Predictors of Significant Coronary Artery Disease in Patients with Cerebral Artery Atherosclerosis.

OBJECTIVE: There are few existing data on the status of coronary artery disease (CAD) in patients with atherosclerosis of the cerebral artery detected by brain imaging studies. We aimed to analyze the predictors of asymptomatic angiographically significant CAD detected by simultaneous cerebral and coronary angiography. METHODS: This retrospective cohort study screened data obtained between August 2009 and April 2019; 11,047 patients underwent cerebral angiography for atherosclerotic change (>50% stenosis or aneurysm) seen in brain magnetic resonance angiography (MRA) or computed tomography angiography (CTA) at a single center by endovascular neurosurgeon's decision. Of these, 700 patients including 622 patients who underwent simultaneous coronary and cerebral angiography and 78 patients who underwent coronary angiography within a month were enrolled. We investigated the characteristics and predictors of angiographically significant CAD (>50% stenosis). Furthermore, we also analyzed the major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, myocardial infarction, and stroke for 5 years. RESULTS: The frequency of significant CAD was 59% (413/700), the mean age was 68.9 ± 10.3 years, and 60.6% were male. During mean follow-up of 50 months, the MACCE rate of our whole cohort was significantly higher in the CAD group (21.5%) than in the non-CAD group (14.6%; hazard ratio 1.65, 95% CI 1.17-2.33, p value = 0.005). Considering that the embolic stroke is less associated with atherosclerotic change, our predictive model of significant CAD was made without embolic stroke (n = 599). In our multivariate model 2 including univariate <0.1, the independent predictors of significant CAD were male (OR 1.62, 95% CI 1.11-2.35, p = 0.012), diabetes mellitus (OR 1.81, 95% CI 1.22-2.68, p = 0.003), previous stroke (OR 1.63, 95% CI 1.02-2.60, p = 0.039), low ankle-brachial index (ABI; <0.9; OR 3.25, 95% CI 1.21-8.73, p = 0.019), left ventricular ejection fraction (EF) <50% on echocardiography (OR 2.82, 95% CI 1.25-6.35, p = 0.012), troponin I or T positive (OR 2.76, 95% CI 1.69-4.53, p < 0.001), and complex features on cerebral angiography (OR 2.73, 95% CI 1.78-4.19, p < 0.001). CONCLUSIONS: Accurate coronary evaluation by coronary angiography might be considered when patients with atherosclerotic cerebral artery detected on brain MRA or CTA planned cerebral angiography were male or have diabetes mellitus, previous stroke, low ABI (<0.9), left ventricular EF <50% on echocardiography, troponin I or T positivity, and complex features on cerebral angiography.

Association of the plasma aldosterone concentration, left atrial deformation and ambulatory blood pressure in never-treated early hypertensive patients.

Left atrial (LA) strain is known to exhibit an early progressive reduction in hypertensive patients with diastolic dysfunction. However, an association of the renin-angiotensin-*aldosterone system (RAAS) with LA deformation has not been found in these patients. We aimed to investigate the association of plasma aldosterone concentration (PAC) and 24-hour ambulatory blood pressure monitoring (ABPM) with LA and left ventricle (LV) deformation in never-treated early hypertensive patients. This cross-sectional study included 101 never-treated subjects who were registered in a working group at The Catholic University of Korea. The patients were divided into a hypertension group (n = 71), which was defined as having a systolic blood pressure (BP) ≥130 mm Hg and/or a diastolic BP ≥80 mm Hg based on ABPM, and a control group (n = 30). Enrolled patients underwent conventional and speckle tracking echocardiography, ABPM, and measurement of pulse wave velocity, PAC, and plasma renin activity. Compared with the control group, the hypertension group had significantly increased PAC, global longitudinal strain (GLS), atrial reservoir strain, atrial pump strain, and atrial systolic strain rate. LA pump strain was independently associated with nighttime systolic BP. PAC was correlated with GLS but not LA deformation in hypertensive patients without clinically apparent target organ damage. The raised LV pressure secondary to the nocturnal systemic pressure overload might be more strongly associated with LA deformation than with the RAAS.

The impact of preload on 3-dimensional deformation parameters: principal strain, twist and torsion.

BACKGROUND: Strain analysis is feasible using three-dimensional (3D) echocardiography. This approach provides various parameters based on speckle tracking analysis from one full-volume image of the left ventricle; however, evidence for its volume independence is still lacking. METHODS: Fifty-eight subjects who were examined by transthoracic echocardiography immediately before and after hemodialysis (HD) were enrolled. Real-time full-volume 3D echocardiographic images were acquired and analyzed using dedicated software. Two-dimensional (2D) longitudinal strain (LS) was also measured for comparison with 3D strain values. RESULTS: Longitudinal (pre-HD: -24.57 ± 2.51, post-HD: -21.42 ± 2.15, P < 0.001); circumferential (pre-HD: -33.35 ± 3.50, post-HD: -30.90 ± 3.22, P < 0.001); and radial strain (pre-HD: 46.47 ± 4.27, post-HD: 42.90 ± 3.61, P < 0.001) values were significantly decreased after HD. The values of 3D principal strain (PS), a unique parameter of 3D images, were affected by acute preload changes (pre-HD: -38.10 ± 3.71, post-HD: -35.33 ± 3.22, P < 0.001). Twist and torsion values were decreased after HD (pre-HD: 17.69 ± 7.80, post-HD: 13.34 ± 6.92, P < 0.001; and pre-HD: 2.04 ± 0.86, post-HD:1.59 ± 0.80, respectively, P < 0.001). The 2D LS values correlated with the 3D LS and PS values. CONCLUSION: Various parameters representing left ventricular mechanics were easily acquired from 3D echocardiographic images; however, like conventional parameters, they were affected by acute preload changes. Therefore, strain values from 3D echocardiography should be interpreted with caution while considering the preload conditions of the patients.

Effects of active rehabilitation therapy on muscular back strength and subjective pain degree in chronic lower back pain patients.

[Purpose] This study applied active rehabilitation therapy to muscular back strength and assessed the subjective pain degree in chronic low back pain patients. [Subjects and Methods] Subjects were randomly assigned to two groups: experimental (n=8) and control (n=8). The experimental group performed two types of rehabilitation therapy programs four times per week for eight weeks. The rehabilitation program was based on the Korea Occupational Safety and Health Agency's program. There were several types of stretching and strengthening. Back strength was measured using the Back Muscle Dynamometer TKK-5402. The visual analog scale score, selected to measure degrees of subjective pain, was used to assess treatment efficacy. [Results] For the experimental group, muscular back strength increased from 133.90 ± 11.84 kg before exercise to 145.59 ± 14.49 kg after exercise. In the control group, muscular back strength decreased from 133.92 ± 3.84 kg before exercise to 133.90 ± 5.81 kg after exercise. In the experimental group, the visual analog scale score for subjective pain decreased from 6.63 ± 0.52 before exercise to 5.75 ± 0.46 after exercise; in the control group, it decreased from 5.61 ± 0.52 before exercise to 5.61 ± 0.52 after exercise. [Conclusion] Active rehabilitation therapy is a positive intervention that can provide relief from back pain.

Usefulness of the parameters of quantitative myocardial perfusion contrast echocardiography in patients with chronic total occlusion and collateral flow.

BACKGROUND: Microvascular obstruction becomes more severe with longer duration of ischemia, such as chronic total occlusion (CTO) which used to have collateral flow. In this study, we explored the correlation between parameters measured using quantitative myocardial perfusion contrast echocardiography (MCE) and the angiographic collateral flow grades in patients with CTO. Furthermore, we investigated the usefulness of the parameters of quantitative MCE for the measurement of microvasculature changes after revascularization of CTO lesions. METHODS: Between January 2011 and January 2013, 44 patients who had undergone coronary angiography (CAG) due to chest pain and had confirmed CTO lesions were enrolled in this prospective observational study. All patients had baseline MCE within 24 hours after diagnostic CAG. Patients were then assigned to one of two groups: a medical therapy group (Group I, n = 20) or a reperfusion group with percutaneous coronary intervention (PCI) (Group II, n = 24). All patients had follow-up MCE 3 months later. RESULTS: Consistent with the CAG results in both groups, on baseline MCE, the myocardial blood flow (AI × ß) values were higher in Grade III collateral flow than in Grade I or II collateral flow (AI of collateral flow Grade I vs. Grade II vs. Grade III: 2.34 ± 2.65 vs. 2.52 ± 2.67 vs. 3.87 ± 4.57, P = 0.038). The plateau acoustic intensity (AI) and wall-motion score index (WMSI) were significantly improved at the 3-month follow-up after successful reperfusion with PCI (5.75 ± 3.52 before vs. 8.11 ± 6.02 after, P = 0.004) and (1.76 ± 0.83 before vs. 1.43 ± 0.64 after, P ≤ 0.001), respectively. However, the AI and WMSI values were not improved in the medical treatment group, (6.04 ± 4.64 before vs. 6.01 ± 5.52 after, P = 0.966) and (1.61 ± 0.82 before vs. 1.66 ± 0.67 after, P = 0.616), respectively. CONCLUSIONS: MCE is a useful tool for estimating microvascularity in patients with CTO lesions and correlates well with angiographic collateral flow.

Negative association between plasma aldosterone concentration/plasma renin activity and morning blood pressure surge in never-treated hypertensive patients.

Morning blood pressure (BP) surge (MS) has been known to be a predictor of cardiovascular events. Currently, few studies have evaluated the underlying mechanism underlying MS, which may include neurohormonal factors and the renin-angiotensin-aldosterone system (RAAS). This study aimed to examine plasma aldosterone concentration (PAC) and plasma renin activity (PRA) and BP parameters with or without MS in never-treated subjects with essential hypertension. This cross-sectional study included a total of 261 patients (mean age: 48.8 years; 60.5% male) with never-treated essential hypertension who were registered in a working group at The Catholic University of Korea. The patients were divided into the MS group, which was defined as having the highest quartile of morning BP increase from sleep (>31 mmHg; n = 66) and the non-MS group (≤31 mmHg; n = 195). We collected 24-h ambulatory BP, pulse wave velocity, ankle brachial index, PAC and PRA from all patients. The measured PAC and PRA were lower in the MS group than in the non-MS group (PAC: 9.0 ± 5.4 ng/dl versus 12.2 ± 8.7 ng/dl, p < 0.001; PRA: 1.7 ± 1.3 ng/ml/h versus 2.6 ± 3.6 ng/ml/h, p = 0.002). The MS group had greater variations in daytime, nighttime and 24-h systolic blood pressure (SBPs) than the non-MS group (24-h SBP: 15.6 ± 4.4 mm Hg for the non-MS group and 18.9 ± 4.9 mmHg for the MS group; p < 0.001 for each). It is generally accepted that the sympathetic nervous system plays a major role in the regulation of BP variability. Therefore, further studies on sympathetic nervous system activation in hypertensives with extreme MS are needed. MS in enrolled patients who were at relatively low risk in this study may be less affected by the RAAS.

PRE-OPerative ECHOcardiograhy for prevention of cardiovascular events after non-cardiac surgery in intermediate- and high-risk patients: protocol for a low-interventional, mixed-cohort prospective study design (PREOP-ECHO).

BACKGROUND: Cardiac evaluation using transthoracic echocardiography before noncardiac surgery is common in real-world practice. However, evidence supporting preoperative echocardiography is lacking. This study aims to evaluate the additional benefit of preoperative echocardiography in predicting postoperative cardiovascular events (CVE) in noncardiac surgery. METHODS: This study is designed as a multicenter, prospective study to assess the utility of preoperative echocardiography in patients undergoing intermediate- or high-risk noncardiac surgery. This trial comprises two studies: (1) a randomized controlled trial (RCT) for patients undergoing intermediate-risk surgery with fewer than three clinical risk factors from the revised cardiac risk index (intermediate-risk group) and (2) a prospective cohort study for patients undergoing intermediate-risk surgery with three or more clinical risk factors, or who undergo high-risk surgery regardless of the number of clinical risk factors (high-risk group). We hypothesize that the use of preoperative echocardiography will reduce postoperative CVEs in patients undergoing intermediate- to high-risk surgery through discovery of and further intervention for unexpected cardiac abnormalities before elective surgery. A total of 2330 and 2184 patients will be enrolled in the two studies. The primary endpoint is a composite of all-cause death; aborted sudden cardiac arrest; type I acute myocardial infarction; clinically diagnosed unstable angina; stress-induced cardiomyopathy; lethal arrhythmia, such as sustained ventricular tachycardia or ventricular fibrillation; and/or newly diagnosed or acutely decompensated heart failure within 30 days after surgery. DISCUSSION: This study will be the first large-scale prospective study examining the benefit of preoperative echocardiography in predicting postoperative CVE. The PREOP-ECHO trial will help doctors identify patients at risk of postoperative CVE using echocardiography and thereby reduce postoperative CVEs. TRIAL REGISTRATION: The Clinical Research Information Service KCT0006279 for RCT and KCT0006280 for prospective cohort study. Registered on June 21, 2021.

Dyssynchrony contributes to false-positive myocardial perfusion SPECT results in patients with stable angina.

AIM: We designed this study to evaluate the possibility that dyssynchrony might lead to false-positive myocardial perfusion single photon emission computed tomography myocardial perfusion image (MPS) results in stable angina patients. METHODS AND RESULTS: This study included 61 patients with both clinically diagnosed stable angina and quantitative MPS results who underwent coronary angiography. The patients were divided into two groups: those who had positive MPS results and normal coronary angiography (Group I, n = 28, 64.05 ± 10.14 years, 11 males and 17 females) and those who had positive MPS results and significant coronary lesions as determined by coronary angiography (Group II, n = 33, 69.2 ± 10.4 years, 14 males and 19 females). The maximal difference in time-to-peak myocardial sustained systolic velocity among all 12 left ventricular (LV) segments (maximal difference in TS) was significantly delayed in Group I as compared with Group II (125.00 ± 46.10 vs. 87.33 ± 40.53 ms, P=0.001). The standard deviation of the time-to-peak myocardial sustained systolic velocity of all 12 LV segments (TS-SD) was also significantly different in the two groups (45.12 ± 19.25 vs. 30.10 ± 15.80 , P=0.002). CONCLUSION: Dyssynchrony may be a cause of false-positive quantitative MPS results, even if patients have narrow QRS complexes on ECG. Dyssynchrony index can increase the specificity of quantitative MPS in stable angina patients.

Morning blood pressure surge in the early stage of hypertensive patients impacts three-dimensional left ventricular speckle tracking echocardiography.

BACKGROUND: The aim of this study was to examine left ventricular (LV) function in untreated, newly diagnosed hypertensive patients with morning blood pressure surge (MBPS) status using three-dimensional (3D) speckle tracking echocardiography (STE). METHODS: In this study, 163 newly diagnosed hypertensive patients were included, and all patients underwent 24-h ambulatory blood pressure monitoring (ABPM). According to ABPM, participants were divided into a MBPS group and a non-MBPS group. The entire study population was examined by complete two-dimensional (2D) transthoracic echocardiography (TTE) and 3D STE. RESULT: The results of this study showed that 3D LV longitudinal strain was significantly decreased in the MBPS group compared with the non-MBPS group (- 30.1 ± 2.0 vs. -31.1 ± 2.7, p = 0.045). Similar trends were observed for 3D twist (9.6 ± 6.1 vs. 12.1 ± 4.8, p = 0.011) as well as for 3D torsion (1.23 ± 0.78 vs. 1.49 ± 0.62, p = 0.042). The LV principal strain was decreased in the MBPS group (- 33.9 ± 1.7 vs. -35.5 ± 2.8, p < 0.001). The 3D LV global longitudinal strain (GLS) and principal strain were significantly associated with quartile of MBPS as measured by systolic blood pressure (SBP). CONCLUSION: The 3D STE revealed that LV mechanics were more impaired in the MBPS group than in the non-surge newly diagnosed, untreated hypertensive patients; even the 2D TTE parameters showed no difference.

Candesartan and carvedilol for primary prevention of subclinical cardiotoxicity in breast cancer patients without a cardiovascular risk treated with doxorubicin.

BACKGROUND: There is no proven primary preventive strategy for doxorubicin-induced subclinical cardiotoxicity (DISC), especially among patients without a cardiovascular (CV) risk. We investigated the primary preventive effect on DISC of the concomitant use of angiotensin receptor blockers (ARBs) or beta-blockers (BBs), especially among breast cancer patients without a CV risk. METHODS: A total of 385 patients who were scheduled for doxorubicin chemotherapy were screened. Among them, 195 patients of the study populations were included and were randomly divided into two groups [candesartan 4 mg q.d. vs. carvedilol 3.125 mg q.d.] and patients who were unwilling to take one of the medications were evaluated as controls. The primary outcomes were the incidence of early DISC (DISC developing within 6 months after chemotherapy), and late DISC (DISC developing only at least 12 months after chemotherapy). RESULT: Compared with the control group (8 out of 43 patients (18.6%)), only the candesartan group (4 out of 82 patients (4.9%)) showed a significantly lower incidence of early DISC (p = 0.022). Compared with the control group, the candesartan group demonstrated a significantly reduced decrease in left ventricular ejection fraction (LVEF) throughout the study period [-1.0% vs. -3.00 (p < 0.001) at the first follow-up, -1.10% vs. -3.40(p = 0.009) at the second follow-up]. CONCLUSIONS: Among breast cancer patients without a CV risk treated with doxorubicin-containing chemotherapy, subclinical cardiotoxicity is prevalent and concomitant administration of low-dose candesartan might be effective to prevent an early decrease in LVEF. Further large-scale, randomized controlled trials will be needed to confirm our findings.

Relationship between resting electrocardiographic parameters and estimated 10-year risk for coronary heart disease in healthy adults in the USA.

BACKGROUND: Little is known about the relationship between resting electrocardiogram (ECG) parameters and the incidence of coronary heart disease (CHD). We sought to establish the association between ECG parameters and estimated 10-year risk for CHD. METHODS: We applied the risk prediction algorithm used by the National Cholesterol Education Program Adult Treatment Panel III guidelines to data from 6399 individuals in the Third National Health and Nutrition Examination Survey (aged 40-79 years) who had sinus rhythm, no previous heart disease, and no evidence of prior myocardial infarction according to the 12-lead Minnesota Code. We used multiple linear and logistic regression models to determine the relationship between 10-year risk for CHD and levels of resting ECG parameters. RESULTS: After adjusting for age, gender, race, and body mass index, individuals with high risk had higher heart rate (HR), left ventricular mass index (LVMI), and cardiac infarction injury score (CIIS), and longer HR-corrected QT (QTc) interval than those with low risk. In models fully adjusted for coronary risk factors, individuals in the highest quintile of HR, PR, and QTc interval were 2.2, 0.7, and 1.8 times, respectively, more likely to have a high 10-year risk as those in the lowest quintiles. There are dose-dependent associations between HR, LVMI, CIIS, and QTc interval and the 10-year risk group. CONCLUSIONS: These findings indicate that high HR, LVMI, and CIIS and prolonged QTc interval are positively and prolonged PR interval is negatively associated with high 10-year risk for CHD in a general population.

Massive pulmonary thromboembolism combined with transient thyrotoxicosis in an 18 year old girl.

BACKGROUND: Pulmonary thromboembolism (PTE) is thought to usually stem from deep vein thrombosis (DVT). However, evidence of DVT could not be found in many cases. Furthermore, transient thyrotoxicosis is a rare but potentially life-threatening emergency involving a systemic hypercoagulable state. We report on an 18 year-old-girl with transient thyrotoxicosis with massive PTE without DVT. CASE PRESENTATION: An 18-year-old girl was admitted to the hospital with syncope. Patient had no history of trauma, any known underlying disease or oral contraceptives use. Chest computed tomography (CT) showed massive PTE in both central pulmonary arteries and diffuse goiter. However, a low extremity Doppler sonogram did not detect DVT. To manage the PTE, we administered low molecular weight heparin. On the other hands, thyroid function test indicated a state of thyrotoxicosis. In addition, patient had a partial protein S deficiency but no other immunologic abnormality. Therefore, the patient was diagnosed with massive PTE, thyrotoxicosis, and partial protein S deficiency. Patient was discharged with oral warfarin and methimazole. A follow-up echocardiogram obtained 3 months after anticoagulation therapy demonstrated normal dimensions and systolic function. After thyrotoxicosis was treated with methimazole for a month, a euthyroid state was achieved and the goiter decreased to a normal size. The methimazole was gradually tapered off and stopped at 4 months. At a 6-month follow up visit, PTE and pulmonary hypertension had disappeared but the patient still had a partial protein S deficiency. We decided to stop all medication with careful monitoring. During a 4-year follow-up period after the episode, she was asymptomatic without any evidence of recurrent systemic thromboembolism or hyperthyroidism. CONCLUSIONS: Early recognition and appropriate treatment of PTE combined with transient thyrotoxicosis were vital to preventing other complications.

Hypertension is associated with oral, laryngeal, and esophageal cancer: a nationwide population-based study.

Several studies have reported an association between hypertension and upper aerodigestive tract cancer, but no large-scale, population-based studies have been conducted to confirm this.The aim of this study was to explore the association between hypertension and risk of upper aerodigestive tract cancer in Koreans. Participants who underwent a national health screening examination from January 1 to December 31, 2009 (n = 9,746,606) were enrolled. We assessed the development of oral, laryngeal, or esophageal cancer until 2016 using records from the Korean Health Insurance claims database during the study period. During the seven-year follow-up period, 6,062, 2,658, and 4,752 subjects were newly diagnosed with oral, laryngeal, and esophageal cancer, respectively. Participants with metabolic syndrome had the highest risk of developing oral cancer (hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.03-1.16), laryngeal cancer (HR 1.27, 95% CI 1.17-1.38), and esophageal cancer (HR 1.11, 95% CI 1.04-1.19). Hypertension was a remarkable risk factor for each cancer (HR 1.11, 95% CI 1.04-1.17 for oral cancer; HR 1.23, 95% CI 1.13-1.33 for laryngeal cancer; HR 1.25, 95% CI 1.18-1.33 for esophageal cancer) after adjusting for age and other variables including gender, smoking status, alcohol intake, exercise, body mass index, and diabetes. Patients with untreated hypertension were at highest risk of developing oral cancer (HR 1.15; 95% CI 1.05-1.26), laryngeal cancer (HR 1.25; 95% CI 1.09-1.44), and esophageal cancer (HR 1.47; 95% CI 1.33-1.63) after adjusting for confounders. Hypertension was associated with the risk of oral, laryngeal, and esophageal cancer, despite of the lack of detailed biochemical information including the cancer cell types (squamous cell carcinoma or adenocarcinoma), cancer stage, physical findings and other medical history. Further studies are warranted to determine the reasons for this association and to establish effective interventions in this vulnerable population.

Right Ventricular Analysis Using Real-time Three-dimensional Echocardiography for Preload Dependency.

BACKGROUND: The importance of the right ventricle (RV) has been increasingly recognized, and accurate RV measurement has become necessary. However, assessment of the RV with two-dimensional (2D) echocardiography has several limitations. As the development of novel methods for RV measurement continues, we can expect more accordant values related to RV geometry. METHODS: Fifty-eight subjects who were examined by transthoracic echocardiography (TTE) immediately before and after hemodialysis (HD) were enrolled. Real-time, full-volume, three-dimensional (3D) echocardiographic images were acquired and analyzed using dedicated software. Conventional RV parameters for RV size and function were measured for comparison with pre-HD and post-HD values by both 2D-TTE and 3D-TTE. RESULTS: 3D RV volumes and ejection fractions were significantly decreased after HD. The values of the 3D image-derived RV dimensions, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and longitudinal strain were also affected by acute preload changes (TAPSE pre-HD: 22.4 ± 4.0 mm, post-HD: 19.0 ± 4.2 mm, p < 0.001; FAC pre-HD: 49.6% ± 5.9%, post-HD: 46.4% ± 5.5%, p < 0.001; septal longitudinal strain pre-HD: -20.1% ± 3.7%, post-HD: -16.8% ± 3.8%, p < 0.001). With the exception of FAC, most 2D RV parameters were well correlated with the 3D values. CONCLUSIONS: Various parameters representing RV anatomy and function were acquired easily and more accurately from 3D echocardiographic images than from 2D images but were affected by acute preload changes. 3D TTE could be a new modality for assessing RV function and size, but each value from 3D TTE should be interpreted with caution while considering the loading condition of the patients.

Prognosis of large, symptomatic pericardial effusion treated by echo-guided percutaneous pericardiocentesis.

BACKGROUNDS: The causes and prognosis of pericardial effusion (PE) may be different according to time, region, economy, and hospital. This study was performed to evaluate the etiology, clinical outcome, and prognosis of patients with large, symptomatic PE treated by echo-guided pericardiocentesis at Kangnam St. Mary's Hospital (the Catholic University of Korea, Seoul, Korea). HYPOTHESIS: According to etiologies of large, symptomatic PE, the prognosis of patients may be different. METHODS: We reviewed 116 consecutive patients who underwent echo-guided pericardiocentesis due to large, symptomatic PE over the last 12 y. The Kaplan-Meier survival curve with log-rank method was applied for the survival analysis. RESULTS: Procedural success rate of echo-guided pericardiocentesis was 99.1%. Common causes of PE requiring pericardiocentesis were lung cancer (27.6%), tuberculosis (TB) (13.8%), and uremia (6.9%). The mortality rate of 6 mo after the pericardiocentesis was 80.3% in malignant PE, whereas the over-all mortality rate was 18.2% in nonmalignant PE (p < 0.0001). Among the malignant PE, lung cancer (27.6%) and breast cancers (6.9%) were the most common causes. The mean cytologic detection rate and mean life expectancy of malignant PE were 44% and 5-7 mo. Patients with breast cancer and lymphoma had relatively better life expectancy (11.4 and 7.7 mo), whereas those with stomach cancer and metastases of unknown origin (MUO) had poorer prognosis (1.2 and 2.3 mo). The most common causes of nonmalignant PE were TB, uremia, and iatrogenic, and their mean life expectancy was approximately 54 mo. CONCLUSIONS: Malignancy, especially lung cancer and TB, were the most common causes of large symptomatic PE. The prognosis of large symptomatic PE was related to the underlying disease. Malignant PE was associated with the poorest prognosis.

Imatinib mesylate attenuates myocardial remodeling through inhibition of platelet-derived growth factor and transforming growth factor activation in a rat model of hypertension.

Imatinib mesylate is a specific tyrosine kinase inhibitor that may block the platelet-derived growth factor and transforming growth factor pathways. These pathways are known to provoke fibroblast activation. We evaluated whether imatinib, by inhibiting these pathways, prevents diastolic dysfunction and attenuates myocardial remodeling using spontaneously hypertensive rats (SHRs). Eight-week-old male SHRs were randomly assigned to either imatinib treatment group (30 mg/kg per day; n=10; SHR-I) or hypertensive control group (distilled water, n=10; SHR-C). Wistar-Kyoto rats were used as normal controls (n=10). At 16 weeks, all rats underwent hemodynamic studies and Doppler echocardiography and then were euthanized. Their hearts were extracted for histopathologic, immunoblotting, and quantitative reverse transcriptase polymerase chain reaction analyses. Although imatinib did not affect blood pressure, it markedly reduced perivascular and interstitial fibrosis in the hearts of SHR. Echocardiogram showed that imatinib significantly reduced the left ventricular wall thickness (septal/posterior wall; SHR-C versus SHR-I, 18±1/19±2 versus 15±1/15±1 mm; P<0.001) and increased the E/A ratio (SHR-C versus SHR-I, 1.59±0.11 versus 1.84±0.16; P=0.001). Also, imatinib significantly reduced the mRNA expression of collagen type I, III, and platelet-derived growth factor receptor-ß phosphorylation in the hearts of SHR. In addition, imatinib reduced collagen production by inhibiting the phosphorylation of c-abl and platelet-derived growth factor receptor-ß in rat cardiac fibroblasts. In conclusion, these results suggest that imatinib could attenuate myocardial remodeling and improve left ventricular diastolic dysfunction in a hypertensive rat model by affecting platelet-derived growth factor and transforming growth factor-ß1 pathway without the blood pressure-lowering effect.

Three-dimensional principal strain analysis for characterizing subclinical changes in left ventricular function.

BACKGROUND: Subendocardial strain analysis is currently feasible in two-dimensional and three-dimensional (3D) echocardiography; however, there is a lack of clarity regarding the most useful strain component for subclinical disease detection. The aim of this study was to test the hypothesis that strain analysis along the direction of strongest and weakest systolic compression (referred to as principal and secondary strain, respectively) circumvents the need for multidirectional strains and provides a more simplified assessment of left ventricular subendocardial function. METHODS: Strain analyses were performed by using two-dimensional and 3D echocardiography in 41 consecutive subjects with normal results on electron-beam computed tomography, including 15 controls and 26 patients with systemic hypertension. The direction of principal strain referenced the myofiber geometry obtained from diffusion tensor magnetic resonance imaging of a normal autopsied human heart. The incremental value of principal strain over multidirectional two-dimensional and 3D strain was analyzed. RESULTS: In healthy subjects, 50 ± 3% of the subendocardial shortening occurred in the cross-fiber direction (left-handed helical); this balance was significantly altered in patients with hypertension (P = .01). The magnitude of longitudinal and circumferential strain was similar in patients with hypertension and controls. However, the alteration of the directional contraction pattern resulted in reduced secondary strain magnitude in patients with hypertension (P = .01), and the differences were further exaggerated when the secondary strain was normalized by the principal strain magnitude (P = .004). CONCLUSIONS: Two-component principal and secondary strain analysis can be related to left ventricular myofiber geometry and may simplify the assessment of 3D left ventricular deformation by circumventing the need to assess multiple shortening and shear strain components.

A high normal thyroid-stimulating hormone is associated with arterial stiffness, central systolic blood pressure, and 24-hour systolic blood pressure in males with treatment-naïve hypertension and euthyroid.

BACKGROUND: We compared the results of laboratory examinations, echocardiography, arterial stiffness, central blood pressure (BP) and ambulatory BP monitoring (ABPM) between treatment-naïve patients with low normal thyroid-stimulating hormone (TSH) and those with high normal TSH levels. METHODS: A total of 285 consecutively-eligible patients with both treatment-naïve hypertension and euthyroid were divided into two groups: those with low-normal TSH (0.40-1.99 µIU/mL, group 1) and high-normal TSH (2.00-4.50 µIU/mL, group 2) and compared according to group and gender. RESULTS: Males were divided into group 1 (n = 113, 68.9%) and group 2 (n = 51, 31.1%) and females were divided into group 1 (n = 71, 58.7%) and group 2 (n = 50, 41.3%). Multivariate analyses revealed that the augmentation index (71.0 [adjusted mean] ± 1.7 [standard error] vs. 78.8 ± 2.5%, P = 0.045), central systolic BP (SBP) (143.3 ± 2.1 vs. 153.0 ± 3.2 mmHg, P = 0.013), systemic vascular resistance (SVR, 21.4 ± 0.6 vs. 23.9 ± 0.9 mmHg/L/min, P = 0.027), SBP during daytime (144.1 ± 1.4 vs. 151.6 ± 2.1 mmHg, P=0.004) and nighttime (130.4 ± 1.6 vs. 138.5 ± 2.5 mmHg, P=0.008), and nighttime pulse pressure (PP, 47.2 ± 0.9 vs. 51.7 ± 1.4 mmHg, P = 0.010) were significantly higher while cardiac output (5.4 ± 0.1 vs. 4.8 ± 0.2L/min, P = 0.043) and PP amplification (1.02 ± 0.02 vs. 0.94 ± 0.03, P = 0.039) were significantly lower in the male group 2 than in the male group 1. However, there were no significant differences between the two groups in females. CONCLUSIONS: Treatment-naïve hypertensive males with high normal TSH and euthyroid showed higher arterial stiffness, central SBP, SVR, and SBP in ABPM and lower cardiac output and PP amplification as compared to the the low normal TSH group, but not females.