Significance of Serum Troponin-T Level in Acute Ischemic Pain Syndrome / 대한내과학회지

OBJECTIVES: In coronary arterial disease, quantitative assessment of the extent of myocardial damage is important both in management of the patient and prediction of prognosis. Measurement of serum Troponin-T is a new method for detecting myocardial cellular injury, used as more specific marker of tissue damage and reperfusion status in acute myocardial infarction, This study was performed to evaluate the significance of serum Troponin-T measurement in various acute chest pain syndrome. METHODS: 37 patients who presented anterior ischemic chest pain enrolled from April, 1994 to September, 1995, From the initial period of admission, serial measurements of serum level of cardiac enzymes (CK, CK MB, Myoglobin, Troponin-T) were made. Then release time, peak time and normalization time of each enzyme were derived and compared each other. To evaluate whether Troponin-T level can reflect the extent of ischemic injury, correlation between peak Troponin-T level and peak CK MB level was analysed by regression method. RESULTS: 1) Acute myocardial infarction was confirmed in 15 cases; Q-wave myocardial infarction was 10 cases(anterior wall-5 cases, inferior wall-4 cases, lateral wall-1 cases), and non Q-wave myocardial infarction was 5 cases. Unstable angina was 22 cases. All cases had significant stenosis in coronary angiography. 2) The appearance in the serum level of 4 cardiac enzymes was as follows. The release time(hours) of 4 cardiac enzymes(Troponin-T, CK, CK MB, Myoglobin) were 7.1(1-30), 9.3(1-30), 9.9(1-30), 6.2(1-30). The peak time(hours) of 4 cardiac enzymes were 23.0(1.5-96), 21.6(2-66), 16.9(2-42), 12.7(3-40). The normalization time(hours) of the enzymes were over 72, 53.7(11-86), 52.3(11-94), 32.3(10-82). 3) Elevation pattern of cardiac enzymes showed concordance of all 3 enzymes(Troponin-T, CK MB, Myoglobin) in 29 of 43 cases(67.4%), There was concordance of 2 enzymes in 10 cases; 5 cases of CK MB and Myoglobin, 5 cases of Troponin-T and Myoglobin. In 4 cases, only Myoglobin level was increased. 4) There was significant correlation between peak Troponin-T level and peak CK level(r=0.66, p=0.0178), significant correlation was also observed between peak Troponin-T level and peak CK MR level(r=0.90, p=0.0001). CONCLUSION: In acute myocardial infarction serum Troponin-T was detectable as early as CK MB, and lasted longer after other enzyme level was normalized. There was significant correlation between peak Troponin-T level and peak CK, CK MB level, suggesting Troponin-T as useful marker for assessing the extent of myocardial damage.

Echocardiographic Findings in Cardiac Tumors

Primary tumors of the heart are uncommon and their incidence in autopsy series ranges from 0.0017 to 0.28 per cent. About 75 per cent of all cardiac tumors are histologically benign and the remainder are malignant. The majority of benign cardiac tumors are myxoma, comprising 30 to 50 per cent of the total cases in most pathological series and the majority of malignant cardiac tumors are sarcoma. But tumors metastatic to the heart are far more common than primary cardiac tumors and actually appear to be increasing in incidence because of prolonged survival of cancer patients. We experienced six cases of cardiac tumors which were diagnosed with echocardiography : 2 hepatocellular carcinoma, 1 malignant melanoma, 1 malignant fibros histiocytoma, 1 lipoma, and 1 myxoma. The mean age of the 3 men and 3 women was 50(range 28 to 71). Two patients with right atrial metastasis from hepatocellular carcinoma and one patient with metastasis from malignant melanoma expired during conservative management. Two benign cardiac tumors(1 lipoma and 1 myxoma) were successfully excised and later follow-up echocardiography showed no signs of tumor recurrence. One patient with biatrial recurrence of malignant histiocytoma was treated medically and expired 4 months later.

Coronary Flow Patterns in the Coronary Artery Narrowings

BACKGROUND: Coronary blood flow shows phasic and diastolic dominant flow pattern in normal coronary artery, which can be changed in coronary artery stenosis. We measured and analysed coronary blood flow velocity by Doppler-tipped guidewire to clarify the change of flow pattern in the proximal and distal segments of coronary narrowings. METHODS: Coronary flow velocity were measured by 0.018 or 0.014 inch Doppler-tipped guidewire in 14 paients, 17 sites(LCS 11, RCA 6) in the proximal and distal segment of coronary narrowings, during coronary angiography or coronary angioplasty after bolus intracoronary infusion of 20microg nitroglycerine. Coronary flow reserve also measured after adenosine intracoronary infusion(LCA 12gmicrog, RCA 6microg). Perent stenosis of coronary artery was measured by digital cailper in 2 different projections and averaged. RESULTS: 1) The was no significant correlation between percent stenosis and proximal distal velocity ratio(P/D) ration(r=0.56. P>0.05). 2) Average peak velocity(APV, cm/sec) and diastolic artery, respectively(p0.01). 3) Coronary flow reserve(CFR) was significantly lower in significant coronary stenotic patients compared to insignificant stenotic patients(1.8 vs 3.6, P<0.01). CONCLUSION: Coronary flow velocity measurement by Doppler dipped guidewire gave us physiologic information. We think it could be used as an important tool to assess the significance of the intermediate coronary narrowings and the effect of conorary angioplasty.

Intravascular Ultrasound Assessment of the Coronary Intervention

BACKGROUND: Coronary arterigraphy has been used as a tool to assess the degree of coronary artery narrowing and the result of balloon angioplasty, which frequently underestimates the degree of atherosclerosis. Intravascular ultrasound(IVUS) can give more delicate information about plaque morphology and the result of coronary intervention. We compared qualitaive and quantitative measurement between IVUS and coronary angiography after coronary intervention. METHODS: We used 30 or 20 MHz intravascular ultrasound catheter which was connected to Hewlett Packard Sonos 1500 Intravasscular equiment in 5 coronary balloon angiopasty and 3 Palmaz-Schatz stent implantation cases. Sites of intervention were at the left anterior descending coronary artery in 7 patients and at the left circumflex artery in one patient. Quantitative coronary angiography(QCA) was done by CAAS II system. We measured referenc diameter(RD), minimal lumen diamter(MLD), Lumen and vessel cross sectional areas(LCSA,VCSA) obstraction area(OA) and plaque area(PA) and also analysed plaque morphology. RESULTS: 1) IVUS is more sensitive in the detection of eccentricity, Calcification and dissection. 2) Before intervention, the mean reference diameter was 2.87+/-0.42mm,3.07+/-0.39mm,% diameter stenosis was 52.4+/-11.6%,65.3+/-9.22% and MLD was 1.32+/-0.24mm, 1.07+/-0.23mm in IVUS and QCA, respectively, which were no statistical significance between these parameters(p>0.05). After intervention, MLD and OA increased significantly(p0.05). Plaque area measured by IVUS decreased from 9.84 to 7.26mm2 without statistical significance(p>0.05). 3) There was a good correlation in the measurement of the reference segments before intervention but this correlation was much lower after intervention in the reference and stenosis segments between 2 methods(r=0.8723 vs 0.6538, p<0.01). CONCLUSION: IVUS is considered as a sensitive tool in the detection of calcification, eccentricity and dissection and in evaluationg the results of the coronary intervention.

A Case of the Thrombi in Left Atrial Appendage Confirmed by Transesophageal Echocardiography(TEE) in A Patient with Acute Myocardial Infarction Accompanied by Cerebral Infarction

Contrary to ventricular mural thrombi, left atrial appendage thrombi are extremely rare in cerebral infarction correlated with acute myocardial infarction but they can be easily detected by transesophageal echocardiography(TEE). We expierienced a case of cerebral infarction which was suspected to be caused from the thrombi in left atrial appendage in a patient with acute myocardial infarction. The cerebral infarction was developed 2 days after myocardial infarction had been occurred and any source of the thrombi could not be detected except in left atrial appendage. The diagnosis was established by TEE and also aided by transthoracic echocardiography, brain computed tomography.