Valsartan 160 mg/Amlodipine 5 mg Combination Therapy versus Amlodipine 10 mg in Hypertensive Patients with Inadequate Response to Amlodipine 5 mg Monotherapy

BACKGROUND AND OBJECTIVES: When monotherapy is inadequate for blood pressure control, the next step is either to continue monotherapy in increased doses or to add another antihypertensive agent. However, direct comparison of double-dose monotherapy versus combination therapy has rarely been done. The objective of this study is to compare 10 mg of amlodipine with an amlodipine/valsartan 5/160 mg combination in patients whose blood pressure control is inadequate with amlodipine 5 mg. SUBJECTS AND METHODS: This study was conducted as a multicenter, open-label, randomized controlled trial. Men and women aged 20-80 who were diagnosed as having hypertension, who had been on amlodipine 5 mg monotherapy for at least 4 weeks, and whose daytime mean systolic blood pressure (SBP) ≥135 mmHg or diastolic blood pressure (DBP) ≥85 mmHg on 24-hour ambulatory blood pressure monitoring (ABPM) were randomized to amlodipine (A) 10 mg or amlodipine/valsartan (AV) 5/160 mg group. Follow-up 24-hour ABPM was done at 8 weeks after randomization. RESULTS: Baseline clinical characteristics did not differ between the 2 groups. Ambulatory blood pressure reduction was significantly greater in the AV group compared with the A group (daytime mean SBP change: -14±11 vs. -9±9 mmHg, p<0.001, 24-hour mean SBP change: -13±10 vs. -8±8 mmHg, p<0.0001). Drug-related adverse events also did not differ significantly (A:AV, 6.5 vs. 4.5%, p=0.56). CONCLUSION: Amlodipine/valsartan 5/160 mg combination was more efficacious than amlodipine 10 mg in hypertensive patients in whom monotherapy of amlodipine 5 mg had failed.

Combined Assessments of Biochemical Markers and ST-Segment Resolution Provide Additional Prognostic Information for Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: The prognostic value of biochemical markers and the resolution of ST-segment elevation on electrocardiogram are well established. However, how a combination of these two tools affects the evaluation of risk stratification has not yet been evaluated. SUBJECTS AND METHODS: Between January 2006 and June 2008, 178 consecutive patients treated with primary percutaneous coronary interventions after ST-segment elevation myocardial infarctions (STEMI) were analyzed at two coronary care units. Patients were divided into the following three groups according to ST-segment resolution: complete (> or =70% depression of the elevated ST-segment, n=63), partial (30% to 70%, n=90), and incomplete (<30%, n=25). Demographic data, including history, electrocardiography, biochemical markers, initial ejection fraction, and angiographic findings were also evaluated. RESULTS: There were 7 deaths, 3 repeated myocardial infarctions, and 17 readmissions for worsening heart failure during six months of follow-up. In a multivariate analysis to predict clinical outcomes, ejection fraction {hazard ratio (HR): 0.83 (0.76-0.91), p<0.01}, high-sensitivity C-reactive protein {HR: 1.15 (1.05-1.26), p<0.05}, and the degree of ST-segment resolution {HR: 0.96 (0.93-0.09), p<0.05} were independently associated with clinical outcomes. According to the Cox-proportional hazards model, the addition of ST-segment resolution markedly improved the prognostic utility of the model containing biochemical markers and ejection fraction. CONCLUSION: Assessment of biomarkers upon admission and ST-segment resolution are strong predictors of clinical outcomes. The combination of these data provides additive information about prognosis at an early point in the disease progression and further improves risk stratification for STEMI.

Updates in the management of patients with acute coronary syndrome / 대한내과학회지

Acute coronary syndrome (ACS) represents a broad spectrum of ischemic myocardial events, including unstable angina, non-ST elevation myocardial infarction, and acute ST elevation myocardial infarction, which are associated with high morbidity and mortality. Early diagnosis and risk stratification are essential for initiation of optimal medical and invasive management. Randomized clinical trials over the past decade have revolutionized the care of patients with ACS. Therapeutic measures consist of administration of aggressive antiplatelet, antithrombotic, and antiischemic agents. In addition, patients with high-risk features, notably positive troponin, ST segment changes, and diabetes, benefit from early invasive intervention as compared to conservative strategies. Lifestyle interventions, modification of risk factor profile, and long-term medical treatment are of pivotal importance in reducing the long-term risk of recurrence.

A Case of Pericardial Tamponade in a Korean Man with Pericardial Abscess due to Bacteroides fragilis

Purulent pericarditis is a rare, life-threatening condition and usually involves the whole pericardium. However only few cases have been reported in which a loculated pericardial abscess occurred from purulent pericarditis. The prevalence of acute pericarditis due to bacteria was 6%. Purulent pericarditis due to anaerobic bacteria has been reported less frequently than aerobic bacteria. There was no report about purulent pericarditis due to Bacteroides fragilis in Korea until now. So we report the first case of pericardial abscess due to B. fragilis in 59 year old Korean male with history of chronic renal failure and hemodialysis, that was complicated with pericardial tamponade.

A Case of Pericardial Tamponade in a Korean Man with Pericardial Abscess due to Bacteroides fragilis

Purulent pericarditis is a rare, life-threatening condition and usually involves the whole pericardium. However only few cases have been reported in which a loculated pericardial abscess occurred from purulent pericarditis. The prevalence of acute pericarditis due to bacteria was 6%. Purulent pericarditis due to anaerobic bacteria has been reported less frequently than aerobic bacteria. There was no report about purulent pericarditis due to Bacteroides fragilis in Korea until now. So we report the first case of pericardial abscess due to B. fragilis in 59 year old Korean male with history of chronic renal failure and hemodialysis, that was complicated with pericardial tamponade.

The Difference of Left Ventricular Hypertrophy and the Diastolic Function between Prehypertensives and Normotensives

BACKGROUND AND OBJECTIVES: We investigated whether prehypertensives (PHs) exhibit more prevalent electrocardiographic and echocardiographic left ventricular hypertrophy (ECG LVH) and if they are are more associated with impaired left ventricular (LV) diastolic function than are normotensives (NTs). SUBJECTS AND METHODS: A total of 608 subjects> or = 40 years of age with normal BP (SBP<120 mmHg and DBP<80 mmHg, n=335) and PH (n=273) and who were without a history of hypertension, diabetes and any other known cardiovascular diseases underwent blood sampling for obtaining the lipid profile, and they also underwent 12-lead electrocardiography and echocardiography. RESULTS: Compared with the NTs, the PHs had significantly higher Sokolow-Lyon and Cornell voltage for ECG LVH, and they ahd a higher prevalence of ECG LVH (men: 16.9% vs 5.9%, women: 2.0% vs 1.0%, respectively). The PHs had a more increased left ventricular mass index (LVMI, Men: 118.1+/-24.4 g/m2 vs 102.0+/-19.1 g/m2, p=0.02; Women: 117.5+/-26.4 g/m2 vs 101.9+/-30.7 g/m2, p=0.02) and a more decreased LV diastolic function (E/A, Men: 1.14+/-0.6 vs 1.30+/-0.4, p=0.03; Wemen: 1.11+/-0.6 vs 1.25+/-0.5, p=0.03) on echocardiography than the NTs. CONCLUSION: The PHs were associated with a higher prevalence of ECG LVH and a more increased LVMI on echocardiography than that of the NTs. Therefore, we should pay earlier attention to diagnose and screen the pre-hypertensive group.

The Relationship between the Upright Serum aldosterone Level and the Left Ventricular Geometry in Essentioal Hypertension

BACKGROUND: Aldosterone acts as a non-hemodynamic factors on the hypertensive heart regarding sodium retension or myocardial fibrosis. To elucidate whether aldosterone is associated with the specific left ventricular geometry or not, we investigated the relationship between the upright serum aldosterone levels and the echocardiographicleft ventricular structure in the essential hypertension patients never treated. METHODS: Echocardiographic indices included M-mode measured left ventricular mass index (LVMI), relative wall thickness (RWT). Aldosterone is measured by Radioimmunoassay for the serum withdrawn from the subjects at least 3 hours upright position. 63 patients and 20 normal control subjects were evaluated. RESULTS: 1) 84.1% (63/53) of cases showed left ventricular hypertrophy. 7 patients showed normal LVMI, 3 patients showed concentric remodeling geometry. 19 patients had concentric left ventricular hypertrophy (LVH). 34 patients had eccentric LVH. 2) The serum aldosterone level has negative correlation with the RWT (r=-0.27, p=0.03) but not with LVMI (r=0.08, p=NS). There was difference among groups (ANOVA, F=0.009). Serum aldosterone is higher in eccentric LVH group than in concentric LVH group (10.5+/-1.2 ng/dL vs 5.2+/-0.6 ng/dL, p=0.0001) and than in control group (10.5+/-1.2 ng/dL vs 6.6+/-0.8 ng/dL, p=0.01). CONCLUSION: In this study, we observed that the serum aldosterone level was not correlated with the LVMI but with RWT negatively so that eccentric LVH group showed higher serum aldosterone levels than control group and concentric LVH group.

Apical Hypertrophic Cardiomyopathy: Clinical and Echocardiographic Follow Up

BACKGROUND: An unusual form of hypertrophic cardiomyopathy localized to the left ventricular apex has racial differences in phenotypic expression between many Japanese reports and most reports from outside Japan. In Japanese patients follow up study of apical hyertrophy has shown benign clinical course without demonstrable genetic transmission, but other ethnic patients with this variant was clinically different from Japanese patients. The purpose of this study was to evaluate the clinical course and the progression of hypertrophy of apical hyper- trophic cardiomyopathy by echocardiography and to define the relationship between the severity of apical hypertrophic cardiomyopathy and the clinical course. METHODS: Between June 1990 and August 1996, 35 out of 53 patients with apical hypertrophic cardiomyopathy diagnosed by echocardiography were studied. In 26 out of 35 patients, two- dimensional echocardiography and EKG were obtained at initial visit and follow up. We analyzed the sum of S wave in lead Vl and R wave in lead VS(mm) and T wave negativity in lead V4 on EKG. Measured echocardiographic parameters were apical thickness and apical cross-sectional area of left ventricle at end-diastole in apical tour chamber view, anteroposterior left atrial dirnension at end systole in parasternal short axis view and pulsed-wave Doppler pattern of transmitral inflow. RESULTS: 1) Mean age at presentation was 57.9+8.3 years(range 37 to 72). Mean follow up duration of echocardiography and EKG were 29.5+/-13.5 months and 27.7+ -1.4 months, respectively. 2) Eleven(31%) out of 35 patients were asymptomatic at initial presentation. In the remaining 24 patients, major symptoms included atypical chest pain(n=7), angina (n=11), dyspnea(n=12), palpitation(n=4) and fatigue(n=l), During follow-up, symptoms aggravated in 5/35(14%), no change in 22/35(63%) and allenated in 8/35(23%). The clinical event during follow up was transient ischemic attack in 1 patient, syncope in 1 patient and death in 1 patient with cerebral infarction and upper gastrointestinal bleeding. 3) Electrocardiography revealed normal sinus rhphm in 24 patients and atrial fibrillation in 2 patients at initial presentation. Paroxysmal atrial fibrillation was observed in 1 patient during follow up period at 24 hours Holter monitoring. Negative T wave amplitude was increased from 11.5+/-5.5 to 13.1+/-6.5mm(p<0.05), however the sum of SV, and RV, did not change significantly. 4) The apical thickness and apical cross-sectional area changed over time, frorn 19.9+/- 3.2 to 21.8+/-4.lmm(p<0.005) with interobservers difference of 2.3+/-1.2mm and from 11.4+/-2.4 to 12.5+/-3.1cm(p<0.05) with interobservers difference of 1.9+/-1.5cm, respectively. Left atrial dimension increased from 43.5+/-6.6 to 46.2+/-6.1mm(p<0.005). Transmitral inflow revealed norrnal E/A ratio and deceleration time of 150~ 40msec in 11 patients with changed to relaxation abnormalities in three and pseudonormalization in ovo and relaxation abnormalities in 14 patients with changed to pseudonormalization in three at follow-up. CONCLUSIONS: Patients with apical hypertrophic cardiomyopathy have relatively favorable prognosis during follow up period without any significant clinical event and symptomatic deterioration. T wave negativity on EKG and left atrial dimension on echocardiographic examination were increased during follow up, but these parameters were not associated with clinical presentation.

Immediate Results of Manually Crimped NIR Stent

BACKGROUND: The several kinds of coronary stents have proven successful in their role to treat acute or subacute closures after balloon angioplasty as well as to reduce the restenosis rate in de novo lesions. However, investigations continue in order to develop an ideal stent with a strong, highly flexible, radial force, especially useful in cases of tortuous vessels, lesions at bends, and lesions distal to previously deployed stents. The NIR stent is a recently developed balloon-expandable, stainless-steel, slotted tube stent; it is designed for improved flexibility with a higher radial force when compared with the traditional Palmaz-Schatz stent. We report the immediate results of our experience with the NIR stent. The purpose of the present study was to assess the feasibility, safety and efficacy of the deployment of manually crimped NIR stents in patients with complex coronary anatomy as well as the clinical outcomes within the first month. METHODS: Between January and July 1997, 143 NIR stents were implanted in the coronary arteries of 124 patients (male 76%, mean age 56+/-10 years). Sixty-one patients had UAP, 43 had SA, and 20 patients had AMI. RESULTS: 1)Indications of stenting were de novo lesions in 123 (95%) and restenosis lesion in 6 (5%). 2)Frequency of used stent length was 16mm in 65 cases (46%), 32mm in 60 cases (42%), 25 mm in 12 cases (8%), and 9mm in 6 cases (4%). 3)Single stents were implanted in 115 (89%) lesions, and overlapping stenting with 2nd NIR stents in 14 (11%) lesions. 4)Procedural success rate (defined as the angiographically residual stenosis of <30% immediately after the procedure with no major clinical events within 4 weeks after the procedure) was 95.2% (118/124 pts). Angiographic success rate (defined as a residual stenosis of <30% without major dissection) was 96.1% (124/129 lesion). The procedural success rate and the angiographic success rate in calcified lesions and/or thrombi containing lesions were 100%. The procedural success rate and the angiographic success rate in cases of tortuous proximal vessels to the lesion were 91% and 91%, respectively. The procedural success rate and the angiographic success rate in more than 45 degrees angulated lesions were 98% and 94%, respectively. 5)The mean lumen diameter of target lesions was increased from 0.6+/-0.4mm to 3.1+/-0.5mm (p<0.001) after stent implantation. The percent of diameter stenosis was decreased from 82+/-12% to -1+/-13% (p<0.001) after stent implantation. The mean diameter of the reference artery was 3.1+/-0.6mm. 6)Incidence of peristent dissection after stenting was 6.2% (8/129 lesion). 7)The rate of stenting failure was 4.8% (6 pts). There were 2 cases of stent migration, 2 cases of failure to cross the lesion and 2 cases of procedure-related emergency CABG. CONCLUSION: There is a higher tendency for stent migration with manually crinped stents compared with that of premounted stents. However, coronary stenting with manually-crimped NIR stents can be safely performed and may be particularly useful in patients with unfavorable clinical and angiographic characteristics for percutaneous coronary intervention. Follow-up data is needed to assess long term patency of this stent.

Coronary Arterial Remodeling in Athersclerotic Disease: An Intravascular Ultrasonic Study in vivo

BACKGROUND: Adaptive remodeling of the wall of diseased arterial segments occurs to compensate for the accumulation of atherosclerotic plaque. Histopathologic studies and intraoperative high-frequency epicardial coronary ultrasound imaging as well as intracoronary ultrasound imaging have shown that human coronary arteries enlarge in parallel with the formation of atherosclerotic plaque. Therefore, the lumen area is preserved until the progressive accumulation of plaque exceeds the compensatory mechanisms of the vessel. In 1995, however, Pastercamp et al. reported that arterial wall constriction (shrinkage) or inadequate enlargement may be a different mechanism associated with the development of severe arterial lumen narrowing in addition to plaque proliferation. The aim of this study is to examine what extent of de novo native coronary arterial stenosis is accompanied by compensatory enlargement and to find the predictors of inadequate remodeling with intravascualr ultrasound. METHODS: Fifty eight patients were enrolled from February 1997 through October 1997. Patients who had the lesion of more than 50% stenosis of minimal luminal diameter in coronary angiography were indicated. The lesion which was located in the ostium or was very tortuous or angulated was excluded. The lesion which had the history of balloon angioplasty or stent insertion was also excluded. We used 20 MHz endosonic intravascular ultrasound catheter. We measured EEM area (External Elastic Membrane area), lumen area and plaque plus media area and analysed plaque characteristics. RESULTS: 1) Fifty-eight consecutive patients (43 men, 15 women; mean age 55.4 years, range 33 to 78) who had not undergone previous catheter intervention were studied with a single intravascular ultrasound system. 2) Among 58 patients, 20 patients (35%) had acute myocardial infarction, 30 patients (52%) unstable angina, 6 patients (10%) stable angina and 2 patients (3%) old myocardial infarction. Lesions were located at the left anterior descending arteries in 29 patients (50%), right coronary arteries in 21 patients (36%) and left circumflex coronary artery in 8 patients (14%). 3) Compensatory enlargement was observed in 19 (32%) of 58 lesions and inadequate compensatory enlargement in 39 (68%). 4) EEM and plaque areas at lesion site of compensatory enlargement group were significantly larger than those of inadequate enlargement group (p240 mg/dl), smokings and plaque characteristics were not statistically related with inadequate enlargement. Although there was no statistical significance, there was a tendency of inadequate enlargement in patients with diabetes mellitus and calcified plaque. 6) The only predictor of inadequate remodeling was the postmenopausal female (p<0.05). CONCLUSION: Adaptive compensatory coronary arterial remodeling was occured less frequently in patients with acute coronary syndromes than in patients with stable angina. The only statistically significant predictor of adaptive compensatory coronary arterial remodeling was postmenopausal women. Inadequate compensatory coronary arterial remodeling was occured more frequently in patients with diabetes mellitus or calcified plaque but without statistical significance.

Influences of the Apolipoprotein E Polymorphism on the Development of Coronary Artery Disease and on Serum Lipids in the Korean Males

BACKGROUND: Apo E lipoprotein is polymorphic and exists in three common isoforms (E2, E3 and E4), which are the gene products of three apo E alleles, e2, e3 and e4. Apo E lipoprotein plays an important role in the regulation of the lipid metabolism through its ability to bind to receptors. Depending on the genotypes apo E polymorphism is either protective or increases risk for atherosclerosis and coronary artery disease. The purpose of this study is to evaluate 1) the association between apo E allele and the development of coronary artery disease, 2) the association between apo E alleles and dyslipidemia in Korean males. METHODS: We studied 241 patients with angiographically verified coronary artery disease and 257 male subjects without evidence of coronary artery disease. Apo E genotyping was determined with the INNO-LiPA Apo E kit (Innogenetics, Belgium), which is based on reverse hybridization. RESULTS: There was a higher frequency of the apo e4 allele in subjects with coronary artery disease than in normal controls. The frequencies of apo E genotype were not significantly associated with apo e2 were associated with higher levels of triglyceride and lower LDL, and the subjects with apo e4 had lower levels of HDL cholesterol. CONCLUSION: ApoE polymorphism is a genetic marker for risk of the development of coronary artery disease and an important determinant of dyslipidemia.

A Case of Primary Gastric Choriocarcinoma / 대한소화기내시경학회지

Extragonadal choriocarcinoma arising in the stomach of a 53-year-old male is presented. The tumor was diagnosed as choriocarcinorna of the stomach by histologic examination and immunohistologic method of biopsy specimens. The tumor showed the multiple metastases to the lung and liver. The level of human chorionic gonadotropin was significantly increased in the serum. The patient died of hepatic failure at the 26th hospital day.

A Case Of Rheumatoid Arthritis Accompanied By Severe Eosinophilia / 대한류마티스학회지

Eosinophilia is usually accompanied by parasite infestation, allergic condition, drug, collagen disease, and idiopathic hypereosinophilic syndrome. In about 10 to 40% of rheumatoid arthritis patients, peripheral blood reveals eosinophilia. Of the rheumatic disease, eosinophilia may occur in rheumatoid arthritis, sarcoidosis, polyarteritis nodosa and other vascultis. Patient with eosinophilia must be carefully followed up due to possibility of progression to eosinophilic leukemia or myeloproliferatire disease. We experienced a case of rheumatoid arthritis with severe eosinophilia for a period of more than one year in a 53 year-old female patient, eosinophil more than 85% in the peripheral blood, but in spite of careful laboratory study, there was no evidence of parasite infestation, allergic disease and malignant condition that may cause eosinophilia. Therefore we concluded that her severe eosinophilia was associated with rheumatoid arthritis itself, and now she is intensively followed up at the outpatient department. We have to look for any malignant transformation during her clinical course. Marked eosinophilia associated with rheumatoid arthritis is very rare, so we report this case with a review of literatures.