Prevalence, Treatment Pattern and Resource Use in Patients with Mixed Dyslipidemia Using Lipid Modifying Agents in Korea (PRIMULA): An Observational Study

OBJECTIVE: Limited information is available on the effectiveness of lipid-modifying therapy (LMT) for low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG) in the Korean population. The objective of this study was to describe the prevalence of different types of lipid disorders in Korean patients using LMT. METHODS: Eight hundred seventy-one dyslipidemia patients, who were LMT-naive for >1 year prior to retrospective enrollment, were included for analysis. Serum levels of LDL-C, HDL-C, TG and total cholesterol (TC) were assessed after >1 year of LMT. We also analyzed the therapeutic effects of LMT in the subjects with high cardiovascular risk factors (n=629), atherosclerotic cardiovascular disease (ASCVD) (n=296) or diabetes without ASCVD (n=316). RESULTS: The rates of elevated LDL-C without other abnormal lipids levels, elevated TG or decreased HDL-C (with normal LDL-C levels) and high LDL-C combined with elevated TG and/or decreased HDL-C were 33.4%, 13.0% and 53.6%, respectively. After at least one year on LMT (statin alone: 81%, statin and cholesterol absorption inhibitor: 10%, fibrates alone: 3%, others: 3%), 61% of patients had at least one lipid abnormality, with 3.4% failing to reach the therapeutic LDL-C target level or a normal level of HDL-C and TG. After LMT, 64.9% of patients with high cardiovascular risk factors, 64.5% of those with ASCVD or and 64.2% of those with diabetes without ASCVD also had at least one lipid abnormality. CONCLUSION: Approximately two-thirds of patients did not reach the target or normal lipid profile after taking LMT, irrespective of combining disease and high cardiovascular risk factors. Tight lipid control is required, especially in patients with dyslipidemia and high cardiovascular risk factors or comorbid diseases.

Early Cardiac Function Monitoring for Detection of Subclinical Doxorubicin Cardiotoxicity in Young Adult Patients with Breast Cancer / 한국유방암학회지

PURPOSE: As doxorubicin cardiotoxicity is considered irreversible, early detection of cardiotoxicity and prevention of overt heart failure is essential. Although there are monitoring guidelines for cardiotoxicity, optimal timing for early detection of subclinical doxorubicin cardiotoxicity is still obscure. The purpose of this study is to determine optimal timing of cardiac monitoring and risk factors for early detection of doxorubicin cardiotoxicity in young adult patients with breast cancer. METHODS: Medical records of 1,013 breast cancer patients diagnosed from January 2009 to December 2010 is being reviewed and analyzed. Properly monitored patients are defined as patients who underwent transthoracic echocardiography before and after the chemotherapy. The definition of subclinical cardiotoxicity (SC) either decreases left ventricular ejection fraction (LVEF) more than 10% or the LVEF declines under 55% from baseline without heart failure symptoms. RESULTS: Twenty-nine out of 174 (16.7%) properly monitored young adult female patients (mean age, 52+/-10 years old) developed SC. The mean interval of cardiac evaluation of SC group was 5.5+/-3.0 months. Among the risk factors, the history of coronary artery disease, cumulative dose of doxorubicin > or =300 mg/m2 and use of trastuzumab after doxorubicin therapy were associated with development of SC. At cumulative dose of doxorubicin 244.5 mg/m2, SC can be predicted (sensitivity, 71.4%; specificity, 70.9%; area under the curve, 0.741; 95% confidence interval, 0.608-0.874; p=0.001). CONCLUSION: In young adult patients with breast cancer, SC was common at cumulative dose of doxorubicin <300 mg/m2 and early performance of cardiac monitoring before reaching the conventional critical dose of doxorubicin might be a proper strategy for early detection of SC.

Feasibility of Real-Time Three-Dimensional Echocardiography for the Assessment of Distorted Biventricular Systolic Function in Patients with Cor Pulmonale

BACKGROUND: This study was to investigate the feasibility of real-time 3-dimensional echocardiography (RT3DE) for the analysis of biventricular ejection fractions and volume measurements in patients with cor pulmonale and the correlations of RT3DE results with 64-slice multi-detector cardiac computed tomography (64-MDCT) results. METHODS: This study included a total of 22 patients (59.3 +/- 16.6 years of age; 10 males and 12 females) who showed flattening or reverse curvature of the interventricular septum and severe pulmonary hypertension [mean right ventricular (RV) systolic pressure = 66.8 +/- 19.7 mmHg] on 2-dimensional transthoracic echocardiography due to cor pulmonale. Biventricular end-diastolic and end-systolic volumes were measured by RT3DE and 64-MDCT. The severity of D-shaped deformation was evaluated by using left ventricular (LV) eccentricity index (ratio of diameters parallel/perpendicular to the interventricular septum on parasternal short axis images of the papillary muscle level). RESULTS: There were moderate correlations between biventricular volumes measured by RT3DE and 64-MDCT except for LV end-systolic volume (59.8 +/- 17.1 vs. 73.2 +/- 20.2 mL, r = 0.652, p = 0.001 for LV end-diastolic volume; 30.6 +/- 9.1 vs. 30.8 +/- 12.5 mL, r = 0.361, p = 0.099 for LV end-systolic volume; 110.1 +/- 42.9 vs. 171.1 +/- 55.3 mL, r = 0.545, p = 0.009 for RV end-diastolic volume; and 80.9 +/- 35.0 vs. 128.7 +/- 45.1 mL, r = 0.549, p = 0.005 for RV end-systolic volume respectively). CONCLUSION: This study suggests that RT3DE may be a modest method for measuring distorted biventricular end-systolic and end-diastolic volumes in patients with cor pulmonale.

Imatinib Mesylate Attenuates Cardiac Fibrosis in Spontaneously Hypertensive Rats

BACKGROUND: Hypertensive myocardial fibrosis promotes abnormalities of cardiac function that may adversely affect the clinical outcome of hypertensive patients. Imatinib mesylate blocks receptor tyrosine kinase and is clinically used to treat leukemia. Platelet-derived growth factor (PDGF) is a downstream target of receptor tyrosine kinases. Cardiac fibroblasts can be activated by PDGF. Thus we evaluated whether imatinib attenuate myocardial fibrosis and prevents diastolic dysfunction in spontaneously hypertensive rats (SHR). METHODS: 8 weeks old male SHRs were subjected to treatment with 8 weeks of low dose imatinib (SHR-10; 10 mg/kg), high dose imatinib (SHR-30; 30 mg/kg) or saline (SHR-C; n = 6 in each group). At the age of 16 weeks, all rats underwent hemodynamic studies and Doppler echocardiography, and were sacrificed. Their hearts were extracted for histopathological, immunoblotting and quantitative reverse transcriptase-polymerase chain reaction analyses. RESULTS: While imatinib did not affect blood pressure (BP), it markedly reduced perivascular and interstitial fibrosis in the hearts of SHR. Echocardigram showed that high-dose imatinib significantly reduced left ventricular (LV) wall thickness (septal/posterior wall; SHR-C vs. SHR-30: 18 +/- 2/19 +/- 2 mm vs. 15 +/- 1/14 +/- 1 mm; p < 0.05) and improved the parameters of LV diastolic function such as E/A ratio (SHR-C vs. SHR-30: 1.60 +/- 0.10 vs. 1.86 +/- 0.20; p < 0.05). Imatinib also significantly reduced mRNA expression of collagen III and PDGF beta-receptor tyrosine phosphorylation in the hearts of SHR. CONCLUSIONS: These results suggest that imatinib, especially high dose, could attenuate myocardial fibrosis and prevent LV diastolic dysfunction in hypertensive rat model by decreased activity of PDGF. Imatinib may provide a potential therapeutic approach for hypertensive heart disease.

Evaluation of the Relationship between Circadian Blood Pressure Variation and Left Atrial Function Using Strain Imaging

BACKGROUND: Non-dippers were reported as showing different left atrial function, compared to dippers, but no study to date investigated the changes in the left atrial function according to the diurnal blood pressure pattern, using tissue Doppler and strain imaging. METHODS: Forty never treated hypertensive patients between 30 and 80 years of age were enrolled in this study. Patients were classified as non-dippers when, during night time, they had a blood pressure decrease of less than 10%. Strain of the left atrium was measured during late systole, and peak strain rates of the left atrium were measured during systole, early and late diastolic periods. RESULTS: The left atrial expansion index, left atrial active emptying volume and left atrial active emptying fraction were all significantly increased in non-dippers. They also had increased values of mean peak left atrial strain (dippers = 21.26 +/- 4.23% vs. non-dippers = 24.91 +/- 5.20%, p = 0.02), strain rate during reservoir (dippers = 1.29 +/- 0.23 s-1 vs. non-dippers =1.52 +/- 0.27 s-1, p = 0.01) and contractile period (dippers = -1.38 +/- 0.24 s-1 vs. non-dippers = -1.68 +/- 0.32 s-1, p < 0.01). CONCLUSION: Strain and strain rate acquired from color Doppler tissue imaging demonstrate exaggerated reservoir and booster pump function in never-treated, non-dipper hypertensive patients. These methods are simple and sensitive for the early detection of subtle changes in the left atrial function.

Spontaneously Healed Membranous Type Ventricular Septal Defect with Malaligned Interventricular Septal Wall and Double-Chambered Right Ventricle in a 56-Year-Old Patient

A 56-year-old male presented with resting dyspnea and chest discomfort for several years. During transthoracic and transesophageal echocardiography, a spontaneously healed membranous type ventricular septal defect (VSD) with malaligned interventricular septal wall, aneurysmal changes, a subaortic ridge and a double-chambered right ventricle (DCRV) was observed. When combined with DCRV, VSD with malalignment between the outlet and trabecular septa was associated with tetralogy of Fallot. The subaortic ridge was due to turbulent flow caused by the malalignment-type VSD. The VSD with malaligned interventricular septal wall can be developed after aneurismal changes of a perimembranous VSD. We report here in the unusual case of a 56-year-old patient who had a pathology complex comprising DCRV, subaortic ridge, spontaneously healed membranous type VSD with malaligned interventricular septal wall, and survived with surgical treatment.

Relationship Between Plasma Adiponectin, Retinol-Binding Protein 4 and Uric Acid in Hypertensive Patients With Metabolic Syndrome

BACKGROUND AND OBJECTIVES: Adipokines have been suggested for their potential use in tracking the clinical progress in the subjects with metabolic syndrome (MS). To investigate the relationship between the serum levels of adipokines {adiponectin and retinol-binding protein 4 (RBP4)} and the serum level of uric acid in hypertensive (HTN) patients with MS. SUBJECTS AND METHODS: In this study, 38 totally untreated HTN patients were enrolled. Anthropometric measurements, blood pressure (BP) were taken in the 12 HTN patients without MS and the 26 HTN patients with MS. Fasting blood samples were collected for measurement of adiponectin, RBP4, nitric oxide (NO), glucose, creatinine, uric acid, lipid profile and insulin. RESULTS: The HTN with MS group had significant higher values of body mass index, waist length, serum uric acid and triglyceride levels than the HTN without MS group. Compared to the HTN without MS group, the HTN with MS group showed significantly lower adiponectin (p=0.030), NO (p=0.003) and high density lipoprotein levels (p<0.001). Serum adiponectin levels negatively correlated with insulin level (R=-0.453, p=0.026) and uric acid level (R=-0.413, p=0.036), and serum RBP4 levels positively correlated with uric acid level (R=0.527, p=0.006) in the HTN with MS group. Multiple linear regression analysis using RBP4 and adiponectin levels as the dependent variables showed that uric acid level correlated with serum RBP4 level (p=0.046) and adiponectin level (p=0.044). CONCLUSION: The HTN with MS group showed a correlation with two types of adipokines (adiponectin, RBP4) and uric acid. Adiponectin, RBP4 and uric acid may be important components associated with MS, especially when associated with hypertension.

Acute Coronary Syndrome Mimicking Atypical Stress-Induced Cardiomyopathy in a Patient with Panhypopituitarism

Stress-induced cardiomyopathy is frequently confused with acute coronary syndromes. We encountered a 64-year old female patient with panhypopituitarism initially suspected as atypical stress-induced cardiomyopathy due to her history and initial echocardiographic findings. She was finally diagnosed as non ST-segment elevation myocardial infarction based on the findings of coronary angiogram, intravascular ultrasound and subsequent echocardiogram.

Clinical, Electrocardiographic, and Procedural Characteristics of Patients With Coronary Chronic Total Occlusions

BACKGROUND AND OBJECTIVES: Percutaneous coronary intervention for chronic total occlusion lesions is technically difficult despite equipment advances. Changes in electrocardiographic patterns, such as Q and T waves, during chronic total occlusion can provide information about procedural success and myocardial viability. In this study, we investigated clinical, electrocardiographic, and procedural characteristics of chronic total occlusions. SUBJECTS AND METHODS: Patients (2,635) who underwent coronary angiography between January 2006 and July 2007 at six Catholic University Hospitals were identified using a dedicated Internet database. RESULTS: A total of 195 patients had total occlusion lesions (7.4%). Percutaneous coronary interventions were attempted in 136 total occlusion lesions (66.0%) in 134 patients. Successful recanalization with stent implantation was accomplished in 89 lesions, with a procedural success rate of 66.4%. One procedure-related death occurred because of no-reflow phenomenon. After excluding 8 patients with bundle branch block, Q and T wave inversions were observed in 60 (32.1%) and 78 patients (41.7%), respectively. The presence of Q waves was associated with severe angina, decreased left ventricular ejection fraction, regional wall motion abnormality, and T wave inversion, but was not related to procedural success. CONCLUSION: Percutaneous coronary intervention is a safe and useful procedure for the revascularization of coronary chronic total occlusion lesions. The procedural success rate was not related to the presence of pathologic Q waves, which were associated with severe angina and decreased left ventricular function.

Aortic Valve Sclerosis on Echocardiography is a Good Predictor of Coronary Artery Disease in Patients With an Inconclusive Treadmill Exercise Test

BACKGROUND AND OBJECTIVES: The treadmill exercise test (TMT) is used as a first-line test for diagnosing coronary artery disease (CAD). However, the findings of a TMT can be inconclusive, such as incomplete or equivocal results. Aortic valve sclerosis (AVS) is known to be a good predictor of CAD. We determined the usefulness of assessing AVS on 2-dimensional (2D) echocardiography for making the diagnosis of CAD in patients with inconclusive results on a TMT. SUBJECTS AND METHODS: This prospective study involved 165 consecutive patients who underwent a TMT that resulted in inconclusive findings, 2D echocardiography to detect AVS, and coronary angiography to detect CAD. Following echocardiography, AVS was classified as none, mild, or severe. CAD was defined as > or =70% narrowing of the luminal diameter on coronary angiography. RESULTS: CAD was more common in patients with AVS than in patients without AVS (75% vs. 47%, respectively, p<0.01). Multiple logistic regression analysis showed that AVS was the only independent predictor of CAD {odds ratio=8.576; 95% confidence interval (CI), 3.739-19.672}. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the presence of AVS for predicting CAD in a patient with an inconclusive TMT were 62%, 67%, 64%, 75%, and 53%, respectively. During a 1-year clinical follow-up, patients with and without AVS were similar in terms of event-free survival rates. CONCLUSION: If the results of TMT for patients with chest pain on exertion are inconclusive, the presence of AVS on echocardiography is a good predictor of CAD.

Age is an Independent Risk Factor for the Early Morning Blood Pressure Surge in Patients Never-Treated for Hypertension

BACKGROUND AND OBJECTIVES: The early morning blood pressure surge (EMBPS) has been reported to be associated with cardiovascular events. The aim of this study was to investigate the relationship between 24-hour ambulatory BP monitoring (ABPM) parameters and conventional cardiovascular risk factors. SUBJECTS AND METHODS: Patients (n=346) never-treated for essential hypertension with no other cardiovascular risk factors, such as diabetes, dyslipidemia, and nephropathy were enrolled. The EMBPS was defined as the early morning systolic BP minus the lowest night systolic BP. We compared the 24-hour ABPM parameters in two groups divided by age ( or =60 years) and examined the association between the 24-hour ABPM parameters and cardiovascular risk factor. RESULTS: The EMBPS (18+/-14 vs. 24+/-14 mmHg, p=0.002), 24-hour mean blood pressure {MBP; 102+/-9 vs. 105+/-11 mmHg, p=0.044}, and 24-hour mean pulse pressure (PP; 52+/-10 vs. 58+/-11 mmHg, p28 mmHg) after adjusting for gender differences, body mass index, and various 24-hour ABPM parameters (odds ratio, 1.051; 95% confidence interval, 1.028-1.075; p<0.001). CONCLUSION: Age is an independent risk factor for EMBPS in patients with never-treated hypertension. BP control in the early morning period is more important in elderly patients so as to prevent cardiovascular events.

Effect of High Dose External Irradiation on the Matrix Metalloprotease-2 Expression in a Rat Carotid Artery Injury Model

BACKGROUND AND OBJECTIVES: Remodeling of the injured arterial wall is dependent on the action of several extracellular proteases, including matrix metalloprotease-2 (MMP-2), and this protein is associated with the migration of vascular smooth muscle cells. The effect of a high dose of external irradiation (20 Gy) on the MMP-2 expression in neointimal hyperplasia is not known. MATERIALS AND METHODS: Sprague-Dawley rats were subjected to balloon injury to the common carotid artery. At 24 hours after injury, 20 Gy external irradiation was done for the irradiated group (n=25) and this was not done for the control group (n=25). The percent area stenosis, the maximal intimal thickness, the intima/media area ratio on H-E staining and the MMP-2 positivity on the immunohistochemical staining were measured. Western blotting and a gelatin zymogram for determining the MMP-2 protein expression were also performed after the injury. RESULTS: The parameters of neointimal hyperplasia such as the percent area stenosis, the maximal intimal thickness and the intima/media area ratio were 40.2+/-12.1%, 0.30+/-0.12 mm and 1.27+/-0.32, respectively, at 14 days after injury, and these parameters were maintained as a hyperplastic state at 28 days after injury in the control group. There was undetectable neointimal hyperplasia in the irradiated group compared with the control group (p<0.01). Western blotting demonstrated an increase in the MMP-2 protein level beginning 2 to 4 days after injury in the control group, but there was only a transient increase in the MMP-2 level at day 2 after injury in the irradiated group. The gelatin zymogram and immunohistochemical staining also showed the expression of MMP-2 in the control group, but not in the irradiated group. CONCLUSION: These findings suggest the suppressed expression of MMP-2 is associated with reduced neointimal hyperplasia in the balloon injury-rat model.

The influence of occlusal loads on stress distribution of cervical composite resin restorations: A three-dimensional finite element study / 대한치과보존학회지

The purpose of this study was to investigate the influence of various occlusal loading sites and directions on the stress distribution of the cervical composite resin restorations of maxillary second premolar, using 3 dimensional (3D) finite element (FE) analysis. Extracted maxillary second premolar was scanned serially with Micro-CT (SkyScan1072; SkyScan, Aartselaar, Belgium). The 3D images were processed by 3D-DOCTOR (Able Software Co., Lexington, MA, USA). HyperMesh (Altair Engineering, Inc., Troy, USA) and ANSYS (Swanson Analysis Systems, Inc., Houston, USA) was used to mesh and analyze 3D FE model. Notch shaped cavity was filled with hybrid (Z100, 3M Dental Products, St. Paul, MN, USA) or flowable resin (Tetric Flow, Vivadent Ets., FL-9494-Schaan, Liechtenstein) and each restoration was simulated with adhesive layer thickness (40 microm). A static load of 200 N was applied on the three points of the buccal incline of the palatal cusp and oriented in 20degrees increments, from vertical (long axis of the tooth) to oblique 40degrees direction towards the buccal. The maximum principal stresses in the occlusal and cervical cavosurface margin and vertical section of buccal surfaces of notch-shaped class V cavity were analyzed using ANSYS. As the angle of loading direction increased, tensile stress increased. Loading site had little effect on it. Under same loading condition, Tetric Flow showed relatively lower stress than Z100 overall, except both point angles. Loading direction and the elastic modulus of restorative material seem to be important factor on the cervical restoration.

Effect of Adult Bone Marrow Stem Cells on Myocardial Regeneration in Doxorubicin-Induced Mouse Cardiomyopathy

BACKGROUND AND OBJECTIVES: Bone marrow cells have been shown to differentiate into various cell lineages, including cardiomyocytes, in recent studies. This study evaluates the hypothesis that intravenous injection of bone marrow mononuclear cells (BMNCs) into rats with doxorubicin-induced cardiomyopathy can induce myocardial regeneration and improve myocardial contractility. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were induced to develop cardiomyopathy by treatment with doxorubicin (2.5 mg/kg, 6 times, 2-week period). Stem cell enriched BMNCs were injected into the tail vein of the rats after cessation of the doxorubicin injections. One week after the injection of PKH-67-labeled BMNCs, the localization of transplanted cells was evaluated. Immunohistochemical studies and Western blots were performed two weeks after BMNCs injection. RESULTS: Cell-treated animals showed significant improvement in left ventricular fractional shortening as compared to untreated (control) rats (cell treated group vs. control group 47.2+/-4.9% vs. 34.4+/-3.6%, p<0.01). Histological analyses showed that in the cell-treated animals there was an increase in ventricular interstitial collagen deposition and the cell-treated animals had an improved number of capillary endothelial cells as compared with the control rats. PKH-67-labeled BMNCs and cell proliferation by BrdU was noted in the cell-treated hearts. Cardiac CXCR4 protein expression increased at day 7 and 14 in the cell-treated rats, but only at day 14 in the control animals. CONCLUSION: These results suggest that intravenous injection of BMNCs effectively induce engraftment of BMNCs into the myocardium and attenuation of fibrosis. Intravenous injection of BMNCs also improved myocardial contractility in doxorubicininduced cardiomyopathy.

Association between the JNC 7 Classification of the Stages of Systolic Hypertension and Inflammatory Cardiovascular Risk Factors

BACKGROUND AND OBJECTIVES: It is well known that the higher the blood pressure, the greater the chance of cardiovascular disease, but the factors that are responsible for this association remain largely unknown. We sought to determine whether blood pressure, in a dose-dependent way, is associated with systemic inflammation, which is a known risk factor for cardiovascular events. SUBJECTS AND METHODS: We analyzed the data from 5,626 participants, aged 40-65 years, of the Third National Health and Nutrition Examination Survey (NHANES III). We quantified the blood pressure by dividing the participants into the normal, pre-, stage 1 and stage 2 hypertension groups based on the Joint National Committee 7 (JNC) classification. We used multiple linear and logistic regression models to determine the relationship between blood pressure and the levels of inflammatory markers. RESULTS: After adjustments were made for various co-morbidities, participants with stage 2 systolic hypertension had higher circulating leukocyte levels [840/microliter (95% confidence interval [CI], 374 to 939/microliter)] and fibrinogen levels [24.5 mg/dL (95% CI, 8.9 to 31.9 mg/dL)] than those participants with normal blood pressure. They also showed higher circulating C-reactive protein levels (C-reactive protein>10.0 mg/L: p for trend=0.001). There was a dose-dependent increase for the circulating levels of the risk factors across the different levels of systolic blood pressure, but not for diastolic blood pressure. CONCLUSION: These findings demonstrate that an elevated systolic blood pressure is an independent risk factor for systemic inflammation and this may explain why systolic hypertension is a risk factor for atherosclerosis and cardiovascular events.

Intracoronary Stent Deployment without Antiplatelet Agents in a Patient with Idiopathic Thrombocytopenic Purpura

Deciding on the appropriate antiplatelet therapy is a challenge when treating patients with idiopathic thrombocytopenic purpura (ITP) and who are undergoing percutaneous coronary intervention (PCI). We describe here a case of PCI in a patient with chronic, refractory ITP. A 61-year-old woman presented with exertional chest pain and a low platelet count (4 x 109/L) at admission. Coronary angiography revealed 99% stenosis of the mid left anterior descending artery and 95% stenosis of the mid left circumflex artery. Antiplatelet agents couldn't be administered because of the risk of bleeding. After transfusion of platelets and administering intravenous immunoglobulin, we deployed baremetal stents in both lesions without administering any antiplatelet agents. Although focal in-stent restenosis developed 5 months later, there was no episode of stent thrombosis despite not using antiplatelet agents. The present case suggests that the rate of stent thrombosis may be lower was previously thought and antiplatelet therapy may be considered on a case by case for patient suffering with thrombocytopenia.

The Relationship Between the Acute Changes of the Systolic Blood Pressure and the Brachial-Ankle Pulse Wave Velocity

BACKGROUND: The brachial-ankle pulse wave velocity (baPWV) is a useful parameter to assess arterial stiffness. However, it is difficult to evaluate arterial stiffness in hypertensive patients because the baPWV is affected by the blood pressure itself. This study was designed to estimate the relationship between the change of the blood pressure parameters and the baPWV (delta baPWV) when hypertensive patients were subjected to an acute reduction of blood pressure. METHODS: Thirty patients with essential hypertension and whose blood pressure was higher than 140/90 mmHg were enrolled. In all the patients, the blood pressure and baPWV were measured using an automatic waveform analyzer with the patients at a resting state. When the reduction of blood pressure was more than 10 mmHg after sublingual administration of nifedipine 10 mg, then the blood pressure and baPWV were measured again in the same manner and then they were compared with the baseline values. Spearman's correlation and multiple linear regression tests were performed to estimate the relationship between the change of the blood pressure parameters (delta SBP, delta DBP, delta MAP and delta PP) and the delta baPWV. RESULTS: The baPWV was significantly decreased shortly after the administration of nifedipine (1903.6+/-305.2 cm/sec vs. 1716+/-252.0 cm/sec, respectively, p<0.01). The delta baPWV was correlated with the delta SBP (r=0.550, p<0.01), delta DBP (r=0.386, p<0.05), delta MAP (r=0.441, p<0.05), and delta PP (r=0.442. p<0.05). On the multiple regression analysis, the delta SBP was the only significant variable for predicting the delta baPWV, and the linear equation was delta baPWV=8.7 x SBP-48. CONCLUSIONS: The baPWV is affected by the systolic blood pressure level to a large degree and careful attention must be paid to the blood pressure level when evaluating arterial stiffness with using the baPWV.

Clinical Implication of Natriuretic Peptides and Left Atrial Volume for the Screening Methods of Advanced Diastolic Dysfunction in the Community

BACKGROUND: Recently, B-natriuretic peptide (BNP) level and left atrial volume index (LAVi) were known to correlate with indices of LV diastolic function. As a screening method, we tried to evaluate the efficacy to BNP, ANP, and LAVi to predict the advanced diastolic dysfunction that means myocardial relaxation abnormality and elevated LV filling pressure. METHODS: In 100 patients who referred for echocardiography, Doppler recording of the mitral inflow and tissue Doppler imaging of the mitral annulus were obtained and classified into 4 diastolic function grades (normal, impaired relaxation, pseudonormal, and restrictive). Advanced diastolic dysfunction was defined as pseudonormal and restrictive physiology. LAVi was measured by modified Simpson's method in apical 4-chamber view at end-systole. Plasma levels of BNP and ANP were measured on the same day as echocardiogram was done. RESULTS: BNP and ANP levels were increased as diastolic function grade was worsening (BNP : 60+/-92, 108+/-204, 778+/-1,023 and 1,426+/-1,421 pg/ml, p<0.001; ANP: 22+/-30, 23+/-26, 94+/-92, 96+/-61 pg/ml, p<0.001). LAVi was also increased as diastolic dysfunction was advanced: 24+/-7 ml/m2, 27+/-9 ml/m2, 37+/-12 ml/m2, 45+/-12 ml/m2, p<0.001. The areas under the curve of receiver-operator characteristic curve for BNP, ANP and LAVi to detect the advanced diastolic dysfunction were 0.91, 0.88 and 0.84, respectively. BNP of 137 pg/ml, ANP of 34 pg/ml, and LAVi of 30 ml/m2 were the best values of sensitivity and specificity, respectively. CONCLUSION: These data suggest that BNP, ANP and LAVi provide meaningful sensitivity and specificity for the detection of advanced diastolic dysfunction, respectively. Among these, BNP is better than ANP or LAVi for the screening method to predict the advanced diastolic dysfunction.

A Case of Acute and Severe Mitral Regurgitation Presented as Acute Perfusion Failure and Treated by Emergency Mitral Valve Replacement

The majority of patients who was presented as severe mitral regurgitation can be managed with medical treatment. However, some cases of severe and acute mitral regurgitation need to rapid surgical intervention like as primary angioplasty for acute myocardial infarction. In this case, a patient with acute and severe mitral regurgitation presented as accelerating shortness of breath and impending multi-organ perfusion failure was dramatically recovered by rapid echocardiographic diagnosis and emergency valve replacement operation.

4 Cases of Intracardiac Metastasis of Hepatocellular Carcinoma

Antemortem diagnosis of inferior vena cava (IVC) and cardiac metastasis of hepatocellular carcinoma (HCC) is difficult but important to decide on treatment strategy. There are only a few cases of cardiac metastasis of HCC which have been diagnosed antemortem by echocardiography. We experienced 3 cases of IVC and Right atrial metastasis and 1 case of Left atrial metastasis of HCC. The tumor was discovered during computed tomography scanning. The patients had exhibited no signs of cardiac involvement. In this case, transesophageal echocardiography was valuable in providing information regarding the exact location of the tumor and its relation to surrounding anatomical structures. Left atrial metastasis of HCC is unusual patterns and probably related to tumor growth from the pulmonary veins following massive metastasis to the lung.