Clinical and Angiographic Outcomes of the First Korean-made Sirolimus-Eluting Coronary Stent with Abluminal Bioresorbable Polymer

BACKGROUND AND OBJECTIVES: This trial evaluated the safety and efficacy of the Genoss drug-eluting coronary stent. METHODS: This study was a prospective, multicenter, randomized trial with a 1:1 ratio of Genoss drug-eluting stent (DES)™ and Promus Element™. Inclusion criteria were the presence of stable angina, unstable angina, or silent ischemia. Angiographic inclusion criteria were de novo coronary stenotic lesion with diameter stenosis >50%, reference vessel diameter of 2.5–4.0 mm, and lesion length ≤40 mm. The primary endpoint was in-stent late lumen loss at 9-month quantitative coronary angiography follow-up. Secondary endpoints were in-segment late lumen loss, binary restenosis rate, death, myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis during 9 months of follow-up. RESULTS: We enrolled 38 patients for the Genoss DES™ group and 39 patients for the Promus Element™ group. In-stent late lumen loss at 9 months was not significantly different between the 2 groups (0.11±0.25 vs. 0.16±0.43 mm, p=0.567). There was no MI or stent thrombosis in either group. The rates of death (2.6% vs. 0%, p=0.494), TLR (2.6% vs. 2.6%, p=1.000), and TVR (7.9% vs. 2.6%, p=0.358) at 9 months were not significantly different. CONCLUSION: This first-in-patient study of the Genoss DES™ stent showed excellent angiographic outcomes for in-stent late lumen loss and major adverse cardiac events over a 9-month follow-up.

Association between the Red Cell Distribution Width and Vasospastic Angina in Korean Patients

PURPOSE: The association between the red cell distribution width (RDW) and vasospastic angina (VSA) has not been elucidated. We investigated the association of the RDW with the incidence and angiographic subtypes of VSA in Korean patients. MATERIALS AND METHODS: A total of 460 patients who underwent intracoronary ergonovine provocation tests were consecutively enrolled and classified into two groups: the VSA group (n=147, 32.0%) and non-VSA group (n=313, 68.0%). The subjects were classified into 3 subgroups (tertiles) according to the baseline level of RDW assessed before the angiographic provocation test. RESULTS: The VSA group had a higher RDW than the non-VSA group (12.9±0.8% vs. 12.5±0.7%, p=0.013). The high RDW level demonstrated an independent association with the high incidence of VSA [second tertile: hazard ratio (HR) 1.96 (1.13-2.83), third tertile: HR 2.33 (1.22-3.47), all p<0.001]. Moreover, the highest RDW tertile level had a significant association with the prevalence of the mixed-type coronary spasm [HR 1.29 (1.03-1.59), p=0.037]. CONCLUSION: The high level of RDW was significantly associated with the prevalence of VSA and the high-risk angiographic subtype of coronary spasm, suggesting that a proactive clinical investigation for VSA could be valuable in Korean patients with an elevated RDW.

Spatial and Temporal Expression, and Statin Responsiveness of Galectin-1 and Galectin-3 in Murine Atherosclerosis

BACKGROUND AND OBJECTIVES: Existing data on the spatiotemporal expression patterns of a variety of galectins in murine atherosclerosis are limited. We investigated the expression levels of galectins, and their in vivo spatiotemporal expression patterns and statin responsiveness in the inflamed atherosclerotic plaques of apolipoprotein E (apoE)-/- mice. MATERIALS AND METHODS: Galectins expression patterns in aortic atherosclerotic plaques and serum galectin-3 levels were investigated in 26-week-old apoE-/- (n=6) and C57BL/6 mice (n=9). To investigate the spatial and temporal patterns of galectin-1 and galectin-3 in plaques, high-cholesterol diet-fed 26-week-old (n=12) and 36-week-old apoE-/- mice (n=6) were sacrificed and their aortas were examined for galectins' expression using immunoblot analysis and immunohistochemical stain. 36-week-old apoE-/- mice were treated with atorvastatin (n=3, 0.57 mg/kg/day) for the evaluation of its effect on aortic galectins' expression. RESULTS: Immunoblot analyses showed that galectin-1 and galectin-3 were the predominant galectins expressed in murine atherosclerosis. The serum galectin-3 level was significantly higher in apoE-/- mice (p<0.001). While galectin-1 was weakly expressed in both intimal plaques and the media of atherosclerotic aortas, galectin-3 was heavily and exclusively accumulated in intimal plaques. Galectin-3 distribution was colocalized with plaque macrophages' distribution (r=0.66). As the degree of plaque extent and inflammation increased, the intraplaque galectin-3 expression levels proportionally elevated (p<0.01 vs. baseline), whereas galectin-1 expression had not elevated (p=0.14 vs. baseline). Atorvastatin treatment markedly reduced intraplaque galectin-3 and macrophage signals (p<0.001 vs. baseline), whereas it failed to reduce galectin-1 expression in the aortas. CONCLUSION: Galectin-3 is the predominant gal and is colocalized with macrophages within atherosclerotic plaques. Intraplaque galectin-3 expression reflects the degree of plaque inflammation.

Microalbuminuria is Independently Associated with Arterial Stiffness and Vascular Inflammation but not with Carotid Intima-Media Thickness in Patients with Newly Diagnosed Type 2 Diabetes or Essential Hypertension

The association between microalbuminuria (MAU) and the indices of macrovascular complication in patients with newly diagnosed type 2 diabetes (D) or essential hypertension (H) was evaluated. Total 446 patients were classified into four groups according to the urinary albumin-to-creatinine ratio: MAU-D (n = 104), normoalbuminuria (NAU)-D (n = 114), MAU-H (n = 116), and NAU-H (n = 112). The indices of macrovascular complication including arterial stiffness evaluated by pulse-wave-velocity (PWV), carotid intima-media thickness (IMT), and vascular inflammation marked by high-sensitivity C-reactive protein (hsCRP) were assessed. PWV, IMT, and hsCRP were higher in patients with MAU than in those with NAU in both diabetes and hypertension groups. In both MAU-D and MAU-H groups, PWV and hsCRP levels were positively correlated with MAU level (MAU-D: r = 0.47, 0.41, MAU-H: r = 0.36, 0.62, respectively, P < 0.05). Additionally, PWV and hsCRP were independent factors predicting MAU (diabetes group: OR 1.85, 1.54, hypertension group: OR 1.38, 1.51, respectively, P < 0.001), but not IMT. MAU is independently associated with arterial stiffness and vascular inflammation but not with IMT in patients with newly diagnosed type 2 diabetes or essential hypertension, which emphasizes the importance of proactive clinical investigations for atherosclerotic complications in patients with MAU, even in newly diagnosed diabetes or hypertension.

Deoxyribonucleic Acid Copy Number Aberrations in Vasospastic Angina Patients Using an Array Comparative Genomic Hybridization

BACKGROUND AND OBJECTIVES: Vasospastic angina (VA) is a specific type of coronary artery disease and develops as a result of coronary artery spasm. Recently, a few studies have revealed that VA caused by coronary artery spasm is related to genetic traits. The objective of this study was to use the recently developed technique of array comparative genomic hybridization (CGH) to screen the genetic aberrations of VA. SUBJECTS AND METHODS: To identify candidate genes that might be causally involved in the pathogenesis of VA, genomic deoxyribonucleic acids were extracted from whole blood of 28 patients with VA who presented at Department of Cardiology at Seoul St. Mary's Hospital, Seoul, Korea. The copy number profiles of these patients was then analyzed using array CGH and reverse transcriptase (RT) quantitative polymerase chain reaction (PCR). RESULTS: Array CGH revealed gains in 31 different regions, with losses in the 4q35.2, 7q22.1, 10q26.3, 15q11.2, 16p13.11, 17p11.2 and 19q13.3 regions (more than 32% aberration in these regions). Several loci were found to be frequently including gains of 5p and 11q (50% of samples). The most common losses were found in 7q (54% of samples). Copy number aberrations in chromosomal regions were detected and corresponding genes were confirmed by RT quantitative PCR. The fold change levels were highest in the CTDP1 (18q23), HDAC10 (22q13.33), KCNQ1 (11p15.5-p15.4), NINJ2 (12p13.33), NOTCH2 (1p12-p11.2), PCSK6 (15q26.3), SDHA (5p15.33), and MUC17 (7q22.1) genes. CONCLUSION: Many candidate chromosomal regions that might be related to the pathogenesis of VA were detected by array CGH and should be systematically investigated to establish the causative and specific genes for VA.

Two Cases of Percutaneous Intervention for Coronary Artery Bypass Graft Anastomoses With Paclitaxel-Eluting Balloon Catheters

Coronary artery bypass graft (CABG) intervention, particularly anastomosis site intervention, is challenging for interventional cardiologists. A paclitaxel-eluting balloon catheter (SeQuent Please) is a recently-introduced device capable of delivering paclitaxel homogeneously into the targeted vessel wall. We herein report our experience with two cases. In the first case, coronary angiography showed significant stenosis at the site of anastomosis between the saphenous vein graft and the left anterior descending artery (LAD). In the second case, coronary angiography showed significant stenosis at the site of anastomosis between the left internal mammary artery and the LAD. We performed percutaneous intervention of these CABG anastomoses using paclitaxel-eluting balloon catheters, and obtained favorable angiographic and clinical outcomes.

The Effect of Cilostazol on Stent Thrombosis After Drug-Eluting Stent Implantation

BACKGROUND AND OBJECTIVES: Placement of drug-eluting stents (DES) can be complicated by stent thrombosis; prophylactic antiplatelet therapy has been used to prevent such events. We evaluated the efficacy of cilostazol with regard to stent thrombosis as adjunctive antiplatelet therapy. SUBJECTS AND METHODS: A total of 1,315 patients (846 males, 469 females) were prospectively enrolled and analyzed for the frequency of stent thrombosis. Patients with known risk factors for stent thrombosis, except diabetes and acute coronary syndrome, were excluded from the study. All patients maintained antiplatelet therapy for at least six months. To evaluate the effects of cilostazol as another option for antiplatelet therapy, triple antiplatelet therapy (aspirin+clopidogrel+cilostazol, n=502) was compared to dual antiplatelet therapy (aspirin+clopidogrel, n=813). Six months after stent placement, all patients received only two antiplatelet drugs: treatment either with cilostazol+aspirin (cilostazol group) or clopidogrel+aspirin (clopidogrel group). There were 1,033 patients (396 in cilostazol group and 637 in clopidogrel group) that maintained antiplatelet therapy for at least 12 months and were included in this study. Stent thrombosis was defined and classified according to the definition reported by the Academic Research Consortium (ARC). RESULTS: defined and classified according to the definition reported by the Academic Research Consortium (ARC). RESULTS: During follow-up (561.7+/-251.4 days), 15 patients (1.14%) developed stent thrombosis between day 1 to day 657. Stent thrombosis occurred in seven patients (1.39%) on triple antiplatelet therapy and four patients (0.49%) on dual antiplatelet therapy (p=NS) within the first six months after stenting. Six months and later, after stent implantation, one patient (0.25%) developed stent thrombosis in the cilostazol group, and three (0.47%) in the clopidogrel group (p=NS). CONCLUSION: During the first six months after DES triple antiplatelet therapy may be more effective than dual antiplatelet therapy for the prevention of stent thrombosis. However, after the first six months, dual antiplatelet treatment, with aspirin and cilostazol, may have a better cost benefit ratio for the prevention of stent thrombosis.

Aortic Valve Sclerosis on Echocardiography is a Good Predictor of Coronary Artery Disease in Patients With an Inconclusive Treadmill Exercise Test

BACKGROUND AND OBJECTIVES: The treadmill exercise test (TMT) is used as a first-line test for diagnosing coronary artery disease (CAD). However, the findings of a TMT can be inconclusive, such as incomplete or equivocal results. Aortic valve sclerosis (AVS) is known to be a good predictor of CAD. We determined the usefulness of assessing AVS on 2-dimensional (2D) echocardiography for making the diagnosis of CAD in patients with inconclusive results on a TMT. SUBJECTS AND METHODS: This prospective study involved 165 consecutive patients who underwent a TMT that resulted in inconclusive findings, 2D echocardiography to detect AVS, and coronary angiography to detect CAD. Following echocardiography, AVS was classified as none, mild, or severe. CAD was defined as > or =70% narrowing of the luminal diameter on coronary angiography. RESULTS: CAD was more common in patients with AVS than in patients without AVS (75% vs. 47%, respectively, p<0.01). Multiple logistic regression analysis showed that AVS was the only independent predictor of CAD {odds ratio=8.576; 95% confidence interval (CI), 3.739-19.672}. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the presence of AVS for predicting CAD in a patient with an inconclusive TMT were 62%, 67%, 64%, 75%, and 53%, respectively. During a 1-year clinical follow-up, patients with and without AVS were similar in terms of event-free survival rates. CONCLUSION: If the results of TMT for patients with chest pain on exertion are inconclusive, the presence of AVS on echocardiography is a good predictor of CAD.

Comparison of Left Ventricular Hypertrophy, Fibrosis and Dysfunction According to Various Disease Mechanisms such as Hypertension, Diabetes Mellitus and Chronic Renal Failure

BACKGROUND: Left ventricular hypertrophy (LVH) has been known as an important predictor of prognosis of cardiovascular disease. Carboxy-terminal propeptide of procollagen type I (PIP) is related with myocardial fibrosis. We sought to analyze the differences in the characteristics of LVH, myocardial fibrosis, and LV functions among hypertension (HBP), diabetes mellitus (DM) and chronic renal failure (CRF). METHODS: We enrolled consecutive patients with LVH. Patients were grouped as HBP (n=50), DM (n=41), CRF (n=31). Age and sex-matched normal control was also enrolled (n=32). Echocardiography and blood sampling for serum PIP level measuring was performedin all participants. RESULTS: There were no differences in baseline characteristics except systolic blood pressure among four groups. In three patients groups, their LV mass indices were significantly increased than control. Serum PIP level in CRF was much higher than others (CRF 1505.5 vs. HBP 868.7 vs. DM 687.5 vs. control 826.4, p<0.0001). LV diastolic and systolic function evaluated by E', E/E, S' and midwall fractional shortening was significantly decreased in three patients groups. However, LAVi was significantly elevated and LV ejection fraction was significantly decreased in CRF compared to others. In correlation analysis, indices of diastolic function were weakly, but statistically correlated with PIP (E': r=0.234, p=0.006; LAVi: r=0.231, p=0.006). CONCLUSION: In CRF, LV function was more deteriorated and serum PIP was more elevated when compared to HBP or DM. Therefore, myocardial fibrosis may play an important role to LV dysfunction as well as LV hypertrophy in CRF in some degree.

Significance of Inflammatory Markers in Diabetic Patients with Stable Coronary Artery Disease

BACKGROUND/AIMS: Patients with diabetes are prone to coronary artery disease (CAD); however, the majority of diabetic patients show normal coronary arteries. We examined differences in the clinical aspects of diabetic patients with insignificant and with significant stenosis of the coronary artery. METHODS: A total of 418 consecutive diabetic patients with stable angina who had undergone coronary angiography from January 2004 to March 2007 were included in this study. Patients were subdivided into control and CAD groups and then clinical characteristics and CAD-associated factors were evaluated. RESULTS: A total of 92 (22%) patients were assigned to the control group and 326 (78%) patients were assigned to the CAD group. Using univariate regression analysis, we found that patients with CAD were significantly older (control vs. CAD; 59+/-21 vs. 64.7+/-33.7, years, p<0.001), had a longer duration of diabetes (8.2+/-21.8 vs. 10.2+/-29.8, years, p=0.027), higher titers of high sensitivity C-reactive protein (hsCRP; 0.3+/-6.79 vs. 0.9+/-12.6, mg/dL, p=0.015), and increased hemoglobin A1c (HbA1c) levels (7.1+/-3.8 vs. 7.5+/-4.8, %, p=0.007) compared to control patients. Multivariate regression analysis showed that only differences in age, hsCRP, and HbA1c were statistically significant. When patients were subdivided into groups based on hsCRP levels (208 patients in the low group [49.8%], 210 patients in the high group [50.2%]), we found that patients with higher hsCRP levels showed more frequent multivessel disease. CONCLUSIONS: In diabetic patients, age, hsCRP, and HbA1c were associated with stable CAD. Among these factors, hsCRP levels were significantly correlated with multivessel involvement in diabetic CAD. Therefore, high hsCRP levels may be a strong predictor for atherosclerotic progression of the coronary arteries in diabetic patients, suggesting that regular screening tests should be performed.

Effect of Adult Bone Marrow Stem Cells on Myocardial Regeneration in Doxorubicin-Induced Mouse Cardiomyopathy

BACKGROUND AND OBJECTIVES: Bone marrow cells have been shown to differentiate into various cell lineages, including cardiomyocytes, in recent studies. This study evaluates the hypothesis that intravenous injection of bone marrow mononuclear cells (BMNCs) into rats with doxorubicin-induced cardiomyopathy can induce myocardial regeneration and improve myocardial contractility. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were induced to develop cardiomyopathy by treatment with doxorubicin (2.5 mg/kg, 6 times, 2-week period). Stem cell enriched BMNCs were injected into the tail vein of the rats after cessation of the doxorubicin injections. One week after the injection of PKH-67-labeled BMNCs, the localization of transplanted cells was evaluated. Immunohistochemical studies and Western blots were performed two weeks after BMNCs injection. RESULTS: Cell-treated animals showed significant improvement in left ventricular fractional shortening as compared to untreated (control) rats (cell treated group vs. control group 47.2+/-4.9% vs. 34.4+/-3.6%, p<0.01). Histological analyses showed that in the cell-treated animals there was an increase in ventricular interstitial collagen deposition and the cell-treated animals had an improved number of capillary endothelial cells as compared with the control rats. PKH-67-labeled BMNCs and cell proliferation by BrdU was noted in the cell-treated hearts. Cardiac CXCR4 protein expression increased at day 7 and 14 in the cell-treated rats, but only at day 14 in the control animals. CONCLUSION: These results suggest that intravenous injection of BMNCs effectively induce engraftment of BMNCs into the myocardium and attenuation of fibrosis. Intravenous injection of BMNCs also improved myocardial contractility in doxorubicininduced cardiomyopathy.

Effect of High Dose External Irradiation on the Matrix Metalloprotease-2 Expression in a Rat Carotid Artery Injury Model

BACKGROUND AND OBJECTIVES: Remodeling of the injured arterial wall is dependent on the action of several extracellular proteases, including matrix metalloprotease-2 (MMP-2), and this protein is associated with the migration of vascular smooth muscle cells. The effect of a high dose of external irradiation (20 Gy) on the MMP-2 expression in neointimal hyperplasia is not known. MATERIALS AND METHODS: Sprague-Dawley rats were subjected to balloon injury to the common carotid artery. At 24 hours after injury, 20 Gy external irradiation was done for the irradiated group (n=25) and this was not done for the control group (n=25). The percent area stenosis, the maximal intimal thickness, the intima/media area ratio on H-E staining and the MMP-2 positivity on the immunohistochemical staining were measured. Western blotting and a gelatin zymogram for determining the MMP-2 protein expression were also performed after the injury. RESULTS: The parameters of neointimal hyperplasia such as the percent area stenosis, the maximal intimal thickness and the intima/media area ratio were 40.2+/-12.1%, 0.30+/-0.12 mm and 1.27+/-0.32, respectively, at 14 days after injury, and these parameters were maintained as a hyperplastic state at 28 days after injury in the control group. There was undetectable neointimal hyperplasia in the irradiated group compared with the control group (p<0.01). Western blotting demonstrated an increase in the MMP-2 protein level beginning 2 to 4 days after injury in the control group, but there was only a transient increase in the MMP-2 level at day 2 after injury in the irradiated group. The gelatin zymogram and immunohistochemical staining also showed the expression of MMP-2 in the control group, but not in the irradiated group. CONCLUSION: These findings suggest the suppressed expression of MMP-2 is associated with reduced neointimal hyperplasia in the balloon injury-rat model.

Elevated Troponin I after Implantation of Drug-Eluting Stents: Incidence, Predictors, and Prognostic Value

BACKGROUND AND OBJECTIVES: The presence of elevated troponin after percutaneous coronary intervention (PCI) is considered to reflect irreversible myocardial injury. However, its prognostic value remains unclear. The purpose of this study was to investigate the incidence, risk factors, and clinical outcomes of troponin I (TnI) elevation after the implantation of drug-eluting stent (DES). SUBJECTS AND METHODS: We performed a retrospective analysis of 335 patients who had undergone PCI with DES. Patients who had acute coronary syndrome with elevated TnI levels before PCI were excluded. TnI levels were measured 6 and 24 hours after PCI. RESULTS: Baseline clinical characteristics were similar in the elevated TnI and normal TnI groups. Elevated postprocedural TnI (>1.5 ng/mL) occurred in 52 patients (15.5%). Univariate analysis revealed that the clinically significant variables were multi-vessel disease (p<0.001), multiple stent implantation (p=0.003), total stent length (p=0.001), side-branch occlusion (p<0.001), and bifurcation lesion (p=0.003). Multivariate analysis indicated that the independent predictors of elevated TnI after DES implantation were multi-vessel disease (p=0.019), side-branch occlusion (p=0.001), and bifurcation (p=0.011). There were no significant differences in major adverse cardiovascular events between the elevated TnI and normal TnI groups (p=0.461). CONCLUSION: Multi-vessel disease, side-branch occlusion, and bifurcation were independent predictors of elevated TnI following DES implantation. The elevation of TnI after successful PCI with DES was not associated with worse 400-day clinical outcomes.

The Association Between Current Helicobacter pylori Infection and Coronary Artery Disease

BACKGROUND: The role of Helicobacter pylori (H. pylori) in the pathogenesis of coronary artery disease (CAD) is still controversial, and the relation between current H. pylori infection and CAD has not been fully examined. This study evaluated the relation between H. pylori infection as confirmed by gastroduodenoscopic biopsy and CAD. METHODS: We determined the presence of H. pylori infections, via gastroduodenoscopy, in 88 patients of the normal coronary angiographic group and also in 175 patients of the CAD group, and the latter patients had more than 50% coronary stenosis angiographically demonstrated. We excluded those patients with a history of previous H. pylori eradication and/or malignancy. A small piece of tissue from the antrum, which was obtained by gastroduodenoscopic biopsy, was stained by Warthin-starry silver stain. We defined a negative staining result that there was no stained tissue in the sample and the stained tissue was also positive for H. pylori infection. RESULTS: There was no significant difference, except for gender, age, smoking and high density lipoprotein cholesterol (HDL-c), of the demographic and laboratory characteristics between the groups. Twenty seven (30.7%) patients of the normal control group and 71 (40.6%) patients of the CAD group were positive of H. pylori infection, yet there was no statistical difference. We angiographically followed up the 80 patients of the CAD group who were treated by percutaneous coronary intervention (PCI) at 6 to 9 months after their primary intervention. Twenty two (37.9%) of the 58 patients of the H. pylori negative group and 10 (45.5%) of the 22 patients of the H. pylori positive group were treated with reintervention, but reintervention was also not significantly different between the group with H. pylori infection and the group without the infection. CONCLUSIONS: These data indicated that H. pylori infection had a modest influence on CAD and progressive atheroma, but the showed a tendency to increase. Further studies are needed to evaluate the relationship between H. pylori infection and CAD.

Clinical features and prognostic factors in Korean patients hospitalized for coronary artery disease (Catholic Heart Care Network Study) / 대한내과학회지

BACKGROUND: Coronary artery disease (CAD) has recently become one of the major causes of mortality and morbidity in Korea. However, not much epidemiologic and demographic data has yet been reported. The purpose of this study was to investigate the clinical features as well as the prognostic factors of patients with CAD. METHODS: We prospectively enrolled 1,665 consecutive patients with CAD who had been admitted to the Catholic University Hospitals from December 1999 to April 2003. RESULTS: Acute myocardial infarction (AMI) was the most common cause of admission (n=715, 42.9%). Dyslipidemia, hypertension and smoking were the most common risk factors. More than 70% of the patients who underwent percutaneous coronary intervention (PCI) received stent implantation. A total of 965 (612 males) patients were followed at least for 6 months (the mean follow-up duration was 23.8+/-12.2 months). The incidence rates of major adverse cardiac events (MACE: cardiac death, acute myocardial infarction, target vessel revascularization) and cardiac death were 15.1% (n=146) and 2.2% (n=21), respectively. There was no difference in overall survival between the patients treated with medical therapy and those treated with PCI. By Cox regression analysis, the independent prognostic factors for MACE were PCI (95% CI: 1.75-4.85; p<0.01) and multivessel disease (95% CI: 1.03-2.04; p<0.05), and the independent prognostic factors for cardiac death were medical therapy (95% CI: 1.08-14.41; p<0.05) and old age (95% CI: 1.13-16.13; p<0.05). CONCLUSIONS: There was no difference in overall survival between the patients treated with medical therapy and those treated with PCI. However, PCI was superior to medical therapy for preventing death of the patients with acute coronary syndrome.

Intracoronary Stent Deployment without Antiplatelet Agents in a Patient with Idiopathic Thrombocytopenic Purpura

Deciding on the appropriate antiplatelet therapy is a challenge when treating patients with idiopathic thrombocytopenic purpura (ITP) and who are undergoing percutaneous coronary intervention (PCI). We describe here a case of PCI in a patient with chronic, refractory ITP. A 61-year-old woman presented with exertional chest pain and a low platelet count (4 x 109/L) at admission. Coronary angiography revealed 99% stenosis of the mid left anterior descending artery and 95% stenosis of the mid left circumflex artery. Antiplatelet agents couldn't be administered because of the risk of bleeding. After transfusion of platelets and administering intravenous immunoglobulin, we deployed baremetal stents in both lesions without administering any antiplatelet agents. Although focal in-stent restenosis developed 5 months later, there was no episode of stent thrombosis despite not using antiplatelet agents. The present case suggests that the rate of stent thrombosis may be lower was previously thought and antiplatelet therapy may be considered on a case by case for patient suffering with thrombocytopenia.

Clinical Implication of Natriuretic Peptides and Left Atrial Volume for the Screening Methods of Advanced Diastolic Dysfunction in the Community

BACKGROUND: Recently, B-natriuretic peptide (BNP) level and left atrial volume index (LAVi) were known to correlate with indices of LV diastolic function. As a screening method, we tried to evaluate the efficacy to BNP, ANP, and LAVi to predict the advanced diastolic dysfunction that means myocardial relaxation abnormality and elevated LV filling pressure. METHODS: In 100 patients who referred for echocardiography, Doppler recording of the mitral inflow and tissue Doppler imaging of the mitral annulus were obtained and classified into 4 diastolic function grades (normal, impaired relaxation, pseudonormal, and restrictive). Advanced diastolic dysfunction was defined as pseudonormal and restrictive physiology. LAVi was measured by modified Simpson's method in apical 4-chamber view at end-systole. Plasma levels of BNP and ANP were measured on the same day as echocardiogram was done. RESULTS: BNP and ANP levels were increased as diastolic function grade was worsening (BNP : 60+/-92, 108+/-204, 778+/-1,023 and 1,426+/-1,421 pg/ml, p<0.001; ANP: 22+/-30, 23+/-26, 94+/-92, 96+/-61 pg/ml, p<0.001). LAVi was also increased as diastolic dysfunction was advanced: 24+/-7 ml/m2, 27+/-9 ml/m2, 37+/-12 ml/m2, 45+/-12 ml/m2, p<0.001. The areas under the curve of receiver-operator characteristic curve for BNP, ANP and LAVi to detect the advanced diastolic dysfunction were 0.91, 0.88 and 0.84, respectively. BNP of 137 pg/ml, ANP of 34 pg/ml, and LAVi of 30 ml/m2 were the best values of sensitivity and specificity, respectively. CONCLUSION: These data suggest that BNP, ANP and LAVi provide meaningful sensitivity and specificity for the detection of advanced diastolic dysfunction, respectively. Among these, BNP is better than ANP or LAVi for the screening method to predict the advanced diastolic dysfunction.

Utilization Pattern of Drug-Eluting Stents and Prognosis of Patients Who Underwent Drug-Eluting Stenting Compared with Bare Metal Stenting in the Real World

BACKGROUND AND OBJECTIVES: Currently, the drug-eluting stent (DES) has been widely used because of its excellent clinical outcome. We compared the utilization patterns and clinical outcomes between the DES and the bare metal stent (BMS) in the real world. SUBJECTS AND METHODS: We retrospectively reviewed the stent registry at the Catholic Medical Center between January 2002 and October 2004. There were 1120 patients treated with DES (n=1837) who were compared to 910 patients who received BMS implantation (n=1238). RESULTS: Patients with de novo lesions in the DES group more frequently had multivessel disease and received a greater number of stents than those in BMS group (p<0.001). The mean diameter of inserted stents was smaller in the DES group (p<0.001). The follow-up rate for clinical and angiographic evaluations at 6 months after stenting was 91% and 65% (n=592) in the BMS group and 90% and 74% (n=829) in the DES group, respectively. The rate of major adverse cardiac events (death, nonfatal myocardial infarction, or target vessel revascularization) at 6 months was 7.3% in the DES group and 17.5% in the BMS group (p<0.001). The rates of target vessel revascularization in the DES group and in the BMS group were 4.2% and 12.9%, respectively (p<0.001). CONCLUSION: The patients in the DES group had longer length, smaller diameter and higher number of placed stents, compared to the BMS group. The rates of revascularization and major adverse cardiac events in the DES group were lower than those in the BMS group.

High Dose Ramipril Inhibits Connective Tissue Growth Factor Expression and Fibrosis in Type 2 Diabetic Rat Heart

BACKGROUND AND OBJECTIVES: Connective tissue growth factor (CTGF) is a profibrotic cytokine, which may play an important role in the development of diabetic cardiovascular complications. ACE inhibition significantly prevents cardiovascular events in diabetics, although the mechanism remains obscure. The purpose of this study was to explore the effect of ACE inhibitors on the expression of CTGF and oxidative stress in the diabetic heart, and determine the effects of long term treatment with ACE inhibitors on diabetic cardiomyopathy. MATERIALS AND METHODS: Thirty OLETF (Otsuka Long Evans Tokushima Fatty) diabetic and thirty LETO (Long Evans Tokushima Otsuka) nondiabetic control rats were randomized into four groups for 24 weeks of treatment with either ramipril (5 mg/kg/day, n=15, each groups) or saline (n=15, each groups). RESULTS: The OLETF diabetic rats had prominent perivascular fibrosis, as shown by picrosirius red stains, compared to the LETO nondiabetic rats. ACE inhibition significantly prevented perivascular fibrosis in OLETF rats (p<0.01). Immunohistochemical stains were used to detect proteins for the receptors of advanced glycation end products (RAGE), CTGF, collagen III and nitrotyrosine. Although there were no significant differences in the myocardiac collagen contents, as found by measuring the hydroxyproline concentration among the four groups, the OLFTF diabetic rats had significantly increased cardiac CTGF and collagen III protein expression compared with the nondiabetic rats. The ACE inhibitor attenuated the increases in RAGE (-50.3%; p<0.01), CTGF (-37.5%; p<0.01) and collagen III (-52.3%; p<0.01) expression in the diabetic heart microvascular area. The OLFTF rats showed marked an increment in cardiac nitrotyrosine, a marker of protein oxidation. Ramipril also inhibited the expression of cardiac nitrotyrosine (-78.3%; p<0.01). CONCLUSION: The present study shows a possible role of RAGE/nitrotyrosine/CTGF in the diabetic cardiomyopathy of OLETF rats. The long term treatment of high dose ACE inhibitors may have beneficial effects on the diabetic heart through both antioxidant and antifibrotic mechanisms.

Prospective, Randomized, Preliminary Clinical Trial with Low-Molecular-Weight Heparin or Unfractionated Heparin as Periprocedural Anticoagulant during Elective Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: LMWH as a periprocedural anticoagulant during PCI has not yet been extensively studied. The aim of this study is to compare the clinical outcomes of enoxaparin to those of unfractionated heparin (UH) during elective PCI. SUBJECTS AND METHODS: The eligible patients were randomized 1:1 into two treatment arms, either a single IV bolus of enoxaparin (75 IU/kg) or UH (100 IU/kg). The patients who had received any anticoagulants at therapeutic doses were excluded in this study. Data on patient characteristics, angiographic complications, laboratory variables and the in-hospital and 1-month clinical outcomes were compared between the two groups. RESULTS: Of the 139 patients enrolled in this study, 68 received enoxaparin and 71 received UH. The patients' demographic and angiographic characteristics (gender, weight, creatinine and the PCI target vessel) were not different except for age between the groups. Multi-vessel angioplasty was performed in 59 (42.4%) patients. At least one stent was implanted in 130 (93.5%) patients. The sheath was removed immediately after PCI, except for one case, and then a collagen plug was applied in all the cases. There were no significant differences in angiographic complications like no reflow, thrombus at the treated lesion site, occlusion of collateral branches, distal embolism, dissection, coronary rupture or abrupt closure. Cardiac markers including CK (6 [8.8%] in the LMWH group vs 8 [11.3%] in the UH group), CK-MB (6 [8.8%] vs 8 [11.3%], respectively), and troponin-I (6 [8.8%] vs 10 [14.1%], respectively) were slightly increased after PCI compared to the last value obtained before the procedure in both groups, but the differences were not statistically significant. One patient in the enoxaparin arm and 2 patients in the UH arm developed NSTEMI during their admission. Four patients from the UH arm and 3 from the enoxaparin arm experienced hematoma at the puncture site. After discharge, no other events were reported at the 1-month follow-up. CONCLUSION: The use of enoxaparin (75 IU/kg) during elective PCI was effective and safe as using UH. Enoxaparin could be used like UH as a periprocedural anticoagulant in the elective PCI setting.