Erratum: Heart rate variability as a predictor of hypotension after spinal anesthesia in hypertensive patients / 대한마취과학회지

In the original article contained an error in Accepted date.

Pharmacodynamic Estimate of Propofol-Induced Sedation and Airway Obstruction Effects in Obstructive Sleep Apnea-Hypopnea Syndrome

PURPOSE: Sedatives must be carefully titrated for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) as oversedation may lead to disastrous respiratory outcomes. This study aimed to investigate the relations between the effect-site concentration (Ce) of propofol and sedation and airway obstruction levels in patients with OSAHS. MATERIALS AND METHODS: In 25 patients with OSAHS, sedation was induced by 2% propofol using target-controlled infusion. Sedation and airway obstruction levels were assessed using the Observer's Assessment of Alertness/Sedation Scale and a four-category scale, respectively. The relationships between propofol Ce and sedation and airway obstruction were evaluated using a sigmoid Emax model. Pharmacodynamic modeling incorporating covariates was performed using the Nonlinear Mixed Effects Modeling VII software. RESULTS: Increased propofol Ce correlated with the depth of sedation and the severity of airway obstruction. Predicted Ce50(m) (Ce associated with 50% probability of an effect> or =m) for sedation scores (m> or =2, 3, 4, and 5) and airway-obstruction scores (m> or =2, 3, and 4) were 1.61, 1.78, 1.91, and 2.17 microg/mL and 1.53, 1.64, and 2.09 microg/mL, respectively. Including the apnea-hypopnea index (AHI) as a covariate in the analysis of Ce50(4) for airway obstruction significantly improved the performance of the basic model (p<0.05). CONCLUSION: The probability of each sedation and airway obstruction score was properly described using a sigmoid Emax model with a narrow therapeutic range of propofol Ce in OSAHS patients. Patients with high AHI values need close monitoring to ensure that airway patency is maintained during propofol sedation.

The Effect of Cilostazol on Arterial Stiffness in Patients Undergoing Percutaneous Coronary Intervention / 대한내과학회지

BACKGROUND/AIMS: Increased arterial stiffness is a well-known risk factor for cardiovascular disease. Cilostazol, a phosphodiesterase type 3 inhibitor, is a unique antiplatelet agent with vasodilatory and vasoprotective effects. Therefore, we hypothesized that cilostazol may affect arterial stiffness. METHODS: We enrolled 161 patients (112 males; mean age, 63 years) who had undergone percutaneous coronary intervention (PCI) for ischemic heart disease. The brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), rAI adjusted for a heart rate of 75 beats/min (rAI75), central systolic blood pressure (cSBP), and central pulse pressure (cPP), were measured at baseline and at the 30-day follow-up. Parameter changes were compared between the cilostazol group (n = 51) and the control group (n = 110). RESULTS: In the cilostazol group, the values for rAI, cSBP, and cPP all improved after 30 days, while the control group displayed no significant interval changes in these parameters. The changes in rAI75 and baPWV did not differ significantly between the two groups. The changes in rAI, cSBP, and cPP were related to brachial systolic blood pressure, brachial diastolic blood pressure, heart rate, and the use of cilostazol and beta-blockers. In a multivariate analysis, the use of cilostazol was identified an independent factor associated with changes in rAI, cSBP, and cPP. CONCLUSIONS: The addition of cilostazol to conventional antiplatelet therapy in patients undergoing PCI may be associated with improvements in rAI, cSBP, and cPP, but not in rAI75 or baPWV. Therefore, the effects of cilostazol might be related to an increased heart rate.

Comparison of Computed Tomography Coronary Angiography and Exercise ECG Test for Diagnostic Accuracy in Real-World Practice / 대한내과학회지

BACKGROUND/AIMS: The exercise ECG test (XECG) and computed tomography coronary angiography (CTCA) have been used widely in initial evaluations of coronary artery disease (CAD) in real-world practice. In this study, we compared the diagnostic power of CTCA and XECG, based on conventional coronary angiography (CCA). METHODS: We enrolled 589 consecutive patients retrospectively who had been examined with both XECG and CTCA for the evaluation of CAD in outpatient clinics. Significant stenosis was defined as more than 50% diameter stenosis. Triage to CCA and/or revascularization treatment (RT) by the results of XECG and CTCA and the diagnostic accuracy of both exams, based on CCA, were investigated. RESULTS: In the 589 patients, 107 (19%) were triaged to CCA for further evaluation; in 77 (12.8%) significant stenosis was detected on CCA. Also, 65 (11%) patients underwent RT. In the CTCA results, 120 patients had significant stenosis. Of them, 58 (48%) and 75 (62%) patients were triaged to RT and CCA, respectively. Based on the XECG, 115 positive patients were triaged to RT and CCA (23 [20%]/41 [35%]). Among 107 patients with CCA, the sensitivity, specificity, positive predictive value, and negative predictive value for significant stenosis on CCA of CTCA were 89.9%, 74.0%, 90.6%, and 71.4%, respectively, and those of XECG were 50.0, 67.9, 78.0, and 37.3, respectively. The kappa value of CCA and CTCA was 0.62 (p < 0.001) and that of CCA and XECG was 0.145 (p = 0.113). CONCLUSIONS: In real-world practice, CCA was decided on more frequently, based on CTCA. CTCA showed better diagnostic accuracy than XECG.

Low-Dose Dexmedetomidine Reduces Emergence Agitation after Desflurane Anaesthesia in Children Undergoing Strabismus Surgery

PURPOSE: Emergence agitation (EA) is frequently observed in children undergoing general anaesthesia. This study tested whether the addition of an intra-operative low-dose infusion of dexmedetomidine to fentanyl treatment reduced the incidence of emergence delirium following desflurane anesthesia in children undergoing strabismus surgery. MATERIALS AND METHODS: A total of 96 children (1-5 years old) undergoing strabismus surgery were enrolled. Anaesthesia was induced with propofol and maintained with desflurane. After induction, fentanyl (1 microg/kg) was administered to all children. During surgery, patients were infused with 0.2 microg/(kg.h)-1 dexmedetomidine (Group FD, n=47) or normal saline (Group F, n=47). Postoperative objective pain score (OPS), Paediatric Agitation and Emergence Delirium (PAED) score, and EA score were documented every 10 minutes in the post-anaesthesia care unit. RESULTS: There were no significant differences between the two groups in demographic characteristics and haemodynamic changes. The mean values of maximum EA, maximum PAED, and maximum OPS score were significantly lower in Group FD than in Group F at 0, 10, and 20 minutes after arrival at the post-anaesthesia care unit (p<0.001). The frequency of fentanyl rescue was lower in Group FD than in Group F (p<0.001). The incidence of severe EA was significantly lower in Group FD than in Group F (12.8% vs. 74.5%, p<0.001). CONCLUSION: Intra-operative low-dose infusion of dexmedetomidine in addition to fentanyl reduces EA following desflurane anaesthesia in children undergoing strabismus surgeries.

Multiple Cardiovascular Manifestations in a Patient with Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is a systemic disorder associated with various extrarenal complications. The major cardiovascular complications of ADPKD include valvulopathies and vascular ectasia. A 64-year-old man who was diagnosed with ADPKD seven years previously was admitted to our hospital for heart failure. Pelvic computed tomography revealed multiple variable-sized cysts in both kidneys. Transthoracic echocardiography showed enlargement of the left ventricle and left atrium. Severe mitral regurgitation and moderate aortic regurgitation with annuloaortic ectasia were observed. The left main coronary artery was dilated. The patient had various cardiovascular features associated with ADPKD.

Perioperative respiratory adverse events in children with active upper respiratory tract infection who received general anesthesia through an orotracheal tube and inhalation agents / 대한마취과학회지

BACKGROUND: Active upper respiratory tract infection (URI), orotracheal intubation and use of inhalation anesthetics are known risk factors for perioperative respiratory adverse events (RAE). This study investigated the risk factors of perioperative RAE in children with these risk factors. METHODS: The records of 159 children who underwent general anesthesia with an orotracheal tube and inhalation were reviewed. These patients also had at least one of the following URI symptoms on the day of surgery: clear or green nasal secretion, dry or moist cough, nasal congestion, or fever. RAE such as laryngospasm, bronchospasm, oxygen desaturation and sustained cough were collected before induction, during intubation, during extubation, after extubation and in the postanesthesia care unit. RESULTS: Forty-five patients had RAE. The patients with RAE were younger than those without RAE. There were more passive smokers and a greater number of intubation attempts in patients with RAE than in those without RAE. The type of surgery and type of inhalation agents were not different between patients with and without RAE. Passive smoking was the only independent risk factor for RAE. CONCLUSIONS: In children with an active URI using orotracheal tube and inhalation anesthetics, passive smoking is an important risk factor for RAE.

Heart rate variability as a predictor of hypotension after spinal anesthesia in hypertensive patients / 대한마취과학회지

BACKGROUND: Hypotension is a common phenomenon after spinal anesthesia in hypertensive patients. We investigated whether heart rate variability could predict the occurrence of hypotension after spinal anesthesia in hypertensive patients. METHODS: Forty-one patients undergoing spinal anesthesia were included. Heart rate variability was measured at five different time points such as before fluid loading (baseline), after fluid loading as well as 5 min, 15 min and 30 min after spinal anesthesia. Fluid loading was performed using 5 ml/kg of a crystalloid solution. Baseline total power and low to high frequency ratio (LF/HF) in predicting hypotension after spinal anesthesia were analyzed by calculating the area under the receiver operating characteristic curves (AUC). RESULTS: Moderate hypotension, defined as a decrease of mean arterial pressure to below 20-30% of the baseline, occurred in 13 patients and severe hypotension, defined as a decrease of mean arterial pressure greater than 30% below the baseline, occurred in 7 patients. LF/HF ratiosand total powers did not significantly change after spinal anesthesia. AUCs of LF/HF ratio for predicting moderate hypotension was 0.685 (P = 0.074), severe hypotension was 0.579 (P = 0.560) and moderate or severe hypotension was 0.652 (P = 0.101), respectively. AUCs of total power for predicting moderate hypotension was 0.571 (P = 0.490), severe hypotension was 0.672 (P = 0.351) and moderate or severe hypotension was 0.509 (P = 0.924), respectively. CONCLUSIONS: Heart rate variability is not a reliable predictor of hypotension after spinal block in hypertensive patients whose sympathetic activity is already depressed.

Asymptomatic Left Ventricular Pseudoaneurysm Evaluated With Multimodality Cardiac Imaging

No abstract available.

Implantable Cardioverter-Defibrillator Implantation in a Patient with Atrial Standstill

We report a 55-year-old female patient who presented with no P waves but with a wide QRS complex escape rhythm at 44 beats/min and prolonged QTc of 0.55 seconds on ECG. The patient had recurrence of ventricular fibrillations and loss of consciousness, and underwent defibrillation and cardiopulmonary resuscitation (CPR) several times because of cardiac arrest. The transthoracic echocardiography showed dilated cardiomyopathy and enlargement of both atria. The Doppler echocardiography documented the absence of A wave in the tricuspid and mitral valve flow. An electrophysiologic study demonstrated electrical inactivity in the right and left atria. Atrial pacing with maximum output did not capture the atria. These findings together with her electrocardiographic finding indicated atrial standstill. Sudden cardiac death was her first clinical manifestation of ventricular arrhythmia. The patient remained asymptomatic after receiving a single chamber implantable cardioverter-defibrillator (ICD) with VVI pacemaker function.

Clinical Predictors of Incomplete ST-Segment Resolution in the Patients With Acute ST Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: The failure of ST-segment resolution (STR) after primary percutaneous coronary intervention (pPCI) is associated with adverse clinical outcomes. However, the clinical predictors on admission for incomplete STR are poorly known. SUBJECTS AND METHODS: Patients undergoing pPCI (n=101, 79 males and 22 females, mean age 60.0 years) were divided into complete STR group (> or =70%, n=58) and incomplete STR group (<70%, n=43). The groups were compared according to clinical factors including history, electrocardiographic (ECG) patterns, angiographic features and laboratory data. RESULTS: The incomplete STR group contained more frequent hypertensive patients (p=0.04) and patients displaying longer tendency in total chest pain duration (p=0.08). This group was associated with worse clinical factors such as low ejection fraction (p=0.06), higher Killip class (p=0.08) and more death (p=0.042). Grade 3 ischemia pattern of ECG and precordial ST elevation (i,e anterior myocardial infarction) at admission were more frequent in the incomplete STR group (p=0.001 and 0.002, respectively). Initial troponin I, creatinin kinase -MB and brain natriuretic peptide levels were higher in the incomplete STR group (p=0.001, 0.002, and 0.043, respectively). Coronary angiography showed that culprit lesions were more frequent in left anterior descending artery than other arteries in the incomplete STR group of patients (p=0.002). Thrombolysis In Myocardial Infarction (TIMI) flow grades 2 or less before PCI was more frequent in the incomplete STR group (p=0.029). However, TIMI flow grade after PCI was not appreciably different between the two groups. Logistic regression analysis demonstrated that TIMI flow grade 2 or less was most powerful predictor for incomplete STR {odds ratio (OR)=12.12, 95% confidence interval (CI) 1.23-119.35, p=0.032}. Other independent predictors were anterior infarction (OR=3.39, CI 1.46-10.57, p=0.007), ischemia grade 3 ECG at admission (OR=3.87, CI 1.31-11.41, p=0.014), and hypertensive patients (OR=3.03, CI 1.13-8.15, p=0.027). CONCLUSION: Incomplete STR after pPCI is associated with poor prognostic clinical factors. TIMI flow grade 2 or less before pPCI, ST elevation on precordial leads, ischemia grade 3 pattern of initial ECG, and hypertensive patients are independent predictors for incomplete STR in the early stage.

Safety and Efficacy of Peroxisome Proliferator-Activated Receptor-alpha Agonist for Treating Cardiovascular Disease

Peroxisome proliferator-activated receptor (PPAR)-alpha belongs to the nuclear family of ligand-activated transcriptional factors. The main role of PPAR-alpha is to activate the expression of the genes that are involved in fatty acid oxidation to achieve energy homeostasis. Fibrates are a known class of PPAR-alpha agonists, and they been used clinically for their effects of lowering triglycerides and elevating high-density lipoprotein-cholesterol (HDL-C). Further, recent experimental studies have demonstrated the anti-inflammatory and anti-atherosclerotic actions of PPAR-alpha agonists directly on the vascular wall. PPAR agonists are currently emerging as a promising therapeutic option to control systemic and vascular atherogenic factors. Regardless of their strong anti-atherosclerotic properties, large clinical studies have demonstrated inconsistent results for the cardioprotective effect of PPAR-alpha agonists; moreover, it has been observed that they did not decrease the total mortality, which stands in contrast to the statin trials. This review summarizes the current knowledge regarding the PPAR biology and the mechanisms of the effects of PPAR-alpha on lipid metabolism, the vessel wall and the cardiac metabolism. We also describe the results and lessons learned from the important clinical trials of PPAR-alpha agonists and we discuss these drugs' efficacy and safety.

Aortic dissection presenting as fever of unknown origin / 대한내과학회지

Aortic dissection most often presents with the severe chest pain and may have variable symptoms including fever. However, fever of unknown origin as the predominant manifestation of aortic dissection seems to be extremely rare. We report the case of a patient who sustained a prolonged spiking fever with unknown origin for 17 days following acute aortic dissection. The case serves as a reminder that prolonged fever may be the principal residual sequelae after aortic dissection.

Carotid artery remodeling in patients with acute coronary syndrome and chronic stable angina / 대한내과학회지

BACKGROUND: Acute adaptive vascular remodeling occurs in active and unstable inflammatory plaques. It has been suggested that the adaptive coronary vascular remodeling, in patients with acute coronary syndrome (ACS), may be systemic and may show similar vascular remodeling in the carotid arteries. We investigated the ultrasonographic features of the common carotid artery (CCA) to determine whether the arterial expansive remodeling found in the coronary artery occurs in the carotid arteries of patients with ACS. METHODS: We measured lumen diameter (LD), interadventitial diameter (IAD) and intima media thickness (IMT) using a B-mode ultrasound in both common carotid arteries in patients with ACS (N=74) and chronic stable angina (CSA) (N=31). Positive remodeling was arbitrarily defined as an IMTmax >1 mm and IAD >8 mm and negative remodeling as an IMTmax >1 mm and IAD <7 mm. Other values were defined as "no remodeling" RESULTS: There were no significant differences in LD IAD and maximal IMT of the right CCA and the left CCA in comparisons between the ACS and the CSA patient groups. There were no differences for number of cases with no remodeling or differences in positive and negative remodeling in the right common carotid artery and left common carotid artery in comparisons between the ACS and CSA patient groups. . Presence of plaque in both common carotid arteries showed similar frequency in the ACS and CSA patient groups. The characteristics of carotid artery plaques were not different in the two groups. The remodeling index (IAD/LD) was correlated with IMTmax (right CCA r=0.797, p<0.001; left CCA r=0.860, p<0.001). CONCLUSIONS: The common carotid arterial structure of ACS patients was not different from that of CSA patients. Therefore, these results suggest that the expansive arterial remodeling, due to coronary inflammatory plaques, appears to take place locally rather than systemically.

A Case of Shoshin Beriberi Presenting as Acute Coronary Syndrome with Shock: Shoshin Beriberi Mimicking Acute Coronary Syndrome

Cardiac beriberi is caused by thiamine deficiency. Shoshin beriberi is a rare and fulminant form of cardiac beriberi characterized by hypotension, high output heart failure, lactic acidosis and anuria. Without early recognition and immediate treatment, most of these patients will be fatal. Therefore clinical diagnosis of shoshin beriberi is most important in emergency situation. We report a case of shoshin beriberi with clinical features mimicking acute coronary syndrome. Fifty year old male patient with chronic alcoholism was presented with shock, hypoxia, right heart failure and severe acidosis. Electrocardiogram showed abnormal Q in V1-3 and mild ST elevation and level of troponin I was slightly elevated. All manifestations including lactic acidosis were dramatically subsided in 18 hours by thiamine infusion. Even in developed country, shoshin beriberi can be occurred in patients with malnutrition and/or chronic alcoholism and should be differentiated with acute coronary syndrome.

The Clinical Effects of a Small-dose of Intrathecal Bupivacaine and Alfentanil for Short-duration Surgery: A Randomized Double-blinded Study / 대한마취과학회지

BACKGROUND: High doses of intrathecal bupivacaine may produce a high level of sensory and motor block, and arterial hypotension and, Intrathecal opioids added to low-dose local anesthetics produced a synergistic effect Thus it may be possible to augment spinal anesthesia without delaying recovery. The aim of this study was to investigate the efficacy and adverse effects of adding alfentanil to intrathecal small-dose bupivacaine for short-duration surgery. METHODS: In this randomized double-blinded, prospective study, 60 patients scheduled for short-duration surgery were randomly assigned to Group B10 (0.5% bupivacaine 10 mg), Group B5AE (0.5% bupivacaine 5 mg + alfentanil 0.25 mg + 0.1% epinephrine 0.2 ml + normal saline 0.3 ml), or Group B5A (0.5% bupivacaine 5 mg + alfentanil 0.25 mg + normal saline 0.5 ml). The final volume of intrathecal injectate was adjusted to 2.0 ml with normal saline. Neural block was assessed by pinprick and a modified Bromage scale. RESULTS: No significant difference was found between three groups at the median peak sensory level, but administered fluid, and the duration of sensory and motor blockade in Group B5A was significantly shorter than in Group B10. CONCLUSIONS: We conclude that alfentanil 0.25 mg with 0.5% bupivacaine 5 mg produced a shorter in neural blockade, than the other groups and that it did not cause hemodynamic instability and produced effective spinal anesthesia for short-duration surgery.