A Clinically Silent Case of Prominent Thebesian System: Diagonal Branch of Left Anterior Descending Coronary Artery to Left Ventricular Communication

Fistulous communication from the coronary artery to the left ventricle (LV) is extremely rare and has received little attention in the literature. Moreover, a case of coronary artery fistula (CAF) from a diagonal branch of the left anterior descending coronary artery to the LV has been reported only once in the literature. Herein, we report a case of CAF from a diagonal branch of the left anterior descending coronary artery to the LV, along with a review of the pertinent literature regarding this disorder.

Effect of Central Losartan on DOCA-Salt Hypertension Rats

BACKGROUND: The purpose of this study was to investigate whether brain AT1 receptor stimulation contributes as a hypertensive mechanism to deoxycorticosterone acetate (DOCA)-salt hypertension. METHODS: 1) Acute injection:Losartan (1 mg/4 uL) or artificial cerebrospinal fluid (aCSF) was injected into the lateral cerebral ventricle (icv) of conscious control uninephrectomized Wistar rats or rats with DOCA-salt at 2 or 4 weeks, and mean arterial pressure (MAP) and heart rates (HR) were recorded. 2) Chronic injection:Using osmotic minipump, losartan (1 mg/kg/d) or aCSF was injected to a sham group or three DOCA-salt rat groups [icv-aCSF, icv-losartan, sc-losartan (subcutaneous) groups] for 4 weeks, after which the MAP and HR were recorded in addition to the weights of the left (LV) and right ventricles (RV) and kidneys. RESULTS: 1) Acute injection: In rats treated with DOCA-salt, resting MAP significantly increased compared to the control group [144+/-6 mmHg (2 weeks), 170+/-5 mmHg (4 weeks) vs 115-120 mmHg (controls)]. MAP decreased significantly (2 weeks, 4 weeks) at 4, 8, 24 hours after icv injection of losartan to the level of the control group. 2) Chronic injection: The general trend showed that MAP decreased more in the icv-losartan group than in the icv-aCSF group (127+/-15.2 mmHg vs 141.1+/-5.5 mmHg, p=0.0578). In all DOCA-salt groups, no differences in RV weight were found. In the icv-aCSF and sclosartan groups, the kidney weight increased compared to the control group, but there was no difference in LV and kidney weight between the icv-losartan group and the control group. CONCLUSION: Normalization of MAP after acute or chronic icv administration of the AT1 receptor antagonist suggests that the stimulation of the brain AT1 receptor plays a significant role in the development and maintenance of hypertension in the DOCA-salt hypertensive rat model. Losartan icv injection appeared to have a protective effect on the heart and kidney.

An Appraisal of the Electrocardiographic Criteria for Diagnosis of Left Ventricular Hypertrophy in Koreans: Comparison to Echocardiographic Measurement of Left Ventricular Mass

BACKGROUND AND OBJECTIVES: Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiovascular morbidity and mortality. Electrocardiography (ECG) is a widely available, simple and cost-effective screening method for the diagnosis of left ventricular hypertrophy. Since all the ECG criteria for LVH used for Koreans are based on ECG data from Caucasians, i.e., people whose body size is generally bigger than Koreans, its test accuracy may be low. The purpose of this study was to investigate by ECG the best cut-off value for LVH in terms of the left ventricular mass, as determined by echocardiogram. SUBJECTS AND METHODS: We investigated ECG and echocardiograms of 200 consecutive patients who visited the Korean University Anam Hospital. The sensitivity, specificity and diagnostic accuracy of the left ventricular mass for LVH, by the Sokolow-Lyon voltage criteria and Romhilt-Estes point score, were calculated and compared according to the cut-off values of 35, 40 and 45 mm and 3, 4 and 5 points, respectively. RESULTS: The sensitivities of the Sokolow-Lyon voltage criteria at 40 mm were slightly decreased (42.5, 37.5 and 8.8%; > or =35, > or =40, > or =45 mm), but the specificities and diagnostic accuracies were increased (specificities of 84.2, 95.0 and 99.2%, and diagnostic accuracies of 67.5, 72.0 and 63%; > or =35, > or =40, > or =45 mm). The sensitivities of a Romhilt-Estes point score of 4 points were slightly decreased (43.8, 37.5 and 13.8%; > or =3, > or =4, > or =5 points), but the specificities and diagnostic accuracies were increased (specificities 85.8, 94.2 and 98/3%, and diagnostic accuracies 69.0, 71.5 and 64.5%; > or =3, > or =4, > or =5 points). CONCLUSION: The Sokolow-Lyon voltage criteria at 40 mm or more and a Romhilt-Estes point score 4 points or more are appropriate ECG criteria for LVH in Koreans.

A Case of Anterior Papillary Muscle Rupture with Total Occlusion of Right Coronary Artery Resulting in Inferior Myocardial Infarction

The arterial supply of the posteromedial papillary muscle of the left ventricle arises from the terminal branches of the right or circumflex arteries, depending on the distribution of these arteries. The anterolateral papillary muscle of the left ventricle is supplied primarily by one or more branches from the left anterior descending coronary artery, although it may also be supplied by circumflex marginal branches. The anterolateral papillary muscle is supplied only by the branches of the left coronary artery. However, in our case, the patient demonstrated a total occlusion of the right coronary artery that resulted in acute inferior myocardial infarction with a complete anterolateral papillary muscle rupture of the left ventricule as well as acute mitral insufficiency.

Effects of Estrogen in the Myocardium of Aged Ovariectomized Rats

BACKGROUND AND OBJECTIVES: The effects of estrogen in the myocardium of aged ovariectomized rats, relating to the estrogen replacement onset time following an ovariectomy, and the replacement duration have not yet been established. The object of this study was to investigate the effects of estrogen replacement in the myocardium of aged ovariectomized rats. MATERIALS AND METHODS: 52 Female Sprague Dawley rats, about 3 months old, were subjected to sham surgery only (Group 1 ; control, n=9) ; a bilateral ovariectomy (OVX) and maintained untreated for a period of 12 weeks following surgery (Group 2 ; OVX only, n=16) ; estrogen conjugate 25 microgram/kg daily for 4weeks from the 8th post ovariectomy week (Group 3 ; OVX+estrogen replacement therapy : ERT 4weeks, n=10) ; estrogen conjugate 25 microgram/kg daily p.o for 12weeks directly post ovariectomy (Group 4 ; OVX+ERT 12weeks, n=17). We measured the left ventricular wall thickness (LVWT), the number of cardiomyocytes and interstitial fibrosis, edema, using light and electron microscopy. RESULTS: The LVWT in group 4 was 2.25 mm, which was significantly decreased compared to groups 2 and 3, which were 2.45 mm (p=0.014) and 2.46 mm (p=0.008), respectively. The LVWT in group 4 was not significantly different to that of group 1. Interstitial edema was significantly decreased in group 4 (41.2%) compared to that of group 3 (62.0%) (p=0.019). The electron microscopic findings showed a decrease of crystae and a loss of matrix, resulting in a whitish discoloration of the mitochondria in groups 2 and 3. A similar finding was not observed in groups 1 and 4. CONCLUSION: These results suggest that early administration and maintenance of estrogen following a bilateral ovariectomy could prevent the myocardial changes caused by estrogen deficiency.

A Case of Moyamoya Disease with Total Occlusion of Left Main Coronary Artery

Moyamoya disease is an occlusive intracranial arteriopathy with an abnormal cerebral vascular collateral network at the base of brain. Despite strict diagnostic guidelines for moyamoya disease, the etiology and pathogenesis remains unknown. There are several reports that moyamoya disease should be regarded as a systemic vascular disorder. However, Moyamoya and coronary artery disease may have common etiologic factors. We decribe here a 35-year-old female with moyamoya disease that was diagnosed as severe coronary artery disease. Coronary angiography showed a left main ostial total obstruction with TIMI grade III collateral blood supply from the normal right coronary artery. We report the first clinical case of moyamoya disease with left main ostial total obstruction in a Korean patient and recommend that an evaluation of the extracranial (especially coronary artery) vascular system should be considered if there is some evidence of coronary artery disease.

Prevalence of Obesity and Correlation Between Obesity and Dyslipidemia in Elderly Population in South-West Seoul

BACKGROUND: Recently obese people have increased in Korea due to change of diet and life style. Obesity itself is an independent risk factor of cardiovascular disease. Also, obesity is associated with hyper tension, dyslipidemia, and diabetes as a componet of insulin resistance syndrome. To assess the health implications of obesity, we investigated the prevalence of obesity and the correlation between obesity and dyslipidemia. METHOD: The study was conducted in 1,733 elderly Korean(male 346, female 1,387) who lived in southwest Seoul area. Subjects were checked sex, age, height, weight, waist circumference, hip circumference blood pressure, serum total cholesterol, triglyceride, HDL cholesterol and LDL cholesterol. Overall obesity was measured by BMI(body mass index) and abdominal obesity was evaluated by WHR(waist-to-hip ratio). Subjects were divided according to their BMI(<25.0, > or = 25.0) and WHR(male< or =0.90, > or =0.90/female< or =0.85, > or =0.85). RESULT: The prevalence of obesity according to BMI was 32.1% in men and 46.4% in women. Systolic and diatolic blood pressure, total cholesterol, triglyceride, LCD cholesterol in the obese group revealed significantly higher than those in the nonobese group. In the abdominal obesity male group according to WHRl, the serum tiglyceride level was increased and the serum cholesterol level was decrea- sed but blood pressure, total cholesterol and LDL cholesterol were not different compared with the non-obese group. In the abdominal obesity female group, sys- tolic and diastolic blood pressure was significantly different in addition to triglyceride and HDL cholesterol compared with the non-obese group. CONCLUSION: Obese Korean elderly population had a characteristics like higher levels of blood pressure, serum total cholesterol, triglyceride and lower level of HDL cholesterol. which were known as cardiovascular risk factors. To evaluate the correla- tion between obesity and cardiovascular risk, prospective study for the difference of incidence of cardiovascular disease between obese and non-obese group will be continued.

Korean multicenter clinical trial of simvastatin ( KS-1 study ) / 대한내과학회지

The aim of this study was to investigate the efficacy of simvastatin to improved lipid profiles in hypercholesterolemic Korean patients. METHODS: From 25 hospitals in Korea, 478 hypercholesterolemic patients were enrolled from November 1996 to April 1998. The inclusion criteria was hypercholesterolemia over 240 mg/dl after diet therapy for 1 month or hypercholesterolemia over 220 mg/dl in patients with definite evidence of ischemic heart disease. Simvastatin 10mg was started and doubled up to 40mg if total cholesterol level remained higher than 200 mg/dl at monthly check. Of 478 subjects, 344 patients in whom study protocol was not violated were analyzed. RESULTS: Male to female ratio was 27:73 and 47% of the subjects were in 6th decade. Hypertension, coronary artery disease, and diabetes mellitus were present in 30, 10, and 4% of the subjects. Baseline lipid profile (mean of total cholesterol-LDL-HDL-triglyceride mg/dl) was 274-185-52-188. The dose of simvastatin for 3 months was 10/10/10mg in 61% of subjects, 10/20/20mg in 21%, 10/10/20mg in 7%, and 10/20/40mg in 12%. The change of total cholesterol level(before-4wk-8wk-12wk-withdrawal 4wk) was 274-209- 205-198-250, and the maximal reduction rate was 27%. The change of LDL-cholesterol was 185-123-116-110-159, with maximal reduction rate 39%. The change of HDL-cholesterol was 52-54-56-55-54, with maximal increase rate 9%. The change of tryglyceride was 188-161- 164-162-189, with maximal reduction rate 15%. The value before/after treatment of ApoA1, ApoB, and Lp(a) was 129/129, 138/83, and 9.3/10.7, respectively. The level of LDL-cholesterol at the end of treatment was below 100mg/dl in 36% of subjects, 100-130 in 45%, 130-160 in 16%, and over 160mg/dl in 4%. The reduction rate of LDL-cholesterol was different between subjects whose LDL decreased below 100 and those whose LDL did not decrease below 130mg/dl, which suggests the existence of the individual difference of responsiveness to simvastatin. There were only 3 subjects (0.9%) who showed increase of liver enzyme over 3 times as the upper normal limit. Conclusion: Simvastatin is effective in improving lipid profiles in hypercholesterolemic Korean patients without serious side effects.

Korean multicenter clinical trial of simvastatin ( KS-1 study ) / 대한내과학회지

The aim of this study was to investigate the efficacy of simvastatin to improved lipid profiles in hypercholesterolemic Korean patients. METHODS: From 25 hospitals in Korea, 478 hypercholesterolemic patients were enrolled from November 1996 to April 1998. The inclusion criteria was hypercholesterolemia over 240 mg/dl after diet therapy for 1 month or hypercholesterolemia over 220 mg/dl in patients with definite evidence of ischemic heart disease. Simvastatin 10mg was started and doubled up to 40mg if total cholesterol level remained higher than 200 mg/dl at monthly check. Of 478 subjects, 344 patients in whom study protocol was not violated were analyzed. RESULTS: Male to female ratio was 27:73 and 47% of the subjects were in 6th decade. Hypertension, coronary artery disease, and diabetes mellitus were present in 30, 10, and 4% of the subjects. Baseline lipid profile (mean of total cholesterol-LDL-HDL-triglyceride mg/dl) was 274-185-52-188. The dose of simvastatin for 3 months was 10/10/10mg in 61% of subjects, 10/20/20mg in 21%, 10/10/20mg in 7%, and 10/20/40mg in 12%. The change of total cholesterol level(before-4wk-8wk-12wk-withdrawal 4wk) was 274-209- 205-198-250, and the maximal reduction rate was 27%. The change of LDL-cholesterol was 185-123-116-110-159, with maximal reduction rate 39%. The change of HDL-cholesterol was 52-54-56-55-54, with maximal increase rate 9%. The change of tryglyceride was 188-161- 164-162-189, with maximal reduction rate 15%. The value before/after treatment of ApoA1, ApoB, and Lp(a) was 129/129, 138/83, and 9.3/10.7, respectively. The level of LDL-cholesterol at the end of treatment was below 100mg/dl in 36% of subjects, 100-130 in 45%, 130-160 in 16%, and over 160mg/dl in 4%. The reduction rate of LDL-cholesterol was different between subjects whose LDL decreased below 100 and those whose LDL did not decrease below 130mg/dl, which suggests the existence of the individual difference of responsiveness to simvastatin. There were only 3 subjects (0.9%) who showed increase of liver enzyme over 3 times as the upper normal limit. Conclusion: Simvastatin is effective in improving lipid profiles in hypercholesterolemic Korean patients without serious side effects.

The Effects of Long Term Use of HMG-CoA Reductase Inhibitor on the Level of Lp (a)

BACKGROUND: Lipoprotein (a) concentration is mainly determined by apo (a) genotype, but elevated in the atherosclerotic vascular disease more than in normal group with the same apo (a) phenotype. It has been known that Lp (a) has independent metabolism in contrast with other lipoproteins and that the use of cholesterol lowering agent such as HMG-CoA reductase inhibitor for 6 months does not change the level of Lp (a). The results of several studies suggests that Lp (a) may be related to inflammation of atherosclerotic plaque and therefore, long term use of cholesterol lowering agents make plaque stable by reduction of inflammation at plaque. We hypothesized that there is a relationship between long term use of HMG-CoA reductase inhibitor and change of Lp (a) level. We prospectively measured Lp (a), lipids and inflammatory markers before and after long term use of HMG-CoA reductase inhibitor to examine our hypothesis. METHODS: Forty-nine subjects (M:F=28:21, age=59.1+/-12.0) with hyperlipidemia were administered HMG-CoA reductase inhibitor for 15 months (minimum 6 months, maximun 44 months), and Lp (a), lipids and inflammatory markers were measured before and after use of the HMG-CoA reductase inhibitor. In control group (ninty-nine subjects, M:F=60:39, age=61.2+/-9.2), these parameters were measured more than 6 months. RESULTS: In the hyperlipidemia group who were given HMG-CoA reductase inhibitor, baseline levels of total cholesterol, TG, LDL were significantly elevated more than those of the control group, but Lp (a) and inflammatory markers were not significantly different. After use of HMG-CoA reductase inhibitor, the level of Lp (a) was reduced significantly (before 28.9+/-29.3 mg/dl, after 20.0+/-19.0 mg/dl, p=0.009), but not significantly in the control group. There was a minimal relation between baseline Lp (a) levels and percent changes of Lp (a) levels. Total cholesterol and LDL levels reduced significantly after use of the drug, but inflammatory markers did not. CONCLUSION: These data showed that Lp (a) level in the hyperlipidemia group after the long term use of HMG-CoA reductase inhibitor decreased significantly. We suggest that these changes of Lp (a) level may be one of reliable markers for plaque stability in atherosclerotic vascular disease.

A Case of Amiodarone Keratopathy

Amiodarone hydrochloride is a benzofuran derivative used for the treatment of cardiac arrhythmias. It is associated with a number of side effects, including thyroidopathy, neuropathy, cutaneous pigmentation, photosensitivity, pulmonary toxicity, hepatotoxicity and keratopathy. Amiodarone keratopathy hasbeen classified into four stages. Corneal pigmentation varies from stage 0, which is a clear cornea without pigment deposition, to stage 3, that is, corneal pigmentation encroaching upon the pupil. We present a case of amiodarone induced keratopathy of stage 3 who received low dose oral amiodarone maintain therapy.

A Case of Clomipramine-Induced Chronic Dilated Cardiomyopathy

Dilated cardiomyopathy is a primary myocardial disease characterized by ventricular dilatation and impaired ventricular contractility. The etiology of dilated cardiomyopathy has not been known yet, but toxin such as alcohol, thiamine deficiency, endocrine disorder, viral or bacterial infection, hereditary disorder, and muscular dystrophy may be related to dilated cardiomyopathy. Cocaine abuse and anticancer drugs (especially doxorubicin) were reported as the causes of drugs of dilated cardiomyopathy also. Recently we experinced a case of dilated cardiomyopathy in 30 years old man who developed dilated cardiomyopathy on chronic clomipramine (one of trcyclic antidepressant drugs) treatment for a obsessive-compulsive disorder. He became asymptomatic and normalization of left ventricular diameters and function was evidenced echocardiographically after withdrawal of the drug. The possible association of cardiomyopathy and tricyclic antidepressant drugs and possibility of functional improvement after tricyclic antidepressant drugs withdrawal should be kept in mind.

Effect of Parathyroid Hormone on Left Ventricular Hypertrophy in Aged Ovariectomized Rats

BACKGROUND: It has been well known that the bone and kidney are the principle organs of parathyroid hormine (PTH) actions. Although patients with primary hyperparathyroidism show a high incidence of LVH and trophic effects of PTH on adult rat ventricular cardiomyocytes were investigated in vitro, effect of PTH on the cardiac tissue in vivo is unknown. METHODS: We examined the effects of PTH on the cardiomyocyte and interstitial tissue using adult rat heart. Twenty-two female Sprague-Dawley rats were ovariectomized bilaterally at three months old and weighing in 250 - 300 gm in order to exclude the trophic effect of estrogen. We administrated human parathyroid hormone (20 ug subcutaneously 5 times per week) to 12 rats for 4 weeks after raising for 8 weeks (PTH group):the remaining 10 rats received only normal saline (control). We measured left ventricular thickness [IVS+LVPW)/2] and number of cardiomyocytes and interstitial fibrosis on LM (H & E and Masson's trochrome stain) and EM. RESULTS: 1) LV wall thickeness tended to increase in PTH group as compared with control (2.16+/-0.31 vs 1.12+/-0.21 mm, p=0.099). 2) The number of cardiomyocyte in PTH group was significantly less than that of control (61.2+/-13.1 vs 70.5+/-14.9, p=0.003, Magnification x 400). 3) There was no significant change of interstitial fibrosis between PTH group and control. CONCLUSION: These results shggest that PTH may produce left ventricular hypertrophic effects in aged ovariectomized rat that resulted form hypertrophy of cardiomyocyte without increase of interstitial connetive tissue.

Response of the Rat Heart to Bilateral Ovariectomy and Estrogen

BACKGROUND AND OBJECTIVES: Although ovarian estrogen is believed to decrease coronary heart disease by improving plasma lipoprotein and enhancing vasodilation, estrogen effect on heart tissue has not been shown yet. So we investigated the effect of the ovariectomy and estrogen on rat heart tissue. MATERIALS AND METHODS: Female Sprague Dawley rats, about 3 months of age, were subjected to sham surgery (n=9) or bilateral ovariectomy (n=20) and maintained untreated for 8 weeks after surgery. We administered estrogen (20 mg/Kg subcutaneously, 3 times/week) to 10 ovariectomized rats for 4weeks; the remaining ovariectmized rats received only saline. Animals were divided in 3 group:group 1 (control); sham op, group 2; ovariectomized only, group 3; ovariectomy+estrogen. We measured left ventricular thickness [IVS+LVPW)/2] and number of cardiomyocytes and interstitial fibrosis on light microscope (H & E and Masson's trochrome stain) and electron microscope. RESULTS: 1) LV wall thicknesses were significantly increased in group 2 and group 3 as compared with group 1 (2.45+/-0.1 and 2.46+/-0.11 vs 2.31+/-0.15 mm). 2) There were no significant change in the number of cardiomyocyte between group 1, group 2 and group 3 (54.3+/-5.7, 60.2+/-19.4, 52.5+/-14.1). 3) Group 2 and group 3 show more interstitial edema (44% and 62.5% vs 0%) on LM and more interstitial edema and the increase of number of mitochondria on EM than group 1. CONCLUSION: Bilateral ovariectomized rats show the increase of LV wall thickness, which was caused by interstitial edema without cardomyocyte hypertrophy and these changes were not reversed by the short-term administration of estrogen for 4 weeks.

Effects of Ischemic preconditioning on the Post-ischemic Myocardial Dysfunction and Coronary Flow in the Isolated Rat Hearts

BACKGROUND: Brief episodic ischemias prior to subsequent prolonged ischemia limit infarct size and attenuate the reperfusion arrythmia. But the effect of ischemic preconditioning on post-ischemic myocardial dysfunction, coronary flow and nitric oxide (NO) remains unclear. METHODS: To investigate the effect of ischemic preconditioning on myocardial function and coronary flow during reperfusion after 15 minutes of global myocardial ischemia, 30 isolated hearts of Sprague-Dowley rats were perfused under constant pressure. Two episodes of three minutes global ischemia followed by 12 minutes of reflow were employed to precondition the hearts. The hearts were randomized to one of three groups : group I had no preconditioning, group II had preconditioning, group III had preconditioning as well as L-arginine pretreatment. Left ventricular developed pressure (LVDP), LV dp/dt, perfused coronary flow, concentration of NO and heart rate were continuously measured. RESULTS: In preconditioning groups (Group II, Group III), LVDP decreased during reflow and was lower than that of the control group. LV dp/dt decreased after reflow and gradually recovered with time but recovered was less in preconditioning groups. Coronary flow increased in the first few minutes after reflow in all groups, but decreased gradually. The decrease of coronary flow was greater in preconditioning groups. NO increased during the first 10 minutes after reflow and then decreased. In preconditioning groups, NO tends to be lower than that in the non-preconditioning group. CONCLUSION: Ischemic preconditioning was not beneficial to post-ischemic myocardial dysfunction, coronary flow and NO concentration in the flow. Cummulative effect of stunning due to repetitive ischemia for preconditioning may be an explanation for worse post-ischemic myocardial dysfunction and coronary flow in preconditioning groups.

Effects of Ischemic preconditioning on the Post-ischemic Myocardial Dysfunction and Coronary Flow in the Isolated Rat Hearts

BACKGROUND: Brief episodic ischemias prior to subsequent prolonged ischemia limit infarct size and attenuate the reperfusion arrythmia. But the effect of ischemic preconditioning on post-ischemic myocardial dysfunction, coronary flow and nitric oxide (NO) remains unclear. METHODS: To investigate the effect of ischemic preconditioning on myocardial function and coronary flow during reperfusion after 15 minutes of global myocardial ischemia, 30 isolated hearts of Sprague-Dowley rats were perfused under constant pressure. Two episodes of three minutes global ischemia followed by 12 minutes of reflow were employed to precondition the hearts. The hearts were randomized to one of three groups : group I had no preconditioning, group II had preconditioning, group III had preconditioning as well as L-arginine pretreatment. Left ventricular developed pressure (LVDP), LV dp/dt, perfused coronary flow, concentration of NO and heart rate were continuously measured. RESULTS: In preconditioning groups (Group II, Group III), LVDP decreased during reflow and was lower than that of the control group. LV dp/dt decreased after reflow and gradually recovered with time but recovered was less in preconditioning groups. Coronary flow increased in the first few minutes after reflow in all groups, but decreased gradually. The decrease of coronary flow was greater in preconditioning groups. NO increased during the first 10 minutes after reflow and then decreased. In preconditioning groups, NO tends to be lower than that in the non-preconditioning group. CONCLUSION: Ischemic preconditioning was not beneficial to post-ischemic myocardial dysfunction, coronary flow and NO concentration in the flow. Cummulative effect of stunning due to repetitive ischemia for preconditioning may be an explanation for worse post-ischemic myocardial dysfunction and coronary flow in preconditioning groups.

Changes of Mitral Inflow According to Position in Patients with Dilated Cardiomyopathy

BACKGROUND AND OBJECTIVES: Dilated cardiomyopathy(DCMP) probably is the end result of myocardial damage produced by various causes and shows various clinical manifestations. Some patients with DCMP experience more shortness of breath when change their position especially in left lateral decubitus position. We investigated whether the symptomatic changes according to position in DCMP patients were related to the changes of mitral inflow pattern. MATERIALS AND METHOD: DCMP patients with New York Heart Association functional class III or IV, who felt more shortness of breath when changed their position, were studied. The patients with atrial fibrillation or with moderate and severe valvular heart disease were excluded. Early and late atrial left ventricular filling velocities and time velocity integrals(TVI) and it's ratios of mitral inflow, heart rates, isovolumic relaxation time(IVRT), decelaration time(DT) of early mitral inflow were analysed in each decubitus position. RESULTS: 4 men and 3 women were included and their mean age was 60.3 years. 6 patients had mild mitral regurgitation and 4 patients had mild aortic regurgition. All patients felt more shortness of breath in left lateral decubitus position. Peak velocity and TVI of early mitral inflow were not changed significantly according to position. Peak velocity of late mitral inflow was increased significantly with right lateral decubitus position(Lt; 39.0+/- 14.1cm/sec, Rt; 49. 4+/-23.6cm/sec, p<0.05). TVI of late mitral inflow was increased significantly with right lateral decubitus position(Lt; 2.8+/-1.1cm, Rt; 3.8+/-1.9cm, p<0.05). Ratio of early and late mitral inflow peak velocity was decreased significantly with right lateral decubitus position(Lt; 2.13+ 0.34, Rt: 1.62+/-0.57, p<0.05). Ratio of early and late mitral inflow TVI was decreased significantly with right lateral decubitus position(Lt; 3.13+/-1.49, Rt; 2.13+/-1.32, p<0.01). Heart rate, IVRT, DT were not changed significantly according to position. CONCLUSION: In DCMP patients with symptomatic relief in right lateral position, mitral inflow patterns were changed. And this finding suggests that symptomatic relief may be related to decreased left ventricular filling pressure.

Effects of L-Arginine on Coronary Artery Spasm Induced by Intracoronary Acetylcholine in Patients with Angina Pectoris with Normal Coronary Angiogram

BACKGROUND: Coronary spasm can be induced by acetylcholine (ACh) ACh casues vasodilation when the endothelium is intact by releasing nitric oxide (NO). The aim of this study was to investigate whether L-arginine, the precursor of NO, could preserve endothelium-dependent vasodilation in patients with coronary artery spasm. METHOD: NO precusor L-arginine (20mg/kg/min) was infused intravenous for 30 minutes in nineteen patients with coronary spastic angina. Coronary spasm of the epicardial coronary artery (>75%) was induced by intracoronary injection of acetylcholine in incremental doses (ACh: A1 20ug, A2 50ug, A3 100ug) the spasm was then documented angiographically in all patients with coronary spastic angina. After the administration of L-arginine, intracoronary injection of acetylcholine was repeated as the same method in all coronary spastic angina patients. RESULTS: After systemic infusion of L-arginine, the constrictor response to ACh was significanfly attenuated : no spastic response in 8 cases (42%), increased doses of ACh for provoking spasm in 8 cases (42%) and no change in 3 cases (16%). There were no significant change in blood pressure and heart rate after the administration of L-arginine. CONCLUSION: The fact that L-arginine attenuated vasospasm provoked by ACh in human coronary arteries, suggests the possibilities that L-arginine may be used in the prevention and treatment of coronary spasm.

The Difference of Thrombogenic and Fibrinolytic Factors inPremenopausal and Menopausal Women

BACKGROUND: Thrombotic and fibrinolytic factors which change in women following menopause, may be of pathogenetic importance in atherogenetic and thrombotic cardiovascular diseases by altering fibrinolysis on vascular surfaces. We investigated whether parameters of thrombosis and fibrinolysis were different before and after menopause. METHODS: Thrombotic factors such as plasma plasminogen activator inhibitor type 1(PAI-1), fibrinogen, a2 antiplasmin, lipoprotein(a) were measured. In addition, fibrinolytic factors such as plasma tissue-type plasminogen activator(t-PA), plasminogen, antithrombin-III were also assessed in 41 premenopausal women, 174 menopausal women and 201 men. RESULTS: PAI-1 and fibrinogen and t-PA were significantly higher in menopausal women than in premenopausal women(13.1+/-6.6 vs 16.9+/-9.5ng/ml, p=0.046, 293.6+/-83.3 vs 347. 5+/-256.9mg/dl, p=0.001, 10.1+/-4.4 vs 12.5+/-5.6ng/ml, p=0.003). A positive significant correlation was found between PAI-1 and any other thrombogenic and fibrinolytic factors. CONCLUSIONS: PAI-1, fibrinogen, t-PA were higher in menopausal women than in premenopausal women. The findings suggest that increase of athersclerotic and thrombotic cardiovascular diseases after menopause may be influenced by these changes.

Effect of Double Bolus Urokinase on Thrombolysis in Acute Myocardial Infarction

BACKGROUND AND PURPOSE: Although thrombolytic strategies with streptokinase(STK) and tissue-type plasminogen activator(t-PA) in the treatment of acute myocardial infarction(AMI) have been studied in large-scale clinical trials in the western countries, such large-scale studies with urokinase(UK) are scanty. Even though UK is most commonly used thrombolytic agent for the treatment of AMI in Korea, there is no consensus on the dosage and the way of administration of UK in patients with AMI. Accordingly, a prospective clinical study was performed to evaluate the effects of thrombolytic strategies of intravenous double bolus method and standard double-infusion method with different dosage of UK in the treatment of AMI. SUBJECTS AND METHODS: Ninety there patients with AMI(male 75, female 18, age 57.5+/-10.8 years) were studied. The patients were divided into 3 groups according to dosage of UK and method of administration. Group I : 19 patients who received 1.5 million U of UK IV bolus, followed by 1.5 million U IV infusion for an hour(High Dose Group). Group II : 34 patients received 20,000U/kg body weight of UK IV bolus, followed by 20,000U/kg IV infusion for an hour(Double Dose Group). Group III : 40 patients received 1.5 million U of UK IV bolus and followed by 20,000U/kg IV bolus in 30 minutes with total dose of no more than 3 million U(Double Bolus Group). Coronary angiography(CAG) and left ventriculography(LVG) were performed 90 minutes after the administration of UK and post-AMI 7-10 days to investigate the patency of infarct-related artery(IRA) and LV function. Patency of IRA was graded according to the extent of flow of IRA. TIMI grade 0-1 was regarded as occluded, and grade 2-3 flow as patent. LV ejection fraction(EF) by echocardiography was measured on day 1, day 7-10 and 1 month after AMI. Indirect clinical parameters of thrombolysis were evaluated and were compared with CAG findings. RESULTS: 1) The 90 minutes IRA patency in Group III(Double bolus ; 79.0%) was higher than that in Group 1, but showed no statistically significant difference(High dose ; 61.5%, p=0.790). The 90 minutes IRA patency in Group III showed borderline significance with Group II(Double dose ; 57.1%, p=0.057). TIMI flow III in Group III(60.6%) was significantly higher than that in Group II(53.6%, p=0.0468) but showed no statistically significant difference with Group I(61.5%, p=0.158). 2) The EF by LVG were 49.1% in Group I, 41.7% in Group II and 49.2% in Group III. The difference in EF between Group I and Group III vs Group II was significant(p=0.008 in Group I, p=0.014 in Group III vs Group II). 3) Fatal bleeding complications(1 intracranial hemorrhage and 1 gastric ulcer bleeding) developed in Group II (Double dose). 4) Pain to door time, pain to needle time and door to needle time tended to be shorter in open(TIMI flow II-III) IRA group than in closed IRA group. 5) Initial EF were similar between open IRA group and closed IRA group(46.1% and 42.1% ; p=NS). The EF of open IRA group measured by LVG on initail coronary angiography(41.8% in closed IRA vs 48.0%, in open IRA, p=0.03) and by 2D-Echo on 7-10 day(41.7% in closed IRA vs 51.0% in open IRA, p=0.004) were better than those of closed IRA group. 6) Indirect clinical indices of reperfusion such as mean CPK peak, time to CPK peak significantly lower in open IRA group than in closed IRA group. 7) Fatal bleeding complications(1 intacranial hemorrhage and 1 gastric ulcer bleeding) developed in closed IRA group. CONCLUSION: The findings we observed in this trial showed that earlier initiation and more rapid infusion of UK were associated with more increased 90min patency of infarct-related artery and more improved LV function without any obviously increased bleeding complications or other serious life-threatening complications than conventional UK therapy. Specifically, double bolus IV injection of UK(1.5 million U bolus followed by 20,000 U/Kg bolus in 30min)was more effective method of thrombolysis than conventional method for achieving optimal reperfusion in AMI patients. Also, IRA patency at 90 minutes after the initiation of thrombolysis was important in preserving global LV function in early recovery phase of AMI. Further trials may be needed to determine more effective thrombolysis with UK in AMI.