Valsartan 160 mg/Amlodipine 5 mg Combination Therapy versus Amlodipine 10 mg in Hypertensive Patients with Inadequate Response to Amlodipine 5 mg Monotherapy

BACKGROUND AND OBJECTIVES: When monotherapy is inadequate for blood pressure control, the next step is either to continue monotherapy in increased doses or to add another antihypertensive agent. However, direct comparison of double-dose monotherapy versus combination therapy has rarely been done. The objective of this study is to compare 10 mg of amlodipine with an amlodipine/valsartan 5/160 mg combination in patients whose blood pressure control is inadequate with amlodipine 5 mg. SUBJECTS AND METHODS: This study was conducted as a multicenter, open-label, randomized controlled trial. Men and women aged 20-80 who were diagnosed as having hypertension, who had been on amlodipine 5 mg monotherapy for at least 4 weeks, and whose daytime mean systolic blood pressure (SBP) ≥135 mmHg or diastolic blood pressure (DBP) ≥85 mmHg on 24-hour ambulatory blood pressure monitoring (ABPM) were randomized to amlodipine (A) 10 mg or amlodipine/valsartan (AV) 5/160 mg group. Follow-up 24-hour ABPM was done at 8 weeks after randomization. RESULTS: Baseline clinical characteristics did not differ between the 2 groups. Ambulatory blood pressure reduction was significantly greater in the AV group compared with the A group (daytime mean SBP change: -14±11 vs. -9±9 mmHg, p<0.001, 24-hour mean SBP change: -13±10 vs. -8±8 mmHg, p<0.0001). Drug-related adverse events also did not differ significantly (A:AV, 6.5 vs. 4.5%, p=0.56). CONCLUSION: Amlodipine/valsartan 5/160 mg combination was more efficacious than amlodipine 10 mg in hypertensive patients in whom monotherapy of amlodipine 5 mg had failed.

Thoracic Endovascular Aortic Repair with the Chimney Technique for Blunt Traumatic Pseudoaneurysm of the Aortic Arch in a No-Option Patient

A 42-year-old man was involved in a motor vehicle collision. Imaging studies revealed the presence of a post-traumatic aortic pseudo-aneurysm (about 34x26 cm) arising from the descending thoracic aorta at the level of the left subclavian artery (LSA), prone to rupture. Thoracic endovascular aneurysm repair (TEVAR) was the only feasible option due to his poor overall medical status. In this case, LSA needed to be covered in order to extend the proximal landing zone. Eventually, modified TEVAR was successfully performed by means of the chimney technique to preserve flow to the LSA and to prevent flow into the pseudoaneurysmal sac.

Hybrid Approach for the Treatment of Thoracic Aortic Arch Aneurysm in a Patient With Chronic Obstructive Lung Disease and Retrosternal Adhesion

A 73-year-old woman with a history of chronic hypertension and severe chronic obstructive pulmonary disease, presented to a district general hospital with thoracic pain in a profound state of shock. She was diagnosed with cardiac tamponade, severe mitral regurgitation, and Stanford type A (Debakey type I) intramural hematoma. Her ascending aorta was of a significant size and therefore emergent repair was done to replace the ascending aorta and mitral valve. After 6 months, an increased aneurysmal size of 6.0 cm was observed in a follow up contrast-enhanced computed tomography angiography. The patient was successfully treated by a staged hybrid procedure involving initial supra-aortic reconstruction.

Acute myocardial infarction coincident with gastric ulcer bleeding following herbal medication-induced acute renal failure / 대한내과학회지

Acute renal failure, acute myocardial infarction (AMI), and gastric ulcer bleeding (GUB) are associated with high rates of morbidity and mortality, especially in older patients. The development of each of these conditions can be followed by the development of another; however, it is rare for these three conditions to develop concurrently. Here, we report the case of a 92-year-old man who was admitted because of generalized weakness that developed after the ingestion of nothing but functional foods, including herbal medications containing Glycyrrhiza and Aloe, for ten days. After admission, AMI and GUB developed approximately six hours apart. Conservative treatment was chosen for the bleeding ulcer because of the high procedural risk, and the use of antiplatelet agents and heparinization for treatment of the infarction were stopped. The patient remained hemodynamically stable following the administration of a statin, diuretics, and proton pump inhibitors. A healed scar at the site of the ulcer was confirmed three weeks later; however, postinfarct angina developed after the patient's last endoscopy. Percutaneous coronary intervention was successfully performed with two stents placed in the left anterior descending artery.

A case of arrhythmogenic right ventricular cardiomyopathy/dysplasia involving the left ventricle / 대한내과학회지

Arrhythmogenic right ventricular cardiomyopathy (ARVC)/dysplasia is characterized by fibro-fatty replacement of the right ventricular myocardium. A 19-year-old soldier was admitted with sudden cardiac arrest that presented as ventricular fibrillation requiring cardiopulmonary resuscitation. His electrocardiogram (ECG) showed normal sinus rhythm with inverted T waves from leads V1 to V4 and isolated premature ventricular beats with a left bundle branch block (LBBB) pattern. Echocardiography showed that the right ventricle was enlarged with apical trabecular formation. The coronary angiogram was normal. Cardiovascular magnetic resonance imaging (MRI) showed thinning and fatty substitution of both the right and left ventricular free walls. Ventricular tachycardia (LBBB pattern) occurred frequently despite anti-arrhythmic drug treatment. His drug-resistant ventricular tachycardia was treated with an implanted cardiac defibrillator. Left ventricle involvement in ARVC is less common and more severe. Cardiac MRI is considered the best imaging technique for evaluating the right ventricle and diagnosing ARVC.

Three cases of right coronary anomaly confirmed by multi-detector computed tomography / 대한내과학회지

Congenital anomaly of the right coronary artery is a very rare disease. It can cause syncope, angina pectoris, acute myocardial infarction, ventricular fibrillation and sudden cardiac death during exercise in the young population. The dominancy of the coronary artery, and the site, shape and pathway of the right coronary artery seems to play a key role in developing those above mentioned events. Especially, it has been known that the right coronary artery that courses between the aorta and pulmonary trunk increases the risk of sudden death. Therefore, precise evaluation is needed to diagnose the presence and type of coronary artery anomaly. Nowadays, multi-detector computed tomography is used to diagnose coronary anomalies and this provides clear images of coronary anomaly in a safe and noninvasive way. We report here on three cases of right coronary anomaly that coursed between the aorta and pulmonic trunk, and this was confirmed by multi-detector computed tomography.

Morphological changes in rat testes after Hindlimb Unloading model / 항공우주의학회지

BACKGROUND: The purpose of this study was to examine histological changes of testes induced by hindlimb unloading & position change of testis in mature adult male rats. METHOD: Eight month old (390~410g) 36 male Sprague-Dawley rats were weight-matched assigned to Ground Control (GC), Hindlimb Unloading (HU), Hindlimb Unloading & Testis Tie(HUT), Intra-abdominal Testis(IAT) for 24 days. Daily body weight was watched for status of animal. Testis weight, Seminiferous Tubule Diameter(STD), Seminiferous Tubule Perimeter(STP), Serminiferous Tubule Area(STA), Sertori Cell Height(SCH) were examined in each group. RESULTS: The 24-day hindlimb unloading of HU, HUT and IAT showed no significant change of body weight compared to GC. HUT maintained the weights, STD, STP, STA, SCH of their testes as GC while HU, IAT had significantly decreased the weights, STD, STP, STA of their testes. CONCLUSION: These results support that hindlimb unloading experiment induces serious morphological changes of testes. Therefore, on the hindlimb unloading experiment, IAT should be avoid or the effect of IAT should be correct. It will be necessary to study the pure effect of hindlimb unloading without IAT on the musculoskeltal system and so on which are associated with testosterone.

The Relationship between the Upright Serum aldosterone Level and the Left Ventricular Geometry in Essentioal Hypertension

BACKGROUND: Aldosterone acts as a non-hemodynamic factors on the hypertensive heart regarding sodium retension or myocardial fibrosis. To elucidate whether aldosterone is associated with the specific left ventricular geometry or not, we investigated the relationship between the upright serum aldosterone levels and the echocardiographicleft ventricular structure in the essential hypertension patients never treated. METHODS: Echocardiographic indices included M-mode measured left ventricular mass index (LVMI), relative wall thickness (RWT). Aldosterone is measured by Radioimmunoassay for the serum withdrawn from the subjects at least 3 hours upright position. 63 patients and 20 normal control subjects were evaluated. RESULTS: 1) 84.1% (63/53) of cases showed left ventricular hypertrophy. 7 patients showed normal LVMI, 3 patients showed concentric remodeling geometry. 19 patients had concentric left ventricular hypertrophy (LVH). 34 patients had eccentric LVH. 2) The serum aldosterone level has negative correlation with the RWT (r=-0.27, p=0.03) but not with LVMI (r=0.08, p=NS). There was difference among groups (ANOVA, F=0.009). Serum aldosterone is higher in eccentric LVH group than in concentric LVH group (10.5+/-1.2 ng/dL vs 5.2+/-0.6 ng/dL, p=0.0001) and than in control group (10.5+/-1.2 ng/dL vs 6.6+/-0.8 ng/dL, p=0.01). CONCLUSION: In this study, we observed that the serum aldosterone level was not correlated with the LVMI but with RWT negatively so that eccentric LVH group showed higher serum aldosterone levels than control group and concentric LVH group.

Four Cases of Management of Congenital Coronary Arteriovenous Fistula

Four cases of congenital coronary arteriovenous fistula were diagnosed using coronary angiography. Three cases had fistula-related chest pain and the remaining case showed no symptoms but displayed electrocardiographic changes suggesting myocardial ischemia. As he was elderly and had a potential for future complications, we decided to close the fistulas of all cases. Three cases were closed with transcatheter coil embolization and one with surgical ligation due to a suspicious accompanying pericardial cyst. None of the patients demonstrated periprocedural or perioperative complications and all were relieved from symptoms during the 2 year follow-up period. We concluded that transcatheter coil embolization and surgical ligation are effective methods for use in the management of coronary arteriovenous fistula.

Relationship between ST segment of lateral leads and culprit arteries in acute inferior myocardial infarction

BACKGROUND AND OBJECT: We intended to assess the characteristics of ST segment deviation in lateral leads(aVL, I, V5, V6) in patients with acute inferior myocardial infarction(AIMI) and find out the relationship with culprit arteries. MATERIALS AND METHOD: The subjects were 51 patients diagnosed as AIMI by standard electrocardiogram, cardiac enzymes and typical chest pain. Subjects were devided into two groups by angiographically proven culprit arteries ; left circumflex artery(LCx) group and right coronary artery(RCA) group. We compared the frequencies of ST segment depression more than 1 mm and less than 1 mm in aVL and I, and ST segment elevation more than 0.5 mm and less than 0.5 mm in V5 and V6 in each culprit artery group. RESULTS: Among 51 patients with AIMI, 42 were RCA group and 9 were LCx group. The frequency of ST segment depression more than 1 mm in aVL was 44% in LCx group and 71% in RCA group(p=0.140). 11% of LCx group and 43% of RCA group showed more than 1 mm ST segment depression in lead I (p=0.128). 56% of LCx group showed more than 0.5 mm ST segment elevation in V5 and V6 and 81% of RCA group showed less than 0.5 mm ST segment elevation in V5 and V6 (p=0.036). CONCLUSION: Culprit arteries in patients with AIMI and ST segment deviation in V5 and V6 are significantly related with each other. ST segment elevation more than 0.5 mm in V5 and V6 was predominantly found in LCx group than RCA group. Observation for ST segment deviation in lateral precordial lead V5 and V6 would be important in predicting the culprit artery in AIMI.

Protective Roles of Adenosine A1 Receptor Agonist and KATP Channel Opener in Adriamycin induced Cardiac Toxicity / 체질인류학회지

Although adriamycin is a potent chemotherapeutic agent, it elicits serious adverse effects, including cardiac toxicity. Evidence suggests that congestive heart failure induced by adriamycin is mediated by oxidative stress. We investigated whether regulators of adenosine A1 receptor and KATP channel, which have been demonstrated to mediate protective effects of ischemic -preconditioning in myocardium, are able to modulate adriamicin -induced impairment of cardiomyocyte. To study the effect of antioxidant, adenosine A1 receptor agonist & antagonist and KATP channel agonist & antagonist, ICR mice were pretreated with Cu,Zn -SOD, dimethyl thiourea, RPIA (R (-)N6 -(2 -Phenylisopropropyl)- adenosine, adenosine A1 receptor agonist), 8 -CPDPX (8 -Cyclopentyl -1, 3 -dipropylxanthine, adenosine A1 receptor antagonist), Pinacidil (KATP channel opener) and glibenclamide (KATP channel closer), followed by i.p injection with adriamycin. Mice were sacrificed day 1 or day 4 after adriamycin injection and cardiac toxicity was accessed by measurement of creatine phosphokinase (CK) levels in serum, immunohistochemistry using anti -Bcl -2 antibody and TUNEL histochemical assay. As expected, pretreatment of mice with Cu, Zn -SOD and DMTU reduced the frequency of TUNEL positive cells, indicating antioxidants protected cardiocytes from adriamycin -induced apoptosis. Interestingly, pretreatment with RPIA and pinacidil induced a significant decrease in adriamycin -induced cytotoxicity, whereas 8 -CPDPX and glibenclamide generated the opposite results. In Bcl -2 immunohistochemistry, an increased expression of Bcl -2 was found in all ADR treated groups, especially in glibenclamide pretreated group, and 8 -CPDPX pretreated groups, but Bcl -2 failed to protect myocytes from apoptosis. All ADR treated groups exhibited elevated levels of serum CK, compared with nomal controls, especially mice sacrificed at day 4 than those at day 1, and showed similar patterns of TUNNEL assay, reflecting heart tissue damages. This observation implicated cytoprotective roles of RPIA and pinacidil against adriamycin -induced cardiac toxicity. In conclusion, these results demonstrated that adriamycin -induced cardiotoxicity was associated with the generation of reactive oxygen species and that regulators including SOD, DMTU, RPIA and pinacidil elicited protective effects on this toxicity. In particular, pinacidil, the KATP channel opener, was more effective than RPIA, the adenosine A, receptor agonist, to attenate the adriamycin -induced cardiac toxicity.

Inhibition of rac1 Reduces PDGF-induced Reactive Oxygen Species and Proliferation in Vascular Smooth Muscle Cells

In vascular smooth muscle cells, reactive oxygen species (ROS) were known to mediate platelet-derived growth factor (PDGF)-induced cell proliferation and NADH/NADPH oxidase is the major source of ROS. NADH/NADPH oxidase is controlled by rac1 in non-phagocytic cells. In this study, we examined whether the inhibition of rac1 by adenoviral-mediated gene transfer of a dominant negative rac1 gene product (Ad.N17rac1) could reduce the proliferation of rat aortic vascular smooth muscle cells (RASMC) stimulated by PDGF via decreasing intracellular ROS. RASMC were stimulated by PDGF (80 ng/mL) with or without N-acetylcysteine 1 mM or infected with 100 mutiplicity of infection of Ad.N17rac1. Intracellular ROS levels were measured at 12 hr using carboxyl-2', 7'-dichlorodi-hydrofluorescein diacetate confocal microscopy. At 72 hr, cellular proliferation was evaluated by cell number counting and XTT assay. Compared with control, ROS levels were increased by 2-folds by PDGF. NAC and Ad.N17rac1 inhibited PDGF-induced increase of ROS by 77% and 65%, respectively. Cell number was increased by PDGF by 1.6-folds compared with control. NAC and Ad.N17rac1 inhibited PDGF-induced cellular growth by 45% and 87%, respectively. XTT assay also showed similar results. We concluded that inhibition of rac1 in RASMCs could reduce intracellular ROS levels and cellular proliferation induced by PDGF.

Left Atrial Function in Various Type of Left Hypertrophy in Hypertensive Patients

BACKGROUND: Left atrium (LA) may serve as a conduit, as a reservoir and as a contractile chamber. Left atrial function in patients with left ventricular concentric hypertrophy was compared with that in eccentric hypertrophy. METHODS: LA volumes were echocardiographically measured in 54 hypertensive patients (mean age: 57.1+/-14.9 years, men: 24, women: 30, concentric hypertrophy: 21, eccentric hypertrophy: 18). Transmitral flow velocities were recorded with pulsed Doppler echocardiography. LA volumes were measured at mitral valve opening (LAVmax) and closure (LAVmin) and at onset of atrial systole (LAVp). LA function was evaluated by the following parameters: 1) LA reservoir volume (LARV=LAVmax-LAVmin), 2) LA conduit volume (LACV=left ventricular stroke volume-LARV), 3) LA active emptying fraction (EF active=[LAVp-LAVmin]/LAVp), 4) LA passive emptying fraction (EF passive=[LAVmax-LAVp]/LAVmax). RESULTS: In concentric hypertrophy compared with eccentric hypertrophy, LARV (59.9+/-20.0 vs 45.6+/-12.0 cm3, p<0.05) and EF active (56.8+/-10.0 vs 41.0+/-15.2%, p<0.01) increased but LACV (16.0+/-19.8 vs 43.7+/-15.0 cm3, p<0.01) decreased. Relative wall thickness (RWT) correlated with LARV (r=0.288, p<0.05) and EF active (r=0.561, p<0.01) but had negative association with LACV (r=-0.508, p<0.01) and EF passive (r=-0.490, p<0.01). There was a positive relationship of left ventricular mass index (LVMI) to LARV (r=0.293, p<0.05) but negative relationship of LVMI to EF passive (r=-0.494, p<0.01). CONCLUSION: The present study showed that LA reservoir function and active emptying fraction increased in concentric hypertrophy comparison with eccentric hypertrophy and LA conduit function decreased in concentric hypertrophy comparison with eccentric hypertrophy. Therefore, these findings suggest that the changes of left atrial function are remarkable in concentric hypertrophy.

A Case of Bland-White-Garland Syndrome

The congenital anomalous origin of the left coronary artery arising from the pulmonary artery, or the Bland-White-Garland syndrome, is uncommon but frequently lethal lesion of both children and adults. In several series, it has a frequency of 0.26-0.46% of all congenital cardiac defects. The mortality rate among infants and children without operation has been eighty to ninety percent. Survival to teen-age and adult has been infrequent ; review of the literature regarding this anomaly in Korean disclosed only 3 cases in infants and children and 2 cases in adults. In a 45-year-old male with palpitation and effort angina, the anomalous origin of the left coronary artery from the pulmonary artery was diagnosed by echocardiogram and coronary arteriography.