Effect of Valsartan on N-Terminal Pro-Brain Natriuretic Peptide in Patient With Stable Chronic Heart Failure: Comparison With Enalapril

BACKGROUND AND OBJECTIVES: The plasma concentration of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a st-rong prognostic indicator for patients with heart failure (HF) across all stages of the condition. Several clinical trials have de-monstrated convincingly that neurohormonal modulation on the renin angiotensin system (RAS) decreases plasma NT-pro-BNP level and results in favorable outcomes. But there are still limited comparative data on the neuro-hormonal modulatory effects of two RAS inhibitors: angiotensin converting enzyme inhibitor and angiotensin receptor blocker. SUBJECTS AND METHODS: This study was a prospective, multi-center, randomized, open-label, controlled, and non-inferiority study involving 445 patients with left ventricular ejection fraction (LVEF) less than 45%. Patients were assigned to receive either valsartan (target dose of 160 mg bid) or enalapril (target dose of 10 mg bid) for 12 months. We compared plasma NT-pro-BNP, high sensitive C-reactive protein (hs-CRP) level and echocardiographic parameters before and after treatment with valsartan or enalapril. RESULTS: The NT-pro-BNP and hs-CRP levels were significantly decreased after 12 months of treatment with valsartan and enalapril. The percentage change was similar between both groups. LVEF improved and left ventricular internal dimensions were decreased in both groups, and there were no significant differences between two groups. CONCLUSION: Valsartan is as effective on improving plasma NT-pro-BNP level as enalapril in patients with stable chronic HF.

Effect of Valsartan on N-Terminal Pro-Brain Natriuretic Peptide in Patient With Stable Chronic Heart Failure: Comparison With Enalapril

BACKGROUND AND OBJECTIVES: The plasma concentration of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a st-rong prognostic indicator for patients with heart failure (HF) across all stages of the condition. Several clinical trials have de-monstrated convincingly that neurohormonal modulation on the renin angiotensin system (RAS) decreases plasma NT-pro-BNP level and results in favorable outcomes. But there are still limited comparative data on the neuro-hormonal modulatory effects of two RAS inhibitors: angiotensin converting enzyme inhibitor and angiotensin receptor blocker. SUBJECTS AND METHODS: This study was a prospective, multi-center, randomized, open-label, controlled, and non-inferiority study involving 445 patients with left ventricular ejection fraction (LVEF) less than 45%. Patients were assigned to receive either valsartan (target dose of 160 mg bid) or enalapril (target dose of 10 mg bid) for 12 months. We compared plasma NT-pro-BNP, high sensitive C-reactive protein (hs-CRP) level and echocardiographic parameters before and after treatment with valsartan or enalapril. RESULTS: The NT-pro-BNP and hs-CRP levels were significantly decreased after 12 months of treatment with valsartan and enalapril. The percentage change was similar between both groups. LVEF improved and left ventricular internal dimensions were decreased in both groups, and there were no significant differences between two groups. CONCLUSION: Valsartan is as effective on improving plasma NT-pro-BNP level as enalapril in patients with stable chronic HF.

A Case of Right Sided Aortic Arch Combined with Atrial Septal Defect

Right sided aortic arch is an uncommon congenital anomaly. It can be classified into three types, depending on the left aortic arch's degenerating pattern and the branching pattern of the great vessels. It can be associated with major congenital heart disease, depending on the type of right sided aortic arch. We report a case of an 18-years-old female who has right sided aortic arch with atrial septal defect (ASD). In our case, the patient had a right sided aortic arch and aberrant left subclavian artery, also she had ASD (ostium secundum) and moderate tricuspid regurgitation with pulmonary hypertension. The patient was successfully performed patch closure of ASD and tricuspid valve annuloplasty via midline sternotomy. The patient had uneventful postoperative course.

Reference Values for the Augmentation Index and Pulse Pressure in Apparently Healthy Korean Subjects

BACKGROUND AND OBJECTIVES: Arterial stiffness is a precursor to premature cardiovascular disease. The augmentation index (AI) and pulse pressure (PP) are cardiovascular risk factors. The aim of this study was to define the diagnostic values of the AI and PP from the peripheral arterial and central aortic waveforms in healthy subjects. SUBJECTS AND METHODS: We recruited 522 consecutive subjects (mean age 46.3+/-9.6 years, 290 males) who came to our facility for a comprehensive medical testing. We measured the body mass index (BMI), blood pressure, peripheral and central PP, and a pulse wave analysis that included the central and peripheral AI. RESULTS: The peripheral and central AIs in the female subjects were significantly higher than that in the male subjects (p<0.001). The peripheral and central PPs in the subjects with hyperlipidemia were significantly higher than subjects with normal lipid profiles (p<0.001). The peripheral and central PPs and peripheral and central AIs significantly increased with age. CONCLUSION: Pending validation in prospective outcome-based studies, a peripheral PP of 70 mmHg, central PP of 50 mmHg, peripheral AI of 100%, and central AI of 40% may be preliminary values in adult subjects.

Assessment of Non-Calcified Coronary Plaques Using 64-Slice Computed Tomography: Comparison With Intravascular Ultrasound

BACKGROUND AND OBJECTIVES: Non-invasive detection and characterization of plaque composition may constitute an important step in risk stratification and monitoring of the progression of coronary atherosclerosis. Multislice computed tomography (MSCT) allows for accurate, non-invasive detection and characterization of atherosclerotic plaques, as well as determination of coronary artery stenosis. The aim of this study was to determine the usefulness of MSCT for characterizing non-calcified coronary plaques previously classified by intravascular ultrasound (IVUS). SUBJECTS AND METHODS: Seventy-one plaques were evaluated in 42 patients undergoing MSCT and IVUS. Coronary plaques were classified as hypoechoic or hyperechoic based on IVUS echogenicity. On MSCT, CT attenuation was measured using circular regions of interest (ROI) and represented as Hounsfield units (HU). RESULTS: MSCT attenuation in hypoechoic plaques was significantly lower than it was in hyperechoic plaques (52.9+/-24.6 HU vs. 98.6+/-34.9 HU, respectively, p<0.001). When comparing CT attenuation between hypoechoic and hyperechoic plaques, 60.2 HU was the cut-off value for differentiating between the two, with a 90.7% sensitivity and a 78.6% specificity. CONCLUSION: MSCT might be a useful tool for non-invasively evaluating the characteristics of coronary artery plaques.

Relationship Between Serum Uric Acid Level and Metabolic Syndrome According to Gender

BACKGROUND AND OBJECTIVES: Hyperuricemia is known to be a risk factor for atherosclerosis, as is gender. The variables related to metabolic syndrome (MS), as well as other cardiovascular risk factors such as serum uric acid (SUA), differ according to gender. The aim of this study was to evaluate the relationship between SUA and the variables of MS according to gender. SUBJECTS AND METHODS: We randomly recruited 675 subjects (373 men and 302 women), who underwent health screening. The subjects were divided into four groups according to SUA quartiles. We compared each quartile of the SUA with the incidence of MS. The variables included body mass index (BMI), hypertension, fasting blood glucose (FBS), high-density lipoprotein (HDL) cholesterol, triglyceride (TG), and the MS score. RESULTS: The incidence of MS in men was significantly increased compared to women, and the incidence of MS was increased according to the SUA values in women. The MS scores tended to increase according to the SUA values in both genders. The incidence of high BMI, high blood pressure, and high TG were correlated with the SUA values in both genders. However, HDL-cholesterol was correlated with MS scores in women, and fasting glucose was not correlated with MS in either gender. CONCLUSION: The variables of the MS might be independently associated with SUA values in both genders. In addition, the incidence of MS in women might be significantly increased according to the SUA values. However, large scale follow-up studies will be required to confirm these possibilities.

Prognostic Significance of the Lown Grades and Late Potentials in Patients after Myocardial Infarction

BACKGROUND AND OBJECTIVES: The aims of this study were to assess the long term overall survival of patients after an acute myocardial infarction (AMI), and to determine the association of survival with the occurrence of ventricular arrhythmia, as recorded by Holter electrocardiography (ECG) and signal-averaged electrocardiography (SAECG). SUBJECTS AND METHODS: One hundred fifty two patients with an AMI were enrolled between January 2000 and August 2006. SAECG and Holter ECG were performed before hospital discharge (at range of 2-10 day). The grading system of Lown was used to evaluate the ventricular premature beats on Holter ECG. Three groups of patients were identified based on the seriousness of the ventricular arrhythmia, as identified by the Holter ECG: Lown grade 0, Lown grades 1, 2 and Lown grades 3, 4, 5. SAECG was performed with a high pass frequency of 25 Hz and 40 Hz. The presence of late potentials (LPs) recorded on SAECG was evaluated. The predictors for survival were assessed using Cox's proportional hazard model and Kaplan-Meier analysis. RESULTS: The mean duration of follow-up was 45.8+/-25.5 months. Twenty four patients (15.8%) died during follow-up. The multivariate predictors of all cause death included age [hazard ratio (HR)=1.25, 95% confidence interval (CI)=1.08-1.47, p=0.003] and Lown grades 3, 4 and 5 (HR=19.17, 95% CI=1.25-290.80, p=0.034). Survival analysis did not show a significant relationship between LPs and overall patient survival. The only predictors for overall mortality were age and the Lown grade. CONCLUSION: SAECG did not predict mortality for the patient with AMI. The ventricular arrhythmias recorded by conventional Holter before hospital discharge may be a useful noninvasive prognostic test after an AMI.

A Case of Primary Cardiac Non-Hodgkin's Lymphoma

Although 25 to 36% of systemic lymphoma patients develop cardiac involvement, a primary lymphoma involving only the heart or pericardium is much less common. We detected an intracavitary mass in the right atrium and right ventricle in a 73-year-old man with dyspnea on exertion and generalized edema using transthoracic and transesophageal echocardiography. A thoracotomy was performed due to a possible cardiac tamponade, and a myocardial biopsy showed a malignant non-Hodgkin's lymphoma of the diffuse large B cell type. We report a rare case of a primary cardiac lymphoma detected using a transthoracic and transesophageal echocardiography in patient presenting with a massive pericardial effusion.

Correlation between Total Anti-oxidant Capacity and Disease Activity in Systemic Lupus Erythematosus / 대한류마티스학회지

OBJECTIVE: To determine the correlation between total anti-oxidant capacity (TAOC)and lipid peroxidase (LPO)levels in serum and disease activity in systemic lupus erythematosus (SLE). METHODS: The study population consisted of 99 patients with SLE according to the 1982 revised ACR criteria and 83 healthy controls.The serum TAOC levels in 99 patients with SLE and 83 healthy controls by the ABTS(R) inhibition method (Randox Ltd,Antrim,UK)and serum malondialdehyde (MDA)levels in 37 out of 99 patients with SLE were measured.Anti-dsDNA antibody (anti-dsDNA),albumin,AST,ALT,cholesterol,uric acid and creatinine were mea-sured to determine the association with the serum TAOC levels.The correlation between the serum TAOC levels and nephritis in 27 cases with nephritis out of 99 SLE patients was also investigated.The SLE disease activity was determined by the SLE disease activity index (SLEDAI)at the time of sample collection. RESULTS: Compared to the controls (1.37 +/- 0.127mmol/L),serum TAOC levels were significantly decreased (1.29 +/- 0.124mmol/L)in SLE patients (p=0.001). And there was a negative correlation between serum TAOC levels and SLEDAI total scores in the SLE patients (r=-0.388,p=0.0001),but no significant correlation between TAOC levels and C3 and anti-dsDNA.Further,a significant difference (p<0.04)in TAOC levels was found in SLE patients with and without nephritis.In comparison with other parameters such as AST,ALT,and cholesterol which might change anti-oxidant level,there was no correlation between the serum TAOC levels and them,except for serum uric acid (r=0.387, p=0.0001),creatinine,and albumin (r=0.507,p=0.0001).Additionally,we couldn't find significant correlation between the serum TAOC levels and MDA. CONCLUSIONS: The serum TAOC levels correlate significantly with SLE disease activity and are associated with nephritis.Also,this study showed a significant correlation with serum albumin levels in these patients.Conclusively,the measurement of the serum TAOC levels in patients with SLE will provide useful information on SLE disease activity.

A Case of Infective Endocarditis Complicated with Multiple Myocotic Aneurysm and Mitral Valve Perforation

Mycotic aneurysm, uncommon complication of infective endocarditis (IE), develope more often in patients with subacute IE than acute IE. We report an unusual case of acute endocarditis complicated with multiple mycotic aneurysm and mitral valve perforation. 42 year old man who are referred for management of uncontrolled fever and dyspnea was diagnosed as acute mitral valve infective endocarditis caused by Staphylococcus aureus. He got complication of mycotic aneurysm on right femoral artery and mitral valve perforation with severe mitral regurgitation during favorable course of antibiotic treatment. Mycotic aneurysm was successfully treated with endovascular coil insertion and thrombin injection and mitral valve replacement was performed. On second day after operation, he died due to catastrophic intracranial hemorrhage which suggests another mycotic aneurysm rupture.

A Case of Myocardial Injury after Phenylpropanolamine Ingestion

Phenylpropanolamine is a sympathomimetic amine used widely as a decongestant or appetite suppressant. Reports of the myocardial injury from the use of phenylpropanolamine are rare and the mechanism of the myocardial injury is not known clearly. We experienced a case of myocardial injury after ingestion of phenyl-propanolamine. A 46-year-old woman was admitted because of chest pain and dyspnea after ingestion of 5 tablets of anorectic pill containing phenylpropanolamine 75 mg per tablet. The serum creatine kinase MB isoenzyme levels were elevated and electrocardiographic abnormalities suggesting myocardial infarction were seen in the precordial lead. In echocardiograpy, left ventricular anteroseptal wall motion was nearly akinetic but coronary angiography showed normal coronary arteries except sluggish blood flow in left anterior descending artery.

The Incidence Rate of Coronary Heart Disease in City Area / 예방의학회지

To estimate the incidence rate of coronary heart disease in Korea, of all residents of the Taegu city aged 25 or above, those who had an acute MI or fatal coronary event between 1 July 1996 and 30 June 1997 were registered. Seven hundreds and eight patients were registered during the study period(685 were identified at hospital and 23 were autopsy cases). Age-standardized annual incidence rate of men in city area was 93 per 100,000(95% CI; 61-142) and 33(95% CI; 16-67) in women(100 in men and 20 in women aged 35-64). The incidence was rapidly increased after age 40 in men, however, in women after age 60. Twenty-eight-days case fatality rate was 45% in men and 47% in women. However, in the age group of 45-59 case fatality rate in women was two times higher than that in men. In conclusion, crude annual incidence rate of CHD in city area was 73 per 100,000 in men and 33 in women. The age-standardized annual incidence of CHD in men(93 per 100,000) was 3.2 times higher than that in women (33 per 100,000) in Korea.

A Case of Pseudomembraneous Colitis by Clostridium Perfringens / 대한소화기내시경학회지

A 62-year-old female was adrnitted to the Catholic University Hospital of Taegu-Hyosung with an intracerebral hemorrhage. She was operated on successfully, but developed bacterial pneumonia. She was then treated with sulperazone, tobramycin, and metronidazole for 1 month. After the antibiotic treatment, she suffered from a fever and bloody, mucoid diarrhea for 3 days, and was examined with a sigmoidoscope. The sigmoidoscopic examination revealed yellow patches of ulcerations and swelling covered with thick sero- sanguinous exudate in the distal transverse colon and sigmoid colon. A latex agglutination test for C. was performed on her stool, whereby difficile cytotoxin was negative, however, metronidazole resistant C. perfringens was isolated from anaerobic culture of the biopsied colon tissue. She recovered with 15 days using oral vancomycin treatment. The possibility of C. perfringens as a causative organism of pseuclomernbraneous colitis was discussed.

Acute Renal Failure in Rhabdomyolysis Associated with Furosemide Induced Hypokalemia / 대한신장학회잡지

Though hypokalemia often goes unrecognized as a cause of rhabdomyolysis, its causal relation for acute renal failure can be considered in cases of extreme hypokalemia when combined with rhabdomyolysis. We present the case of a 21-year-old female in whom acute renal failure was developed by myoglobinuria which was associated with furosemide induced hypokalemia. She had taken 2 grams of furosemide daily over 6 months before developing rhabdomyolysis. Initial neurologic examination revealed painful quadriplegia and laboratory findings showed markedly elevated blood CPK, LDH and AST levels with azotemia. Arterial blood gas analysis showed pH 7.439, serum Na 128mEq/L, K 1.5mEq/L, Cl 87mEq/L, HCO3- 12.6mmol/L and calculated anion gap of 29.9 which indicated that she was under the condition of mixed metabolic alkalosis and metabolic acidosis. Though intravenous infusion of potassium chloride improved muscle strength, azotemia and acidemia persisted for several days. This case suggest that large amount of furosemide, when used for a long time, can be result in the acute renal failure by rhabdomyolysis which was caused by hypokalemia.

Oxygen Uptake, Heart Rate and Oxygen Pulse at Maximal Exercise / 대한내과학회지

OBJECTIVES: Despite the fact that determinations of cadiorespiratory fitness levels by exercise stress tests are becoming widely used in healthy individuals as well as in patients with cardiopulmonary diseases, the normal standards in this field have not been well established in Korea. The purpose of this study is to provide normal standards or reference values for the VO2 max, HR max and O2 pulse max for normal Korean adults by age and sex, along with the derivation of regression formulae of these parameters. METHODS: In 1,000 healthy adults (20-66years) consisting of 603men and 397women, symptomlimited maximal exercise was carried out by Bruce protocol, allowing holding on to the hand rail of the treadmill during exercise for the safety purpose. All the subjects were non-athletes and were members of a health center and were more conscious about their health and physical fitness than the ordinary population. RESULTS: The VO2 max and HR max were decreased with age as expected and, as a whole, the values of the VO2 max and HR max of females were approximately 84% and 90% of those of males, respectively. Estimated yearly reductions in the V max for males and females were 0.45 and 0.32mL/kg/min, respectively and those of the HR max were 0.72 and 0.76/min, respectively. The O2 pulse max of the female was approximately 70% of that of the male, and was slightly related to weight and exercise time. The regression equations of the parameters obtained using exercise time (ET, sec), age (A, year), weight (W, kg) and sex (S, O=male; 1= female) were: HR max=215.3-0.74A-5,04S, O2 pulse max= 5.371+0.216W+0.0107ET-1.505S and VO2 max=40.612+1.950ET-0.206A-0.147W-6.060S, CONCLUSION: The VO2 max in our study was higher than hitherto reported. This was primarily due to longer exercise time of the subjects on the treadmill, because they were allowed to hold on to the hand rail during exercise. And also, the fact that our subjects, being members of a health center, might have had higher physical fitness levels than general population could have contributed to the high VO2 max. Thus, we feel that our results could be the ideal target or- reference values to be achieved for those patients or individuals who have to do the tests with holding on to the rail of a treadmill for safety purpose.

Adrenal Myelolipoma Confirmed by Fine Aspiration Biopsy / 대한내분비학회지

Adrenal myelolipomas are rare, benign tumors cornposed of mature fat and bone marrow elements. Most are small, asymptomatic tumors found incidentally at postmortem examination, Fine needle aspiration biopsy can be used to confirm the diagnosis and avoid an unnecessary operation. We report a case of adrenal myelolipoma confirmed by fine needle aspiration biopsy. A 77-year-old woman with complaining of upper abdominal pain for 2 days was found to have an adrenal mass. She took dexamethasone frequently for 3 years due to multiple arthralgia. Ultrasono-graphy showed a 6cm-sized, suprarenal mass and a stone in the gall bladder with thickened wall. Computed tomography and magnetic resonance imaging scan also presented a suprarenal mass. Endocrinologic results were within normal limits. Adrenal myelolipoma was confirmed by computed tomography-guided fine needle aspiration biopsy without surgery.

Cardiopulmonary Response to Maximal Exercise Loading in Professional Soccer Players

BACKGROUND: Although maximal exercise stress tests are widely used in the athletic and medical fields, studies on professional soccer players are few. The purpose of our study is to observe the cardiopulmonary response to maximal exercise loading and the AT in professional soccer players. METHODS: Maximal exercise stress tests were carried out by a ramp protocol using a treadmill on 20 professional soccer players with a mean age of 25.2 years and with over 10 career years. The tests were also done on 21 college students majoring in physical education with a mean age of 19.4 years, which served as the control group. The AT was determined by the V-slope method. RESULTS: In the players, the VO2 max, VCO2 max and O2 pulse max were significantly larger than those in the control group, and the HR max was smaller for their ages. The VE max, VT max and RP max showed not much difference between the 2 groups but the VE max/VO2 max and VE max/VCO2 max were significantly lower in the players. The AT was larger in the players but the AT/VO2 max was essentially similar to that of the control group. CONCLUSION: Our study reveals that the professonal soccer players, despite their mean ages were approximately 6 years older than the subjects in the control group, had larger VO2 max and VCO2 max, and smaller HR max for their ages. The VE max was similar in both groups. This suggests that the players have higher aerobic capacity than the control group and exchange respiratiory gases more efficiently.

Cardiorespiratory response to maximal exercise loading in mild anemia

BACKGROUND: Mild iron deficiency anemia is known to be asymptomatic in most of the cases. In view of this, we studied response of the mild anemics to the maximal exercise loading test to learn whether or not they respond similarly to the normals. METHODS: The maximal exercise loading tests by Bruce's protocol were carried out in 22 female asymptomatic anemics with hemoglobin level of between 10.0gm/dL and less than 12.0gm/dL, and the results were compared with those of 44 non-anemic matched controls with mean hemoglobin level of 13.1gm/dL. The ages in both groups were in their 30's to 40's, and even the anemics were otherwise normal clinically and on various laboratory tests. RESULTS: There were no significant difference between two groups in VO2 max, HR max, VCO2 max and VE max and their derivatives including VT/VC and VE/MVV. CONCLUSIONS: Our results indicate that in patients with mild iron deficiency anemia, the cardiorespiratory response to maximal exercise loading is not different from the normals, and suggest that oxygen transport to tissues is not affected even at maximal exercise. probably by adaptive compensatory mechanism.

The Relationship between ST-T Electrical Alternans on EKG and Ventricular Arrhythmia

In order to observe the development of ventricular arrhythmia during regional myocardial ischemia and reperfusion, especially under the presence or absence of ST-T electrical alternans on epicardial EKG. The proximal left descending coronary artery(LAD) was ligated for 20 minutes and then reperfused suddenly in twenty-three cats. Standard lead EKG(Lead??, chest lead EKG and epicardial lead EKG were recorded simultaneously during the occlusion and reperfusion respectively. During the ligation of LAD, STEA was observed in thirteen cats(56.5%). In occlusion period, the incidence of ventricular tachycardia in STEA positive group was significantly higher than in the negative group(p<0.01) and arrhythmic score was significantly higher(p<0.005) also In the reperfusion period the incidence of vefntricular fibrillation in STEA positive group was significantly higher than in the negative group(p<0.025). But there was the tendency to be higher in arrhythmic score of STEA positive group. There were no differences in heart rate, systolic left ventricular pressure, ST elevation and ST width in both groups. Most forms of ST-T of sinus rhythm before and after development of ventricular premature beat was low form(L). It was concluded that at the presence of STEA on EKG, the incidence of ventricular arrhythmia was more prevalent. So, STEA can be available as a marker of ventricular arrhythmia and prognostic factor.

Comparison of ECG Findings between Hypertrophic Obstructive Cardiomyopathy and Hypertension with Disproportionate Septal Thickening

Electrocardiographic findings in 18 cases of hypertrophic obstructive cardiomyopathy(HOCM) were compared with those in 20 hypertensives with disproportinate septal hypertrophy(DSH) and in 20 normal controls. In conventional 12 leads electrocardiograms, abmormal Q waves were seen only in 6 cases of HOCM and none in the remadinder. The R waves were tallest in leads V4 in 6 cases(33%) of HOCM, 3(15%) hypertensives with DSH, and 4(20%) of the controls. The correlations of the QRS voltages with echocardiographically measured left ventricular dimension, interventricular septal thickness and left ventricular mass were significant in the hypertensives with DST and normal controls, but insignificant in patients with HOCM. We conclude that these electrocardiographic differences in patients with HOCM from the others would be caused by uneven distribution of hypertrophied muscle mass in the left ventricule and/or by the altered depolarization in hypertrophied cardiac muscles.