Long-term Clinical Outcomes of Radiofrequency Catheter Ablation versus Permanent Pacemaker Implantation in Patients with Tachycardia-Bradycardia Syndrome

Background and Objectives@#Pacemaker (PM) implantation is a well-accepted treatment option for patients with paroxysmal atrial fibrillation (AF) and related tachycardiabradycardia syndrome (TBS). Data on the long-term clinical outcomes after radiofrequency catheter ablation (RFCA) or PM implantation are sparse. @*Methods@#The medical records of 217 patients with TBS were retrospectively assessed.Outcomes in patients who underwent RFCA (n=108, 49.8%) were compared to those with PM implantation (n=109, 50.2%). The clinical outcomes were sinus rhythm maintenance, conversion to persistent AF, additional procedure or crossover, and the composite of cardiovascular hospitalization and death. @*Results@#During the follow-up period (mean 3.5±2.0 years), the RFCA group, compared to the PM group, showed better sinus rhythm maintenance (adjusted hazard ratio [aHR], 0.27;95% confidence interval [CI], 0.15–0.46; p=0.002) and less progression to persistent AF (aHR, 0.20; 95% CI, 0.06–0.63; p=0.006). Additional procedure or crossover did not differ significantly between the groups (aHR, 2.07; 95% CI, 0.71–6.06; p=0.185 and aHR, 0.69; 95% CI, 10.8–2.67; p=0.590, respectively). Most RFCA patients (92.6%) did not require pacemaker implantation during long term follow-up period (>3.5 years). The composite endpoint of cardiovascular rehospitalization and death was not significantly different between the groups (aHR, 0.92; 95% CI, 0.50–1.66; p=0.769).Background and Objectives: Pacemaker (PM) implantation is a well-accepted treatment option for patients with paroxysmal atrial fibrillation (AF) and related tachycardiabradycardia syndrome (TBS). Data on the long-term clinical outcomes after radiofrequency catheter ablation (RFCA) or PM implantation are sparse. @*Methods@#The medical records of 217 patients with TBS were retrospectively assessed.Outcomes in patients who underwent RFCA (n=108, 49.8%) were compared to those with PM implantation (n=109, 50.2%). The clinical outcomes were sinus rhythm maintenance, conversion to persistent AF, additional procedure or crossover, and the composite of cardiovascular hospitalization and death. @*Results@#During the follow-up period (mean 3.5±2.0 years), the RFCA group, compared to the PM group, showed better sinus rhythm maintenance (adjusted hazard ratio [aHR], 0.27;95% confidence interval [CI], 0.15–0.46; p=0.002) and less progression to persistent AF (aHR, 0.20; 95% CI, 0.06–0.63; p=0.006). Additional procedure or crossover did not differ significantly between the groups (aHR, 2.07; 95% CI, 0.71–6.06; p=0.185 and aHR, 0.69; 95% CI, 10.8–2.67; p=0.590, respectively). Most RFCA patients (92.6%) did not require pacemaker implantation during long term follow-up period (>3.5 years). The composite endpoint of cardiovascular rehospitalization and death was not significantly different between the groups (aHR, 0.92; 95% CI, 0.50–1.66; p=0.769). @*Conclusions@#RFCA is an effective alternative to PM implantation in patients with TBS.In these patients, successful RF ablation of AF is related to a higher rate of sinus rhythm maintenance compared to PM implantation, and the composite outcome of cardiovascular rehospitalization and death is similar.

Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting for the Treatment of Left Main Coronary Artery Disease

Severe stenosis of the left main coronary artery (LMCA) generally occurs as a result of atherosclerosis and compromises the blood supply to a wide area of myocardium, thereby increasing the risk of serious adverse cardiac events. Current revascularization strategies for patients with significant LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), both of which have a range of advantages and disadvantages. In general, PCI is associated with a lower rate of periprocedural adverse events and provides more rapid recovery, while CABG provides more durable revascularization. Most clinical trials comparing PCI and CABG for the treatment of LMCA disease have shown PCI to be non-inferior to CABG with respect to mortality and the serious composite outcome of death, myocardial infarction, or stroke in patients with low-to-intermediate anatomical complexities. Remarkable advancements in PCI standards, including safer and more effective stents, adjunctive intravascular imaging or physiologic evaluation, and antithrombotic treatment, may have contributed to these favorable results. This review provides an update on the current management of LMCA disease with an emphasis on clinical data and academic and clinical knowledge that supports the use of PCI in an increasing proportion of patients with LMCA disease.

Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting for the Treatment of Left Main Coronary Artery Disease

Severe stenosis of the left main coronary artery (LMCA) generally occurs as a result of atherosclerosis and compromises the blood supply to a wide area of myocardium, thereby increasing the risk of serious adverse cardiac events. Current revascularization strategies for patients with significant LMCA disease include coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), both of which have a range of advantages and disadvantages. In general, PCI is associated with a lower rate of periprocedural adverse events and provides more rapid recovery, while CABG provides more durable revascularization. Most clinical trials comparing PCI and CABG for the treatment of LMCA disease have shown PCI to be non-inferior to CABG with respect to mortality and the serious composite outcome of death, myocardial infarction, or stroke in patients with low-to-intermediate anatomical complexities. Remarkable advancements in PCI standards, including safer and more effective stents, adjunctive intravascular imaging or physiologic evaluation, and antithrombotic treatment, may have contributed to these favorable results. This review provides an update on the current management of LMCA disease with an emphasis on clinical data and academic and clinical knowledge that supports the use of PCI in an increasing proportion of patients with LMCA disease.

The Transradial Approach for Coronary Intervention: More Comfort, Better Outcome

No abstract available.

Metabolic Syndrome Causes Cardiovascular Disease under Stable Statin Medication

OBJECTIVE: Statins are known to prevent only 30–50% of cardiovascular disease(CVD) by reducing low-density lipoprotein cholesterol (LDL-C). There is a controversy about whether metabolic syndrome(MS) can increase the risk of CVD. The aim of this study is to investigate whether MS can increase the risk of CVD, even after LDL-C is ideally controlled by taking statins. METHODS: As a retrospective observational study, we investigated CVD events of 909 patients (61.3±10.2 years old) by reviewing medical records for at least 1 year before and after taking statins respectively, from June 2005 to February 2008, and analyzed the risk factors of CVD. RESULTS: During the study period (881.4±232.8 days), 46 cases of CVD events occurred in patients with a very high risk of CVD and in patients with a high risk of CVD. In patients with a very high risk of CVD, 56.8% (21 cases over 37) of CVD events occurred in patients who achieved LDL-C goal (< 70 mg/dL). A total of 9 events developed among high risk patients who reached LDL-C goal (< 100 mg/dL). The patients with MS revealed significantly higher rates of CVD events [p=0.015; hazard ratio (HR) 3.033; 95% confidence interval (CI) 1.184–7.768]. Significantly higher rates of CVD events were also found in subgroup analysis of the patient with a past history of CVD events [p=0.017; HR 3.431; 95% CI 1.183–9.956]. Similar pattern was demonstrated in patients with diabetes [p=0.049; HR 2.738; 95% CI 0.963–7.782]. Cox regression analysis identified metabolic syndrome [p=0.025; HR 5.237; 95% CI 1.235–22.204], a past history of CVD events [p=0.000; HR 5.349; 95% CI 2.321–12.327], basal LDL-C level [p=0.024; HR 1.013; 95% CI 1.002–1.025] and total cholesterol level after statin therapy [p=0.024; HR 0.978; 95% CI 0.959–0.997] as independent predictors of CVD among LDL-C goal achieved patients. CONCLUSION: Metabolic syndrome is the independent risk factor of CVD events in high risk patients with or without a past history of CVD events or diabetes. In these patients, statins could not prevent CVD events effectively.

Vertebral Osteomyelitis Caused by Mucormycosis / 대한내과학회지

Mucormycosis is a rare but fatal disease and usually affects the rhinocerebrum, lungs, traumatic wounds or surgical sites. Vertebral osteomyelitis due to mucormycosis is very rare, with only three cases caused by mucormycosis since 1970 being reported, and none in Korea. Here, we present a case of vertebral osteomyelitis caused by mucormycosis in a 67-year-old woman, having type 2 diabetes mellitus for 10 years, who was in complete remission from acute leukemia after chemotherapy 3 years previously.

Fabry Disease Presenting with Hypertrophic Cardiomyopathy and Tricuspid Regurgitation

A 71-year-old female who was diagnosed with nonobstructive hypertrophic cardiomyopathy since 1999 presented with dyspnea and severe edema on both legs. For the management of her symptom, cardiac surgery including tricuspid annuloplasty, Maze operation and right atrial reduction plasty was performed. During follow-up after cardiac surgery, a plasma α-galactosidase activity was checked for the screening of Fabry disease and the result was around lower normal limit. DNA analysis was implemented for confirmation and it revealed a heterozygote α-galactosidase mutation at exon 6 [c.901C>T (p.Arg301Ter)]. This case suggests that Fabry disease might be easily undetected, and clinical suspicion is critical.

A Case of Near Total Occlusion of the Renal Artery after Endovascular Abdominal Aortic Aneurysm Repair

Endovascular abdominal aortic aneurysm repair is a safe, durable, and effective procedure. However, complications could occur with stent graft devices. When the renal ostia become obstructed by this device, renovascular hypertension may result. In general, renal artery occlusion secondary to stent graft impingement remains uncommon. We herein describe a patient with renal atrophy, new-onset hypertension, and elevated serum renin and aldosterone levels following endovascular aneurysm repair. Blood pressure and the levels of renin and aldosterone were normalized by renal artery stenting.

Obesity Increases Blood Pressure Variability during the Night

BACKGROUND: Previous studies have reported that obesity increases heart rate variability. Body mass index (BMI) has been reported to affect blood pressure variability (BPV) over 24 hours. However, the diurnal variation in the effect of BMI on BPV has not been evaluated. This study aimed to clarify the diurnal variation in the effect of BMI on BPV. METHODS: A total of 2,044 patients were consecutively enrolled in this study, and the data were analyzed retrospectively. All patients underwent 24-hour ambulatory blood pressure monitoring. We divided patients into two groups according to BMI (non-obese group: n = 1,145, BMI or = 25). We compared BPV during daytime and nighttime between the non-obese and obese groups. We also evaluated the impact of BMI on BPV by multivariate regression analysis. RESULTS: On univariate regression analysis, there was no significant difference in BPV during daytime (systolic BP [SBP] variability: 20.7 vs. 21.7, p = 0.511; diastolic BP [DBP] variability: 16.8 vs. 17.5, p = 0.539). However, both SBP variability (13.8 vs. 17.6, p = 0.009) and DBP variability (11.7 vs. 14.3, p = 0.042) during nighttime were affected significantly by BMI. After adjusting other compounding variables (age > 60 years, current smoking habit, hypertension, diabetes mellitus, and use of calcium channel blockers and renin-angiotensin-aldosterone system blockers), multivariate analysis showed that BMI was an independent factor associated with increase in BPV during the night (SBP variability: p = 0.039; DBP variability: p = 0.034). CONCLUSIONS: Obesity increased BPV during nighttime.

Comparison of Coronary Plaque and Stenosis Between Coronary Computed Tomography Angiography and Virtual Histology-Intravascular Ultrasound in Asymptomatic Patients with Risk Factors for Coronary Artery Disease

OBJECTIVES: The purpose of the study was to compare plaque characteristics by coronary computed tomography angiography (CCTA) with those by virtual histology-intravascular ultrasound (VH-IVUS). METHODS: We enrolled 50 asymptomatic patients with diabetes mellitus or more than two risk factors for coronary artery disease such as hypertension, smoking, and hyperlipidemia. If the patient had a coronary lesion (plaque with more than 50% stenosis or calcium score more than 100), we recommended coronary angiography and VH-IVUS and compared CCTA findings with VH-IVUS findings. RESULTS: 35 patients (70%) had coronary lesions, and we performed both CCTA and VH-IVUS in 23 patients. All 23 patients had multiple risk factors, and the majority of target lesions were located at left anterior descending artery (73.9%), and calcium score of lesion site was 106+/-162 with plaque volume of 232+/-153 mm3 by CCTA. Calcium score of lesion site was significantly greater in diabetic patients (n=14) than non-diabetic patients (n=9) (118+/-159 vs. 88+/-175, p=0.038). By VH-IVUS, plaque volume was 174+/-127 mm3, absolute necrotic core (NC) volume was 22+/-21 mm3, and relative NC volume was 20.8+/-8.7%. Absolute dense calcium (DC) volume and absolute NC volumes were significantly greater in diabetic patients than non-diabetic patients (11.5+/-13.8 mm3 vs. 9.1+/-11.0 mm3, p=0.028, and 23.9+/-24.7 mm3 vs. 18.1+/-14.3 mm3, p=0.035, respectively). Plaque volume by CCTA correlated with that of VH-IVUS (r=0.742, p<0.001), and plaque volume by CCTA correlated with absolute NC volume by VH-IVUS (r=0.621, p<0.001), and calcium score of lesion site by CCTA correlated with absolute dense calcium volume by VH-IVUS (r=0.478, p=0.028). CONCLUSION: Coronary lesion was detected by CCTA in 70% of asymptomatic patients with multiple coronary risk factors, and parameters detected by CCTA correlated well with those detected by VH-IVUS.

Postimplantation Syndrome After Endovascular Aortic Aneurysm Repair in an Elderly Patient

Endovascular procedures have been proposed as minimally invasive alternative treatments, allowing safe and effective aortic aneurysm repair. Despite the potential benefits, endovascular stent grafting may elicit an unexpected systemic inflammatory response, called postimplantation syndrome (PIS). The main features of PIS include fever, elevated C-reactive protein levels, leukocytosis and/or coagulation disturbances, perigraft air on abdominal computed tomography, and no evidence of infection. The main management of PIS is supportive care. Antibiotics have no clinical benefit. We report a case of PIS after endovascular aortic aneurysm repair in an elderly patient.

A Case of Periaortitis Diagnosed with Abdomen CT in a Patient with Malignant Fibrous Histiocytosis

Periaortitis is a very rare disease, characterized by a fibro-inflammatory tissue which develops around abdominal aorta and iliac arteries, and spreads into the structures of retroperitoneum. Computed tomography (CT) or magnetic resonance imaging (MRI) is the modality of choice for the diagnosis. Here, we report a case of periaortitis diagnosed with abdomen CT in patient with malignant fibrous histiocytoma.

The Inflammation Markers According to the Presence of Coronary Artery Disease in Patients with Peripheral Artery Disease

OBJECTIVE: Prevalence of coronary artery disease (CAD) has been reported to be high in patients with atherosclerotic peripheral artery disease (PAD) in lower extremities. Various inflammatory markers have been known to be associated with CAD. The aim of study was to explore the role of inflammatory makers for CAD in patients with PAD. METHODS: A total of 346 PAD patients (71.51+/-9.41 years, 337 males) who underwent percutaneous transluminal angioplasty from June 2006 to April 2012 were included in this study. Patients were divided into the Group I (PAD with CAD: n=151, 149 males) and the Group II (PAD without CAD: n=195, 188 males). RESULTS: Among 346 patients, 149 patients had CAD (43.6%). The prevalence of diabetes mellitus (DM) (p=0.023) and smoking (p=0.010) were significantly higher in the group I when compared withthe group II. The level of high sensitivity C-reactive protein (hs-CRP) increased (p or =3.0 mg/dL) (OR=2.595, 95% CI: 1.548-4.350, p<0.001), and age (OR=0.645; 95% CI, 0.454-0.915; p=0.014) were independent predictors for the development of CAD in PAD patients. CONCLUSION: 43.6% of patients with PAD also had CAD, and the predictors of CAD were smoking, DM, and high level of hs-CRP.

The Impact of Ischemic Time on the Predictive Value of High-Sensitivity C-Reactive Protein in ST-Segment Elevation Myocardial Infarction Patients Treated by Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: The high-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, has been known to be elevated in patients with coronary artery disease. However, there is controversy about the predictive value of hs-CRP after acute myocardial infarction (MI). Therefore, we evaluated the impact of ischemic time on the predictive value of hs-CRP in ST-segment elevation myocardial infarction (STEMI) patients who were treated by primary percutaneous coronary intervention (PCI). SUBJECTS AND METHODS: We enrolled 5123 STEMI patients treated by primary PCI from the Korean Working Group in Myocardial Infarction and divided enrolled patients into four groups by symptom-to-balloon time (SBT) and level of hs-CRP (Group I: SBT or =3 mg/L, Group III: SBT > or =6 hours and hs-CRP or =6 hours and hs-CRP > or =3 mg/L). To evaluate the impact of ischemic time on the predictive value of hs-CRP in STEMI patients, we compared the cumulative cardiac event-free survival rate between these four groups. RESULTS: The sum of the cumulative incidence of all-cause mortality and recurrence of MI was higher in Group IV than in the other groups. However, there was no significant difference among Group I, Group II, and Group III. The Cox-regression analyses showed that an elevated level of hs-CRP (> or =3 mg/L) was an independent predictor of long-term cardiovascular outcomes only among late-presenting STEMI patients (p=0.017, hazard ratio=2.462). CONCLUSION: For STEMI patients with a long ischemic time (> or =6 hours), an elevated level of hs-CRP is a poor prognostic factor of long-term cardiovascular outcomes.

Stress-Induced Cardiomyopathy Presenting as Ventricular Tachycardia

No abstract available.

The Effect of Telmisartan on Endothelial Function and Arterial Stiffness in Patients With Essential Hypertension

BACKGROUND AND OBJECTIVES: Several studies have shown that angiotensin II receptor blockers (ARBs) improve endothelial function and arterial stiffness. Telmisartan is a highly selective ARB that activates peroxisome proliferator-activated receptor gamma (PPARgamma). The purpose of this study was to evaluate the effects of telmisartan, such as endothelial function, arterial stiffness, and insulin sensitivity, in patients with essential hypertension. SUBJECTS AND METHODS: Thirty-nine patients with essential hypertension were administered telmisartan (80 mg once daily) using an open-labeled and prospective protocol. The patients were examined before and 8 weeks after treatment to assess changes in flow mediated-vasodilation (FMD), pulse wave velocity (PWV), quantitative insulin-sensitivity check index (QUICKI), homeostasis model assessment (HOMA), and adiponection. RESULTS: The systolic and diastolic blood pressure (BP) decreased from 153+/-15 mmHg and 90+/-13 mmHg to 137+/-16 mmHg and 84+/-10 mmHg after telmisartan treatment, respectively (p<0.01). Telmisartan therapy increased the FMD from 7.6+/-3.5 to 9.0+/-2.8% (p<0.01). The following parameters of arterial stiffness were significantly improved after telmisartan therapy: brachial-ankle pulse wave velocity (baPWV), from 17.2+/-3.1 to 15.9+/-2.6 m/sec; heart-carotid PWV (hcPWV), from 9.7+/-1.8 to 9.0+/-1.9 m/sec; and heart-femoral PWV (hfPWV), from 11.3+/-1.9 to 10.7+/-1.9 m/sec (p<0.01). There were no changes in QUICKI, the HOMA level, and plasma adiponectin (p=NS). CONCLUSION:These results suggest that telmisartan is effective in improving endothelial function and arterial stiffness in patients with essential hypertension.

A Case of Acute Lower Gastrointestinal Bleeding from a Benign Appendiceal Ulcer / 대한소화기내시경학회지

A hemorrhoid is the most common cause of acute lower gastrointestinal (LGI) bleeding. Diverticulosis, angiodysplasia and ischemic colitis can also cause LGI bleeding. Acute LGI bleeding from the appendix is very rare. We experienced a case of a 33-year-old woman with acute LGI bleeding from the appendix. Colonoscopy demonstrated an active hemorrhage from the orifice of the appendix. The patient was treated with a appendectomy, and a histological examination showed the presence of a small ulcer with inflamed granulation tissue in the mucosa and submucosa.

Clinical characteristics of Korean acute myocardial infarction patients who are younger than 40 years old / 대한내과학회지

BACKGROUND/AIMS: It is known that mortality increases with age for patients who suffer with acute myocardial infarction (AMI). Yet there isn't much data on the clinical characteristics and long-term prognosis of young patients with AMI. METHODS: We analyzed two groups of patients with AMI who underwent coronary angiogram : 108 patients younger than 40 years as group I and 64 patients over 70 years old as group II. We compared the baseline clinical characteristics, the echocardiographic and coronary angiographic findings, and the major adverse cardiac event (MACE). RESULTS: Male gender (94.4% vs. 56.1%, respectively, p<0.001), smoking (78.7% vs. 46.9%, respectively, p<0.001) and hyperlipidemia (45.4% vs. 14.1%, respectively, p<0.001) were more frequent in group I, whereas hypertension (23.1% vs. 40.6%, respectively, p=0.015) and diabetes (11.6% vs. 34.4%, respectively, p<0.001) were more common in group II. The left ventricular ejection fraction (55.1+/-12.2% vs. 50.5+/-14.1%, respectively, p=0.042) was higher in group I. The serum levels of high sensitivity C-reactive protein (1.7+/-2.6 vs. 3.4+/-4.4 mg/L, respectively, p=0.015) and homocysteine (11.5+/-7.0 vs. 15.3+/-9.7 microgram/L, respectively, p=0.029) were higher in group II. One vessel disease (78.7% vs. 59.4%, respectively, p=0.007) and good Thrombolysis In Myocardial Infarction (TIMI) flow (TIMI II-III, 58.3% vs. 41.2%, respectively, p=0.040) were more common in group 1. There were no differences between the two groups for the development of MACE during the 28+/-21 months of clinical follow-up, but cardiac death was lower in group I than in group II (2.1% vs. 15.4%, respectively, p=0.002). CONCLUSIONS: Male gender, smoking and hyperlipidemia were the major risk factors of Korean young AMI patients. In addition, single vessel disease and good TIMI flow were more frequent and cardiac death was less frequent in the younger AMI patients.

Is cardiovascular disease more common in Vietnam veterans exposed to agent orange? / 대한내과학회지

BACKGROUND: TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin), a material of agent orange, was reported as a deadly poison in spite of its presence at extremely small doses. It has been reported that TCDD can cause various kinds of cancers and harmful effects on humans. However, a correlation between exposure to TCDD and cardiovascular disease is not yet known. Thus, we intended to examine the correlation between TCDD exposure and cardiovascular disease through an analysis of coronary angiograms in veterans of the Vietnam War. METHODS: A consecutive 115 patients undergoing coronary angiograms between April 2004 and June 2005 at Gwangju Veterans Hospital were analyzed. The patients were divided into two groups: 57 patients exposed to TCDD (Group I, average age 59.2+/-4.2 years) and 58 patients that were not exposed to TCDD (Group II, Average age 60.1+/-5.6 years). The clinical and coronary angiographic findings were evaluated. RESULTS: Baseline clinical characteristics, inflammatory markers and echocardiographic parameters were not different between patients in the two groups. The incidence of diabetes (43.9% vs. 25.0%, p=0.035) and hyperlipidemia (47.4% vs. 27.6%, p=0.028) were higher in group I patients than group II patients. Significant coronary artery stenosis was more common in group I (45 cases, 78.9%) thanin group II (33 cases, 56.9%) (p=0.011). CONCLUSIONS: There was a higher incidence of diabetes, hyperlipidemia, and significant coronary artery stenosis in patients that underwent a diagnostic coronary angiogram that were previously exposed to TCDD.