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Background: The sequential organ failure assessment (SOFA) score has been validated in various clinical situations. However, it has not been investigated during a short stay in the intensive care unit (ICU). This study aimed to evaluate the association between the SOFA score and outcomes in patients who were monitored for less than one day after non-cardiac surgery. Methods: From a total of 203,787 consecutive adult patients who underwent non-cardiac surgery between January 2011 and June 2019, we selected 17,714 who were transferred to the ICU immediately after surgery and stayed for less than 24 h. Patients were divided according to quartile value and change between the initial and follow-up levels of SOFA score. Results: Three-year mortality tended to increase with a higher initial SOFA score (11.7%, 11.8%, 15.1%, and 17.8%, respectively). The patients were divided according to changes in the SOFA score at the midnight postoperative follow-up check: 16,176 (91.3%) in the stable group and 1538 (8.7%) in the worsened group. The worsened group showed significantly higher three-year mortality and complications (13.2% vs. 18.6%; HR [hazard ratio]: 1.236; 95% CI [confidence interval]: 1.108–1.402; p ≤ 0.0021 for three-year mortality and 3.8% vs. 9.1%; HR: 2.13; 95% CI: 1.73–2.60; p < 0.001 for acute kidney injury). Conclusions: The SOFA score during a short stay in the ICU after non-cardiac surgery showed an association with mortality. The change in SOFA score may need to be considered at discharge from the ICU.

Background: Hyperglycemia in surgical candidates is associated with increased mortality and morbidity. We aimed to evaluate the effect of intraoperative blood glucose level on the incidence of myocardial injury after non-cardiac surgery (MINS) in diabetic patients.Methods: Diabetic patients with available intraoperative blood glucose measurement during non-cardiac surgery were enrolled in this study. Based on the highest intraoperative blood glucose level, patients were stratified into two groups; the normal group (intraoperative peak glucose < 180mg/dL) and the hyperglycemia group (intraoperative peak glucose ≥ 180mg/dL). The primary outcome was the incidence of MINS, and secondary outcomes were in-hospital and 30-day mortalities.Results: Of the 11,302 diabetic patients, 8,337 patients were in the normal group (73.8%), and 2,965 patients were in the hyperglycemia group (26.2%). After inverse probability weighting adjustment, MINS was significantly higher in the hyperglycemia group (24.0% vs 17.2%; odds ratio [OR], 1.26; 95% confidence interval [CI], 1.14 – 1.40; p < 0.001). In addition, in-hospital and 30-day mortalities were also higher in the hyperglycemia group compared to the normal group (4.2% vs 2.3%, hazard ratio [HR], 1.39; 95% CI, 1.07 - 1.81; p=0.01, and 3.1% vs 1.8%; HR, 1.76; 95% CI, 1.31 - 2.36; p < 0.001, respectively). Receiver-operating characteristic plots showed that the threshold of glucose level related to MINS was 149mg/dL.Conclusion: Intraoperative hyperglycemia was associated with an increased MINS incidence and postoperative mortality in diabetic patients. Intraoperative blood glucose control may be helpful in preventing MINS.

Background Diastolic blood pressure has a J-curve relation with coronary heart disease and death, but it is debating whether a J-curve association exists in general population. We aimed to assess the relation of blood pressure to mortality, and whether their association is interacted with presence of high coronary artery calcium (CAC). Methods The KOICA registry is a retrospective, multicenter observational study designed to investigate the effectiveness and prognostic value of CAC score for primary prevention of cardiovascular disease in asymptomatic Korean adults. The association between CAC score and blood pressure was assessed. Patients were divided into 2 groups according to the baseline CACS (> 300 and ≤ 300), and all-cause mortality was assessed. Results The study population composed 48903 subjects with a mean age of 54 ± 9. There were 425 (0.9%) deaths during follow-up. At baseline, SBP (systolic blood pressure) more than 110 mmHg and DBP (diastolic blood pressure) more than 80 mmHg was associated with increased risk for CACS > 300. In patients with baseline CACS ≤ 300, all-cause mortality was increased in patients with SBP of 110-119 mmHg (HR 1.47, p = 0.023), 130-139 mmHg (HR 1.72, p = 0.002) and ≥ 140 mmHg (HR 1.47, p = 0.042) compared to SBP of 120-129 mmHg, whereas DBP did not predict all-cause mortality. In contrast, SBP was not associated to all-cause mortality in patients with CACS > 300, whereas DBP < 60 mmHg (HR 3.53, p =0.018) and 70-79 mmHg (HR 2.21, p = 0.042) was associated with increased risk for all-cause mortality compared to DBP of 80-89 mmHg. Conclusion Low DBP was associated with increased risk for all-cause mortality in subjects with high CAC score, suggesting high-risk for coronary artery disease. However, this J-curve relation was not shown in the population with low CAC score.

Aims: To evaluate the impact of metabolic syndrome (MetS) status on the incidence of atrial fibrillation (AF) in Koreans. Methods and results: Data obtained from the Korean National Health Insurance Service from 2009 to 2016 were analyzed. In total, 7,830,602 men and women (between 30 and 69 years of age) without baseline AF who underwent a national health examination between January 2009 and December 2009 were enrolled. Patients were evaluated to determine the impact of MetS status on their risk of developing AF until December 2016. Using the National Cholesterol Education Program Adult Treatment Panel III criteria, patients were placed into one of three groups depending on MetS component numbers: 0 (normal), 1&ndash, 2 (Pre-MetS) or 3&ndash, 5 (MetS). During a mean follow-up of 7.3 years, 20,708 subjects (0.26%) were diagnosed with AF. After multivariable adjustment, the risk of AF was significantly and positively correlated with MetS status (hazard ratios (HR) 1.391, 95% confidence interval (CI) 1.322&ndash, 1.464 in Pre-MetS and HR 1.722, 95% CI 1.621&ndash, 1.829 in MetS). When subgroup analyses were conducted according to MetS components, abdominal obesity (HR 1.316, p &lt, 0.001), elevated blood pressure (HR 1.451, p &lt, 0.001), and elevated fasting glucose (HR 1.163, p &lt, 0.001) were associated with an increased risk of AF. Conclusion: MetS and pre-MetS are significantly associated with an increased risk of AF in Korean adults. Of the MetS components, abdominal obesity, elevated blood pressure, and elevated fasting glucose are potent risk factors for the risk of AF in this population.

A left ventricular assist device (LVAD) is a mechanical circulation support implanted for patients with end-stage heart failure. It may be used either as a bridge to cardiac transplantation or as a destination therapy. The health of a 75-year-old man with a medical history of systolic heart failure worsened. Therefore, he was recommended to have implanted a LVAD (Thoratec Corp.) as a destination therapy. After the surgery, he was enrolled in patient cardiac rehabilitation for the improvement of dyspnea and exercise capacity. In results, there is an improvement on his exercise capacity and quality of life. For the first time in Korea, we reported a benefit of exercise therapy after being implanted with a LVAD.

Background: We frequently encounter high levels of activated partial thromboplastin time (aPTT) during heparin anticoagulation. The purpose of this study is, first, to investigate the rate of achieving and maintaining therapeutic aPTT in patients treated with heparin anticoagulation and second, to assess the adequacy the current nomogram. Methods: We included 197 patients who underwent anticoagulation with unfractionated heparin (UFH) according to the standard nomogram between September 2008 and May 2010. The primary endpoints were the rate of achieving a therapeutic range (TR) at the first sample, 24 hours, or 48 hours. We also compared heparin nomograms according to age (Results: Of the 197 patients, 131 had heparin loading. In the heparin loading group, there were 19.1% (n=25), 69.5% (n=91), and 90.1% (n=18) achieving TR at the first aPTT, 24 hours, and 48 hours, respectively. The therapeutic aPTT proportion was 39.2%, and the rate of peak level above 90 seconds was 93.1%. Peak levels of aPTT were higher in the older age group than in the younger age group (202.3 ± 124.2 versus 152.0 ± 78.9, p=0.007). Conclusion: Our results indicate a high rate of achieving therapeutic aPTT at 24hous and 48hours, but a low success rate for maintenance within the TR. Most patients had supratherapeutic aPTT of more than 90 seconds. Therefore, the TR of aPTT that matches heparin levels of 0.3 to 0.7 IU/mL measured by antifactor Xa assay should be determined. If not, we should consider adopting a new heparin dosing nomogram.

Introduction: Zero coronary artery calcium (CAC) is a reliable predictor of absent atherosclerosis and serves as a useful adjunct for identifying those at low risk. Despite this, the “warranty period” that displays the protective value associated with the absence of CAC towards experiencing a cardiovascular event among Asians is not well established. Hypothesis: To examine whether the absence of CAC displays a more favorable warranty period for all-cause death compared with the presence of CAC in a Korean cohort. Methods: A total of 48,215 asymptomatic Koreans (mean age: 54±8.8 years; 25% women) were enrolled and stratified by the absence or presence of CAC. Time to exceeding 1% of cumulative all-cause death was estimated in order to identify low-risk individuals. Hazard ratios (HR) with 95% confidence intervals (95% CI) for all-cause death were estimated according to prespecified cardiac risk factors and the presence of CAC. Results: In total, 30,605 (63.5%) individuals presented with a zero CAC. Across a median follow-up of 4.4 years (Interquartile range: 2.7-6.6 years), 415 (0.9%) individuals experienced the endpoint of all-cause death. For those with a zero CAC, the time to exceeding 1% risk was found to be 9 years, indicating a substantially longer warranty period compared with participants with a CAC>0 (e.g., 5 year warranty period). The time to exceeding 1% risk tended to decline for individuals on the background of increasing CAC scores. For each of the other prespecified risk factor groups, a zero CAC provided a longer cumulative event free period than in the presence of any CAC. Cox regression analyses also revealed that the absence of CAC was independently associated with a lower risk of all-cause death in each of the respective risk factor groups when compared with CAC>0. Conclusions: In a large cohort of asymptomatic Korean individuals, the absence of CAC evokes a strong protective effect against all-cause death as demonstrated by a longer warranty period.

Background The N-terminal fragment of pro Brain Natriuretic Peptide (NT-pro BNP) is a neuro-hormone synthesized in the cardiac ventricles in response to increased wall tension. The purpose of this study was to assess the correlation between the NT-pro BNP levels and the New York Heart Association function class (NYHA Fc) of dyspnea and echocardiographic findings for the patients who visited our cardiology departments. Methods From October, 2002 to April, 2003, serum NT-pro BNP levels were measured in 348 patients who visited the Samsung Medical Center and the Jong Koo Lee Heart Clinic. Results The NT-pro BNP levels were increased with the progression of NYHA Fc of dyspnea (p

Background and Objectives:There are several reports of cardiac rehabilitation (CR) having beneficial effects on the reduction of cardiovascular mortality and in the prevention of recurrent coronary events in patient with myocardial infarction (MI). An 8-week CR program was investigated to see if it affected the prognostic factors, such as inflammatory markers, after acute MI. Subjects and Methods:33 male and 5 female patients, with a mean age of 55±10 yrs, were consecutively assigned to the CR (n=19) and the control (n=19) groups three weeks after acute MI. The 8-week CR program consisted of life style modification and aerobic exercise training. At the baseline, and after 8 weeks, the symptom limited exercise test and peripheral blood sampling were performed to measure the physiologic capacity, the serum levels of high sensitive C-reactive protein (hs-CRP) and the plasma levels of interleukin (IL)-6 and tumor necrosis factor (TNF)-α. The interval changes of each parameter were compared between the two groups. Results:The interval increments of the maximal oxygen uptake (14.3% vs. 10.6%, CR vs. control group, p=0.014), anaerobic threshold (18.8% vs. 7.0%, CR vs. control group, p=0.044) and exercise duration (9.4% vs. 3.1%, CR vs. control group, p=0.009) were larger in the CR than in the control group. The magnitudes of the interval changes in hs-CRP, IL-6 and TNF-α, as inflammatory markers, did not differ between the two groups (p>0.05). Conclusion:This 8-week CR program demonstrated an improved exercise capacity for MI patients, but a larger clinical trial, with modified exercise intensity and duration, will be necessary to detect any possible effect on the inflammatory markers. (Korean Circulation J 2004;34(8):820-827)

Background and Objectives:Biochemical markers are useful for the prediction of cardiac events in patients with acute coronary syndrome (ACS). The N-terminal fragment of the BNP prohormone (NT-proBNP), which is synthesized by cardiac ventricles in response to increased wall stress, may be a prognostic marker in ACS. The relation between the NT-pro BNP levels on admission and major adverse cardiovascular events (MACEs) were assessed in a cohort of patients with ACS. Subjects and Methods:Between October 2002 and April 2004, blood samples for the determination of NT-proBNP level were obtained on admission from 78 patients with ST-elevation myocardial infarction (STEMI), 32 with non-ST elevation MI (NSTEMI) and 66 with unstable angina (UA). Patients were followed concerning MACEs (death, MI, heart failure, stroke and revascularization) for a median of 7 months in median. Results:22 patients (13%) had events. The mean NTproBNP level was significantly lower in the event-free survivors than in those with events (1342±1598 versus 6129±6522 pg/mL, p

Background and Objectives:Recent advances in trans-radial coronary intervention (TRI) have shown a reduction in patient’s morbidity. However, the role of TRI for a chronic total occlusion (CTO) is not well established. The aim of this study was to assess the safety and feasibility of TRI for a CTO. Subjects and Methods:Sixty-three successive CTO lesions of more than 2 months duration were prospectively included in this registry between April 2002 and November 2003. Guiding catheters with strong back-up, stiff guide wires and supportive infusion catheters were actively used. The angiographic and procedural characteristics were prospectively evaluated. Results:There were 45 male and 18 female patients, with a mean age of 59.8±9.5 years. The most common clinical diagnosis was stable angina (95.2%). The mean duration of the occlusions was 10.3±1.6 months. Procedural success was achieved in 53 lesions (84.1%). No cases were crossed over to transfemoral procedure. The most common cause of procedural failure was guide wire passage failure (7 lesions). The mean duration of occlusions was significantly longer in the failure group (7.5±1.1 versus 24.8± 6.5 months, p

Background:Recent advances of percutaneous coronary intervention (PCI) and transradial coronary intervention (TRI) have made it possible to reduce the local complication rate and the time until a return to ambulation. The aim of this study is to assess the safety and the patient satisfaction of the TRI-based one-day admission program for PCI. Methods:Total 230 consecutive patients underwent TRI on the day of admission, according to pre-determined inclusion criteria, from May 2001 to October 2003. The subjects were examined for clinical and angiographic characteristics. The patients having a same-day discharge were telephone-interviewed one day and seven days after discharge to assess late complications and the patients’ satisfaction. Results:The mean age of the subjects was 59±9 years and 77.4% were male patients. 169 (73.4%) had stable angina and 37 (16.1%) had unstable angina. Stents were implanted in 178 cases (69.3%). Of the 230 patients who underwent TRI, 206 patients (89.6%) could discharge on the same day after the procedure. The procedure was successful in 98.5%. The average hospital stay for them was 9.4±1.4 hours. Two subjects reported hematoma near the puncture site within 24 hours after discharge, and one reported this problem 7 days after discharge. During the follow-up, there were no cases reporting chest pain needing rehospitalization or such complications as subacute vessel closure. No deaths, myocardial infarctions or revascularization were noted during the follow-up period. The majority of the patients (n=197, 95.6%) were satisfied with the same-day admission and discharge. Conclusions:Sameday admission and discharge after TRI seems to be safe as well as satisfactory for not low-risk patients. (Korean Circulation J 2004; 34 (7):647-654)

Background and Objectives:Tilt training as a non pharmacological therapy was recently introduced to treat the patients with neurocardiogenic syncope. Tilt training has been known to prevent neurocardiogenic syncope by desensitizing abnormal autonomic reflex. Herein, the early effect of tilt training and the preventive effect on the relapse of syncope were studied during a long-term follow-up period. Subjects and Methods: Fifteen patients (11 males) who experienced recurrent syncope, despite drug treatment or were intolerant to drug treatment, among those diagnosed as neurocardiogenic syncope by the head-up tilt test at Samsung Medical Center between March 2000 and May 2003 were recruited. Each patient underwent tilt training after admission and was educated to continue self-tilt training after discharge. Data for recurrences after discharge were obtained via questionnaires on outpatient visits or by telephone interviews. Results:Eleven (73%) of the 15 who underwent tilt training on admission showed therapeutic effects. The mean follow-up period was 21±10 months (5-40 months). Only one patient was excluded due to follow-up loss. Ten of the above patients underwent training by themselves for an average of 4 months after discharge, and experience no relapse of syncope during the follow-up period. Conclusion:Tilt training maintained its therapeutic effect during long-term follow-up. This could be a new treatment for patients non responsive or intolerant to medical therapy. (Korean Circulation J 2004;34(8):789-794)

Background and Objectives:Coronary artery perforation is a rare, but potentially deadly, complication of percutaneous coronary intervention (PCI). The purpose of this study was to analyze the clinical characteristics, and outcome, of coronary artery perforation. Subjects and Methods:We retrospectively reviewed 3,782 consecutive PCIs, performed between January, 1994 and May, 2002 at the Samsung Medical Center, from the database records. The medical records and angiograms of the patients were also reviewed. The coronary artery perforations were classified according to Ellis’ classification. Results:A coronary artery perforation was noted in 24 patients (0.6%). It was most commonly observed during PCI of the right coronary artery (46%) and a chronic total occlusion intervention (42%). The number of the patients with Ellis’ classes I, II and III were 11, 8 and 5, respectively. The most frequent causes of the perforation were guidewire, followed by balloon (11 and 8 cases, respectively). The interventional modality with the highest risk of perforation in this study was rotational atherectomy, (4 out of 157, 2.6%). Five patients had cardiac tamponade, of which four occurred during a rotablator procedure. Pericardiocentesis was performed in 5 patients, while 3 patients with class III perforations received emergent coronary artery bypass surgery. There were no in-hospital mortalities, although the duration of the hospital stay for the class III patients was longer than those with classes I or II perforations. Conclusion:A coronary artery perforation during percutaneous coronary intervention is a potentially serious complication. However, the immediate and adequate management results in a fairly good prognosis. (Korean Circulation J 2003;33(4):277-283)

Background and Objectives:The impact on long-term adverse cardiac events of troponin T (TnT or creatine kinase-MB (CK-MB release after percutaneous transluminal coronary angioplasty (PTCA is not well defined. The purpose of the study is to evaluate the effect of elevated TnT or CK-MB on the late major adverse cardiac events (MACE;Q wave myocardial infarction (MI, revascularization, or cardiac death). Subjects and Methods:Study population were 207 consecutive patients (M:F=148:59, mean 60.8± 9.2 years who underwent PTCA. Patients with acute MI, unstable angina with abnormal levels of TnT or CK- MB, or newly developed Q MI after PTCA were excluded. Cardiac enzyme levels were measured before and 8, 24 hours after PTCA for CK-MB, and before and 16 hours after PTCA for TnT. Group I (n=181, 87.4% had normal levels of both after PTCA. Group II (n=26, 12.6% had abnormal levels of CK-MB (≥16 U/L and/or TnT (≥0.2 ng/mL. 1-year follow-up was available in 201 (97.1% patients. Results:Incidence of non-Q MI after PTCA was 26/207 (12.6%. Major complications such as acute coronary occlusion, side branch occlusion, and major dissection were significantly associated with elevation of TnT or CK-MB after PTCA (p=0.01. However, elevation of CK-MB or TnT was not significantly associated with late MACE by Kaplan-Meier survival curve (p=0.46. During 1-year follow-up, event free rate of group I and II were 76.6% and 69.2%, respectively. Conclusion:Acute coronary occlusion, side branch occlusion, or major dissection can increase the level of TnT or CK-MB after PTCA. But, elevation of CK-MB or TnT after PTCA dose not

Background and Objectives:The so-called 'stress-induced cardiomyopathy' or takotsubo cardiomyopathy, mimicking acute myocardial infarction (AMI, has recently been reported, particularly in Japan. We pro- spectively studied the clinical characteristics of, for the first time with a Korean series, this novel syndrome. Subjects and Methods:Eighteen patients, fore filling the inclusion criteria, were entered onto the study. The criteria for inclusion were:1 no previous history of cardiac disease, 2 acute onset, 3 a regional wall motion abnormality in the left ventriculogram, typically in the apical segment, and 4 no significant stenosis in the coronary angiogram. Results:The events preceding the condition included:emotional stress (N=7, acute illness (N=5, non-cardiac surgery or medical procedure (N=4 and accident (N=2. Chest pain, dyspnea, or nausea/vomiting were initially noted in 12 cases (66%. Pulmonary edema was demonstrated in 10 (56%, and cardiogenic shock in 4 (23% of the patients. The peak creatinine kinase MB fraction was 69±136 IU/L. A T wave inversion was noted in all patients, whereas, a Q wave was noted transiently in only 1. The average left ventricular ejection fraction (LVEF was 38±8% on the initial echocardiograms. On the left ventriculograms, 15 patients showed akinetic wall motion, or aneurysmal dilatation in the apical wall, however, notably in 3 patients in the mid-ventricular wall. The coronary vasospasm provocation tests were negative in all 10 patients tested. An intravascular ultrasonography showed no infarct-related plaques in the 4 patients examined. On a follow-up echocardiogram, the average LVEF was improved to 51±8%, and regional wall motion was normalized after 30±29 days following onset. Conclusion:We report, for the first time in a series of Korean patients, on a novel stress-induced cardiomyopathy with transient regional wall motion abnormality, mimicking AMI. The precise etiology remains to be elucidated in further studies. (Korean Circulation J 2002;32(12 :1054-1063