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Takotsubo syndrome (TS) is a reversible form of cardiomyopathy characterized by transient systolic dysfunction with regional wall motion abnormalities and absence of coronary artery obstruction, which can be precipitated by severe emotional or physical stress. Its clinical presentation is similar to that of acute coronary syndrome. However, TS presenting with atrioventricular (AV) block with ventricular asystole is rarely reported. In this article, we describe the case of a postmenopausal woman who experienced near cardiac arrest due to high-degree AV block. Although transthoracic echocardiography revealed left ventricular dysfunction with severe global hypokinesia, coronary angiography and cardiac magnetic resonance imaging showed normal coronary arteries without myocardial scarring. The patient's condition improved after permanent pacemaker implantation and medical treatment for heart failure. Echocardiography and pacemaker analysis at two-month follow-up revealed normalization of heart function and cardiac rhythm, and the patient was finally diagnosed with TS.

Inflammation plays an important role in the progression of peripheral artery disease (PAD). We investigated the predictive value of the C-reactive protein-to-albumin ratio (CAR) on the severity of PAD and outcomes after endovascular therapy (EVT). Patients (n = 307) with PAD who underwent EVT were retrospectively reviewed and categorized according to CAR tertiles. The groups were compared for the prevalence of complex lesions and multilevel involvement as well as the incidence of major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The rates of complex lesions and multilevel involvement increased with increasing CAR tertiles (all P < .001). These associations remained significant even after adjustment for other confounders (complex lesion odds ratio, 1.22 [1.03-1.50]; P = .036; multilevel disease odds ratio, 1.20 [1.01-1.44]; P = .041). The third CAR tertile showed a significantly higher incidence of MACEs and MALEs than the second and first tertiles within a year (log-rank P < .001). A higher CAR as a continuous variable was also independently associated with the 4-year rate of MACE (hazard ratio, 1.20 [1.04-1.38]; P = .015). Elevated CAR was a powerful surrogate marker of severe PAD and worse outcomes. Thus, CAR might become a predictor of poor prognosis in patients with PAD.

Only a few Asian studies have discussed the impact of statin intensity on clinical outcomes in patients with peripheral artery disease (PAD). We aimed to investigate the clinical impact of statin intensity in patients with PAD after endovascular revascularization.From April 2009 to June 2019, 376 patients with lower extremity PAD treated with endovascular revascularization were enrolled. They were classified into three groups according to statin intensity: no-statin, low-to-moderate intensity (LMI), and high-intensity (HI). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE).During the 40-month follow-up, MACE occurred less frequently in the HI and LMI groups than the no-statin group (11.4% vs. 16.0% vs. 39%,HI and LMI statin use is associated with a significant reduction in MACE events than no-statin use. HI statin use was associated with better MALE outcomes than no-statin or LMI statin use.

Background: The duration of antiplatelet therapy after endovascular revascularization in patients with lower-extremity artery disease (LEAD) has not been well-established. This study aimed to investigate the optimal strategy for antiplatelet therapy after successful endovascular revascularization in patients with LEAD. Methods: From April 2009 to June 2019, 376 patients with LEAD underwent successful endovascular revascularization. After the procedure, the patients received mono-antiplatelet therapy (MAPT) or dual-antiplatelet therapy (DAPT) of various durations and were classified into 2 groups (MAPT or DAPT < 6 months vs. DAPT ≥ 6 months). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE). The safety outcome was moderate-to-severe bleeding according to the Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria.Results: Over the 40-month follow-up period, MACE occurred less frequently in the DAPT ≥ 6 months group than the MAPT or DAPT < 6 months group (12.4% vs. 23.8%; hazard ratio: 0.62; 95% confidence interval: 0.40 to 0.97; p = 0.038) after inverse probability-weighted adjustment and propensity-score matching. The incidence of MALE showed no significant intergroup difference (17.1% vs. 13.1%; hazard ratio: 0.94; 95% confidence interval: 0.56 to 1.59; p = 0.822). The incidence of moderate-to-severe GUSTO bleeding also showed no significant intergroup difference (3.5% vs. 4.9%; hazard ratio: 0.59; 95% confidence interval: 0.21 to 1.63; p = 0.308). Conclusions: For patients with LEAD, DAPT for ≥6 months after endovascular revascularization was associated with a lower incidence of MACE without increasing the risk of bleeding events.

Clinical benefits of bioresorbable vascular scaffold (BVS) implantation for long coronary lesions were not sufficiently evaluated. The efficacy and safety of BVS and metallic everolimus-eluting stent (EES) were compared for the treatment of long coronary narrowings. A total of 341 patients with diffuse long lesions (requiring device length ≥28 mm) were randomized to receive either BVS (n = 171) or EES (n = 170) implantation. The primary endpoint was major adverse cardiovascular events which included death from cardiac cause, myocardial infarction, device thrombosis, or ischemia-driven target-lesion revascularization at 12 months. The trial was terminated early because the manufacturer stopped supplying BVS. The mean lesion length was 32.2 ± 13.1 mm in the BVS group and 35.3 ± 13.0 mm in the EES group. The 12-month follow-up was completed in 332 patients (97.4%). At 12 months, the primary endpoint events occurred in 2 patients (1.2%) in the BVS group and in 4 patients (2.4%) in the EES group (hazard ratio = 0.49, 95% confidence interval = 0.09 to 2.67, p = 0.398). Definite or probable device thrombosis occurred in 1 patient (0.6%) in the BVS group and 1 patient (0.6%) in the EES group (hazard ratio = 1.00, 95% confidence interval = 0.06 to 15.94, p = 0.998). In conclusion, in patients with long native coronary artery disease, significant differences between BVS and EES were not observed regarding the primary composite endpoint of death from cardiac cause, myocardial infarction, device thrombosis, or target-lesion revascularization at 12 months. However, due to the early termination of this trial and a low number of events, the results cannot be considered clinically relevant (clinicalTrials.gov Identifier: NCT02796157 ).

Aims Several studies have been reported using right ventricular (RV) strain as a method for evaluating RV function in patients with various cardiovascular diseases; however, the clinical relevance of RV strain in dilated cardiomyopathy (DCM) patients with sinus rhythm is unknown. The aim of this study was to investigate the relationship between RV strain and adverse events in DCM patients with sinus rhythm. Methods and results We enrolled 143 DCM patients with sinus rhythm who had been first diagnosed, evaluated, and followed at Sanggye Paik Hospital between March 2013 and August 2017. We performed echocardiography and measured RV strain values using the apical four-chamber view. The mean age was 64.6 years. During the median follow-up period of 40.0 months, adverse cardiovascular events developed in 21 patients (14.7%). By Cox proportional hazards multivariate analysis, only RV free wall longitudinal strain (RV-FWLS) independently predicted the primary outcome. Receiver-operating characteristic curve analysis showed that the optimal RV-FWLS cut-off value to identify patients with an event was −16.5% (area under the curve = 0.703, P = 0.003). When we divided the subjects into two groups based on the RV-FWLS of −16.5%, patients with RV-FWLS Conclusion RV-FWLS was associated with a significant prognostic impact in DCM patients with sinus rhythm.

Background We investigated whether the improvement in endothelial function, measured using flow-mediated dilatation (FMD), an important predictor of cardiovascular outcomes, was comparable in acute coronary syndrome (ACS) versus stable angina patients after percutaneous coronary intervention (PCI) and a six-month cardiac rehabilitation (CR) programme. Methods We analysed the results from 119 patients who completed a six-month CR programme after successful PCI for stable angina (n = 50) and ACS (n = 69). Results After six months of CR, the results of FMD were significantly improved in both groups. There were no significant between-group differences in the FMD results at the six-month follow up. Conclusions After successful PCI and a six-month CR programme, FMD values were equally improved in both stable angina and ACS patients.

Rational: Kallmann syndrome (KS) is a genetic gonadotropin-releasing hormone deficiency associated with hyposmia or anosmia and characterized by various modes of inheritance. Patient concerns: A 16-year-old male did not reach puberty and was associated with hypogonadotropic hypogonadism and anosmia. His magnetic resonance imaging of brain revealed the absence of the olfactory bulb. Diagnosis: His karyotype was 46 XY. Sanger sequencing of the KAL1 gene revealed no mutations. Diagnostic exome sequencing identified a prokineticin-receptor 2 (PROKR2) gene variant, c.337T > C (p.Tyr113His), previously reported to be a pathogenic mutation; we confirmed the presence of the mutation via Sanger sequencing of the coding exons of PROKR2. His apparently unaffected mother and sister, but not his father, were heterozygous for the PROKR2 Tyr113His mutation. Lessons: This work advances our understanding of the role played by PROKR signaling and the mode of inheritance of the gene in patients with KS.

Purpose: The prevalence and clinical outcomes of asymptomatic carotid artery stenosis (CAS) in patients with coronary artery disease (CAD) have not been thoroughly studied. We examined the prevalence and predictors of asymptomatic CAS detected by carotid angiography and determined the impact of concomitant CAS on prognosis in patients undergoing coronary angiography (CAG) due to CAD. Materials and methods: Between January 2013 and July 2015, 395 patients who underwent carotid digital subtraction angiography to screen for CAS during CAG were analyzed. The presence of CAS was defined as angiographically significant stenosis (≥50%). Major adverse cardiac and cerebrovascular event (MACCE) rates were compared between patients with and without CAS. MACCEs included a composite of cardiac death, cerebrovascular death, acute myocardial infarction, and stroke. Results: Of the 395 patients, 101 (25.5%) patients had significant CAS. The independent predictors of CAS were age, male sex, hypertension, diabetes, and multi-vessel disease. In patients with CAD, the presence of CAS was as an independent predictor for MACCEs after adjusting for confounding factors (hazard ratio 2.47, 95% confidence interval 1.16-5.24, p=0.018). Conclusion: Asymptomatic CAS was documented in up to 25% of patients with CAD. The presence of CAS in patients with CAD was associated with a higher rate of MACCEs. Therefore, detection of CAS by carotid angiography during CAG may be important for risk stratification for CAD patients, particularly those with multi-vessel disease.

Background: Early invasive approach is recommended for non-ST-segment elevation acute coronary syndromes (NSTE-ACS). However, recent guidelines propose early or deferred angiography within the routine invasive strategy. We sought to perform an updated meta-analysis to determine whether early invasive therapy improves clinical outcomes in patients with NSTE-ACS. Methods: Randomized controlled trials (RCTs) identified through search of MEDLINE, EMBASE, and the Cochrane databases (1991 through December 2012) and hand searching of cross references from original articles and reviews. Clinical trials that randomized NSTE-ACS patients to early invasive versus delayed invasive or more conservative approach were included for analysis. Major outcomes of death and myocardial infarction (MI) occurring from index hospitalization to the end of follow-up were extracted from published results of eligible studies. Secondary end points included the composite of death or MI; rehospitalization; recurrent angina; and repeat revascularization. The pooled effects were calculated using fixed-effects model (Mantel-Haenszel method) or random effects models (Dersimonian and Laird method). Results: A total of fifteen RCTs including 15,315 patients were included in this meta-analysis. No statistically significant differences in the risk of death (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.70–1.06, p=0.15) or MI (OR 0.92, 95% CI 0.74–1.13, p=0.41) were detected between early invasive group versus delayed invasive or conservative approach group. Early invasive strategy significantly reduced the risk of composite of death or MI (OR 0.82, 95% CI 0.70–0.96, p=0.02), rehospitalization (OR 0.80, 95% CI 0.72–0.89, p