Rivaroxaban has emerged as a potential alternative to warfarin for the prevention of thromboembolism in patients with atrial fibrillation (AF). However, there has been concern for the risk of major bleeding, especially in Asian patients. We investigated the efficacy and safety of rivaroxaban compared to warfarin in Korean real world practice. A total of 2,208 consecutive non-valvular AF patients were divided into the Warfarin group (n=990) and the Rivaroxaban group (n=1218). Propensity matched 1-year clinical outcomes were compared (Warfarin, n=804; Rivaroxaban, n=804). The efficacy outcome was defined as stroke/systemic embolism (SE). The safety outcome was major bleeding. The primary net clinical benefit (NCB) was defined as the composite of stroke/SE, major bleeding, and all-cause mortality. Secondary, NCB was defined as the composite of stroke, SE, and major bleeding. Rivaroxaban had the similar efficacy in terms of thromboembolic event prevention [hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.37–1.32, p=0.266] compared to warfarin. Rivaroxaban significantly lowered the risk of major bleeding [HR 0.41, 95% CI 0.22–0.76, p=0.004]. Primary NCB was significantly low in the rivaroxaban group [HR 0.54, 95% CI 0.36–0.81, p=0.003]. Secondary NCB was also low in the rivaroxaban group [HR 0.62, 95% CI 0.40–0.99, p=0.041]. Both rivaroxaban 15 mg and 20 mg groups had similar efficacy and significantly lower risks of major bleeding as well as primary and secondary NCB compared to the warfarin group. In patients with non-valvular AF, rivaroxaban had a similar efficacy to warfarin in Korean real world practice. However, rivaroxaban had better safety and net clinical outcomes compared to warfarin.
Asian Continental Ancestry Group ; Atrial Fibrillation* ; Cohort Studies* ; Embolism ; Hemorrhage ; Humans ; Mortality ; Rivaroxaban* ; Stroke ; Thromboembolism ; Warfarin*

BACKGROUND AND OBJECTIVES: Although current guidelines recommend early initiation of statin in patients with acute myocardial infarction (AMI), there is no consensus for optimal timing of statin initiation. METHODS: A total of 3,921 statin-naïve patients undergoing percutaneous coronary intervention were analyzed, and divided into 3 groups according to statin initiation time: group 1 (statin initiation <24 hours after admission), group 2 (24–48 hours) and group 3 (≥48 hours). We also made 3 stratified models to reduce bias: model 1 (<24 hours vs. ≥24 hours), model 2 (<48 hours vs. ≥48 hours) and model 3 (<24 hours vs. 24–48 hours). The endpoint was major adverse cardiac events (MACE; composite of cardiac death, myocardial infarction and target-vessel revascularization) during median 3.8 years. RESULTS: During follow-up, incidence of MACE was lower in early statin group in both model 1 (14.3% vs. 18.4%, hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.66–0.91; p=0.002) and model 2 (14.6% vs. 19.7%, HR, 0.81; 95% CI, 0.67–0.97; p=0.022). After propensity-score matching, results remained unaltered. Statin initiation <24 hours reduced MACE compared to statin initiation ≥24 hours in model 1. Statin initiation <48 hours also reduced MACE compared to statin initiation later in model 2. However, there was no difference in incidence of MACE between statin initiation <24 hours and 24–48 hours) in model 3. CONCLUSIONS: Early statin therapy within 48 hours after admission in statin-naïve patients with AMI reduced long-term clinical outcomes compared with statin initiation later. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02385682
Bias (Epidemiology) ; Consensus ; Death ; Follow-Up Studies ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Incidence ; Myocardial Infarction ; Percutaneous Coronary Intervention

BACKGROUND/AIMS: It is well known that gender differences are associated with clinical outcomes in patients with acute myocardial infarction (AMI). However, it is not clear whether gender differences affect the prognosis of elderly patients with AMI. METHODS: We analyzed the incidence of in-hospital complications and mortality in the Korea Acute Myocardial Infarction Registry-National Institutes of Health from November 2011 to June 2015. This study included elderly patients (≥ 75 years) diagnosed with AMI. RESULTS: A total of 2,953 patients were eligible for this study. Among them, 1,529 (51.8%) patients were female, and the mean age of the female group was older than that of the male group (80.7 ± 4.4 vs. 79.6 ± 4.0 years, respectively, p < 0.001). Elderly females utilized emergency medical services less frequently compared with elderly males (11.5 vs. 15.4%, respectively, p < 0.001). Elderly female AMI patients had a similar rate of in-hospital mortality compared with elderly males (7.1 vs. 8.4%, respectively, p = 0.196). The rate of major cardiac adverse events (MACEs) was lower in elderly females than males during a 12-month follow-up (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.00-1.41, p = 0.045). According to multivariate analysis, the male gender is an independent factor for predicting 1-year MACEs (HR 1.37, 95% CI 1.14-1.65, p < 0.001). CONCLUSIONS: No significant differences in peri-procedural complications or in-hospital mortality were observed between male and female elderly patients with AMI. However, elderly female patients had a more favorable prognosis than male patients during a 1-year clinical follow-up.
Academies and Institutes ; Aged ; Emergency Medical Services ; Female ; Follow-Up Studies ; Hospital Mortality ; Humans ; Incidence ; Korea ; Male ; Mortality ; Multivariate Analysis ; Myocardial Infarction ; Prognosis

OBJECTIVE: This study examined the clinical characteristics of suicide attempters who exposed their suicidal intension to suggest an active intervention strategy for suicide prevention based on the regional emergency medical service system. METHODS: A prospective database of suicide attempters who visited the emergency department of Chungbuk National University Hospital between October 2013 and December 2017 was used. All of the adult patients who provided consent for the initial assessment for suicidal attempters were eligible, excluding cases with unknown exposure of suicidal intension. The primary and secondary endpoints were the risk factors affecting exposure to the suicidal intension and characteristics of the exposure group. The adjusted odds ratios (AORs) of exposure to suicidal attempts after adjusting for potential confounders was calculated. RESULTS: Of a total 1,035 suicidal attempters enrolled, 332 (32.1%) were included in the exposure group. The exposure group was more likely to have an educational level above high school and no religion, and have suicidal characteristics at night time (18:00–08:00), under the influence of alcohol, suicidal plan before 1 week, and suicidal method involving asphyxia (P<0.05). The exposure group was more likely to have no guardian (AORs, 1.46; 95% confidence interval [CI], 1.00–2.12), use methods involving asphyxia (AORs, 2.07; 95% CI, 1.46–2.91), and attempt suicide at night (18:00 to 08:00) (AORs, 1.38; 95% CI, 1.05–1.83) compared to the no exposure group. CONCLUSION: Models need to be established, where regional mental health welfare center, local government, fire headquarter, and tele-communication companies can participate in the implementation of an active intervention strategy.
Adult ; Asphyxia ; Chungcheongbuk-do ; Emergency Medical Services ; Emergency Service, Hospital ; Fires ; Humans ; Local Government ; Mental Health ; Methods ; Odds Ratio ; Prospective Studies ; Risk Factors ; Suicidal Ideation ; Suicide ; Suicide, Attempted

OBJECTIVE: This study aimed to achieve expert consensus for the evaluation of Emergency medical system operation fund (EMSOF) support projects using the Delphi method in Korea. METHODS: The Delphi study was performed in June 2018. Experts who are members of the policy committee of the Korean Society of Emergency Medicine (KSEM) participated in the study. Respondents were asked to express their level of agreement of appropriateness for the following 6 categories for 21 projects: project contents, amount of support, indicators, performance, overall evaluation, and need to maintain. With a possible score of 9 points, the project categories were classified into 3 groups, inappropriate, moderate and appropriate, based on the median score of the respondents' ratings in each question. RESULTS: Sixteen of the 18 policy committee members participated in the survey. Their average professional work years were 8.2 years. All 21 projects were evaluated as appropriate for content. Amount of support and indicators were evaluated as moderate. Only 5 out of the 21 projects were evaluated as having appropriate indicators. No projects were evaluated as ineffective. Comprehensive evaluation of the projects was evaluated as moderate, and no project was evaluated as inappropriate in fund support. CONCLUSION: Overall, the contents of the EMSOF assistance project were rated high; however, there was a disagreement on the amount of support and evaluation indicators for each project. The results of this study are expected to be used as basic data to improve the use of EMSOF.
Committee Membership ; Consensus ; Delphi Technique ; Emergencies ; Emergency Medicine ; Financial Management ; Korea ; Methods ; Resource Allocation ; Surveys and Questionnaires

OBJECTIVE: This study examined the clinical effects of discharge against medical advice (DAMA) on suicide reattempts and clarified the risk factors related to DAMA. METHODS: A cross-sectional observational study was conducted in the emergency department (ED) of Chungbuk National University Hospital from 2015 to 2017. The medical records of suicide attempters from the National Emergency Department Information System were reviewed. The primary outcome was the ED revisit rate. The characteristics of the patients associated with DAMA were also examined. RESULTS: Among 889 eligible suicide attempters, 328 patients (36.9%) were reported to have DAMA at least once during the study period. Patients who were discharged against medical advice were more likely to reattempt suicide compared to normal disposition patients (11.0% vs. 3.7%, adjusted odds ratio [AOR], 3.002; 95% confidence interval [CI], 1.71–5.28). The independent risk factors for DAMA were age≤60 (AOR, 1.77; 95% CI, 1.20–2.59), female (AOR, 1.45; 95% CI, 1.09–1.91), ED visit at night time (AOR, 1.41; 95% CI, 1.03–1.92), and ED discharge at night time (AOR, 1.40; 95% CI, 1.06–1.85). CONCLUSION: Patients who were discharged against medical advice revisited the ED more after suicide attempts. Public efforts will be needed for patients who are discharged against medical advice considering those risk factors.
Chungcheongbuk-do ; Emergencies ; Emergency Medical Services ; Emergency Service, Hospital ; Female ; Humans ; Information Systems ; Medical Records ; Observational Study ; Odds Ratio ; Patient Discharge ; Risk Factors ; Suicide ; Suicide, Attempted

PURPOSE: This study aimed to develop a multi-channel near-infrared spectroscopy (NIRS) and ultrasonography (USG) fusion imaging system for imaging prostate cancer and to verify its diagnostic capability by applying the hybrid imaging system to a prostate cancer phantom. METHODS: A multi-channel NIRS system using the near-infrared 785-nm wavelength with 12 channels and four detectors was developed. After arranging the optical fibers around a USG transducer, we performed NIRS imaging and grayscale USG imaging simultaneously. Fusion imaging was obtained by processing incoming signals and the spatial reconstruction of NIRS, which corresponded with grayscale USG acquired at the same time. The NIRS-USG hybrid system was applied to a silicone-based optical phantom of the prostate gland containing prostate cancer to verify its diagnostic capability qualitatively. RESULTS: The NIRS-USG hybrid imaging system for prostate cancer imaging simultaneously provided anatomical and optical information with 2-dimensional registration. The hybrid imaging system showed more NIR attenuation over the prostate cancer model than over the model of normal prostate tissue. Its diagnostic capability to discriminate a focal area mimicking the optical properties of prostate cancer from the surrounding background mimicking the optical properties of normal prostate tissue was verified by applying the hybrid system to a silicone-based optical phantom of prostate cancer. CONCLUSION: This study successfully demonstrated that the NIRS-USG hybrid system may serve as a new imaging method for improving the diagnostic accuracy of prostate cancer, with potential utility for future clinical applications.
Diagnosis ; Methods ; Optical Fibers ; Prostate ; Prostatic Neoplasms ; Spectroscopy, Near-Infrared ; Transducers ; Ultrasonography

We investigated predictors of major adverse cardiac events (MACE) with two years after medical treatment for lesions with angiographically intermediate lesions with intravascular ultrasound (IVUS) minimum lumen area (MLA) <4 mm² in non-proximal epicardial coronary artery. We retrospectively enrolled 104 patients (57 males, 62±10 years) with angiographically intermediate lesions (diameter stenosis 30–70%) with IVUS MLA <4 mm² in the non-proximal epicardial coronary artery with a reference lumen diameter between 2.25 and 3.0 mm. We evaluated the incidences of major adverse cardiovascular events (MACE including death, myocardial infarction, target lesion and target vessel revascularizations, and cerebrovascular accident) two years after medical therapy. During the two-year follow-up, 15 MACEs (14.4%) (including 1 death, 2 myocardial infarctions, 10 target vessel revascularizations, and 2 cerebrovascular accidents) occurred. Diabetes mellitus was more prevalent (46.7% vs. 18.0%, p=0.013) and statins were used less frequently in patients with MACE compared with those without MACE (40.0% vs. 71.9%, p=0.015). Independent predictors of MACEs with two years included diabetes mellitus (odds ratio [OR]=3.41; 95% CI=1.43–8.39, p=0.020) and non-statin therapy (OR=3.11; 95% CI=1.14–6.50, p=0.027). Long-term event rates are relatively low with only medical therapy without any intervention, so the cut-off of IVUS MLA 4 mm² might be too large to be applied for defining significant stenosis. The predictors of long-term MACE were diabetes mellitus and statin therapy in patients with angiographically intermediate lesions in non-proximal epicardial coronary artery.
Constriction, Pathologic ; Coronary Artery Disease ; Coronary Vessels* ; Diabetes Mellitus ; Follow-Up Studies ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Incidence ; Male ; Myocardial Infarction ; Plaque, Atherosclerotic ; Retrospective Studies ; Ultrasonography* ; Ultrasonography, Interventional

BACKGROUND/AIMS: Coronary vasospasms are one of the important causes of sudden cardiac death (SCD). Provocation of coronary vasospasms can be useful, though some results may lead to false positives, with patients potentially experiencing recurrent SCD despite appropriate medical treatments. We hypothesized that it is not coronary vasospasms but inherited primary arrhythmia syndromes (IPAS) that underlie the development of SCD. METHODS: We analyzed 74 consecutive patients (3.8%) who survived out-of-hospital cardiac arrest among 1,986 patients who had angiographically proven coronary vasospasms. Electrical abnormalities were evaluated in serial follow-up electrocardiograms (ECGs) during and after the index event for a 3.9 years median follow-up. Major clinical events were defined as the composite of death and recurrent SCD events. RESULTS: Forty five patients (60.8%) displayed electrocardiographic abnormalities suggesting IPAS: Brugada type patterns in six (8.2%), arrhythmogenic right ventricular dysplasia patterns in three (4.1%), long QT syndrome pattern in one (2.2%), and early repolarization in 38 (51.4%). Patients having major clinical events showed more frequent Brugada type patterns, early repolarization, and more diffuse multivessel coronary vasospasms. Brugada type pattern ECGs (adjusted hazard ratio [HR], 4.22; 95% confidence interval [CI], 1.16 to 15.99; p = 0.034), and early repolarization (HR, 2.97; 95% CI, 1.09 to 8.10; p = 0.034) were ultimately associated with an increased risk of mortality. CONCLUSIONS: Even though a number of aborted SCD survivors have coronary vasospasms, some also have IPAS, which has the potential to cause SCD. Therefore, meticulous evaluations and follow-ups for IPAS are required in those patients.
Arrhythmias, Cardiac* ; Arrhythmogenic Right Ventricular Dysplasia ; Coronary Vasospasm* ; Death, Sudden, Cardiac* ; Electrocardiography ; Follow-Up Studies ; Heart Arrest ; Humans ; Long QT Syndrome ; Masks* ; Mortality ; Out-of-Hospital Cardiac Arrest ; Survivors

OBJECTIVE: The purpose of this study was to evaluate the applicability of data obtained from a wearable activity tracker (Fitbit Charge HR) to medical research. This was performed by comparing the wearable activity tracker (Fitbit Charge HR) with actigraphy (Actiwatch 2) for sleep evaluation and circadian rest-activity rhythm measurement. METHODS: Sixteen healthy young adults (female participants, 62.5%; mean age, 22.8 years) wore the Fitbit Charge HR and the Actiwatch 2 on the same wrist; a sleep log was recorded over a 14-day period. We compared the sleep variables and circadian rest-activity rhythm measures with Wilcoxon signed-rank tests and Spearman's correlations. RESULTS: The periods and acrophases of the circadian rest-activity rhythms and the sleep start times did not differ and correlated significantly between the Fitbit Charge HR and the Actiwatch 2. The Fitbit Charge HR tended to overestimate the sleep durations compared with the Actiwatch 2. However, the sleep durations showed high correlation between the two devices for all days. CONCLUSION: We found that the Fitbit Charge HR showed high accuracy in sleep evaluation and circadian rest-activity rhythm measurement when compared with actigraphy for healthy young adults. The results suggest that the Fitbit Charge HR could be applicable on medical research as an alternative tool to actigraphy for sleep evaluation and measurement of the circadian rest-activity rhythm.
Actigraphy* ; Humans ; Wrist ; Young Adult*