Association of Early Hysterectomy With Risk of Cardiovascular Disease in Korean Women.

Importance: Women who undergo surgical hysterectomy before natural menopause may have an earlier increase in hematocrit and storage iron levels than those who continue menstruation, thereby increasing the risk of cardiovascular disease (CVD) at ages younger than usually seen. Examining this issue may provide important implications for women's cardiovascular health to both physicians and patients. Objective: To evaluate the association of hysterectomy with the risk of incident CVD among women before age 50 years. Design, Setting, and Participants: In this Korean population-based cohort study, 135 575 women aged 40 to 49 years were evaluated from January 1, 2011, to December 31, 2014. After propensity score matching in covariates including age, socioeconomic status, region, Charlson Comorbidity Index, hypertension, diabetes, dyslipidemia, menopause, menopausal hormone therapy, and adnexal surgery before inclusion, 55 539 pairs were included in the hysterectomy and nonhysterectomy groups. Participants were followed up until December 31, 2020. Data analysis was conducted from December 20, 2021, to February 17, 2022. Main Outcomes and Measures: The primary outcome was an incidental CVD, a composite of myocardial infarction, coronary artery revascularization, and stroke. The individual components of the primary outcome were also evaluated. Results: A total of 55 539 pairs were included; median age in the combined groups was 45 (IQR, 42-47) years. During median follow-up periods in the hysterectomy group of 7.9 (IQR, 6.8-8.9) years and nonhysterectomy group of 7.9 (IQR, 6.8-8.8) years, the incidence of CVD was 115 per 100 000 person-years for the hysterectomy group and 96 per 100 000 person-years for the nonhysterectomy group. After adjusting for confounding factors, the hysterectomy group had an increased risk of CVD compared with the nonhysterectomy group (hazard ratio [HR], 1.25; 95% CI, 1.09-1.44). The incidences of myocardial infarction and coronary artery revascularization were comparable between the groups, whereas the risk of stroke was significantly higher in the hysterectomy group (HR, 1.31; 95% CI, 1.12-1.53). Even after excluding women who underwent oophorectomy, the hysterectomy group had higher risks of CVD (HR, 1.24; 95% CI, 1.06-1.44). Conclusions and Relevance: The findings of this cohort study suggest early menopause owing to hysterectomy was associated with increased risks for a composite of CVD, particularly stroke.

Effect of direct stenting on microvascular dysfunction during percutaneous coronary intervention in acute myocardial infarction: a randomized pilot study.

OBJECTIVE: Whether direct stenting (DS) without predilatation during primary percutaneous coronary intervention (PPCI) reduces microvascular dysfunction in patients with ST-elevation myocardial infarction is unclear. We performed a randomized study to assess the effect of DS on microvascular reperfusion. METHODS: Seventy-two patients undergoing PPCI were randomly assigned to the DS or conventional stenting (CS) with predilatation groups. The primary endpoint was the post-PPCI index of microcirculatory resistance (IMR). We compared thrombolysis in myocardial infarction myocardial perfusion (TMP) grades, ST-segment resolution, and long-term clinical outcomes between the groups. RESULTS: Microvascular reperfusion parameters immediately after PPCI (e.g., the IMR, TMP grade, and ST-segment resolution) were not different between the groups. However, significantly fewer patients in the DS group had the IMR measured because of no-reflow or cardiogenic shock during PPCI than those in the CS group. No differences were found in left ventricular functional recovery or clinical outcomes between the groups. CONCLUSIONS: This trial showed no effect of DS on the IMR. However, our finding should be interpreted with caution because the number of patients who could not have the IMR measured was higher in the CS group than in the DS group. A larger randomized trial is required (Research Registry number: 8079).

Takotsubo syndrome presenting with high-degree atrioventricular block with ventricular asystole.

Takotsubo syndrome (TS) is a reversible form of cardiomyopathy characterized by transient systolic dysfunction with regional wall motion abnormalities and absence of coronary artery obstruction, which can be precipitated by severe emotional or physical stress. Its clinical presentation is similar to that of acute coronary syndrome. However, TS presenting with atrioventricular (AV) block with ventricular asystole is rarely reported. In this article, we describe the case of a postmenopausal woman who experienced near cardiac arrest due to high-degree AV block. Although transthoracic echocardiography revealed left ventricular dysfunction with severe global hypokinesia, coronary angiography and cardiac magnetic resonance imaging showed normal coronary arteries without myocardial scarring. The patient's condition improved after permanent pacemaker implantation and medical treatment for heart failure. Echocardiography and pacemaker analysis at two-month follow-up revealed normalization of heart function and cardiac rhythm, and the patient was finally diagnosed with TS. .

Elevated C-Reactive Protein/Albumin Ratio Is Associated With Lesion Complexity, Multilevel Involvement, and Adverse Outcomes in Patients With Peripheral Artery Disease.

Inflammation plays an important role in the progression of peripheral artery disease (PAD). We investigated the predictive value of the C-reactive protein-to-albumin ratio (CAR) on the severity of PAD and outcomes after endovascular therapy (EVT). Patients (n = 307) with PAD who underwent EVT were retrospectively reviewed and categorized according to CAR tertiles. The groups were compared for the prevalence of complex lesions and multilevel involvement as well as the incidence of major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The rates of complex lesions and multilevel involvement increased with increasing CAR tertiles (all P < .001). These associations remained significant even after adjustment for other confounders (complex lesion odds ratio, 1.22 [1.03-1.50]; P = .036; multilevel disease odds ratio, 1.20 [1.01-1.44]; P = .041). The third CAR tertile showed a significantly higher incidence of MACEs and MALEs than the second and first tertiles within a year (log-rank P < .001). A higher CAR as a continuous variable was also independently associated with the 4-year rate of MACE (hazard ratio, 1.20 [1.04-1.38]; P = .015). Elevated CAR was a powerful surrogate marker of severe PAD and worse outcomes. Thus, CAR might become a predictor of poor prognosis in patients with PAD.

Impact of Statin Treatment Intensity after Endovascular Revascularization on Lower Extremity Peripheral Artery Disease.

PURPOSE: Only a few Asian studies have discussed the impact of statin intensity on clinical outcomes in patients with peripheral artery disease (PAD). We aimed to investigate the clinical impact of statin intensity in patients with PAD after endovascular revascularization. MATERIALS AND METHODS: From April 2009 to June 2019, 376 patients with lower extremity PAD treated with endovascular revascularization were enrolled. They were classified into three groups according to statin intensity: no-statin, low-to-moderate intensity (LMI), and high-intensity (HI). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE). RESULTS: During the 40-month follow-up, MACE occurred less frequently in the HI and LMI groups than the no-statin group (11.4% vs. 16.0% vs. 39%, p<0.001). In adjusted Cox models, the HI group had the fewest MACE [hazard ratio (HR): 0.447; 95% confidence interval (CI): 0.244-0.834; p=0.018] and MALE (HR: 0.360; 95% CI: 0.129-1.006; p=0.051) events, while the LMI group had fewer MACE (HR: 0.571; 95% CI: 0.326-1.0; p=0.050) events than the no-statin group. HI statin therapy was associated with better outcomes in terms of MALE (HR: 0.432; 95% CI: 0.223-0.837; p=0.003) than LMI statin therapy after inverse probability treatment weighting analysis. CONCLUSION: HI and LMI statin use is associated with a significant reduction in MACE events than no-statin use. HI statin use was associated with better MALE outcomes than no-statin or LMI statin use.

Ambulatory blood pressure response to S-amlodipine in Korean adult patients with uncontrolled essential hypertension: A prospective, observational study.

Although amlodipine is recommended as the first-line therapy for the treatment of hypertension, its use is limited by its potential side effects. S-amlodipine is expected to be able to minimize side effects of amlodipine with a similar antihypertensive effect by removing the malicious R-chiral form. However, sustainable blood pressure control with S-amlodipine has not been well established yet. The purpose of the current study was to evaluate ambulatory blood pressure (ABP) profiles before and after a 12-week treatment of S-amlodipine. Patients received once-daily S-amlodipine 2.5 or 5 mg. ABP during 24 hr and office blood pressure were measured at baseline and after the 12-week treatment. Primary endpoints were changes of systolic and diastolic 24 hr ABP. After 12-week S-amlodipine treatment, mean systolic ABP (-15.1 ± 16.2 mmHg, p < .001) and diastolic ABP (-8.9 ± 9.8 mmHg, p < .001) were decreased significantly. Both daytime and night-time mean systolic BP and diastolic BP were also significantly decreased after the 12-week treatment. Global trough-to-peak ratio and smoothness index after 12-week S-amlodipine treatment were .75 and .79 for SBP and .65 and .61 for DBP, respectively. Age ≥65 years (hazard ratio [HR]: 3.13; 95% confidence interval [CI]: 1.67-14.3) and nonalcohol drinking (HR: 3.09; 95% CI: 1.34-7.17) were independent clinical factors for target ABP achievement. Adverse drug reactions (ADR) were developed in 16 (6.4%) patients, including two (.8%) cases of peripheral edema. In conclusion, this study demonstrated the efficacy and safety of S-amlodipine in patients with uncontrolled essential hypertension.

Comparison of the improvement of flow-mediated dilatation in patients with acute coronary syndrome versus stable angina after six-month cardiac rehabilitation.

BACKGROUND: We investigated whether the improvement in endothelial function, measured using flow-mediated dilatation (FMD), an important predictor of cardiovascular outcomes, was comparable in acute coronary syndrome (ACS) versus stable angina patients after percutaneous coronary intervention (PCI) and a six-month cardiac rehabilitation (CR) programme. METHODS: We analysed the results from 119 patients who completed a six-month CR programme after successful PCI for stable angina (n = 50) and ACS (n = 69). RESULTS: After six months of CR, the results of FMD were significantly improved in both groups. There were no significant between-group differences in the FMD results at the six-month follow up. CONCLUSIONS: After successful PCI and a six-month CR programme, FMD values were equally improved in both stable angina and ACS patients.

Bioresorbable Vascular Scaffolds Versus Drug-Eluting Stents for Diffuse Long Coronary Narrowings.

Clinical benefits of bioresorbable vascular scaffold (BVS) implantation for long coronary lesions were not sufficiently evaluated. The efficacy and safety of BVS and metallic everolimus-eluting stent (EES) were compared for the treatment of long coronary narrowings. A total of 341 patients with diffuse long lesions (requiring device length ≥28 mm) were randomized to receive either BVS (n = 171) or EES (n = 170) implantation. The primary endpoint was major adverse cardiovascular events which included death from cardiac cause, myocardial infarction, device thrombosis, or ischemia-driven target-lesion revascularization at 12 months. The trial was terminated early because the manufacturer stopped supplying BVS. The mean lesion length was 32.2 ± 13.1 mm in the BVS group and 35.3 ± 13.0 mm in the EES group. The 12-month follow-up was completed in 332 patients (97.4%). At 12 months, the primary endpoint events occurred in 2 patients (1.2%) in the BVS group and in 4 patients (2.4%) in the EES group (hazard ratio = 0.49, 95% confidence interval = 0.09 to 2.67, p = 0.398). Definite or probable device thrombosis occurred in 1 patient (0.6%) in the BVS group and 1 patient (0.6%) in the EES group (hazard ratio = 1.00, 95% confidence interval = 0.06 to 15.94, p = 0.998). In conclusion, in patients with long native coronary artery disease, significant differences between BVS and EES were not observed regarding the primary composite endpoint of death from cardiac cause, myocardial infarction, device thrombosis, or target-lesion revascularization at 12 months. However, due to the early termination of this trial and a low number of events, the results cannot be considered clinically relevant (clinicalTrials.gov Identifier: NCT02796157).

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

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

The prognostic value of 2D strain in assessment of the right ventricle in patients with dilated cardiomyopathy.

AIMS: Several studies have been reported using right ventricular (RV) strain as a method for evaluating RV function in patients with various cardiovascular diseases; however, the clinical relevance of RV strain in dilated cardiomyopathy (DCM) patients with sinus rhythm is unknown. The aim of this study was to investigate the relationship between RV strain and adverse events in DCM patients with sinus rhythm. METHODS AND RESULTS: We enrolled 143 DCM patients with sinus rhythm who had been first diagnosed, evaluated, and followed at Sanggye Paik Hospital between March 2013 and August 2017. We performed echocardiography and measured RV strain values using the apical four-chamber view. The mean age was 64.6 years. During the median follow-up period of 40.0 months, adverse cardiovascular events developed in 21 patients (14.7%). By Cox proportional hazards multivariate analysis, only RV free wall longitudinal strain (RV-FWLS) independently predicted the primary outcome. Receiver-operating characteristic curve analysis showed that the optimal RV-FWLS cut-off value to identify patients with an event was -16.5% (area under the curve = 0.703, P = 0.003). When we divided the subjects into two groups based on the RV-FWLS of -16.5%, patients with RV-FWLS <-16.5% showed more favourable clinical outcomes than that in those with RV-FWLS ≥-16.5% (log-rank test, P < 0.001). CONCLUSION: RV-FWLS was associated with a significant prognostic impact in DCM patients with sinus rhythm.

Kallmann syndrome with a Tyr113His PROKR2 mutation.

RATIONAL: Kallmann syndrome (KS) is a genetic gonadotropin-releasing hormone deficiency associated with hyposmia or anosmia and characterized by various modes of inheritance. PATIENT CONCERNS: A 16-year-old male did not reach puberty and was associated with hypogonadotropic hypogonadism and anosmia. His magnetic resonance imaging of brain revealed the absence of the olfactory bulb. DIAGNOSIS: His karyotype was 46 XY. Sanger sequencing of the KAL1 gene revealed no mutations. Diagnostic exome sequencing identified a prokineticin-receptor 2 (PROKR2) gene variant, c.337T > C (p.Tyr113His), previously reported to be a pathogenic mutation; we confirmed the presence of the mutation via Sanger sequencing of the coding exons of PROKR2. His apparently unaffected mother and sister, but not his father, were heterozygous for the PROKR2 Tyr113His mutation. LESSONS: This work advances our understanding of the role played by PROKR signaling and the mode of inheritance of the gene in patients with KS.

Study to find the best extraction solvent for use with guava leaves (Psidium guajava L.) for high antioxidant efficacy.

The effects of guava leaves extracted using solvents of water, ethanol, methanol, and different concentrations of hydroethanolic solvents on phenolic compounds and flavonoids, and antioxidant properties have been investigated. The antioxidant capability was assessed based on 2,2-diphenyl-1-picrylhydrazyl radical and 2,2'-azinobis-(3-ethylbenzothiazoline-6-sulfonic acid) radical-scavenging abilities, reducing power, and nitric oxide-and nitrate-scavenging activities. The results demonstrated that the antioxidant ability of guava leaf extracts has a strong relationship with phenolic compound content rather than flavonoid content. Phenolic compound content of water extracted guava leaves was higher compared to pure ethanol and methanol extracts. However, phenolic compound content extracted using hydroethanolic solvent was higher than water, whereas 50% hydroethanolic was observed to be the most effective solvent showing high antioxidant ability.