Valsartan 160 mg/Amlodipine 5 mg Combination Therapy versus Amlodipine 10 mg in Hypertensive Patients with Inadequate Response to Amlodipine 5 mg Monotherapy

BACKGROUND AND OBJECTIVES: When monotherapy is inadequate for blood pressure control, the next step is either to continue monotherapy in increased doses or to add another antihypertensive agent. However, direct comparison of double-dose monotherapy versus combination therapy has rarely been done. The objective of this study is to compare 10 mg of amlodipine with an amlodipine/valsartan 5/160 mg combination in patients whose blood pressure control is inadequate with amlodipine 5 mg. SUBJECTS AND METHODS: This study was conducted as a multicenter, open-label, randomized controlled trial. Men and women aged 20-80 who were diagnosed as having hypertension, who had been on amlodipine 5 mg monotherapy for at least 4 weeks, and whose daytime mean systolic blood pressure (SBP) ≥135 mmHg or diastolic blood pressure (DBP) ≥85 mmHg on 24-hour ambulatory blood pressure monitoring (ABPM) were randomized to amlodipine (A) 10 mg or amlodipine/valsartan (AV) 5/160 mg group. Follow-up 24-hour ABPM was done at 8 weeks after randomization. RESULTS: Baseline clinical characteristics did not differ between the 2 groups. Ambulatory blood pressure reduction was significantly greater in the AV group compared with the A group (daytime mean SBP change: -14±11 vs. -9±9 mmHg, p<0.001, 24-hour mean SBP change: -13±10 vs. -8±8 mmHg, p<0.0001). Drug-related adverse events also did not differ significantly (A:AV, 6.5 vs. 4.5%, p=0.56). CONCLUSION: Amlodipine/valsartan 5/160 mg combination was more efficacious than amlodipine 10 mg in hypertensive patients in whom monotherapy of amlodipine 5 mg had failed.

Peripheral Artery Disease in Korean Patients Undergoing Percutaneous Coronary Intervention: Prevalence and Association with Coronary Artery Disease Severity

Peripheral artery disease (PAD) is an important marker for the risk stratification of patients with coronary artery disease (CAD). We investigated the prevalence of PAD in patients undergoing percutaneous coronary intervention (PCI) with CAD and the relationship between ankle-brachial pressure index (ABPI) and CAD severity. A total of 711 patients undergoing PCI for CAD from August 2009 to August 2011 were enrolled. PAD diagnosis was made using the ABPI. The prevalence of PAD was 12.8%. In PAD patients, mean values of right and left ABPI were 0.71 +/- 0.15 and 0.73 +/- 0.15. Patients with PAD had a higher prevalence of left main coronary disease (14.3% vs 5.8%, P = 0.003), more frequently had multivessel lesions (74.9% vs 52.1%, P < 0.001) and had higher SYNTAX score (18.2 +/- 12.3 vs 13.1 +/- 8.26, P = 0.002). Using multivariate analysis, we determined that left main CAD (OR, 2.954; 95% CI, 1.418-6.152, P = 0.004) and multivessel CAD (OR, 2.321; 95% CI, 1.363-3.953, P = 0.002) were both independently associated with PAD. We recommend that ABPI-based PAD screening should be implemented in all patients undergoing PCI with CAD, especially in severe cases.

Simvastatin and Losartan Differentially and Synergistically Inhibit Atherosclerosis in Apolipoprotein E-/- Mice

BACKGROUND AND OBJECTIVES: Since statins and angiotensin receptor blockers are a frequently prescribed combination in patients with atherosclerotic cardiovascular diseases, we tested the interactive effects of simvastatin and losartan on atherosclerosis in apolipoprotein E (apoE)-/- mice. MATERIALS AND METHODS: Apolipoprotein E-/- mice were fed a high-fat, high-cholesterol (HFHC) diet for 12 weeks, with and without simvastatin (40 mg/kg) and/or losartan (20 mg/kg). The mice were divided into 5 groups and were fed as follows: regular chow (control diet, n=5), HFHC diet (n=6), HFHC diet with losartan (n=6), HFHC diet with simvastatin (n=6), and HFHC diet with both losartan and simvastatin (n=6). RESULTS: Losartan treatment in apoE-/- mice significantly decreased atherosclerotic lesion areas in whole aortic strips stained with Oil Red O. The plaque area measured at the aortic sinus level was reduced significantly by 17% (HFHC; 346830.9+/-52915.8 microm2 vs. HFHC plus losartan; 255965.3+/-74057.7 microm2, p<0.05) in the losartan-treated group. Simvastatin and simvastatin plus losartan treatments reduced macrophage infiltration into lesions by 33% (HFHC; 183575.6+/-43211.2 microm2 vs. HFHC plus simvastatin; 120556.0+/-39282.8 microm2, p<0.05) and 44% (HFHC; 183575.6+/-43211.2 microm2 vs. HFHC plus simvastatin and losartan; 103229.0+/-8473.3 microm2, p<0.001, respectively). In mice fed the HFHC diet alone, the smooth muscle cell layer in the aortic media was almost undetectable. In mice co-treated with losartan and simvastatin, the smooth muscle layer was more than 60% preserved (p<0.05). Given alone, losartan showed a slightly stronger effect than simvastatin; however, treatment with losartan plus simvastatin induced a greater inhibitory effect on atherosclerosis than either drug given alone. Serum lipid profiles did not differ significantly among the groups. CONCLUSION: Losartan displayed anti-atherosclerotic effects in apoE-/- mice that were equivalent to or greater than the effects of simvastatin. Combined treatment with these drugs had greater effect than either drug alone.

Identification of Vulnerable Plaque in a Stented Coronary Segment 17 Years after Implantation Using Optical Coherence Tomography

A patient presented with exertional chest pain two months prior to admission. Coronary angiography revealed a subocclusive stenosis within the boundaries of the stent. Optical coherence tomography showed remarkable intimal growth inside the stent, which demonstrated a heterogeneous appearance including low-intensity areas. These findings were congruent with the morphology of fibroatheroma in the native coronary artery and suggested that new atherosclerotic progression of the intima within the stent had occurred over 17 years following bare metal stent implantation. To the best of our knowledge, this is one of the most delayed instances of a bare metal stent restenosis described in the medical literature.

The Use of an Implantable Loop Recorder in Patients With Syncope of Unknown Origin

BACKGROUND AND OBJECTIVES: Possible mechanisms of syncope often remain unknown despite the performance of extensive cardiological and neurological tests. An implantable loop recorder (ILR) has been introduced to monitor the heart rhythm continuously over a year. We evaluated the diagnostic value of the use of the ILR for unexplained syncope. SUBJECTS AND METHODS: Between 2006 and 2007, an ILR was implanted in 9 patients (7 male, 2 female, mean age 55+/-17 years) where syncope remained unexplained after extensive diagnostic tests. We analyzed the recorded electrocardiogram signal in the memory of the ILR. RESULTS: During a follow-up period of 8.8+/-7.3 months, arrhythmia was detected in five patients. Two patients had a sinus pause and received a permanent pacemaker, and one patient had sustained ventricular tachycardia and fibrillation and received an implantable cardioverter defibrillator. One patient had micturition syncope with sinus pause and is waiting for permanent pacemaker implantation, and one patient had symptomatic paroxysmal atrial fibrillation and was administered anticoagulation therapy. Inappropriate auto-activations such as a pseudopause or a decreasing signal were also noted. CONCLUSION: ILR monitoring seems to be a useful diagnostic tool to identify the arrhythmic cause in patients with unexplained syncope.

The Feasibility of 5-French Transradial Coronary Intervention, as Compared with a 6-French Approach, for Treating Chronic Total Occlusion

BACKGROUND AND OBJECTIVES: Recent studies have shown that transradial coronary intervention (TRI) is feasible for percutaneous revascularization of chronic total occlusion (CTO). We investigated the feasibility and safety of using a 5-French catheter (5F) TRI for CTO and we compared it with that of using a 6F catheter TRI. SUBJECTS AND METHODS: One hundred fifteen patients (117 lesions) who underwent TRI for CTO (TIMI 0 or 1 for more than 2 months) were prospectively registered in this study from April 2002 to July 2004 (54 patients for the 5F and 61 patients for the 6F). The clinical, angiographic and procedural characteristics were evaluated and compared between the 2 groups. RESULTS: No major difference was noted for the clinical characteristics between the 2 groups. Coronary angiography showed a shorter occlusion length (5F: 8.8+/-7.6 mm, 6F: 14.7+/-12.7, p=0.008) and a higher incidence of the tapered type of entry morphology (5F: 74%, 6F: 56%, p=0.042) in the 5F group. A deep-seating technique was used more often in the 5F group (5F: 83%, 6F: 51%, p<0.001). The procedural success rate was similar between the 2 groups (5F: 82%, 6F: 86%, p<0.54). The most common cause of procedural failure for both groups was failure to pass the guidewire. The occlusion duration, lesion length and lesion angulation were the statistically significant predictors of procedural failure. No major procedural or local complication was noted. Minor hematoma occurred in 2 patients and no radial artery occlusion was noted. CONCLUSION: A 5F catheter TRI may be feasible and safe to use for a selected group of CTO lesions.

Pathophysiology of Atherosclerosis / 한양의대학술지

In humans, early lesions of atherosclerosis, fatty streaks, already begin to be observed from the twenties. In animals grown in nature, atherosclerosis is not known to exist and serum cholesterol levels in the animals are lower than 100mg/dL. Recent clinical trials suggest that if we lower the LDL cholesterol to below 40mg/dL, we can probably halt the progression of atherosclerosis. Atherosclerosis can either progress or regress according to the control of risk factors. If the risk factors are not well controlled, the pressure in the core can be increased and the cap weakens because of the infiltration of macrophages and foam cells instead of healthy smooth muscle cells and the matrix metalloprotenases secreted from these cells weakens the collagen. Acute coronary syndrome results when rupture or erosion occurs in the cap. Recently, atherosclerosis is understood as an inflammatory process, because the infiltrating cells, inflammatory cytokines and T-cells are very much similar to the other inflammatory lesions such as rheumatoid arthritis. Endothelial dysfunction, lipid oxidation and insulin resistance are also the main abnormal findings observed from the early stages of atherosclerosis. HMG Co-A reductase inhibitors can effectively prevent and regress atherosclerosis and is now very widely prescribed for these purposes.

Enhancement of Gene Delivery into Mouse Skeletal Muscle with Microbubble Destruction by Low-Frequency Ultrasound

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the value of microbubble destruction using low-frequency ultrasound for enhancing gene delivery to skeletal muscles of laboratory animals. MATERIALS AND METHODS: Lac-Z gene was injected into 21 mouse anterior tibialis muscles. Seven muscles received the gene only, and seven each received either 20-kHz ultrasound exposure or ultrasound-PESDA (perfluorocarbon-exposed sonicated albumin) destruction, respectively, following the injection; the extent of Lac-Z expression was then compared. Luciferase gene was injected into the muscles (N=80). The muscles were divided into two groups according to the mixture; in the first group saline was used as the mixture solute, with PESDA used in the second group. The groups were subdivided into two groups, one receiv 10 seconds of ultrasound at the injection site after injection, and the other that received no further intervention. Luciferase activities were measured and compared. RESULTS: The proportions of Lac-Z stained cells were 0, 5.7+/-1.2 and 7.7+/-1.7%, respectively, showing a significant stepwise increase microbubble destruction (p<0.05). Luciferase activities were as follows: Luciferase only (Group 1, N=17), 5727+/-2178 RLU/mg; luciferase plus PESDA (Group 2, N=17), 1170+/-470.7 RLU/mg; luciferase plus ultrasound (Group 3, N=17), 16480+/-5239 RLU/mg; and luciferase plus PESDA destruction (Group 4, N=17), 49910+/-16500 RLU/mg. The activity in group 4 was significantly higher than in group 1 (p<0.01), showing an 8.7-fold increase in gene delivery due to microbubble destruction. CONCLUSION: Microbubble destruction using low-frequency ultrasound is an efficient method for increasing the efficacy of direct gene delivery to skeletal muscles.

Effect of Different Conditioning on Perfluorocarbon Exposed Sonicated Dextrose Albumin Manufacture

BACKGROUND: Generation of perfluorocarbon-exposed sonicated dextrose albumin (PESDA), the custom-made contrast agent, is performed under certain conditions that have been proposed by its original developer. We doubted whether the known composition and manufacturing method of PESDA is ideal and if there is an optimal method of storing batches of PESDA for a significant time duration. METHODS: PESDA was generated with several different composition of ingredients (5% human serum albumin, 5% dextrose water, and perfluorocarbon (PFC) gas), where various ratios of each were used. Sonication was performed for various durations. After manufacturing, the mean size and concentration of the microbubbles were evaluated by hemocytometer and compared. The generated PESDA was stored for 48 hours under 4 degrees C or -20 degrees C and changes in size and concentration of microbubbles were evaluated and compared. RESULTS: The best concentration of microbubbles was found with a mix ratio of albumin: PFC: dextrose of 1:1:1 and sonication time of 90 sec. The microbubble concentration of the optimal PESDA was not different to that of the conventionally manufactured one (9.47+/-1.70 x 10(8) /mL vs. 8.34+/-0.87 x 10(8) /mL, p>0.05) but the mean microbubble size was significantly smaller (1.22+/-0.31 um vs. 1.66+/-0.32 um, p<0.01). After 48 hours, the concentration of microbubbles was reduced by 34+/-3% (p=NS) and 55+/-0.2% (p<0.05) and the size increased by 77+/-25% and 108+/-41% (p=NS in both) in the 4 degrees C -stored and -20 degrees C -stored PESDA, respectively. CONCLUSION: The optimal composition of PESDA ingredients is 1:1:1 for albumin, PFC, and dextrose water, and the best duration of sonication is 90 seconds. Refrigeration under 4 degrees C may be the best way for storage of PESDA for 48 hours.

Risk Factors and Predictors for the Progression of Carotid Atherosclerotic Stenosis in Korean Adults

BACKGROUND AND OBJECTIVES: The goals of this study were to investigate the prevalence and risk factors of carotid atherosclerotic stenosis and also the predictors for the progression of carotid atheroslcerotic stenosis in Korean adults. SUBJECTS AND METHODS: Carotid ultrasonography was performed for 22,782 adults who volunteered for a routine health check-up. Carotid atheroslcerotic stenosis was defined as a finding of at least one lesion of an intima-media thickness greater than 1.2 mm with atherosclerotic plaque. Among the 22,782 people, 4,077 persons underwent follow-up carotid ultrasonography at an average interval of 27.6 months. The past medical history and information on the cardiovascular risk factors were obtained from standardized questionnaires and the subjects' blood chemistry. RESULTS: Carotid atheroslcerotic stenosis was detected in 1,875 adults (8.2%) and it was significantly associated with a history of stroke, hypertension, heart disease, hyperlipidemia, higher HbA1C, older age, a wider pulse pressure, lower HDL-cholesterol and a large amount of smoking (p<0.05). In the subjects without history of stroke (22,444 persons), those with more than 5 risk factors showed a higher prevalence (36.8%) of carotid atherosclerotic stenosis than those with a history of stroke (29.0%). The independent predictors of stenosis progression were older age, male gender, hypertension, a large amount of smoking, a high LDL cholesterol level, a low HDL-cholesterol level and a high fibrinogen level (p<0.05). CONCLUSION: Carotid ultrasonographic screening for a population with these risk factors will lead to a more efficient screening process and our identification of the predictors of disease progression may help to design therapeutic trials for preventing the progression of carotid atherosclerotic stenosis.

Correlation Between Levels of N-terminal Pro-B-Type Natriuretic Peptide and Degrees of Heart Failure

BACKGROUND: The N-terminal fragment of pro Brain Natriuretic Peptide (NT-pro BNP) is a neuro-hormone synthesized in the cardiac ventricles in response to increased wall tension. The purpose of this study was to assess the correlation between the NT-pro BNP levels and the New York Heart Association function class (NYHA Fc) of dyspnea and echocardiographic findings for the patients who visited our cardiology departments. METHODS: From October, 2002 to April, 2003, serum NT-pro BNP levels were measured in 348 patients who visited the Samsung Medical Center and the Jong Koo Lee Heart Clinic. RESULTS: The NT-pro BNP levels were increased with the progression of NYHA Fc of dyspnea (p< 0.001 by ANOVA), the increase in the systolic left ventricular internal dimension (p< 0.05), and the decrease in the ejection fraction (p< 0.01). For the NYHA Fc I patients, the NT-pro BNP levels were positively correlated with age (p< 0.001) and left atrial size (p< 0.001). For the patients with ischemic heart disease, the NT-pro BNP levels were also positively correlated with the NYHA Fc (p< 0.001 by ANOVA). The NT-pro BNP levels were increased with the increase in the systolic (p< 0.001) and diastolic pressure (p=0.017), the left ventricular internal dimension as well as the decrease in the ejection fraction (p< 0.001). The area under the receiver operating characteristic (ROC) curve for the NT-pro BNP levels was 0.994 (95% confidence interval, 0.979-0.999), and the most reliable cut-off level for the NT-pro BNP was 293.6 pg/mL. CONCLUSION: The NT-pro BNP levels were positively correlated with the NYHA Fc of dyspnea and the systolic dysfunction for the patients who visited our cardiology departments. A 300 pg/mL value for the NT-pro BNP cut-off point appears to be a sensitive level to differentiate dyspnea originating from an ailing heart or not for the patients who visited our cardiology departments.

Study of Compliance to Antihypertensive Medication in Korean Hypertensive Patients Using Medication Event Monitoring System

BACKGROUND AND OBJECTIVES: Compliance to a prescribed antihypertensive regimen influences the management of hypertension in various steps, but studies on this issue are very rare in Korea. The medication event monitoring system (MEMS) is the gold standard in measurement of compliance, which is a special pill container, designed to electronically monitor drug intake patterns. Here, the authors investigated the compliance to the antihypertensive regimen in the cardiology practice of a tertiary care hospital using the MEMS. SUBJECTS AND METHODS: Monitoring using the MEMS was performed in 80 hypertensive patients during monotherapy. Demographic, clinical and psychological profiles were collected through a standardized questionnaire. The parameters used for compliance were the percentage of doses taken (PDT) and the percentage of doses taken correctly (PDTc), according to the prescribed regimen. RESULTS: The mean age of the patients and duration of monitoring were 53+/-10 years and 60+/-26 days, respectively. The median and range for the PDT and PDTc were 97% (88-100%) and 92% (80-97%), respectively. About 16% of patients showed relatively poor compliance (PDT<80%). Predicting factors for poor compliance were a recent history of self-discontinuation of drug treatment, not currently being on medication and a young age (p<0.05). Agreement between intuitive prediction by the physician and the actual compliance was closer to what would be expected by chance (kappa coefficient=-0.11). CONCLUSION: Although average compliance to the single drug antihypertensive regimen was relatively high in the cardiology practice of the tertiary care hospital in this study, a significant proportion of patients show low compliance. Special consideration should be given to patients with factors predictive of poor compliance. Investigation of compliances in other clinical settings is also warranted.

The Changes of Pacing Lead Impedance Over Time: Differences in the Atrial and Ventricular Leads

BACKGROUND AND OBJECTIVES: It has been suggested that lead impedance measurements with using real-time telemetry may offer a good estimation of the lead system integrity, and the serial measurement of the pacing lead impedance over time is a useful tool to monitor the pacing lead performance. However, there has been no consistent data about the changes of lead impedance over time. Therefore, we investigated the correlation of the direct lead impedance and the telemetered lead impedance, and the changes of lead impedance over time in both the atrial and ventricular leads. SUBJECTS AND METHODS: The direct and telemetered lead impedances were measured at the time of the initial implantation. One-hundred and five patients (mean age: 62.5+/-13.5 years, 47 males, 47 atrial leads and 105 ventricular leads) who were without lead failure for more than 4 years since the initial implantation were included in the study. Afterwards, the telemetered lead impedance was examined at 2-month and at 12-month after implantation and then annually for 4 years in all the patients at a pacemaker clinic. RESULTS: At the initial implantation, the direct lead impedance and the telemetered lead impedance were 470.2+/-12.2omega and 540.9+/-11.6omega, respectively, in the atrial leads (r=0.72, p<0.01) and 623.7+/-14.6omega and 717.1+/-17.3omega, respectively, in the ventricular leads (r=0.82, p<0.01). In the atrial leads, the mean telemetered lead impedance rose to 583.0+/-14.0omega (p<0.01 vs baseline) at 2 months and it stabilized thereafter (p=NS). In contrast, the mean lead impedance was decreased to 653.6+/-15.6omega (p<0.01 vs baseline) at the 2-month follow-up, and then it stabilized in the ventricular leads (p=NS). CONCLUSION: There was a good correlation between the direct and telemetered lead impedance, and there was a different tendency for the change of lead impedance during the lead maturation between the atrial and ventricular leads. The telemetered lead impedance was substantially stable since the 2 months after the implantation.

Correlation between levels of n-terminal pro-b-type natriuretic peptide and degrees of heart failure / 대한내과학회지

BACKGROUND: N-terminal fragment of pro Brain Natriuretic Peptide (NT-pro BNP) is a neuro-hormone synthesized from the cardiac ventricles in response to increased wall tension. The purpose of this study was to assess the correlation between NT-pro BNP levels and New York Heart Association function class (NYHA Fc) and echocardiographic findings in patients, who visited cardiology department. METHODS: From October, 2002 to April, 2003, serum NT-pro BNP levels were measured in 348 patients, who visited Samsung Medical Center and Jong Koo Lee Heart Clinic. RESULTS: NT-pro BNP levels were increased with the progression of NYHA Fc of dyspnea (p<0.001 by ANOVA) as well as with the increase in systolic left ventricular internal dimension (p<0.05) and the decrease in ejection fraction (p<0.01). In NYHA Fc I patients, NT-pro BNP levels were positively correlated with age (p<0.001) and left atrial size (p<0.001). In patients with ischemic heart disease, NT-pro BNP levels were also positively correlated with NYHA Fc (p<0.001 by ANOVA). NT-pro BNP levels were increased with the increase in systolic (p<0.001) and diastolic (p=0.017) left ventricular internal dimension as well as the decrease in ejection fraction (p<0.001). The area under the receiver operating characteristic (ROC) curve for NT-pro BNP levels was 0.994 (95% confidence interval, 0.979-0.999), and the most reliable cut-off level of NT-pro BNP was 293.6 pg/mL. CONCLUSION: NT-pro BNP levels were positively correlated with NYHA Fc of dyspnea and systolic dysfunction in patients, who visited cardiology department. A 300 pg/mL of NT-pro BNP level appears to be a sensitive level to differentiate dyspnea of heart origin or not in patients, who visited cardiology department.

Predictors of Sinus Rhythm Restoration after Maze Operation and Relationship between Pre- and Post-operative Left Atrial Volume

BACKGROUND AND OBJECTIVES: The Maze operation is known to be an effective measure for restoring sinus rhythm in patients with atrial fibrillation (AF). The purpose of this study was to identify the relationship of pre- and post-operative left atrial volume (LAV) and diameter (LAD) with successful restoration of sinus rhythm in the Maze operation. SUBJECTS AND METHODS: The subjects for this study were 28 patients who underwent open-heart surgery in conjunction with the Maze-III operation for chronic AF from October, 2002, to April, 2003. Electrocardiographic and transthoracic echocardiographic studies were done pre-operatively and three months post-operatively. LAV and LAD were assessed and corrected for body surface area (LAV index=LAV/BSA, LAD index=LAD/BSA). RESULTS: Sinus rhythm was restored and maintained in 22 of the 28 patients (78.6%). Between the group with successful restoration of sinus rhythm (Group A;n=22) and the group with unsuccessful restoration (Group B;n=6), there was no difference in age, gender, and NYHA functional class. The duration of AF in group A was significantly shorter than that of B (3.6+/-2.7 years versus 15.8+/-7.5 years, p=0.003). Group A and B did not show any difference in pre-operative left ventricular ejection fraction. However, pre-operative LAV index in group A was significantly smaller than that of group B (80.7+/-22.4 mL/m2 versus 118.1+/-42.5 mL/m2, p=0.048). In group A, the LAV index (80.7+/-22.4 mL/m2 versus 52.8+/-14.7 mL/m2, p<0.001) and LAD index (35.4+/-5.3 mm/m2 versus 31.7+/-4.7 mm/m2, p=0.001) decreased significantly three months after the operation. In group B, however, no significant changes are found in the LAV index (118.1+/-42.5 mL/m2 versus 89.2+/-38.9 mL/m2, p=0.116) and LAD index (39.1+/-7.9 mm/m2 versus 36.2+/-9.2 mm/m2, p=0.144). CONCLUSION: Pre-operative LAV index measured by echocardiography and the duration of AF were significant predictors of successful sinus rhythm restoration after the Maze operation. Significant reduction of the LAV index after the Maze operation was found in patients whose rhythm was successfully restored and maintained.

The efficacy and safety of angioseal(R) compared to conventional manual compression after transfemoral percutaneous coronary intervention / 대한내과학회지

BACKGROUND: Although the number and the quality of percutaneous coronary intervention have been recently increased dramatically, the vascular complication at puncture site is still the major cause of patients' morbidity. We evaluated the safety and efficacy of newly-developed collagen-based arterial closure device, angioseal(R) after transfemoral percuatenous coronary intervention. METHODS: This study was designed as a prospective single center non-randomized comparative study. A total 200 patients undergoing transfemoral percutaneous coronary intervention were enrolled between April 2002 and May 2003. They were divided into two groups; angioseal(R) group (group A, n=100) and manual compression group (group B, n=100). The baseline clinical and angiographic characteristics were reviewed. The time to sit up, the time to ambulation, the duration of hospital stay, major and minor vascular puncture site complications were monitored. The patients were followed-up for 1 week after the procedure by telephone. RESULTS: The baseline clinical characteristics, clinical diagnosis, cardiovascular risk factors, types of procedure, doses and numbers of anticoagulants were similar between two groups. The blood pressure and activated clotting time were also similar. The time to sit up (group A: 4.3 0.3 hours, group B: 13.7 0.8 hours, p=0.004) and the time to ambulation (group A: 6.8 0.5 hours, group B: 18.8 2.1 hours, p=0.013) were shorter in group A. No major vascular complications were noted. The incidence of hematoma and bleeding were not significantly different between two groups. The incidence of ecchymosis, however, was significantly lower in group A (group A: 12%, group B: 3%, p=0.001) The duration of hospital stay was similar between two groups. During 7 days of follow-up period, the incidence of hematoma was significantly lower in group A (p=0.004). Although the incidence of ecchymosis was not significantly different between two groups. CONCLUSION: The angioseal(R) may be associated with earlier ambulation and less patients' morbidity with low incidence of local complication rate compared to manual compression after transfemoral percutaneous coronary intervention.

N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Marker in Acute Coronary Syndrome

BACKGROUND AND OBJECTIVES: Biochemical markers are useful for the prediction of cardiac events in patients with acute coronary syndrome (ACS). The N-terminal fragment of the BNP prohormone (NT-proBNP), which is synthesized by cardiac ventricles in response to increased wall stress, may be a prognostic marker in ACS. The relation between the NT-pro BNP levels on admission and major adverse cardiovascular events (MACEs) were assessed in a cohort of patients with ACS. SUBJECTS AND METHODS: Between October 2002 and April 2004, blood samples for the determination of NT-proBNP level were obtained on admission from 78 patients with ST-elevation myocardial infarction (STEMI), 32 with non-ST elevation MI(NSTEMI) and 66 with unstable angina (UA). Patients were followed concerning MACEs (death, MI, heart failure, stroke and revascularization) for a median of 7 months in median. RESULTS: 22 patients (13%) had events. The mean NT-proBNP level was significantly lower in the event-free survivors than in those with events (1342+/-1598 versus 6129+/-6522 pg/mL, p<0.0001). The optimal cut-off value of the NT-proBNP level using a receiver-operating-characteristic curve was 1445 pg/mL. The unadjusted risk ratio of patients with an NT-proBNP level greater than the threshold was 7.0 (95% confidence interval, 2.6 to 19.0). In a multivariate Cox regression model, including clinical background factors and other biochemical markers, the NT-proBNP level was the most powerful indicator of MACEs (risk ratio, 8.0 [95% confidence interval, 1.7 to 37.1]). The coronary angiographic Gensini score was also a predictor of prognosis in ACS (risk ratio, 3.8 [95% confidence interval, 1.0 to 14.0]). CONCLUSION: A single measurement of the NT-proBNP level on admission appears to be useful as a prognostic factor in the prediction of MACEs in patients after ACS.

afety and Feasibility in Trans-radial Coronary Interventions for Chronic Total Occlusion

BACKGROUND AND OBJECTIVES: Recent advances in trans-radial coronary intervention (TRI) have shown a reduction in patient's morbidity. However, the role of TRI for a chronic total occlusion (CTO) is not well established. The aim of this study was to assess the safety and feasibility of TRI for a CTO. SUBJECTS AND METHODS: Sixty-three successive CTO lesions of more than 2 months duration were prospectively included in this registry between April 2002 and November 2003. Guiding catheters with strong back-up, stiff guide wires and supportive infusion catheters were actively used. The angiographic and procedural characteristics were prospectively evaluated. RESULTS: There were 45 male and 18 female patients, with a mean age of 59.8+/-9.5 years. The most common clinical diagnosis was stable angina (95.2%). The mean duration of the occlusions was 10.3+/-1.6 months. Procedural success was achieved in 53 lesions (84.1%). No cases were crossed over to transfemoral procedure. The most common cause of procedural failure was guide wire passage failure (7 lesions). The mean duration of occlusions was significantly longer in the failure group (7.5+/-1.1 versus 24.8+/-6.5 months, p<0.001). Bridging collateral vessels, long occlusions, calcification at lesion sites, a side branch at the occlusion site and blunt entry morphology were also statistically significant predictors for procedural failure. Procedure-related complications were noted in 6 patients (9.8%), which included coronary perforations (3.3%), severe dissections (3.3%), arrhythmia (1.6%) and branch artery occlusion (1.6%). No patients suffered from local complications, such as hematoma or radial artery occlusion. CONCLUSION: TRI for a CTO seems to be safe and feasible, with acceptable success and complication rates.

Correlation between Vascular Compliance and Increase of Blood Pressure on Exercising in Normotensive Group

BACKGROUND AND OBJECTIVES: Vascular compliance is known to be decreased in hypertension, even at an early stage. The blood pressure response to exercise reflects the future risk of developing hypertension. A study was performed on the relationship between the vascular compliance and blood pressure response to exercise, to evaluate whether the vascular compliance is decreased in normotensive persons with a relatively higher future risk of developing hypertension. SUBJECTS AND METHODS: The subjects of the study were adults with normal blood pressure (SBP<120 mmHg, DBP<80 mmHg), who had undergone health screening and both echocardiography and treadmill test. Those patients with a history of diabetes mellitus or clinical cardiovascular diseases were excluded form the subjects. An index of overall vascular compliance (SVI/PP) was calculated using echocardiography. The relationship between the peak systolic blood pressure during exercise and vascular compliance was also investigated. RESULTS: The subjects were 77 patients, 54 male and 23 female, with a mean age of 47.6+/-7.7 years. The measured vascular compliance and average of peak systolic pressure on exercising were 1.08+/-0.24 L/m2/mmHg and 154+/-21 mmHg, respectively. The peak systolic pressure was correlated with the vascular compliance (r=-0.24, p<0.05). The peak systolic pressure at stage 3 was also correlated with the vascular compliance (r=-0.24, p<0.05). This relationship persisted after adjustment for age, gender, basal systolic blood pressure and maximal oxygen consumption (p<0.05). CONCLUSION: The vascular compliance was lower in subjects with a larger increase in blood pressure during exercise whose basal blood pressure was even below 120/80 mmHg. This finding may suggest that a decreased vascular compliance precedes the changes of hypertension. A longitudinal follow-up study is warranted.

Long-term Follow-up Results of Tilt Training in Patients with Neurocardiogenic Syncope

BACKGROUND AND OBJECTIVES: Tilt training as a non pharmacological therapy was recently introduced to treat the patients with neurocardiogenic syncope. Tilt training has been known to prevent neurocardiogenic syncope by desensitizing abnormal autonomic reflex. Herein, the early effect of tilt training and the preventive effect on the relapse of syncope were studied during a long-term follow-up period. SUBJECTS AND METHODS: Fifteen patients (11 males) who experienced recurrent syncope, despite drug treatment or were intolerant to drug treatment, among those diagnosed as neurocardiogenic syncope by the head-up tilt test at Samsung Medical Center between March 2000 and May 2003 were recruited. Each patient underwent tilt training after admission and was educated to continue self-tilt training after discharge. Data for recurrences after discharge were obtained via questionnaires on outpatient visits or by telephone interviews. RESULTS: Eleven (73%) of the 15 who underwent tilt training on admission showed therapeutic effects. The mean follow-up period was 21+/-10 months (5-40 months). Only one patient was excluded due to follow-up loss. Ten of the above patients underwent training by themselves for an average of 4 months after discharge, and experience no relapse of syncope during the follow-up period. CONCLUSION: Tilt training maintained its therapeutic effect during long-term follow-up. This could be a new treatment for patients non responsive or intolerant to medical therapy.