Gender Difference of Blood Pressure Control Rate and Clinical Prognosis in Patients With Resistant Hypertension: Real-World Observation Study

Background@#There are several differences in the clinical course of hypertension due to the biological and social differences between men and women. Resistant hypertension is an advanced disease state, and significant gender difference could be expected, but much has not been revealed yet. The purpose of this study was to compare gender differences on the current status of blood pressure (BP) control and clinical prognosis in patients with resistant hypertension. @*Methods@#This is a multicenter, retrospective cohort study using common data model databases of 3 tertiary hospitals in Korea. Total 4,926 patients with resistant hypertension were selected from January 2017 to December 2018. Occurrence of dialysis, heart failure (HF) hospitalization, myocardial infarction, stroke, dementia or all-cause mortality was followed up for 3 years. @*Results@#Male patients with resistant hypertension were younger but had a higher cardiovascular risk than female patients. Prevalence of left ventricular hypertrophy and proteinuria was higher in men than in women. On-treatment diastolic BP was lower in women than in men and target BP achievement rate was higher in women than in men.During 3 years, the incidence of dialysis and myocardial infarction was higher in men, and the incidence of stroke and dementia was higher in women. After adjustment, male sex was an independent risk factor for HF hospitalization, myocardial infarction, and all-cause death. @*Conclusion@#In resistant hypertension, men were younger than women, but end-organ damage was more common and the risk of cardiovascular event was higher. More intensive cardiovascular prevention strategies may be required in male patients with resistant hypertension.

Tachycardia induced Cardiomyopathy

Recent studies on radiofrequency catheter ablation (RFCA) in atrial fibrillation show its effectiveness in heart failure (HF) patients; hence, tachycardia-induced cardiomyopathy (T-CMP) is gaining attention. Tachycardia-mediated cardiomyopathy is a reversible left ventricular (LV) dysfunction, which can be induced by any tachyarrhythmia. Early recognition of T-CMP with appropriate treatment of the arrhythmia culprit will lead to the recovery of LV function. Patients with tachycardia and LV dysfunction should be suspected of having T-CMP, with or without established etiology of HF, because T-CMP may present by itself or contribute as a co-existent component. Therapeutic options include rate control, anti-arrhythmic drugs, or catheter ablation. Unlike in animal models, clinical data on human T-CMP is limited. Hence, future research should be more focused on tachyarrhythmia-induced cardiomyopathy as its burden is increasing.

Tachycardia induced Cardiomyopathy

Recent studies on radiofrequency catheter ablation (RFCA) in atrial fibrillation show its effectiveness in heart failure (HF) patients; hence, tachycardia-induced cardiomyopathy (T-CMP) is gaining attention. Tachycardia-mediated cardiomyopathy is a reversible left ventricular (LV) dysfunction, which can be induced by any tachyarrhythmia. Early recognition of T-CMP with appropriate treatment of the arrhythmia culprit will lead to the recovery of LV function. Patients with tachycardia and LV dysfunction should be suspected of having T-CMP, with or without established etiology of HF, because T-CMP may present by itself or contribute as a co-existent component. Therapeutic options include rate control, anti-arrhythmic drugs, or catheter ablation. Unlike in animal models, clinical data on human T-CMP is limited. Hence, future research should be more focused on tachyarrhythmia-induced cardiomyopathy as its burden is increasing.

Long-term Survival Benefit of Statin in Patients with Coronary Chronic Total Occlusion without Revascularization

BACKGROUND: Limited data are available on the efficacy of statin therapy in stable ischemic heart disease with chronic total occlusion (CTO) without revascularization. We investigated whether statin therapy could be beneficial in stable patients with CTO without revascularization. METHODS: From March 2003 to February 2012, 2,024 patients with at least one CTO were enrolled in a retrospective, single-center registry; 664 of these patients were managed conservatively without an initial revascularization strategy. Among them, we excluded CTO cases involving acute coronary syndrome, in-hospital death or incomplete data and classified 551 patients into statin (n = 369) and non-statin (n = 182) groups according to use of statin at discharge. Propensity score matching analysis was also performed in 148 pairs. The primary outcome was cardiac death. RESULTS: The median overall follow-up duration was 45.7 months (interquartile range: 19.9–70.5 months). Cardiac death occurred in 22 patients (6.0%) in the statin group vs. 24 patients (13.2%) in the non-statin group (P 70 years, renal insufficiency, prior myocardial infarction, left ventricular ejection fraction < 40%, proximal-to-mid CTO location, and no use of statin in CTO patients. CONCLUSION: Statin therapy at discharge may be associated with a reduction in long-term cardiac mortality in stable CTO patients without revascularization.

Hospital Arrival Rate within Golden Time and Factors Influencing Prehospital Delays among Patients with Acute Myocardial Infarction

PURPOSE: This research was done to identify the hospital arrival rate and factors related to prehospital delay in arriving at an emergency medical center within the golden time after symptom onset in patients with acute myocardial infarction (AMI). METHODS: Data used in the research was from the National Emergency Department Information System of the National Emergency Medical Center which reported that in 2014, 9,611 patients went to emergency medical centers for acute myocardial infarction. Prehospital time is the time from onset to arrival at an emergency medical center and is analyzed by subdividing arrival and delay based on golden time of 2 hour. RESULTS: After onset of acute myocardial infarction, arrival rate to emergency medical centers within the golden time was 44.0%(4,233), and factors related to prehospital delay were gender, age, region of residence, symptoms, path to hospital visit, and method of transportation. CONCLUSION: Results of this study show that in 2014 more than half of AMI patients arrive at emergency medical centers after the golden time for proper treatment of AMI. In order to reduce prehospital delay, new policy that reflects factors influencing prehospital delay should be developed. Especially, public campaigns and education to provide information on AMI initial symptoms and to enhance utilizing EMS to get to the emergency medical center driectly should be implemented for patients and/or caregivers.

Hereditary protein S deficiency presenting acute pulmonary embolism / 영남의대학술지

Protein S deficiency is one of the several risk factors for thrombophilia and can cause blood clotting disorders such as deep vein thrombosis and pulmonary embolism. A 54-year-old man was admitted with the complaint of dyspnea and was diagnosed with pulmonary embolism. The patient had very low level of free protein S, total protein S antigen, and protein S activity (type I protein S deficiency). In history taking, we found that his mother, 78 year old, had a history of same disease 10 years ago, and confirmed the pronounced low level of protein S. The patient's son also had very low level of protein S, however there had not been any history of pulmonary embolism yet. This case study suggests that asymptomatic persons with a family history of protein S deficiency and pulmonary embolism should be checked regularly for early detection of the disease, as protein S deficiency can be suspected.

Physician's Awareness and Education for Patient on Life Style Modification and Home Blood Pressure Monitoring Recommended in Hypertension Guideline

BACKGROUND: It is important to understand physicians' awareness and knowledge on hypertension guideline to comprehend physician oriented barrier against proper hypertension management. Current guidelines emphasize on the role of home blood pressure monitoring. The aim of this study is to investigate the level of awareness and knowledge of Korean physicians on home blood pressure monitoring recommended in current guideline. METHODS: A questionnaire survey asking home blood pressure measurement, as well as prehypertension and life style modification, was conducted among 36 primary physicians and 25 residents of a tertiary medical center. RESULTS: Except the limitation alcohol intake (80.3%), the physicians demonstrated above 90% of agreement with other contents of life style modification recommended by published guidelines (salt restriction, stop smoking, weight loss, and regular aerobic exercise). Majority (77.7%) of primary physicians recommend home blood pressure measurement to their patients. Significantly primary physicians were likely to recommend home blood pressure monitoring than residents (48% vs. 77.7%, p = 0.027). But both physicians and residents show poor compliance to home blood pressure monitoring guideline in the point of blood pressure measuring (12% vs. 19.4%, p > 0.05). But most of participants are aware of adverse effect of prehypertension (88.5%) and the need of its treatment (96.7%). CONCLUSIONS: This result suggest screening alcohol use disorder and brief counseling by physicians should be encouraged as a part of hypertension management and promoting physicians to equip the correct knowledge of home blood pressure measuring recommended in guideline is warranted.

Slow Coronary Flow is Related to Increased Carotid Intima-Media Thickness but Not Pulse Wave Velocity

BACKGROUND AND OBJECTIVES: Slow coronary flow (SCF) is characterized by delayed contrast dye opacification without significant stenosis of epicardial coronary arteries. However, the pathophysiology and clinical implications of SCF are not fully understood. Some reports have suggested that SCF might be caused by atherosclerosis in the coronary artery microvasculature. Measuring carotid intima-media thickness (IMT) and pulse wave velocity (PWV), which are non-invasive and simple diagnostic tools, was developed to detect subclinical atherosclerosis. Thus, we determined IMT and PWV, and their possible relationship in a SCF group and a normal coronary flow (NCF) group of patients. SUBJECTS AND METHODS: We included 101 patients who complained of chest pain but had a normal coronary angiogram. Thrombolysis in Myocardial Infarction frame count (TIMI frame count, TFC) was evaluated in the left and right coronary arteries. We defined SCF as a TFC of more than 25. Carotid IMT was measured by ultrasonography in both common carotid arteries. PWV was calculated from pulse transit time between the brachial and ankle arteries. RESULTS: Fifteen patients were included in the SCF group and 86 patients in the NCF group. Male patients (n=11, 73.3%) were significantly more common in the SCF group than in the NCF group (n=37, 43.0%, p<0.05). The TFC of the SCF and NCF groups were 28.8+/-3.5 and 15.7+/-4.5, respectively. The carotid IMT in the SCF group increased significantly compared to that in the NCF group (1.2+/-0.3 mm vs. 0.8+/-0.1 mm, p<0.01). However, no significant difference in PWV was observed between the two groups. CONCLUSION: SCF may reflect early atherosclerotic changes in the coronary artery microvasculature.

Carotid Intima-Media Thickness and Plaque as a Predictor for Ischemic Etiology in Patients With Severe Left Ventricular Systolic Dysfunction

BACKGROUND AND OBJECTIVES: Coronary artery disease (CAD) is a major cause of heart failure associated with left ventricular systolic dysfunction (LVSD). The prognosis of LVSD is significantly influenced by the etiology of heart failure and therefore, differentiation of significant CAD from other etiologies is important. Carotid intima-media thickness (IMT) and plaque are useful predictors for cardiovascular events, including stroke and CAD. The purpose of this study was to evaluate the predictive value of carotid IMT and plaque for the diagnosis of CAD in LVSD patients. SUBJECTS AND METHODS: Seventy-three (n= 73, 47 male, 67.6+/-12.4 years) patients hospitalized for heart failure with severe LVSD were retrospectively enrolled. The severity of CAD was analyzed by the Duke Jeopardy Score system, and carotid IMT and plaque were measured according to the Mannheim Carotid IMT Consensus. RESULTS: Significant CAD was found in 41 patients (56.1%, CAD group) on coronary angiography. Mean common carotid artery (CCA) IMT (0.74+/-0.05 mm vs. 1.04+/-0.04 mm, p<0.01) was significantly higher in the CAD group. Plaque in CCA (6.25% vs. 19.5%, p<0.01) and plaque in bulb (25.0% vs. 60.9%, p<0.001) were significantly higher in the CAD group. Mean CCA IMT {odds ratio (OR) 2.61, 95% confidence interval (CI) 1.134-4.469, p<0.01} and plaque in bulb (OR 4.69, 95% CI 1.702-12.965, p<0.01) were significant predictors for the diagnosis of CAD according to multivariate logistic regression analysis. CONCLUSION: In patients with severe LVSD, mean CCA IMT and bulb plaque can be useful additional predictors for the diagnosis of CAD.

Clinical Utility and Accuracy of Coaguchek(R) XS, a Reliable Alternative to Laboratory International Normalized Ratio Monitoring in Korean Patients With Atrial Fibrillation

BACKGROUND AND OBJECTIVES: To evaluate the accuracy and the clinical utility of the Coaguchek(R) XS, a portable point-of-care coagulometer, compared to standard laboratory methods in Korean patients. SUBJECTS AND METHODS: We included 107 patients with atrial fibrillation on long-term oral warfarin therapy. The prothrombin time as expressed by the international normalized ratio (INR) was measured by the portable Coaguchek(R) XS system as well as standard laboratory methods. Agreement between the two methods was defined as a difference of less than 0.3 between the INR values. RESULTS: The INR determined by the portable Coaguchek(R) XS had excellent correlation with the values obtained by standard methods (r=0.984, p3.0). There was a 91.6% agreement between the two methods. Only nine cases (8.4%) had a difference of more than 0.3; this was mainly noted in the high INR group. CONCLUSION: The portable self-testing of the INR by the Coaguchek(R) XS might be a reliable alternative to hospital based laboratory testing in Korean patients.

Changes in Left Ventricular Systolic Function According to Thrombolysis in Myocardial Infarction Frame Count Immediately After Coronary Intervention in Patients With Obstructive Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Some reports have suggested that coronary microvascular dysfunction plays a role in the recovery of myocardial function in patients with obstructive coronary artery disease. Thrombolysis in myocardial infarction (TIMI) frame count (TFC) is regarded as a simple, reliable method for evaluating microvascular function. We evaluated microvascular function using TFC immediately after coronary intervention and compared TFC with left ventricular systolic function eight months later. SUBJECTS AND METHODS: We studied 68 patients with obstructive coronary artery disease who underwent coronary intervention. Just after intervention, TFC was calculated with the standard method. Left ventricular systolic function was assessed with left ventricular diastolic dimension (LVEDd), ejection fraction (EF), and wall motion score index (WMSI). Eight months after intervention, we completed follow-up coronary angiography and echocardiography. We defined high TFC (HTFC) as a TFC greater than 18. RESULTS: Ten patients were in the HTFC group, and 58 patients were in the low TFC (LTFC) group. There was no difference between the two groups with regard to baseline cardiovascular characteristics and angiographic findings. Just after intervention, the HTFC group showed significantly higher LVEDd (56.6+/-8.9 mm) and WMSI (1.60+/-0.65) compared to the LTFC group (50.3+/-5.9 mm, p0.05). Eight months after intervention, there was also a significant decrease in the WMSI in the LTFC group (1.23+/-0.25, p0.05). CONCLUSION: Increased TFC immediately after coronary intervention is an important poor prognostic factor related to myocardial systolic function eight months after coronary intervention. Coronary microvascular dysfunction may influence myocardial recovery in the setting of obstructive coronary artery disease.

Perioperative Predictors for Recurrence of Mitral Regurgitation after Surgery for Ischemic Mitral Regurgitation

BACKGROUND AND OBJECTIVES : In clinical practice, significant recurrence of mitral regurgitation (MR) is observed frequently even after surgical treatment for ischemic MR (IMR). The purpose of this study is to evaluate the recurrence rate of MR and to investigate perioperative predictors for its recurrence following surgery for IMR. SUBJECTS AND METHODS : We retrospectively analyzed 106 patients who underwent surgical management for IMR. Echocardiographic parameters, such as severity of MR, ejection fraction, diastolic left ventricular (LV) dimension, systolic LV dimension, left atrial size, LV sphericity index, mitral valve (MV) tenting area, MV tenting height (TH), tethering distance, MV intraleaflet angle (MVILa), and MV intraleaflet height (MVILh) were measured. RESULTS : Two types of surgery were performed to treat IMR, including valvuloplasty combined with coronary artery bypass graft (CABG)(group A, n=79) and LV volume reduction surgery combined with CABG (group B, n=27). Significant MR was detected echocardiographically 5.4+/-6.7 months after the surgery. The overall recurrence rate of MR was 17% (n=18), and 15.2% (n=12) in group A and 22.2% (n=6) in group B. The preoperative TH and the postoperative MVILh were independent perioperative predictors for the recurrence of significant MR according to multiple logistic regression analysis (p<0.05, respectively). CONCLUSION : The overall postoperative recurrence rate of significant MR after surgical repair is 17% within 6 months. Independent perioperative predictors of recurrent MR after surgery for IMR are the preoperative TH and the postoperative MVILh. For better outcomes in IMR management, those two factors should be considered in the surgical repair of IMR.

Successful Treatment of Prosthetic Tricuspid Valve Thrombosis with Repeated Urokinase Therapy

Prosthetic valve thrombosis (PVT) can be a life-threatening complication that requires immediate treatment. This is a case report on repeated thrombolytic therapy for thrombosis of a prosthetic tricuspid valve. After repeated urokinase therapy, mechanical clicks were audible and the hemodynamics of the patient rapidly improved. Echocardiography showed the disappearance of thrombi and a normalized pressure gradient. Cine-fluoroscopy showed a well-functioning prosthetic valve.

Usefulness of Korean Guideline for Grading Disability in Patient with Congestive Heart Failure

BACKGROUND AND OBJECTIVES: The increased prevalence of congestive heart failure (CHF) and disabled population with heart diseases has led, in 2000, to the establishment of Korean guidelines for grading disability in patients with CHF, but its usefulness has not been tested. The purpose of this study is to investigate the usefulness of the guidelines in grading disability and predicting the prognosis of patients with CHF. SUBJECTS AND METHODS: Between January, 1999 and March, 2003, 546 consecutive CHF patients were enrolled. Of these 546 patients, only 240 completed one year of follow up before the severity of disability was graded. They were classified into either the disabled or non-disabled groups according to the Korean guidelines for grading disability. They were also subdivided into severe CHF or non severe groups. Severe CHF was defined as a status greater than New York Heart Association class III or to those requiring frequent hospitalization, i.e. more than twice. The mortality and frequency of severe CHF between the disabled and non-disabled groups were evaluated. RESULTS: The prevalence of the disabled with CHF was 7.1% (17/240); one patient was graded in the severe disabled (grade 1), 4 in the moderate (grade 2) and 12 in the mild disabled (grade 3) groups. The mortality within the disabled group was higher than that in the non disabled group (8/17 vs. 1/223, 47.6% vs. 0.4%, p<0.001), but there was no difference according to the severity of disability (p=0.26). All survivors (9 patients) in the disabled group were classified with severe CHF, but 15 from 222 (6.8%) patients not classified in the disabled group also showed severe CHF stati. Half (8 patients, 50%) of the 16 whose total disability scores ranged between 15 and 19, 7 (21.2%) of the 33 with total scores between 10 and 14 were classified with severe CHF stati. CONCLUSION: The current Korean guidelines for grading of disability were able to relatively well predict the prognosis of CHF between the disabled and non disabled groups, but appeared too strict, in that some severe patients cannot be classified into the disabled group. Therefore, the current guidelines will either require modification following a large scaled study or the disability grades will have to be classified into more than 4 categories.

Experience with Intracardiac Echocardiography for Guiding Transcatheter Device Closure of Atrial Septal Defects

BACKGROUND AND OBJECTIVES: Phased-array intracardiac echocardiography (ICE) is a novel method for monitoring intracardiac procedures. We report our initial experience with ICE for guiding transcatheter device closure of atrial septal defects (ASD). SUBJECTS AND METHODS: From April 2004 to March 2005, ICE was performed in 27 consecutive patients during percutaneous device closure of ASDs. The procedural feasibility, the procedure time, the fluoroscopic time, and the complication rate were compared with 27 prior cases that had utilized transesophageal echocardiography. RESULTS: The procedure was performed successfully in all patients. The total procedure time (PT), device deployment time (DT), and fluoroscopic time (FT) were 65.7+/-22.3, 30.4+/-23.8, and 12.1+/-6.4 minutes for the study group, and 73.6+/-23.7, 29.8+/-16.1, and 11.9+/-6.0 for the control group, respectively, with no significant difference between the groups. However, PT and DT were significantly shorter in the later 14 cases of the study group compared to the 13 initial cases (52.1+/-10.9 and 13.2+/-4.2 vs. 80.3+/-22.4 and 48.8+/-22.2, p<0.01, respectively). These differences were also significant compared to the control group, suggesting that there was a learning curve for the procedure. CONCLUSION: ICE is a feasible and relatively safe method for monitoring and guiding percutaneous transcatheter closure of ASDs, but a learning period can be expected to achieve better proficiency.

A recurrent intracardiac thrombosis in a patient with Behet's disease / 대한내과학회지

Behet's disease is a systemic disorder presenting with recurrent oral and genital ulcerations as well as uveitis often leading to blindness. Although vascular lesions are common complications of this disease, cardiac involvement is extremely rare. A 34-year-old man was admitted to the hospital with intermittent low-grade fever 8 months ago. At that time, the echocardiographic examination revealed a right atrial wall mass that was initially thought to be a vegetation, and surgical excision was performed. Histological finding was consistent with organizing thrombus. The patient was readmitted to the hospital with fever, chill and sore throat for about 4 weeks. His past medical history included recurrent oral and genital ulcerations and uveitis for 5 years. Right atrial mass was seen again on echocardiographic examination. On the basis of the clinical course and the presence of recurrent cardiac thrombus, a diagnosis of Beh?et's disease with recurrent intracardiac thrombosis was made. The patient was treated with prednisolone, colchicine, cyclosporine, and aspirin. Medical therapy resulted in complete resolution of his symptoms and disappearance of the right atrial thrombus.

Long-term Follow-up Results of Tilt Training in Patients with Neurocardiogenic Syncope

BACKGROUND AND OBJECTIVES: Tilt training as a non pharmacological therapy was recently introduced to treat the patients with neurocardiogenic syncope. Tilt training has been known to prevent neurocardiogenic syncope by desensitizing abnormal autonomic reflex. Herein, the early effect of tilt training and the preventive effect on the relapse of syncope were studied during a long-term follow-up period. SUBJECTS AND METHODS: Fifteen patients (11 males) who experienced recurrent syncope, despite drug treatment or were intolerant to drug treatment, among those diagnosed as neurocardiogenic syncope by the head-up tilt test at Samsung Medical Center between March 2000 and May 2003 were recruited. Each patient underwent tilt training after admission and was educated to continue self-tilt training after discharge. Data for recurrences after discharge were obtained via questionnaires on outpatient visits or by telephone interviews. RESULTS: Eleven (73%) of the 15 who underwent tilt training on admission showed therapeutic effects. The mean follow-up period was 21+/-10 months (5-40 months). Only one patient was excluded due to follow-up loss. Ten of the above patients underwent training by themselves for an average of 4 months after discharge, and experience no relapse of syncope during the follow-up period. CONCLUSION: Tilt training maintained its therapeutic effect during long-term follow-up. This could be a new treatment for patients non responsive or intolerant to medical therapy.

Four cases of transient hyperammonemic encephalopathy following continuous infusion of 5-fluorouracil / 대한내과학회지

5-Fluorouracil (5-FU) is a chemotherapeutic agent commonly used in the treatment of a variety of solid tumors. Common adverse effects of fluorouracil chemotherapy include diarrhea, mucositis and myelosuppression. However, neurologic toxicities including hyperammonemic encephalopathy are rare and not well recognized. Transient hyperammonemic encephalopathy related to continuous infusion of high-dose 5-FU has rarely been reported. We report four cases of transient hyperammonemic encephalopathy in patients receiving continuous infusion of 5-FU. The mentality of all patients was altered during or just after the infusion of 5-FU. There were no focal neurological signs, laboratory excluding hyperammonemia or radiological abnormalities. After patients received adequate hydration and repeated lactulose enema, the mental status completely recovered within one or two days, and serum ammonium level subsequently returned to normal. In conclusion, we suggest that a transient hyperammonemic encephalopathy should be considered in differential diagnosis of patients receiving continuous 5-FU infusion with altered mentality.

Role of NT-proBNP in Evaluation of Functional Status in Congestive Heart Failure

BACKGROUND AND OBJECTIVE: NT-proBNP, a sensitive and specific marker of congestive heart failure (CHF), is also useful in monitoring the effectiveness of treatment and in predicting prognosis. However, the usefulness of NT-proBNP for measuring the functional capacity as a component of the quality of life (QoL) in patients with CHF remains to be discovered. The Korean Activity Scale/Index (KASI) is a Koreanized tool for measuring the functional capacity in patients with cardiac diseases during daily activities, thus representing the physical domain of the QoL. The purpose of this study was to evaluate the relationship between NT-proBNP and the KASI. SUCJECTS AND METHODS: Between July, 2003 and September, 2003, the NT-proBNP levels were measured in 76 patients with CHF that visited the OPD or who were hospitalized. They were asked to fill out a self-administered questionnaire, from which their KASI scores were obtained. NYHA Fc and Heart Failure scores were also obtained from a history taking and physical examination conducted by the investigator. RESULTS: The level of NT-proBNP increased with increasing NYHA Fc (p<0.001 by Kruskall-Wallis test). The Spearman correlation coefficient between NT-proBNP and the KASI score was -0.730 (p<0.001), which was higher than that between the HF and KASI scores (rho=-0.557, p<0.001). The level of NT-proBNP also had a positive correlation with the HF score (rho=0.706, p<0.001). CONCLUSION: The level of NT-proBNP has a strong negative correlation with the KASI score, reflecting the functional capacity during daily activities. This suggests that NT-proBNP is useful in measuring the functional capacity as an element of the QoL in patients with CHF.

N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Marker in Acute Coronary Syndrome

BACKGROUND AND OBJECTIVES: Biochemical markers are useful for the prediction of cardiac events in patients with acute coronary syndrome (ACS). The N-terminal fragment of the BNP prohormone (NT-proBNP), which is synthesized by cardiac ventricles in response to increased wall stress, may be a prognostic marker in ACS. The relation between the NT-pro BNP levels on admission and major adverse cardiovascular events (MACEs) were assessed in a cohort of patients with ACS. SUBJECTS AND METHODS: Between October 2002 and April 2004, blood samples for the determination of NT-proBNP level were obtained on admission from 78 patients with ST-elevation myocardial infarction (STEMI), 32 with non-ST elevation MI(NSTEMI) and 66 with unstable angina (UA). Patients were followed concerning MACEs (death, MI, heart failure, stroke and revascularization) for a median of 7 months in median. RESULTS: 22 patients (13%) had events. The mean NT-proBNP level was significantly lower in the event-free survivors than in those with events (1342+/-1598 versus 6129+/-6522 pg/mL, p<0.0001). The optimal cut-off value of the NT-proBNP level using a receiver-operating-characteristic curve was 1445 pg/mL. The unadjusted risk ratio of patients with an NT-proBNP level greater than the threshold was 7.0 (95% confidence interval, 2.6 to 19.0). In a multivariate Cox regression model, including clinical background factors and other biochemical markers, the NT-proBNP level was the most powerful indicator of MACEs (risk ratio, 8.0 [95% confidence interval, 1.7 to 37.1]). The coronary angiographic Gensini score was also a predictor of prognosis in ACS (risk ratio, 3.8 [95% confidence interval, 1.0 to 14.0]). CONCLUSION: A single measurement of the NT-proBNP level on admission appears to be useful as a prognostic factor in the prediction of MACEs in patients after ACS.