Efficacy and Safety of Omega-3 Fatty Acids in Patients Treated with Statins for Residual Hypertriglyceridemia: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

BACKGROUND: Cardiovascular risk remains increased despite optimal low density lipoprotein cholesterol (LDL-C) level induced by intensive statin therapy. Therefore, recent guidelines recommend non-high density lipoprotein cholesterol (non-HDL-C) as a secondary target for preventing cardiovascular events. The aim of this study was to assess the efficacy and tolerability of omega-3 fatty acids (OM3-FAs) in combination with atorvastatin compared to atorvastatin alone in patients with mixed dyslipidemia.METHODS: This randomized, double-blind, placebo-controlled, parallel-group, and phase III multicenter study included adults with fasting triglyceride (TG) levels ≥200 and <500 mg/dL and LDL-C levels <110 mg/dL. Eligible subjects were randomized to ATOMEGA (OM3-FAs 4,000 mg plus atorvastatin calcium 20 mg) or atorvastatin 20 mg plus placebo groups. The primary efficacy endpoints were the percent changes in TG and non-HDL-C levels from baseline at the end of treatment.RESULTS: After 8 weeks of treatment, the percent changes from baseline in TG (−29.8% vs. 3.6%, P<0.001) and non-HDL-C (−10.1% vs. 4.9%, P<0.001) levels were significantly greater in the ATOMEGA group (n=97) than in the atorvastatin group (n=103). Moreover, the proportion of total subjects reaching TG target of <200 mg/dL in the ATOMEGA group was significantly higher than that in the atorvastatin group (62.9% vs. 22.3%, P<0.001). The incidence of adverse events did not differ between the two groups.CONCLUSION: The addition of OM3-FAs to atorvastatin improved TG and non-HDL-C levels to a significant extent compared to atorvastatin alone in subjects with residual hypertriglyceridemia.

Changes in serum magnesium concentration after use of a proton pump inhibitor in patients undergoing percutaneous coronary intervention

BACKGROUND: Although cross-sectional studies have suggested a relationship between proton pump inhibitor (PPI) use and hypomagnesemia, no large-scale cohort study has been conducted to date. Here, we examined the changes in serum magnesium levels in response to PPI use. We hypothesized that PPI use might change the serum magnesium concentration. METHODS: Of the 2,892 patients hospitalized for percutaneous coronary intervention between January 2007 and May 2012, 1,076 patients with normal baseline (1.6-2.5 mg/dL) and follow-up serum magnesium concentrations were enrolled. These patients were divided into two groups: the PPI group and the control group. RESULTS: The mean follow-up period was 9.51+/-2.94 months. The incidence of hypomagnesemia ( or =12 months, n = 71) and short-term PPI groups (duration of use <12 months, n = 763), and the control group (n = 242; P = 0.620). The effect of PPI use on change in serum magnesium concentration was affected by the use of multiple diuretics (-0.01+/-0.25 mg/dL; P = 0.025), although a single diuretic use with PPI did not alter the change in magnesium level (0.12+/-0.27 mg/dL). CONCLUSION: Changes in magnesium levels might be subtle after PPI use in patients with normal baseline magnesium values.

Acute myocardial infarction caused by a floating thrombus in the proximal ascending aorta

No abstract available.

The Impact of Vascular Access for In-Hospital Major Bleeding in Patients with Acute Coronary Syndrome at Moderate- to Very High-Bleeding Risk

The aim of our study was to determine the impact of vascular access on in-hospital major bleeding (IHMB) in acute coronary syndrome (ACS). We analyzed 995 patients with non-ST elevation myocardial infarction and unstable angina at the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) moderate- to very high-bleeding risk scores in trans-radial intervention (TRI) retrospective registry from 16 centers in Korea. A total of 402 patients received TRI and 593 patients did trans-femoral intervention (TFI). The primary end-point was IHMB as defined in the CRUSADE. There were no significant differences in in-hospital and 1-yr mortality rates between two groups. However, TRI had lower incidences of IHMB and blood transfusion than TFI (6.0% vs 9.4%, P = 0.048; 4.5% vs 9.4%, P = 0.003). The patients suffered from IHMB had higher incidences of in-hospital and 1-yr mortality than those free from IHMB (3.1% vs 15.0%, P < 0.001; 7.2% vs 30.0%, P < 0.001). TRI was an independent negative predictor of IHMB (odds ratio, 0.305; 95% confidence interval, 0.109-0.851; P = 0.003). In conclusions, IHMB is still significantly correlated with in-hospital and 1-yr mortality. Our study suggests that compared to TFI, TRI could reduce IHMB in patients with ACS at moderate- to very high-bleeding risk.

Transcatheter Arterial Embolization as Treatment for a Life-Threatening Retroperitoneal Hemorrhage Complicating Heparin Therapy

Spontaneous retroperitoneal hemorrhage is a distinct clinical entity that can present in the absence of specific underlying pathology or trauma and is typically associated with anticoagulation therapy. We report a case of a 74-year-old female patient with a cerebral infarction related to atrial fibrillation who developed a spontaneous lumbar arterial hemorrhage complicating heparin therapy. The diagnosis was suggested by a computed tomography scan and confirmed by angiography. She was treated successfully with transcatheter embolization.

Long QT Syndrome and Torsade de Pointes Associated with Takotsubo Cardiomyopathy

Prolongation of QTc interval associated with Takotsubo cardiomyopathy (TC) has previously been reported in published case series. We report an unusual case of a patient who presented with TC associated with long-QT syndrome and developed cardiac arrest secondary to torsade de pointes. Since QT prolongation and bradycardia persisted after the resolution of TC, the patient received permanent pacemaker. Since then additional event did not occur. QT prolongation and bradycardia could be persistent even after recovery of TC, and permanent pacemaker insertion may be a treatment option of long QT syndrome related with TC.

Direct Comparison between Brachial Pressure Obtained by Oscillometric Method and Central Pressure Using Invasive Method

OBJECTIVE: The importance of central blood pressure evaluation for cardiovascular risk stratification has been emphasized. The aim of this study is to evaluate whether brachial blood pressure obtained by the oscillometric method accurately reflects central blood pressure. METHODS: The subjects consisted of 84 consecutive patients with suspected coronary artery disease who underwent cardiac catheterization. Central blood pressure was invasively measured in the origin of the left subclavian artery by using the fluid-filled system, and at the same time, brachial blood pressure in the left upper arm was measured by the oscillometric method. RESULTS: No significant difference was found between central systolic pressure and brachial systolic pressure (144.49+/-18.84 mmHg vs. 142.44+/-14.96 mmHg, P=0.063). Bland-Altman analysis accounted for only a small bias of +2.25 mmHg, and the limits of agreement were 24.15 mmHg and -19.65 mmHg. Central diastolic pressure was significantly lower than brachial diastolic pressure (75.80+/-8.74 mmHg vs. 86.70+/-10.48 mmHg, P<0.001). Bland-Altman analysis showed a significant bias of -5.45 mmHg, and the limits of agreement were 2.83 mmHg and -13.73 mmHg. CONCLUSION: These results indicate that central systolic pressure can be directly estimated from brachial systolic pressure using the noninvasive oscillometric method and observed biases seem to remain within the practical range. However, use of the brachial diastolic pressure and pulse pressure measured by the noninvasive oscillometric method is doubtful in clinical practice because of their large biases.

Use of Drug-Eluting Stent with Provisional T-Stenting Technique in the Treatment of Renal Artery Bifurcation Stenosis; Long-term Angiographic Follow-up

Atherosclerotic renal artery stenosis (RAS) usually involves the ostium and the proximal one-third of the renal artery main branch. Percutaneous renal artery angioplasty with stent placement is a well recognized treatment for atherosclerotic RAS. Occasionally, atherosclerotic RAS involves renal artery bifurcations. However, stent implantation in atherosclerotic RAS involving bifurcation is not only troublesome, but also challenging because of side branch occlusion and in-stent restenosis (ISR). In the present report, we describe the use of drug-eluting stents (DES) with provisional T-stenting technique for the treatment of renal artery bifurcation lesion. Follow-up angiogram showed no significant ISR 18 months after the procedure. In the treatment of renal bifurcation lesions, a two-stent strategy using DES could be a viable option in selected patients.

An Extremely Rare Variety of Anomalous Coronary Artery: Right Coronary Artery Originating From the Distal Left Circumflex Artery

A single coronary artery (SCA) is a rare congenital anomaly of the coronary circulation, which is often associated with myocardial ischemia and other congenital cardiac anomalies. A 77-year-old woman visited our hospital complaining of typical chest pain. Coronary angiography revealed an isolated SCA. The right coronary artery did not originate from the aorta, but instead emerged from the distal left circumflex artery, with significant stenosis at the proximal portion of the left anterior descending artery. A stent was successfully implanted at the culprit lesion. There was no perfusion defect detected by a cardiac SPECT study.

The Association Between Left Ventricular Hypertrophy and Biomarkers in Patients on Continuous Ambulatory Peritoneal Dialysis

BACKGROUND AND OBJECTIVES: Left ventricular hypertrophy (LVH) is a major cardiovascular complication and an important predictor of mortality in patients with end stage renal disease. Some studies have shown that the serum aldosterone levels are correlated with LVH in non-diabetic patients undergoing hemodialysis. The objective of this study was to elucidate the relationships between serum biomarkers, including aldosterone, and echocardiographic findings, such as LVH, in patients on peritoneal dialysis. SUBJECTS AND METHODS: Thirty patients on continuous ambulatory peritoneal dialysis (CAPD) for >12 months at Soonchunhyang University Cheonan Hospital were included. Transthoracic echocardiography was performed and the left ventricular mass index (LVMI) was calculated using the Devereux formula. Serum biomarkers {N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin T, C-reactive protein, renin, and aldosterone} were measured. RESULTS: Sixteen of 30 patients had LVH on the basis of the LVMI. The mean serum aldosterone level was 62.53+/-60.73 pg/mL (range, 5.03-250.68 pg/mL). LVH, on the basis of the LVMI, was not correlated with the serum aldosterone level. The serum aldosterone levels were not associated with echocardiographic findings, even with co-existing diabetes mellitus. The LVMI had a negative correlation with the hemoglobin (r=-0.405, p=0.029) and hematocrit (r=-0.374, p=0.042), and a positive correlation with NT-proBNP (r=0.560, p=0.002). The other biomarkers (renin, aldosterone, troponin T, and C-reactive protein) were not correlated with the LVMI. The LVMI was correlated with the left atrium volume index (r=0.675, p<0.001). CONCLUSION: NT-proBNP is a good marker to predict LVH in patients undergoing CAPD. The serum aldosterone level is not correlated with LVMI, even with co-existing diabetes mellitus.

Coronary Artery Thrombosis Associated With Paclitaxel in Advanced Ovarian Cancer

A 63-year-old woman was diagnosed with ovarian cancer and peritoneal carcinomatosis. The day after paclitaxel was administered, an acute myocardial infarction occurred. Emergency coronary angiography revealed a filling defect in the left main coronary artery and total occlusion in the distal left anterior descending coronary artery, with no luminal irregularity or narrowing. Intravascular ultrasonography showed no significant plaque in the left main coronary artery. A thrombophilia work-up was negative, and the patient was treated with tirofiban, clopidogrel, and aspirin. The follow-up coronary angiogram showed that the occlusion of the distal obtuse marginal branch and distal left anterior descending artery had cleared. Paclitaxel has been associated with acute myocardial infarction. However, the pathogenesis of myocardial infarction associated with paclitaxel is not known. This case raises the possibility that paclitaxel can induce coronary artery thrombosis, resulting in myocardial infarction.

Spontaneous Retroperitoneal Hemorrhage and Hemothorax After Intravenous Heparin Treatment

Spontaneous retroperitoneal hemorrhage is a rare complication after percutaneous coronary intervention (PCI). The patient can be in danger if bleeding is not stopped immediately. However, it is not easy to control the bleeding completely because the bleeding foci can be multiple and there is a rich network of collateral circulation. We report a case of spontaneous retroperitoneal hemorrhage successfully treated using multiple microcoils. One year later, panhypopituitarism occurred as a likely consequence of the accompanying hypovolemic shock.

Post-cardiac injury syndrome (PCIS) following coronary artery perforation during PCI / 대한내과학회지

Post-cardiac injury syndrome (PCIS) includes post-myocardial infarction syndrome and post-pericardiotomy syndrome. PCIS is usually observed 1~6 weeks after cardiac surgery or myocardial infarction, and rarely after pacemaker implantation, coronary perforation, pulmonary thromboembolism, or radio-frequency ablation. PCIS is characterized by a low-grade fever, pleuritic chest pain, myalgia, a pericardial friction rub, increased inflammatory markers, and pericardial and pleural effusions. Although the pathophysiology of PCIS is controversial, the presence of anti-heart antibodies has implicated an autoimmune response, which has been widely accepted. The treatment of PCIS includes nonsteroidal anti-inflammatory drugs and corticosteroids. Currently, intervention is being performed increasingly in complicated obstructive coronary artery disease, such as chronic total occlusion, long-segment obstructive lesion, and left main coronary artery disease. We report a very rare case of PCIS following coronary artery perforation during PCI.

A Case of Hypereosinophilic Syndrome Presenting as Pericardial Effusion, Myocarditis and Ascites

Hypereosinophilic syndrome is a clinical disorder characterized by peripheral eosinophilia and eosinophilic infiltration of multiple organ systems, including the cardiovascular system. The manifestations are variable, but cardiac involvement is the major source of morbidity and mortality, and several case reports have highlighted the various types of cardiac involvement. However, no reported case has simultaneously presented with pericardial effusion, myocarditis, and ascites. We report a case of a 28-year-old woman with hypereosinophilic syndrome involving both the heart and intra-abdominopelvic cavity.

Probable Left Atrial Myxoma Presenting as Concurrent Cerebral and Myocardial Infarctions

Concurrent cerebral and coronary artery embolization is a theoretically possible, but extremely rare complication of an atrial myxoma. We present a paitent with a left atrial mass (a probable myxoma) who presented with concurrent cerebral and myocardial infarctions due to emboli of tumor origin. An 84-year-old woman presented with an acute cerebral infarction of the middle cerebral artery territory. Several hours after admission, she complained of chest pain consistent with a myocardial infarction. Transthoracic and transesophageal echocardiographic studies revealed the presence of a large, mobile, heteroechoic mass with a few daughter nodules in the left atrium, compatible with a myxoma. Coronary angiography disclosed subtotal occlusion of the ramus intermedius branch and visible tumor vascularization adjacent to the right coronary artery. With medical treatment, including anticoagulation, the patient was stabilized and had an uneventful clinical course for the ensuing 6 months since discharge.

The Effect of Isosorbide Dinitrate Intravenous Injection on the Hemodynamics and Arterial Stiffness of Patients with Isolated Systolic Hypertension

BACKGROUND AND OBJECTIVES: In clinical practice, isolated systolic hypertension (ISH) is common for elderly patients and it is correlated with cardiovascular mortality. However, it is difficult to control the systolic blood pressure (BP) with using the currently available antihypertensive drugs without influencing the diastolic BP. The purpose of this study is to evaluate the effect of isosorbide dinitrate on the central BP and arterial stiffness by performing invasive testing. SUBJECTS AND METHODS: Thirty subjects who had ISH and who underwent coronary angiography were enrolled in this study. The invasively measured central blood pressure, pulse pressure and pulse wave velocity were obtained after isosorbide dinitrate was injected intravenously and these values were analyzed in relation to age, gender, the body mass index, diabetes mellitus, dyslipidemia, smoking and the current dosing with antihypertensive drugs. RESULTS: One minute after intravenous injection of isosorbide dinitrate, the central systolic BP was significantly decreased compare to the baseline value (142.23+/-12.32 mmHg vs 164.97+/-14.43 mmHg, respectively, p<0.001), and this change was sustained for 5 minutes (141.05+/-14.84 mmHg vs 164.97+/-14.43 mmHg, respectively, p<0.001). The mean values, during the 5 minute period, of the pulse pressure (65.99+/-13.63 mmHg vs 87.30+/-13.71 mmHg, respectively, p<0.001) and the pulse wave velocity (11.22+/-3.20 m/sec vs 12.91+/-4.11 m/sec, respectively, p<0.001) also revealed significant changes. Yet there was no significant decrease of the diastolic BP. Analysis of subgroups that were classified by gender, age, BMI, diabetes mellitus, dyslipidemia, smoking, the degree of the systolic BP and PWV, and taking antihypertensive drugs showed a similar pattern. CONCLUSION: Isosorbide dinitrate was very effective for selective control of the systolic BP in ISH patients. It is also expected to prevent cardiovascular complications by improving arterial stiffness.

Clinical Factors that Predicts Successful Eradication of Helicobacter pylori / 대한소화기학회지

BACKGROUND/AIMS: Antibiotic resistance and compliance are regarded to be important which affect the eradication of Helicobacter pylori (H. pylori). However, it is not easy to apply the antibiotic resistance test in clinical field. We investigated other clinical factors predicting the successful eradication of H. pylori. METHODS: From January 2004 to March 2005, 195 patients with documented H. pylori infection received proton pump inhibitor (PPI)-based triple therapy for one week and were assessed for the underlying chronic illnesses, smoking, alcohol habit, therapeutic indication and compliance. RESULTS: The intention-to-treat (ITT) eradication rates were 69.2%, while per protocol (PP) analysis with 169 patients showed an initial eradication rate of 79.9%. The eradication rates of H. pylori according to the underlying disease were 73.9% (17/23) in diabetes, 66.7% (18/27) in hypertension, 66.7% (2/3) in renal disease, 100% (9/9) in liver disease, 63.7% (7/11) in cardiovascular disease and 64.3% (9/14) in chronic NSAIDs user. There was no statistical difference in the eradication rates according to the therapeutic indication, underlying disease, sex, age, smoking, alcohol, and PPI. However, the eradication rate was statistically lower in patients with multiple underlying diseases. Eradication rate was significantly higher in patients with good compliance than in those with poor compliance in taking medications (p<0.05). CONCLUSIONS: Underlying chronic disease does not affect the H. pylori eradication rate significantly. In clinical practice, apart from antibiotic resistance test, drug compliance is the most important factor affecting the H. pylori eradication rate.

A Case of Partial Intestinal Obstruction due to Ascaris lumbricoides / 대한소화기내시경학회지

Ascaris lumbricoides (A. lumbricoides) is the largest and most common human intestinal helminth in the world. However, the prevalence of ascariasis has, in recent years, been very low in Korea. The majority of patients infected with A. lumbricoides are asymptomatic. However, sometimes these infections may give rise to intestinal obstructions or pancreatobiliary disease, via retrograde migration through the ampulla of Vater. Intestinal obstruction associated with A. lumbricoides is a complication that is frequently observed in children living in endemic areas. However, no cases of A. lumbricoides-associated intestinal obstruction have been reported in Korea since 1967. In this report, we describe the case of a 78-year-old man, who presented with sustained nausea and postprandial vomiting, and was diagnosed with a partial intestinal obstruction due to A. lumbricoides after undergoing an esophagogastroduodenoscopy.

Apolipoprotein E Polymorphism in Patients with Myocardial Infarction

BACKGROUND AND OBJECTIVES: In this study we investigated the association between the polymorphism of apolipoprotein E and the development of myocardial infarction, and assessed whether this polymorphism produces any changes of plasma lipid level. SUBJECTS AND METHODS: A total of 182 patients participated in this study and were divided into two groups; 91 patients with myocardial infarction (MI group) and 91 patients with no known heart disease (control group). For both groups we analyzed the clinical parameters, the changes of plasma lipid level and the degree of polymorphism of apolipoprotein E. RESULTS: Total cholesterol, triglyceride and LDL cholesterol levels were significantly higher in the MI group, while the HDL cholesterol level was significantly lower. Compared with the control group, the frequency of epsilon2 allele was significantly lower while that of epsilon3 allele was significantly higher in the MI group. As for the control group, the triglyceride level was significantly higher in the patients with epsilon 2 allele than in those without epsilon 2 allele, and the total cholesterol level was significantly higher in the patients with epsilon 4 allele than in those without epsilon 4 allele. In the MI group, the plasma lipid levels were not significantly different from those in the control group. CONCLUSION: We suggested that apolipoprotein E polymorphism could affect the lipid metabolism as well as the development of myocardial infarction. However further study is needed in patients with myocardial infarction.

Aortic Root Remodeling Procedure in Marfan Syndrome associated with Aortic Dissection: Yacoub-David Technique / 대한흉부외과학회지

We operated on a Marfan patient who had Stanford type A acute aortic dissection, aortic root aneurysm, and aortic regurgitation. The Yacoub-David aortic root remodeling procedure which preserves native aortic valve and replaces all three aortic sinuses and ascending aorta by a Dacron graft, was applied for this patient. A 24mm Hemashield graft was designed to three tongues at the aortic root end to meet the shape of the Valsalva sinuses. The patient recovered from the procedure uneventfully and there was no aortic regurgitation postoperatively.