We compared the efficacy and safety of low-intensity atorvastatin and ezetimibe combination therapy with moderate-intensity atorvastatin monotherapy in patients requiring cholesterol-lowering therapy.At 19 centers in Korea, 290 patients were randomized to 4 groups: atorvastatin 5 mg and ezetimibe 10 mg (A5E), ezetimibe 10 mg (E), atorvastatin 5 mg (A5), and atorvastatin 10 mg (A10). Clinical and laboratory examinations were performed at baseline, and at 4-week and 8-week follow-ups. The primary endpoint was percentage change from baseline in low-density lipoprotein (LDL) cholesterol levels at the 8-week follow-up. Secondary endpoints included percentage changes from baseline in additional lipid parameters.Baseline characteristics were similar among the study groups. At the 8-week follow-up, percentage changes in LDL cholesterol levels were significantly greater in the A5E group (49.2%) than in the E (18.7%), A5 (27.9%), and A10 (36.4%) groups. Similar findings were observed regarding the percentage changes in total cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B levels. Triglyceride levels were also significantly decreased in the A5E group than in the E group, whereas high-density lipoprotein levels substantially increased in the A5E group than in the E group. In patients with low- and intermediate-cardiovascular risk, 93.3% achieved the target LDL cholesterol levels in the A5E group, 40.0% in the E group, 66.7% in the A5 group, and 92.9% in the A10 group. In addition, 31.4% of patients in the A5E group, 8.1% in E, 9.7% in A5, and 7.3% in the A10 group reached the target levels of both LDL cholesterol < 70 mg/dL and reduction of LDL ≥ 50% from baseline.The addition of ezetimibe to low-intensity atorvastatin had a greater effect on lowering LDL cholesterol than moderate-intensity atorvastatin alone, offering an effective treatment option for cholesterol management, especially in patients with low and intermediate risks.
The use of a single abnormal finding on electrocardiography (ECG) is not recommended for stratifying the risk of cardiovascular (CV) events in low-risk general populations because of its low discriminative power. However, the value of a scoring system containing multiple abnormal ECG findings for predicting CV death has not been sufficiently evaluated. In a prospective community-based cohort study, 8417 participants without atherosclerotic CV diseases (ASCVDs) and any related symptoms were followed for 18 years. The standard 12-lead ECGs were recorded at baseline and the ECG findings were categorized using the Minnesota code classification. CV deaths were defined as death from myocardial infarction (MI), chronic ischemic heart disease, heart failure, fatal arrhythmia, cerebrovascular event, pulmonary thromboembolism, peripheral vascular disease and sudden cardiac arrest and identified using the Korean National Statistical Office (KOSTAT) database. In a multivariate Cox proportional hazard (CPH) model, major and minor ST-T wave abnormalities, atrial fibrillation (AF), Q waves in the anterior leads, the lack of Q waves in the posterior leads, high amplitudes of the left and right precordial leads, left axis deviation and sinus tachycardia were associated with higher risks of CV deaths. The ECG score consisted of these findings showed modest predictive values represented by C-statistics that ranged from 0.632 to 760 during the follow-up and performed better in the early follow-up period. The ECG score independently predicted CV death after adjustment for relevant covariates in a multivariate model, and improved the predictive performance of the 10-year ASCVD risk estimator and a model of conventional risk factors including age, diabetes and current smoking. The combined ECG score (Harrell’s C-index: 0.852, 95% confidence interval [CI], 0.828–0.876) composed of the ECG score and the conventional risk factors outperformed the 10-year ASCVD risk estimator (Harrell’s C-index: 0.806; 95% CI, 0.780–0.833) and the model of the conventional risk factors (Harrell’s C-index: 0.841, 95% CI, 0.817–0.865) and exhibited an excellent goodness of fit between the predicted and observed probabilities of CV death. The ECG score could be useful to predict CV death independently and may add value to the conventional CV risk estimators regarding the risk stratification of CV death in asymptomatic low-risk general populations. The ECG score based on the Minnesota code classification can independently predict CV death and significantly improve the predictive power of the conventional CV risk estimators in asymptomatic low-risk general population.The combined ECG score comprised the ECG score, age and the presence of diabetes and current smoking predicted CV mortality more accurately than the conventional SV risk estimators.ECG may still be a viable CV risk stratification tool for population-based health screening projects. The ECG score based on the Minnesota code classification can independently predict CV death and significantly improve the predictive power of the conventional CV risk estimators in asymptomatic low-risk general population. The combined ECG score comprised the ECG score, age and the presence of diabetes and current smoking predicted CV mortality more accurately than the conventional SV risk estimators. ECG may still be a viable CV risk stratification tool for population-based health screening projects.
Abstract Home blood pressure (HBP) is useful to decide whether blood pressure (BP) is controlled. However, applying HBP to daily clinical practices is still challenging without easy access to the average HBP. Therefore, we developed a simple method to make a binary decision for the control of HBP through high BP counts. We simulated 100 cases of HBP series for each combination of 3 numbers of BP readings ( K = 16, 20, 24) and 4 levels of the standard deviations (SDs = 5, 10, 15, 20). A high BP was defined as an individual BP ≥ 135/85 mmHg, and an uncontrolled HBP was defined as a mean HBP ≥ 135/85 mmHg. Validation for the decision method was conducted using actual HBP data. The C-statistics and the accuracy of the high BP counts for the uncontrolled HBP were generally high (> 0.85) for all combinations of K s and SDs but decreased as SDs increased but remained steady as K s increased. In the validation, the C-statistic of the high BP count-to-total BP reading (C-T) ratio was 0.985, and a C-T ratio ≥ 0.5 showed a sensitivity of 0.957, a specificity of 0.907 and an accuracy of 0.927. The count-based decision method can provide an accurate quick assessment of the controlledness of HBP.
Cardiogenic unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed at first.Most cases of cardiogenic UPE occur in the right upper lobe and are caused by severe mitral regurgitation (MR).We present an unusual case of right-sided UPE in a patient with cardiogenic shock due to acute myocardial infarction (AMI) without severe MR.The patient was successfully treated by percutaneous coronary intervention and medical therapy for heart failure.Follow-up chest Radiography showed complete resolution of the UPE.This case reminds us that AMI can present as UPE even in patients without severe MR or any preexisting pulmonary disease affecting the vasculature or parenchyma of the lung.
Abstract Home blood pressure (HBP) is useful to decide whether blood pressure (BP) is controlled. However, applying HBP to daily clinical practices is still challenging without easy access to the average HBP. Therefore, we developed a simple method to make a quick decision regarding the controlledness of HBP through high BP counts. We simulated 100 cases of HBP series for each combination of 3 numbers of BP readings ( K = 16, 20, 24) and 4 levels of the standard deviations (SDs = 5, 10, 15, 20). A high BP was defined as an individual BP ≥ 135/85 mmHg, and an uncontrolled HBP was defined as a mean HBP ≥ 135/85 mmHg. Validation for the decision method was conducted using actual HBP data. The C-statistics and the accuracy of the high BP counts for the uncontrolled HBP were generally high (> 0.85) for all combinations of K s and SDs and decreased as SDs increased but remained steady as K s increased. In validation, the C-statistic of the high BP count-to-total BP reading (C/T) ratio was 0.985, and the C/T ratio ≥ 0.5 showed a sensitivity of 0.957, a specificity of 0.907, and an accuracy of 0.927. The count-based decision method can provide an accurate quick assessment of the controlledness of HBP.
Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.
BackgroundAtrial fibrillation (AF) patients are at high risk of stroke with ∼90% clots originating from the left atrial appendage (LAA). Clinical understanding of blood-flow based parameters and their potential association with stroke for AF patients remains poorly understood. We hypothesize that slow blood-flow either in the LA or the LAA could lead to the formation of blood clots and is associated with stroke for AF patients.MethodsWe retrospectively collected cardiac CT images of paroxysmal AF patients and dichotomized them based on clinical event of previous embolic event into stroke and non-stroke groups. After image segmentation to obtain 3D LA geometry, patient-specific blood-flow analysis was performed to model LA hemodynamics. In terms of geometry, we calculated area of the pulmonary veins (PVs), mitral valve, LA and LAA, orifice area of LAA and volumes of LA and LAA and classified LAA morphologies. For hemodynamic assessment, we quantified blood flow velocity, wall shear stress (WSS, blood-friction on LA wall), oscillatory shear index (OSI, directional change of WSS) and endothelial cell activation potential (ECAP, ratio of OSI and WSS quantifying slow and oscillatory flow) in the LA as well as the LAA. Statistical analysis was performed to compare the parameters between the groups.ResultsTwenty-seven patients were included in the stroke and 28 in the non-stroke group. Examining geometrical parameters, area of left inferior PV was found to be significantly higher in the stroke group as compared to non-stroke group (p = 0.026). In terms of hemodynamics, stroke group had significantly lower blood velocity (p = 0.027), WSS (p = 0.018) and higher ECAP (p = 0.032) in the LAA as compared to non-stroke group. However, LAA morphologic type did not differ between the two groups. This suggests that stroke patients had significantly slow and oscillatory circulating blood-flow in the LAA, which might expose it to potential thrombogenesis.ConclusionSlow flow in the LAA alone was associated with stroke in this paroxysmal AF cohort. Patient-specific blood-flow analysis can potentially identify such hemodynamic conditions, aiding in clinical stroke risk stratification of AF patients.
Heart rate (HR) control is a mainstay of atrial fibrillation (AF) management. Guidelines recommend first-line β-blockers for HR control in paroxysmal, persistent, or permanent AF.1January C.T. Wann S. Alpert J.S. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2014; 64: e1-e76Crossref PubMed Scopus (3017) Google Scholar Carvedilol, a non-selective β-blocker, has a documented HR-lowering effect; in a dose-escalation study of Japanese patients with chronic AF (AF Carvedilol study), each dose of carvedilol (5, 10 or 20 mg, once daily) significantly reduced HR from baseline (HR ≥80 bpm) during 6 weeks of treatment.2Inoue H. Atarashi H. Okumura K. et al.Heart rate control by carvedilol in Japanese patients with chronic atrial fibrillation: The AF Carvedilol study.J Cardiol. 2017; 69: 293-301Abstract Full Text Full Text PDF PubMed Google Scholar Although off-label carvedilol indications include AF,3Singh S. Carvedilol. 2022; Accessed February 23, 2024. https://www.statpearls.com/ArticleLibrary/viewarticle/102Google Scholar there are currently no phase 3 clinical trial data to support carvedilol use for HR control in patients with AF. We report results from a phase 3, multicenter, randomized, double-blind, placebo-controlled trial of patients with persistent or permanent AF treated with once-daily carvedilol (Dilatrend® SR Capsule, Chong Kun Dang Pharmaceutical, Seoul, Republic of Korea) 8, 16 or 32 mg for 6 weeks (NCT03950843). Eligible patients who received carvedilol during the 6-week treatment period entered a 4-week open-label extension. Overall, 154 subjects were enrolled (safety analysis set [SAS]). Subjects in the full analysis set received carvedilol (n = 93) or placebo (n = 42): mean (SD) age 66.4 (9.6) years, mostly male (72.6%), with a mean (SD) resting HR of 98.3 (14.7) bpm, and CHA2DS2-VASc score of 2.43 (1.64), and the majority (80.7%) had a modified European Heart Rhythm Association (EHRA) score of 2a. Most subjects had persistent AF (77.0%) and the mean (SD) AF duration was 60.7 (73.8) months. There were no significant between group differences in baseline characteristics. Change in 24-hour mean HR from baseline to week 6 (primary endpoint) was reduced significantly by carvedilol vs. placebo (P < 0.0001; Figure 1A); changes were maintained in the 4-week extension period. Post-hoc subgroup analysis showed that changes in 24-hour mean HR from baseline to week 6 with carvedilol were dose-dependent: respective mean (SD) changes for carvedilol 8 mg (n = 14), 16 mg (n = 26), and 32 mg (n = 53) were −5.07 (5.97), −9.69 (6.34), and −7.58 (8.00) (P = 0.0072, P < 0.0001, and P < 0.0001, respectively). More subjects achieved HR <80 bpm at week 6 (secondary endpoint) in carvedilol vs. placebo groups (30.1% vs. 14.3%; P = 0.0499), with a risk difference of 15.82 (95% confidence interval: 1.72–29.93). Carvedilol was associated with significant improvement in modified EHRA scores from baseline to week 6 (P < 0.0001; secondary endpoint). Mean hourly HR at baseline was similar between the two groups (Figure 1B, upper panel) but, at week 6, carvedilol produced significant changes from baseline in mean HR at each hourly time point. In contrast, no significant changes from baseline in hourly mean HR were found in the placebo group. At week 6, modest but significant decreases in mean hourly HR were generally observed with carvedilol compared to placebo during the daytime, but there were fewer significant between-group differences at nighttime (exploratory endpoints; Figure 1B, lower panel). In the SAS, 60 treatment-emergent adverse events (TEAEs) were reported in 43 subjects (27.9%) during the 6-week trial: 43 AEs in 31 subjects (29.8%) in the carvedilol group, and 17 in 12 subjects (24.0%) in the placebo group. Most TEAEs were mild (41 cases) or moderate (18 cases) in severity. The most common TEAEs were dizziness in 9 subjects (5.8%) and dyspnea in 7 subjects (4.6%). This is the first pivotal phase 3 clinical trial to show the efficacy of once-daily carvedilol for HR control in patients with AF. Compared with placebo, carvedilol significantly decreased 24-hour mean HR from baseline to week 6 and this effect was maintained during the 4-week extension period. Changes were dose-dependent with higher carvedilol doses (16 and 32 mg) effecting larger changes than the 8 mg dose. Similar results were reported in the AF Carvedilol Japanese trial of patients with persistent or permanent AF, which demonstrated that once-daily carvedilol significantly reduced HR from baseline during 6 weeks of treatment.2Inoue H. Atarashi H. Okumura K. et al.Heart rate control by carvedilol in Japanese patients with chronic atrial fibrillation: The AF Carvedilol study.J Cardiol. 2017; 69: 293-301Abstract Full Text Full Text PDF PubMed Google Scholar In conclusion, carvedilol for 6 weeks was effective in reducing HR in patients with AF and maintained efficacy during the extension period. Carvedilol was well tolerated and the safety profile was consistent with previous reports.
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