A Case of Klippel-Trenaunay Syndrome with Acute Submassive Pulmonary Thromboembolism Treated with Thrombolytic Therapy

Klippel-Trenaunay syndrome is a rare congenital mesodermal abnormality characterized by varicose veins, cutaneous hemangiomas, soft tissue and bony hypertrophy of limb. Potential complications such as deep venous thrombosis and pulmonary thromboembolism have not been reported in Korea to date. We demonstrate the case of a 48-year-old woman with Klippel-Trenaunay syndrome with extensive varicose veins on right lower limb, hypertrophy of left big toe and basilar artery tip aneurysm, complicated with acute submassive pulmonary thromboembolism treated successfully with intravenous thrombolytic therapy.

Takotsubo Cardiomyopathy Associated with Chronic Psychiatric Stress in Major Depressive Disorder in an Elderly Patient

Takotsubo cardiomyopathy (TC) is a transient form of acute heart failure that most often occurs in postmenopausal women, typically triggered by a preceding emotional or physical stressor. A 74-year-old woman who suffered from chronic psychiatric stress visited National Medical Center for dyspnea. Acute emotional or physical stress could not be identified despite careful history taking. An electrocardiogram showed diffuse T-wave inversions with prolonged QT interval, and the echocardiogram showed akinesia of mid and apical segments of the left ventricle with hyperkinesia at the base. There was no significant stenosis on coronary angiography. Differing from the typical case of TC, which follows acute stress triggers, our case indicates that underlying chronic psychiatric illness exacerbation can lead to TC. We suggest that cardiologists and psychiatrists be aware of this predisposition to TC, especially in the circumstances of acute heart failure.

Severe Resistant Hypertension Induced by Carbamazepine in an Elderly Patient

We report a case of a 73-year-old patient with a 17 year-history of well-controlled primary hypertension with a single antihypertensive drug, which became uncontrolled since 9 months ago when he started on oral carbamazepine (CBZ) therapy for syringomyelia. On admission, the patient had a blood pressure of 200-215/95-104mmHg despite an antihypertensive combination therapy with five different drugs. Further investigations ruled out secondary hypertension such as primary aldosteronism, pheochromocytoma and renal artery stenosis. After the discontinuation of CBZ, the blood pressure profile became significantly improved. The rechallenge with CBZ aggravated his blood pressure profile. Therefore, we considered that resistant hypertension was induced by the oral CBZ therapy.

Preoperative B-type Natriuretic Peptide as a Predictor of Postoperative Cardiac Events Following Orthopedic Elderly Patients

BACKGROUND: The aim of this study was to evaluate the value of preoperative plasma B-type natriuretic peptide (BNP) level in predicting postoperative in-hospital major adverse cardiac events (MACE, defined as atrial fibrillation, congestive heart failure, nonfatal myocardial infarction and cardiac death) in elderly patients undergoing orthopedic surgery. METHODS: Between March 2010 and September 2011, data from 156 patients (aged 65 years or older) who underwent scheduled or emergent orthopedic surgery, were investigated. Screening for postoperative in-hospital MACE was performed using clinical criteria. RESULTS: MACE occurred in 12 patients (7.7%). The BNP level was significantly higher in patients with MACE than in those without (median, 152.0; interquartile range [36.3 to 352.8] pg/mL vs. median, 36.8; interquartile range [15.5 to 98.1] pg/mL, p=0.005). The BNP level was positively correlated with the revised cardiac risk index score (r=0.300, p=0.001). In a receiver operating characteristic (ROC) analysis for MACE, the ROC for BNP was 0.746 (95% confidence interval, 0.602 to 0.891). At the optimal cut-off point (BNP=110 pg/mL), the sensitivity, specificity and positive and negative predictive values were 66.7, 81.2, 22.0% and 96.6%, respectively. On multivariate analysis, preoperative BNP was an independent predictor for MACE (odds ratio, 5.091; p=0.018) after adjusting for baseline confounding factors such as diabetes mellitus and history of cerebrovascular accident. CONCLUSION: The preoperative BNP level may be a useful tool in stratifying the risk for MACE in elderly patients undergoing orthopedic surgery.

Severity of Coronary Atherosclerosis; Influence of Metabolic Syndrome Risk Factor Clustering and hs-CRP

BACKGROUND AND OBJECTIVES: Metabolic syndrome and high sensitivity C-reactive protein (hs-CRP) are known to be strong predictors of coronary atherosclerosis. Even though there have been many observations and much research concerning the association of coronary atherosclerosis with CRP and metabolic syndrome, certain problems still need to be resolved in order to produce clear mechanistic illustrations. Therefore, the correlations of metabolic syndrome, hs-CRP and the severity of coronary atherosclerosis were evaluated herein. SUBJECTS AND METHODS: 271 patients, aged between 29 and 87, who had undergone diagnostic coronary angiograms at the National Medical Center, between January, 2004 and June, 2006 were evaluated. Coronary angiograms were performed in patients who complained of typical chest pain and had risk factors associated with coronary atherosclerosis. The correlations of metabolic syndrome, hs-CRP and coronary atherosclerosis were analyzed in these patients. RESULTS: Positive relationships were found between the metabolic syndrome risk factor clustering and an increased level of hs-CRP (p<0.01). The severity of coronary atherosclerosis increased with the increasing number of metabolic syndrome risk factors. As metabolic syndrome risk factor clustering increased, the quantity of 1, 2 and 3 vessel diseases also increased (Odd ratios 1.61, 1.83 and 2.50; p=0.001, <0.001 and <0.001, respectively). In contrast to metabolic syndrome risk factor clustering, no definite relationship between the hs-CRP level and the severity of coronary atherosclerosis was observed. CONCLUSION: The more metabolic syndrome risk factors clustered, the greater the severity of coronary atherosclerosis. The extension of coronary atherosclerosis maybe predicted using evaluation of metabolic syndrome risk factor clustering in patients with angina.

A Case of Hyperhomocysteinemia Manifested by Deep Vein Thrombosis and Pulmonary Embolism

Homocysteine has been reported as an independent risk factor of intravascular thrombosis and atherosclerosis by its participation in vascular endothelial cell dysfunction, platelet activation and thrombus formation. The serum homocysteine concentration is influenced by not only heredity, but also by environmental factors, and it interacts with the former reported risk factors of atherosclerosis. We report here on a case of a young patient with hyperhomocysteinemia that manifested by deep vein thrombosis and pulmonary embolism.

The of First Symptom and Diagnosis of Acute Coronary Syndrome in Elderly Patients of Korea

BACKGROUNDS: As Korea has advanced into the aging society, Acute Coronary Syndrome is increased in number, especially elderly age group. The symptoms of acutecoronary syndrome in eldery were presented in atypical feature frequently. We studied the relation of the first symptom and diagnosis of acutecoronary syndrome and distribution of risk factor and coronary angiographic finding in elderly patient of korea society. METHODS: The subjects who were under went coronary angiography between 2002.5 and 2003.8 were dividedunder 65 years old group and over 65 years old group. And each group described diagnosis, risk factor, first symptom and coronary angiographic finding retrospectively. RESULTS: The diagnosis of unstable angina are more higher(46.5% vs. 26.1%, p<0.01) in the over 65 years old group and the first significant symptom of typical chest pain was more higher(57.4% vs. 47.6%, p<0.01) in the under 65 years old group and dyspnea was more higher(22.8% vs. 9.2%, p<0.01) in the over 65 years old group. The number of abnormal vessel were more higher(66.3% vs. 46.9%, p<0.01) in the over 65 years old group. CONCLUSION: Over 65 years old group compared with younger age group were prewented more frequently angina equivalent symptom than typical chest pain. And at the diagnosis of Acute Coronary Syndrome, over 65 years old group showed more severe coronary angiographic finding. Consequently, early stage of diagnostic approach and treatment need scrupulous attention in the elderly patients.

The Relationship of Infection and Inflammation with Coronary Restenosis after Percutaneous Coronary Interventions

BACKGROUND AND OBJECTIVES: Possible correlations between the serologic status concerning Cytomegalovirus(CMV), Chlamydia pneumoniae (CP), Helicobacter pylori(HP), their related markers of C-reactive protein(CRP), erythrocyte sedimentation rate(ESR), and the restenosis(RS) in patients underwent percutaneous coronary intervention(PCI) were analyzed. Materials and METHODS: The 142 patients(58.010.9 year-old, M;F=116:26) with 189 coronary lesions, who underwent follow-up angiography after PCI, were evaluated. RESULTS: The overall RS rate was 47.1%(89/189), and the RS rate according to clinical diagnosis was 50.6% in acute myocardial infarction(MI), 41.8% in unstable angina(UA), 6.3% in stable angina(SA), and 1.3% in old MI. The values of RS rate in acute MI and UA were higher than those of old MI and SA(p=0.02). Thrombolysis In Myocardial Infarction(TIMI) flow was significantly lower in group with RS than without RS(p=0.039). Seropositivities of CMV, CP, HP were not different between groups with and without RS. Titers of CMV and HP were not different between two groups. Positivity of CRP was 56.3% in group with RS and 30.2% in group without RS(p=0.005). Titers of ESR and CRP were higher in group with RS than without RS(20.322.4 mm/hr, 2.24.5 mg/dL vs. 11.811.6 mm/hr, 0.70.8 mg/dL, p=0.007, p=0.010 respectively). CONCLUSION: RS rate after PCI is higher in patients with acute coronary syndrome and low TIMI flow. Inflammatory markers, such as CRP and ESR, might be associated with the RS after PCI.

The percutaneous coronary intervention in elderly women over 70 years of age / 대한내과학회지

BACKGROUND: Previous reports have mentioned the increased mortality of percutaneous coronary intervention (PCI) in elderly female patients compared with elderly male. The purpose of this study was to evaluate the clinical characteristics, coronary lesion, characteristics and differences of success rate of PCI between male and female elderly patients. METHODS: Three hundred sixty six elderly patients (454 lesions), including 210 male (255 cases, 73.4+/-2.45 year-old) and 156 female (199 cases, 73.5+/-2.55 year-old) who underwent PCI at Chonnam National University Hospital between Jan '96 and Dec '98 (out of 3,030 patients during same period). We compared clinical characteristic, coronary artery lesion morphology, success and complication rates of PCI in elderly male and female patients. RESULTS: Clinical diagnosis and risk factors for atherosclerosis were not different between two groups. Right coronary lesions were more common in female and left circumflex artery lesion less common in female patients. The success rate of balloon angioplasty was 93.2% (110/118) in male and 93.3% in (98/105) in female patients, and the success rates of stenting were 99.2% (136/137) in male and 100% (94/94) in female. Success rates of PCI were not different between two groups. Procedure-related mortality was one cardiac death (1/255, 0.39%) in male group only. Complications of elderly male were two occlusive dissection (OD: 2/255, 0.8%), three thrombotic occlusion (TO: 3/255, 1.2%) and two ventricular arrhythmia (VA) with shock (2/255, 0.8%). In 199 female patients, three OD (3/199, 1.5%), three TO (3/199, 1.5%) and two VA (2/199, 1.0%) developed. The complications rates were not different two groups. CONCLUSION: PCI in female patients older than 70 years can be performed with comparable success and complication rates to those of elderly male patients.

The percutaneous coronary intervention in elderly women over 70 years of age / 대한내과학회지

BACKGROUND: Previous reports have mentioned the increased mortality of percutaneous coronary intervention (PCI) in elderly female patients compared with elderly male. The purpose of this study was to evaluate the clinical characteristics, coronary lesion, characteristics and differences of success rate of PCI between male and female elderly patients. METHODS: Three hundred sixty six elderly patients (454 lesions), including 210 male (255 cases, 73.4+/-2.45 year-old) and 156 female (199 cases, 73.5+/-2.55 year-old) who underwent PCI at Chonnam National University Hospital between Jan '96 and Dec '98 (out of 3,030 patients during same period). We compared clinical characteristic, coronary artery lesion morphology, success and complication rates of PCI in elderly male and female patients. RESULTS: Clinical diagnosis and risk factors for atherosclerosis were not different between two groups. Right coronary lesions were more common in female and left circumflex artery lesion less common in female patients. The success rate of balloon angioplasty was 93.2% (110/118) in male and 93.3% in (98/105) in female patients, and the success rates of stenting were 99.2% (136/137) in male and 100% (94/94) in female. Success rates of PCI were not different between two groups. Procedure-related mortality was one cardiac death (1/255, 0.39%) in male group only. Complications of elderly male were two occlusive dissection (OD: 2/255, 0.8%), three thrombotic occlusion (TO: 3/255, 1.2%) and two ventricular arrhythmia (VA) with shock (2/255, 0.8%). In 199 female patients, three OD (3/199, 1.5%), three TO (3/199, 1.5%) and two VA (2/199, 1.0%) developed. The complications rates were not different two groups. CONCLUSION: PCI in female patients older than 70 years can be performed with comparable success and complication rates to those of elderly male patients.

The Clinical Effects of Transdermal Nitrate (Angiderm Patch) in Patients with Angina

BACKGROUND AND OBJECTIVES: The clinical efficacy of transdermal nitroglycerin patch in patients with angina has not known exactly. After the application of transdermal nitroglycerin, the influences of transdermal nitrate on exercise capacity and clinical symptom in patients with angina were compared with the clinical effects of oral nitroglycerin. MATERIALS AND METHOD: Long acting oral nitrate was administered in 20 patients (9 male, 11 female, age:56.3+/-4.6) and transdermal nitrate (Angiderm Patch ) applied in 20 patients (8 male, 12 female, age:53.9+/-9.8), who suffered from angina more than 4 attacks per week. All patients were evaluated at 4-week interval:after 2 weeks' run-in period, after 4 weeks of randomized non-titrated treatment (first visit), after 8 and 12 weeks of titrated treatment (second and third visits). The frequency of angina, side effects of headache and skin irritation, blood pressure, echocardiographic ejection fraction and exercise treadmill score were compared between the two groups. RESULTS: The frequency of angina attack was 14.4+/-6.0 in oral nitrate and 14.0+/-4.9 in transdermal nitrate per two weeks during run-in period. After nitrates, the frequency of angina reduced to 8.1+/-4.5, 5.4+/-2.2 on the first, to 3.0+/-3.5 and 1.7+/-1.4 on the second, and to 1.2+/-1.7 and 0.3+/-0.4 on the third visit in oral and transdermal nitrate groups respectively. Blood pressure and ejection fraction were unchanged in both groups. Exercise treadmill score was 10.4+/-4.3 in oral and 10.6+/-2.3 in transdermal nitrate group during run-in period, which was increased to 12.6+/-4.0, 13.7+/-2.5 on the first, to 13.6+/-3.0, 15.1+/-2.2 on the second, and to 15.3+/-2.7, 15.6+/-1.9 on the third visit after oral and transdermal nitrates respectively. However, changes in the frequency of anginal episodes and exercise treadmill score were not different between two groups. Side effects of headache were observed in 7 of oral and 4 of transdermal nitrate group and skin irritation in 2 of transdermal group. CONCLUSION: Transdermal nitroglycerin is equally effective as oral nitroglycerin in the reduction of the frequency of angina attack and the improvement of exercise tolerance without significant side effects in patients with angina.

The Effects of Local Delivery of Paclitaxel Nanoparticle on Porcine Coronary Stent Restenosis

BACKGROUND AND OBJECTIVES: Late coronary in-stent restenosis remains an important clinical problem in coronary intervention. The effects of Paclitaxel (Taxol), an antimicrotubule agent, on neointimal proliferation within porcine coronary arteries were evaluated. METHOD: Stent overdilation injury was performed in porcine coronary arteries without local delivery of paclitaxel (n=10, Group I). Stent overdilation injury was also performed after local delivery of paclitaxel nanoparticle using the Dispatch Catheter(TM) in other coronary arteries (n=10, Group II). Coronary angiography and histopathologic examinations, which were performed 4 weeks after stenting, and complete blood counts and blood chemistry before and 4 weeks after the local delivery were compared. RESULT: 1) Reference vessel diameter, stented artery diameter, and diameter stenosis were not different between two groups. 2) Histopathologic injury score, external elastic lamina area, internal elastic lamina area, and luminal area were not different between two groups. 3) Neointimal area and histopathologic area stenosis were smaller significantly in the group II than in group I (2.3+/-0.33 vs 3.7+/-1.40 mm2, 22.2+/-19.26 vs 31.1+/-7.15%: p=0.04, 0.03, respectively). 3) Proliferating cell nuclear antigen index was lower in the stent overdilation injury with local paclitaxel delivery group than in the stent overdilation injury alone (31.10+/-3.70 vs 46.80+/-5.20%, p=0.04). 4) No significant laboratory changes were observed before and 4 weeks after the local delivery. CONCLUSION: Local delivery of paclitaxel nanoparticle inhibits neointima formation after stent overdilation injury in porcine coronary arteries without systemic toxicity.

A Case of Primary Pulmonary Hypertension with the Congenital Absence of Inferior Vena Cava

Primary pulmonary hypertension (PPH) is one of rare and fatal vascular disorder. The exact mechanisms for the increased pulmonary vascular resistance and pressure in PPH are unknown. The disease is advanced pro-gressively and patients naturally die within three years after the initial diagnosis. PPH is characterized with mean pulmonary artery pressure over 25-30 mmHg and intractable hypertension despite any intensive therapeutic maneuvers. Associated congenital anomaly is very rare. We report a 19 year-old female patient who diagnosed as PPH 10 years ago and suffered from severe pulmonary hypertension (100 mmHg of pulmonary arterial pressure) with the congenital absence of inferior vena cava. Her venous blood from lower body was drained through azygous vein into superior vena cava.

A Case of Giant Septic Mitral Valvular Aneurysm

The incidence of mitral valve aneurysm in infective endocarditis is 9-10%. However, a huge giant mitral valve aneurysm larger than 3 cm in length associated with acute mitral regurgitation is very rare. The mitral valve aneurysm can be complicated with perforation, leading to severe mitral regurgitation and congestive heart failure, pending to surgical correction. We hereby report a case of twenty-three year-old female who suffered from sudden onset of chest pain and dyspnea due to acute left ventricular failure, which was developed after the perforation of huge, hanging, giant septic aneurysm on the mitral valve. The patient underwent mitral valvuloplasty and recovered uneventfully.

Change of Clinical Outcome in Patients with Unstable Angina according to Early Revascularization Therapeutic Strategy

BACKGROUND AND OBJECTIVES: It has been well known that the Braunwald classification is an appropriate clinical parameter in the prediction of the outcome in patients with unstable angina. However, the ability of the classification to predict prognosis of unstable angina according to treatment strategy is not established. We evaluated the relation between severity of angina on admission and outcome of primary unstable angina with early invasive strategy. MATERIALS AND METHOD: 148 patients (M 85, F 63, age 61+/-10) with suspected unstable angina were divided into three subgroups on the basis of the Braunwald classification on admission. The patients were followed up to 6 months prospectively if the final diagnosis was primary unstable angina. Early invasive strategy was used for the treatment of unstable angina. Major cardiac events were assessed during hospitalization and 6 months follow-up period according to the Braunwald classification. RESULTS: Unstable angina was diagnosed in 95 patients (64%). Among these patients, 89 patients with primary unstable angina were followed up to 6 months. Clinical characteristics including number of patients, mean age, sex ratio, risk factors, coronary angiographic findings and revascularization rate during hospitalization were not different in three subgroups of these patients. Among these patients, early coronary revascularizations was performed in 67 patients (75%) and 2 (2%) deaths/myocardial infarctions occurred during hospitalization. During the follow-up period, 1 (1%) myocardial infarction/death and 12 (13%) revascularizations occurred. Cardiac event rate (death, myocardial infarction or revascularization) was not different during hospitalization and 6 months follow-up period among subgroups of severity class. CONCLUSION: Clinical outcome should be reevaluated after early coronary intervention to predict cardiac event in patients with unstable angina.

The Association of Hypertension and Dyslipidemia in Postmenopausal Women

BACKGROUND AND OBJECTIVES: The purpose of this study was to figure out the correlation of hypertension and atherogenic dyslipidemia in postmenopausal women. MATERIALS AND METHODS: The study population consisted of consecutive 380 postmenopausal women (age> or =50, FSH>40IU/L and triglyceride[TG] or =160 mmHg or DBP> or =100 mmHg, n=57). We measured thier body mass index (BMI) and waist-hip ratio (WHR). We also measured their levels of glucose, total cholesterol and TG by automatic biochemical analyzer (Hitachi 7150) and HDL cholesterol by direct method using AutoDAIICHI reagent. We calculated LDL cholesterol levels by Friedewald formula. RESULTS: MI, WHR and glucose level of group IV were significantly higher than those of group I. But there were no significant differences among the groups in the levels of total cholesterol, LDL cholesterol and apolipoprotein B. HDL cholesterol level of group I was statistically higher than that of group IV. TG level and LDL cholesterol/apo B ratio of group IV were significantly higher and lower than those of other groups respectively. CONCLUSION: Postmenopausal women who had moderate or severe hypertension show the trend toward abdominal obesity and atherogenic dyslipidemia. We might have to pay attention to these metabolic abnormalities in postmenopausal women with hypertension.

Influence of Ischemic-Simulation on the Action Potential Characteristics in Rat Atrial Fibers

BACKGROUND: To investigate the mechanisms of myocardial ischemia induced changes of electrophysiological properties, influences of various ischemic-simulated Tyrode's solutions on the changes of action potential characteristics were examined. METHOD: Action potential characteristics were measured during superfusion with various ischemic-simulated solutions (modified physiologic salt solution: MPSS) by the method of conventional microelectrode technique in rat atrial fibers. RESULTS: Hypoxic-, hyperkalemic-, and mixed-MPSS decreased 'maximum diastolic potential' (MDP) and 'action potential amplitude' (APA), however, no significant changes of MDP and APA were observed by acidic- and glucose-free-MPSS. 'Maximum velocity of phase 0 depolarization' (dV/dt(max)) and 'time for 90% repolarization' (APD90) significantly decreased during hypoxic- and mixed-MPSS superfusion, and hyperkalemic-MPSS also decreased the dV/dt(max) and APD90. However, no significant changes in dV/dt(max) and APD90 were observed by acidic- and glucose-free-MPSS. The decreasing effects of dV/dt(max) and APD90 by the MPSSes were attenuated when the MPSSes were replaced with normal Tyrode's solution. DPCPX (2x10(-6)M), a purinergic antagonist, inhibited the decreasing effects of APD90 at 5, 10, and 20 min superfusion of the mixed-MPSS, and glibenclamide (10(-6)M), a K(ATP) channel blocker, inhibited those at 10 and 20 min superfusion of the mixed-MPSS. Diclofenac (10(-6)M), a cyclooxygenase inhibitor inhibited only those at 20 min superfusion of the mixed-MPSS. CONCLUSION: The primary factors for changing the electrophysiological characteristics during ischemic insults could be hypoxia and high-extracellular K+, and the mechanisms of the electrophysiological changes are inferred that adenosine through purinoceptors is involved initially, and followed by K(ATP) channel and prostanoids.

Severe Cholestatic Jaundice and Subsequent Pancytopenia Associated with Ticlopidine

No abstract available.

Torsades de Pointes After Combined Treatment of Terfenadine and Ketoconazole / 대한내과학회지

Terfenadine is widely used because of nonsedating effect. But It could rarely provoke a potentially lethal ventricular tachyarrhythmia. Recently, we experienced two cases of torsades de pointes(TDP) of occurred after combined use of terfenadine and ketoconazole in usual dose. In one case, 31-yr-old female presented palpitation and recurrent syncope of sudden onset after ingestion of terfenadine 60mg and ketoconzole 200mg 5 times. On attack, ECG showed a polymorphic ventricular tachycardia, and after attack, showed prolongation of QT interval and TU wave changes. Her laboratory findings were not contributory. TDP was controlled with MgSO4 and isoproterenol infusion. Then, QT interval was normalized and no further episode occurred. In the other case, 32-yr-old female presented palpitation and recurrent syncope of sudden onset after ingestion of terfenadine 60mg and ketoconzole 200mg 5 times. ECG showed prolongation of QT interval and TU wave changes. Her laboratory findings were not contributory. TDP was controlled with MgSO4 and isoproterenol infusion. Then, QT interval was normalized and no further episode occurred.

The Correlation between Coronary Artery Disease and Carotid Atherosclerosis

BACKGROUND: In patients with coronary artery disease (CAD), atherosclerotic changes of carotid arteries (CA) often coexist with CAD itself. If the degree of carotid atherosclerosis can be estimated, it would be very helpful in the management of patients with CAD. METHODS: CA intima-media thickness (IMT) was evaluate by ultrasonography at 12segments (both proximal, middle, distal common CA, bifurcation, internal and external CA-of the extracranial CA) on the 182 subjects whom underwent coronary angiograms. The subjects were divided into 4 groups according to the severity of CAD; control (C, n=23), single vessel disease (1, n=64), two vessel disease (II, n=44), three vessel disease (III, n=51). RESULTS: The means (+/-SD) of maximal IMT, chosen from the 12 segments, of each group were 1.4+/-0.7mm (C), 2.1+/-1.4mm (I), 2.2+/-1.2mm (II), and 2.9+/-1.7mm (II). The 4 groups showed significant differences between each other. The only conparison to yield unsignificant differences was between group I and group II (p=0.02 for C and I, p=0.001 for C and II, p<0.001 for C and III, p=0.01 for I and III, p=0.04 for II and III). When multivariate analysis was used to assess which major risk factors for CAD (age, male sex, smoking, hypertension, diabetes, cholesterol, triglycerides and CAD groups affected CA IMT), group III and increasing age were the most significant variables (p=0.0001 and 0.0035, respectively). CONCLUSIONS:It is necessary to evaluate the status of the extracranial carotid arterial system with ultrasonography in patients with three vessel CAD even if neurologically symptomless. It becomes especially evident in elderly patients.