Safety and Efficacy of Everolimus-Eluting Bioresorbable Vascular Scaffold Versus Second-Generation Drug-Eluting Stents in Real-World Practice

Background@#The risk of device thrombosis and device-oriented clinical outcomes with bioresorbable vascular scaffold (BVS) was reported to be significantly higher than with contemporary drug-eluting stents (DESs). However, optimal device implantation may improve clinical outcomes in patients receiving BVS. The current study evaluated mid-term safety and efficacy of Absorb BVS with meticulous device optimization under intravascular imaging guidance. @*Methods@#The SMART-REWARD and PERSPECTIVE-PCI registries in Korea prospectively enrolled 390 patients with BVS and 675 patients with DES, respectively. The primary endpoint was target vessel failure (TVF) at 2 years and the secondary major endpoint was patientoriented composite outcome (POCO) at 2 years. @*Results@#Patient-level pooled analysis evaluated 1,003 patients (377 patients with BVS and 626 patients with DES). Mean scaffold diameter per lesion was 3.24 ± 0.30 mm in BVS group.Most BVSs were implanted with pre-dilatation (90.9%), intravascular imaging guidance (74.9%), and post-dilatation (73.1%) at proximal to mid segment (81.9%) in target vessel.Patients treated with BVS showed comparable risks of 2-year TVF (2.9% vs. 3.7%, adjusted hazard ratio [HR], 1.283, 95% confidence interval [CI], 0.487–3.378, P = 0.615) and 2-year POCO (4.5% vs. 5.9%, adjusted HR, 1.413, 95% CI, 0.663–3.012,P = 0.370) than those with DES. The rate of 2-year definite or probable device thrombosis (0.3% vs. 0.5%, P = 0.424) was also similar. The sensitivity analyses consistently showed comparable risk of TVF and POCO between the 2 groups. @*Conclusion@#With meticulous device optimization under imaging guidance and avoidance of implantation in small vessels, BVS showed comparable risks of 2-year TVF and device thrombosis with DES.

Rationale and Design of the High Platelet Inhibition with Ticagrelor to Improve Left Ventricular Remodeling in Patients with ST-Segment Elevation Myocardial Infarction (HEALING-AMI) Trial

BACKGROUND AND OBJECTIVES: Impaired recovery from left ventricular (LV) dysfunction is a major prognostic factor after myocardial infarction (MI). Because P2Y12 receptor blockade inhibits myocardial injury, ticagrelor with off-target properties may have myocardial protection over clopidogrel. In animal models, ticagrelor vs. clopidogrel protects myocardium against reperfusion injury and improves remodeling after MI. We aimed to investigate the effect of ticagrelor on sequential myocardial remodeling process after MI. METHODS: High platelet inhibition with ticagrelor to improve LV remodeling in patients with ST-segment elevation MI (HEALING-AMI) is an investigator-initiated, randomized, open-label, assessor-blinded, multi-center trial done at 10 sites in Korea. Patients will be enrolled if they have ST-segment elevation MI (STEMI) treated with primary percutaneous coronary intervention and a planned duration of dual antiplatelet treatment of at least 6 months. Screened patients will be randomly assigned (1:1) using an internet-based randomization with a computer-generated blocking with stratification across study sites to either ticagrelor or clopidogrel treatment. The co-primary primary endpoints are LV remodeling index with three-dimensional echocardiography and the level of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) at 6 months representing post-MI remodeling processes. Changes of LV end-systolic/diastolic volume indices and LV ejection fraction between baseline and 6-month follow-up will be also evaluated. Analysis is per protocol. CONCLUSIONS: HEALING-AMI is testing the effect of ticagrelor in reducing adverse LV remodeling following STEMI. Our trial would show the benefit of ticagrelor vs. clopidogrel related to the recovery of post-MI LV dysfunction beyond potent platelet inhibition. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02224534

The Proximal Optimization Technique Improves Clinical Outcomes When Treated without Kissing Ballooning in Patients with a Bifurcation Lesion

BACKGROUND AND OBJECTIVES: There are limited data regarding the clinical efficacy of the proximal optimization technique (POT) in the treatment of coronary bifurcation lesions. We investigated the influence of POT on the clinical outcomes of patients with coronary bifurcation lesions. METHODS: We enrolled a total of 1,191 patients with a bifurcation lesion with a side branch (SB) diameter ≥2.5 mm treated with a drug-eluting stent from 18 centers between January 2003 and December 2009. The primary outcome was major adverse cardiac events (MACEs: cardiac death, myocardial infarction or target lesion revascularization [TLR]). We performed one-to-many (1:N) propensity score matching with non-fixed matching ratio. RESULTS: POT was performed in 252 patients. During follow-up (median 37 months), the incidence of MACE was lower in the POT group than it was in the non-POT group (adjusted hazard ratio, 0.43; 95% confidence interval [CI], 0.24–0.79; p=0.006). After propensity score matching, these were 0.34; 95% CI, 0.17–0.69; p=0.003 for MACE and 0.37; 95% CI, 0.17–0.78; p=0.01 for TLR. The use of POT was associated with significantly lower TLR in patients treated without kissing ballooning, but was not in those who underwent kissing ballooning (p for interaction=0.03). CONCLUSIONS: In coronary bifurcation lesions with a large SB, POT may be beneficial to improve long-term clinical outcome, particularly in patients treated without kissing ballooning during the procedure. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01642992

Safety and Efficacy of Biodegradable Polymer-biolimus-eluting Stents (BP-BES) Compared with Durable Polymer-everolimus-eluting Stents (DP-EES) in Patients Undergoing Complex Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: There are no data comparing clinical outcomes of complex percutaneous coronary intervention (PCI) between biodegradable polymer-biolimus-eluting stents (BP-BES) and durable polymer-everolimus-eluting stents (DP-EES). We sought to evaluate the safety and efficacy of BP-BES compared with DP-EES in patients undergoing complex PCI. METHODS: Patients enrolled in the SMART-DESK registry were stratified into 2 categories based on the complexity of PCI. Complex PCI was defined as having at least one of the following features: unprotected left main lesion, ≥2 lesions treated, total stent length >40 mm, minimal stent diameter ≤2.5 mm, or bifurcation as target lesion. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (TV-MI), or target lesion revascularization (TLR) at 2 years of follow-up. RESULTS: Of 1,999 patients, 1,145 (57.3%) underwent complex PCI: 521 patients were treated with BP-BES and 624 with DP-EES. In propensity-score matching analysis (481 pairs), the risks of TLF (3.8% vs. 5.2%, adjusted hazard ratio [HR], 0.578; 95% confidence interval [CI], 0.246–1.359; p=0.209), cardiac death (2.5% vs. 2.5%, adjusted HR, 0.787; 95% CI, 0.244–2.539; p=0.689), TV-MI (0.5% vs. 0.4%, adjusted HR, 1.128; 95% CI, 0.157–8.093; p=0.905), and TLR (1.1% vs. 2.9%, adjusted HR, 0.390; 95% CI, 0.139–1.095; p=0.074) did not differ between 2 stent groups after complex PCI. CONCLUSIONS: Clinical outcomes of BP-BES were comparable to those of DP-EES at 2 years after complex PCI. Our data suggest that use of BP-BES is acceptable, even for complex PCI.

The Proximal Optimization Technique Improves Clinical Outcomes When Treated without Kissing Ballooning in Patients with a Bifurcation Lesion

BACKGROUND AND OBJECTIVES@#There are limited data regarding the clinical efficacy of the proximal optimization technique (POT) in the treatment of coronary bifurcation lesions. We investigated the influence of POT on the clinical outcomes of patients with coronary bifurcation lesions.@*METHODS@#We enrolled a total of 1,191 patients with a bifurcation lesion with a side branch (SB) diameter ≥2.5 mm treated with a drug-eluting stent from 18 centers between January 2003 and December 2009. The primary outcome was major adverse cardiac events (MACEs: cardiac death, myocardial infarction or target lesion revascularization [TLR]). We performed one-to-many (1:N) propensity score matching with non-fixed matching ratio.@*RESULTS@#POT was performed in 252 patients. During follow-up (median 37 months), the incidence of MACE was lower in the POT group than it was in the non-POT group (adjusted hazard ratio, 0.43; 95% confidence interval [CI], 0.24–0.79; p=0.006). After propensity score matching, these were 0.34; 95% CI, 0.17–0.69; p=0.003 for MACE and 0.37; 95% CI, 0.17–0.78; p=0.01 for TLR. The use of POT was associated with significantly lower TLR in patients treated without kissing ballooning, but was not in those who underwent kissing ballooning (p for interaction=0.03).@*CONCLUSIONS@#In coronary bifurcation lesions with a large SB, POT may be beneficial to improve long-term clinical outcome, particularly in patients treated without kissing ballooning during the procedure.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01642992

Rationale and Design of the High Platelet Inhibition with Ticagrelor to Improve Left Ventricular Remodeling in Patients with ST-Segment Elevation Myocardial Infarction (HEALING-AMI) Trial

BACKGROUND AND OBJECTIVES@#Impaired recovery from left ventricular (LV) dysfunction is a major prognostic factor after myocardial infarction (MI). Because P2Y12 receptor blockade inhibits myocardial injury, ticagrelor with off-target properties may have myocardial protection over clopidogrel. In animal models, ticagrelor vs. clopidogrel protects myocardium against reperfusion injury and improves remodeling after MI. We aimed to investigate the effect of ticagrelor on sequential myocardial remodeling process after MI.@*METHODS@#High platelet inhibition with ticagrelor to improve LV remodeling in patients with ST-segment elevation MI (HEALING-AMI) is an investigator-initiated, randomized, open-label, assessor-blinded, multi-center trial done at 10 sites in Korea. Patients will be enrolled if they have ST-segment elevation MI (STEMI) treated with primary percutaneous coronary intervention and a planned duration of dual antiplatelet treatment of at least 6 months. Screened patients will be randomly assigned (1:1) using an internet-based randomization with a computer-generated blocking with stratification across study sites to either ticagrelor or clopidogrel treatment. The co-primary primary endpoints are LV remodeling index with three-dimensional echocardiography and the level of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) at 6 months representing post-MI remodeling processes. Changes of LV end-systolic/diastolic volume indices and LV ejection fraction between baseline and 6-month follow-up will be also evaluated. Analysis is per protocol.@*CONCLUSIONS@#HEALING-AMI is testing the effect of ticagrelor in reducing adverse LV remodeling following STEMI. Our trial would show the benefit of ticagrelor vs. clopidogrel related to the recovery of post-MI LV dysfunction beyond potent platelet inhibition.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02224534

Safety and Efficacy of Biodegradable Polymer-biolimus-eluting Stents (BP-BES) Compared with Durable Polymer-everolimus-eluting Stents (DP-EES) in Patients Undergoing Complex Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES@#There are no data comparing clinical outcomes of complex percutaneous coronary intervention (PCI) between biodegradable polymer-biolimus-eluting stents (BP-BES) and durable polymer-everolimus-eluting stents (DP-EES). We sought to evaluate the safety and efficacy of BP-BES compared with DP-EES in patients undergoing complex PCI.@*METHODS@#Patients enrolled in the SMART-DESK registry were stratified into 2 categories based on the complexity of PCI. Complex PCI was defined as having at least one of the following features: unprotected left main lesion, ≥2 lesions treated, total stent length >40 mm, minimal stent diameter ≤2.5 mm, or bifurcation as target lesion. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (TV-MI), or target lesion revascularization (TLR) at 2 years of follow-up.@*RESULTS@#Of 1,999 patients, 1,145 (57.3%) underwent complex PCI: 521 patients were treated with BP-BES and 624 with DP-EES. In propensity-score matching analysis (481 pairs), the risks of TLF (3.8% vs. 5.2%, adjusted hazard ratio [HR], 0.578; 95% confidence interval [CI], 0.246–1.359; p=0.209), cardiac death (2.5% vs. 2.5%, adjusted HR, 0.787; 95% CI, 0.244–2.539; p=0.689), TV-MI (0.5% vs. 0.4%, adjusted HR, 1.128; 95% CI, 0.157–8.093; p=0.905), and TLR (1.1% vs. 2.9%, adjusted HR, 0.390; 95% CI, 0.139–1.095; p=0.074) did not differ between 2 stent groups after complex PCI.@*CONCLUSIONS@#Clinical outcomes of BP-BES were comparable to those of DP-EES at 2 years after complex PCI. Our data suggest that use of BP-BES is acceptable, even for complex PCI.

Usefulness of an Implantable Loop Recorder in Patients with Syncope of an Unknown Cause

PURPOSE: The mechanisms underlying syncope remain unknown in about 20% of patients with recurrent syncope. The implantable loop recorder (ILR) has been shown to be a useful diagnostic tool in patients with unexplained syncope even after negative initial evaluations. Nevertheless, ILR has rarely been used in clinical practice. MATERIALS AND METHODS: This study included 18 consecutive patients who had an ILR implanted at our center because of recurrent unexplained syncope after extensive diagnostic tests between February 2006 and June 2011. RESULTS: Diagnosis was confirmed in 10 (55.6%) of the 18 enrolled patients (13 males, 61+/-15 years). The confirmed diagnoses included sick sinus syndrome (n=6, 60%), advanced atrioventricular block (n=2, 20%) and ventricular tachyarrhythmia (n=2, 20%). The mean follow-up durations of the total study subjects and the diagnosed patients were 11.3+/-10.6 months and 5.6+/-9.2 months, respectively. Of the 10 diagnosed patients, 8 (80%) were diagnosed within 6 months of loop recorder implantation. CONCLUSION: ILR may be a valuable and effective diagnostic tool for patients with unexplained syncope.

Diagnostic Patterns in the Evaluation of Patients Presenting with Syncope at the Emergency or Outpatient Department

PURPOSE: Patterns of syncope evaluation vary widely among physicians and hospitals. The aim of this study was to assess current diagnostic patterns and medical costs in the evaluation of patients presenting with syncope at the emergency department (ED) or the outpatient department (OPD) of a referral hospital. MATERIALS AND METHODS: This study included 171 consecutive patients with syncope, who visited the ED or OPD between January 2009 and July 2009. RESULTS: The ED group had fewer episodes of syncope [2 (1-2) vs. 2 (1-5), p=0.014] and fewer prodromal symptoms (81.5% vs. 93.3%, p=0.018) than the OPD group. Diagnostic tests were more frequently performed in the ED group than in the OPD group (6.2+/-1.7 vs. 5.3+/-2.0; p=0.012). In addition, tests with low diagnostic yields were more frequently used in the ED group than in the OPD group. The total cost of syncope evaluation per patient was higher in the ED group than in the OPD group [823000 (440000-1408000) won vs. 420000 (186000-766000) won, p<0.001]. CONCLUSION: There were some differences in the clinical characteristics of patients and diagnostic patterns in the evaluation of syncope between the ED and the OPD groups. Therefore, a selective diagnostic approach according to the presentation site is needed to improve diagnostic yields and to reduce the time and costs of evaluation of syncope.

Factors Related to Prehospital Time Delay in Acute ST-Segment Elevation Myocardial Infarction

Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 +/- 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.

Gene Expression Profile in Microglia following Ischemia-Reperfusion Injury

Microglial activation is thought to play a role in the pathogenesis of many brain disorders. Therefore, understanding the response of microglia to noxious stimuli may provide insights into their role in disorders such as stroke and neurodegeneration. Many genes involved in this response have been identified individually, but not systematically. In this regards, the microarray system permitted to screen a large number of genes in biological or pathological processes. Therefore, we used microarray technology to evaluate the effect of oxygen glucose deprivation (OGD) and reperfusion on gene expression in microglia under ischemia-like and activating conditions. Primary microglial cultures were prepared from postnatal mice brain. The cells were exposed to 4 hrs of OGD and 1 h of reperfusion at 37 degrees C. Isolated mRNA were run on GeneChips. After OGD and reperfusion, > 2-fold increases of 90 genes and > 2-fold decrease of 41 genes were found. Among the genes differentially increased by OGD and reperfusion in microglia were inflammatory and immune related genes such as prostaglandin E synthase, IL-1beta, and TNF-alpha. Microarray analysis of gene expression may be useful for elucidating novel molecular mediators of microglial reaction to reperfusion injury and provide insights into the molecular basis of brain disorders.

Angiographic Outcomes and Predictors of Recurrent Restenosis after Cutting Balloon Angioplasty for the Treatment of In-Stent Restenosis

BACKGROUND AND OBJECTIVES: The optimal treatment for in-stent restenosis(SR) s controversial, although intracoronary radiation therapy(CRT) as provided the most consistent results to date. This study was designed to assess the early and late angiographic results, and to find independent predictors of recurrent restenosis, following cutting balloon angioplasty(BA) or ISR. SUBJECTS AND METHODS: Eighty patients(7 lesions) ith first time ISR underwent CBA and systematic follow-up(U) ngiography. A conventional balloon was used before, or after, the CBA, if required. ICRT was used in 18 lesions(1%). A multivariate logistic regression analysis was performed.(why?) RESULTS: he ISR was focal(n=2, 37%), diffuse or proliferative(n=1, 58%) nd occlusive(n=4, 5%). Procedural success was achieved in all 87 lesions(00%). No significant edge dissection occurred. The pre- and post-procedural diameter stenoses(S) ere 81.5+/-10.8% and 6.7+/-6.0%, respectively, and the pre- and post-procedural MLD(efine MLD?) .71+/-0.44 mm and 2.85+/-0.32mm, respectively, with 2.14+/-0.44mm of acute gain. A FU angiography was performed in 54(8%) f the 69 lesions treated with CBA alone. The overall angiographic restenosis rate was 24%(3/54), with 9%(/22) n the focal ISR and 34%(1/32) n the diffuse or occlusive ISR. The FU DS and MLD were 32.0+/-23.4% and 2.1+/-0.7mm, respectively, with 0.79+/-0.69mm of late loss. The length of a restenotic lesion(R 12.2, 95% CI:1.3-115.2, p=.0286) as an independent predictor of recurrent restenosis. CONCLUSION: CBA is a simple and efficient first line treatment for ISR, with an acceptable restenosis rate, and the length of a restenotic lesion is an independent predictor of recurrent restenosis. In diffuse or occlusive ISR, more definite treatment modalities, such as ICRT combined with CBA or debulking techniques, might be required to reduce recurrent restenosis.

The Role of Intraoperative Transesophageal Echocardiography

BACKGROUND AND OBJECTIVES: Intraoperative echocardiography (IOE), mostly done by transesophageal methods, provides an important means of accessing cardiac structure and function during cardiac and noncardiac surgery. The purpose of this study was to determine the role of IOE by identifying the frequency of the use of IOE during cardiac surgery, the rate of second pump operations determined by IOE findings, and the results of the operations. SUBJECTS AND METHODS: Sixty-five patients (93 lesions) underwent cardiac surgery with the concomitant IOE done by a cardiologist in a single institution between March 1997 and October 1998. The data was collected retrospectively by reviewing the hospital records and IOE videotapes. IOE was applied to 18.9% of total cardiac operations, primarily being used in MV surgery (48.4%). A pre-pump IOE was done in 2 cases and the post-pump procedure was done in the remainder. A second pump operation was performed in 4 cases (6.25%) and all of these were found to be successful after immediate re-operation. CONCLUSION: IOE was primarily used in valve operations, particularly in procedures involving the mitral valve. IOE appears to be useful in determining the immediate results following cardiac surgery and may contribute to determining the prognosis of the patient.

A Case of Single Coronary Artery Originating from Ascending Aorta Above the Left Coronary Sinus

We report a case with an isolated single coronary artery originating from the ascending aorta, which to our knowledge has never been described before. A 51-year-old man presented for evaluation of atypical chest pain, suffering from a short resting chest pain for 3 days. However, serial electrocardiogram showed no change during chest pain. Cardiac enzymes such as CK-MB, Troponin-I, and myoglobin were within normal limit. Aortography and coronary angiography revealed a single coronary artery originating from the postero-lateral wall of the ascending aorta above the left coronary siuns. However, this anomaly was not of clinical significance based on the atypical nature of the chest pain, negative exercise echocardiography and an absence of obstruction of the coronary artery.

Changes of Heart Rate Variability in Patients with Postmenopausal Syndrome after Hormonal Replacement Treatment

BACKGROUND AND OBJECTIVES: Climacteric women often suffer from vasomotor symptoms. These symptoms are thought to be related to an imbalance of autonomic control of the cardiovascular system and are effectively controlled with hormonal replacement therapy. Heart rate variability (HRV) reflects the autonomic integration of the cardiovascular system. In this study, we attempted to compare the HRV indices of postmenopausal women before and after hormonal replacement therapy. SUBJECTS AND METHODS: Eighteen patients with postmenopausal syndrome (mean age:53+/-4 years) received estrogen and/or progesterone replacement therapy. They underwent 24-hour ambulatory electrocardiographic monitoring at baseline and after the early period of therapy (mean:112+/-19 days) and eleven patients underwent the examination after the later period of therapy (mean 213+/-23 days). HRV was analyzed over a full 24-hour period, using time and frequency domain parameters. RESULTS: No statistically significant HRV change was observed during the early period of therapy. However, during the later therpy period , HRV indices such as rMSSD[from 27.6 to 31.3 (msec)], HF[from 4.8 to 5.05 ln (ms2)], LF/HF ratio (from 1.17 to 1.12) were significantly changed (p value<0.05). CONCLUSION: HRV was significantly changed in postmenopausal women during the later period of hormonal replacement therapy.

Characteristics of gene transfer and VEGF expression using naked plasmid vectors in the rat heart / 대한내과학회지

BACKGROUND: The purpose of this study was to compare gene expression among newly designed eukaryotic expression vectors, and to characterize the pattern of vascular endothelial growth factor(VEGF) expression using the most potent plasmids DNA vector. METHODS: After exposure of a beating rat heart (Sprague-Dawley, 250-300g), 5 different types of plasmid DNA was injected directly into the myocardium. Reporter protein was analyzed by ELISA in the extracted heart. RESULTS: The vector harboring cytomegalovirus (CMV) promoter and enhancer induced the strongest expression of reporter gene (chloramphenicol acetyl transferase; CAT) compared to those of pC3.1, pEF1a, RSV, pActin in the rat heart via direct injection of plasmid DNA into the apex (p<0.001). Using pCN-CAT, gene expression showed a dose-dependent response over a range of 0.3-10 (mu)g. CAT expression could be detected up to 30 days after 10 (mu)g of pCN-CAT injection with the maximal expression on day 5. In X-gal staining of injected pCN-lacZ gene, beta-galactosidase was found only around the needle track in the apex. The expressed hVEGF121 had biologic activity with vascular permeability assay (Miles assay) in guinea pigs. After injection of pCN-hVEGF121 into the apex of the rat heart, the expression of VEGF protein was dose-dependent over the range of 25 and 500 (mu)g. VEGF expression was detected up to 14 days with its peak on day 2 after injection of 250 (mu)g of pCN-hVEGF121. When plasmid was injected into the apex of the rat heart, the expression of VEGF in the heart showed concentration gradient from the apex to the base. However, the expression of CAT was detected only in the apex. CONCLUSION: Plasmids vector with hCMV IE promoter/enhancer will provide clear advantages over other previously developed plasmids and the information regarding the behaviors of VEGF expression may be useful in angiogenic gene therapy of the heart.

Association of Angiotensin-Converting Enzyme Gene Polymorphism and Angiotensin-Converting Enzyme Activity in Korean patients with Coronary Artery Disease

BACKGROUND: Insertion/Deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE) gene has been postulated as a risk factor for coronary artery disease. However, controversies exist whether deletion polymorphism in the ACE gene and/or high levels of ACE activity may be a risk factor for coronary artery disease (CAD). We investigated the association of the I/D polymorphism of the ACE gene and serum ACE activity in Korean patients with CAD. METHODS: Study subjects were 629 patients who underwent coronary angiography. CAD group (n=77) was subdivided according to either clinical manifestation or the number of diseased vessels on angiography. The control group comprised 152 patients who did not have a significant coronary lesion. Low risk group (n=5) was defined as subjects with age <55 years, a body mass index (BMI) <26 kg/m2 and a plasma ApoB <125 mg/dl. RESULTS: 1) The genotype and allele frequencies of ACE gene polymorphism were not different between control (DD:DI:II=.20:0.48:0.32, D:I=.44:0.56) and CAD group (DD:DI:II=.18:0.46:0.36, D:I=.41:0.59). 2) When the CAD group was subdivided into stable angina (SA) and acute coronary syndrome (ACS) group, neither ACE genotype nor allele frequencies differed between the SA and ACS group. 3) There was no significant association between the ACE polymorphism and the severity of CAD, as assessed by the number of diseased coronary vessels. 4) A significant difference in serum ACE activity was apparent among ACE genotypes in both controls and CAD subjects. Serum ACE activity in individuals with the DD genotype was significantly greater than that in individuals with DI or II genotypes. 5) There was no difference in serum ACE activity between controls and the CAD subjects of all genotypes or of the same genotype. 6) There was no association between the ACE polymorphism or serum AC activity and CAD in the low risk group. CONCLUSIONS: We have shown that neither the ACE I/D polymorphism nor serum ACE activity act as an independent risk factor in the development of CAD in Korean. This result indicates that the gene polymorphism and variation in serum ACE activity are not risk factors for CAD in this population.

Head-up Tilt Test in Subjects with No History of Syncope or Presyncope

BACKGROUND AND OBJECTIVES: Head-up tilt test is increasingly being used to diagnosis neurocardiogenic syncope. But the protocol of head-up tilt test has not been settled. The purpose of this study was to evaluate the effect of isoproterenol provocation during head-up tilt test in normal volunteers with no prior history of syncope or presyncope. METHOD: Head-up tilt test was performed with 53 volunteers (age 309, male 27, female 26) in the fasting state. After supine heart rate and blood pressure were obtained, each volunteer was tilted to the 70 degree upright position for 30 minutes using a motorized tilt table with a footboard. If the test was negative in the baseline tilt, intravenous isoproterenol was started at 1g/min and then increased by 1g/min every three minutes to a maximum of 5g/min while maintaining 70 degree upright position. The end points of test were positive response, intolerance to isoproterenol, heart rate >150beat/min and completion of the protocol. When an end point was reached, the volunteer was rapidly returned to the supine position. RESULTS: Positive response to head-up tilt test was noted in 14 cases (26%). The pattern of positive response was vasodepressive in all cases. There was no significant side effect of isoproterenol. There was no significant difference between positive and negative response group in terms of age, sex, peak infusion rate of isoproterenol and hemodynamic response. The positive response rate at 2 g/min , 3 g/min, 4 g/min and 5 g/min of isoproterenol infusion was 1.9%, 9.7%, 23.7% and 32.5%, respectively. CONCLUSION: Head-up tilt test at 70 degree angle with isoproterenol infusion provided an adequate specificity.

A case of spontaneous pneumomediastinum and subcutaneous emphysema in dermatomyositis: Including analysis of cases with dermatomyositis and pneumomediastinum in the literature / 대한내과학회지

Spontaneous pneumomediastnum is a very rare complication of systemic autoimmune diseases. The precise mechanism of pneumomediastinum in dermatomyositis is not well known. Pulmonary alveoli rupture secondary to interstitial pneumonitis or pulmonary infarctions consequent upon vasculitis are the suggested mechanisms. Among the idiopathic inflammatory myopathies, dermatomyositis and polymyositis show similar clinical manifestations except skin lesions. But pneumomediastinum occurs exclusively in cases with dermatomyositis, not in case with polymyositis. In a literature review, patients with dermatomyositis and pneumomediastinum had some characteristic features. As compared with dermatomyositis without pneumomediastinum, CK level was normal in about half and concomitance of interstitial lung disease and cutaneous vasculitis were very frequent. We experienced a case of dermatomyositis with spontaneous pneumomediastinum and subcutaneous emphysema. Thus we report that with a review of the literature and analysis of reported cases.