2018년 대한부정맥학회 실신 평가 및 치료 지침 – 총론

박준범,차명진,김대혁,Yoo Ri Kim,문희선,배은정,서대원,송미경,안진희,윤희,이영수,천광진,이대인,김준수 대한부정맥학회 2018 International Journal of Arrhythmia Vol.19 No.2

Syncope is a very common symptom that occurs in all age groups, especially in adolescents and elderly people. The cause of syncope is very diverse, and patients with syncope visit various medical departments such as general medicine, cardiology, neurology, and emergency medicine. If we do not perform appropriate diagnostic tests based on detailed history of syncope, we may have some difficulty to identify the cause of syncope. Failure to identify the cause of syncope can lead to physical trauma due to recurrence of syncope or may increase the risk of cardiovascular events in the future. However, there is no Korean guidelines for the diagnosis and treatment of syncope yet. Considering these circumstances in Korea, we prepared writing and publishing committee for evaluation and management guidelines of syncope in the Korean Society for Holter and Noninvasive Electrocardiology (KSHNE) under the Korean Heart Rhythm Society (KHRS). In this guideline, we reviewed the Korean published literatures and European / American guidelines on syncope.

2018년 대한부정맥학회 실신 평가 및 치료 지침 – 각론

Yoo Ri Kim,천광진,김준수,문희선,박준범,서대원,송미경,안진희,윤희,이대인,이영수,차명진,배은정,김대혁 대한부정맥학회 2018 International Journal of Arrhythmia Vol.19 No.2

The general concept and initial approach to syncope patients has been mentioned in the general sections. This special sections have been described the characteristics, diagnosis, and treatment with patient education for the each syncope. It has been described in order of reflex syncope, orthostatic hypotension, postural orthostatic tachycardia syndrome (POTS), cardiac syncope, and unexplained syncope. Several clinical issues will have been dealt with in special issues. Neurological assessment is added when the patients were diagnosed with psychogenic pseudosyncope (PPS). Although many childhood syncope caused by reflex syncope, they are also presented as syncope caused by arrhythmic events in patients with congenital heart disease. In the elderly patients, syncope is because of not only a single cause of syncope but a combination of various conditions. In case of a syncope patient visiting the emergency department, a standardized systematic approach will be required to determine whether hospitalize the patient according to the risk of recurrence and the needs for the syncope management unit. We also mention recommendations on the limits of driving, exercising and social life style that are relevant to syncope in all patients. In this guideline, we reviewed the Korean published literatures and European/American guidelines on syncope. We, writing and publishing committee for evaluation and management guidelines of syncope in the Korean Society for Holter and Noninvasive Electrocardiography (KSHNE) under the Korean Heart Rhythm Society (KHRS) are very pleased to be able to publish this guideline. We also hope this guideline will be a good support to manage the syncope patients and a useful trigger for further research in Korea.

2018 대한부정맥학회 심실빈맥 전극도자 절제술 가이드라인 Part 1

노승영,김성환,김윤년,김주연,김준,김태훈,남기병,박경민,박형섭,박희남,배은정,오세일,윤남식,이만영,조영진,조용근,진은선,차태준,최종일,Yoo Ri Kim 대한부정맥학회 2018 International Journal of Arrhythmia Vol.19 No.2

Ventricular arrhythmias (VA) are a major cause of sudden cardiac death (SCD) in patients with known heart disease. Risk assessment and effective prevention of SCD are key issues in these patients. Implantable cardioverter defibrillator (ICD) insertion effectively treats sustained VA and reduces mortality in patients at high risk of SCD. Appropriate anti-arrhythmic drugs and catheter ablation reduce the VA burden and the occurrence of ICD shocks. In this guideline, authors have described the general examination and medical treatment of patients with VA. Medications and catheter ablation are also used as acute phase therapy for sustained VA.

2018 대한부정맥학회 심실빈맥 전극도자 절제술 가이드라인 Part 2

김주연,김성환,Yoo Ri Kim,김윤년,김준,김태훈,남기병,노승영,박경민,박형섭,박희남,배은정,오세일,윤남식,이만영,조영진,진은선,조용근,차태준,최종일 대한부정맥학회 2018 International Journal of Arrhythmia Vol.19 No.2

The recommendations outlined constitute the first clinical practice guidelines of the Korean Heart Rhythm Society regarding catheter ablation of ventricular arrhythmias (VA). This is a guideline PART 2, which includes VA in the structurally normal heart, inherited primary arrhythmia syndromes, VA related to congenital heart disease, as well as VA and sudden cardiac death observed in specific populations. In the structurally normal heart, treatment is guided by the occurrence of symptoms or the frequency of arrhythmias that cause ventricular dysfunction over time. Catheter ablation can be recommended in patients in whom anti-arrhythmic medications are ineffective. The sites of origin of arrhythmic activity are known to be the outflow tract, fascicles, papillary muscle, or the annulus. Specific cardiac channelopathies include congenital long QT and Brugada syndrome. This guideline discusses the diagnostic criteria, risk stratification, and treatment of these syndromes. We have included recommendations for adult congenital heart disease. Moreover, we have discussed the management of VA occurring in specific populations such as in patients with psychiatric and neurological disorders, pregnant patients, those with obstructive sleep apnea or drug-related pro-arrhythmias, athletes, and elderly patients.

2018 대한부정맥학회 심실빈맥 전극도자 절제술 가이드라인 Part 3

조영진,김성환,Yoo Ri Kim,김윤년,김주연,김태훈,남기병,노승영,박경민,박형섭,박희남,배은정,오세일,윤남식,이만영,조용근,진은선,차태준,최종일,김준 대한부정맥학회 2018 International Journal of Arrhythmia Vol.19 No.2

Treatment of ventricular arrhythmias (VA) usually involves managing the underlying cardiac conditions that cause the arrhythmia. However, managing the underlying disease is often challenging, and catheter ablation, or treatment targeting the VA itself might be required in a few patients. In this article, we explored evidence and recommendations regarding the treatment of VA in patients with structural heart disease focusing on the utilization of catheter ablation in these patients. The administration of optimal medical therapy, insertion of an implantable cardioverter-defibrillator, or resynchronization therapy improves survival in patients with left ventricular dysfunction. The role of catheter ablation in preventing sudden cardiac death remains uncertain in this population. In patients with coronary artery disease, reversing myocardial ischemia via revascularization is important in managing VA. Catheter ablation is recommended in patients with recurrent ventricular tachycardia in a setting of ischemic heart disease. In patients with non-ischemic cardiomyopathies such as dilated cardiomyopathy or hypertrophic cardiomyopathy, catheter ablation may be considered for those presenting with drug-refractory ventricular tachycardia.

Prognostic Value of Inferior Shift of P wave Axis after Catheter Ablation for Longstanding Persistent Atrial Fibrillation based on Dallas Lesion Set Including Anterior Line

신동금,김태훈,정현민,Alexander Kim,엄재선,정보영,이문형,Chun Hwang,박희남 대한부정맥학회 2017 International Journal of Arrhythmia Vol.18 No.2

Background and Objectives: Although an anterior linear ablation is an effective lesion set in radiofrequency catheter ablation (RFCA) for longstanding persistent atrial fibrillation (L-PeAF), its durability for bidirectional block (BDB) is only about 60% at repeat procedure. We hypothesized that changes in electrocardiogram (ECG) may predict an anterior line block state and the clinical outcome of L-PeAF ablation. Subjects and Methods: We studied 304 L-PeAF patients (77% male, 60±10yrs), who consistently underwent RFCA Dallas lesion set (circumferential pulmonary vein isolation, posterior box lesion, and anterior line) protocol with subsequent comparison of pre-procedural and post-procedural P wave axes, and one year follow-up (n=205) sinus rhythm (SR) ECGs. Results: 1. P wave axis shifted inferiorly at immediate post-procedure (p<0.001), and was independently correlated with BDB of anterior line (ß=10.4, 95% confidence interval [CI] 2.79–17.94, p=0.008). 2. The degree of post-procedural inferior shift of P wave axis did not reflect clinical recurrence within one-year (n=205, p=0.923), potentially due to conduction recovery of an anterior line. However, among 160 patients without clinical recurrence within one-year, P wave axis at one-year ECG was independently associated with very late recurrence of AF after one-year (n=160, hazard ratio [HR] 0.98; 95% CI 0.97–0.99, p=0.001), during 45.6±16.7 months of follow-up. 3. Among 22 patients who underwent repeat procedures, P wave axis shift was more significant in patients with maintained BDB of an anterior line than in those without (p=0.015). Conclusion: An inferior shift of P wave axis reflects the achievement and the maintenance of an anterior line BDB, and is associated with better long-term clinical outcome after catheter ablation for L-PeAF based on Dallas lesion set.

Design of Korean Noninvasive Risk Evaluation Study for Sudden Cardiac Death from Infarction or Heart Failure – Myocardial infarction study of K-REDEFINE registry -

박승정,황교승,남기병,박형욱,정중화,신승용,김상민,김준형,이영수,박예민,김종윤,김대혁,김대경,남궁준,신대희,최준혁,박형섭,최종일,김진석,차태준,박상원,엄재선,김남호,안민수,신동구,장누리,박미모,김준수 대한부정맥학회 2017 International Journal of Arrhythmia Vol.18 No.1

Background and Objectives: Despite significant advances in the treatment of acute myocardial infarction (MI), the prevention of sudden cardiac death (SCD), the most common mode of death in patients with MI, remains challenging. Furthermore, previous Korean MI registries did not address the issue of post-MI SCD. Additional risk stratifiers of post-MI SCD are still required to compensate for the limitation of using left ventricular ejection fraction to predict lethal arrhythmic events. Subjects and Methods: We designed the first Korean prospective nationwide multicenter registry primarily focused on SCD; the Korean noninvasive Risk Evaluation study for sudden cardiac DEath From INfarction or heart failurE (K-REDEFINE). The registry consists of 2 groups of patients presenting with (1) acute MI or (2) acute heart failure (HF) at 25 tertiary referral cardiovascular centers. The primary endpoint of the MI group study of K-REDEFINE registry is the incidence and risk factors of post-MI SCD. In particular, the association between the risk of SCD and non-invasive Holter-based electrocardiogram (ECG) variables will be evaluated, such as T-wave alternans (marker of repolarization heterogeneity) and heart rate tur-bulence/variability (a marker of autonomic function). Other secondary study outcomes include atrioventricular arrhythmias, HF-related admission, repeated myocardial ischemic events, stroke, and overall deaths. Conclusion and Perspective: The K-REDEFINE registry will provide new prospects for the better management of MI patients with high risk of SCD by clarifying the burden and predictors of SCD and the clinical utility of various non-invasive ambulatory ECG-based variables in risk stratification for SCD in this patient population.

Chronic Obstructive Pulmonary Disease Increases the Risk of New-onset Atrial Fibrillation and Mortality of Patients with Atrial Fibrillation

송신정,양필성,김태훈,엄재선,박희남,이문형,정보영 대한부정맥학회 2017 International Journal of Arrhythmia Vol.18 No.4

Background: Although a few previous studies have analyzed the role of reduced lung function in predicting atrial fibrillation (AF), the relationship between the incidence of AF and comorbid chronic obstructive pulmonary disease (COPD) is unclear. We hypothesized that COPD is associated with the occurrence of new-onset AF and clinical outcomes in AF patients. Methods: We analyzed the development of new-onset AF in 501,668 patients without AF and clinical outcomes in 4,541 patients with AF using Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC). Results: Comorbid COPD was found in 4.8% (11,442 of 501,668) of non-AF patients and 18.6% (820 of 4,541) of AF patients. The incidence of AF in COPD patients was significantly higher compared to non-COPD patients (2.6% vs. 0.6%, p<0.001) over the follow-up period (45.5±14.9 months). In a multivariate Cox regression analysis, COPD predicted higher risk of AF independently from other risk factors (HR: 1.41, 95% CI: 1.25-1.60, p<0.001). The all-cause mortality of AF patients with COPD was significantly higher in patients who used b-blockers (20.6% vs 13.1% during follow-up, p<0.008). Multivariate Cox regression analysis showed that COPD is still an independent risk factor for all-cause mortality (HR: 1.25, 95% CI: 1.03-1.51, p=0.022), and stroke (HR: 1.19, 95% CI: 1.00- 1.41, p=0.039). Conclusion: The presence of COPD is an independent risk factor for new-onset AF. COPD is independently associated with all-cause mortality and stroke in AF patients.

Prevalence of Atrial Fibrillation in Korean Population

이소령,최의근 대한부정맥학회 2017 International Journal of Arrhythmia Vol.18 No.4

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and has been a major public health problem. The prevalence of AF globally has been reported to range from 0.4% to 2% in the adult population; however, the prevalence widely varies depending on the study population. Although AF prevalence in Asian population is about 1% lower than that in European and North American population, the number of AF patients in Asia is rapidly increasing concomitant with the increased aging of the population. However, previous studies that reported AF epidemiology in the Korean population are limited. According to a recent report based on the national health claims database, prevalence of AF in 2015 was 0.7% in the entire Korean adult population and showed a continuous increase with population aging. Additionally, among patients with AF, mean CHA2DS2-VASc score was significantly increased and the number of high thromboembolic risk patients has increased over time. Although oral anticoagulation (OAC) prescription in AF patients increased from 35% to 51%, especially after introduction of non-vitamin K antagonist anticoagulants, a substantial proportion of Korean patients with AF still remain undertreated. In this review, we aimed to summarize temporal changes in the prevalence and incidence of AF and to evaluate the thromboembolic risk in patients with AF. In addition, we also discussed the utilization of OAC therapy in patients with AF in Korean population.

ST segment

곽충환 대한부정맥학회 2017 International Journal of Arrhythmia Vol.18 No.2

The ST segment corresponds to the plateau phase of ventricular repolarization, i.e., phase 2 of the action potential. Heightened awareness of the characteristic patterns of ST segment changes is vital to quickly identifying life-threatening disorders. The differential diagnosis of ST segment elevation includes four major processes: ST segment elevation myocardial infarction (STEMI); early repolarization; pericarditis; and ST elevation secondary to an abnormality of the QRS complex (left bundle branch block, left ventricular hypertrophy, or preexcitation). Other processes that may be associated with ST elevation include hyperkalemia, pulmonary embolism, and Brugada syndrome. Two particular patterns of ST segment depression reflect STEMI rather than non-ST-segment elevation acute coronary syndrome: ST segment depression that is reciprocal to a subtle and sometimes overlooked ST-segment elevation, and ST segment depression that is maximal in leads V1-V3, suggesting true posterior infarction. The clinical setting and specific electrocardiographic criteria often allow identification of the cause.