Effect of revascularization strategy in patients with acute myocardial infarction and renal insufficiency with multivessel disease

BACKGROUND/AIMS: The aim of this study was to compare the risk of complications and outcome between infarct-related artery (IRA)-only revascularization and multivessel (MV) revascularization in patients with acute myocardial infarction (MI) with renal insufficiency and MV disease. METHODS: A total of 1,031 acute MI patients with renal insufficiency and MV disease who were registered in the Korea Working Group on Myocardial Infarction were enrolled. They were divided into two groups (IRA-only revascularization group, n = 404; MV revascularization group, n = 627), and investigated the cumulative incidence of major adverse cardiac events (MACE) and the incidence of complications after percutaneous coronary intervention (PCI). RESULTS: Complications after PCI occurred in 19.9% of all patients (206/1,031). Complications after PCI occurred more frequently in the MV revascularization group compared with the IRA-only revascularization group (20.1% [126/627] vs. 15.3% [62/404], respectively; p = 0.029]. The overall in-hospital mortality rate was 6.3%, and there was no significant difference between the groups (5.2% in the IRA-only revascularization group vs. 7.0% in the MV revascularization group; p = 0.241). The total incidence of MACE was 11.1%, and there was no significant difference between the groups (11.6% in the IRA-only revascularization group vs. 10.7% in the MV revascularization group; p = 0.636). CONCLUSIONS: The incidence of complications after PCI was significantly lower in the IRA-only revascularization group compared with the MV revascularization group. However, there were no significant difference in the 12-month outcomes between groups in patients with acute MI and renal insufficiency with MV disease.

Characteristics, In-Hospital and Long-Term Clinical Outcomes of Nonagenarian Compared with Octogenarian Acute Myocardial Infarction Patients

We compared clinical characteristics, management, and clinical outcomes of nonagenarian acute myocardial infarction (AMI) patients (n=270, 92.3+/-2.3 yr old) with octogenarian AMI patients (n=2,145, 83.5+/-2.7 yr old) enrolled in Korean AMI Registry (KAMIR). Nonagenarians were less likely to have hypertension, diabetes and less likely to be prescribed with beta-blockers, statins, and glycoprotein IIb/IIIa inhibitors compared with octogenarians. Although percutaneous coronary intervention (PCI) was preferred in octogenarians than nonagenarians, the success rate of PCI between the two groups was comparable. In-hospital mortality, the composite of in-hospital adverse outcomes and one year mortality were higher in nonagenarians than in octogenarians. However, the composite of the one year major adverse cardiac events (MACEs) was comparable between the two groups without differences in MI or re-PCI rate. PCI improved 1-yr mortality (adjusted hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.36-0.69, P<0.001) and MACEs (adjusted HR, 0.47; 95% CI, 0.37-0.61, P<0.001) without significant complications both in nonagenarians and octogenarians. In conclusion, nonagenarians had similar 1-yr MACEs rates despite of higher in-hospital and 1-yr mortality compared with octogenarian AMI patients. PCI in nonagenarian AMI patients was associated to better 1-yr clinical outcomes.

The Association of Socioeconomic Status with Three-Year Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

The aim of this study was to evaluate whether the clinical outcomes were associated with socioeconomic status (SES) in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI). The author analyzed 2,358 patients (64.9 +/- 12.3 yr old, 71.5% male) hospitalized with AMI between November 2005 and June 2010. SES was measured by the self-reported education (years of schooling), the residential address (social deprivation index), and the national health insurance status (medical aid beneficiaries). Sequential multivariable modeling assessed the relationship of SES factors with 3-yr major adverse cardiovascular events (MACEs) and mortality after the adjustment for demographic and clinical factors. During the 3-yr follow-up, 630 (26.7%) MACEs and 322 (13.7%) all-cause deaths occurred in 2,358 patients. In multivariate Cox proportional hazards regression modeling, the only lower education of SES variables was associated with MACEs (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.91) and mortality (HR, 1.93; 95% CI, 1.16-3.20) in the patients with AMI who underwent PCI. The study results indicate that the lower education is a significant associated factor to increased poor clinical outcomes in patients with AMI who underwent PCI.

Comparison of Coronary Plaque and Stenosis Between Coronary Computed Tomography Angiography and Virtual Histology-Intravascular Ultrasound in Asymptomatic Patients with Risk Factors for Coronary Artery Disease

OBJECTIVES: The purpose of the study was to compare plaque characteristics by coronary computed tomography angiography (CCTA) with those by virtual histology-intravascular ultrasound (VH-IVUS). METHODS: We enrolled 50 asymptomatic patients with diabetes mellitus or more than two risk factors for coronary artery disease such as hypertension, smoking, and hyperlipidemia. If the patient had a coronary lesion (plaque with more than 50% stenosis or calcium score more than 100), we recommended coronary angiography and VH-IVUS and compared CCTA findings with VH-IVUS findings. RESULTS: 35 patients (70%) had coronary lesions, and we performed both CCTA and VH-IVUS in 23 patients. All 23 patients had multiple risk factors, and the majority of target lesions were located at left anterior descending artery (73.9%), and calcium score of lesion site was 106+/-162 with plaque volume of 232+/-153 mm3 by CCTA. Calcium score of lesion site was significantly greater in diabetic patients (n=14) than non-diabetic patients (n=9) (118+/-159 vs. 88+/-175, p=0.038). By VH-IVUS, plaque volume was 174+/-127 mm3, absolute necrotic core (NC) volume was 22+/-21 mm3, and relative NC volume was 20.8+/-8.7%. Absolute dense calcium (DC) volume and absolute NC volumes were significantly greater in diabetic patients than non-diabetic patients (11.5+/-13.8 mm3 vs. 9.1+/-11.0 mm3, p=0.028, and 23.9+/-24.7 mm3 vs. 18.1+/-14.3 mm3, p=0.035, respectively). Plaque volume by CCTA correlated with that of VH-IVUS (r=0.742, p<0.001), and plaque volume by CCTA correlated with absolute NC volume by VH-IVUS (r=0.621, p<0.001), and calcium score of lesion site by CCTA correlated with absolute dense calcium volume by VH-IVUS (r=0.478, p=0.028). CONCLUSION: Coronary lesion was detected by CCTA in 70% of asymptomatic patients with multiple coronary risk factors, and parameters detected by CCTA correlated well with those detected by VH-IVUS.

Recurrent Stent Thrombosis and Pulmonary Thromboembolism Associated with Hyperhomocysteinemia

Stent thrombosis is a fatal complication that can cause sudden cardiac death in patients implanted coronary stent. Also, pulmonary thromboembolism is associated with increased mortality. Usually, these vascular thromboembolic diseases did not occured simultaneously. If this circumstance develops, possible mechanisms and causes should be described. Here, we report a case of patient underwent percutaneous coronary intervention under diagnosis of ST-segment elevation myocardial infarction with recurrent stent thrombosis and pulmonary thromboembolism associated with hyperhomocysteinemia despite optimal medical therapy.

A Rapid Improvement of Heart Failure after Treatment of Hyperthyroidism

BACKGROUND: Heart failure is a rare condition of thyrotoxicosis. We report a case of thyrotoxicosis-inducing heart failure. CASE REPORT: A 29-year old female had been suffered from thyrotoxicosis for 3 years without proper medication. She complained progressive dyspnea and palpitation with atrial fibrillation with rapid ventricular response. Marked cardiomegaly, and severe right ventricular dysfunction with biatrial enlargements were found on Two-dimensional (2D) echocardiography. We treated her with medications for heart failure and thyrotoxicosis, and the patient's symptoms and objective cardiac functions are improved after two weeks. CONCLUSION: Severe heart failure caused by thyrotoxicosis could be reversible with proper management. Patients who have thyrotoxicosis should be assessed closely, and suitable treatment can markedly improve the patient's prognosis.

Very Late Stent Thrombosis due to Neointimal Rupture After Paclitaxel-Eluting Stent Implantation

We report our experience of very late stent thrombosis (VLST) in a young male patient who underwent implantation of two paclitaxel-eluting stents (PES) six years ago. The patient was compliant with standard dual antiplatelet therapy, but he presented with acute myocardial infarction which was associated with VLST. Intravascular ultrasound showed neointimal rupture with thrombus within the PES implanted in the right coronary artery. The lesion was successfully treated with balloon angioplasty without complications, however he was found to be hyporesponsive to clopidogrel when tested for adenosine diphosphate-induced platelet aggregation. The patient was discharged after uneventful recovery with triple anti-platelet therapy using aspirin, clopidogrel and cilostazol. To the best of our knowledge, a time interval of 2,223 days is the longest reported time interval between PES deployment and VLST occurrence. VLST may indeed occur in clinically stable patients, as multiple factors can influence the pathological mechanisms of VLST.

The effects of statins on electrical stability in patients with essential hypertension / 대한내과학회지

BACKGROUND/AIMS: Essential hypertension is the most common cardiovascular disease and is involved in the development of the various cardiac arrhythmias, including atrial fibrillation. Recently, several studies have shown that statins have anti-arrhythmic effects, including the prevention of atrial fibrillation. This study investigated the effects of statins on cardiac electrophysiologic remodeling in patients with essential hypertension using the signal-averaged electrocardiogram (ECG) and standard 12-lead ECG. METHODS: This prospective multicenter study enrolled 115 patients with hypertension. Various antihypertensive drugs were administered alone or in combination according to their blood pressure. Statins were administrated in 56 patients. Laboratory tests, a standard 12-lead ECG, and signal-averaged ECG were performed at 1, 3, 6, and 12 months. Statistical analysis was performed using paired and independent t-tests and repeated measures analysis of variance (ANOVA). RESULTS: There was no significant difference in the clinical characteristics of the patients with and without statins. After antihypertensive therapy for 1 year, the P wave dispersion, high-frequency low-amplitude (HFLA) signals in the QRS complex of less than 40 micronV, and T peak-to-end dispersion were increased significantly (p<0.001, p<0.05, and p<0.01, respectively) in the patients who were not taking statins, while these changes were not seen in the statin group. CONCLUSIONS: These results demonstrate that electrophysiologic remodeling was progressive in patients with essential hypertension, despite antihypertensive therapy. However, combination therapy with a statin may inhibit the deterioration of inhomogeneity in atrial refractoriness and conduction disturbance.

The factors influencing ventricular dyssynchrony in patients with permanent pacemaker / 대한내과학회지

BACKGROUND/AIMS: Chronic right ventricular pacing (RVP) can lead to increased risks of ventricular dyssynchrony (VD), heart failure, and mortality. This study examined the factors influencing VD in patients treated with a permanent pacemaker (PPM). METHODS: The study enrolled 139 patients (M:F=1:1.35, 66.8+/-1.0 years) who had permanent pacemaker implanted [AAI (R): 11, VVI (R): 39, VDD (R): 50, DDD: 39]. Their clinical characteristics, 12-lead electrocardiogram (ECG), echocardiography, and laboratory parameters were evaluated. The patients were divided into two groups according to the presence of VD. RESULTS: VD was seen in 71.9% of the patients with a PPM. No significant difference was observed in the clinical characteristics, except for the indications and current action mode of the PPM. VD was more frequently associated with patients with AV block and ventricular pacing. The QRS duration and QTc interval were significantly wider in patients with VD (159.9+/-3.2 vs. 129.4+/-6.3 ms, p<0.001; 487.7+/-4.0 vs. 470.9+/-8.0 ms, p<0.05, respectively). On echocardiography, tricuspid regurgitation was more common in patients with VD. The N-terminal B-type natriuretic peptide (NT-proBNP) level was higher in the dyssynchrony group (431.4+/-66.1 vs. 202.8+/-40.8, p<0.05). CONCLUSIONS: Patients with AV block and ventricular pacing developed VD more frequently. A higher serum NT-proBNP level and prolonged QRS duration, QTc, and tricuspid regurgitation might be associated with VD.