Prevalence and Clinical Outcomes of Asymptomatic Carotid Artery Stenosis in Patients Undergoing Concurrent Coronary and Carotid Angiography

PURPOSE: The prevalence and clinical outcomes of asymptomatic carotid artery stenosis (CAS) in patients with coronary artery disease (CAD) have not been thoroughly studied. We examined the prevalence and predictors of asymptomatic CAS detected by carotid angiography and determined the impact of concomitant CAS on prognosis in patients undergoing coronary angiography (CAG) due to CAD. MATERIALS AND METHODS: Between January 2013 and July 2015, 395 patients who underwent carotid digital subtraction angiography to screen for CAS during CAG were analyzed. The presence of CAS was defined as angiographically significant stenosis (≥50%). Major adverse cardiac and cerebrovascular event (MACCE) rates were compared between patients with and without CAS. MACCEs included a composite of cardiac death, cerebrovascular death, acute myocardial infarction, and stroke. RESULTS: Of the 395 patients, 101 (25.5%) patients had significant CAS. The independent predictors of CAS were age, male sex, hypertension, diabetes, and multi-vessel disease. In patients with CAD, the presence of CAS was as an independent predictor for MACCEs after adjusting for confounding factors (hazard ratio 2.47, 95% confidence interval 1.16–5.24, p=0.018). CONCLUSION: Asymptomatic CAS was documented in up to 25% of patients with CAD. The presence of CAS in patients with CAD was associated with a higher rate of MACCEs. Therefore, detection of CAS by carotid angiography during CAG may be important for risk stratification for CAD patients, particularly those with multi-vessel disease.

Rupture of Right Ventricular Free Wall Following Ventricular Septal Rupture in Takotsubo Cardiomyopathy with Right Ventricular Involvement

Most patients diagnosed with takotsubo cardiomyopathies are expected to almost completely recover, and their prognosis is excellent. However, complications can occur in the acute phase. We present a case of a woman with takotsubo cardiomyopathy with right ventricular involvement who developed a rupture of the right ventricular free wall following ventricular septal rupture, as a consequence of an acute increase in right ventricular afterload by left-to-right shunt. Our case report illustrates that takotsubo cardiomyopathy can be life threatening in the acute phase. Ventricular septal rupture in biventricular takotsubo cardiomyopathy may be a harbinger of cardiac tamponade by right ventricular rupture.

Three-Dimensional Echocardiographic Views of Bicuspid Pulmonic Valve

No abstract available.

A Case of Primary Cardiac Lymphoma Mimicking Acute Coronary and Aortic Syndrome

Primary cardiac lymphoma (PCL) is a rare disorder, but the incidence is increasing and its clinical manifestations are various. We report a case of PCL, which mimics an acute coronary and aortic syndrome. A 51 year-old female was presented with chest pain radiating to the back. Her initial electrocardiogram revealed T wave inversion in the leads of V 5-6, II, III and aVF. Additionally, cardiac troponin-T was slightly elevated. Chest radiography showed marked mediastinal widening. Computed tomography scan showed a huge pericardial mass. The histopathologic findings of the mass were compatible with diffuse large B cell lymphoma. She died of refractory ventricular tachycardia, probably, due to an extensive infiltration of PCL to the myocardium.

A Case of Acute Total Obstruction of the Left Main Coronary Artery Presenting with Atypical Momentary Electrocardiogram Changes

Acute total obstruction of the left main coronary artery (LMCA) is a serious emergency condition requiring prompt diagnosis and treatment. Unless properly treated, it will likely progress to cardiogenic shock and a high mortality rate. We report a case of acute LMCA total obstruction presenting with atypical momentary electrocardiogram (ECG) changes including right bundle branch block with left axis deviation, and ST-segment elevation in aVR and aVL. We focus on the unusual ECG changes associated with LMCA obstruction which should be noted in order to ensure revascularization without delay, especially when this condition is accompanied by cardiogenic shock.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count

BACKGROUND AND OBJECTIVES: Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. SUBJECTS AND METHODS: Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. RESULTS: There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. CONCLUSION: A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count

BACKGROUND AND OBJECTIVES: Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. SUBJECTS AND METHODS: Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. RESULTS: There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. CONCLUSION: A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

Primary Cardiac Angiosarcoma Presenting With Cardiac Tamponade

Primary cardiac angiosarcoma is a very rare disease with a poor prognosis. We report a case of a patient with a primary cardiac angiosarcoma who presented with cardiac tamponade; the angiosarcoma was successfully resected surgically.

Primary Cardiac Lymphoma Presenting With Atrioventricular Block

Primary cardiac lymphomas (PCL) are extremely rare. Clinical manifestations may be variable and are attributed to location. Here, we report on a case of PCL presenting with atrioventricular (AV) block. A 55 year-old male had experienced chest discomfort with unexplained dyspnea and night sweating. His initial electrocardiogram (ECG) revealed a first degree AV block. Along with worsening chest discomfort and dyspnea, his ECG changed to show second degree AV block (Mobitz type I). Computed tomography (CT) scan showed a cardiac mass (about 7 cm) and biopsy was performed. Pathologic finding confirmed diffuse large B-cell lymphoma. The patient was treated with multi-drug combination chemotherapy (R-CHOP: Rituximab, cyclophoshamide, anthracycline, vincristine, and prednisone). After treatment, ECG changed to show normal sinus rhythm with complete remission on follow-up CT scan.

Early Detection of Perforation of the Right Ventricle by a Permanent Pacemaker Lead

Ventricular perforation is a rare complication of permanent cardiac pacemaker implantation. We report here on a 68-year-old woman with a dual chamber permanent pacemaker that had been implanted one month earlier, and she suffered cardiac perforation from the pacemaker lead. Frequent follow-up via12-lead surface electrocardiography and chest radiography and the proper work-up for pacemaker implantation are needed for detecting rare complications after pacemaker implantation.

Effectiveness of the Cardiac Rehabilitation on Exercise Capacity and Risk Factor in Coronary Artery Obstructive Disease

OBJECTIVE: To evaluate the effectiveness of cardiac rehabilitation (CR) program on the exercise capacity and secondary prevention in coronary artery obstructive disease (CAOD). METHOD: CR group of 48 CAOD patients had underwent regularly supervised exercise training for 6~8 weeks as well as home exercise continued for 1 year. CR group was advised to control their risk factors by nutrition counsel, abstaining from smoking and reducing their weight. Control group of 16 CAOD patients did not participate in the CR program. Two groups were evaluated for their exercise capacity and risk factors at baseline and after 1 year. RESULTS: CR group showed significantly higher maximal oxygen consumption, maximal rate pressure product and ratings of perceived exertion at stage 3 compared with control group (p<0.05). The number of risk factors per person after 1 year in both groups was significantly lower than baseline (p<0.05), but there was no significant difference between the two groups. CONCLUSION: CR program can improve the exercise capacity and level of risk factor in CAOD patients. Therefore, CR program is recommended for helping CAOD patients improve their functional capacity and reduce the possibility of recurrence.

Congestive heart failure: Tips for primary care physician

No abstract available.

Korean multicenter clinical trial of simvastatin ( KS-1 study ) / 대한내과학회지

The aim of this study was to investigate the efficacy of simvastatin to improved lipid profiles in hypercholesterolemic Korean patients. METHODS: From 25 hospitals in Korea, 478 hypercholesterolemic patients were enrolled from November 1996 to April 1998. The inclusion criteria was hypercholesterolemia over 240 mg/dl after diet therapy for 1 month or hypercholesterolemia over 220 mg/dl in patients with definite evidence of ischemic heart disease. Simvastatin 10mg was started and doubled up to 40mg if total cholesterol level remained higher than 200 mg/dl at monthly check. Of 478 subjects, 344 patients in whom study protocol was not violated were analyzed. RESULTS: Male to female ratio was 27:73 and 47% of the subjects were in 6th decade. Hypertension, coronary artery disease, and diabetes mellitus were present in 30, 10, and 4% of the subjects. Baseline lipid profile (mean of total cholesterol-LDL-HDL-triglyceride mg/dl) was 274-185-52-188. The dose of simvastatin for 3 months was 10/10/10mg in 61% of subjects, 10/20/20mg in 21%, 10/10/20mg in 7%, and 10/20/40mg in 12%. The change of total cholesterol level(before-4wk-8wk-12wk-withdrawal 4wk) was 274-209- 205-198-250, and the maximal reduction rate was 27%. The change of LDL-cholesterol was 185-123-116-110-159, with maximal reduction rate 39%. The change of HDL-cholesterol was 52-54-56-55-54, with maximal increase rate 9%. The change of tryglyceride was 188-161- 164-162-189, with maximal reduction rate 15%. The value before/after treatment of ApoA1, ApoB, and Lp(a) was 129/129, 138/83, and 9.3/10.7, respectively. The level of LDL-cholesterol at the end of treatment was below 100mg/dl in 36% of subjects, 100-130 in 45%, 130-160 in 16%, and over 160mg/dl in 4%. The reduction rate of LDL-cholesterol was different between subjects whose LDL decreased below 100 and those whose LDL did not decrease below 130mg/dl, which suggests the existence of the individual difference of responsiveness to simvastatin. There were only 3 subjects (0.9%) who showed increase of liver enzyme over 3 times as the upper normal limit. Conclusion: Simvastatin is effective in improving lipid profiles in hypercholesterolemic Korean patients without serious side effects.

Korean multicenter clinical trial of simvastatin ( KS-1 study ) / 대한내과학회지

The aim of this study was to investigate the efficacy of simvastatin to improved lipid profiles in hypercholesterolemic Korean patients. METHODS: From 25 hospitals in Korea, 478 hypercholesterolemic patients were enrolled from November 1996 to April 1998. The inclusion criteria was hypercholesterolemia over 240 mg/dl after diet therapy for 1 month or hypercholesterolemia over 220 mg/dl in patients with definite evidence of ischemic heart disease. Simvastatin 10mg was started and doubled up to 40mg if total cholesterol level remained higher than 200 mg/dl at monthly check. Of 478 subjects, 344 patients in whom study protocol was not violated were analyzed. RESULTS: Male to female ratio was 27:73 and 47% of the subjects were in 6th decade. Hypertension, coronary artery disease, and diabetes mellitus were present in 30, 10, and 4% of the subjects. Baseline lipid profile (mean of total cholesterol-LDL-HDL-triglyceride mg/dl) was 274-185-52-188. The dose of simvastatin for 3 months was 10/10/10mg in 61% of subjects, 10/20/20mg in 21%, 10/10/20mg in 7%, and 10/20/40mg in 12%. The change of total cholesterol level(before-4wk-8wk-12wk-withdrawal 4wk) was 274-209- 205-198-250, and the maximal reduction rate was 27%. The change of LDL-cholesterol was 185-123-116-110-159, with maximal reduction rate 39%. The change of HDL-cholesterol was 52-54-56-55-54, with maximal increase rate 9%. The change of tryglyceride was 188-161- 164-162-189, with maximal reduction rate 15%. The value before/after treatment of ApoA1, ApoB, and Lp(a) was 129/129, 138/83, and 9.3/10.7, respectively. The level of LDL-cholesterol at the end of treatment was below 100mg/dl in 36% of subjects, 100-130 in 45%, 130-160 in 16%, and over 160mg/dl in 4%. The reduction rate of LDL-cholesterol was different between subjects whose LDL decreased below 100 and those whose LDL did not decrease below 130mg/dl, which suggests the existence of the individual difference of responsiveness to simvastatin. There were only 3 subjects (0.9%) who showed increase of liver enzyme over 3 times as the upper normal limit. Conclusion: Simvastatin is effective in improving lipid profiles in hypercholesterolemic Korean patients without serious side effects.

Assessment of the Difference of Left Ventricular Mass by Echocardiography between Korean and Whites

No abstract available.

Clinical Efficacy and Safety of Gepefrin in the Treatment of Hypotension

BACKGROUND: The proper management of the patients with hypotention remains a difficult clinical problem. This study was designed to evaluate the efficacy and safety of gepefrin in the treament of symptomatic hypotensive patients in outpatient clinic of university hospital. METHODS: Thirty milligrams of Gepefrin was given twice daily for 4 weeks in 30 patients with hypotension(6 males, 24 females ; 23-60 years of age). Blood pressure, heart rate, subjective symptoms and side effects were checked before medication and at the end of 1st, 2nd, 3rd, 4th week of medication. RESULTS: 1) Grpefrin increased sitting systolic blood pressure significantly(p<0.05) by the end of 1st week and thereafter. 2) Hypotensive symptoms were improved in 76% of hypotensive patients and overall rate of usefulness was 70%. 3) Heart rate did not change significantly. 4) One patient complained of loose bowel movement and another one, of anorexia among 30 study patients and all laboratory parameters were within normal limits before and after drug treatment, thus the rate of safety was 93%. CONCLUSION: Results from this study suggests that gepefrin 60mg daily increases the blood pressure mildly and improves the symptoms moderately in symptomatic hypotensive patients.

Stress Scintigraphy in Patients with Left Bundle Branch Block

BACKGROUND: To assess the valve of stress scintigraphy in patients with left bundle branch block(LBBB), patients with LBBB underwent stress scintigraphy, coronary angiography and left ventriculography. METHOD: Exercise(n=12) or pharmacology(n=1) scintigraphy, coronary angiography and left ventriculography were performed in 13 patients(12 men and 1 woman, aged 53-81 years) with LBBB. RESULT: 1) All patients had anteroseptal defects on scintigram. 2) Among these, 3 patients(23%) did not have any significant coronary artery stenosis on coronary angiogram. CONCLUSION: Stress scintigraphic change may not help much in the detection of coronary artery disease(CAD) in patients with LBBB.

The Evaluation of Coronary Artery Stenosis by Exercise-Induced Negative U Wave

BACKGROUND: Negative U wave is frequent maker of systemic hypertension, aortic or mitral regurgitation and myocardial ischemia. This study was undertaken to determine the diagnostic significance of exercise-induced negative U wave in coronary artery stenosis. METHOD: 72 patients(46 men and 26 women ; 24~66 years of age) with chest pain were analysed with exercised-induced negative U wave and coronary angiographic finding. RESULT: Exercise-induced negative U wave was seen in 14 patients(19%). Among 14 patients with exercise-induced negative U wave, the predictive value of significant coronary artery stenosis(> or =75% stenosis of major coronary artery) was 71%, Exercise-induced negative U wave is more prevalent in patients with significant coronary artery stenosis(p<0.05). CONCLUSION: Exercise-induced negative U wave is a good marker of significant coronary artery stenosis.

Reproducibility of Ambulatory Electrocardiography

To evaluate the reproducibility of the Ambulatory Electrocardiography (AECG), we examined the consistency rates of premature beats between the baseline AECG's and the repeat AECG's in 23 patients who underwent AECG's times within 1 year. 12 patients were male and 11 patients were female. Their mean age was 48 years. (Range ; 20 years-75 years) The time interval between both AECG's was 1 month 20 days. (Range ; 1 day-9months) They did not take any antiarrhythmic druge during the observation period except 4 patients who were taking calcium channel blockers or beta receptor blockers for hypertensive heart disease or ischemic heart disease. The consistency rate of both frequency and complexity of ventricular premature beats was 52%. The consisency rate of both frequency and complexity of supraventicular premature beats was 35%. These consistency rates seemed to vary as the time interval between both AECG's differed. In the case of ventricular premature beats, the consistency rates of 1 day, 8 days and 5 months as the time interval were 100%, 38% and 14% respectively. In the case of supraventricular premature beats, the consistency rates were 50%, 25% and 29%. We concluded that the reproducility of the AECG was low and this reproducibility became lower as the time interval between both AECG's became longer and that hese facts had to be considered when the effect of the antiarrhythmic drugs was evaluated.

Effects of Pravastatin(Mevalotin(R)) on Hyperlipidemia

Effects of Pravastatin(Mevalotin(R)), a new HMG-CoA reductase inhibitor on the blood lipids were studied for the period of 3 months in 40 subjects with hypercholesterolemia more than 250mg/dl. Age of the subject was 50 years in average with range of 34 to 72 years. There were 22 cases of male and 18 cases of female. The cause of hyperlipidemia was not specified, but there were no case of liver, thyroid and renal disease. The 10mg of Preavastatin was given in devided doses in the morning and at bed time for 3 months. Serum LDL-cholesterol, total cholesterol, HDL-cholesterol, triglyceride and atherogenic index were measured before and after the medication in every month and following results were obtained. 1) Serum cholesterol decreased maximally at 2months after the medication with average decrease of LDL-cholesterol 79.8mg/dl(43%), serum total cholesterol 99.8mg/dl(34%) and the atherogenic index 3.0(45%). The decrease of total serum cholesterol was dependent on the pretreatment level. 2) The serum triglyceride decreased in average 81mg/dl(26%) in one month after the medication however the change was not statistically significant because of wide variation. 3) The HDL-cholesterol decreased in average 1.6mg/dl(4%) in one month and statistically significant. 4) The serum total cholesterol started to change in 3 days and tended to decrease with unstable variation up to the end of 2 weeks after the medication. In one month after cutting drug, there were slight increase of cholesterol but did not return to control value. 5) The significant effect of blood lipid lowering drug in non-specific hyperlipidemia should be evaluated when the changes are more than intra-individual variation of blood lipids. 6) There were only 2 cases of side effect with epigastric pain and fullness which subsided soon and there was no change in liver functions, serum creatinine and fasting blood sugar after the medication. In conclusion, the pravastatin is an excellent new lipid lowering drug with safety.