Comprehensive assessment of a post-coronary bypass graft patient with cardiovascular magnetic resonance imaging and multi-detector computed tomography / 老年心脏病学杂志（英文版）

Coronary bypass graft surgery (CABG) is a revascularization procedure which reduces myocardial ischemia and cardiovascular morbidity and mortality in selected patients; however, up to 40% of saphanous vein grafts may degenerate over 10 years. Although coronary angiography is the gold standard to detect graft patency and native vessel disease, sometimes it is difficult to locate the grafts resulting in increased exposure to radiation and contrast administration. This case highlights the utility of cardiac computerized tomography and magnetic resonance imaging to provide comprehensive noninvasive assessment in a patient post CABG.

The association of apolipoprotein B and low density lipoprotein with cardiovascular risk factors in the Thai population.

BACKGROUND: Although direct and calculated low density lipoprotein cholesterol (LDL-cholesterol) has been widely used as an important predictor for cardiovascular risk, many studies have shown that apolipoprotein B (apo B) may be a more important lipoprotein marker. MATERIAL AND METHOD: We performed a cross-sectional study on 191 volunteers who were Shinawatra employees during their annual physical check up. The following cardiovascular risk factors were recorded or measured: direct and calculated LDL, apo B, gender age, total cholesterol, triglyceride, HDL-cholesterol (HDL), calculated LDL, fasting plasma glucose (FPG), systolic and diastolic blood pressure, smoking status, body mass index (BMI), waist circumference, and waist-hip ratio (WHR). Apo B, direct LDL and calculated LDL levels were tested for their associations with other potential cardiovascular risk factors. RESULTS: There were a total of 76 men and 115 women with an average age of 28.8 +/- 5.4 years. Male gender, cigarette smoking, high cholesterol, high triglyceride, high fasting plasma glucose, hypertension, high WHR and high BMI were associated with increased apo B level. Only male gender and high cholesterol were associated with increased calculated and direct LDL level. The association of direct and calculated LDL-cholesterol level with cardiovascular risk factors appears to be similar. CONCLUSION: We demonstrated that apo B level correlates more with other cardiovascular risk factors compared to direct and calculated LDL-cholesterol. The clinical relevance of this finding needs to be explored in large-scale studies.

Accuracy of sixteen-slice CT scanners in detected coronary artery disease.

BACKGROUND: The coronary artery disease, now, the incidence is increasing in both developed and developing countries. The investigation is evoluted and non-invasive multislice CT scanners have been used more frequently, although the gold standard is still the coronary angiography. OBJECTIVE: To investigate the accuracy in detected coronary artery disease by using 16-slice CT scanners compared to the conventional coronary angiography. MATERIAL AND METHOD: Fifty-five patients were 43 males, 12 females, median aged 62 years (43-82 years), and average heart rates 67 beats/minute (46-147 beats/minute) had the ECG-gated CT angiography followed by coronary angiography in 3 months. The ECG-gated CT angiography was performed by using 16-slice MSCT detector (0.42-s rotation time, 16 x 0. 75-mm detector collimation). RESULTS: All patients were classified into two major groups; one was significant coronary artery stenosis which was designed by stenosis at least 50% and the other was non-significant stenosis which was designed by normal or stenosis less than 50%. The site having blooming artifact due to calcification that causes complete obliteration of the lumen or having significant motional artifacts was ruled out. There were 285 evaluable sites in 19 patients with high heart rates, more than 70 beats/minute. The sensitivity, specificity, and accuracy in significant stenosis were 72.9%, 99.6%, and 94.0% respectively. In 36 patients with a lower heart rate, there were 563 evaluable sites, the sensitivity was 86.5%, specificity was 98.5%, and accuracy was 96.6%. The overall showed 81.1% of sensitivity, 98.9% of specificity, and 95.8% of accuracy. CONCLUSION: The accuracy of the 16-slice CT angiography for patients suspected of having coronary artery disease was high. However, blooming artifacts from the calcium, respiratory artifacts, and small size of the distal and branching artery still caused limited luminal assessment. These problems have challenged the new coming generation of MDCT.

Accuracy of magnetic resonance imaging in the diagnosis of coronary artery disease.

BACKGROUND: Coronary magnetic resonance angiography is a noninvasive method to visualize coronary arteries. The objective of this study was to determine the accuracy of coronary magnetic resonance imaging in the detection of coronary artery stenosis. METHOD: The authors studied 61 patients who were scheduled for their first diagnostic X-ray coronary angiography. Magnetic resonance imaging of the coronary arteries under free-breathing was performed prior to the catheterization schedule. The results were compared. RESULTS: Forty-one out of 61 patients (67.2%) had significant coronary stenosis of at least one major coronary artery. Sixteen (26.2%) had triple vessel disease. A total of 391 of 427 segments had interpretable image quality (91.6%). The diagnostic accuracy of the left main artery, left anterior descending artery, left circumflex artery, and right coronary artery was 96.7 per cent, 90 per cent, 80 per cent and 85.2 per cent respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the detection of any significant coronary disease were 97.6 per cent, 75 per cent, 91.2 per cent, 90.9 per cent and 92.3 per cent respectively. CONCLUSIONS: Coronary magnetic resonance imaging is an accurate non-invasive imaging technique in the detection of coronary artery stenosis.

Clinical experience of sirolimus-eluting stents in patients with coronary artery disease at Bangkok Heart Institute.

Drug eluting stents represent one of the fastest growing fields in interventional cardiology today. From a recent study, the sirolimus eluting stent (SES) (CYPHER, Cordis, Johnson & Johnson) appear to demonstrate a remarkable efficacy and safety in preventing restenosis. From the present study, the authors reported clinical experience of SES in 40 consecutive patients with coronary artery disease (CAD) between 25th June and 11th October, 2002. The mean age was 59 +/- 12.16 years (mean +/- SD) and 80 per cent of the patients were male. The majority of the patients had chronic stable angina and most percutaneous coronary interventions were performed by elective procedure (85%). Thirty-five per cent of the patients had single vessel disease and 42.5 per cent of the patients had double vessel disease. The authors successfully implanted 52 (69.3%) SES in 75 target lesions revascularization. Twenty-four (60%) of the patients had more than 1 vessel intervention. Twenty-seven (67.5%) of the patients had complete revascularization by percutaneous coronary intervention (PCI) and only 16 of 27 patients (59.3%) who had complete revascularization with SES. The SES were usually implanted at middle part of the left anterior descending artery (MLAD) (11 lesions), proximal part of the left anterior descending artery (PLAD) (8 lesions), middle part of the right coronary artery (MRCA) (8 lesions) and middle part of the left circumflex artery (MLCX) (6 lesions). The authors had to cover plaque entirely with SES, so SES implantation usually took longer than the bare stent (BS). The authors followed the initial clinical outcome of the patients within 1 month after discharge. Few adverse clinical events were found during 1 month follow-up because SES have a very low rate of restenosis in the short-term so, we have to follow-up the patients over a longer period and will report the clinical outcome in the next study.

Role of the plasma brain natriuretic peptide in differentiating patients with congestive heart failure from other diseases.

BACKGROUND: Heart failure (HF) is primarily a disease of the elderly. The incidence of congestive heart failure (CHF) in Thailand has been increasing during the last 10 years. Unlike other diseases, physicians have only rough patients' symptoms and physical findings to guide the adequacy of treatment. Recently, there has been evidence of the role of brain natriuretic peptide (BNP) and its use in HF concerning diagnosis, prognosis, and treatment follow-up. The purpose of this study was to determine the sensitivity and specificity of N-terminal part of brain natriuretic peptide plasma level (NT-proBNP) in the diagnosis of HF in Thai patients who presented with dyspnea. METHOD: The design was a cross sectional study. The authors enrolled 50 consecutive patients from the Respiratory Unit with dyspnea from chronic obstructive pulmonary disease (COPD), asthma, or anxiety. The cardiovascular cause of dyspnea such as pulmonary emboli and poor left ventricular ejection fraction (LVEF) were excluded. Forty eight consecutive patients with evidence of HF who presented to the Cardiac Center with a history of dyspnea on exertion were assigned as cases. Five milliliters of venous blood samples were taken and sent together with 200 samples from a normal healthy population from the check up department for NT-proBNP measurement. RESULTS: In case and control groups, there were no statistical significances in sex (males 68.8% vs females 52.0%, p > 0.05) and age (63.3 +/- 14.9 vs 55.6 +/- 16.9; p > 0.05). The mean left ventricular ejection fraction in the case group was 32.4 +/- 9.7 per cent. There was significant difference between value of NT-proBNP in the control group (386 +/- 1,041 pg/ml) and in the case group (8,912 +/- 12,525 pg/ml, p < 0.001). To diagnose HF in patients who presented with dyspnea using the cut-off value of NT-proBNP at > 150 pg/ml in patients with dyspnea the sensitivity was 96 per cent, and the specificity of 72 per cent; at > 200 pg/ml the sensitivity was 96 per cent and the specificity was 80 per cent and at > 300 pg/ml the sensitivity was 94 per cent and specificity of 82 per cent. Plasma level of NT-proBNP increased significantly with increasing New York Heart Association (NYHA) functional class (class II: 1,107 +/- 1,091 pg/ml; class III: 5,097 +/- 4,201 pg/ml, class IV: 19,389 +/- 15,966 pg/ml p < 0.01). There was no significant difference of plasma NT-proBNP levels in patients with ischemic (8,586 +/- 11,601 pg/ml; n = 35) and those with non ischemic cardiomyopathy (9,789 +/- 15,229 pg/ml; n = 13). Plasma NT-proBNP was associated with neck vein distension (p < 0.05) but there was no significant association with S3, paroxysmal nocturnal dyspnea, rales, cardiomegaly, acute pulmonary edema, serum sodium (r = 0.22), ejection fraction (r = -0.18) and subsequent hospital death (p > 0.05). CONCLUSION: Measurement of plasma NT-proBNP proved to be a useful diagnostic test in differentiating HF from other causes in patients who presented with dyspnea.

Serum N-terminal pro-brain natriuretic peptide in normal Thai subjects.

Aminoterminal portion of pro-brain natriuretic peptide (NT-proBNP) appears to be useful in the screening, diagnosis and prognosis of left ventricular dysfunction and congestive heart failure. The purpose of this study was to determine the values of serum NT-proBNP in normal Thai subjects compared with subjects from other countries. The design is a cross sectional study. The authors enrolled 243 consecutive healthy subjects (134 males and 109 females) from the checkup department of Bangkok Hospital for NT-proBNP measurement. The serum fraction was measured for NT-proBNP concentration by using Elecsys 2010 (Roche Diagnostics, Switzerland). The concentrations of NT-proBNP in normal Thai subjects were 33.30 +/- 35.43 pg/ml. The NT-proBNP levels increased with age (age < or = 50 years = 27.56 + 28.77 pg/ml and age > 50 years = 47.20 +/- 45.18 pg/ml, p < 0.001). Females usually have higher NT-proBNP than males (females = 40.42 +/- 31.59 pg/ml, males = 27.51 +/- 37.40 pg/ml, p = 0.0045). This study established the NT-proBNP concentrations in normal Thai subjects, which were not different from other studies. The authors suggested the normal cut-off values for subjects aged < or = 50 years should be 100 pg/ml and the normal cut-off values for subjects aged > 50 years should be 200 pg/ml. The NT-proBNP assay could be used as a rule out marker for heart failure in patients and may trigger further cardiac investigation.