Lipid-Lowering Efficacy of Combination Therapy With ModerateIntensity Statin and Ezetimibe Versus High-Intensity Statin Monotherapy:A Randomized, Open-Label, NonInferiority Trial From Korea

Objective@#This phase IV, multicenter, randomized controlled, open-label, and parallel clinical trial aimed to compare the efficacy and safety of ezetimibe and moderate intensity rosuvastatin combination therapy to that of high intensity rosuvastatin monotherapy in patients with atherosclerotic cardiovascular disease (ASCVD). @*Methods@#This study enrolled patients with ASCVD and after a four-week screening period, patients were randomly assigned to receive either rosuvastatin and ezetimibe (RE 10/10 group) or high-intensity rosuvastatin (R20 group) only in a 1:1 ratio. The primary outcome was the difference in the percent change in the mean low-density lipoprotein cholesterol (LDL-C) level from baseline to 12 weeks between two groups after treatment. @*Results@#The study found that after 12 and 24 weeks of treatment, the RE10/10 group had a greater reduction in LDL-C level compared to the R20 group (−22.9±2.6% vs. −15.6 ± 2.5% [p=0.041] and −24.2±2.5% vs. −12.9±2.4% [p=0.001] at 12 and 24 weeks, respectively). Moreover, a greater number of patients achieved the target LDL-C level of ≤70 mg/dL after the treatment period in the combination group (74.6% vs. 59.9% [p=0.012] and 76.2% vs. 50.8% [p<0.001] at 12 and 24 weeks, respectively). Importantly, there were no significant differences in the occurrence of overall adverse events and adverse drug reactions between two groups. @*Conclusion@#Moderate-intensity rosuvastatin and ezetimibe combination therapy had better efficacy in lowering LDL-C levels without increasing adverse effects in patients with ASCVD than high-intensity rosuvastatin monotherapy.

Characteristics of the pneumonia patients transferred from long-term care hospitals:retrospective study of one regional emergency medical center

Objective@#This study investigated the characteristics of elderly pneumonia patients transferred from long-term care hospitals(LTCH). @*Methods@#The initial emergency department (ED) data of patients, who were transferred from other hospitals and over 65years old and hospitalized from 2014 to 2018 for pneumonia management through the ED, were extracted from the electronicmedical records. The differences in the initial status and prognosis between the LTCH group and non-LTCH groupwere compared, and the initial ED variables that affect the in-hospital mortality of the LTCH group were investigated. @*Results@#The total number of patients was 1,032; 423 (41.0 %) were included in the LTCH group. Compared to the non-LTCH group, the following severity indices, some laboratory data, and mortality were worse in the LTCH group: systemicinflammatory reaction syndrome (SIRS) criteria ≥2 (65.0% vs. 56.7%, P=0.008), quick Sequential Organ FailureAssessment score ≥2 (48.2% vs. 20.4%, P<0.001), CURB-65 (Confusion, Urea nitrogen, Respiration rate, Blood pressure,Age≥65 years) criteria ≥3 (51.8% vs. 29.2%, P<0.001), pneumonia severity index (PSI) class ≥4 (86.5% vs.61.2%, P<0.001), modified early warning score ≥5 (38.8% vs. 18.4%, P<0.001), serum albumin (median [IQR], 2.6 [2.2-2.9] g/dL vs. 2.8 [2.4-3.2] g/dL; P<0.001), blood urea nitrogen/albumin (B/A) ratio (median [IQR], 8.0 [5.0-12.8] vs. 6.6[4.4-10.4]; P<0.001), and in-hospital mortality (26.0% vs. 15.9%, P<0.001). Multivariate regression analysis revealed thealbumin grade, B/A ratio grade, PSI class, and SIRS criteria to independently affect the in-hospital mortality of the LTCHgroup. @*Conclusion@#The LTCH group had poorer initial severity indices and higher in-hospital mortality than the non-LTCHgroup. In addition, the albumin grade, B/A ratio grade, could be used for the severity index of pneumonia patients transferredfrom the LTCH.

Evaluation of pneumonia management effectiveness associated withinternal medicine management changes in the emergency department:a retrospective cohort study using a historically controlled group

Objective@#In Korea, many hospitals have recently changed the process of internal medicine management in the emergencydepartment (ED) because of reduced manpower, raising concerns regarding the decreased quality of medicalcare. The process of medical management in the ED was streamlined to resolve the reduced manpower. Thus, this studycompared the pneumonia treatment effectiveness before and after the process changes. @*Methods@#This study included patients who were diagnosed with pneumonia in the ED and hospitalized from January2014 to December 2016. They were divided into two groups based on before and after the changes. The disease severity,management adequacy, and prognosis were compared using the initial quick sequential organ failure assessmentscore (qSOFA), systemic inflammatory response syndrome criteria (SIRS), CURB-65 score, door-to-antibiotic time(DAT), length of stay (LOS), hospitalization period (HP), and in-hospital mortality, were collected retrospectively from themedical records. @*Results@#The qSOFA, SIRS, and CURB-65 scores did not differ between the two groups. The median (interquartilerange) DAT, LOS, and HP were reduced after the process changes: DAT (160.0 minutes [111.0-230.0] vs. 120.0 minutes[74.0-175.0], P<0.001), LOS (7.6 hours [4.8-15.8] vs. 4.7 hours [3.2-6.8], P<0.001), and HP (9.0 days [6.0-16.0] vs. 8.0days [5.0-15.0], P=0.011). On the other hand, the in-hospital mortality was similar in the two groups (14.1% vs. 11.2%,P=0.162). @*Conclusion@#The DAT, LOS, and HP decreased after the process changes, but the in-hospital mortality did not worsen.This shows that pneumonia management in the ED was not compromised, but rather improved, after the changes.

A case of isolated noncompaction of the ventricular myocardium in an elderly patient / 대한내과학회지

Noncompaction of the ventricular myocardium is a rare congenital cardiomyopathy that is thought to be caused by arrest of normal endomyocardial embryogenesis. It is usually diagnosed via echocardiography. The three major clinical manifestations of noncompaction are heart failure, arrhythmia and embolic events. We report here on a case of isolated noncompaction of the ventricular myocardium, and the patient was admitted due to palpitation and dyspnea. Sadly, he died of intractable heart failure despite that we administered intensive medical treatment.

Analysis of Korean Carotid Intima-Media Thickness in Korean Healthy Subjects and Patients with Risk Factors: Korea Multi-Center Epidemiological Study

BACKGROUND AND OBJECTIVES: We performed this study to evaluate the common carotid artery intima-media thickness (CCA IMT), and its correlation with several clinical variables, including the 10 year coronary heart disease (10 Yr CHD) risk in both healthy and hyperlipidemic hypertensive (HH) Koreans. SUBJECTS AND METHODS: This was a multi-centered prospective epidemiological study. The study population consisted of 227 healthy subjects without risk factors, with the exception of age (mean 49 years old, 114 males), and 243 HH subjects (mean 51 years old, 120 males). The carotid IMT and presence of plaques were semi automatically measured in both carotid arteries at a central reading facility. RESULTS: Linear regression analysis of all the subjects revealed that the independent factors of both CCA IMT were age, pulse pressure (PP) and HDL-cholesterol, and that of the right CCA IMT were sex and 10 Yr CHD risk. In healthy subjects, the independent factor of both CCA IMTs was age, and that of the right CCA IMT was body weight. In the HH subjects, age, sex, total cholesterol, HDL-cholesterol and PP were independent factors of both CCA IMTs, but 10 Yr CHD risk was an independent factor of only the right CCA IMT. Carotid plaques were seen in 17% of the healthy subjects and 35% of the HH subjects. An ROC curve analysis showed a right CCA IMT of 0.646 mm and left CCA IMT of 0.656 mm demonstrated 60% sensitivity and specificity in differentiating healthy from HH subjects. CONCLUSION: This result reliably demonstrates the Korean CCA IMT, as well as several other significant pieces of information.

The Evaluation of Diagnostic Validity of ECG for the Subendocardial Infarction by Myocardial Contrast Echocardiography

BACKGROUND AND OBJECTIVES: The pathological findings of Non-Q wave myocardial infarction(NQMI) on ECG did not always correspond to subendocardial infarction(SEMI). The purpose of this study was to evaluate the diagnostic validity of ECG for SEMI by myocardial contrast echocardiography (MCE) in the patients with acute myocardial infarction(AMI). MATERIALS AND METHODS: The study population was 84 patients who underwent MCE under the diagnosis of AMI. MCE was performed by intracoronary injection of sonicated Hexabrix into the infarct related artery and SEMI was diagnosed by inspecting endocardial defect with epicardial enhancement on MCE. RESULTS: (1) Among 19 NQMI cases, 7 cases showed SEMI with MCE score 0.5, 11 cases with score 1, and 1 case with score 0. Among 65 Q-wave MI(QMI) cases, only 5 cases showed SEMI. (2) 7 cases who had NQMI with SEMI showed LV wall motion recovery at follow-up echocardiography except 1 case. Whereas, of 5 QMI cases who had SEMI, only 1 case improve LV wall motion. CONCLUSION: NQMI on ECG does not always imply SEMI on MCE, but the absence of pathologic Q wave in the patients with SEMI is thought to be a predictive factor of the recovery of LV wall motion.

The Evaluation of Diagnostic Validity of ECG for the Subendocardial Infarction by Myocardial Contrast Echocardiography

BACKGROUND AND OBJECTIVES: The pathological findings of Non-Q wave myocardial infarction(NQMI) on ECG did not always correspond to subendocardial infarction(SEMI). The purpose of this study was to evaluate the diagnostic validity of ECG for SEMI by myocardial contrast echocardiography (MCE) in the patients with acute myocardial infarction(AMI). MATERIALS AND METHODS: The study population was 84 patients who underwent MCE under the diagnosis of AMI. MCE was performed by intracoronary injection of sonicated Hexabrix into the infarct related artery and SEMI was diagnosed by inspecting endocardial defect with epicardial enhancement on MCE. RESULTS: (1) Among 19 NQMI cases, 7 cases showed SEMI with MCE score 0.5, 11 cases with score 1, and 1 case with score 0. Among 65 Q-wave MI(QMI) cases, only 5 cases showed SEMI. (2) 7 cases who had NQMI with SEMI showed LV wall motion recovery at follow-up echocardiography except 1 case. Whereas, of 5 QMI cases who had SEMI, only 1 case improve LV wall motion. CONCLUSION: NQMI on ECG does not always imply SEMI on MCE, but the absence of pathologic Q wave in the patients with SEMI is thought to be a predictive factor of the recovery of LV wall motion.

Comparison between Adaptive Arterial Remodeling and Inadequate Arterial Remodeling Assessed by Intravascular Ultrasound / 대한내과학회지

OBJECTIVES:Adaptive arterial remodeling (AAR) is a process to maintain luminal patency despite atherosclerotic plaque accumulation, whereas some of the lesions undergo a negative remodeling (vessel shrinkage), namely inadequate arterial remodeling (IAR). Histopathologic and intravascular ultrasound (IVUS) studies have shown lumen compromise is delayed until the atherosclerotic lesion occupies more than an estimated 40% to 50% of the potential area within the internal elastic lamina and proposed contributors to lumen compromise are medial and adventitial damage, superficial calcification, apoptosis. However the precise mechanisms and factors leading to these two vascular remodeling patterns are still unclear. The aim of this study is to investigate the effect of plaque accumulation on compensatory dilatation in arterial remodeling and their relationship according to their remodeling patterns. METHODS: Preinterventional intravascular ultrasound images of 56 focal, de novo native and nonosteal lesions on coronary angiography were obtained. Cross sectional area of external elastic membrane (LEEM), Minimal lumen (MLA) and plaque plus media (P&M; P&M=EEM- MLA) in the target lesions were measured. Cross sectional area of external elastic membrane (REEM) and lumen (RLA) in proximal reference segments were measured. The lesions were divided into two groups according to their remodeling patterns ; adequate arterial remodeling (LEEM/REEM>0.78) and inadequate arterial remodeling (LEEM/REEM0.05). CONCLUSION: In adaptive arterial remodeling, the amount of plaque accumulation seems to be an important determinant of compensatory arterial dilatation and contribute weakly to stenosis severity. On the contrary, in inadequate arterial remodeling, it seems to contribute greatly to stenosis severity.

Clinical Comparison of Coronary Flow Reserve and Fractional Flow Reserve after PTCA in Patients with Coronary Artery Disease / 대한내과학회지

OBJECTIVES: Severity of coronary artery stenosis has been defined in terms of geometric dimensions, pressure gradient-flow relations, resistance to flow and coronary flow reserve(CFR) after maximum arteriolar vasodilation. Myocardial fractional flow reserve(FFR) is a new index of the functional severity of coronary stenosis that is calculated from pressure measurements during coronary angiography. We compared the relationship between FFR and CFR after PTCA and the residual stenosis with FFR and CFR in the patients with acute myocardial infarction (AMI) and angina. METHODS: The study population consisted of 25 patients with AMI and 18 patients with angina. All AMI patients had successful restoration of infarc-related artery by thrombolysis or direct PTCA. Doppler index was measured using 0.014 inch Doppler wire 15 minutes after successful restoration of infarc- related artery. Hyperemic index was measured after intracoronary injection of adenosine(16-18ug). Baseline and hyperemic distal coronary artery pressure was measured using 0.014 inch pressure wire with advancing the wire distal to the lesion and simultaneous proximal aortic pressure was measured using guiding catheter. RESULTS: 1) Post-interventional FFR and CFR were 0.91+/-0.09 and 1.87+/-0.45 in AMI and 0.93+/-0.06 and 2.73+/-0.67 in angina. There was no significant correlation between FFR and CFR in AMI and angina(p=NS). CFR showed the weak correlation with hyperemic distal pressure(hPd) in AMI(p=0.04) and FFR with hDSVR in angina(p=0.04). FFR and CFR were not correlated with mean blood pressure and heart rate(p=NS). 2) FFR and hyperemic pressure gradient had the close correlation with residual stenosis after successful PTCA in AMI and angina(p<0.001). Baseline pressure gradient also showed weak correlation with FFR(p<0.05). 3) CFR was 1.87+/-0.45 in AMI and 2.73+/-0.67 in angina with significant difference between two groups (p<0.001) and FFR was 0.91+/-0.09 in AMI and 0.93+/-0.06 in angina without difference(p=NS). hPa and hPd showed the significant difference between the two groups(p<0.05). CONCLUSION: FFR seems to be a new index of the functional severity of coronary stenosis that is calculated from pressure measurements during coronary angiography.

Fractional Flow Reserve in Coronary Artery Disease: Comparison with Intravascular Ultrasound

BACKGROUND AND OBJECTIVE: Precise assessment of lesion severity is fundamental for the clinical decision making in the patients with coronary artery disease. Coronary angiography has limitation to projection imaging techniques. Intravascular ultrasound (IVUS) has been known to be a gold standard of morphological severity of coronary stenosis. Fractional flow reserve (FFR) is known to be a lesion specific functional index of epicardial stenosis that can be derived from intracoronary pressure assessed during maximal vasodilation. The objective of this study was to investigate the validity of fractional flow reserve for stenosis severity in comparison with IVUS. METHODS: The study population consisted of 24 patients with angina pectoris (M:F=19:5, age: 58+/-12 yrs). The IVUS and intracoronary pressure wire performed at 26 lesions after diagnostic coronary angiography. We measured angiographical diameter stenosis (DST), minimal luminal diameter (MLD), minimal luminal area (MLA) and reference area stenosis (r-AST). FFR was defined by the ratio of distal mean coronary pressure (Pd) to aortic mean pressure (Pa). RESULTS: FFR showed significant correlation with both r-AST (r=-0.93, p<0.00001) than DST (r=-0.79, p<0.0001). When the lesions with MLD less than 1.1 mm were excluded, considering the limitation of IVUS for the thickness of its catheter, FFR showed excellent correlation with r-AST with higher correlation coefficient (r=-0.96, p<0.00001). FFR showed significant correlation with MLA (r=0.87, p=0.0001) or MLD (r=0.83, p=0.0005). CONCLUSION: FFR with excellent correlation with r-AST measured by IVUS seems to be a useful lesion specific functional index for the assessment of coronary stenosis in angina patients.

Temporal Changes of Myocardial Capillary Flow after Attempted Reperfusion in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: As lack of myocardial perfusion was demonstrated Microvascular function after reperfusion of infarct related artery (IRA) can be changed in convalescent stage for several possible mechanisms such as hyperemia and microvascular stunning. Therefore, myocardial contrast echocardiography (MCE) performed early stage after reperfusion of IRA may cause over or underestimation of the extent of myocardial necrosis. The aims of the study were to demonstrate the temporal changes of myocardial perfusion after revascularization of IRA and to explore the association of late changes of myocardial capillary flow with contractile recovery. METHODS: MCE was performed 5-7days after the attack of acute myocardial infarction (AMI) in 21 patients (M:F=17:4, age: 58+/-12yrs) who underwent successful reperfusion of IRA. MCE was graded by semiquantitative score (0: no opacification, 0.5: partial opacification, 1: homogenous opacification) by 16 segment model. Every patient underwent 1-2months follow up 2D echocardiography and MCE. Improvement of wall motion score more than 1 at follow up was considered to have contractile recovery. RESULTS: Thirty-one of 71 initially akinetic segments were scored as 1, 30 segments as 0.5 and 10 segments as 0 after attempted reperfusion. Twelve of 30 segments with score of 0.5 and 5 of 10 segments with score of 0 showed late improvement of MCE score to 1 and 0.5. Only 1 of 30 segments with score of 0.5 got worse to score of 0. Every segment with late improvement from 0.5 to 1 showed contractile recovery, whereas none of 5 segments with late improvement from 0 to 0.5 showed contractile recovery. There was no significant difference of predictive value between early and late MCE (p=ns). CONCLUSION: Temporal changes of myocardial perfusion from 1week to 2 months in AMI were mainly progressive improvement caused by recovery of microvascular function from stunning rather than progressive microvascular damage or reactive hyperemia. However, it may not significantly affect the validity of MCE in predicting contractile recovery.

Temporal Changes of Myocardial Capillary Flow after Attempted Reperfusion in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: As lack of myocardial perfusion was demonstrated Microvascular function after reperfusion of infarct related artery (IRA) can be changed in convalescent stage for several possible mechanisms such as hyperemia and microvascular stunning. Therefore, myocardial contrast echocardiography (MCE) performed early stage after reperfusion of IRA may cause over or underestimation of the extent of myocardial necrosis. The aims of the study were to demonstrate the temporal changes of myocardial perfusion after revascularization of IRA and to explore the association of late changes of myocardial capillary flow with contractile recovery. METHODS: MCE was performed 5-7days after the attack of acute myocardial infarction (AMI) in 21 patients (M:F=17:4, age: 58+/-12yrs) who underwent successful reperfusion of IRA. MCE was graded by semiquantitative score (0: no opacification, 0.5: partial opacification, 1: homogenous opacification) by 16 segment model. Every patient underwent 1-2months follow up 2D echocardiography and MCE. Improvement of wall motion score more than 1 at follow up was considered to have contractile recovery. RESULTS: Thirty-one of 71 initially akinetic segments were scored as 1, 30 segments as 0.5 and 10 segments as 0 after attempted reperfusion. Twelve of 30 segments with score of 0.5 and 5 of 10 segments with score of 0 showed late improvement of MCE score to 1 and 0.5. Only 1 of 30 segments with score of 0.5 got worse to score of 0. Every segment with late improvement from 0.5 to 1 showed contractile recovery, whereas none of 5 segments with late improvement from 0 to 0.5 showed contractile recovery. There was no significant difference of predictive value between early and late MCE (p=ns). CONCLUSION: Temporal changes of myocardial perfusion from 1week to 2 months in AMI were mainly progressive improvement caused by recovery of microvascular function from stunning rather than progressive microvascular damage or reactive hyperemia. However, it may not significantly affect the validity of MCE in predicting contractile recovery.

Contractile Reserve versus Cell Membrane Integrity for Predicting Contractile Recovery after Reperfusion in Acute Myocardial Infarction and Their Relationship

BACKGROUND: Early prediction of functional recovery could have very important prognostic and therapeutic implication. Modalities evaluating functional recovery of dysynergic segments have included metabolic and perfusion imaging as well as assessment of contractile reserve in response to inotropic agent. Dobutamine stress echocardiography(DSE) assesses contractile reserve whereas rest and 24hr delayed Tl-201 SPECT(T1-201) assesses cell membrane integrity. Does contractile reserve always imply cell membrane integrity? If not, which one could be more useful predictor of contractile recovery of the infarcted segment after restoration of the infarct related artery(IRA) in acute myocardial infarction(AMI)? The aim of this study was to evaluate comparative accuracy of contractile reserve and cell membrane integrity in predicting contractile recovery and their relation. METHODS: We prospectively compared DSE with Tl-201 in 22 of 34 patients with acute myocardial infarction from August 1996 to September 1997. AU patients underwent coronary angiography and got revascularization treatment if they had significant stenosis. DSE and Tl-201 were done within 24hrs after successful restoration without flow limiting residual stenosis. An intravenous infusion of dobutamine(5(mg/kg/min) was started with an infusion pump and continued in 3-minute dose increment up to 20(mg/kg/min under continuous ECG and echocardiographic monitoring. Regional wall motion was assessed according to 16-segment model from American Society of Echocardiography recommendation. Wall motion was scored as 1 (normal), 2(mild to moderate hypokinesia), 3(severe hypokinesia), 4(akinesia), 5(dyskinesia). The improvement of wall motion score(WMS) more than 1 from asynergy during dobutmine infusion was considered to have contractile reserve. SPECT images were obtained at rest and 24hours later. The Tl-201 images were analyzed visually according to 16 segment model, scored by grade 0: normal uptake, 1: mild to moderate decreased, 2: severe decreased, 3: defect. Those segments were considered to have a cellular integrity if the defect at rest improved more than grade 1 on delayed images. All patients underwent 1 month follow up echocardiography after discharge. The improvement of WMS more than score 1 from asynergy at follow up was considered to have contractile recovery. RESULTS: 71 akinetic segments out of total of 352 segments were analyzed. There was no significant difference of sensitivity(88 vs 82%), specificity(82 vs 82%), and accuracy(86 vs 81%) in predicting contractile recovery between DSE and Tl-201. The agreement between contractile reserve and cellular integrity was 73% with kappa value of 0.42(p=0.001). CONCLUSION: Contractile reserve has similar sensitivity, specificity and predictive value with cell membrane integrity in predicting contractile recovery. However contractile reserve immediately after restoration does not necessarily imply cell membrane integrity in acute myocardial inFarction.

Frequency and Clinical Significance of Intrapulmonary Shunt in Liver Cirrhosis; Detection by Contrast Echocardiography / 대한내과학회지

OBJECTIVES: Intrapulmonary vascular abnormalities resulting in right-to-left shunt have been described in patients with severe liver disease, especially advanced hepatic cirrhosis. They result in hypoxemia which is associated with liver cirrhosis without preexisting cardiac or pulmonary diseases. Since Rydell and Hoffbauer first described intrapulmonary shunt in a cirrhotic patient in 1956, it has been reported recently that 13 to 47 percent of the end-stage hepatic disease patients have these intrapulmonary vascular abnormalities. Contrast echocardiography(CE) has been proved useful in detecting intrapulmonary shunt. The aim of the study is to determine the prevalence of intrapulmonary shunt by CE in patients with hepatic cirrhosis, and to compare the clinical characteristics of those with and without evidence of intrapulmonary shunt. METHODS: We performed CE studies in 24 stable cirrhotic patients without the evidence of severe complications such as massive ascites, upper GI bleeding, and hepatic coma. Clinical information including symptom and sign, results of liver and pulmonary function tests, and arterial blood gas values measured both at the supine and erect position, were analyzed in each group of patients with or without intrapulmonary shunt. RESULTS: Positive CE suggesting intrapulmonary shunt was found in 8 of 24 patients(33.3%). However the degree of relative opacifications were one positive(1+) in all 8 patients, and hypoxemia and its related symptom and sign appeared to be rare. Any of the parameters of liver and pulmonary function test did not show the significant difference between CE-positive and CE-negative group. CONCLUSION: Only the presence of spider angioma was associated with intrapulmonary shunt among the several clinical signs, which suggests common pathogenesis of both vascular abnormalities.

Comparison of Myocardial Fractional and Coronary Flow Reserve after Revascularization in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the residual diameter stenosis after PTCA with fractional flow reserve (FFR) and coronary flow reserve (CFR), and investigate the correlation between FFR and CFR in patients with acute myocardial infarction (AMI). MATERIALS AND METHOD: The study population consisted of twenty seven patients with myocardial infarction. Baseline and hyperemic average peak velocity (APV) were measured using Doppler wire 15 minutes after restoration of infarct-related artery (IRA). CFR was obtained by the ratio of distal hyperemic APV to baseline APV. Distal coronary arterial pressure (Pd) was measured with advancing the wire distal to the lesion of IRA. Simultaneous proximal aortic pressure (Pa) was measured using guiding catheter. Myocardial FFR was obtained by the ratio of hyperemic Pd to hyperemic Pa. RESULTS: Post-interventional CFR and FFR were 0.85+/-0.44, 0.91+/-0.09. CFR did not show significant correlation with luminal diameter stenosis (%ST). There was no significant correlation between FFR and CFR with a correlation coefficient of 0.29 (p=.25). But, significant correlation was found between %ST and FFR, %ST and hyperemic PG (hPG) with correlation coefficient of -0.70 (p=.0012) and 0.68 (p=.0018). CONCLUSION: In AMI patients, %ST has a significant correlation with FFR and hPG after PTCA. But, there was no significant correlation between FFR and CFR.

Variant Aangina Diagnosed by Beta-Blocker Provocation Test and a Case of Subendocardial inFarction Induced by This Test

The provocation test of variant angina are known as ergonovine test, hyperventilation, acetylcholine, exercise and cold pressor test, but beta-blocker provocation test has not been reported as a case. So, this paper reports on the diagnosis of variant angina by beta-blocker provocation test and the case of subendocardial infarcion induced by this test. This study reports with literature and investigation about the following case : A 45-year-old man with a history of recurrent episode of typical angina on the early morning for the past 20 days. He was administrated beta-blocker given by oral route, and on the next morning there was chest pain as same degree as before, Holter EKG displayed ST segment elevation and ventricular tachycardia. It was confirmed focal spasm on coronary angiography, ST segment elevation on EKG, and newly developed hypokinesia on left ventriculogram and followed-up echocardiagraphy. When the chest pain is absent, EGK was normal. And we confirmed that elevation of cardiac enzyme was absent as a result of serial follow up study.

Clinical Study of Potential Embolic Sources in Patients with Ischemic Cerebrovascular Diseases

BACKGROUND: The etiologies of ischemic cerebrovascular diseases are various-thrombosis or artery to artery embolism, cardiogenic embolism and lipohyalinosis. In the past embolic cerebral infarct was thought to occur uncommonly. But these days substantial portion of patients have been found to have potential embolic sources by transesophageal echo cardiography and carotid duplex doppler. As transesophageal echocardiography has a high yield for identification of potential sources of cardiac embolism in patients with ischemic cerbrovascular diseases, its use has been increasing. In Korea an increasing number of patients with ischemic cerebrovascular diseases have been examined by transesophageal echocardiography since 1990. But in all the previous studies transesophageal echocardiographic evaluation has been confined to the patients with high probability of embolic cerebral infarct. All kinds of ischemic cerebrovascular diseases patients have never been examined by transesophageal echocardiography and carotid duplex doppler and the prevalence of potential embolic sources in Korean ischemic cerebrovascular disease patients is not known. The aim of this study was to evaluate the prevalence of potential cardiovascular embolic sources by transesophageal echocardiography and carotid duplex doppler in unselected patients with ischemic cerebrovascular diseases. METHODS: We evaluated all kinds of ischemic cerebrovascular diseases patients admitted from 1994. 9. 1. until 1995 9. 31. to the Departments of Neurology and Internal Medicine of Kangnam General Hospital. We evaluated them by transesophageal echocardiography, carotid doppler, brain CT(or brain MRI). A significant carotid stenosis was defined as a duplex scandetected lesion producing at least 50% vessel narrowing. The following echocardiographic findings were defined prospectively as potential cardiac sources of embolism : atrial appendage or left atrial cavity thrombus, spontaneous echocardiographic contrast, atrial septal aneurysm, interatrial shunt, ventricular aneurysm, ventricular thrombus, myxomatous mitral valve and protruding atherosclerotic plaque in the ascending aorta or transverse aortic arch. RESULTS: Of 64 patients admitted during the study period, 30 were excluded(Three patients were critically ill, and twenty seven patients refused diagnostic work-up.). Thorough diagnostic work-up was performed in 34 patients. Transesophageal echocardiographic positive findings were present in six patients(17.6%). Of them four(4/34, 11.7%) had spontaneous echo contrast, two(2/34, 5.8%) had left atrial thrombi, one(1/34, 2.9%) had ascending aorta atheroma. Eleven patients(11/34, 32.3%) had abnormalities in carotid doppler study. Five patients(5/34, 14.7%) had abnormalities both in transesophageal echocardiography and carotid doppler study. CONCLUSIONS: The results suggest that among ischemic cerebrovascular diseases patients substantial portion of patients have potential embolic sources. The prevalence of potential embolic sources in Korea may be higher than previously expected. Because the relative small number of the patients studied make it difficult to generalize the results, further studies with a large number of patients are needed.

Correlation between Insertion/Deletion Polymorphism of Angiotensin I-Converting Enzyme Gene and Left Ventricular Hypertrophy

BACKGROUND: It was reported that patients who have left ventricular hypertrophy have higher D allele frequency of angiotensin I-converting enzyme gene polymorphism, especially in Caucasian normotensive men. We studied to know whether genetic polymorphism of angiotensin I-converting enzyme gene is associated with the development of left ventricular hypertrophy in Korean people whose genotype frequency is quite different from that of Caucasians. METHODS: Total 156 patients were included in this study. Presence of hypertension was checked with the criteria that hypertensives are one whose blood pressures were all above 140/90 at least 3 times spanning 2 months or one who had been diagnosed as hypertension and on his medication. Left ventricular mass index(LVMI) was calculated using electrocardiogram by Rautaharju equation, and left ventricular hypertrophy(LVH) was defined as LVMI was above 131g/m2 in male or above 110g/m2 in female. Genomic DNA was extracted from the mononuclear cell of each subjects and PCR was performed using new primers for the region of intron 16 and exon 17. RESULTS: Genotype frequencies of D/D genotype and D allele were 0.200 and 0.413 respectively in group with LVH(n=40), 0.103 and 0.392 respectively in group without LVH(n=116). There was no significant difference with each other group. However, when only the normotensives were included in this analysis, frequency of D/D genotype is significantly higher in group with LVH(0.231, n=26) than in group without LVH(0.076, n=79)(Fisher's exact test,p<0.05). There was no significant difference in genotype frequency between the normotensives(n=105) and the hypertensives(n=51). CONCLUSIONS: In Korean people, D allele of polymorphism of angiotensin I-converting enzyme gene is also associated with development of left ventricular hypertrophy in the normotensives and is not associated with essential hypertension.

Correlation between Insertion/Deletion Polymorphism of Angiotensin I-Converting Enzyme Gene and Left Ventricular Hypertrophy

BACKGROUND: It was reported that patients who have left ventricular hypertrophy have higher D allele frequency of angiotensin I-converting enzyme gene polymorphism, especially in Caucasian normotensive men. We studied to know whether genetic polymorphism of angiotensin I-converting enzyme gene is associated with the development of left ventricular hypertrophy in Korean people whose genotype frequency is quite different from that of Caucasians. METHODS: Total 156 patients were included in this study. Presence of hypertension was checked with the criteria that hypertensives are one whose blood pressures were all above 140/90 at least 3 times spanning 2 months or one who had been diagnosed as hypertension and on his medication. Left ventricular mass index(LVMI) was calculated using electrocardiogram by Rautaharju equation, and left ventricular hypertrophy(LVH) was defined as LVMI was above 131g/m2 in male or above 110g/m2 in female. Genomic DNA was extracted from the mononuclear cell of each subjects and PCR was performed using new primers for the region of intron 16 and exon 17. RESULTS: Genotype frequencies of D/D genotype and D allele were 0.200 and 0.413 respectively in group with LVH(n=40), 0.103 and 0.392 respectively in group without LVH(n=116). There was no significant difference with each other group. However, when only the normotensives were included in this analysis, frequency of D/D genotype is significantly higher in group with LVH(0.231, n=26) than in group without LVH(0.076, n=79)(Fisher's exact test,p<0.05). There was no significant difference in genotype frequency between the normotensives(n=105) and the hypertensives(n=51). CONCLUSIONS: In Korean people, D allele of polymorphism of angiotensin I-converting enzyme gene is also associated with development of left ventricular hypertrophy in the normotensives and is not associated with essential hypertension.

Determinants of Left Ventricular Mass in Healthy Adults : A Study Using Echocardiography and 24 Hour Ambulatory Blood Pressure Monitoring

BACKGROUND: Echocardiographically detected left ventricular(LV) hypertrophy is a risk factor for cardiovascular morbidity and mortality. A better understanding of the determinants of LV mass may aid in strategies directed toward the promary and secondary prevention of LV hypertrophy and its consequences. Previous studies have reported that male gender, arterial blood pressure(BP), obesity, age, aortic valvular stenosis, dietary sodium, endocrine factors, and physical activity are positively correlated with LV mass. Of these determinants male gender, hypertension, and obesity are well known but age and blood pressure in healthy adults are controversial. To assess the determinants of LV mass, the relation of 2-dimensional(2D) echocardiographically determined LV mass to body mass inedx(BMI), age, sex, casual BP, and 24 hour ambulatory blood pressure(ABP : systolic, diastolic, and mean BP of 24 hour, day-time, and night-time) was examined in healthy adults. METHODS: The study population consisted of 200 healthy adults who were normotensive, nonobese, and had no evidence of cardiovascular disease(range in age from 20 to 69 years, five decades, 20 men and 20 women per each decade). LV mass was derived from area length method measurements obtained by 2D echocardiography and corrected for height. ABP monitoring was performend over 24 hour(divided into day-time(6am-10pm) and night-time(10pm-6am)periods) with 30 minute inervals. RESULTS: 1) BMI was significantly and independently related to LV mass corrected for height (p<0.001, partial R2=0.31 in men and 0.43 in women). An increase of BMI by 1 kg/m2increased LV mass corrected for height by 1.9g/m in men and 2.0g/m in women. 2) Age was significantly and independently related to LV mass corrected for height(p<0.001, partial R2=0.15 in men and 0.17 in women). The increments of Lv mass corrected for height per decade were 2.1 g/m in men and 3.4 g/m in women. 3) Gender was significantly and independently related to LV mass corrected for height(p<0.001, partial R2=0.12), which was greater in men than in women by 6.34g/m. 4) Casual Bp and 24 hour ABP were not significantly associated with LV mass corrected for height in total population and women, and 24 hour systolic BP was significantly related to LV mass corrected for height only in men(p<0.001) with weak partial R2(0.05). CONCLUSION: BMI, age, and male gender were statistically significant and independent correlates of LV mass corrected for height(p<0.001). Maintenance of ideal body weight and normal BP, weight reduction in obese persons and BP control inhypertensive patients may contribute to the primary and secondary prevention of LV hypertrophy and its sequalae.