The Relationships between Body Mass Index and Left Ventricular Diastolic Function in a Structurally Normal Heart with Normal Ejection Fraction

BACKGROUND: We conducted research to determine the effect of the weight on left ventricular (LV) diastolic function in Asians, who are at greater risk of cardiovascular events compared to individuals from Western countries with similar body mass indices (BMIs). METHODS: We studied 543 participants with structurally normal hearts and normal ejection fractions. Participants were classified as normal-weight (BMI < 23.0 kg/m²), overweight (BMI 23.0–27.4 kg/m²), or obese (BMI ≥ 27.5 kg/m²). Peak E velocity, peak A velocity, and E′ velocity were measured and E/E′ was calculated. RESULTS: Overweight participants had lower E than normal-weight participants (p = 0.001). E′ velocities in overweight and obese participants were less than those in normal weight participants (both p < 0.001). The E/E′ ratio in obese participants was higher compared to the value in normal-weight participants (p < 0.001) and overweight participants (p = 0.025). BMI was associated with E (R = −0.108), A (R = 0.123), E′ (R = −0.229), and E/E′ ratio (R = 0.138) (all p < 0.05). In multivariate analyses, BMI was independently associated with higher A, lower E′, and higher E/E′. The risk of diastolic dysfunction was significantly higher among overweight [adjusted odds ratio: 2.088; 95% confidence interval (CI): 1.348–3.235; p = 0.001] and obese participants (adjusted odds ratio: 5.910; 95% CI: 2.871–12.162; p < 0.001) compared to normal-weight participants. CONCLUSION: Obesity and overweight independently predicted diastolic dysfunction. An optimal body weight lower than the universal cut-off is reasonable for preventing LV heart failure in Asians.

Combined Use of Neutrophil to Lymphocyte Ratio and C-Reactive Protein Level to Predict Clinical Outcomes in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Both neutrophil to lymphocyte ratio (NLR) and C-reactive protein (CRP) are biomarkers associated with poor prognosis of patients with acute myocardial infarction (AMI). However, the combined usefulness of NLR and CRP in predicting adverse outcomes has not been investigated. SUBJECTS AND METHODS: We analyzed 381 consecutive AMI patients who underwent percutaneous coronary intervention (PCI) from January 2012 to January 2014. The endpoints were all-cause mortality, recurrent myocardial infarction (MI), stent thrombosis, repeat revascularization, stroke, and major adverse cardiac and cerebrovascular events (MACCE) at 2-year follow-up. Included patients were divided into 4 groups according to the optimal cut-off values for NLR and CRP on receiver operating characteristic analysis predicting mortality. RESULTS: Patients with both high NLR (>6.30) and high CRP (>0.76) had significantly greater risk of all-cause death and MACCE at 24 months, with no significant increase in the risk of recurrent MI, stent thrombosis, or stroke compared with patients with either low NLR or low CRP, as well as those with low NLR and low CRP. Kaplan-Meier analysis revealed significantly lower survival in patients with high NLR-CRP. On Cox multivariate analysis, high NLR-CRP (hazard ratio 23.172, 95% confidence interval 6.575 to 81.671, p<0.001) was an independent predictor of all-cause death. CONCLUSION: Elevated levels of both NLR and CRP are associated with increased risk of long-term mortality in AMI patients who have undergone PCI.

Erratum: Diagnostic Performance of Intravascular Ultrasound-Derived Minimal Lumen Area to Predict Functionally Significant Non-Left Main Coronary Artery Disease: a Meta-Analysis

In the article, the weighted overall mean MLA cut-off value has been miscalculated. Tha authors deeply apologize for any inconvenience it may have caused.

Local Atrial/Ventricular Ratio as an Adjuvant Marker for Catheter Ablation of Atrioventricular Accessory Pathways

BACKGROUND AND OBJECTIVES: The earliest atrial (A)/ventricular (V) activation potential, or accessory pathway (AP) potential are commonly used as ablation targets for atrioventricular (AV) APs. However, these targets are sometimes ambiguous. SUBJECTS AND METHODS: We reviewed 119 catheter ablation cases in 112 patients diagnosed with orthodromic atrioventricular reentrant tachycardia (AVRT) or Wolff-Parkinson-White (WPW) syndrome. Local A/V amplitude potentials with the earliest activation or AP potential were measured shortly before achieving antegrade AP conduction block, ventriculoatrial block during right ventricle (RV) pacing, or AVRT termination with no AP conduction. RESULTS: APs were located in the left lateral (55.5%), left posterior (17.6%), left posteroseptal (10.1%), midseptal (1.7%), right posteroseptal (7.6%), right posterior (1.7%), and right lateral (5.9%) regions. The mean earliest activation time was 16.7±15.5 ms, mean A/V potential was 1.1±0.9/1.0±0.9 mV, and mean A/V ratio was 1.7±2.0. There was no statistically significant difference between the activation methods (antegrade vs. RV pacing vs. orthodromic AVRT) or AP locations (left vs. right atrium). However, when the local A/V ratio was divided into 3 groups (≤0.6, 1.0±0.3, and ≥1.4), the antegrade approach resulted in an A/V ratio greater than 1.0±0.3 (86.7%, p=0.007), and the orthodromic AVRT state resulted in a ratio of less than 1.0±0.3 (87.5%, p<0.001). CONCLUSION: The mean local A/V potential and ratio did not differ by activation method or AP location. However, a different A/V ratio based on activation method (≥1.0±0.3, antegrade approach; and ≤1.0±0.3, orthodromic AVRT state) could be a good adjuvant marker for targeting AV APs.

Diagnostic Performance of Intravascular Ultrasound-Derived Minimal Lumen Area to Predict Functionally Significant Non-Left Main Coronary Artery Disease: a Meta-Analysis

BACKGROUND AND OBJECTIVES: Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention frequently results in unnecessary stenting due to the low positive predictive value of IVUS-derived minimal lumen area (MLA) for identification of functionally significant coronary stenosis. We appraised the diagnostic accuracy of IVUS-derived MLA compared with the fractional flow reserve (FFR) to assess intermediate coronary stenosis. SUBJECTS AND METHODS: We searched MEDLINE and Cochrane databases for studies using IVUS and FFR methods to establish the best MLA cut-off values to predict significant non-left main coronary artery stenosis. Summary estimates were obtained using a random-effects model. RESULTS: The 17 studies used in our analysis enrolled 3920 patients with 4267 lesions. The weighted overall mean MLA cut-off value was 2.58 mm². The pooled MLA sensitivity that predicted functionally significant coronary stenosis was 0.75 (confidence interval [CI]: 0.72 to 0.77) and the specificity was 0.66 (CI: 0.64 to 0.68). The positive likelihood ratio (LR) was 2.33 (CI: 2.06 to 2.63) and LR (-) was 0.33 (CI: 0.26 to 0.42). The pooled diagnostic odds ratio (DOR) was 7.53 (CI: 5.26 to 10.76) and the area under the summary receiver operating characteristic curve for all the trials was 0.782 with a Q point of 0.720. Meta-regression analysis demonstrated that an FFR cut-off point of 0.75 was associated with a four times higher diagnostic accuracy compared to that of 0.80 (relative DOR: 3.92; 95% CI: 1.25 to 12.34). CONCLUSION: IVUS-derived MLA has limited diagnostic accuracy and needs careful interpretation to correlate with functionally significant non-left main coronary artery stenosis.

Non-Interventional and Interventional Treatment of Aortic Dissection / 대한내과학회지

A new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies (including biomarkers and imaging), endograft design, and surgical treatment. These have led to a better understanding of the epidemiology, risk factors, and molecular nature of aortic dissection. Although open surgery is the main treatment for proximal aortic repair, the use of endovascular management is now established for complicated distal dissection and distal arch repair and has recently been discussed as a pre-emptive measure to avoid late complications by inducing aortic remodeling.

Randomized Comparison of the Platelet Inhibitory Efficacy between Low Dose Prasugrel and Standard Dose Clopidogrel in Patients Who Underwent Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Increased bleeding rates with standard dose prasugrel have led to increased questions about the effectiveness and safety of the lower maintenance dose. We compared platelet inhibitory efficacy between low dose prasugrel and standard dose clopidogrel in patients on maintenance dose dual antiplatelet therapy. SUBJECTS AND METHODS: Forty-three patients who underwent percutaneous coronary intervention were randomized to receive 75 mg clopidogrel (n=23) or 5 mg prasugrel (n=20). Another 20 patients were allocated to 10 mg prasugrel as a reference comparison group. All patients (weight, > or =60 kg; age, 235) was significant lower in the 5 mg prasugrel group than that in the 75 mg clopidogrel group (15.0% vs. 56.5%, p=0.010). CONCLUSION: Prasugrel (5 mg) is more potent antiplatelet therapy than 75 mg clopidogrel in non-low body weight and non-elderly patients on a maintenance dose dual antiplatelet therapy.

Fatal acute right heart failure in gastric cancer patients

Pulmonary tumor thrombotic microangiopathy [PTTM] is a rare condition causing pulmonary artery hypertension and acute right heart failure in patients with cancer. However, chest computer tomography shows negative finding of pulmonary thromboembolism. Serum D-dimer level may be elevated. Echocardiography reveals a dilated right ventricle and feature of pulmonary artery hypertension. Establishing this diagnosis can be very difficult, and most cases are diagnosed during autopsy, although a history of cancer may be a predictor. PTTM should be considered in all patients with apparent pulmonary artery hypertension and elevated D-dimer level, particularly when the patient is known to have an underlying malignancy, especially adenocarcinoma and most of all, the clinical manifestation is very rapidly progressive.

Neutrophil to Lymphocyte Ratio Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: A higher neutrophil to lymphocyte ratio (NLR) has been associated with poor clinical outcomes in various cardiac diseases. However, the clinical availability of NLR in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been known. We evaluated the availability of NLR to predict clinical outcomes in patients with STEMI undergoing primary PCI. SUBJECTS AND METHODS: We analyzed 326 consecutive STEMI patients treated with primary PCI. The patients were divided into tertiles according to NLR: NLR6.53 (n=110). We evaluated the incidence of major adverse cardiac events (MACE), a composite of all causes of death, non-fatal MI, and ischemic stroke at the 12-month follow-up. RESULTS: The high NLR group was associated with a significantly higher rate of 12-month MACE (19.1% vs. 3.7%, p<0.001), 12-month death (18.2% vs. 2.8%, p<0.001), in-hospital MACE (12.7% vs. 2.8%, p=0.010) and in-hospital death (12.7% vs. 1.9%, p=0.003) compared to the low NLR group. In the multivariable model, high NLR was an independent predictor of 12-month MACE {hazard ratio (HR) 3.33 (1.09-10.16), p=0.035} and death {HR 4.10 (1.17-14.46), p=0.028} after adjustment for gender, left ventricular ejection fraction, creatinine clearance, angiographic parameters and factors included in the Thrombolysis in Myocardial Infarction risk score for STEMI. There was a significant gradient of 12-month MACE across the NLR tertiles with a markedly increased MACE hazard in the high NLR group (log rank test p=0.002). CONCLUSION: The NLR is a useful marker to predict 12-month MACE and death in patients with STEMI who have undergone primary PCI.

A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture

Traumatic tricuspid regurgitation is a rare complication of blunt chest trauma. With the increase in the number of automobile accidents, traumatic tricuspid regurgitation has become an important problem after blunt chest trauma. It has been reported more frequently because of better diagnostic procedures and a better understanding of the pathology. The early diagnosis of traumatic tricuspid regurgitation is important because traumatic tricuspid injury could be effectively corrected with reparative techniques, early operation is considered to relieve symptoms and to prevent right ventricular dysfunction. Echocardiography can reveal the cause and severity of regurgitation. We experienced a case of tricuspid regurgitation after blunt chest trauma early diagnosis and valve repair were performed. This case reminds the physicians in the emergency department should be aware of this potential complication following non-penetrating chest trauma and echocardiography is useful and should play an early role.

Analysis of Treatment Patterns and Blood Pressure Changes According to Risk Stratification in Hypertensive Subjects / 대한내과학회지

BACKGROUND/AIMS: The aims of this study were to identify real world treatment patterns of hypertension according to cardiovascular risk stratification and to evaluate blood pressure changes with anti-hypertensive treatment in each risk group. METHODS: This study included patients who were newly-diagnosed with hypertension or known hypertensive patients with uncontrolled blood pressure (BP) at seven tertiary hospitals in Busan and Ulsan. World Health Organization/International Society of Hypertension (WHO/ISH) cardiovascular risk stratification was performed through retrospective chart review. RESULTS: Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers were the most frequently prescribed drugs. The higher WHO/ISH risk group received a greater number of drugs at the initial treatment, and one year after treatment. Target BP was achieved less frequently in the higher risk group (68.2% vs. 85.2% vs. 89.0%, p < 0.001). The rate of attaining target BP was lower (50.7% vs. 81.6%, p < 0.001), and the time to attaining target BP was longer (106.5 +/- 79.2 days vs. 82.1 +/- 75.3, p = 0.001), in patients with renal disease or diabetes. Initial systolic BP above 160 mmHg (OR: 4.91, 95% CI: 2.27~10.65), renal disease (3.42, 1.60~7.32), medium or high risk group status (2.27, 1.23~4.20), initial diastolic BP above 100 mmHg (2.11, 1.11~4.04), and diabetes (2.06, 1.29~3.25) were independent factors that predicted failure of attaining the target BP. CONCLUSIONS: BP control was relatively unsatisfactory in patients with higher initial BP, renal disease, higher WHO/ISH risk group status, and diabetes. Individualized approaches for such patients are needed to improve BP control in routine clinical practice.

Comparison of Plaque Composition in Diabetic and Non-Diabetic Patients With Coronary Artery Disease Using Multislice CT Angiography

BACKGROUND AND OBJECTIVES: Plaque composition rather than degree of luminal narrowing may be predictive of future coronary events in high risk patients. The purpose of this study was to compare degree of plaque burden and composition with multislice computed tomography (MSCT) angiography between diabetic and non-diabetic patients. SUBJECTS AND METHODS: A total of 452 consecutive MSCT angiography examinations were performed between July 2007 and June 2009. Of these, the patients who underwent invasive coronary angiography were evaluated for the presence and type of atherosclerotic plaque and severity of luminal narrowing. RESULTS: Ninety two (46 in the diabetic group and 46 in the non-diabetic group) patients underwent both MSCT angiography and invasive coronary angiography. Among them, 30 patients (65.2%) in the diabetic group and 26 patients (56.5%) in the non-diabetic group had significant coronary narrowing on MSCT angiography. Sixteen patients (34.8%) in the diabetic group and 15 patients (32.6%) in non-diabetic group underwent coronary angioplasty and stenting. Forty-two patients (93.3%) in the diabetic group and 39 patients (88.6%) in the non-diabetic group had multiple types of coronary plaque (p=0.485). MSCT angiography was similar to conventional coronary angiography in its ability to predict significant coronary artery disease in that the area under the curve was 0.88 (95% confidence interval, 0.81 to 0.95). Diabetic patients had more mixed plaque compared with non-diabetic patients. CONCLUSION: Differences in coronary plaque composition between diabetic and non-diabetic patients can be determined noninvasively by MSCT angiography. In patients with diabetes, mixed plaque types contribute to the total plaque burden to a higher degree than in non-diabetic patients.

A case of familial primary pulmonary hypertension / 대한내과학회지

Primary Pulmonary Hypertension (PPH) predominantly affects women frequently in the prime of life and usually leads to death from right ventricular failure within a few years after diagnosis. The prevalence and etiology of familial PPH are uncertain. The age of onset is variable and penetrance is incomplete. Although its occurrence in families was reported within a few years after the original clinical report, PPH was formely believed rarely to have a gene basis. Recent progress has not only clarified a basic molecular mechanism for PPH in familise, but also identified mutations of the same gene in many sporadic PPH patients, suggestion that its basis is commonly genetic. We report a case of familial PPH in a 20-year-old male with exetional dyspnea, who has a family history of PPH in his mother. We report this case with a brief review of recent literatures.

Association between Aortic Valve Sclerosis and Risk Factors of Coronary Artery Disease in Patients with Suspected Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Aortic valve sclerosis (AVS) is often considered to be benign and it is also considered to be a manifestation of generalized atherosclerosis that involves the aortic valve. However, it is associated with high cardiovascular morbidity and mortality in a population-based study. This study was performed to evaluate the significance of AVS in patients with suspected coronary artery disease (CAD). SUBJECTS AND METHODS: Patients with AVS (AVS group, n=111) and patients with normal aortic valves (control group, n=99) who underwent coronary angiography (CAG) between May, 2004 and June, 2004 were enrolled in this study. We compared the CAG findings and the CAD risk factors in both groups, and we evaluated the diagnostic value of AVS for predicting CAD. We also performed multivariate logistic regression analysis for the risk factors, including AVS, of CAD. RESULTS: This study showed that AVS is an independent echocardiographic predictor of significant CAD in the patients with suspected CAD (OR=2.55, 95% CI: 1.25 to 5.17, p<0.001). The other independent predictors include the male gender and hypertension. AVS has a relatively high positive predictive value (75.7%) and predictive accuracy (65.2%) for the patients with suspected CAD. CONCLUSION: The recognition of AVS on transthoracic echocardiography should alert the physicians to the possibility of significant underlying CAD and further evaluation is indicated, even though angiographic documentation might not be available.