Slow Coronary Flow is Related to Increased Carotid Intima-Media Thickness but Not Pulse Wave Velocity

BACKGROUND AND OBJECTIVES: Slow coronary flow (SCF) is characterized by delayed contrast dye opacification without significant stenosis of epicardial coronary arteries. However, the pathophysiology and clinical implications of SCF are not fully understood. Some reports have suggested that SCF might be caused by atherosclerosis in the coronary artery microvasculature. Measuring carotid intima-media thickness (IMT) and pulse wave velocity (PWV), which are non-invasive and simple diagnostic tools, was developed to detect subclinical atherosclerosis. Thus, we determined IMT and PWV, and their possible relationship in a SCF group and a normal coronary flow (NCF) group of patients. SUBJECTS AND METHODS: We included 101 patients who complained of chest pain but had a normal coronary angiogram. Thrombolysis in Myocardial Infarction frame count (TIMI frame count, TFC) was evaluated in the left and right coronary arteries. We defined SCF as a TFC of more than 25. Carotid IMT was measured by ultrasonography in both common carotid arteries. PWV was calculated from pulse transit time between the brachial and ankle arteries. RESULTS: Fifteen patients were included in the SCF group and 86 patients in the NCF group. Male patients (n=11, 73.3%) were significantly more common in the SCF group than in the NCF group (n=37, 43.0%, p<0.05). The TFC of the SCF and NCF groups were 28.8+/-3.5 and 15.7+/-4.5, respectively. The carotid IMT in the SCF group increased significantly compared to that in the NCF group (1.2+/-0.3 mm vs. 0.8+/-0.1 mm, p<0.01). However, no significant difference in PWV was observed between the two groups. CONCLUSION: SCF may reflect early atherosclerotic changes in the coronary artery microvasculature.

Carotid Intima-Media Thickness and Plaque as a Predictor for Ischemic Etiology in Patients With Severe Left Ventricular Systolic Dysfunction

BACKGROUND AND OBJECTIVES: Coronary artery disease (CAD) is a major cause of heart failure associated with left ventricular systolic dysfunction (LVSD). The prognosis of LVSD is significantly influenced by the etiology of heart failure and therefore, differentiation of significant CAD from other etiologies is important. Carotid intima-media thickness (IMT) and plaque are useful predictors for cardiovascular events, including stroke and CAD. The purpose of this study was to evaluate the predictive value of carotid IMT and plaque for the diagnosis of CAD in LVSD patients. SUBJECTS AND METHODS: Seventy-three (n= 73, 47 male, 67.6+/-12.4 years) patients hospitalized for heart failure with severe LVSD were retrospectively enrolled. The severity of CAD was analyzed by the Duke Jeopardy Score system, and carotid IMT and plaque were measured according to the Mannheim Carotid IMT Consensus. RESULTS: Significant CAD was found in 41 patients (56.1%, CAD group) on coronary angiography. Mean common carotid artery (CCA) IMT (0.74+/-0.05 mm vs. 1.04+/-0.04 mm, p<0.01) was significantly higher in the CAD group. Plaque in CCA (6.25% vs. 19.5%, p<0.01) and plaque in bulb (25.0% vs. 60.9%, p<0.001) were significantly higher in the CAD group. Mean CCA IMT {odds ratio (OR) 2.61, 95% confidence interval (CI) 1.134-4.469, p<0.01} and plaque in bulb (OR 4.69, 95% CI 1.702-12.965, p<0.01) were significant predictors for the diagnosis of CAD according to multivariate logistic regression analysis. CONCLUSION: In patients with severe LVSD, mean CCA IMT and bulb plaque can be useful additional predictors for the diagnosis of CAD.

Impact of Pulmonary Hypertension on the Regional Right Ventricular Strain

BACKGROUND AND OBJECTIVES: Evaluation of right ventricular dysfunction in patients with pulmonary hypertension is useful for clinical management and it has prognostic implications. The purpose of this study was to evaluate the impact of pulmonary hypertension on the regional strain of the right ventricle and to assess the correlation between pulmonary arterial (PA) pressure and right ventricular (RV) strain. SUBJECTS AND METHODS: A total of fiftyone patients with chronic obstructive lung disease were classified into two groups on the basis of the presence of normal PA pressure (group I, PA pressure<35 mmHg, n=22) or high PA pressure (group II, PA pressure(35 mmHg, n=29), as estimated by the peak tricuspid regurgitation velocity on Doppler echocardiography. The left ventricular (LV) ejection fraction and RV fractional area change were assessed by conventional echocardiography, and the strain values were obtained from the RV, the LV free wall and the septum. RESULTS: The baseline characteristics were similar in both groups except for the peak PA pressure (group I: 30.2+/-3.9 mmHg, group II: 44.4+/-7.5 mmHg, p<0.00001). Group II had statistically reduced basal RV strain (-%) (20.3+/-7.1) compared to group I (24.1+/-6.7, p=0.033). The basal RV strain correlated with the PA pressure (r2=0.269, p=0.004). CONCLUSION: RV strain could determine regional RV dysfunction in patients with pulmonary hypertension.

A case of hyperthyroidism presented as diabetic ketoacidosis / 대한내과학회지

Diabetic ketoacidosis is an acute complication of diabetic mellitus. The most common triggering factors are infection, insulin therapy omission and the onset of the disease, but if these are excluded, other less frequent etiologic factors must be ruled out. We report a case of 22-year-old woman with Graves' disease presented as diabetic ketoacidosis. She was diagnosed type 1 diabetes mellitus at 13 years old and continually has been treated with insulin therapy until now. She typically showed tachycardia at rest in spite of correction of metabolic acidosis. Hyperthyroidism worsens glycemic control in diabetic patients and may precipitate diabetic ketoacidosis. Hyperthyroidism always should be investigated in diabetic patients presenting diabetic ketoacidosis without obvious triggering factors.

Plasma Adiponectin and Insulin Resistance in Korean Type 2 Diabetes Mellitus

Insulin resistance, which implies impairment of insulin signaling in the target tissues, is a common cause of type 2 diabetes. Adipose tissue plays an important role in insulin resistance through the dysregulated production and secretion of adipose-derived proteins, including tumor necrosis factor-alpha, plasminogen activator inhibitor-1, leptin, resistin, angiotensinogen, and adiponectin. Adiponectin was estimated to be a protective adipocytokine against atherosclerosis, and also to have an anti-inflammatory effect. In this study, the relationship between fasting plasma adiponectin concentration and adiposity, body composition, insulin sensitivity (ITT, HOMAIR, QUICK), lipid profile, fasting insulin concentration were examined in Korean type 2 diabetes. The difference in the adiponectin concentrations was also examined in diabetic and non-diabetic subjects, with adjustment for gender, age and body mass index. 102 type 2 diabetics and 50 controls were examined. After a 12-h overnight fast, all subjects underwent a 75gram oral glucose tolerance test. Baseline blood samples were drawn for the determinations of fasting plasma glucose, insulin, adiponectin, total cholesterol, triglyceride, LDL-cholesterol, and HDL-cholesterol. The body composition was estimated using a bioelectric impedance analyzer (Inbody 2.0). The insulin sensitivity was estimated using the insulin tolerance test (ITT), HOMAIR and QUICK methods. In the diabetic group, the fasting adiponectin concentrations were significantly lower in men than in women. They were negatively correlated with BMI (r=-0.453), hip circumference (r=-0.341), fasting glucose concentrations (r=-0.277) and HOMAIR (r=-0.233). In addition, they were positively correlated with systolic blood pressure (r=0.321) and HDL-cholesterol (r= 0.291). The systolic blood pressure and HDL-cholesterol were found to be independent variables, from a multiple logistic regression analysis, which influenced the adiponectin concentration. Compared with the non-diabetic group, the adiponectin concentrations were significantly lower in the diabetic group, with the exception of obese males. In conclusion, the plasma adiponectin concentrations were closely related to the insulin resistance parameters in Korean type 2 diabetic patients.

Effects of Carvedilol on Left Ventricular Function in Elderly Patients with Congestive Heart Failure

BACKGROUND AND OBJECTIVES: Neurohormonal compensation plays an important role on the pathophysiologic aspects of congestive heart failure (CHF). There is recent clinical evidence that beta blocker is beneficial in selected patients. However, there is little information regarding the effect of beta blocker on elderly patients. MATERIALS AND METHODS: 26 patients of CHF under stable condition by conventional management were selected and were divided into two age subgroup. Group 1 were more than 65 years (n=12) and group 2 were less than 65 years (n=14). From 12.5 to 25 mg/day of carvedilol was given according to the clinical condition. The left ventricular end diastolic dimension (LVEDD), left ventricular end systolic dimension (LVESD), left ventricular volume index (LVVI), ejection fraction (LVEF), E/A ratio and E wave deceleration time (EwDT) of mitral inflow doppler velocity were measured by echocardiographic examination before and 3 months after carvedilol trial. Six-minute walk distance were also measured. RESULTS: Between before and after carvedilol treatment, there were significant decrease of LVVI and sign-ificant increase of EF in group I and group II. The EwDT and 6 minute walk distance of both group were also increased significantly after carvedilol trial. The delta EF of group I is smaller than group II (4.1+/-5.7 vs 9.7+/-10.0, p<0.05). CONCLUSION: When compared to younger patients with CHF, the efficacy of carvedilol on LV function in aged patients was evident. Improved clinical conditions would be expected by using carvedilol in elderly patients with CHF.

Second Harmonic Imaging Myocardial Contrast 2D Echocardiography before and after Left Anterior Descending Coronary Artery Ligation

BACKGROUND: Although myocardial contrast 2D echocardiography is a good method to diagnose and evaluate myocardial ischemia and reperfusion, it has required intracoronary or intra aortic root injection of contrast agent and furthemore, the degree of myocardial contrast produced is small. Second harmonic imaging which is based on the non linear emission of harmonics by resonant microbubble in the ultrasound field improves the ultrasound contrast single to noise ratio. METHODS: We measure the videointensity of interventricular septum(IVS) and lateral wall(LW) of second harmonic imaging myocardial contrast 2D echocardiography before and after LV injection of Levovist(300mg/ml, 0.4ml/Kg) in both pre and post left anterior descending coronary artery(LAD) ligation in 7 open chest pigs. RESULTS: 1) The mean(+/-SD) pre LAD ligation videointensity is significantly greater with after contrast than before contrast(IVS : 111.1+/-33.9 vs 31.1+/-7.6 ; p=0.00046, LW : 120.5+/-21.5 vs 42.2+/-10.0 ; p=0.00006). The post LAD ligation videointensity is also significantly greater with after contrast than before contrast(IVS : 62.8+/-24.6 vs 35.6+/-15.1 ; p=0.00379, LW : 129.9+/-10.9 vs 48.7+/-21.1 ; p=0.00006). 2) The videointensity of IVS is significantly greater with after contrast than before contrast in both pre and post LAD ligation(62.8+/-24.6 vs 111.1+/-33.9 ; p=0.0031). The post LAD ligation videointensity of LW after contrast is not different from that of pre LAD ligation(129.9+/-10.9 vs 120.5+/-21.5 ; p=0.1037). 3) The post LAD ligation videointensity increase of IVS is lower than pre LAD ligantion videointensity increase(27.2+/-18.3 vs 79.9+/-35.0 ; p=0.0006). But the videointensity increase of LW is not different between pre and post LAD ligation(78.2+/-23.4 vs 81.2+/-24.5 ; p=0.3778). CONCLUSION: These findings indicate that the myocardial blood flow and its decrease due to LAD ligation can be evaluated accurately by second harmonic imaging myocardial contrast 2D echocardiography.

Effects of vanadate on vascular contractility and membrane potential in the rabbit aorta

Isolated rabbit aortic ring with intact endothelial cell preparations precontracted with NE (10(-7) M) were relaxed by vanadate in a dose dependent manner (from 0.2 to 2 mM). Application of vanadate and ACh during the tonic phase of high K+(100 mM)-induced contraction showed a slight relaxation in contrast to that in NE-induced contraction, but sodium nitroprusside (10 microM) more effectively relaxed the aortic ring preparations in high K+ contraction than that of vanadate. Vanadate-induced relaxation in NE-contracted aortic rings was reversed by application of BaCl2 (50 microM) or glibenclamide (10 microM). Furthermore, Vanadate hyperpolarized membrane potential of smooth muscle cells in endothelium-intact aortic strips and this effect was abolished by application of glibenclamide. The above results suggest that vanadate release EDHF (Endothelium-Derived Hyperpolarizing Factor), in addition to EDRF (Endothelium-Derived Relaxing Factor) from endothelial cell. This EDHF hyperpolarize the smooth muscle cell membrane potential via opening of the ATP-sensitive K+ channel and close a voltage dependent Ca++ channel. So it is suggested that the vanadate-induced relaxation of rabbit thoracic aortic rings may be due to the combined effects of EDRF and EDHF.

The Effect of Antihypertensive Therapy on Left Ventricular Mass in Hypertensive Patients

BACKGROUND: Hypertension is the major risk factor for cardiovascular disease. The increased left ventricular mass has been recognized as an independent predictor of morbidity and mortality in hypertensive patients. The assessment of the regression of left ventricular(LV) mass after antihypertensive therapy offers prognostic information. 2D echocardiography has proved a sensitive tool for the detection of the change of LV mass. METHOD: LV mass and LV mass index were measured by area-length method of 2D echocardiography in 26 hypertensive patients and 10 normal control to evaluate the effect of betablocker(group I, n=16) and angiotensin converting enzyme(ACE) inhibitor(group II, n=10) on the regression of LV mass. RESULT: There was a significant increase of LV mass and LV mass index in the hypertensive patients(199.0+/-37.7gm, 119.2+/-21.2gm/m2) compaired to the control(129.7+/-11.7gm, 87.4+/-8.8gm/m2)(p<0.01, p<0.01). After 13.1 week treatment, LV mass was significantly decreased in group I(200.9+/-35.3gm vs 164.7+/-25.4gm)(p<0.01) and group II(195.9+/-43.3gm vs 152.4+/-27.1gm)(p<0.01). The LV mass index was also significantly decreased in group I(120.3+/-20.7gm/m2 vs 98.8+/-15.5gm/m2)(p<0.01) and group II(117.5+/-22.9gm/m2 vs 91.5+/-13.6gm/m2)(p<0.01). CONCLUSION: This results showed that LV mass can be reduced in hypertensive patients who receive beta blocker and ACE inhibitor. The effect of antihypertensive therapy on LV mass should be considered in treatment of the hypertensive patients who had hypertrophied LV.

Clinical Followed-Up after Percutaneous Transluminal Coronary Angioplasty (PTCA) in Patients with Angina Pectoris

In the 4 years from June 1983 to July 1987, PTCA was performed in 104 patients with coronary artery disease at Severance Hospital, Fifty-seven of 61 patients after successful PTCA in non infarct-related artery, underwent follow-up from 1 to 42 months (mean 11 months) after successful PTCA. Degree of stenosis before PTCA was 83.1+/-9.8% and after 30.2+/-10.9%, Twenty-four of them was performed followed coronary angiogram, and so reangiography rate was 42.1%. The symptomatic recurrence rate after first PTCA was 49.1% (n=28). Angiographic restenosisi rate after first PTCA was 28.1%(n=16). Sixteen(88.9%) of 18 patients who was performed follow-up reangiogram due to symptomatic recurrence showed angiographic retenosis. Patients who received successful second angioplasty due to restenosis (n=11), had a symptomatic recurrence rate of 63.6%(n=7). all symptomatic recurrences developed within 1 to 4 months (mean 50.9+/-21.5 days)after PTCA. Despite uneven attempt rates in patients undergoing PTCA to the left anterior descending artery (LAD), right coronary artery(RCA) and left circumflex, restenosis rates wer 28% (13/47) in LAD and 10% (1/10) in RCA after first PTCA. Two of the patients with second retenosis after repeat PTCA had taken 3rd PTCA, one of them had a symptomatic recurrence within 1 month after 3rd PTCA. PTCA is an effective and relatively safe therapeutic procedure in selected patients with coronary artery disease, but restenosis after PTCA is a critical factor limiting the overall usefullness.

A Study on Graft Angiography and Patency after Coronary Artery Bypass Graft

Surgical revascularization is very effective for the relief of chest pain, improvement of exercise tolerance and ventricular performance in certain ischemic heart diseases. Bypass graft angiography and native coronary angiography after coronary artery bypass graft(CABG) were required for the evaluation of graft patency, progression of the native coronary artery disease and to predict the prognosis of the patients after CABG. The cases included in this study involved 15 patients who underwent selective bypass graft angiography among 102 CABG cases. Thirty eight sites were bypassed by saphenous vein and two sites by internal mammary artery. The results were as follows: 1) The overall patency rate of the saphenous vein bypass graft was 76.3% and the two sites of the internal mammary artery bypass graft were both patent. 2) The patency rate of direct anastomosis was 86.2% and of sequential anastomosis, 44.4%. 3) In eight patients who underwent native coronary angiography, five patients showed progression of grafted coronary artery disease. Among them, two patients had accompanying progression of coronary artery disease in non-grafted vessels. 4) Follow up treadmill test performed in six patients showed improvement of exercise tolerance in all patients. 5) There was some increase in the ejection fraction of the left ventricle after CABG in six patients who received follow up left ventriculography.

An Echocardiographic Study of Left Ventricular Functional Change in Pure Aortic Regurgitation Patients after Aortic Valve Replacement after Aortic Valve Replacement

Twenty-one patients undergoing aortic valve replacement for pure aoritic regurgitation were studied retrospectively to evaluate the left ventricular function and internal dimension change before, 1-6 weeks(early postoperative) and 2-36 months after(late postoperative) aortic valve replacement by serial echocardiography. Postoperatively, NYHA function class improved remarkably (from 3.3+/-0.6 to 1.4+/-0.7). Early postoperatively, left ventricular end-diastolic dimension (EDD), left ventricular end-systolic dimension(ESD), left ventricular fractional shortenting(FS) significantly decreased in all patients(7.6+/-1.2cm vs 5.8+/-1.5cm P<0.001, 5.5+/-1.3cm vs 4.7+/-1.3cm P<0.001, 39+/-12% vs20+/-8% P<0.001 respectively). Interventricular septum thickness(IVS) and posterior wall thickness (PW) were slightly thickened before(1.4+/-0.3cm, 1.3+/-0.3cm respectively) and in the early postoperative period (1.3+/-0.4cm, 1.3+/-0.3cm respectively) without significant interval change. Late postoperatively, EDD and ESD decreased significantly (7.8+/-1.2cm vs 5.1+/-0.8cm P<0.01, 5.1+/-1.1cm vs 3.4+/-0.8cm P<0.001. respectively), and FS increased significantly (25+/-9% vs 34+/-9%, P<0.05). Among 3 patients of so called high risk group mentioned by Henry(22,33), ESD and FS improved to normal range in 2 patients, and ESD decreased to 4.4cm and FS increased to 33% in the other one. EDD and ESD decreased significantly in both group I(preoperative ESD<5.5cm) and group II(preoperative ESD<5.5cm), without no decrement difference between two groups, and there was a significant difference of FS decrement between group I and group II at early postoperative period. Preoperative ESD correlated highly with the early postoperative EDD(r=0.89) and ESD(r=0.87) with statistical significance, and moderately high with late postoperative EDD(r=0.45), ESD(r=0.50) and FS(r=0.42) without statistical signiticance. We concluded that there was significant improvement in left ventricular function in pure aortic regurgitation patients postoperatively. Preoperative left ventricular and systolic dimension above 5.5cm and fractional shortenting below 25% are not so reliabel index of poor postoperative prognosis.

Left Main Coronary Artery Disease:Comparison of Clinical and Hemodynamic Findings in Patients with and without Left Main Coronary Artery Disease

Twenty-five patients(6.3% of 400 cases with significant coronary disease) with 50 percent or greater diameter obstruction in the left main coronary artery(Group 1) were compared with 187 patients with at least two vessel disease without left main involvement (Group 2) in clinical, arteriographic and hemodynamic findings. The ratio of male to female was 4:1 in Group 1 and 4.8:1 in Group 2, and the average was 51.0+/-11.6 and 55.6+/-8.6 years respectively. Twenty-two patients(88%)had moderate to server angina pectoris important risk factors, cigarette smoking was present in 10 patients(40%), hypertension in 7 (28%), diabetes mellitus in 7 (28%), and hypercholesterolemia(over 220 mg%) was in 4 (16%) out of 25 patients(Group 1). There were no difference between patients with Group1 and Group 2 in sex, clinical manifestation, duration of chest pain, treadmill test, major risk factors and the average resting left ventricular end-diastolic pressure. But the average age of Group 1 was slightly lower than that of Group 2(P<0.05). Image intensification fluoroscopy revealed clacification in the left main coronary artery in 5 patients. Sixteen patients(64%)had significant obstructive disease in the other coronary arteries. Contraction abnormalities in the left ventricullgram were present in 7(28%). The left ventricular end-diastolic pressure wea greater than 12mmHg in 13 of the 23 patients(56.5%). The average resting left ventricular end-diastolic pressure was 12.0+/-5.2mmHg. No significant comlplications were associated with cardiac catheterization. Three of 11 patients who underwent aocoronary bypass surgery died. One patients underwent PTCA, and the remaining 13 patients were treated medically.