and to improve clinical outcomes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Although the survival benefit of obesity has been suggested in patients with heart failure (HF), the impact of sex on obesity paradox is less clear. This study was performed to investigate whether there is a sex difference in the association between body mass index (BMI) and long-term clinical outcomes in patients hospitalized for HF., Method: A total of 2616 patients hospitalized for HF (Mean age 66 years and 52% males) from the nation-wide registry database were analyzed. Patients were categorized using baseline BMI as normal (18.5 to 22.9 kg/m 2 ), overweight (23 to 27.4 kg/m 2 ) and obese (≥ 27.5 kg/m 2 ). Their all-cause mortality and long-term composite events, including all-cause mortality and HF readmission, were assessed according to the BMI groups., Results: During the median follow-up period of 1499 days, there were 662 patients (25.3%) with all-cause mortality and 1071 patients (40.9%) with composite events. Compared to the normal weight group, the overweight (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.51-0.99; P = 0.045) and obese (HR, 0.53; 95% CI, 0.29-0.95; P = 0.032) group showed lower all-cause mortality rates even after adjusting for confounding factors in the male patients. Otherwise, BMI was not associated with composite events in males; it was not associated with all-cause mortality or composite events in females in the multivariable analyses (P > 0.05 for each)., Conclusions: Among patients with HF, a greater BMI was associated with low all-cause mortality in males, but not in females. Obesity paradox should be considered in the management of HF patients., (Copyright © 2020. Published by Elsevier B.V.)

Background: The optimal duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome remains uncertain. This study investigated the benefit of DAPT beyond 12 months after drug-eluting stents (DES) for acute myocardial infarction (MI)., Methods: From Korea Acute Myocardial Infarction Registry-National Institute of Health database, 6199 patients treated with DAPT for 12 months after DES (second-generation DES 98%) without ischemic or bleeding events were analyzed. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), a composite of death from any cause, MI, or ischemic stroke during the period from 12 to 24 months., Results: After adjustment using inverse probability of treatment weighting, patients who received DAPT beyond 12 months (n=4795), compared to patients treated with 12-month DAPT (n=1404), had a similar incidence of MACCE (1.3% vs. 1.0%, HR: 1.32, 95% CI: 0.71-2.45, p=0.378). The 2 groups did not differ significantly in the rates of death (0.1% vs. 0.1%), MI (0.8% vs.0.6%), stent thrombosis (0.1% vs. 0.2%), ischemic stroke (0.4% vs. 0.2%), and major bleeding (0.1% vs. 0.1%). The rate of net adverse clinical events was 1.4% with DAPT beyond 12 months and 1.1% with 12-month DAPT (p=0.466)., Conclusions: DAPT beyond 12 months, as compared with 12-month DAPT, in real-world patients with acute MI treated predominantly with second-generation DES did not reduce the risk of MACCE. The rates of major bleeding and net adverse clinical events did not differ significantly between the 2 treatments., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Potent P2Y12 blockers are preferred in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention (PCI). However, the risk of bleeding remains a major concern. We assessed the association of potent P2Y12 blockers with ischemic and bleeding outcomes in patients with NSTEMI., Methods: From the Korea Acute Myocardial Infarction Registry-National Institute of Health database, 4927 patients with NSTEMI receiving drug-eluting stents (DES) were divided into potent P2Y12 blocker (ticagrelor or prasugrel, n=901) and clopidogrel (n=3180) groups. Propensity-matched 12-month ischemic and bleeding events were compared. Patients who received anticoagulants or who discontinued P2Y12 blockers or switched between potent P2Y12 blockers and clopidogrel were excluded., Results: In the overall population, patients at higher ischemic and bleeding risks more often received clopidogrel. After propensity matching (n=901 in each group), 12-month rates of major adverse cardiac and cerebrovascular events were lower (7.3% vs. 10.1%, p=0.038), but Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding rates were higher (5.9% vs. 2.2%, p<0.001) with potent P2Y12 blockers. Twelve-month rates of death from any cause, MI, stroke, or TIMI major bleeding were not different. On multivariate analysis, 12-month risk of TIMI major or minor bleeding was higher with B2 or C lesion, potent P2Y12 blocker use, body weight <60kg, and lower with time to PCI <12h and radial artery access., Conclusions: In patients with NSTEMI receiving DES, potent P2Y12 blockers were associated with reduced ischemic but increased bleeding risk with similar net clinical benefits., (Copyright © 2018. Published by Elsevier Ltd.)

Background: Identifying patients with acute heart failure (HF) at high risk for readmission or death after hospital discharge will enable the optimization of treatment and management. The objective of this study was to develop a risk score for 30-day HF-specific readmission or death in Korea., Methods: We analyzed the data from the Korean Acute Heart Failure (KorAHF) registry to develop a risk score. The model was derived from a multiple logistic regression analysis using a stepwise variable selection method. We also proposed a point-based risk score to predict the risk of 30-day HF-specific readmission or death by simply summing the scores assigned to each risk variable. Model performance was assessed using an area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, the net reclassification improvement (NRI), and the integrated discrimination improvement (IDI) index to evaluate discrimination, calibration, and reclassification, respectively., Results: Data from 4566 patients aged ≥40 years were included in the analysis. Among them, 446 (9.8%) had 30-day HF-specific readmission or death. The final model included 12 independent variables (age, New York Heart Association functional class, clinical history of hypertension, HF admission, chronic obstructive pulmonary disease, etiology of cardiomyopathy, systolic blood pressure, left ventricular ejection fraction, serum sodium, brain natriuretic peptide, N-terminal prohormone of brain natriuretic peptide at discharge, and prescription of β-blockers and angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists at discharge). The point risk score showed moderate discrimination (AUC of 0.710; 95% confidence interval, 0.685-0.735) and good calibration (χ 2 =8.540, p=0.3826)., Conclusions: The risk score for the prediction of the risk of 30-day HF-specific readmission or death after hospital discharge was developed using 12 predictors. It can be utilized to guide appropriate interventions or care strategies for patients with HF., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Dual antiplatelet therapy (DAPT) is recommended in patients receiving drug-eluting stents (DES). However, bleeding risk should be weighed against ischemic risk. Utility of GRACE risk score and ACUITY-HORIZONS bleeding risk score was assessed in patients with acute myocardial infarction (MI) according to use of P2Y12 blocker., Methods: From the Korea Acute Myocardial Infarction Registry-National Institute of Health database, 7791 patients with acute MI receiving DES were divided into ticagrelor (n=1554) and clopidogrel (n=6237) groups. Propensity-matched 12-month mortality and bleeding event rates were compared according to GRACE and ACUITY-HORIZONS scores. Patients who received thrombolysis, prasugrel or anticoagulants, or who discontinued or switched DAPT were excluded., Results: In all patients, high-risk patients more often received clopidogrel. After propensity score matching (n=1553 in each group), 12-month mortality was not different, but TIMI major bleeding rate was higher with ticagrelor (2.8% vs. 1.4%, p=0.007). On subgroup analysis, 12-month mortality was lower with ticagrelor in patients with high (>140) compared to low-to-moderate risk GRACE score (5.1% vs. 7.9%, p=0.04). When combined with ACUITY-HORIZONS bleeding score, 12-month mortality was lower with ticagrelor in patients with high GRACE score but without very high (≥20) ACUITY-HORIZONS score (2.4% vs. 5.3%, p=0.03)., Conclusions: In patients with acute MI receiving DES, GRACE and ACUITY-HORIZONS scores may help guide DAPT. In patients with high GRACE score, a more potent P2Y12 blocker may be considered, particularly in the subset not at very high risk of bleeding., (Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Renin-angiotensin system blockade (RAB) is the cornerstone in the management of patients with heart failure. However, the benefit of RAB in patients with accompanying severe renal impairment is not clear. We aimed to examine the effect of RAB and the differential effect of RAB depending on renal replacement (RR) in patients with severe renal insufficiency and acute heart failure., Methods and Results: Among 5625 patients from the Korean Acute Heart Failure registry, 673 in-hospital survivors (70.9 ± 12.8 years, 376 men) who had left ventricular ejection fraction < 40% and estimated glomerular filtration rate < 30 mL/min/1.73 m 2 during hospitalization were analyzed. The inverse probability of treatment weighting (IPTW)-adjusted survival analysis was used to compare the composite of all-cause mortality and rehospitalization between patients with and without pre-discharge RAB. A total of 334 (49.6%) adverse events were observed during the 1-year follow-up. The IPTW-adjusted Kaplan-Meier survival analysis showed that the 1-year event rate was 48.7% and 53.8% for patients with RAB and those without, respectively (log rank p = 0.048). RAB was significantly related to better prognosis in patients receiving RR therapy (hazard ratio [HR] = 0.436 [0.269-0.706], p = 0.001), but not in patients not receiving RR therapy (HR 0.956 [0.731-1.250], p = 0.742) in a weighted cohort (p for interaction = 0.005)., Conclusions: Early RAB treatment in patients with heart failure and severe renal insufficiency was related to better prognosis. The benefit of RAB was particularly prominent in patients receiving RR therapy., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The optimal time for initiating β-blocker (BB) treatment in patients with severe acute decompensated heart failure requiring inotropic therapy has not been well defined. We evaluated the effect of predischarge initiation of BB treatment on clinical outcomes., Methods: Among the 5625 patients enrolled in the Korean Acute Heart Failure (KorAHF) registry, 672 BB-naive patients suffering from heart failure with reduced ejection fraction (median, 67.0 years; 62.5% male; median left ventricular ejection fraction, 24.1%) who received inotropic support during hospitalization were evaluated. We compared the risk of post-discharge mortality and rehospitalization between groups with (n = 282) and without (n = 390) pre-discharge BB treatment., Results: During a median follow-up of 2.6 years, all-cause mortality occurred in 252 patients (37.5%). Those who received pre-discharge BB treatment showed lower 2-year mortality rates compared with those who did not (21.3% vs 39.3%; P < 0.001). In a Cox proportional hazards model, all-cause mortality was consistently lower in pre-discharge BB groups after multivariable adjustment (hazard ratio, 0.69; 95% confidence interval, 0.50-0.95; P = 0.025) and adjustment for propensity score methods using the inverse probability of treatment weighting (hazard ratio, 0.70; 95% confidence interval, 0.52-0.93; P = 0.016). The same trend was observed for secondary outcomes of rehospitalization for any cause and rehospitalization for heart failure. Pre-discharge BB was associated with higher rates of BB prescription after 6 (90.1% vs 23.9%; P < 0.001) and 12 (88.9% vs 25.0%; P < 0.001) months., Conclusions: Pre-discharge BB initiation is associated with better clinical outcomes after severe acute decompensated heart failure episodes requiring inotropic therapy., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: After introduction of up-titration strategy, there are limited data on comparison between the effects of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blocker (ARB) in patients with heart failure with reduced ejection fraction (HFrEF). The study sought to investigate the association between treatment with ARB at discharge and clinical outcomes in patients with HFrEF compared with treatment with ACEI or no renin angiotensin system blocker (RASB)., Methods: The KorAHF registry is a prospective multicenter cohort and included patients who were hospitalized for acute heart failure (AHF). We studied 3005 patients with HFrEF (<40%), and divided into ARB (n=1190), ACEI (n=1090), and no RASB (n=725) groups. Propensity score matching was performed., Results: All-cause death occurred in 346 patients (29.1%) in the ARB group, 315 patients (28.9%) in the ACEI group, and 305 (42.1%) in the no RASB group. After propensity score matching (ARB vs. ACEI, 827 pairs), there was no significant difference between the two groups in the rate of death (HR 0.91, 95% CI 0.76-1.09, p=0.32). All-cause death was significantly lower in the ARB group than in the no RASB group (ARB vs. no RASB, 538 pairs, HR 0.69, 95% CI 0.56-0.83, p<0.001). The ARB group had a significantly lower discontinuation rate than the ACEI group (20.8% vs. 33.6%, p<0.001)., Conclusions: For treatment of AHF with reduced EF after hospitalization, ARB at discharge shows a mortality benefit comparable to that of ACEI. In addition, tolerability of medication was greater for ARB than for ACEI., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: This study sought to examine the impact of door-to-diuretic (D2D) time on mortality in patients with acute heart failure (AHF) who were presenting to an emergency department (ED)., Background: Most patients with AHF present with congestion. Early decongestion with diuretic agents could improve their clinical outcomes., Methods: The Korea Acute Heart Failure registry enrolled 5,625 consecutive patients hospitalized for AHF. For this analysis, the study included patients who received intravenous diuretic agents within 24 h after ED arrival. Early and delayed groups were defined as D2D time ≤60 min and D2D time >60 min, respectively. The primary outcomes were in-hospital death and post-discharge death at 1 month and 1 year on the basis of D2D time., Results: A total of 2,761 patients met the inclusion criteria. The median D2D time was 128 min (interquartile range: 63 to 243 min), and 663 (24%) patients belonged to the early group. The baseline characteristics were similar between the groups. The rate of in-hospital death did not differ between the groups (5.0% vs. 5.1%; p > 0.999), nor did the post-discharge 1-month (4.0% vs. 3.0%; log-rank p = 0.246) and 1-year (20.6% vs. 19.3%; log-rank p = 0.458) mortality rates. Get With the Guidelines-Heart Failure risk score was calculated for each patient. In multivariate analyses with adjustment for Get With the Guidelines-Heart Failure risk score and other significant clinical covariates and propensity-matched analyses, D2D time was not associated with clinical outcomes., Conclusions: The D2D time was not associated with clinical outcomes in a large prospective cohort of patients with AHF who were presenting to an ED. (Registry [Prospective Cohort] for Heart Failure in Korea [KorAHF]; NCT01389843)., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hyponatremia is a well-known risk factor for worse outcomes in heart failure (HF) patients. The impact of hyponatremia according to the ejection fraction (EF) is unclear. We evaluated the prognostic value of hyponatremia according to HF type., Methods and Results: The Korea Acute Heart Failure (KorAHF) registry consecutively enrolled 5625 patients. Hyponatremia was defined as serum sodium level<135mmol/L at hospital admission. HF with preserved and reduced ejection fraction were defined as an LVEF ≥50% and LVEF ≤40%, respectively. Among 5103 patients with available EF, 2088 (60%) had HFrEF, and 1284 (25%) had HFpEF. There was no difference in serum sodium level between the groups (HFrEF: 137.4±4.7mmol/L vs. HFpEF: 137.5±5.0mmol/L, P=0.710). Hyponatremic patients had higher in-hospital mortality or urgent heart transplantation in all (11.3% vs. 4.5%, P<0.001), in HFrEF (13.1% vs. 4.9%, P<0.001), and in HFpEF (6.0% vs. 1.9%, P<0.001). After adjustment for significant covariates, hyponatremia was associated with 1.5 fold increased risk for 1-year post-discharge death in the HFrEF group (HR, 1.52; 95% CI, 1.24-1.86), but not in the HFpEF group (HR, 1.16; 95% CI, 0.84-1.61). During admission, the sodium status changed in 22% of the patients and the discharge sodium status had greater prognostic value., Conclusions: Hyponatremia is independent of HF type. Hyponatremia is a significant risk factor for adverse in-hospital outcomes; however its long-term prognostic value is only limited to patients with HFrEF, but not for those with HFpEF., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Objectives: This study aimed to assess the relationship between on-treatment blood pressure (BP) and clinical outcomes of patients with heart failure (HF)., Background: Lower BP has been reported to be related to increased mortality in various cardiovascular diseases. The optimal BP level for patients already experiencing HF is contentious., Methods: The Korean Acute Heart Failure registry prospectively enrolled a total of 5,625 consecutive patients hospitalized for acute HF in 10 tertiary university hospitals in Korea between March 2011 and February 2014. Clinical profiles including BP were collected at admission, discharge, and during outpatient follow-up. Mean on-treatment BP was calculated from BP at discharge and at each follow-up visit. We evaluated the effects of mean on-treatment BP on the clinical outcomes of patients., Results: Patients were followed up for a median 2.2 years. One-year mortality after discharge was 18.2%. The relationship between on-treatment BP and all-cause mortality followed a reversed J-curve relationship. A nonlinear, multivariable Cox proportional hazard model identified a nadir of systolic and diastolic BPs of 132.4/74.2 mm Hg in patients, for whom the mortality rate was lowest (p < 0.0001). The relationship with increased mortality above and below the reference BP was more definitive for diastolic BP and for HF with a preserved ejection fraction., Conclusions: Systolic and diastolic BPs <130/70 mm Hg at discharge and during follow-up was associated with worse survival in HF patients. These data suggest that the lowest BP possible might not be an optimal target for HF patients. Further studies should establish a proper BP goal in HF patients. (Registry [Prospective Cohort] for Heart Failure in Korea [KorAHF]; NCT01389843)., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Hemoconcentration (HC) is associated with reduced mortality, whereas hyponatremia (HN) has been associated with an increased risk of adverse outcomes in patients with acute decompensated heart failure (ADHF). We sought to determine if the presence of HN influences the beneficial prognostic value of HC in ADHF patients., Methods: We analyzed 2046 ADHF patients from the Korean Heart Failure Registry. We defined HC as an increased hemoglobin level from admission to discharge, and HN as sodium <135mmol/L at admission. Our primary composite endpoint was all-cause mortality and/or HF re-hospitalization., Results: Overall, HC occurred in 889 (43.5%) patients and HN was observed in 418 patients (20.4%). HC offered higher 2-year event-free survival in patients without HN (73.2% vs. 63.1% for no-HC, log-rank p<0.001), but not in patients with HN (54.2% vs. 58.7% for no-HC, log-rank p=0.879, p for interaction=0.003). In a multiple Cox proportional hazard analysis, HC without HN conferred a significant event-free survival benefit (hazard ratio: 0.703, 95% confidence interval 0.542-0.912, p=0.008) over no-HC with HN., Conclusions: Only HC occurring in ADHF without HN was associated with improved clinical outcomes. These results provide further support for the importance of HN as a challenging therapeutic target in ADHF patients., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The benefit of manual thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) remains uncertain, and the effect of TA in relation to total ischemic time has not been evaluated., Methods: We analyzed 5641 patients with ST-elevation myocardial infarction (STEMI) (<12h) from the Korea Acute Myocardial Infarction Registry undergoing primary PCI. Patients were divided into 2 groups: TA (n=1245) and PCI only (n=4396). Propensity-matched 12-month clinical outcome was compared between the groups according to different total ischemic times (≤2h, 2-4h, 4-6h, >6h)., Results: Twelve-month rates of death and major adverse cardiac events (MACE: composite of death, recurrent myocardial infarction, target-vessel revascularization, and coronary artery bypass grafting) were not different between TA and PCI only. After propensity matching (n=1162 for each group), there were no differences in the 12-month outcome between TA and PCI only, which was consistent across subgroups. In the propensity-matched cohort, the effect of TA on 12-month outcome showed a U-shaped relationship with longer total ischemic time: TA in patients with total ischemic time between 4 and 6h was associated with lower rates of death [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.24-1.19, p for interaction=0.01] and MACE (HR: 0.28, 95% CI: 0.12-0.66, p for interaction=0.01)., Conclusions: Manual TA during primary PCI was not associated with improved clinical outcome at 12 months. The impact of TA may become clinically relevant with longer total ischemic time, forming a U-shaped relationship., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Successful percutaneous coronary intervention (PCI) of the occluded infarct-related artery (IRA) in latecomers may improve long-term survival mainly by reducing left ventricular remodeling. It is not clear whether inhibition of renin-angiotensin system (RAS) brings additional better clinical outcomes in this specific population subset., Methods: Between January 2008 and June 2013, 669 latecomer patients with acute ST-segment elevation myocardial infarction (STEMI) (66.2±12.1 years, 71.0% males) in Korea Acute Myocardial Infarction Registry (KAMIR) who underwent a successful PCI were enrolled. The study population underwent a successful PCI for a totally occluded IRA. They were divided into two groups according to whether they were prescribed RAS inhibitors at the time of discharge: group I (RAS inhibition, n=556), and group II (no RAS inhibition, n=113)., Results: During the one-year follow-up, major adverse cardiac events (MACE), which consist of cardiac death and myocardial infarction, occurred in 71 patients (10.6%). There were significantly reduced incidences of MACE in the group I (hazard ratio=0.34, 95% confidence interval 0.199-0.588, p=0.001). In subgroup analyses, RAS inhibition was beneficial in patients with male gender, history of hypertension or diabetes mellitus, and even in patients with left ventricular ejection fraction (LVEF) ≥40%. In the baseline and follow-up echocardiographic data, benefit in changes of LVEF and left ventricular end-systolic volume was noted in group I., Conclusions: In latecomers with STEMI, RAS inhibition improved long-term clinical outcomes after a successful PCI, even in patients with low risk who had relatively preserved LVEF., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Despite large reductions in door-to-balloon times over the period, several studies from regional and national data showed that annual mortality rates were not decreased among patients who underwent primary percutaneous coronary intervention (PCI). However, these studies mostly focused on door-to-balloon time, and there was no consideration of total ischemic time in a trend of mortality. The aim of this study was to assess the annual trend between time to treatment and 1-month mortality among patients undergoing primary PCI., Methods and Results: The study population consisted of 8040 patients who underwent primary PCI at hospitals participating in the nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) between January 2008 and December 2011. The primary end point of this study was 1-month all-cause mortality, and time to treatment (door-to-balloon time, symptom-to-balloon time). One-month death occurred in 452 patients (5.6%) from 2008 to 2011. Additional reductions in door-to-balloon time were not translated into parallel reductions in mortality rate and total ischemic time. After adjustment using clinical risk, shorter total ischemic time was an independent predictor of 1-month mortality [adjusted odds ratio (OR) 0.78, 95% confidential interval (CI) 0.62-0.99, p=0.04]. Total ischemic time could be reduced by using emergency medical services., Conclusion: Despite improvements in door-to-balloon time, no parallel reductions in mortality rate and total ischemic time were observed. Total ischemic time was associated with mortality. The present study suggests that additional efforts are needed to shorten total ischemic time including patient and pre-hospital systemic delay for better prognosis after primary PCI., (Copyright © 2016. Published by Elsevier Ltd.)

Background: It is unclear whether simvastatin-ezetimibe could be an alternative therapy to high-intensity statin therapy in high-risk patients. The aim of this study was to compare the clinical outcomes of simvastatin-ezetimibe and high-intensity statin therapy in patients with acute myocardial infarction (AMI), and especially in those with high-risk factor., Methods: A total of 3520 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were classified into simvastatin-ezetimibe group (n=1249) and high-intensity statin group (n=2271). Multivariate analysis and propensity-score matching analysis were performed. The primary endpoint was major adverse cardiac events (MACE) at 12-months follow-up., Results: In overall AMI patients, MACE occurred in 116 patients (9.3%) in simvastatin-ezetimibe group and 116 patients (5.1%) in high-intensity statin group. The difference in MACE between groups was driven by repeat revascularization (5.9% vs. 2.2%). After propensity matching analysis, simvastatin-ezetimibe was associated with a higher incidence of MACE than high-intensity statin therapy (adjusted hazard ratio: 3.090, 95% confidence interval: 1.715 to 5.566, p<0.001). However, in patients with high-risk factors, such as diabetes, old age, or heart failure, simvastatin-ezetimibe had similar incidence of MACE compared with high-intensity statin therapy in further adjusted analysis., Conclusions: In overall AMI patients, high-intensity statin therapy had better clinical outcomes than simvastatin-ezetimibe. However, in patients with high-risk factor, simvastatin-ezetimibe had comparable clinical outcomes to high-intensity statin therapy. Therefore, simvastatin-ezetimibe could be used as an alternative to high-intensity statin therapy in such patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Immediate invasive approach for non-ST-segment elevation myocardial infarction (NSTEMI) may permit treatment of the underlying plaque rupture as early as possible with subsequent reduction of death and myocardial infarction (MI). We sought to assess clinical impact of immediate percutaneous coronary intervention (PCI) for NSTEMI., Methods: A total of 6134 NSTEMI patients undergoing PCI from the Korea Acute Myocardial Infarction Registry were divided into group 1 (immediate PCI within 4h, n=1132) and group 2 (non-immediate PCI after 4h, n=5002). Propensity-matched 12-month clinical outcome was compared., Results: In all patients and propensity-matched cohort (n=1131 in each group), group 1 had higher peak troponin level, higher rate of pre-PCI Thrombolysis In Myocardial Infarction (TIMI) grade 0 or 1, higher use of glycoprotein IIb/IIIa inhibitor, and lower use of unfractionated heparin and nitrates. In all patients, 12-month rates of MI and death/MI were higher in group 1. No differences were observed in 12-month death and major adverse cardiac events (MACE: composite of death, MI, target-vessel revascularization, and coronary artery bypass graft surgery). In propensity-matched cohort, no significant differences were observed in 12-month rates of death, MI, death/MI or MACE. However, group 1 had less major bleeding (0.8% vs. 3.0%, p=0.024) and shorter hospital stay., Conclusions: Immediate PCI for patients with NSTEMI was associated with lower pre-PCI culprit vessel patency and not with improved 12-month clinical outcome., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Coronary artery spasm is associated with vascular smooth muscle hyper-reactivity. Statins suppress coronary spasm by inhibiting the vascular smooth muscle contraction. However, it is unclear whether statin therapy benefits patients with coronary spasm-induced acute myocardial infarction (AMI)., Methods and Results: We analyzed 501 (median age 57 years; male/female, 346/155) patients with coronary spasm-induced AMI with nonobstructive coronary arteries (stenosis severity <50%) from the Korea AMI Registry between November 2005 and October 2013. They were divided into two groups according to statin prescription at discharge (statin group n=292; nonstatin group n=209). The primary endpoint was the composite of 12-month major adverse cardiac events, including all causes of death, non-fatal myocardial infarction, and target vessel revascularization. The primary endpoint occurred in 17 patients during 12 months of follow-up. Statin therapy significantly reduced the risk of the composite primary endpoint [adjusted hazard ratio (HR): 0.30; 95% confidence interval (CI): 0.09-0.97; p=0.045]. Statin therapy reduced the risk of myocardial infarction (HR: 0.19; 95% CI: 0.04-0.93; p=0.040). However, we found no significant difference in the risk of the composite of all-cause death., Conclusion: Statin therapy in patients with coronary spasm-induced AMI with nonobstructive coronary arteries was associated with improved clinical outcome, which was predominantly accounted for by reducing the incidence of myocardial infarction., (Copyright © 2016. Published by Elsevier Ltd.)

Background: The aim of this study was to investigate the clinical effects of intra-aortic balloon pump (IABP) in patients who received cardiopulmonary resuscitation (CPR) before procedure., Methods and Results: Between November 2005 and April 2014, 49,542 patients were enrolled in a prospective cohort study for acute myocardial infarction (AMI) in Korea (KAMIR). CPR was performed in 1700 patients with cardiac arrest. Patients were excluded from the study if they had not undergone a coronary angiogram, if extracorporeal membrane oxygenation or thrombolysis was performed, and if mechanical complications presented. The primary end point was 1-month all-cause mortality. A total of 883 patients in the IABP group and 476 in the control group were included. During the 1-month follow-up, all-cause death occurred in 749 patients (55.1%). The IABP group was predominantly male and had a higher prevalence of ST-segment elevation MI and a higher risk of coronary lesions including left main disease and three-vessel disease. Glycoprotein IIb/IIIa inhibitor was administered less in the non-IABP group. In the total population, the IABP group had worse outcomes in terms of mortality rates after multivariate analysis [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.02-1.47, p=0.034] without increasing the incidence of recurrent MI, stroke, and major bleeding. After propensity matching with a pair of 452 patients, no significant differences were observed in baseline characteristics or clinical outcomes (HR 1.21, 95% CI 0.93-1.57, p=0.158)., Conclusion: The use of IABP did not show clinical benefits in patients with AMI complicated by severe cardiogenic shock after propensity matching analysis., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Despite common use of second-generation drug-eluting stents in treating patients with coronary artery disease, there is lack of data comparing these stents exclusively in patients with acute myocardial infarction (AMI), especially with metabolic syndrome (MetS), which is highly prevalent in AMI and potential to worsen clinical outcomes. The aim of this study was to compare clinical outcomes of everolimus-eluting stent (EES) and Resolute-zotarolimus-eluting stent (R-ZES) in AMI patients with MetS, in terms of stent-related and patient-related outcomes., Methods: A total of 3942 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were grouped according to the presence of MetS and stent type: EES (N=1582) and R-ZES (N=255) in MetS (1837). Target lesion failure (TLF) and patient-oriented composite events (POCE) at 1 year were evaluated., Results: In MetS patients, TLF (3.7% vs. 2.7%, p=0.592) and POCE (7.9% vs. 6.7%, p=0.764) were similar between EES and R-ZES. Also in Non-MetS patients, TLF (3.9% vs. 3.1%, p=0.307) and POCE (6.4% vs. 7.3%, p=0.866) were similar between 2 groups. TLF was similar between MetS and Non-MetS patients (3.6% vs. 3.8%), while POCEs (7.7% vs. 6.6%) were higher in MetS. Propensity-score matching analysis showed similar results between stent groups in MetS and Non-MetS. In multivariate analysis, left ventricular ejection fraction and symptom-to-door time were independent predictors of TLF and POCE in MetS patients with AMI., Conclusions: In MetS patients with AMI, EES and R-ZES showed excellent performance and safety. However, patient-oriented composite events were relatively high, suggesting more efforts to improve them., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Background: Despite good treatment, there are residual risks in acute myocardial infarction (AMI) patients, and low level of high-density lipoprotein-cholesterol (HDL) has drawn attention as a possible cause. However, the impact of low HDL on ST-segment-elevation myocardial infarction (STEMI) compared with non-ST-segment-elevation myocardial infarction (NSTEMI) is not clear. Our aim was to evaluate the impact of low HDL on clinical outcomes in patients with STEMI or NSTEMI., Methods: We included 9270 AMI patients undergoing successful percutaneous coronary intervention. They were grouped into STEMI and NSTEMI, and subdivided into two groups according to HDL level sampled in overnight fasting state. Primary end point was in-hospital death. Secondary end point was a composite of major adverse cardiac events (MACE) in hospital survivors during one-year follow-up., Results: In the STEMI population, low HDL group showed significantly higher in-hospital death rate [4.6% vs. 1.4%, hazard ratio (HR): 2.380, 95% confidence interval (CI): 1.143-4.956, p=0.020] than normal HDL group. In NSTEMI population, there was no significant difference between two groups (1.8% vs. 0.9%, HR: 1.231, 95% CI: 0.649-2.335, p=0.525), but in subgroup analysis, very low HDL subgroup showed higher in-hospital mortality rate compared with normal HDL group (4.0% vs. 0.9%, respectively, p=0.009). In 12-month MACE rates, there was no significant difference between two groups in both populations., Conclusions: Low HDL was associated with significantly higher risk of in-hospital mortality in STEMI patients, but not in NSTEMI patients. Thus, more aggressive treatment should be considered in STEMI patients with low HDL., (Copyright © 2014. Published by Elsevier Ltd.)

Background: In contrast to many studies comparing everolimus-eluting stent (EES) with paclitaxel-eluting stent (PES), data directly comparing EES with sirolimus-eluting stent (SES) are limited, especially in patients with acute myocardial infarction (AMI)., Methods: This study includes 2911 AMI patients treated with SES (n=1264) or EES (n=1701) in Korea Acute Myocardial Infarction Registry (KAMIR). Propensity score matching was applied to adjust for baseline imbalance in clinical and angiographic characteristics, yielding a total of 2400 well-matched patients (1200 receiving SES and 1200 receiving EES). One-year clinical outcomes were compared between the two propensity score matched groups., Results: Baseline clinical and angiographic characteristics were similar between the two propensity score matched groups. One-year clinical outcomes of the propensity score matched cohort were comparable between the EES versus the SES groups including the rates of cardiac death (4.8% vs. 4.8%, P=1.000), recurrent myocardial infarction (1.4% vs. 1.7%, P=0.619), target lesion revascularization (1.4% vs. 1.6%, P=0.737), target lesion failure (7.0% vs. 7.3%, P=0.752), and probable or definite stent thrombosis (0.5% vs. 0.9%, P=0.224) except for a trend toward lower incidence of target vessel revascularization (1.9% vs. 3.0%, P=0.087) and a lower rate of total major adverse cardiac events (9.3% vs. 11.9%, P=0.034) in the EES group., Conclusions: The present propensity score matched analysis performed in a large-scale, prospective, multicenter registry suggests that the second-generation drug-eluting stent EES has at least comparable or even better safety and efficacy profiles as compared with SES in the setting of AMI., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Chronic kidney disease (CKD) is associated with poor outcomes after percutaneous coronary intervention (PCI). The aim of the study was to compare zotarolimus- and everolimus-eluting stents used during primary PCI in patients with acute myocardial infarction (AMI) and CKD., Methods: We selected 854 consecutive ST-elevation MI patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m(2)) undergoing primary PCI who were followed up for 12 months. They were divided into two groups based on type of stents implanted: (1) zotarolimus-eluting stent (ZES) and (2) everolimus-eluting stent (EES). The study end point was the 12-month major adverse cardiac events (MACE) which included all-cause death, non-fatal MI, target lesion revascularization (TLR), and target vessel revascularization (TVR)., Results: The average number of stents used per vessel was 1.4 ± 0.7. A total of 433 patients received ZES and 421 patients received EES. There was no significant difference in the incidence of 12-month MI, TLR, or TVR. All-cause death was found to be borderline significant between two groups (2.8% in ZES vs 0.9% in EES, p=0.05). The incidence of 12-month MACE in ZES and EES was 5.7% and 2.6% respectively, p=0.022. Stent thrombosis did not differ between groups (p=0.677). Kaplan-Meier analysis did not show significant difference for 12-month MACE-free survival between groups (log-rank p=0.158). It remained the same even after propensity adjustment for multiple confounders in Cox model (p=0.326)., Conclusions: Implantation of ZES or EES provided comparable clinical outcomes with similar risk of 12-month MACE and death in STEMI patients with CKD undergoing primary PCI., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Cardiac arrest complicating acute ST elevation myocardial infarction (STEMI) is known to be associated with increased in-hospital mortality. However, little is known about the long-term outcomes after cardiac arrest complicating first onset STEMI in contemporary percutaneous coronary intervention (PCI) era., Methods: We analyzed 7942 consecutive patients who were diagnosed with STEMI and had no previous history of MI. They were divided into two groups according to the presence of cardiac arrest (group I, patients with cardiac arrest; n=481, group II, patients without cardiac arrest; n=7641)., Results: In a stepwise multivariate model, previous history of chronic kidney disease, high serum level of glucose and low high density lipoprotein-cholesterol was an independent predictor of cardiac arrest complicating STEMI. Group I had significantly higher in-hospital mortality (adjusted hazard ratio [HR] 3.06, 95% confidence interval [CI] 2.08-4.51, p<0.001) and 30-day mortality after hospital discharge (adjusted HR 2.92, 95% CI 1.86-4.58, log-rank p<0.001). However, there was no significant increase in mortality beyond 30 days (6-month, adjusted HR 1.46, 95% CI 0.45-4.77, log rank p=0.382; 1-year, adjusted HR 1.84, 95% CI 0.83-4.05, log-rank p=0.107). Also, there were no significant differences in 6-month and 1-year major adverse cardiac events in 30-day survivors. Performing PCI was associated with decreased 12-month mortality in 30-day survivors., Conclusions: Although patients with cardiac arrest complicating first onset STEMI had higher in-hospital and 30-day mortality after hospital discharge, cardiac arrest itself did not have any residual impact on mortality as well as clinical outcomes., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background and Purpose: There were limited data about comparison of zotarolimus-eluting stents (ZES) and everolimus-eluting stents (EES) in patients with small coronary artery disease (CAD), especially in patients with acute myocardial infarction (AMI). The objective of this study was to compare the clinical outcomes of ZES and EES in patients with AMI for small CAD., Methods and Subjects: A total 1565 AMI patients treated with Endeavor-ZES (n=651) (Medtronic CardioVascular, Santa Rosa, CA, USA) or Xience V/Promus-EES (n=914) (Abbott Vascular, Temecula, CA/Boston Scientific, Natick, MA, USA) for small CAD (stent diameter ≤ 2.75 mm) in KAMIR (Korea Acute Myocardial Infarction Registry) were enrolled. After propensity score matching to adjust for baseline clinical and angiographic characteristics, we compared a total 1302 patients (651 ZES and 651 EES) about major adverse cardiac events (MACE) at 1-year. Subgroup analysis about 1-year clinical outcomes was undertaken in patients who were discharged alive., Results: Baseline clinical and angiographic characteristics were similar between the two groups after propensity score matching. Total MACE did not differ between the two groups before (9.8% vs. 8.2%, p=0.265) and after (9.8% vs. 9.4%, p=0.778) propensity score matching. The EES group showed lower rate of 1-year cardiac death (5.4% vs. 3.3%, p=0.041), target lesion failure (TLF; 6.9% vs. 4.3%, p=0.022), and stent thrombosis (1.4% vs. 0.4%, p=0.042) compared with the ZES group. However, there were no differences in 1-year cardiac death, TLF, and stent thrombosis in propensity score matched populations. Other various 1-year clinical outcomes showed no difference between the two groups. Subgroup analysis in patients who were discharged alive showed similar outcomes between the two groups at 1-year follow-up., Conclusion: In-this propensity score matched analysis, EES and ZES showed no significant difference in clinical outcomes at 1-year follow-up in patients with AMI for small CAD., (Copyright © 2013. Published by Elsevier Ltd.)

Aims: We elucidated the therapeutic potential of human umbilical vein endothelial cells (HUVECs) for ameliorating progressive heart failure in a myocardial infarction (MI) rat model., Main Methods: MI was induced by ligation of left anterior descending artery, and HUVEC was transplanted 1week after MI. Cardiac function was evaluated by echocardiography, and histological analyses were performed., Key Findings: Phosphate-buffered saline (MI-V, n=5) or HUVEC (MI-HV, n=5) were injected into the border zone and infarcted area 7days after ligation of the left coronary artery in rats. The MI-HV group showed attenuation of left ventricular (LV) remodeling compared with the MI-V group. In the infarcted myocardium, a few of injected HUVEC was retained up to 28days. The ratios of matrix metalloproteinase (MMP)-2 or MMP-9 to tissue inhibitor of metalloproteinase (TIMP)-1 or TIMP-3 were decreased in the MI-HV group compared with the MI-V group. In vivo zymography analysis showed that HUVEC transplantation decreased the activities of MMP-2 and MMP-9. In immunohistochemistry, decreased MMP-2 and increased TIMP-1 and TIMP-3 expression were observed at 48h after HUVEC transplantation. These effects on MMP/TIMP balance were inhibited by L-NAME administration (an eNOS inhibitor, 10mg/kg). NOS inhibition decreased the protein expressions of TIMP-1 and TIMP-3 but did not change the protein expressions of MMP-2 and MMP-9., Significance: Our data suggest that altered balance between MMP and TIMP by HUVEC transplantation contributed to attenuation of ventricular remodeling after MI via eNOS., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The mechanisms of antagonism vary between the angiotensin II type 1 receptor blockers (ARBs): insurmountable antagonism and surmountable antagonism. Recent retrospective observational studies suggest that ARBs may not have equivalent benefits in various clinical situations. The aim of this study was to compare the effect of two categories of ARBs on the long-term clinical outcomes of patients with acute myocardial infarction (AMI)., Methods: We analyzed the large-scale, prospective, observational Korea Acute Myocardial Infarction Registry study, which enrolled 2740 AMI patients. They divided by the prescription of surmountable ARBs or insurmountable ARBs at discharge. Primary outcome was major adverse cardiac events (MACEs), defined as a composite of cardiac death, nonfatal MI, and re-percutaneous coronary intervention, coronary artery bypass graft surgery., Results: In the overall population, the MACEs rate in 1 year was significantly higher in the surmountable ARB group (14.3% vs. 11.2%, p=0.025), which was mainly due to increased cardiac death (3.3% vs. 1.9%, p=0.031). Matching by propensity-score showed consistent results (MACEs rate: 14.9% vs. 11.4%, p=0.037). In subgroup analysis, the insurmountable ARB treatment significantly reduced the incidence of MACEs in patients with left ventricular ejection fraction greater than 40%, with a low killip class, with ST segment elevation MI, and with normal renal function., Conclusions: In our study, insurmountable ARBs were more effective on long-term clinical outcomes than surmountable ARBs in patients with AMI., (© 2013.)

Backgrounds: The disparity between ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) remains controversial. We compared clinical outcomes and prognostic factors between STEMI and NSTEMI using large-scale registry data., Methods: We recruited 28,421 patients with STEMI (n=16,607) and NSTEMI (n=11,814) between November 2005 and April 2010 from a nationwide registry in Korea. We performed landmark analysis of cardiac death, recurrent acute myocardial infarction (re-AMI), revascularization, and major adverse cardiac events (MACE) at 30 days (early term) and 1 year (late term) after admission., Results: Patients with NSTEMI had a greater number of co-morbidities than STEMI patients. Early term MACE (6.9% vs. 4.5%, p<0.001) and cardiac death (6.1% vs. 3.7%, p<0.001) were higher in STEMI patients. However, late-term MACE (8.0% vs. 9.1%, p=0.007), cardiac death (1.9% vs. 2.6%, p=0.001), and re-AMI (0.6% vs. 1.3%, p<0.001) were lower in the STEMI group. The independent predictors of cardiac death were old age, renal dysfunction, LV dysfunction, Killip class, post-thrombolysis in myocardial infarction (TIMI) flow, and major bleeding in both groups. Female gender, previous ischemic heart disease, diabetes, current smoking, multivessel disease, and body mass index were MI type- or time-dependent predictors., Conclusion: The STEMI group displayed poor early term clinical outcome, whereas the NSTEMI group displayed poor late-term clinical outcome. The STEMI and NSTEMI groups had different predictor profiles for cardiac death, suggesting that different strategies are required for improving the late-term outcome of STEMI and NSTEMI patients., (© 2013.)

Background: Hemoconcentration is a surrogate marker of effective decongestion and diuresis therapy. Recently, hemoconcentration has been associated with decreased mortality and rehospitalization in heart failure (HF) patients. However, the prognostic power of hemoconcentration in a large sample-sized HF cohort was limited until now., Methods and Results: We analyzed data from hospitalized patients with acute heart failure (AHF) that were enrolled in the Korean Heart Failure Registry(n=2,357). The primary end point was a composite of all-cause mortality and HF rehospitalization during the follow-up period (median=347, interquartile range=78-744 days).Hemoconcentration, defined as an increased hemoglobin level between admission and discharge, was presented in 1,016 AHF patients (43.1%). In multivariable logistic regression, hemoglobin, total cholesterol, and serum glucose levels at admission, and ischemic HF, were significant determinants for hemoconcentration occurrence. The Kaplan-Meier curve showed that event-free survival was significantly higher in the hemoconcentration group compared to the non-hemoconcentration group (65.1% vs. 58.1%, log rank p<0.001). In multiple Cox proportional hazard analysis, hemoconcentration was an independent predictor of the primary end point after adjusting for other HF risk factors (hazard ratio=0.671, 95% confidence interval=0.564-0.798, p<0.001)., Conclusions: Hemoconcentration during hospitalization was a prognostic marker of fewer clinical events in the AHF cohort. Therefore, this novel surrogate marker will help in the risk stratification of AHF patients., (© 2013.)

Background and Purpose: Octogenarians (age ≥ 80 years) with coronary artery disease constitute a high-risk group. However, octogenarian patients with acute myocardial infarction (AMI) in the drug-eluting stents (DES) era have not been widely reported. We aimed to identify clinical outcomes in octogenarian compared with non-octogenarian AMI patients., Methods and Subjects: We retrospectively analyzed 9877 patients who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and who were enrolled in the Korean Acute Myocardial Infarction Registry (KAMIR). They were divided into 2 groups, octogenarians (n=1494) and non-octogenarians (n=8383), in order to compare the incidence of 1-year all-cause death and 1-year major adverse cardiac events (MACE), where MACE included all-cause death, recurrent myocardial infarction, target vessel revascularization (TVR), target lesion revascularization (TLR), and coronary artery bypass grafting (CABG)., Results: The clinical status was significantly inferior in octogenarians compared to non-octogenarians: Killip class ≥ II (34.8% vs. 22.5%, p<0.001), multivessel disease (65.8% vs. 53.7%, p<0.001). Rates of 1-year all-cause death were significantly higher in octogenarians than in non-octogenarians (22.3% vs. 6.5%, p<0.001). However, the rates of 1-year recurrent myocardial infarction (1.3% vs. 0.9%, p=0.68), TLR (2.4% vs. 3.1%, p=0.69), TVR (3.6% vs. 4.3%, p=0.96), and CABG (0.9% vs. 0.9%, p=0.76) did not differ significantly between the 2 groups., Conclusions: Octogenarian AMI patients have higher rates of mortality and MACE even in the DES era. According to KAMIR subgroup analysis, the TLR/TVR rates in octogenarians were comparable to those in non-octogenarian AMI patients., (Copyright © 2013. Published by Elsevier Ltd.)

Objective: We investigated whether statin therapy and high-sensitivity C-reactive protein (hs-CRP) levels were associated with the risk of stent thrombosis (ST) in acute myocardial infarction (AMI) patients., Methods: A total of 9,162 AMI patients who underwent coronary stent implantation were analyzed in the Korean Acute Myocardial Infarction Registry. The study population was divided into four groups according to level of hs-CRP and peri-procedural statin treatment: low hs-CRP (≤ 2.0mg/L) and high hs-CRP (>2mg/L) with or without statin therapy. We compared the incidence of early ST among the groups., Results: Statin therapy did not significantly affect the development of early ST in the low hs-CRP group. In the high hs-CRP group, however, the incidence of early ST was significantly decreased with statin treatment. In a subgroup analysis of the high hs-CRP group, patients aged less than 65 years, without diabetes, with a high body mass index, and with a high Killip class seemed to benefit more from statin therapy. In a multivariable Cox regression analysis of the high hs-CRP group, lack of statin therapy was a significant predictor of ST incidence., Conclusions: Peri-procedural statin treatment had an effect on reduced incidence of early ST in AMI patients with high levels of hs-CRP., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Hydrophilic guide wire-related renal artery perforation (RAP) and subsequent retroperitoneal hemorrhage (RPH) during coronary angiography (CAG) is very rare. We present the case of a 68-year-old woman who suffered accidental hydrophilic 0.035-inch guide wire piercing-related RAP and RPH during CAG and coronary intervention. This RAP was diagnosed by bedside ultrasonography and selective renal angiography, and was successfully treated by transcatheter polyvinyl alcohol injection., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to compare everolimus-eluting stents (EES) with zotarolimus-eluting stents (ZES) in patients with acute myocardial infarction (AMI)., Background: There is a paucity of data to exclusively evaluate the safety and efficacy of second-generation drug-eluting stents (DES) in the setting of AMI., Methods: The present study enrolled 3,309 AMI patients treated with ZES (n = 1,608) or EES (n = 1,701) in a large-scale, prospective, multicenter registry-KAMIR (Korea Acute Myocardial Infarction Registry). Propensity score matching was applied to adjust for differences in baseline clinical and angiographic characteristics, producing a total of 2,646 patients (1,343 receiving ZES, and 1,343 receiving EES). Target lesion failure (TLF) was defined as the composite of cardiac death, recurrent nonfatal myocardial infarction, or target lesion revascularization. Major clinical outcomes at 1 year were compared between the 2 propensity score-matched groups., Results: After propensity score matching, baseline clinical and angiographic characteristics were similar between the 2 groups. Clinical outcomes of the propensity score-matched patients showed that, despite similar incidences of recurrent nonfatal myocardial infarction and in-hospital and 1-year mortality, patients in the EES group had significantly lower rates of TLF (6.5% vs. 8.7%, p = 0.029) and probable or definite stent thrombosis (0.3% vs. 1.6%, p < 0.001), compared with those in the ZES group. Furthermore, there was a numerically lower rate of target lesion revascularization (1.2% vs. 2.2%, p = 0.051) in the EES group than in the ZES group., Conclusions: In this propensity-matched comparison, EES seems to be superior to ZES in reducing TLF and stent thrombosis in patients with AMI., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The role of thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PPCI) remains a matter of controversy., Methods and Results: A total of 2105 patients enrolled in the nationwide prospective Korea Acute Myocardial Infarction Registry, a cohort of 745 (35.4%) patients who underwent TA during PPCI was compared with 1360 (64.6%) patients who underwent conventional PCI without TA. Clinical outcomes at 12-months of overall enrolled patients and subgroups according to key variables were assessed using Cox regression models adjusted by propensity score. Although there was no significant difference among overall patients, in subgroup analyses, administration of glycoprotein (GP) IIb/IIIa inhibitor during PPCI [adjusted hazard ratio (HR) 0.329, 95% confidence interval (CI) 0.126-0.860, p=0.023] and left anterior descending (LAD) as a culprit lesion (adjusted HR 0.516, 95% CI 0.275-0.971, p=0.040) were the settings, in which TA was associated with a lower major adverse cardiac events (MACE) rate compared with non-TA., Conclusions: Although TA does not improve clinical outcomes in overall patients who underwent PPCI, TA for LAD occlusion improves 12-month MACE. Furthermore, use of GP IIb/IIIa inhibitor with TA has a synergistic effect on clinical outcomes., (Copyright © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Introduction: It is unknown whether drug-eluting stents (DES), in comparison with bare-metal stents (BMS), improve clinical outcomes of ST-elevation myocardial infarction (STEMI) patients with renal insufficiency. We aimed to compare the clinical outcomes of BMS versus DES, as well as sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES), in STEMI patients with renal insufficiency., Methods: From the Korea Acute Myocardial Infarction Registry, 874 STEMI patients with renal insufficiency (glomerular filtration rate < 60 ml/min) comprising 116 patients with BMS and 758 patients with DES (430 SES and 328 PES) implantation were selected. Major adverse cardiac events (MACE) within 1 year, defined as composite of all-cause mortality, nonfatal myocardial infarction and target lesion revascularization were compared. In addition to multivariate adjusted analysis, propensity analysis for stent choice was performed., Results: With a median follow-up of 342 days, 116 MACE occurred. MACE was more frequent in the BMS group than in the DES group before (HR [95% CI]=2.3 [1.3-3.8]) and after propensity score matching (HR [95% CI]=2.0 [1.0-3.8]). The difference of MACE was mainly driven by a higher rate of target lesion revascularization rate in the BMS group. In comparison between SES and PES, there was no significant difference between the 2 groups in propensity score-matched populations (HR [95% CI]=0.7 [0.4-1.1])., Conclusions: In STEMI patients with renal insufficiency, DES implantation exhibits a favorable 1 year clinical outcomes than BMS implantation, however, no difference was found between SES and PES., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: In patients with non-ST-elevation myocardial infarction (NSTEMI), current guidelines did not recommend optimal revascularization management in multivessel coronary artery disease. We compared clinical outcomes between multivessel revascularization and culprit-only revascularization in this setting., Methods: A total of 1919 patients with multivessel disease (1011 patients; multivessel revascularization group, 908 patients; culprit-only revascularization group) diagnosed as NSTEMI was enrolled in a nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to January 2008. The primary end-points were major adverse cardiac events (MACE), all-causes of deaths, myocardial infarction (MI), and repeated percutaneous coronary intervention (PCI) during 1-year clinical follow-up. Also, subgroup analysis was performed in patients with high TIMI (Thrombolysis In Myocardial Infarction) risk score (≥ 4) to find efficacy of multivessel PCI in high-risk patients., Results: Baseline clinical characteristics and the risk factors of coronary artery disease were similar between both groups. In angiography, three-vessel lesion was more presented in the multivessel group (46.1% vs. 40.9%, p = 0.024) and rates of left anterior descending and left main stem coronary artery as culprit vessel were higher in the multivessel group (p = 0.003 and p = 0.001 respectively). In-hospital mortality was higher in the culprit-only group (1.4% vs. 2.9%, p = 0.025). Primary end-points occurred in 241 patients (15.5%) during 1-year follow-up. Multivessel revascularization reduced MACEs [hazard ratio (HR) 0.658, 95% confidence interval (CI) 0.45 to 0.96, p = 0.031], death or myocardial infarction (HR 0.58, 95% CI 0.35 to 0.97, p = 0.037) and non-target vessel revascularization (HR 0.44, 95% CI 0.24 to 0.81, p = 0.008). There were no significant differences in target lesion revascularization (TLR; HR 1.38, 95% CI 0.51 to 3.71, p = 0.529) and target vessel revascularization (TVR; HR 0.28, 95% CI 0.05 to 1.47, p = 0.131). In subgroup analysis in patients with a higher TIMI risk score, similar results were presented., Conclusion: Multivessel revascularization in multivessel coronary artery disease presenting with NSTEMI showed better clinical outcomes without significant in-stent restenosis and progression of diseased-vessel compared to culprit-only revascularization., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Left circumflex artery (LCX) related acute myocardial infarction (AMI) has been known to be under diagnosed with 12-lead electrocardiogram (ECG). However, there were only a few studies that have focused on the clinical characteristics of LCX-related AMI. We studied the clinical characteristics and hospital mortality in patients with angiographically confirmed LCX-related AMI. A total of 2281 AMI patients with single acutely occluded culprit vessel in coronary angiography (pre-Thrombolysis In Myocardial Infarction flow: 0) were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to January 2008. These patients were divided into three groups according to culprit vessel [left anterior descending artery (LAD), right coronary artery (RCA), and LCX]. This study showed the patients with LCX-related AMI were less likely to present with ST elevation in ECG (46.3%, 87.0%, and 82.3%; p<0.001) and primary percutaneous coronary intervention (PCI) (43.4%, 78.9%, and 74.5%; p<0.001) and door to balloon time <90 min (31.3%, 52.8%, and 51.0%; p<0.001), compared with LAD and RCA. However, no statistical difference was found in hospital mortality among the three groups. Multivariate analysis showed primary PCI decreased the hospital mortality in patients with occluded coronary artery. In conclusion, AMI patients with an occluded LCX presented with less ST elevation and primary PCI. These results suggest that clinical physicians should be careful with patients presenting with chest pain but apparently normal ECG and must rule out LCX occlusion., (Copyright © 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: There is a paucity of data concerning the clinical outcome of patients presenting with acute myocardial infarction (AMI) and near-normal coronary angiograms. The purpose of this study was to evaluate the clinical outcome and the prognosis of the patients with near-normal coronary angiograms who were registered in the Korean Acute Myocardial Infarction Registry (KAMIR)., Methods: The subjects were divided into three groups according to findings from coronary angiograms performed between September 2005 and November 2006. Among 8510 consecutive AMI patients, 372 patients (Group I) had near-normal coronary arteries, 6136 patients (Group II) had one- or two-vessel disease, and 2002 patients (Group III) had three-vessel or left main disease., Results: Clinical characteristics, in-hospital mortality, and major cardiac adverse events (MACE) were analyzed. Group I was younger, had the lower prevalence of DM, and showed the higher percentage of previous angina history compared to the other two groups. Group III showed a higher incidence of in-hospital mortality, but there was no significant difference between Group I and Group II (2.6% in Group II and 2.2% in Group I, p=0.952). Furthermore, MACE at 1 month, 6 months and 12 months revealed no significant difference between Groups I and II (12 month MACE: 7.8% in Group I and 12.2% in Group II, p=0.359)., Conclusions: Patients with near-normal coronary angiograms had similar clinical outcomes and prognosis compared with one- or two-vessel diseased patients presenting with an acute myocardial infarction., (Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.)