Lifestyle Modification in the Management of Metabolic Syndrome:Statement From Korean Society of CardioMetabolic Syndrome (KSCMS)

With the recent rapid increase in obesity worldwide, metabolic syndrome (MetS) has gained significant importance. MetS is a cluster of obesity-related cardiovascular risk factors including abdominal obesity, atherogenic dyslipidemia, high blood pressure and impaired glucose tolerance. MetS is highly prevalent and strongly associated with an increased risk of developing diabetes and cardiovascular disease, putting a great burden on human society. Therefore, it is very important to reduce MetS risk, which can improve patients’cardiovascular prognosis. The primary and most effective strategy to control each component of MetS is lifestyle change such as losing body weight, keeping regular exercise, adopting a healthy diet, quitting smoking and alcohol drinking in moderation. Many studies have shown that lifestyle modification has improved all components of MetS, and reduces the incidence of diabetes and cardiovascular disease. Here, the Korean Society of CardioMetabolic Syndrome has summarized specific and practical methods of lifestyle modification in the management of MetS in the healthcare field.

The effect of beta-blockers in acute heart failure according to heart rate

Background/Aims@#Beta-blockers (BBs) have been shown to improve clinical outcomes in heart failure (HF) patients. We evaluated the prescribing status of BBs in patients with HF with reduced ejection fraction (HFrEF) at discharge according to the presence or not of bradycardia, and its effect on prognosis. @*Methods@#Study data were obtained from a multicenter cohort of 3,200 patients hospitalized for HF. Patients were classified into four groups according to the presence of bradycardia and use of BBs at discharge. The primary outcome was the incidence of all-cause death during follow-up. @*Results@#Of 1,584 patients with HFrEF, 281 patients died during follow-up (median 523 days, mean 578.5 ± 429.7 days). In patients with bradycardia, the all-cause death rate did not significantly differ according to the use of BBs, but in those patients without bradycardia, the incidence of all-cause death was significantly lower in the BBs group than the no BBs group. Among these four groups, patients with heart rate (HR) ≥ 60 beats/min with no BBs group had the lowest cumulative death-free survival rate. In addition, HR ≥ 60 beats/min with BBs use was independently associated with a 31% reduced risk of all-cause death in patients with HFrEF. @*Conclusions@#BBs had a beneficial effect on clinical prognosis only in those HFrEF patients without bradycardia. Therefore, BBs should be given by clinicians to HF patients without bradycardia to improve their clinical outcomes.

The effect of beta-blockers in acute heart failure according to heart rate

Background/Aims@#Beta-blockers (BBs) have been shown to improve clinical outcomes in heart failure (HF) patients. We evaluated the prescribing status of BBs in patients with HF with reduced ejection fraction (HFrEF) at discharge according to the presence or not of bradycardia, and its effect on prognosis. @*Methods@#Study data were obtained from a multicenter cohort of 3,200 patients hospitalized for HF. Patients were classified into four groups according to the presence of bradycardia and use of BBs at discharge. The primary outcome was the incidence of all-cause death during follow-up. @*Results@#Of 1,584 patients with HFrEF, 281 patients died during follow-up (median 523 days, mean 578.5 ± 429.7 days). In patients with bradycardia, the all-cause death rate did not significantly differ according to the use of BBs, but in those patients without bradycardia, the incidence of all-cause death was significantly lower in the BBs group than the no BBs group. Among these four groups, patients with heart rate (HR) ≥ 60 beats/min with no BBs group had the lowest cumulative death-free survival rate. In addition, HR ≥ 60 beats/min with BBs use was independently associated with a 31% reduced risk of all-cause death in patients with HFrEF. @*Conclusions@#BBs had a beneficial effect on clinical prognosis only in those HFrEF patients without bradycardia. Therefore, BBs should be given by clinicians to HF patients without bradycardia to improve their clinical outcomes.

Comparison of calcium-channel blockers for longterm clinical outcomes in patients with vasospastic angina

Background/Aims@#Calcium channel blockers (CCBs) are the most widely prescribed medication for patients with vasospastic angina (VA). However, few studies have compared the prognosis of VA patients who are prescribed different CCBs. @*Methods@#We enrolled 2,960 patients who received provocation test prospectively in 11 university hospitals in Korea. We divided 1,586 patients received four major CCBs into two groups: a first generation CCB (diltiazem and nifedipine) group and a second generation CCB (amlodipine and benidipine) group. Primary outcome was time to events of composite of death from any cause, acute coronary syndrome (ACS) and symptomatic arrhythmia during 3-year follow-up. We also compared the effect of each CCB on the control of angina symptoms. @*Results@#There was no difference of the primary outcome among the two groups with a cumulative incidence rate of 5.4%, 2.9%, and a person-month incidence rate of 2.33 and 1.26, respectively (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.25 to 1.17; p = 0.120, as reference with the 1st generation CCBs). The incidence of ACS was significantly lower in 2nd generation CCBs group with a person-month incidence rate of 1.66 vs. 0.35 (HR, 0.22; 95% CI, 0.05 to 0.89; p = 0.034). Use of benidipine showed a significant better control of angina symptom compared with diltiazem for 3 years (odds ratio, 0.17; 95% CI, 0.09 to 0.32; p < 0.0001 at 3rd year). @*Conclusions@#The first and second generation CCB groups did not differ in terms of composite outcome occurrence. However, the ACS incidence rate was significantly lower in the users of the 2nd generation CCBs.

Systematic Review of Treatment for Trapped Thrombus in Patent Foramen Ovale

BACKGROUND AND OBJECTIVES: Trapped thrombus in patent foramen ovale (PFO) is a rare complication of pulmonary embolism that may lead to tragic clinical events. The aim of this study was to identify the optimal treatment for different clinical situations in patients with trapped thrombus in a PFO by conducting a literature review. SUBJECTS AND METHODS: A PubMed database search was conducted from 1991 through 2015, and 194 patients (185 articles) with trapped thrombus in a PFO were identified. Patient characteristics, paradoxical embolic events, and factors affecting 60-day mortality were analyzed retrospectively. RESULTS: Among all patients, 112 (57.7%) were treated with surgery, 28 with thrombolysis, and 54 with anticoagulation alone. Dyspnea (79.4%), chest pain (33.0%), and syncope (17.5%) were the most common presenting symptoms. Pretreatment embolism was found in 37.6% of cases, and stroke (24.7%) was the most common event. Surgery was associated with fewer post-treatment embolic events than were other treatment options (p=0.044). In the multivariate analysis, initial shock or arrest, and thrombolysis were independent predictors of 60-day mortality. Thrombolysis was related with higher 60-day mortality compared with surgery in patients who had no initial shock or arrest. CONCLUSION: This systematic review showed that surgery was associated with a lower overall incidence of post-treatment embolic events and a lower 60-day mortality in patients with trapped thrombus in a PFO. In patients without initial shock or arrest, thrombolysis was related with a higher 60-day mortality compared with surgery.

Pulmonary Vein Thrombosis Caused by Lobar Pneumonia / 대한내과학회지

Pulmonary vein thrombosis is a rare disease related to a lung malignancy or complication after lung surgery. Generally, it is caused by tumor invasion or localized stenosis of a vein anastomosis site after an operation. Here we report a case of pulmonary vein thrombosis that occurred in a patient with local thrombophlebitis due to lobar pneumonia.

Asymptomatic Bone Cement Pulmonary Embolism after Percutaneous Vertebroplasty: A Case Report

Pulmonary embolism is a rare complication after percutaneous vertebroplasty for compression fracture. Embolization is related to cement leakage outside the treated vertebral body into the adjacent venous system. We report on a case of pulmonary embolism with bone cement in the right pulmonary artery in a 75-year-old female who had undergone percutaneous vertebroplasty 2 months before. Her simple X-ray of the spine captured polymethyl metacrylate leakage from the vertebral body, which indicated the pathophysiology of this event.

Myocardial Ischemia by Aggravation of Myocardial Bridging

Myocardial bridging (MB) occurs when the myocardium covers a segment of a major epicardial coronary artery, resulting in a tunneled arterial segment. Although MB is generally considered benign, it has been associated with myocardial ischemia. A 70-year-old man with MB (50% luminal narrowing during systole) at the mid-left anterior descending artery (LAD) on previous coronary angiography (CAG) visited our hospital with worsening chest pain. His blood pressure (BP) was not well controlled because of poor compliance. Follow-up CAG showed that MB at the mid-LAD progressed to severe stenosis (>90% luminal narrowing during systole) and the total length of tunneled artery extended from 22.5 to 23.9 mm. His chest pain was relieved by BP control. This is the first report of myocardial ischemia secondary to progression of MB demonstrated by CAG in Korea.

Intramural Hematoma with Air Density on Computed Tomography after Percutaneous Kyphoplasty

Iatrogenic aortic dissection occurs in association with diverse invasive procedures. It occurs primarily as a complication of cardiac surgery or after catheterization procedure. We found a case of iatrogenic abdominal aortic dissection caused by traumatic needle injury. The patient complained of abdominal pain after balloon kyphoplasty. Abdominal computed tomography (CT) showed intramural hematoma with air density suggestive of an iatrogenic cause. The patient was managed conservatively, and no lesion progression was noted in the follow-up CT. To the best of our knowledge, this is the first case of iatrogenic aortic dissection associated with kyphoplasty.

Development of a Rabbit Model for a Preclinical Comparison of Coronary Stent Types In-Vivo

Along with the development of innovative stent designs, preclinical trials in animal models are essential. Many animal models have been used and appear to yield comparable results to clinical trials despite substantial criticisms about their validity. Among the animal models, porcine coronary artery models have been the standard models for the preclinical evaluation of endovascular devices. However, rapid growth rate, high body weight potential, and the propensity to develop granulomatous inflammatory reactions are major limitations of the porcine coronary artery model. Compared with porcine coronary artery models, the comparative rabbit iliac artery model has the advantages of being small and easy to handle and relatively inexpensive. Furthermore, the rabbit model has been known to reliably reflect human restenosis histopathologically and have major advantages such as pairwise comparison, which makes each animal serve as its own control subject, therefore, maximizing its statistical power for comparative testing. However, despite the widespread use of this model, a systematic description of the procedure and harvest protocols has never been published. This article describes the surgical procedure, stent implantation procedure, method for tissue harvesting, and how measurements are performed. Although the results of animal models may not perfectly extrapolate to humans, the comparative rabbit iliac artery model may be a useful tool for assessing and comparing the efficacy of new coronary stents with conventional stent systems. This thorough description of the techniques required for vascular access, stent implantation, tissue preparation, and measurement, should aid investigators wishing to begin using the comparative rabbit iliac artery model.

Reversibility of Atrioventricular Block According to Coronary Artery Disease: Results of a Retrospective Study

BACKGROUND AND OBJECTIVES: The causal relationship of clinically-significant atrioventricular block (AVB) and coronary artery disease (CAD) is uncertain. We investigated whether CAD is related to irreversible AVB that requires treatment with a permanent pacemaker. SUBJECTS AND METHODS: We included 188 consecutive patients with new-onset AVB considering pacemaker, who had undergone invasive or noninvasive coronary evaluation. Patients were divided into one of 2 groups: irreversible AVB who underwent implantation of permanent pacemaker {irreversible block (IB) group, n=173} or reversible AVB {reversible block (RB) group, n=15}. RESULTS: In IB group, significant CAD was observed in 44 patients (25.4%) and there were 2 (1.2%) patients with acute myocardial infarction (AMI). In RB group, 14 patients (93.3%) had CAD (p<0.001) and 13 patients (86.7%) presented with AMI (p<0.001). On the aspect of CAD type and reversibility of AVB, 13/15 (86.7%) patients of AMI, 0/2 (0%) of unstable angina, and 1/41 (2.4%) of stable angina had reversible AVB. CONCLUSION: AVB in patients with AMI is usually reversible. Therefore, permanent pacemaker implantation should be delayed in cases of AMI. AVB in patients with CAD other than AMI is usually irreversible.

A Case of von Hippel-Lindau Disease Presenting with Pancreatic Neuroendocrine Tumor

Von Hippel-Lindau (VHL) disease is an autosomal dominant disorder that results from a germline mutation of the VHL gene. The affected individuals might develop several benign or malignant tumors such as central nervous system or retinal haemangioblastomas, endolymphatic sac tumors, renal cell carcinomas, pheochromocytomas or pancreatic cysts and neuroendocrine tumors. We report here on a case of a 21 year old female with von Hippel-Lindau disease and she presented with only pancreatic neuroendocrine tumor and no evidence of haemangioblastomas or other visceral complications. Further, direct sequencing of the VHL gene reveals a novel germline frameshift mutation of codon 198 from the deletion of nucleotide 592 (cytosine), leading to truncation of the VHL protein.

Clinical Significance and Outcomes of Initial No Growth Peritonitis from Peritoneal Dialysis Patients: Role of Mycobacterial or Fungal Peritonitis / 대한신장학회지

PURPOSE: Peritoneal dialysis associated peritonitis (PD peritonitis) is an important complication in maintaining. There have been only a few reports on the clinical outcome of initial no-growth peritonitis (INGP). METHODS: We reviewed 332 episodes of PD peritonitis between January 2002 and August 2009. INGP was defined as PD peritonitis with no growth of etiologic microorganism within 3 days of peritonitis. INGP was compared with initial positive growth peritonitis (IPGP) in view of clinical manifestations and outcomes. RESULTS: We divided PD peritonitis episodes into two groups: INGP (n=90) and IPGP (n=242). Peritonitis-related mortality was 5.6% in INGP, while 0.8% in IPGP (p=0.017). Further relapse was noted in INGP (10.0%) than in IPGP (vs. 4.1%; p=0.041). Salvage antibiotics were used more frequently in INGP (21.1%) than in IPGP (vs. 11.6%; p=0.027). Odds ratio of INGP to IPGP for peritonitis-related mortality was 7.14 (95% CI 1.36-37.51; p=0.017). Growth of mycobacteria or fungi increased the risk of peritonitis-related mortality with an odds ratio of 18.11 (95% CI 2.99-109.89; p=0.013). In multivariate analysis, growth of mycobacteria or fungi was the only independent risk factor for peritonitis-related mortality with an odds ratio of 10.63 (95% CI 1.27-88.75; p=0.029). CONCLUSION: INGP revealed poorer outcome than IPGP. Higher growth rate of mycobacteria or fungi in INGP than in IPGP accounted for the poor outcome. Thus one should make vigorous efforts to detect surreptitious organism when there is no growth by 3 days, especially for the possibility of either mycobacteria or fungi.

The Value of Brachial-Ankle Pulse Wave Velocity as a Predictor of Coronary Artery Disease in High-Risk Patients

BACKGROUND AND OBJECTIVES: Arterial stiffness has been known as an independent contributory factor for coronary artery disease (CAD). Brachial-ankle pulse wave velocity (baPWV) is widely used as a simple noninvasive measure of arterial stiffness. The aim of our study was to test whether baPWV had predictive value for CAD in the subset of patients with high pretest probability. SUBJECTS AND METHODS: We enrolled 174 consecutive patients who were referred for evaluation of suspected CAD, and who underwent both baPWV measurement and computed tomography (CT) for coronary artery calcium scoring (CACS) as part of a diagnostic work-up. Subsequently, 160 of those patients underwent invasive coronary angiography. The CAD indices consisted of 1) CACS, 2) modified Gensini scoring system, and 3) presence of obstructive CAD and 4) multi-vessel obstructive CAD. RESULTS: baPWV correlated with CACS (r=0.25, p=0.001), but not with modified Gensini scoring (r=0.10, p=0.19). However, after adjustment for factors influencing PWV, baPWV no longer correlated with CACS (r=0.14, p=0.14). By receiver operating characteristic (ROC) curve analysis, baPWV was neither a sensitive nor specific index for predicting the presence of obstructive CAD or multi-vessel obstructive CAD (sensitivity: 53% and 59%; specificity: 50% and 55%, respectively). CONCLUSION: Our findings demonstrated that baPWV is associated with CACS, however, this may be primarily attributed to common risk factors, such as age. Furthermore, baPWV may be of limited value in identifying patients at risk for CAD.

Subclinical Coronary Artery Disease as Detected by Coronary Computed Tomography Angiography in an Asymptomatic Population

BACKGROUND AND OBJECTIVES: Primary prevention of coronary artery disease (CAD) has become a public health issue, according to increasing awareness of the substantial risks posed by asymptomatic atherosclerosis. The aims of this study were to determine the prevalence and characteristics of subclinical CAD using coronary computed tomography angiography (CCTA), and to evaluate the role of this advanced technology in identifying subclinical CAD in asymptomatic Korean individuals, compared with conventional risk stratification. SUBJECTS AND METHODS: We enrolled 4,320 consecutive asymptomatic individuals (61% males, aged 50+/-9 years), who underwent 64-slice CCTA during a routine health check. RESULTS: Coronary artery plaques were present in 1,053 (24%) individuals. Significant stenosis (diameter stenosis > or =50%) was identified in 139 (3%) subjects, and most of the significant lesions (87%) were located in the left anterior descending artery. CCTA revealed noncalcified plaques in 5% of subjects with a coronary calcium score of zero (n=801). Although 25% (n=10) of those with noncalcified plaque had significant stenosis, most of them (90%) were classified into low- or moderate-risk groups according to National Cholesterol Education Program risk stratification guidelines. In a young population (age < or =55 years for males, < or =65 years for females), 30% of subjects with significant stenosis were classified into a low-risk group and 60% had low (0 to 100) calcium scores. CONCLUSION: Subclinical CAD in asymptomatic individuals cannot be ignored for its considerable prevalence, CCTA may be helpful in identifying at-risk subclinical CAD in a noninvasive manner, especially in the young and traditionally low-risk population.