BACKGROUND: Epidural administration of dilute solution of local anesthetic and lipid-soluble opioid provides the best pain relief during labor and delivery. The purpose of this study was to evaluate the safety, efficacy and patient satisfaction of patient-controlled epidural analgesia compared with continuous infusion epidural analgesia. METHODS: Forty healthy full-term parturients who requested epidural analgesia were assigned randomly to either patient-controlled epidural analgesia (PCEA) group or continuous infusion epidural analgesia (CIEA) group. All parturients received proper dose of 0.25% bupivacaine with 0.0008% fentanyl to block T10 sensory level. PCEA was programmed as followings; no background infusion, a 4 ml bolus dose and 15min lock-out interval using 0.0625% bupivacaine with 0.0002% fentanyl. CIEA was started with the same solution at 12ml/hr constantly. RESULTS: Hourly requirement of 0.0625% bupivacaine (mean+/-SD 7.1+/-5.8 ml/hr, median 7.6 ml/hr in PCEA group and mean+/-SD 13.2+/-2.9 ml/hr, median 12 ml/hr in CIEA group) during labor was significantly reduced in PCEA group (p<0.05). Maternal satisfaction, obstetric and neonatal parameters were shown no statistically significant difference. Incidences of postpartum complications such as gait disturbance, urinary difficulty, pruritus, nausea and vomiting were rare in both groups. CONCLUSIONS: Patient-controlled epidural analgesia is safe and effective and has 37% sparing effect of bupivacaine dosage used per hour compared with continuous infusion epidural analgesia.
Analgesia ; Analgesia, Epidural* ; Anesthetics ; Bupivacaine ; Fentanyl ; Gait ; Incidence ; Nausea ; Patient Satisfaction ; Postpartum Period ; Pruritus ; Vomiting

The Thrombolysis in Myocardial Infarction (TIMI) risk score (TRS) has proven value in predicting prognosis in unstable angina/non ST-elevation myocardial infarction (NSTEMI) as well as in ST-elevation myocardial infarction. The TRS system has little implication, however, in the extent of myocardial damage in high-risk patients with NSTEMI. A total of 1621 patients (63.6+/-12.2 years; 1043 males) with NSTEMI were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR). We analyzed the risk for major adverse cardiac events (MACE) during a 6-month follow-up period. The TRS system showed good correlation with MACE for patients in the low and intermediate groups but had poor correlation when the high-risk group was included (p=0.128). The MACE rate was 3.8% for TRS 1, 9.4% for TRS 2, 10.7% for TRS 3, and 12.3% for TRS 4 (HR=1.29, p=0.026). Among the biomarkers and clinical risk factors, elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) (HR=2.61, p=0.001) and Killip class above III showed good correlation with MACE (HR=0.302, p<0.001). Therefore, we revised an alternative clinical scoring system by including these two variables that reflect left ventricular dysfunction: age > 65 years, history of ischemic heart disease, Killip class above III, and elevated pro-BNP levels above the 75th percentile. This modified scoring system, when tested for validity, showed good predictive value for MACE (HR=1.64, p<0.001). Compared with the traditional TRS, the novel alternative scoring system based on age, history of ischemic heart disease, Killip class, and NT-proBNP showed a better predictive value for 6-month MACE in high-risk patients with NSTEMI.
Angina, Unstable ; Biomarkers ; Follow-Up Studies ; Humans ; Korea ; Myocardial Infarction ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Peptide Fragments ; Prognosis ; Risk Factors

BACKGROUND/AIMS: The aim of this study was to evaluate the impact of diabetes mellitus (DM) on in-hospital and 1-year mortality in patients who suffered acute myocardial infarction (AMI) and underwent successful percutaneous coronary intervention (PCI). METHODS: Among 5,074 consecutive patients from the Korea AMI Registry with successful revascularization between November 2005 and June 2007, 1,412 patients had a history of DM. RESULTS: The DM group had a higher mean age prevalence of history of hypertension, dyslipidemia, ischemic heart disease, high Killip class, and diagnoses as non-ST elevation MI than the non-DM group. Left ventricular ejection fraction (LVEF) and creatinine clearance were lower in the DM group, which also had a significantly higher incidence of in-hospital and 1-year mortality of hospital survivors (4.6% vs. 2.8%, p = 0.002; 5.0% vs. 2.5%, p < 0.001). A multivariate analysis revealed that independent predictors of in-hospital mortality were Killip class IV or III at admission, use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, LVEF, creatinine clearance, and a diagnosis of ST-elevated MI but not DM. However, a multivariate Cox regression analysis showed that DM was an independent predictor of 1-year mortality (hazard ratio, 1.504; 95% confidence interval, 1.032 to 2.191). CONCLUSIONS: DM has a higher association with 1-year mortality than in-hospital mortality in patients with AMI who underwent successful PCI. Therefore, even when patients with AMI and DM undergo successful PCI, they may require further intensive treatment and continuous attention.
Aged ; Angioplasty, Balloon, Coronary/adverse effects/*mortality ; Chi-Square Distribution ; Diabetes Mellitus/*mortality ; Female ; Hospital Mortality ; Humans ; Kaplan-Meier Estimate ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Myocardial Infarction/mortality/*therapy ; Proportional Hazards Models ; Prospective Studies ; Registries ; Republic of Korea ; Risk Assessment ; Risk Factors ; Time Factors ; Treatment Outcome

BACKGROUND AND OBJECTIVES: The benefit of early statin treatment following acute myocardial infarction (MI) complicated with cardiogenic shock (CS) has not been well studied. We sought to assess the effect of early statin therapy in patients with CS complicating acute MI. SUBJECTS AND METHODS: We studied 553 statin-naive patients with acute MI and CS (Killip class IV) who underwent revascularization therapy between November 2005 and January 2008 at 51 hospitals in the Korea Acute Myocardial Infarction Registry. Patients were divided into 2 groups: those who received statins during hospitalization (n=280) and those who did not (n=273). The influence of statin treatment on a 12-month clinical outcome was examined using a matched-pairs analysis (n=200 in each group) based on the propensity for receiving statin therapy during hospitalization. RESULTS: Before adjustment, patients receiving statin, compared to those not receiving statin, had a more favorable clinical profile, were less likely to suffer procedural complications, and more likely to receive adequate medical therapy. Patients receiving statin had lower unadjusted in-hospital mortality and composite rate of mortality, MI, and repeat revascularization at 12 months, which remained significantly lower after adjustment for patient risk, procedural characteristics, and treatment propensity. CONCLUSION: In CS patients with acute MI undergoing revascularization therapy, early statin treatment initiated during hospitalization was associated with lower rates of in-hospital death and 12-month adverse cardiac events.
Angioplasty ; Hospital Mortality ; Hospitalization ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Korea ; Myocardial Infarction ; Secondary Prevention ; Shock ; Shock, Cardiogenic

BACKGROUND AND OBJECTIVES: The benefit of early statin treatment following acute myocardial infarction (MI) complicated with cardiogenic shock (CS) has not been well studied. We sought to assess the effect of early statin therapy in patients with CS complicating acute MI. SUBJECTS AND METHODS: We studied 553 statin-naive patients with acute MI and CS (Killip class IV) who underwent revascularization therapy between November 2005 and January 2008 at 51 hospitals in the Korea Acute Myocardial Infarction Registry. Patients were divided into 2 groups: those who received statins during hospitalization (n=280) and those who did not (n=273). The influence of statin treatment on a 12-month clinical outcome was examined using a matched-pairs analysis (n=200 in each group) based on the propensity for receiving statin therapy during hospitalization. RESULTS: Before adjustment, patients receiving statin, compared to those not receiving statin, had a more favorable clinical profile, were less likely to suffer procedural complications, and more likely to receive adequate medical therapy. Patients receiving statin had lower unadjusted in-hospital mortality and composite rate of mortality, MI, and repeat revascularization at 12 months, which remained significantly lower after adjustment for patient risk, procedural characteristics, and treatment propensity. CONCLUSION: In CS patients with acute MI undergoing revascularization therapy, early statin treatment initiated during hospitalization was associated with lower rates of in-hospital death and 12-month adverse cardiac events.
Angioplasty ; Hospital Mortality ; Hospitalization ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Korea ; Myocardial Infarction ; Secondary Prevention ; Shock ; Shock, Cardiogenic

This study compared clinical outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in large coronary arteries in patients with acute myocardial infarction (MI). A total of 985 patients who underwent single-vessel percutaneous coronary intervention (PCI) in large coronary arteries (> or = 3.5 mm) in lesions < 25 mm were divided into DES group (n = 841) and BMS group (n = 144). Clinical outcomes during 12 months were compared. In-hospital outcome was similar between the groups. At six months, death/MI rate was not different. However, DES group had significantly lower rates of target-lesion revascularization (TLR) (1.7% vs 5.6%, P = 0.021), target-vessel revascularization (TVR) (2.2% vs 5.6%, P = 0.032), and total major adverse cardiac events (MACE) (3.4% vs 11.9%, P = 0.025). At 12 months, the rates of TLR and TVR remained lower in the DES group (2.5% vs 5.9%, P = 0.032 and 5.9% vs 3.1%, P = 0.041), but the rates of death/MI and total MACE were not statistically different. The use of DES in large vessels in the setting of acute MI is associated with lower need for repeat revascularization compared to BMS without compromising the overall safety over the course of one-year follow-up.
Acute Disease ; Adult ; Aged ; *Angioplasty, Balloon, Coronary/adverse effects/instrumentation ; Coronary Angiography ; Coronary Vessels/pathology ; *Drug-Eluting Stents/adverse effects ; Female ; Follow-Up Studies ; Hospital Mortality ; Humans ; Male ; Middle Aged ; Myocardial Infarction/mortality/radiography/*therapy ; *Stents/adverse effects ; Survival Rate ; Time Factors

This study was performed to evaluate the effects of diabetes on short- and mid-term clinical outcomes in patients with acute myocardial infarction (AMI). Between October 2005 and December 2009, a total of 22,347 patients with AMI from a nationwide registry was analyzed. At the time point of the day 30 after AMI onset, landmark analyses were performed for the development of major adverse cardiovascular events (MACEs), including death, re-infarction and revascularization. In this cohort, 6,131 patients (27.4%) had diabetes. Short-term MACEs, which occurred within 30 days of AMI onset, were observed in 1,364 patients (6.1%). Among the 30-day survivors (n = 21,604), mid-term MACEs, which occurred between 31 and 365 days after AMI onset, were observed in 1,181 patients (5.4%). After adjustment for potential confounders, diabetes was an independent predictor of mid-term MACEs (HR, 1.25; 95% CI, 1.08-1.45; P = 0.002), but not of short-term MACEs (HR: 1.16; 95% CI: 0.93-1.44; P = 0.167). Diabetes is a poor prognostic factor for mid-term clinical outcomes but not for short-term outcomes in AMI patients. Careful monitoring and intensive care should be considered in diabetic patients, especially following the acute stage of AMI.
Acute Disease ; Aged ; Cardiovascular Diseases/etiology ; Cohort Studies ; Diabetes Mellitus, Type 2/complications/*diagnosis ; Diagnosis, Differential ; Female ; Humans ; Incidence ; Male ; Middle Aged ; Myocardial Infarction/*diagnosis/epidemiology/mortality ; Prognosis ; Proportional Hazards Models ; Registries ; Survival Analysis ; Time Factors

BACKGROUND AND OBJECTIVES: Metabolic syndrome (MetS) is an important risk factor for cardiovascular disease. However, the clinical outcome of acute myocardial infarction (AMI) with MetS has not been well examined. The purpose of this study was to evaluate the clinical outcomes of AMI patients with MetS. SUBJECTS AND METHODS: We evaluated a total of 6352 AMI patients who had successful percutaneous coronary interventions and could be identified for MetS between 2005 and 2008 at 51 hospitals participating in the Korea Acute Myocardial Infarction Registry. They were divided into 2 groups according to the presence of MetS: the MetS group (n=2493, 39.2%) versus the Non-MetS group (n=3859, 60.8%). In addition, 4049 AMI patients with high levels of low density lipoprotein-cholesterol (LDL-C) (> or =100 mg/dL) among them, were divided into the MetS group (n=1561, 38.6%) versus the Non-MetS group (n=2488, 61.4%). RESULTS: In the overall population, there was no significant difference in 12-month the major adverse cardiac events (MACE) rate between the 2 groups. However, the MetS group showed a significantly higher 12-month MACE rate in the high LDL-C population. Multivariate analysis showed that MetS was an independent prognostic factor for 12-month MACE {hazard ratio (HR) 1.607, 95% confidence interval (CI) 1.027 to 2.513, adjusted p=0.038} and for 12-month target vessel revascularization (HR 1.564, 95% CI 1.092 to 2.240, adjusted p=0.015) in the high LDL-C population. CONCLUSION: MetS patients with AMI in the overall population showed no significant difference in 12-month clinical outcomes. However, in patients with higher LDL-C > or =100 mg/dL, they showed significantly worse clinical outcome than Non-MetS patients. Therefore, it is important to ascertain the presence of MetS in AMI patients, and more aggressive therapy should be strongly considered for AMI patient with MetS.
Cardiovascular Diseases ; Humans ; Korea ; Multivariate Analysis ; Myocardial Infarction ; Percutaneous Coronary Intervention ; Risk Factors

OBJECTIVE: The complete blood count is the most widely available laboratory data in the early in-hospital period after acute myocardial infarction. We assessed the clinical utility of the combined use of hemoglobin (Hb) level and neutrophil to lymphocyte ratio (N/L) for early risk stratification in patients with non-ST-elevation myocardial infarction (STEMI). METHODS: We analyzed 6,157 consecutive patients with non-STEMI (65±12.4 years, male 69%) were included in the final analysis. Patients were categorized into 3 groups by using the median value of N/L (4.42) and the presence of anemia (Hb <13 mg/dL in men and <12 mg/dL in women): group I, low N/L & no anemia (n=3,170); group II, no group I or III (n=2,168); group III, high N/L & anemia (n=819). RESULTS: There were significant differences on clinical outcomes during 180-day follow-up among 3 groups. The prognostic discriminatory capacity of the combined use of Hb level and N/L was also significant in high-risk subgroups, such as patients with a renal dysfunction, multivessel coronary disease, low ejection fraction, and even in those having higher mortality risk based on the thrombolysis in myocardial infarction risk score. In a multi-variate logistic regression, after adjusting for multiple covariates, group III had higher incidence of major adverse cardiac events at 180-day (hazard ratio, 2.4; 95% confidence interval, 1.5–4.0;p≤0.001) compared with group I. CONCLUSIONS: The combined use of Hb level and N/L provides valuable timely information for early risk stratification in patients with non-STEMI.
Anemia ; Blood Cell Count ; Coronary Disease ; Follow-Up Studies ; Humans ; Incidence ; Logistic Models ; Lymphocytes* ; Male ; Mortality ; Myocardial Infarction* ; Neutrophils* ; Prognosis

BACKGROUND AND OBJECTIVES: It is thought that patients with diabetes mellitus (DM) have a poor prognosis after an acute myocardial infarction (AMI), but the effect of diabetes on the outcomes of hypertensive patients with AMIs has not been elucidated in the Korean population. The aim of this study was to investigate the effects of diabetes on long-term clinical outcomes following AMIs in patients with hypertension. SUBJECTS AND METHODS: Using data from the Korea Acute Myocardial Infarction Registry (November 2005 to December 2006), 2,233 hypertensive patients with AMIs were grouped as follows based on the presence of DM: group I, diabetic hypertension (n=892, 544 men, mean age=66.2+/-10.9 years); and group II, non-diabetic hypertension (n=1341, 938 men, mean age=63.9+/-12.8 years). The primary study outcomes included in-hospital death and major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), repeat percutaneous coronary intervention, and coronary artery bypass surgery) at the 1 year follow-up. RESULTS: Hypertensive patients with DM were older and more likely to be women. The diabetic group had lower blood pressure (p<0.001), a lower left ventricular ejection fraction (p<0.001), a more severe degree of heart failure (p<0.001), a longer duration of coronary care unit admission (p<0.001), and a higher incidence of hyperlipidemia (p=0.007). The N-terminal pro-brain natriuretic peptide level (4602.5+/-8710.6 pg/mL vs. 2320.8+/-5837.9 pg/mL, p<0.001) was higher and the creatinine clearance (62.4+/-29.9 mL/min vs. 73.0+/-40.8 mL/min, p<0.001) was lower in the diabetic group than the non-diabetic group. Coronary angiographic findings revealed more frequent involvement of the left main stem (p=0.002) and multiple vessels (p<0.001) in the diabetic group. The rate of in-hospital death was higher in the diabetic group (p<0.001). During follow-up, the rates of composite MACE at 1 month, 6 months, and 12 months were higher in the diabetic group (p<0.001). CONCLUSION: In hypertensive patients with AMI, DM was associated with worse clinical and angiographic features, with a higher risk of development of severe heart failure, and an increased risk of MACE on long-term clinical follow-up.
Blood Pressure ; Coronary Artery Bypass ; Coronary Care Units ; Creatinine ; Death ; Diabetes Mellitus ; Female ; Follow-Up Studies ; Heart Failure ; Humans ; Hyperlipidemias ; Hypertension ; Incidence ; Korea ; Male ; Myocardial Infarction ; Percutaneous Coronary Intervention ; Prognosis ; Stroke Volume