Consensus Document on Perioperative Antithrombotic Management: Part 1. A Review / 대한내과학회지

The prevalence of ischemic heart disease is steadily growing as populations age. Antithrombotic treatment is a key therapeutic modality for the prevention of secondary cerebro-cardiovascular disease. Patients with acute coronary syndrome or who are undergoing percutaneous coronary intervention must be treated with dual antiplatelet therapy for a mandatory period. The optimal perioperative antithrombotic regimen remains debatable; antithrombotics can cause bleeding. Inadequate antithrombotic regimens are associated with perioperative ischemic events, but continuation of therapy may increase the risks of perioperative hemorrhagic complications (including mortality). Many guidelines on the perioperative management of antithrombotic agents have been established by academic societies. However, the existing guidelines do not cover all specialties, nor do they describe the thrombotic and hemorrhagic risks associated with various surgical interventions. Moreover, few practical recommendations on the modification of antithrombotic regimens in patients who require non-deferrable interventions/surgeries or procedures associated with a high risk of hemorrhage have appeared. Therefore, cardiologists, specialists performing invasive procedures, surgeons, dentists, and anesthesiologists have not come to a consensus on optimal perioperative antithrombotic regimens. The Korean Platelet-Thrombosis Research Group presented a positioning paper on perioperative antithrombotic management. We here discuss commonly encountered clinical scenarios and engage in evidence-based discussion to assist individualized, perioperative antithrombotic management in clinical practice.

Consensus Document on Perioperative Antithrombotic Management: Part 2. Case Study / 대한내과학회지

Given the progressive improvements in antithrombotic strategies, management of cardiovascular disease has become sophisticated/refined. However, the optimal perioperative management of antithrombotic therapy in patients with acute coronary syndrome or who are scheduled for percutaneous coronary intervention remains unclear. Assessments of the thrombotic and hemorrhagic risks are essential to reduce the rates of mortality and major cardiac events. However, the existing guidelines do not mention these topics. This case-based consensus document deals with common clinical scenarios and offers evidence-based guidelines for individualized perioperative management of antithrombotic therapy in the real world.

The Role of Preoperative NT-proBNP in Elderly Orthopedic Patients with Normal Left Ventricular Systolic Function / 대한내과학회지

BACKGROUND/AIMS: Preoperative N-terminal pro-brain natriuretic peptide (NT-proBNP) is a useful predictor of postoperative cardiovascular complications. The present study investigated whether blood NT-proBNP values are suitable for predicting postoperative cardiovascular complications after non-cardiac surgery in elderly patients showing normal left ventricular (LV) function on preoperative echocardiograms. METHODS: This study was performed by analyzing the medical records of elderly patients referred to the cardiology department for the purpose of assessing their cardiac function before orthopedic surgery. Of the patients who underwent echocardiography and NT-proBNP assessment simultaneously, 275 patients aged > or = 70 years and with an LV ejection fraction of > or = 55% were included in the study. RESULTS: Major adverse cardiac and cerebrovascular events (MACCEs) occurred in 33 (12%) of the 275 patients, and the NT-proBNP concentration was higher in patients with complications than in those without complications (1,904.20 +/- 2,300.23 vs. 530.58 +/- 882.27 pg/mL, p 80 years (odds ratio, 2.313; p = 0.047) and an increased blood NT-proBNP concentration (odds ratio, 3.189; p = 0.009) were independent risk factors for the prediction of MACCEs. CONCLUSIONS: Although elderly patients scheduled to undergo non-cardiac surgery may show normal LV systolic function on echocardiography, measurement of their preoperative blood NT-proBNP concentration is useful for predicting MACCEs occurring after non-cardiac surgery.

Complete Revascularization of Juxtarenal Aortic Occlusion by Endovascular Treatment and Adjunctive Anticoagulation / 대한내과학회지

Chronic atherosclerotic occlusion of the abdominal aorta is a rare disease in clinical practice. In this disease, juxtarenal aortic occlusion is defined as the condition extended, adjacent to the renal arteries. The treatment of juxtarenal aortic occlusion is more difficult than a 'simple' abdominal aortic occlusion. Vascular surgery of a juxtarenal aortic occlusion-specifically aortic endarterectomy and bypass grafting-is a challenging procedure that almost invariably requires aortic cross-clamping above the level of the renal arteries, and may be associated with significant morbidity and mortality. With the advent of endovascular treatment, percutaneous transluminal angioplasty and stent implantation have been used increasingly as an alternative to conventional surgery in the management of patients with aortoiliac disease. However, endovascular treatment for juxtarenal aortic occlusion is not common and, also, special attention is needed with regard to possible renal complications. Here, we report the successful revascularization of a case of chronic juxtarenal aortic occlusion with endovascular treatment and adjunctive anticoagulation.

Preventive Effect of Pretreatment with Intravenous Nicorandil on Contrast-Induced Nephropathy in Patients with Renal Dysfunction Undergoing Coronary Angiography (PRINCIPLE Study)

PURPOSE: To investigate the effect of pretreatment with intravenous nicorandil on the incidence of contrast-induced nephropathy (CIN) in patients with renal dysfunction undergoing coronary angiography. MATERIALS AND METHODS: This randomized controlled multicenter study enrolled a total of 166 patients (nicorandil n=81; control n=85) with an estimated glomerular filtration rate 0.5 mg/dL increase or >25% rise in serum creatinine (SCr) concentration within 48 hours of contrast exposure compared to baseline. RESULTS: The final analysis included 149 patients (nicorandil n=73; control n=76). The baseline characteristics and the total volume of the used contrast (Iodixanol, 125.6+/-69.1 mL vs. 126.9+/-74.6 mL, p=0.916) were similar between the two groups. The incidence of CIN also did not differ between the nicorandil and control groups (6.8% vs. 6.6%, p=0.794). There was no difference between the two groups in the relative change in SCr from baseline to peak level within 48 hours after coronary angiography (-1.58+/-24.07% vs. 0.96+/-17.49%, p=0.464), although the nicorandil group showed less absolute change in SCr than the control group (-0.01+/-0.43 mg/mL vs. 0.02+/-0.31 mg/mL, p=0.005). CONCLUSION: Prophylactic intravenous infusion of nicorandil did not decrease the incidence of CIN in patients with renal dysfunction undergoing coronary angiography.

Fatal Delayed Coronary Artery Perforation After Coronary Stent Implantation

Most type I and II perforations are predominately caused by hydrophilic and stiff wires, often presented in the delayed form, and do not require pericardial drainage or surgical interventions. However, we report a type III delayed coronary artery perforation at the site of stent implantation after intervention without any evidence of immediate perforations. To the best of our knowledge, this is the first case report of angiographic documentation and treatment of delayed coronary perforation at the site of stent, presented as a cardiac arrest.

Current Concepts in Cardiac CT Angiography for Patients With Acute Chest Pain

This article presents specific examples of delayed diagnosis of acute coronary syndrome, acute aortic dissection, and pulmonary embolism resulting from evaluating patients with nonspecific acute chest pain who did not undergo immediate dedicated coronary CT angiography (CTA) or triple rule-out protocol (TRO). These concrete examples of delayed diagnosis may advance the concept of using cardiac CTA (i.e., dedicated coronary CTA versus TRO) to triage patients with nonspecific acute chest pain. This article also provides an overall understanding of how to choose the most appropriate examination based on the specific clinical situation in the emergency department (i.e., dedicated coronary CTA versus TRO versus dedicated pulmonary or aortic CTA), how to interpret the CTA results, and the pros and cons of biphasic versus triphasic administration of intravenous contrast material during TRO examination. A precise understanding of various cardiac CTA protocols will improve the diagnostic performance of radiologists while minimizing hazards related to radiation exposure and contrast use.

Myocardial Infarction in a Young Man due to a Hypoplastic Coronary Artery

Hypoplastic coronary artery disease (HCAD) is a rare condition that may lead to myocardial infarction (MI) and sudden death. We discovered HCAD in a young man who developed chest pain after heavy drinking and who was found to have suffered an MI. His ECG showed ST-segment elevation with Q waves in the anterior leads, and echocardiography revealed apical dyskinesia with moderate left ventricular (LV) dysfunction. Coronary angiography showed hypoplasia of the left anterior descending (LAD) artery. (99m)Tc-tetrofosmin-gated myocardial perfusion scintigraphy showed a large, fixed perfusion defect in the anteroseptal and apical segments. Sixty-four-slice cardiac CT and cardiac MR imaging demonstrated thinning of the apical wall with calcification and delayed enhancement, supporting the diagnosis of long-standing MI. The patient was discharged symptom-free on medication for ischemic heart failure two weeks after admission. Although HCAD is very uncommon, it should be considered in children and young adults who suffer MI or sudden cardiac death.

Clinical Effects of Calcium Channel Blocker and Angiotensin Converting Enzyme Inhibitor on Endothelial Function and Arterial Stiffness in Patients with Angina Pectoris

To evaluate the effects of calcium channel blocker (CCB) and angiotensin converting enzyme inhibitor (ACEI) on endothelial function and arterial stiffness in stable angina pectoris (SAP), 87 patients with SAP (57.6+/-10.0 yr, 52 males) were divided into two groups; CCB group (group I: n=44, 57.9+/-9.7 yr, 23 males) vs. CCB plus ACEI group (group II: n=43, 57.2+/-10.5 yr, 29 males). Flow mediated vasodilation (FMD) of the brachial artery, pulse wave velocity (PWV), urinary albumin excretion (UAE), and high sensitivity C-reactive protein (hsCRP) were compared. FMD, PWV, UAE, and hsCRP were not different between the groups at baseline. After 6 months of treatment, FMD were significantly improved in group II (7.5+/-3.7 to 8.8+/-2.7%, p<0.001), but not in group I (7.9+/-2.7 to 8.2+/-2.8%, p=0.535). Brachial-ankle PWV were significantly improved in both groups (1,621.3+/-279.4 to 1,512.1+/-225.0 cm/sec in group I, p<0.001, 1,586.8+/-278.5 to 1,434.5+/-200.5 cm/sec in group II, p<0.001). However, heart-femoral PWV were significantly improved (1,025.7+/-145.1 to 946.2+/-112.2 cm/sec, p<0.001) and UAE were significantly decreased (20.19+/-29.92 to 13.03+/-16.42 mg/g Cr, p=0.019) in group II only. In conclusion, combination therapy with CCB and ACEI improves endothelial function, arterial stiffness, and UAE than CCB mono-therapy more effectively in patients with SAP.

The Effects of Rosuvastatin on Plaque Regression in Patients Who Have a Mild to Moderate Degree of Coronary Stenosis With Vulnerable Plaque

BACKGROUND AND OBJECTIVES: Intensive lipid-lowering therapy with statins improves the clinical outcomes and patient survival and it reduces the progression of atherosclerosis. Intravascular ultrasound (IVUS) has been used for calculating the plaque volumes to evaluate the mechanisms that may be involved in the progression or regression of coronary artery disease. We used serial IVUS exams to assess the efficacy of rosuvastatin on plaque regression in angina patients who had a mild to moderate degree of vulnerable plaque burden. SUBJECTS AND METHODS: This study was a prospective, randomized, comparative study for lipid lowering therapy with using rosuvastatin 20 mg or atorvastatin 40 mg. IVUS was performed during the baseline coronary angiography and it was repeated after 12 months of treatment. The efficacy parameters included the changes in the atheroma volume and the lipid pool size as determined by IVUS. A total of 45 lesions in 30 patients were analyzed (rosuvastatin: 24 lesions in 16 patients vs. atorvastatin: 21 lesions in 14 patients). RESULTS: The low density lipoprotein (LDL)-cholesterol level was reduced from 121+/-45 mg/dL to 65+/-25 mg/dL in the rosuvastatin group (a 46% decrease, p<0.001), and from 127+/-37 mg/dL to 72+/-26 mg/dL in the atorvastatin group (a 43% decrease, p<0.001). The total atheroma and vessel volumes were significantly decreased, whereas the lumen volume was significantly increased from baseline to follow-up in both groups (for the rosuvastatin group: the total atheroma volume, 252+/-80 to 246+/-79 mm3, p<0.001; the vessel volume, 555+/-158 to 553+/-130 mm3, p<0.001; the lumen volume, 303+/-91 to 307+/-92 mm3, p<0.001, and for the atorvastatin group: the total atheroma volume, 288+/-98 to 283+/-98 mm3, p<0.001; the vessel volume, 607+/-165 to 604+/-166 mm3, p<0.001; the lumen volume, 319+/-71 to 321+/-73 mm3, p<0.001). The follow-up LDL-cholesterol level was correlated with the change in the total atheroma volume (r=0.577, p<0.001), the change in the percent atheroma volume (r=0.558, p<0.001) and the change in the lipid pool size (r=0.470, p=0.001). CONCLUSION: Both rosuvastatin 20 mg and atorvastatin 40 mg could contribute to the regression of lipid-rich plaque. The follow-up LDL-cholesterol level is related to the regression and stabilization of vulnerable coronary plaque.

Anomalous Origin of a Right Coronary Artery With Extrinsic Compression Between the Great Vessels: The Intravascular Ultrasound Images

The anomalous origin of the right coronary artery is a rare condition, but it has clinical importance because there have been reports of nonfatal or fatal myocardial infarction and sudden death associated with exercise for patients with this anatomy. We describe here a patient for whom 64 channel multi-detector row computed tomography was useful to identify this anomaly, and intravascular ultrasound was used to evaluate the myocardial ischemia by visualizing the coronary lumen.

Nitroglycerin-Induced Headache is Associated With Mild Coronary Artery Disease in Patients With Chest Pain

BACKGROUND AND OBJECTIVES: We hypothesized that patients with nitroglycerin-induced headache had preserved systemic vasomotion and there might be an increased nitroglycerin-mediated dilation (NMD) response in the brachial artery. The aim of this study is to evaluate whether nitroglycerin (NTG)-induced headache is associated with the level of the NMD and flow-mediated dilation (FMD) or the severity of coronary artery disease (CAD). SUBJECTS AND METHODS: The study included 87 patients (Group I: mean age: 54.8+/-9.5 years, 46 males) with headache and new onset chest pain, and 109 patients (Group II: mean age: 57.4+/-8.9 years, 67 males) without headache and with new onset of chest pain. Patients were excluded from this study if they had a history of chronic headache, long term nitrates use and coronary artery procedures. Coronary angiography was performed within one month after administering nitroglycerin for the usual clinical indications. RESULTS: The clinical characteristics did not differ between the two groups. The NMD was significantly higher in Group I than in Group II (23.0+/-7.5% vs. 18.5+/-8.6%, respectively, p<0.001). The FMD was significantly higher in Group I than in Group II (9.0+/-4.1% vs. 7.5+/-4.3%, respectively, p=0.007). On multiple regression analysis, NTG-induced headache was a predictor of CAD {oddsratio (OR), 0.04, 95% confidence interval (CI), 0.02-0.11: p<0.001, respectively}. CONCLUSION: We have shown that the vasodilator response to NTG and FMD are increased in the patients with NTG-induced headache. More NTGinduced headache developed in the patients with normal coronary arteries or minimal CAD than in the patients with obstructive CAD. This finding might be helpful as additional information for evaluating the patients with chest pain syndrome.

A Multicenter, Randomized, Open-Label, Therapeutic, and Exploratory Trial to Evaluate the Tolerability and Efficacy of Platelet Glycoprotein IIb/IIIa Receptor Blocker (Clotinab(TM)) in High-Risk Patients with Percutaneous Coronary Intervention

PURPOSE: This study was designed as a multicenter, randomized, open-label study to evaluate the efficacy and tolerability of Clotinab(TM). We expected to obtain same results as with ReoPro(R) in improving ischemic cardiac complications in high-risk patients who were about to undergo percutaneous coronary intervention (PCI). PATIENTS AND METHODS: Patients of 19-80 years of age with acute coronary syndrome (ACS) who were about to undergo PCI were enrolled. After screening and confirmation of eligibility, patients were randomly assigned to different groups. Clotinab(TM) was given to 84 patients (58.7+/-10.6 years, M:F=68:16)and ReoPro(R)(59.0+/-10.5 years, M:F=30:10) was given to 40 patients before PCI. The primary efficacy endpoint was the onset of major adverse cardiac event (MACE) within 30 days from day 1. The tolerability endpoints were assessed based on bleeding, thrombocytopenia, change in Hb/Hct, human antichimetric antibody development, and adverse events. RESULTS: The number of Clotinab(TM) patients experiencing MACE was 0 out of 76 per protocol (PP) patients. The MACE rate was 0%, and its 95% exact CI was [0.00-4.74%]. A major bleeding event developed in 3 patients in the ReoPro(R) group. The probability of MACE onset in Clotinab(TM) was estimated to be less than 5%. There was no clinically significant result in tolerability variables. CONCLUSION: Clotinab(TM) is an effective and safe medicine in preventing ischemic cardiac complications for high-risk patients who will receive PCI.

Increase of Metabolic Syndrome Score is an Independent Determinant of Increasing Pulse Pressure

PURPOSE: The objective of this study was to determine whether the progressive increase of metabolic syndrome (MetS) score, the number of components of MetS, is correlated significantly with increasing pulse pressure (PP). MATERIALS AND METHODS: 4,034 subjects were enrolled from the Cardiovascular Genome Center of Yonsei University (M:F=2344:1690, 55.2 +/- 10.5). Most of the study population were recruited from hypertension clinics, controlled with medications according to JNC7 guidelines. The Asian modified criteria of MetS were applied and MetS score was estimated. The HOMA index for insulin resistance, cholesterol profiles, and anthropometric measurements were assessed. RESULTS: Among 4034 participants, 1690 (41.9%) were classified as MetS. Progressive increase in PP was demonstrated for increasing components of the MetS score. Multiple linear regression analysis with PP as the dependent variable showed that age (beta=0.311, p < 0.001), MetS score (beta=0.226, p < 0.001), male gender (beta=-0.093, p < 0.001) and HOMA index IR (beta=0.033, p=0.03) are significantly associated with PP (R(2)=0.207, p < 0.001). CONCLUSION: The present results from this study demonstrate that increasing MetS score is an independent determinant of increasing PP. The results also demonstrate the independent role of MetS in increasing arterial stiffness and PP.

Predictors of total occlusion of the infarct-related artery in patients with acute Non-ST elevation myocardial infarction / 대한내과학회지

BACKGROUND/AIMS: Some patients with non-ST elevation myocardial infarction (NSTEMI) have total occlusion of the infarct related artery (IRA) and may benefit from early invasive treatments. The aim of this study was to investigate the predictors of total occlusion of the IRA in patients with NSTEMI before coronary angiography. METHODS: A total of 205 consecutive patients with NSTEMI (63.3+/-10.5 years, 123 males) who were admitted and underwent coronary angiogram from April 2005 to December 2006 at Chonnam National University Hospital were divided into two groups: group I (total occlusion of IRA: n=62, 61.1+/-13.3 years, 42 males) and group II (patent IRA: n=143, 64.2+/-11.3 years, 81 males). Clinical, biochemical and echocardiographic parameters on admission were compared between the groups. RESULTS: A total occlusion of the IRA in patients with NSTEMI was observed in 62 (30.2%) patients most frequently in the left circumflex coronary artery. The predictive factors for total occlusion, according to the multivariate analysis, were prolonged duration of continuous chest pain (OR:9.67, 95% CI:1.59~80.6, p=0.03), a higher level of the creatine kinase-MB fraction (CK-MB) (OR:5.35, 95% CI:1.31~90.0, p=0.035) and fibrinogen (OR:6.73, 95% CI:1.48~50.2, p=0.043), and multiple leads with ST depression on the ECG (OR:4.78, 95% CI:1.22~41.9, p=0.048). CONCLUSIONS: Total occlusion of the IRA in patients with acute NSEMI is associated with a long duration of chest pain, high levels of CK-MB and fibrinogen, and ST changes in multiple ECG leads.

Predictive Factors for the Recovery of Left Ventricular Dysfunction in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: The left ventricular ejection fraction (LVEF) is known to be a significant prognostic factor for patients with acute myocardial infarction (AMI). The aim of this study was to investigate clinical or therapeutic factors associated with the recovery of a low LVEF for patients with AMI. SUBJECTS AND METHODS: From January to December 2004, we enrolled 89 patients (mean age: 62.5+/-10.6 years, 43 males and 26 females) with AMI and who had a LVEF less than 50%. Forty five patients whose LVEF improved more than 10% were classified as group I (mean age: 62.4+/-10.4 years, 34 males and 11 females) and 44 patients whose LVEF was not changed or decreased were classified as group II (mean age: 62.3+/-10.9 years, 29 males and 15 females). The clinical variables, including risk factors and the pain-to-door time, the biochemical markers of myocardial injury, the coronary angiographic findings and the treatment-related variables, were compared between the two groups. RESULTS: The cardiovascular risk factors were not different between the groups. The location of infarction, the success rate of percutaneous coronary intervention and the coronary angiographic lesion morphologies were not different between the groups. However, the pain-to-door time was significantly shorter in group I than in group II (6.0+/-9.5 vs 22.4+/-7.5 hours, respectively, p=0.046). Improved control of risk factors was not associated with the recovery of LV function. The use of beta-blocker, statin, anti-platelet agents, vasodilators and diuretics were not different between the groups. However, the use of angiotensin converting enzyme inhibitor (ACEI) was more common in group I than group II (79.3% vs 47.4%, respectively, p=0.03). CONCLUSION: A shorter pain-to-door time and the use of ACEI were significant predictors of the recovery of LV dysfunction for patients with AMI.

The Frequency, Treatment and Clinical Outcomes of Stent Thrombosis after Use of TAXUSTM Stent

BACKGROUND AND OBJECTIVES: Findings from randomized controlled trials have showed that there is no difference in the development of stent thrombosis (ST) in patients implanted with drug-eluting stents (DES) as compared to the use of bare metal stents. The aim of this study was to evaluate the incidence, clinical characteristics, and clinical outcome of ST after implantation of TAXUSTM stents in routine clinical practice. SUBJECTS AND METHODS: This was a retrospective, single center cohort study. The study included 1,584 patients that underwent successful TAXUSTM stent implantation (2,513 lesions treated) between May 2004 and Dec 2006. RESULTS: ST developed in 18 patients (1.14%) of the 1,584 patients. Acute ST occurred in one patient (0.06%), subacute ST occurred in nine patients (0.57%), and late ST developed in eight patients (0.51%). Sixteen patients that developed ST received medication with dual antiplatelet agents. The incidence of ST in patients with acute coronary syndrome (ACS) showed was higher than in patients with stable coronary disease. The mean follow-up duration for patients was 13.3 months. There were 13 myocardial infarctions and 3 deaths attributable to ST. CONCLUSION: The cumulative incidence of ST that was confirmed by angiography after successful TAXUSTM stent implantation in consecutive "real-world" patients was substantially higher than the rate reported in clinical trials. Patients with ACS should be treated more aggressively as the risk of stent thrombosis is higher than for patients with stable angina. A large prospective study for the identification of predictors of DES thrombosis should be conducted.

The clinical effects of body mass index in patients with acute myocardial infarction after percutaneous coronary intervention / 대한내과학회지

BACKGROUND: Obesity is one of the major risk factors for coronary artery disease. However, the long-term clinical effects of obesity after percutaneus coronary intervention (PCI) in Korean patients with acute myocardial infarction (AMI) have not been sufficiently evaluated. METHODS: A total of 309 patients (mean age 60.5+/-11.3 years, M:F=243:66) that underwent PCI with a diagnosis of AMI between February 2002 and June 2006. Thepatients were divided into two groups according to the body mass index (BMI): group I (n=194; BMI or =25 kg/m2, mean age 58.2+/-11.3 years, M:F=92:23). Clinical characteristics and risk factors, and major adverse cardiac events during a six-month follow-up were compared between patients in the two gropus. RESULTS: The mean age of group I patients was older than that of group II patients (61.7+/-11.1 years vs. 58.6+/-11.5 years, p=0.017). The prevalence of hypertension was higher in group II patients (75/194, 38.7% vs.59/115, 51.3%, p=0.033) and hyperlipidemia was more prevalent in group II patients (75/194, 38.7% vs. 60/115, 52.2%, p=0.024). The levels of total cholesterol (184.3+/-39.9 mg/dL vs. 201.4+/-42.6 mg/dL, p=0.001), triglycerides (121.2+/-61.6 mg/dL vs. 147.1+/-96.2 mg/dL, p=0.005), low-density lipoprotein-cholesterol (120.3+/-35.1 mg/dL vs. 134.1+/-37.8 mg/dL, p=0.002) were lower in group I patients than in group II patients. The restenosis rate on a follow-up coronary angiogram was higher in group II patients (18/69, 26.1%) than in group I patients (14/109, 12.8%, p=0.025). CONCLUSIONS: Obesity is associated with hyperlipidemia and hypertension in patients with AMI. The restenosis rate after PCI was higher in obese AMI patients.

Predictive Factors after Percutaneous Coronary Intervention in Young Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Acute myocardial infarction (AMI) at a young age less than 40 years is an uncommon condition and it is characterized by multiple cardiovascular risk factors. We analyzed the risk factors of restenosis in AMI patients who underwent percutaneous coronary intervention (PCI), and these patients were under the age of 40 years. SUBJECTS AND METHODS: Between January 1997 and December 2006, 88 out of the 121 young AMI patients (mean age: 35.6+/-4.0 years, 115 males) who underwent follow-up coronary angiography after PCI were divided into two groups: the patients without restenosis (group I: n=62, mean age: 35.6+/-3.9 years, 60 males) and the patients with restenosis (group II: n=26, mean age: 36.3+/-3.8 years, 23 males). The clinical and coronary angiographic characteristics were compared between the two groups. RESULTS: Smoking (79.3%) was the most common risk factor in all the patients. The baseline clinical characteristics and baseline laboratory findings were not different between the two groups. There was no significant difference in the sex ratio (p=0.124). The Thrombolysis In Myocardial Infarction (TIMI) flows were not different between the two groups. The level of homocysteine (hcy) was significantly decreased from 12.4+/-8.8 micronmol/L to 9.3+/-3.8 micronmol/L in group I (p=0.011), but this was not changed significantly in group II (p=0.062). According to multiple logistic regression analysis, a high triglyceride level (>200 mg/dL) was an independent predictor of restenosis (p=0.046). CONCLUSION: A high level of serum triglyceride is a predictive factor of restenosis after PCI in young age patients with acute myocardial infarction.

The Effects of Trimetazidine on the Enhancement Pattern of Multi-detector Computed Tomography in a Porcine Myocardial Infarction Model

BACKGROUND AND OBJECTIVES: There is increasing evidence to suggest that trimetazidine (TMZ) has the ability to improve ischemic heart failure by way of optimizing the heart's energy metabolism. The aim of this study was to examine the changes of the myocardial enhancement pattern by using two-phase, contrast enhanced, ECG-gated, multi-detector computed tomography (MDCT) after the administration of TMZ in a porcine myocardial infarction model. SUBJECTS AND METHODS: The porcine myocardial infarction model was created by balloon occlusion of the left anterior descending coronary artery. We randomized the swine into two groups: group I (n=7: aspirin only) and group II (n=7: aspirin plus 1 mg/kg TMZ for 4 weeks). Echocardiography and MDCT were performed and the ejection fraction (EF, %), end-systolic volume (ESV, mL) and end-diastolic volume (EDV, mL) were measured at 28 days after induction of myocardial infarction. Three enhancement patterns, including the early arterial phase defect (ED), the 4-min late enhancement (LE) and the residual defect (RD), were also investigated and those were described as class I [ED (-), RD (-), LE (+/-)], class II [ED (+), RD (-), LE (+)], and class III [ED (+), RD (+), LE (+)]. We performed histopathologic examination after sacrificing the animals. RESULTS: The baseline and follow-up echocardiography at 4 weeks after the induction of MI demonstrated no significant differences between the two groups. The LV indices by MDCT were also similar between the two groups (group I: EF, ESV and EDV=46.0+/-12.5%, 35.9+/-23.0 mL and 69.0+/-40.2 mL, respectively, group II: EF, ESV and EDV=49.8+/-13.2%, 43.8+/-23.1 mL and 82.8+/-24.6 mL, respectively, p=NS). The percent wall thickness was similar (69.1+/-19.6% vs. 64.9+/-10.5%, respectively, p=NS), but the enhancement pattern was different between the two groups (group I: class I, II and III=0 (0%), 0 (0%): and 7 (100%) respectively, group II: class I, II and III=0 (0%), 2 (28.6%) and 5 (71.4%), respectively, p<0.001). The volume of tissue that lacked triphenyl tetrazolium chloride was similar between two groups (8.4+/-1.9% vs. 7.3+/-2.6%, respectively, p=NS). CONCLUSION: TMZ administration produced different enhancement patterns on MDCT. This result suggests that TMZ administration can reduce the residual defect in a porcine myocardial infarction model. Although further experiments are needed for determining the effect of TMZ on reducing the irreversible area of infarcted myocardium, this is the first report that proved the beneficial effect of TMZ by performing MDCT.