Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Diabetics with Multivessel Coronary Artery Disease: The Korean Multicenter Revascularization Registry (KORR)

This study was designed to assess the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD), particularly for Korean diabetics. Among 3,279 patients with MVCAD who were recommended for revascularization were enrolled from nine centers in Korea, 2,154 were selected after statistical adjustments for the disparities between two groups. Survival rates were not significantly different for three years between two groups. Among diabetic patients, the three-year mortality rate in PCI group was 1.9-fold higher than that of CABG group, although it was not statistically significant (PCI 19.8%, CABG 11.4%, p=0.14). The three-year mortality rate was similar between the two groups in non-diabetics (PCI 8.3%, CABG 10.0%, p=0.50). The 30-day rate of cerebrovascular event was higher in CABG group, for both diabetic (CABG 3.6%, PCI 0.0%, p<0.001) and non-diabetic patients (CABG 2.4%, PCI 0.0%, p<0.001). Short- and long-term revascularization rates were higher in PCI group than in CABG group. As a conclusion, this Korean registry demonstrates that PCI was associated with comparable survival rates and lower short-term morbidity, but a greater requirement for repeated revascularization compared with CABG in Korean diabetics.

Prognostic Value of C-reactive Protein in Patients with Non-ischemic Dilated Cardiomyopathy: Prospective Study

BACKGROUND AND OBJECTIVES: Previous studies advocated the C-reactive protein (CRP) as an objective marker of the inflammatory reaction in cardiovascular disease, and an independent risk factor for predicting the progression of heart failure (HF) of an ischemic origin. However, it is unclear if this can also be applied to non-ischemic HF. We report the measurement of the CRP in non-ischemic dilated cardiomyopathy (DCM), and its relationship to the prognosis. SUBJECTS AND METHODS: Sixty-nine consecutive patients, with non-ischemic DCM, were enrolled based on their history, echocardiography and coronary angiography findings. The variables, including NYHA functional class, were examined. The CRP levels were measured with high sensitive turbidometry; and each patient followed up for 18 months. The endpoints of the study were considered as readmission and death. RESULTS: Out of the 69 patients, there were 47 (68%) were males and 22 (32%) females, with an average age of 60+/-12. The CRP level (mg/d) in the patients with DCM (1.66+/-2.91) was higher than in the controls (0.07+/-0.25;p<0.001), and increased in relation to the NYHA functional class on discharge (I:0.98+/-2.15, II:0.78+/-1.48, III:3.55+/-4.66, IV:2.94+/-2.39;p<0.01). During the follow-up, 19(28%) experienced the aggravation of HF and had higher CRP and NYHA functional classes, and lower Na+, K+ and hemoglobin levels. From a multiple regression analysis, only the K+ and NYHA functional class on discharge revealed significant relationships with the aggravation of HF (p<0.05). Moreover, an increased in the CRP level had a significant negative relation to the Na+ only (p<0.05). CONCLUSION: The patients with non-ischemic DCM exhibited an increase in CRP levels in relation to the severity of the HF. However, the levels of CRP in non-ischemic DCM could not elucidate the prognosis as with ischemic HF.

Endothelial Dysfunction and Alteration of Nitric Oxide/ Cyclic GMP Pathway in Patients with Exercise-Induced Hypertension

The diagnostic and prognostic implication of exaggerated blood pressure response to exercise have been controversial, with opinions ranging from a benign process to a harbinger of potential cardiovascular morbidity. Endothelial dysfunction has been demonstrated in patients with atherosclerosis and as a risk factor for coronary artery disease. However, whether the cause of exercise-induced hypertension might be related to endothelial dysfunction has not been well elucidated. We evaluated endothelial function in patients who showed a systolic blood pressure > or =210 mmHg in males and > or = 190 mmHg in females during treadmill exercise test. We measured the endothelial function of the brachial artery in 35 patients with exercise-induced hypertension, and in 35 age- and gender-matched normal control subjects, by a high resolution ultrasound technique, and the concentration of NO2-/NO3- and cyclic guanosine monophosphate (GMP). Endothelial-dependent vasodilation was impaired in patients with hypertension compared to normal controls (3.14+/-0.61 vs. 6.5+/-0.76%, p < 0.05). The extent of vasodilation was significantly correlated with age (r=-0.28, p < 0.05) and systolic blood pressure difference (r=-0.36, p < 0.05). The levels of NO2-/NO3- and cyclic GMP at maximal exercise were significantly higher than those at rest and recovery in both controls and the hypertensive group (p < 0.05). Although there was no significant difference in the increment of NO2-/NO3- during maximal exercise between the controls and hypertensive group (55+/-17 vs. 56+/-12micromol/L, p=NS), cyclic GMP level during maximal exercise was significantly higher in the control group than the hypertensive group (10+/-1.8 vs. 8.3+/-2.5 pmol/ml, p 0.05). Patients with exercise-induced hypertension have poor endothelium-dependent vasodilation due to an impaired nitric oxide/cyclic GMP pathway, which may play a significant role in increasing blood pressure during exercise with inadequate peripheral adjustment to changing cardiac output.

Alteration of Nitric Oxide/cyclic-GMP pathway in patients with exaggerated systolic blood pressure response during exercise test / 대한내과학회지

BACKGROUND: The diagnostic and prognostic implication of exaggerated blood pressure response to exercise has not been well characterized. Endothelial dysfunction has been demonstrated in patients with atherosclerosis or with risk factors for coronary artery disease. However, whether the cause of exercise induced hypertension might be due to endothelial dysfunction has not been well elucidated. Therefore, we designed this study to evaluate the endothelial function in patients with exaggerated blood pressure response during exercise. METHODS: Exercise hypertension is defined as a systolic blood pressure >or= 210 mmHg in men and >or= 190 mmHg in female, during treadmill exercise test. The endothelial function of the brachial artery, in 35 patients with exercise hypertension and 35 control subjects (mean age of 45.5+/-8.1) were measured by a high resolution ultrasound technique. The concentrations of nitrite and cyclic-GMP were measured from exercise hypertension group and control subjects during, before and after treadmill exercise. RESULTS: There were no significant differences in the clinical variables between the control and exercise hypertension group. The LVH on ECG was detected more frequently in exercise hypertension group (14 % vs. 40 %, p0.05), a significant difference of cyclic GMP level during the maximal exercise was noted between the groups (10+/-1.8 vs. 8.3+/-2.5 pmol/mL, p<0.05). CONCLSUION: Patients with exercise induced hypertension have impaired endothelium-dependent vasodilation. This study supports the concept that endothelial dysfunction may play a significant role in exercise induced hypertension.

The Origin of Proinflammatory Cytokines in Patients with Idiopathic Dilated Cardiomyopathy

Proinflammatory cytokines and their receptors are increased in the peripheral blood of patients with heart failure. We measured cytokines and their receptors in systemic artery (SA), coronary sinus (CS) and infra-renal inferior vena cava (IVC), in order to investigate their origin and influential factors. Thirty patients with idiopathic dilated cardiomyopathy were performed echocardiography at admission, and right heart catheterization after stabilization. Blood was drawn from 3 sites for measurement of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and soluble tumor necrosis factor- receptor (sTNFR) I, II. TNF-alpha at CS (3.25+/-0.34 pg/mL) was higher than those of SA (1.81+/-0.39 pg/mL) and IVC (1.88+/-0.38 pg/mL, p<0.05). IL-6 at CS (18.3+/-3.8 pg/mL) was higher than that of SA (5.8+/-1.2 pg/mL, p<0.01). The levels of sTNFR I, II showed increasing tendency in sequence of SA, IVC and CS. TNF-alpha and sTNFR I, II from all sites were proportional to worsening of functional classes at admission (p<0.05). E/Ea by Doppler study at admission, which reflects left ventricular end-diastolic pressure (LVEDP) was positively correlated with TNF-alpha from SA (R=0.71, p<0.01), CS (R=0.52, p<0.05) and IVC (R=0.46, p<0.05). Thus, elevated LVEDP during decompensation might cause cytokine release from myocardium in patients with idiopathic dilated cardiomyopathy.

Predictors of Side Branch Occlusion Immediately after Coronary Stenting: an Intravascular Ultrasound Study

BACKGROUND AND OBJECTIVES: Previous studies have indicated that side branch occlusion (SBO) remains a significant problem in coronary bifurcation lesions during percutaneous intervention. SUBJECTS AND METHODS: To evaluate the predictors of SBO by intravascular ultrasound (IVUS), 35 patients (28 males, mean age 56+/-11 years) were studied at their left anterior descending artery (LAD)-diagonal branch (DB) bifurcation lesions, prior to coronary intervention for the measurement of the following plaque characteristics: total plaque area (PA), PA of the branch-side semicircle, % area stenosis (%AS) of the LAD, the presence of bull's eye in the DB, the diameter of the vessel and the ostial lumen of the DB, and the LAD-DB angle. SBO was defined as a persistant reduction in the TIMI flow to < OR = 1 by the end of the procedure. RESULTS: The PA of the branch-side semicircle, the vessel diameter and the ostial lumen diameter of the DB all significantly affected the SBO. The total PA and the %AS of the LAD were not related to the SBO. Multivariate analysis identified that the PA of the branch-side semicircle was the only predictor of SBO (odds ratio 3.2, 95% confidence interval 1.3 to 8.6, p=0.015). CONCLUSION: It appears that the plaque distribution of LAD is a major determinant of SBO. These findings support the theory that the plaque shift ("snow plow effect") may be the mechanism of the SBO following stenting.

A Case of Pseudoaneurysm Complicated to Infective Endocarditis

No abstract available.

Correlation of Infarct Size and Late Troponin T Peak Concentration in Acute Myocardial Infarction / 대한내과학회지

OBJECTIVES:The estimation of infarct size has been important in evaluation of prognosis of the patients who had acute myocardial infarction. The infarct size estimated by the thallium-201 SPECT has been known to correlate with the prognosis of patient. The enzymatic estimation by the total release of creatine kinase isoenzyme MB(CK-MB) has been widely used in estimating infarct size clinically, but inconvienent and not cardiospecific. Recently, serum troponin T, cardiospecific myofibrillar protein, has been used in the diagnosis of acute myocardial infarction, and used in the estimation of reperfusion following myocardial infarction. To assess the role of the late troponin T peak concentration on the estimation of infarct size, this prospective study was carried out. METHODS: The patients with acute myocardial infarction who were admitted, within 48hours after the onset of chest pain, to Ajou University Hospital between April 1995 and August 1995 were evaluated. All patients were divided into anterior and inferior infarct and checked serum troponin T and CK-MB serially, and underwent stress Thallium-201 SPECT 1 week after infarction, In each group, we assessed the correlation of the late toponin T peak concentration, the total release of CK-MB, and the infarct size estimated by thallium-201 single photon emission computed tomography(SPECT). RESULTS: 1) The eligible subjects consisted of 22 patients (17 men and 5 women), and age ranged from 29 to 77 years(mean 57.8 +/- 12.5 years). 2) The mean arrival time to the hospital after the onset of chest pain was 15.5 +/- 13.2 hours. The 19 patients had at least one risk factor for coronaryartery disease. 3) The late troponin T peak concentration and the total release of CK-MB in patients with anterior infarction were not different from those with inferior infarction. The infarct size estimated by the thallium-201 SPECT in patients with anterior infarction was larger than patients with inferior infarction The left ventricular ejection fraction in anterio infarction was lower than inferior infarction. 4) The late troponin T peak concentration ha: positive correlation with the infarct size estimated by the thallium-201 SPECT in the total patients, and both patients with anterior infarction and inferio infarction. 5) The total release of CK-MB correlated with the infarct size estimated by the thallium-20 SPECT in the total patients, and the patients of inferior infarction. CONCLUSION: The late troponin T peak concentration was more accurate than the total release o CK-MB in the estimation of infarct size. Therefore, when the patient arrived to the hospital less than 48hr after the onset of chest pain, the late troponin T peak concentration is useful in the decision and evaluation of therapeutic intervention and in the prediction of prognosis.