Cost-Effectiveness of Rivaroxaban Compared to Warfarin for Stroke Prevention in Atrial Fibrillation

Kim, Hyunmee,Kim, Hyeongsoo,Cho, Seong-Kyung,Kim, Jin-Bae,Joung, Boyoung,Kim, Changsoo The Korean Society of Cardiology 2019 Korean Circulation Journal Vol.49 No.3

<P><B>Background and Objectives</B></P><P>Rivaroxaban is noninferior to warfarin for preventing stroke or systemic embolism in patients with high-risk atrial fibrillation (AF) and is associated with a lower rate of intracranial hemorrhage (ICH). We assessed the cost-effectiveness of rivaroxaban compared to adjusted-dose warfarin for the prevention of stroke in patients with nonvalvular AF.</P><P><B>Methods</B></P><P>We built a Markov model using the Korean Health Insurance Review & Assessment Service database. The base-case analysis assumed a cohort of patients with prevalent AF who were aged 18 years or older without contraindications to anticoagulation.</P><P><B>Results</B></P><P>Number of patients with CHA<SUB>2</SUB>DS<SUB>2</SUB>-VASc scores 0, 1 and ≥2 were 56 (0.2%), 1,944 (6.3%) and 28,650 (93.5%), respectively. In patients with CHA<SUB>2</SUB>DS<SUB>2</SUB>-VASc scores ≥2, the incidence rate of ischemic stroke was 3.11% and 3.76% in warfarin and rivaroxaban groups, respectively. The incidence rates of ICH were 0.42% and 0.15%, and those of gastrointestinal bleeding were 0.32% and 0.15% in warfarin and rivaroxaban, respectively. Patients with AF treated with rivaroxaban lived an average of 11.8 quality-adjusted life years (QALYs) at a lifetime treatment cost of $20,886. Those receiving warfarin lived an average of 11.4 QALYs and incurred costs of $17,151. Patients with rivaroxaban gained an additional 0.4 QALYs over a lifetime with an additional cost of $3,735, resulting in an incremental cost-effectiveness ratio of $9,707 per QALY.</P><P><B>Conclusions</B></P><P>Patients who had been treated with rivaroxaban may be a cost-effective alternative to warfarin for stroke prevention in Korean patients with AF.</P>

Clinical Characteristics of Korean Patients with Bicuspid Aortic Valve Who Underwent Aortic Valve Surgery

Sun, Byung Joo,Jin, Xin,Song, Jae-Kwan,Lee, Sahmin,Lee, Ji Hye,Park, Jun-Bean,Lee, Seung-Pyo,Kim, Dae-Hee,Park, Sung-Ji,Kim, Yong-Jin,Cho, Goo-Yeong,Song, Jong-Min,Kang, Duk-Hyun,Sohn, Dae-Won The Korean Society of Cardiology 2018 Korean Circulation Journal Vol.48 No.1

<P><B>Background and Objectives</B></P><P>Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited.</P><P><B>Methods</B></P><P>Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters.</P><P><B>Results</B></P><P>Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p<0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p<0.001).</P><P><B>Conclusion</B></P><P>BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.</P>

Clinical Characteristics and Outcomes of Acute ST-Segment Elevation Myocardial Infarction in Younger Korean Adults

Lee, Seung Hun,Kim, Ju Han,Jeong, Myung Ho,Park, Hyukjin,Jeong, Yun Ah,Ahn, Youngkeun,Kim, Jong Hyun,Chae, Shung Chull,Kim, Young Jo,Hur, Seung Ho,Seong, In Whan,Hong, Taek Jong,Choi, Donghoon,Cho, My The Korean Society of Cardiology 2015 Korean Circulation Journal Vol.45 No.4

<P><B>Background and Objectives</B></P><P>This study aims to investigate the clinical features, angiographic findings, and outcomes of younger Korean ST-segment elevation myocardial infarction (STEMI) patients.</P><P><B>Subjects and Methods</B></P><P>We analyzed major adverse cardiac events (MACE) in the Korea Acute Myocardial Infarction Registry from November 2005 to October 2010. The registered patients were divided into two groups; young age group (<65 years) and old age group (≥65 years).</P><P><B>Results</B></P><P>The young age group included 5281 patients (age, 53±7.8 years), and the old age group included 4896 patients (age, 74.3±6.5 years). Male gender, smoking, family history, dyslipidemia, and metabolic syndrome were more frequently observed in the young age group than in the old age group (89.5% vs. 59.3%, p<0.001; 77.3% vs. 47.2%, p<0.001; 11% vs. 4.6%, p<0.001; 11.2% vs. 7.7%, p<0.001; 67.6% vs. 62.9%, p<0.001). Most of the young Korean adults with STEMI complained of typical chest pain (89.8%), and they had a shorter symptom-to-door time (12±53.2 hours vs. 17.3±132 hours, p=0.010). The young age group showed a favorable prognosis, which was represented by the MACE, compared with the old age group at one month (1.8% vs. 2.8%, p=0.028), six months (6.8% vs. 8.2%, p<0.001), and twelve months (10.1% vs. 11.9%, p=0.025). However, there was no significant difference in the adjusted MACE rate at one month {hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.60-1.51, p=0.828} and twelve months (HR 0.86, 95% CI 0.68-1.10, p=0.233).</P><P><B>Conclusion</B></P><P>Younger Korean adults with STEMI have clinical outcomes similar to old aged patients, and therefore, they should be treated intensively like the elderly patients.</P>

Comparison between Right and Left Upper Arms in Detection of Hypertension

Song, Bo Mi,Kim, Hyeon Chang,Shim, Jee-Seon,Kang, Dae Ryong The Korean Society of Cardiology 2019 Korean Circulation Journal Vol.49 No.3

<P><B>Background and Objectives</B></P><P>This study aimed to investigate the right-left arm difference in detection of hypertension in the general Korean population.</P><P><B>Methods</B></P><P>This study analyzed data from the Cardiovascular and Metabolic Disease Etiology Research Center cohort. Study population was 2,103 people who were aged 30 to 64 years old, without history of major cardiovascular diseases, and did not use antihypertensive medication. Brachial blood pressures (BPs) were measured for both arms using an automated oscillometric device equipped with 2 cuffs for simultaneous double-arm measurements. Systolic and diastolic blood pressures (SBP and DBP) were measured 3 times, and the average value was used in the analysis. Overall hypertension was defined as elevated blood pressure (SBP/DBP ≥140/90 mmHg) at the arm with higher value, while right-arm or left-arm hypertension was defined as elevated BP at each arm. Sensitivity was calculated as the number of each-arm hypertension divided by the number of overall hypertension.</P><P><B>Results</B></P><P>Overall 8.6% of the population had hypertension at either arm, while 7.8% had right-arm hypertension, 7.2% had left-arm hypertension, and 6.4% had both arms hypertension. The sensitivity for the detection of hypertension was 90.6% when BP was measured only at right arm, and 83.4% when measured only at left arm. Corresponding sensitivity were 87.9% and 87.1% in men, and 95.4% and 76.9% in women.</P><P><B>Conclusions</B></P><P>Single-arm measurements, compared to double-arm measurements, may underestimate the prevalence of hypertension. However, if double-arm measurements are unavailable, right arm is preferred for measurement of BP, especially in women.</P>

Prevalence of Non-valvular Atrial Fibrillation Based on Geographical Distribution and Socioeconomic Status in the Entire Korean Population

Lee, So-Ryoung,Choi, Eue-Keun,Han, Kyungdo,Cha, Myung-Jin,Oh, Seil The Korean Society of Cardiology 2018 Korean Circulation Journal Vol.48 No.7

<P><B>Background and Objectives</B></P><P>Prevalence of atrial fibrillation (AF) varies based on geographical location and socioeconomic status. We aimed to evaluate the prevalence of AF and utilization of antithrombotic therapy based on geographical regions and income levels in the entire Korean population.</P><P><B>Methods</B></P><P>We performed a cross-sectional analysis of Korean adults (aged ≥20 years) using the 2015 National Health Insurance Service database (n=41,505,679). The study population was stratified into 17 geographical regions and 21 income levels.</P><P><B>Results</B></P><P>We identified 276,842 patients diagnosed with AF. Overall prevalence of AF in suburban/rural regions was significantly higher than that observed in urban regions (0.72% vs. 0.61%, respectively, p<0.001). Elderly patients (age ≥75 years) showed a higher prevalence of AF and comorbidities related to AF development showed a higher prevalence among the population residing in suburban/rural regions. Among AF patients with a CHA<SUB>2</SUB>DS<SUB>2</SUB>-VASc score ≥2, oral anticoagulation (OAC) therapy utilization was lower in the suburban/rural regions than that observed in the urban regions (48.2% vs. 51.8%, respectively, p<0.001). The relationship between income levels and AF prevalence showed a J-shaped curve. The OAC prescription rate showed a positive correlation with income levels. Non-vitamin K antagonist oral anticoagulants tended to be more commonly prescribed among the higher income groups.</P><P><B>Conclusions</B></P><P>Geographical location of residence and income levels were closely associated with the prevalence of AF and antithrombotic therapy utilization. This information may provide further insights for more effective surveillance of AF and stroke prevention for improved clinical outcomes.</P>

The Prevalence, Awareness and Treatment of High Low Density Lipoprotein-Cholesterol in Korean Adults Without Coronary Heart Diseases - The Third Korea National Health and Nutrition Examination Survey, 2005 -

Choi, Sun-Ja,Park, Sung-Hee,Lee, Kwang-Soo,Park, Hyun-Young The Korean Society of Cardiology 2012 Korean Circulation Journal Vol.42 No.2

<P><B>Background and Objectives</B></P><P>The purpose of this study was to estimate the prevalence, awareness and treatment of high low density lipoprotein-cholesterol (LDL-C) level in Korean adults without coronary heart disease.</P><P><B>Subjects and Methods</B></P><P>National representative cross-sectional surveys, data of 5248 Korean adults (2246 men and 3002 women) aged between 20 and 79 years from the Third Korea National Health and Nutrition Examination Survey (KNHANES III, 2005) was used. High LDL-C level was defined with the risk prediction algorithm published by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III).</P><P><B>Results</B></P><P>The prevalence of the Korean adults with high LDL-C level who need therapeutic lifestyle changes was 19.9%, treatment with lipid-lowing medication was 2.1% and awareness of this condition was 7.9%. Meanwhile, the prevalence of the Korean with very high LDL-C level who should be considered for drug therapy was 13.5%, treatment with lipid-lowing medication was 2.7% and awareness of this condition was 8.1%. Overall, 47.9% (60.3% in male and 39.1% in female) of participants had a single lipid disorder (high LDL-C, high triglycerides: ≥200 mg/dL, low high density lipoprotein-cholesterol: <40 mg/dL), whereas 15.5% (23.5% in male and 9.7% in female) had at least two. Only 1.9% (2.8% in male and 1.2% in female) of all participants had all three lipid abnormalities as defined.</P><P><B>Conclusion</B></P><P>These findings indicate that continuous efforts are needed to increase awareness and treatment of high LDL-C level in our population to prevent cardiovascular disease.</P>

Tumor Suppressor Serine/Threonine Kinase LKB1 Expression, Not Kinase Activity, Increased in the Vascular Smooth Muscle Cells and Neointima in the Rat Carotid Artery Injury Model

Jeong, Jin-Ok,Kim, Jeong-Hee,Ahn, Kye-Taek,Park, Hyung Seo,Jang, Won Il,Park, Jae-Hyeong,Lee, Jae-Hwan,Choi, Si Wan,Kim, Jin Man,Seong, In-Whan The Korean Society of Cardiology 2010 Korean Circulation Journal Vol.40 No.11

<P><B>Background and Objectives</B></P><P>Vascular smooth muscle cell (VSMC) proliferation is responsible for the restenosis of previously inserted coronary stents. Angiotensin II (Ang II) is known to regulate VSMC proliferation. LKB1, a serine/threonine kinase, interacts with the p53 pathway and acts as a tumor suppressor.</P><P><B>Materials and Methods</B></P><P>We assessed the association of Ang II and the expression of LKB1 in primary cultured murine VSMCs and neointima of the Sprague Dawley rat carotid artery injury model. We created carotid balloon injuries and harvested the injured carotid arteries 14 days after the procedure.</P><P><B>Results</B></P><P>Ang II increased LKB1 expression in a time-dependent manner and peaked at an Ang II concentration of 10<SUP>-7</SUP> mole/L in VSMCs. In the animal experiment, neointima was markedly increased after balloon injury compared to the control group. Immunohistochemical studies showed that LKB1 expression increased according to neointima thickness. Ang II augmented LKB1 expression after the injury. Western blot analysis of LKB1 with carotid artery lysate revealed the same pattern as LKB1 immunohistochemistry. Increased LKB1 expression started at 5 days after the balloon injury, and peaked at 14 days after the injury. Although LKB1 expression was increased after the injury, LKB1 kinase activity was not increased. Ang II or balloon-injury increased the expression of LKB1 although the LKB1 activity was reduced.</P><P><B>Conclusion</B></P><P>Ang II increased LKB1 expression in VSMCs and neointima. These findings were not kinase dependant.</P>

Kawasaki Disease Presenting as Parotitis in a 3-Month-Old Infant

Do, Hyun-Jeong,Baek, Jong-Geun,Kim, Hyun-Jung,Yeom, Jung-Sook,Park, Ji-Sook,Park, Eun-Sil,Seo, Ji-Hyun,Lim, Jae-Young,Park, Chan-Hoo,Woo, Hyang-Ok,Youn, Hee-Shang The Korean Society of Cardiology 2009 Korean Circulation Journal Vol.39 No.11

<P>A male infant aged 3 months and 1 week had persistently high fever with parotitis that was unresponsive to antibiotics. Mumps was identified by serologic study, but he was finally diagnosed by clinical features as having Kawasaki disease and echocardiographic findings on the 9th day of fever. Parotitis, which is unresponsive to antibiotics, should be considered Kawasaki disease even though typical symptoms are not present.</P>

miR-18a-5p MicroRNA Increases Vascular Smooth Muscle Cell Differentiation by Downregulating Syndecan4

Kee, Hae Jin,Kim, Gwi Ran,Cho, Soo-Na,Kwon, Jin-Sook,Ahn, Youngkeun,Kook, Hyun,Jeong, Myung Ho The Korean Society of Cardiology 2014 Korean Circulation Journal Vol.44 No.4

<P><B>Background and Objectives</B></P><P>Differentiation and de-differentiation of vascular smooth muscle cells (VSMCs) are important events in atherosclerosis and restenosis after angioplasty. MicroRNAs are considered a key regulator in cellular processes such as differentiation, proliferation, and apoptosis. Here, we report the role of new miR-18a-5p microRNA and its downstream target genes in VSMCs and in a carotid balloon injury model.</P><P><B>Materials and Methods</B></P><P>Expression of miR-18a-5p and its candidate genes was examined in VSMCs and in a carotid artery injury model by quantitative reverse-transcription polymerase chain reaction (qRT-PCR) and microRNA microarray analysis. VSMC differentiation marker genes including smooth muscle (SM) α-actin and SM22α were determined by Western blot, qRT-PCR, and a SM22α promoter study. Gene overexpression or knockdown was performed in VSMCs.</P><P><B>Results</B></P><P>miR-18a-5p was upregulated in the rat carotid artery at the early time after balloon injury. Transfection of the miR-18a-5p mimic promoted the VSMC differentiation markers SM α-actin and SM22α. In addition, miR-18a-5p expression was induced in differentiated VSMCs, whereas it decreased in de-differentiated VSMCs. We identified syndecan4 as a downstream target of miR-18-5p in VSMCs. Overexpression of syndecan4 decreased Smad2 expression, whereas knockdown of syndecan4 increased Smad2 expression in VSMCs. Finally, we showed that Smad2 induced the expression of VSMC differentiation marker genes in VSMCs.</P><P><B>Conclusion</B></P><P>These results indicate that miR-18a-5p is involved in VSMC differentiation by targeting syndecan4.</P>

Dyslipidemia, Low Left Ventricular Ejection Fraction and High Wall Motion Score Index Are Predictors of Progressive Left Ventricular Dilatation After Acute Myocardial Infarction

Yoon, Hyun Ju,Jeong, Myung Ho,Bae, Jang Ho,Kim, Kye Hun,Ahn, Youngkeun,Cho, Jeong Gwan,Park, Jong Chun,Kang, Jung Chaee The Korean Society of Cardiology 2011 Korean Circulation Journal Vol.41 No.3

<P><B>Background and Objectives</B></P><P>Left ventricular (LV) remodeling is a heterogeneous process, involving both infarcted and non-infarcted zones, which affects wall thickness and chamber size, shape and function.</P><P><B>Subjects and Methods</B></P><P>A total of 758 consecutive patients (62.8±12.0 years, 539 males) with acute myocardial infarction (AMI), who were examined by echocardiography at admission and after 6 months. An increase in LV end-diastolic volume index >10% was defined as a progressive LV dilation. They were divided into two groups according to the extent of progressive LV dilatation during 6 months. Group I with progressive LV dilatation (n=154, 61.4±11.0 years, 110 males) vs. group II without LV dilatation (n=604, 64.1±12.0 years, 429 males).</P><P><B>Results</B></P><P>The age and gender were no significant differences between two groups. The levels of glucose, creatinine, maximal creatine kinase (CK), CK-MB, troponin T and I were significantly increased in group I than in group II (p<0.05). Low ejection fraction (EF) and high wall motion score index (WMSI) were more common in group I than in group II (p<0.05). The presence of dyslipidemia {odds ratio (OR); 1.559, confidence interval (CI); 1.035-2.347, p=0.03}, low EF less than 45% (OR; 3.328, CI 2.099-5.276, p<0.01) and high WMSI above 1.5 (OR; 3.328, CI 2.099-5.276, p<0.01) were sig-nificant independent predictors of progressive LV dilatation by multivariate analysis.</P><P><B>Conclusion</B></P><P>Dyslipidemia, decreased systolic function and high WMSI were independent predictors of LV remodeling process in patients with AMI.</P>