Multidimensional Aspects of de qi Sensations in MASS and ASQ Assessment: A Pilot Study.

Background. De qi comprises varied senses depending on the individual. No single method can yet fully measure the multiple dimensions of de qi adequately. Objective. We examined the advantages of implementing multiple questionnaires for de qi measurement. Methods. Fourteen participants completed a preacupuncture questionnaire regarding their perception toward acupuncture treatment. After acupuncture stimulation at the HT7 point, de qi sensations were measured by MASS and ASQ. In groups with different levels of expectation, we compared the subtotal scores of each phase in the ASQ, as well as the VAS de qi intensity and MASS index using Kruskal-Wallis test. For the structural comparison of questionnaires, we first performed Spearman's rank correlation test between the scores of individual descriptors in MASS and ASQ. The subtotal scores of each phase in ASQ was compared with VAS de qi intensity and MASS index. Results. The subtotal score of the manipulation phase in ASQ strongly correlated with the VAS score of de qi intensity (Spearman's ρ = 0.654, p = 0.011) and MASS index (Spearman's ρ = 0.488, p = 0.076). MASS and ASQ showed strong correlations in certain analogous descriptors. Unpleasant perceptions toward acupuncture treatment did not significantly correlate with overall de qi intensity. Conclusions. De qi sensations in acupuncture treatment have multidimensional aspects. Intensity of stimulation, ASQ, and MASS index assess somewhat restricted aspects of de qi. Those questionnaires have exclusive differences of sets in spite of their strong intersections. Use of multiple questionnaires may enable a more comprehensive understanding of de qi properties and the elicitation of relevant construction in de qi features of acupuncture.

Load independence of two-dimensional speckle-tracking-derived left ventricular twist and apex-to-base rotation delay in nonischemic dilated cardiomyopathy: implications for left ventricular dyssynchrony assessment.

BACKGROUND: Left ventricular (LV) twist mechanics are a promising, sensitive tool for assessing pathophysiologic changes in patients with systolic heart failure. Although LV twist is known to be load dependent in healthy volunteers, this has not been examined in patients with "long-standing" dilated cardiomyopathy (DCM). The aim of this study was to determine whether LV twist remains load dependent in the setting of long-standing, nonischemic DCM. METHODS: Thirty-four patients with DCM with baseline LV ejection fractions (LVEFs) < 40% and 13 subjects with preserved LVEFs (≥50%) were enrolled. After baseline measurements, pneumatic compression of the lower extremities (Pcom) was used to increase LV afterload. Subsequently, sublingual nitroglycerin (SL-NG) was administered to modify preload. Conventional echocardiographic parameters, LV end-systolic wall stress, net LV twist angle, and apex-to-base-rotation delay (ABRD) were assessed under each condition. RESULTS: In patients with DCM, although LV end-systolic wall stress significantly increased under Pcom (196.9 ± 64.9 g/m(2) at baseline vs 231.8 ± 78.9 g/m(2) under Pcom, P < .017) and decreased after SL-NG application (231.8 ± 78.9 g/m(2) under Pcom vs 197.4 ± 67.4 g/m(2) after SL-NG, P < .017), net LV twist angle and ABRD showed no significant changes depending on LV loading condition (for LV twist, 7.63 ± 4.47° at baseline vs 7.03 ± 4.13° under Pcom vs 7.35 ± 4.36° after SL-NG, P = 0.65; for ABRD, 16.56 ± 13.81% at baseline vs 17.19 ± 14.81% under Pcom vs 15.95 ± 13.27% after SL-NG, P = .53). Careful examination of individual patient data revealed that LV twist was load independent when patients had LV twist < 12°. ABRD was also found to be load independent, but only in patients with LVEFs < 34%. In contrast, LV twist and ABRD were load dependent in patients with preserved LVEFs. CONCLUSIONS: LV twist and its component, ABRD, had relatively load insensitive properties in patients with long-standing DCM and can be used in future clinical trials as load-independent indexes of LV dyssynchrony.

Clinical predictors of high posttreatment platelet reactivity to clopidogrel in Koreans.

INTRODUCTION: High posttreatment platelet reactivity to clopidogrel (HPPR) is associated with major adverse cardiac events. However, the clinical predictors of HPPR in Asians have not been studied previously. AIMS: We sought to determine clinical predictors of HPPR in Koreans. RESULTS: We measured platelet reactivity with the VerifyNow P2Y12 assay in 1431 consecutive patients undergoing coronary angiography. We used the cut-off value of greater than 275 P2Y12 Reaction Unit (PRU) to define patients with HPPR. The clinical characteristics were compared between patients with HPPR (36.3%) and those without HPPR (63.7%). The mean age (65.4 ± 9.1 vs. 62.2 ± 9.7 years) was higher, hypertension (68.5% vs. 62.0%), diabetes mellitus (35.4% vs. 28.5%), chronic kidney disease (36.3% vs. 22.5%), renal replacement treatment (1.2% vs. 0.2%), and congestive heart failure (1.3% vs. 0.3%) were more common among patients with HPPR, while male gender (72.6% vs. 54.8%) and smoking (19.9% vs. 13.1%) were more common among non-HPPR patients. Mean glomerular filtration rate (63.5 ± 18.6 vs. 69.7 ± 16.1 mL/min/1.73 m(3) ) was lower and C-reactive protein (hs-CRP) (6.6 ± 20.5 mg/L vs. 4.2 ± 12.1 mg/L) level was higher among those with HPPR. Independent predictors of HPPR were female gender (OR 1.90, P≤ 0.001), chronic kidney disease (OR 1.51, 0 = 0.004), diabetes mellitus (OR 1.35, P= 0.024), hs-CRP ≥ 2.0 mg/L (OR 1.31, P= 0.005), and age increase in decades (OR 1.21, P= 0.002), while smoking was negative risk factor (OR 0.63, P= 0.015). The number of risk factors was linearly associated with the risk of HPPR, with most patients having one or two predictors. CONCLUSION: In Korean population, independent clinical predictors of HPPR included diabetes mellitus, increased age, female gender, chronic kidney disease, and hs-CRP ≥ 2.0 mg/L, while cigarette smoking was associated with better responsiveness. Mean platelet reactivity and HPPR prevalence steadily increased with the number of clinical predictors.

Enhanced clopidogrel responsiveness in smokers: smokers' paradox is dependent on cytochrome P450 CYP1A2 status.

OBJECTIVE: Observational studies have reported enhanced response to clopidogrel in smokers (the smokers' paradox). We examined whether genetic variations in the cytochrome and drug transporter system are associated with the effect of smoking on clopidogrel response. METHODS AND RESULTS: Clopidogrel on-treatment platelet reactivity (OPR) was measured in 1431 consecutive patients who underwent coronary angiography. Gene samples were available and genotyping was successful in 1123 patients. Nine candidate single-nucleotide polymorphisms in 5 cytochrome genes and 1 drug transporter gene were assessed. The mean OPR of the entire population was 241.9 ± 79.3 (P2Y(12) reaction units). Two hundred forty-nine (17%) smokers had lower OPR compared with 1182 (83%) nonsmokers (227.6 ± 76.0 versus 244.9 ± 79.7, P=0.001). Among the 9 single-nucleotide polymorphisms, only CYP1A2 showed a genotype-dependent change in the effect of smoking on OPR. After adjustment for possible confounding factors, cigarette smoking was associated with a lower OPR by -19 P2Y(12) reaction units (P=0.009) and lower risk for high OPR (odds ratio [OR], 0.48; 95% CI, 0.31 to 0.74) in the AA and CA genotypes but not in the CC genotype. CONCLUSIONS: Enhanced clopidogrel response in smokers, known as the smokers' paradox, is not universal but was observed only in cytochrome P450 CYP1A2 (-163C>A) A-allele carriers, suggesting a genotype-dependent effect of smoking on clopidogrel responsiveness.

Assessment of haemodynamic effects of surgical correction for severe functional tricuspid regurgitation: cardiac magnetic resonance imaging study.

AIMS: There has been growing attention for the development of functional tricuspid regurgitation (TR) long after left-sided valve surgery. We attempted to determine the long-term haemodynamic effects of corrective surgery for severe functional TR in patients who had prior left-sided valve surgery using cardiac magnetic resonance imaging (CMR). METHODS AND RESULTS: Thirty-one patients with severe functional TR (TR fraction of 46.0+/-16.2% by CMR) were analysed. CMR was performed within 1 month before and at a median 27.0 months after surgery. Long after TR surgery, 28 of the 31 patients had no or mild residual TR, two had mild-to-moderate TR, and one showed moderate TR. Remarkable reductions in the right ventricular (RV) end-diastolic volume index (RV-EDVI) (177.4+/-59.1 mL/m(2) vs. 118.2+/-31.2 mL/m(2), P<0.001) and end-systolic volume index (RV-ESVI) (88.5+/-30.1 mL/m(2) vs. 67.2+/-31.0 mL/m(2), P=0.002) were observed, whereas RV ejection fraction (RV-EF) showed no change (49.7+/-8.3% vs. 44.9+/-12.5%, P=0.09). Pre-operative RV-EDVI (R=-0.86, P<0.001) and RV-ESVI (R=-0.55, P=0.001) were significantly associated with their respective changes after corrective surgery. Post-surgery, a normal RV-EF was achieved in 14 patients (42.5%). Pre-operative RV-EDVI of 164 mL/m(2) effectively discriminated patients with normal RV-EF from those without post-surgery, with a sensitivity of 77% and a specificity of 72% (P=0.01). A significant rise in the left ventricular (LV) EDVI and cardiac index (CI) was found after surgery (from 92.9+/-24.4 to 123.2+/-31.6 mL/m(2) for LV-EDVI, P<0.001; from 3.8+/-1.3 to 4.2+/-0.8 L/min/m(2) for CI, P=0.03). Functional capacity as assessed by NYHA class showed a significant improvement from 2.7+/-0.6 before surgery to 2.0+/-0.6 long after surgery (P<0.001). CONCLUSION: Successful TR surgery can remarkably reduce RV volumes and preserve RV systolic function. In addition, successful TR surgery led to a significant rise in LV preload and CI, which may significantly contribute to a significant amelioration in the functional capacity of the patients. It seems that RV volume measurement by CMR is helpful for determining optimal timing for TR surgery.

Persistent regional diastolic dysfunction after myocardial ischemia and the effect of statin treatment: assessment with two-dimensional radial strain rate.

BACKGROUND: Persistence of regional diastolic dysfunction after ischemic insult remains debatable. With speckle tracking echocardiography (STE), we sought to (1) prove the persistence of regional diastolic dysfunction, (2) assess the feasibility of applying persistent regional diastolic dysfunction to differentiating ischemic and nonischemic chest pain, and finally (3) examine statin effects on postischemic regional diastolic dysfunction. METHODS: Nineteen patients with variant angina (VA) and 12 normal subjects were enrolled. Comprehensive echocardiographic examinations were performed before and 1 day after coronary angiography (CAG) with ergonovine provocation. Radial systolic (rSRsys) and diastolic (rSRdia) strain rates were obtained and averaged using standard segmentation models corresponding to the three major coronary territories assigned. RESULTS: No significant changes in rSRsys and rSRdia values were observed for controls and in rSRsys for VA. However, rSRdia for VA demonstrated a weak, but significant, decrease from -2.25 +/- 0.71/sec to -2.04 +/- 0.71/sec (P = 0.003) 1 day after CAG. However, because of the wide overlap between rSRdia values in normal and ischemic segments for VA patients, predictability of remote ischemia based solely on the rSRdia was limited. Subgroup analysis according to statin prescription showed that statin administration contributed to the elimination of rSRdia reduction (-2.28 +/- 0.84/sec on pre-CAG vs. -2.29 +/- 0.77/sec on post-CAG, P = 0.72 for patients without statin premedication; -2.23 +/- 0.64/sec for pre-CAG vs. -1.88 +/- 0.65/sec for post-CAG, P = 0.002 for those without). Expectedly, rSRsys values showed no significant changes in all situations. CONCLUSIONS: The presence and sustained nature of regional diastolic dysfunction can be demonstrated with STE. Statin minimized the persistence of regional diastolic dysfunction after an acute ischemia. Although the clinical usefulness of rSRdia by STE appears to be limited, its clinical utility requires further consideration, given the brevity of the ischemia provoked during CAG with ergonovine and the protracted regional diastolic dysfunction.

Assessment of left ventricular rotation and torsion with two-dimensional speckle tracking echocardiography.

BACKGROUND: Speckle tracking echocardiography (STE) has a unique feature of angle independence and, thus, may provide a powerful means of assessing left ventricular (LV) torsion (LVtor). The aims of this study were to assess: (1) the feasibility of 2-dimensional STE in the measurement of LVtor; and (2) the relationship of LVtor with age and conventional echocardiographic parameters. METHODS: We consecutively recruited 160 healthy volunteers. After obtaining conventional echocardiographic parameters, apical and basal short-axis rotations were assessed with STE. LVtor was defined as the net difference between rotation angles in the two short-axis planes normalized for LV longitudinal length. RESULTS: Reliable LVtor measurement was possible only in 56 volunteers (35%). This low feasibility was largely a result of the failure to obtain reliable basal rotation values. In 56 volunteers who were finally enrolled in this study, a significant correlation was found between LV ejection fraction and LVtor (r = 0.56, P < .001) and this correlation was attributed to apical (r = 0.47, P < .001) but not basal (P = .14) rotation. There was no significant change in LVtor with aging. However, initial counterclockwise motion (r = -0.51, P = .001) and its interval (r = -0.44, P = .001) in the basal rotation gradually decreased with aging, and correlated with early transmitral inflow velocity (r = 0.44 and 0.49, respectively) and its deceleration time (r = -0.43 and -0.48, respectively) (all P < .001). In contrast, such correlations were not found for initial clockwise motion and its interval in the apical rotation. CONCLUSIONS: Currently, STE has limited feasibility in the measurement of LVtor. There was no significant age-related change in LVtor. In LV rotations, basal rotation was affected by the age-related changes in the LV early diastolic filling, whereas apical rotation was mainly related to LV systolic performance.

Assessment of coronary vasodilatation in response to nitroglycerin with transthoracic Doppler echocardiography.

BACKGROUND: Previous studies demonstrated impaired coronary vasodilatory response (VR) to nitroglycerin (NG) in patients with coronary atherosclerosis. We hypothesized that the effect of the NG on the coronary blood flow (CBF) is negligible compared with its effect on the epicardial coronary artery dilatation and, therefore, that CBF velocity reduction after NG can reflect the magnitude of epicardial coronary artery dilatation. METHODS: Quantitative coronary angiography was performed at the left anterior descending coronary artery (LAD) before and after intracoronary NG (200 mug) infusion in 18 patients with normal-looking coronary angiogram. VR assessed by quantitative coronary angiography (VRangio) was defined as: (LAD diameter after NG)(2)/(LAD diameter before NG)(2). Mean values measured at the ostium and at the junction of mid and distal LAD were used in the analysis. Diastolic CBF velocity was evaluated by using a 7-MHz transducer at the distal LAD before and 3 minutes after sublingual NG. VR assessed by echocardiography (VRecho) was defined as: (mean diastolic CBF velocity before sublingual NG)/(mean diastolic CBF velocity after sublingual NG). In 11 patients, plaque burden was assessed by intravascular ultrasound and results were compared with VRangio and VRecho. RESULTS: VRecho was found to correlate well with VRangio (r = 0.71, P = .001), and VRangio and VRecho showed significant negative correlations with plaque burden (r = -0.66, P = .03; r = -0.77, P = .005, respectively). CONCLUSIONS: VR to NG can be evaluated noninvasively with transthoracic Doppler echocardiography.

Physiologic assessment of jailed side branch lesions using fractional flow reserve.

OBJECTIVES: This study was performed to evaluate the feasibility of the physiologic assessment of jailed side branches using fractional flow reserve (FFR) and to compare the measured FFR with the stenosis severity assessed by quantitative coronary angiography (QCA). BACKGROUND: It is not well-known which side branches should be treated after stent implantation at main branches and how to assess the functional significance of these lesions. METHODS: Ninety-seven jailed side branch lesions (vessel size > 2.0 mm, percent stenosis > 50% by visual estimation) after stent implantation at main branches were consecutively enrolled. The FFR was measured using a pressure wire at 5 mm distal and proximal to the ostial lesion of the jailed side branch. RESULTS: The FFR measurement was successful in 94 lesions. Mean FFRs were 0.94 +/- 0.04 and 0.85 +/- 0.11 at the main branches and jailed side branches, respectively. There was a negative correlation between the percent stenosis and FFR (r = -0.41, p < 0.001). However, no lesion with < 75% stenosis had FFR < 0.75. Among 73 lesions with > or = 75% stenosis, only 20 lesions were functionally significant. CONCLUSIONS: The FFR measurement in jailed side branch lesions is both safe and feasible. Quantitative coronary angiography is unreliable in the assessment of the functional severity of jailed side branch lesions, and measurement of FFR suggests that most of these lesions do not have functional significance.