The Clinical Effects of Drug-Eluting Stents for the Treatment of Coronary In-Stent Restenosis

BACKGROUND AND OBJECTIVES: Treating coronary in-stent restenosis (ISR) has become one of the major challenges for the interventional cardiologist. The aim of this study was to determine the feasibility and safety of treating ISR with drug eluting stents (DESs), and we also wanted to determine the effect of DESs on the prevention of recurrent restenosis. SUBJECTS AND METHODS: Eighty patients (age range: 60.9+/-6.4 year-old, males:females=63:17) with 82 ISR lesions that were treated successfully with DES (sirolimus- and paclitaxel-eluting stents) were enrolled in our study. Five patients received 2 stents for a total mean of 1.1+/-0.3 stents per lesion. The major adverse cardiac events (MACEs) during hospitalization, at 30 days and at 6 months after the stenting were analyzed along with the coronary angiographic findings. RESULTS: At the time of DES implantation, the mean number of ISRs was 1.4+/-0.9, and the patterns of ISR according to the Mehran classification were IB in 9 lesions (10.5%), IC in 3 lesions (3.7%), ID in 6 lesions (7.3%), II in 19 lesions (23.2%), III in 30 lesions (36.7%), and IV in 15 lesions (18.3%). The mean stent length was 27.1+/-5.6 mm and the mean acute gain was 2.58+/-0.67 mm. No in-hospital MACE was observed. During the 30-day clinical follow-up, one patient developed acute myocardial infarction due to a subacute stent thrombosis. Forty two patients with 43 lesions underwent a 6-month follow-up coronary angiogram. The mean late loss at 6 months was 0.30+/-0.74 mm. The binary restenosis rate was 9.3% (4/43 lesion). The restenosed lesions were treated by balloon angioplasty in three lesions and by additional DES implantation in one lesion. CONCLUSION: Our results demonstrated that DES was a safe and very effective method for the treatment of ISR.

The Relationship between Hemoglobin A1c and Major Adverse Cardiac Events in Nondiabetic Acute Myocardial Infarction Patients Underwent Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Hyperglycemia on hospital admission is a known important risk factor in patients with acute myocardial infarction. The purpose of this study was to investigate the relation between the level of hemoglobin A1c (HbA1c) and major adverse cardiac events (MACE) in non-diabetic acute myocardial infarction patients who underwent primary percutaneous coronary intervention (PCI). SUBJECTS AND METHODS: Of the 105 acute myocardial infarction patients who underwent primary PCI between January 2002 and December 2002, 68 non diabetic patients were analyzed. The patients were divided into two groups: group I (n=46, 58.7+/-12.5 years, 37 male) with low levels of HbA1c (<6%) and group II (n=22, 64.6+/-13.1 years, 18 male) with elevated levels of HbA1c (6% to 7%). MACE was observed during the six-month clinical follow-up. RESULTS: There were no differences in the risk factors for atherosclerosis and angiographic characteristics between the two groups. Group II had a significantly higher rate of MACE (13% vs. 36%, p=0.026) compared to Group I. Logistic regression analysis disclosed that an elevated level of HbA1c, between 6 and 7%, was a significant independent predictor of MACE. CONCLUSION: An elevated level of HbA1c is a significant prognostic factor in non-diabetic acute myocardial infarction patients after primary PCI.

Is Thyroid Hormone a Risk Factor of Coronary Atherosclerosis in Korean Patients?

BACKGROUND AND OBJECTIVES: Overt and subclinical hypothyroidism is known to be associated with developing atherosclerosis and adverse changes in blood lipid. There has been no data regarding the effects of a normal range of thyroid hormone on the presence of coronary atherosclerosis. SUBJECTS AND METHODS: We studied 1 25 consecutive patients (age: 60.0 +/-11.1 years, male: female=84:41) who underwent diagnostic coronary angiography. The clinical diagnoses on admission were stable angina (32.0%), unstable angina (53.6%), and acute myocardial infarction (14.4%). The thyroid hormones [thyroid stimulating hormone (TSH), free thyroxine and free 3 -iodothyronine], serum lipid levels, high sensitivity C-reactive protein (hsCRP) level, homocysteine and fibrinogen levels were measured. The coronary angiographic results were compared with laboratory findings. RESULTS: The angiographic diagnoses of coronary artery disease were no significant stenosis in 4 1 patients (32.8%), single vessel disease in 47 patients (37.6%) and multivessel disease in 37 patients (29.6%). The serum TSH levels showed a trend toward higher levels in the patients with multivessel disease compared to the patients with no significant stenosis (1.22+/-0.96 uIU/mL vs. 0.73+/-0.53 uIU/mL, respectively, p=0.053). According to the levels of TSH ( or =1.0 IU/mL), the incidence of multivessel disease was significantly higher in the patients with high serum TSH levels (23.1 % vs. 40.0%, respectively, p=0.038). A significant correlation was observed between the levels of TSH and the monocyte count (r=0.251, p=0.005), hsCRP level (r=0.208, p=0.023) and homocysteine level (r=0.279, p=0.002). CONCLUSION: The high level of serum TSH is associated with multivessel disease, abnormal inflammatory markers and high homocysteine levels.

The Relationship between Microalbuminuria and Coronary Artery Stenosis or Inflammatory Markers in Patients with Angina Pectoris

BACKGROUND AND OBJECTIVES: Microalbuminuria is associated with increased cardiovascular risk factors and mortality. The aims of this study were to clarify the relationship between the spot urine albumin-creatinine ratio (ACR) and coronary artery stenosis on diagnostic coronary angiograms and to investigate its association with inflammatory markers. SUBJECTS AND METHODS: One hundred thirteen consecutive patients, who underwent a diagnostic coronary angiogram, between April 2004 and July 2004, were divided into two groups: group I (n=89, 58+/-1 2 years, 6 1 male, no microalbuminuria) and group II (n=24, 65+/-10 years, 14 male, microalbuminuria). Microalbuminuria was diagnosed when the ACR was between 30 and 300 mg/g.cr. RESULTS: The mean age was higher in group II than group I (58+/-1 2 vs. 65+/-1 0 years, p=0.013), and group II also showed higher levels of white blood cell (7.0+/-2.4 vs. 9.5+/-4.1 x 103/mm3, p=0.009), monocyte (0.4+/-0.2 vs. 0.5+/-0.2 x 103/mm3, p=0.039), homocysteine (8.8+/-3.5 vs. 10.8+/-4.1 micro mol/L, p=0.02) and fasting plasma glucose (126.1+/-33.6 vs. 183.7+/-75.3mg/dL, p=0.001), and more frequent higher value of high sensitivity C-reactive protein (>0.5mg/dL) (16.9 vs. 66.7%, p<0.001 ) compared with those of group I. There was a correlation between the ACR and all the inflammatory markers tested. Significant coronary lesions, requiring percutaneous coronary intervention, were more frequently detected in group II than in group I (50.6 vs. 75%, p=0.032). CONCLUSION: The ACR was associated with significant coronary artery disease and the inflammatory markers.

The Long-Term Clinical Results of a Platelet Glycoprotein IIb/IIIa Receptor Blocker (Abciximab : ReoPro(R)) Coated Stent in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: The inhibition of coronary restenosis with an Abciximab (ReoPro(R))-coated stent has previously been reported by us. This study investigated the clinical outcomes of patients with acute myocardial infarction (AMI) treated with ReoPro-coated stents. SUBJECTS AND METHOD: A prospective randomized trial was conducted to compare two types of stent for the revascularization in 63 patients [Group I (ReoPro(r)-coated stent):n=32, 53.7+/-11.8 years, 27 male, and Group II (control stent):n=31, 55.4+/-12.1 years, 27 male] with AMI. The primary effective end points were major adverse coronary events (MACE):cardiac death, acute myocardial infarction, target lesion revascularization (TLR), in-stent restenosis and late lumen loss at the 1 year clinical and angiographic follow-ups. RESULTS: Baseline clinical characteristics and diameters of stenosis and the minimal luminal diameters were no different between the two groups. There was one myocardial infarction and revascularization during the hospital stay in group II. Follow-up coronary angiograms were performed in 71.9 (23/32) and 77.4% (24/31) of groups I and II, respectively. The diameter of stenosis and late loss were significantly lower in group I than group II (19.4+/-5.1 vs. 34.8+/-5.9%, p=0.013;and 0.39+/-0.26 vs. 0.89+/-0.45 mm;p=0.008, respectively). However, the restenosis rates were no different between the two groups (21.7 vs. 37.5%, p=0.341). One year clinical follow-ups were possible in 98.4% (62/63), and there were two AMI found in group II, but none in group I. The TLR rates and total MACE of group I were relatively lower compared with group II [12.9 (4/31) vs. 29.0% (9/31);p=0.122 and 12.9 (4/31) vs. 35.5% (11/31), p=0.038, respectively]. CONCLUSION: The ReoPro(R)-coated stent was safe, with no stent thrombosis, and effective in patients with AMI.

The Usefulness of Color M-mode Doppler Echocardiographic Indices in the Assessment of Left Ventricular Diastolic Function

BACKGROUND AND OBJECTIVES: Early color M-mode Doppler flow propagation (Vp) has been used to distinguish pseudonormal from normal diastolic filling patterns. However, the role of other indices, including the late diastolic propagation velocity (Ap) and time delay of mitral flow propagation (VpTD and ApTD), is not clear. SUBJECTS AND METHODS: Doppler echocardiographic examinations were performed in 89 patients (60.6+/-9.9 years, male 59.6%), with an ejection fraction > or =40%, who were admitted for diagnostic coronary angiography. The clinical diagnoses on admission were stable angina (41.6%), unstable angina (30.3%), old myocardial infarction (24.7%) and atypical chest pain (3.3%) The diastolic filling patterns, as confirmed by mitral inflow and pulmonary venous flow, were compared with the Ap, VpTD and ApTD indices using color M-mode Doppler echocardiography. RESULTS: The age, left ventricular ejection fraction, left ventricular end diastolic and end systolic dimensions, the left atrial size, and the E'and A'velocities of the mitral annulus tissue Doppler were significantly different between patients with normal and abnormal diastolic filling patterns. In patients with normal filling, impaired relaxation and pseudonormalized filling patterns, the VpTD were 63.1+/-14.9, 85.2+/-25.5 and 107.8+/-36.8 ms (p<0.001), the E/Vp were 1.3+/-0.4, 1.6+/-0.6 and 3.1+/-0.7 (p<0.001), and the E/VpTD were 1.2+/-0.5, 0.7+/-0.2 and 0.9+/-0.4 (p<0.001), respectively. The Ap and ApTD showed significant differences between patients with normal and pseudonormalized filling patterns (Ap 58.3+/-23.5 vs. 36.2+/-15.1, p=0.000; ApTD 47.1+/-19.5 vs. 66.7+/-22.2, p=0.001). The PVa duration, an index that depends on the left ventricular end-diastolic pressure, was the most important independent predictor for ApTD from a multiple regression analysis (R2=71.4%). CONCLUSION: The color M-mode Doppler indices, Ap, VpTD and ApTD, are new diagnostic parameters for diastolic dysfunction.

Relationship between plasma homocysteine levels and chronic diabetic complications in NIDDM patients / 대한내과학회지

BACKGROUND: Elevated plasma homocysteine is a recently-recognized independent risk factor for cardiovascular disease. In patients with non-insulin dependent diabetes mellitus (NIDDM), plasma homocysteine concentration was reported to be elevated in association with nephropathy. However, inconsistent results were reported about the association with other microvascular complications. METHODS: To determine the relationship between plasma homocysteine and the development of chronic diabetic microvascular complications, fasting plasma homocysteine, glycemic control, lipid and lipoprotein levels, vitamin status, renal function test, and chronic diabetic microvascular complications were assessed in 101 patients with NIDDM in the present study. RESULTS: There was no difference in the plasma levels of homocysteine by sex, age, status of sugar control, duration of diabetes, other cardiovascular risk factors. Patients with diabetic microangiopathy had higher plasma homocysteine concentrations than those without diabetic microangiopathy. Moreover, there was a significant correlation between amount of urinary albumin excretion and plasma homocysteine level (p=0.004, r=0.357). However, multivariate analysis showed that only serum creatinine (beta=0.635) was independently associated with plasma homocysteine level in NIDDM patients. The increase in plasma homocysteine was not shown to increase the risk of diabetic microvascular complications independently on multiple logistic regression analysis. CONCLUSION: In conclusion, decrease of renal function is an independent determinant of plasma homocysteine level and higher plasma homocysteine is associated to diabetic microangiopathy. But an increase in plasma homocysteine in patients with NIDDM is not independently associated with diabetic microvascular complications considering renal function. Therefore, the renal function should be considered in study about relationship between plasma homocysteine level and the development and/or progression of chronic diabetic microvascular complications in diabetic patients.

The effects of angiotensin converting enzyme ingibitors on proteinuria and lipoprotein(a) in non-insulin dependent diabetic patients / 대한내과학회지

BACKGROUND: We determined the serum Lipoprotein(a) [Lp(a)] level in patients with NIDDM and evaluated the relationship between serum Lp(a) level and proteinuria, and the efficacy of angiotensin converting enzyme inhibitor(ACEI) in reducing serum Lp(a) level in NlDDM patients. METHOD:A total of 86 patients with NlDDM(age: 61.2 +/- 1.2 years) was divided into ACEI treatment group (n=45) and control group(n=41). The changes of the amount of proteinuria and serum Lp(a) were analyzed in both groups. Mean duration of follow-up in control group or ACEI administration in ACEI group was 8.4 months. RESULTS: 1) Befare ACEI treatment, the positive correlation between serum Lp(a) level and amount of proteinuria was present in ACEI group, but not in total subjects and control group. ACEI treatment was associated with decrease in serum Lp(a) level, but not with change in the amounts of proteinuria. 2) Serum Lp(a) levels decreased significantly by ACEI treatment, not only in patients whose diastolic blood pressure(DBP) decreased by more than 10mmHg, but also in patients whose DBP did not response to ACEI administration. 3) Patients with overt proteinuria(> 500rng/day) had higher serum Lp(a) level than patients without overt proteinuria before ACEI treatment. After ACEI treatment, serum Lp(a) levels and amount of proteinuria decreased significantly in patients with overt proteinuria, but not in patients without overt proteinuria. 4) In both subgroups of patients with serum Lp(a) level 30mg/dl and patients with serum Lp(a) level <30mg/dl, serum Lp(a) levels decreased significantly after ACEI treatment, but the amount of proteinuria did not change in both subgroups. 5) In the analyses of subgroups of patients whose amounts of proteinuria definitively decreased (responder group) or increased (non-responder group) after ACEI, serum Lp(a) levels decreased even in the non-responder group. CONCLUSION: NIDDM patients with overt proteinuria have higher level of serum Lp(a) than patients without overt proteinuria, and ACEI treatment could reduce serum Lp(a) level as well as proteinuria. Although decrease in Lp(a) is thought to be associated with decreased proteinuria, there may be another effect of ACEI that should be clarified further.

A Case of Bilateral Long Coronary Arteriovenous Fistula

Congenital coronary arteriovenous fistulas represent abnormal communication between coronary arteries and any cardiac chambers, pulmonary artery, coronary sinus, superior vena cava or pulmonary vein. A 60 year-old male patient presented with severe effort-induced chest pain radiating to left arm. Resting electrocardiogram was normal and anterior ischemia was demonstrated on stress myocardial SPECT. Coronary angiogram reve-aled very long and tortuous coronary arteriovenous fistulas originated from the left circumflex and right coronary artery, which drained into intercostal arteries. Proximal segment of left anterior descending artery stenosed about 50%. Both coronary artery fistulas were ligated and left internal mammary artery was grafted into left anterior descending artery. After surgical correction he has no cardiovascular events on 7-month clinical follow-up.

A Case of Neonatal Hyperthyroidism

No abstract available.

A Case of Chylous Ascites

No abstract available.