Comparison of Office Blood Pressure, Automated Unattended Office Blood Pressure, Home Blood Pressure, and 24-Hour Ambulatory Blood Pressure Measurements

Background@#Although previous studies have reported differences of blood pressure (BP) according to BP measurement methods, studies in Korean population were scarce. This study aimed to compare BP differences according to different BP measurement methods and assess hypertension phenotype. @*Methods@#This prospective study recruited 183 individuals (mean 55.9 years; 51.4% males).The BP measurements included office BP (auscultatory attended office BP [ausAOBP], automated attended office BP [aAOBP], and automated unattended office BP [aUAOBP]) and out-of-office BP (home BP [HBP] and ambulatory BP [ABP]) measurements taken within one week of each other. @*Results@#The mean systolic/diastolic BP differences between ausAOBP and other BPs according to different BP measurement methods were 3.5/2.3 mmHg for aAOBP; 6.1/2.9 mmHg for aUAOBP; 15.0/7.3 mmHg for daytime ABP; and 10.6/3.4 mmHg for average HBP.The increasing disparity between ausAOBP and other BPs in multivariable regression analysis was significantly associated with increasing BP. The prevalence of white-coat hypertension and masked hypertension in 107 individuals not taking antihypertensive medication was 25.4–26.8% and 30.6–33.3% based on ausAOBP, daytime ABP, and average HBP, respectively.The prevalence of white-coat uncontrolled hypertension and masked uncontrolled hypertension in 76 of those taking antihypertensive medication was 31.7–34.1% and 17.1– 37.1%, respectively. @*Conclusion@#This study showed a large disparity between office BP and out-of-office BP which became more pronounced when office BP by auscultation increased, suggesting that various BP measurement methods should be used to more accurately assess BP status.

Association between Low-Density Lipoprotein Cholesterol Level and Cardiovascular Outcomes in Korean Adults: A Nationwide Cohort Study

Background@#To validate the treatment target of low-density lipoprotein cholesterol (LDL-C) level according to the cardiovascular disease (CVD) risk which was recommended by Korean dyslipidemia guideline. @*Methods@#We used the Korean National Health Insurance Service database which included 3,958,048 people aged 20 to 89 years who underwent regular health screening. The primary outcome was incident CVD, defined as a composite of myocardial infarction and stroke during the follow-up period from 2009 to 2018. @*Results@#The risk of CVD increased from LDL-C level of 70 mg/dL in very high-risk and high-risk groups and from 130 mg/dL in moderate-risk and low-risk groups. Adjusted hazard ratios (HRs) of LDL-C ranges 70–99, 100–129, 130–159, 160–189, and ≥190 mg/dL were 1.20 (95% confidence interval [CI], 1.08–1.33), 1.27 (1.15–1.42), 1.39 (1.23–1.56), 1.69 (1.45–1.96), and 1.84 (1.49– 2.27) in very high-risk group, and 1.07 (1.02–1.13), 1.16 (1.10–1.21), 1.29 (1.22–1.36), 1.45 (1.36–1.55), and 1.73 (1.58–1.90) in high-risk group. Adjusted HRs (95% CI) of LDL-C ranges 130–159, 160–189, and ≥190 mg/dL were 1.15 (1.11–1.20), 1.28 (1.22– 1.34), and 1.45 (1.36–1.54) in moderate-risk group and 1.07 (1.02–1.13), 1.20 (1.13–1.26), and 1.47 (1.37–1.57) in low-risk group. @*Conclusion@#We confirmed the incidence of CVD was increased in higher LDL-C range. The risk of CVD increased from ≥70 mg/dL of LDL-C in very high-risk and high-risk groups, and from ≥130 mg/dL of LDL-C in moderate-risk and low-risk groups in Korean adults.

Cardiovascular Outcomes according to Comorbidities and Low-Density Lipoprotein Cholesterol in Korean People with Type 2 Diabetes Mellitus

Background@#There are no clear data to support the cardiovascular (CV) risk categories and low-density lipoprotein cholesterol (LDL-C) treatment goals in Korean people with type 2 diabetes mellitus (T2DM). We evaluated the incidence of cardiovascular disease (CVD) according to comorbidities and suggested LDL-C treatment goals in Korean people with T2DM in nationwide cohort data. @*Methods@#Using the Korean National Health Insurance Service database, 248,002 people aged 30 to 90 years with T2DM who underwent routine health check-ups during 2009 were included. Subjects with previous CVD were excluded from the study. The primary outcome was incident CVD, defined as a composite of myocardial infarction and ischemic stroke during the follow-up period from 2009 to 2018. @*Results@#The mean age of the study participants was 59.6±10.9 years, and median follow-up period was 9.3 years. CVD incidence increased in the order of DM duration of 5 years or more (12.04/1,000 person-years), hypertension (HT) (12.27/1,000 personyears), three or more CV risk factors (14.10/1,000 person-years), and chronic kidney disease (18.28/1,000 person-years). The risk of incident CVD increased linearly from an LDL-C level of ≥70 mg/dL in most patients with T2DM. In T2DM patients without HT or with a DM duration of less than 5 years, the CVD incidence increased from LDL-C level of ≥100 mg/dL. @*Conclusion@#For primary prevention of CVD in Korean adults with T2DM, it can be helpful to lower LDL-C targets when there are chronic kidney disease, HT, a long duration of diabetes mellitus, or three or more CV risk factors.

Assessment for Macular Thickness after Uncomplicated Phacoemulsification Using Optical Coherence Tomography

Purpose@#Macular edema including cystoid macular edema is one of the main causes of unfavorable visual outcomes after cataract surgery. The macular thickness and the occurrence of macular edema after uncomplicated cataract surgery was evaluated using optical coherence tomography (OCT) in this study. @*Methods@#Macular map images were taken by OCT before surgery and at 1 week, 1 month, and 2 months postsurgery. The subjects were classified into two groups (group 1, patients with no macular edema; group 2, patients with macular edema). Group 2 was defined as increase in central macular thickness (CMT) by 30% compared with that before surgery. The risk factors for macular edema were evaluated. Group 2 was divided into two subgroups: subclinical macular edema (group 2A) and cystoid macular edema (group 2B) and they were assessed in terms of the clinical course of best-corrected visual acuity and CMT. @*Results@#A total of 376 patients were enrolled in this study, of which 36 (9.57%, group 2) showed macular edema measured by OCT after the surgery. Univariate analysis for group 1 and 2 revealed that intracameral injection of epinephrine during phacoemulsification was associated with the development of macular edema. In group 2, five patients (1.33%) developed cystoid macular edema. Statistically significant differences in the clinical course of CMT were observed at 2 months (201.2 ± 23.1, 250.0 ± 29.8, and 371.0 ± 160.3 in group 1, group 2A, and group 2B, respectively; p 0.2 with CMT in the normal range. @*Conclusions@#The intracameral injection of epinephrine may cause macular edema after uncomplicated cataract surgery. Examination of CMT using OCT is recommended for the early detection of macular edema.

Spontaneous Closure of a Carotid-cavernous Fistula after Contrast-enhanced Orbit Computed Tomography

Purpose@#We report a case of spontaneous closure of a carotid-cavernous fistula (CCF) after contrast-enhanced orbit computed tomography (CT).Case summary: A 80-year-old female was referred to our clinic under suspicion of chronic angle- closure glaucoma because of persistently high intraocular pressure commencing one month prior. Slit-lamp examination revealed a conjunctival injection and corkscrew-like vessel dilatation in the left eye, and a high intraocular pressure. Dilated fundus examination revealed central retinal vein occlusion in that eye. Contrast-enhanced orbit CT revealed a dilated, superior ophthalmic vein in the left orbit, and she was transferred to our department of neurosurgery for digital subtraction angiography (DSA); this is the gold standard imaging modality for the diagnosis of direct and indirect CCFs. DSA was performed two weeks after orbit CT; however, no CCF was visible. Thereafter, the conjunctival injection and the elevated intraocular pressure improved gradually over eight months. We suspect that the CCF closed spontaneously. @*Conclusions@#Our case highlights the fact that a CCF can close spontaneously after contrast-enhanced orbit CT; ophthalmologists may wish to bear this in mind.

Association between secondhand smoke exposure and new-onset hypertension in self-reported never smokers verified by cotinine

Background/Aims@#There is no study assessing the effect of changes of secondhand smoke (SHS) exposure and new-onset hypertension. We investigated the effect of a change of SHS exposure status on new-onset hypertension in self-reported and cotinine-verified never smokers. @*Methods@#Out of individuals enrolled in the Kangbuk Samsung Health Study between 2011 and 2016, 87,486 self-reported and cotinine-verified never smokers without hypertension at baseline visit were included with a median follow-up of 36 months. Individuals were divided into four groups on the basis of their SHS exposure status at baseline and at follow-up: no, new, former, and sustained SHS exposure groups. @*Results@#The incidence rates per 10,000 person-year of new-onset hypertension in no, new, former, and sustained SHS exposure groups were 84.7, 113.3, 102.0, and 123.7, respectively (p < 0.001). A multivariable Cox-hazard analyses showed that new and sustained SHS exposure groups increased their hazard ratio (HR) for new-onset hypertension compared to no SHS exposure group (HR, 1.31; 95% confidence interval [CI], 1.08 to 1.60 for new SHS exposure group; and HR, 1.24; 95% CI, 1.06 to 1.45 for sustained SHS exposure group). However, being part of the former SHS exposure group did not increase the risk of new-onset hypertension (HR, 0.91; 95% CI, 0.81 to 1.03). @*Conclusions@#This study showed that either new, or sustained SHS exposure, but not former SHS exposure, increased the risk for new-onset hypertension in self-reported never smokers verified as nonsmokers by urinary cotinine. These findings show the possibility that changing exposure to SHS even for a relatively short period can modify the risk of new-onset hypertension in self-reported and cotinine-verified never smokers.

Association between Secondhand Smoke Exposure and Metabolic Syndrome in 118,609 Korean Never Smokers Verified by Self-Reported Questionnaire and Urine Cotinine

Background@#No study has reported the association between secondhand smoke (SHS) exposure and metabolic syndrome (MetS) in self-reported never smokers verified by both self-reported questionnaire and urine cotinine. @*Methods@#A total of 118,609 self-reported and cotinine-verified never smokers (38,385 male; age 34.8±7.1 years) who participated in the Kangbuk Samsung Health Study between 2011 and 2016 were included. Cotinine-verified never smokers were defined as individuals with urinary cotinine <50 ng/mL. SHS exposure was defined as current exposure to passive smoking indoors at home or workplace. @*Results@#Prevalence of SHS exposure in the overall population was 22.6% (27.4% for males and 20.3% for females (P<0.001). The overall prevalence of MetS was 6.8% and was higher in males than in females (10.7% vs. 4.9%, P<0.001). In both genders, MetS prevalence was higher in the SHS exposure group than the non-SHS exposure group (11.3% vs. 10.4%, P=0.010 for males; 5.8% vs. 4.6%, P<0.001 for females). However, there was significant gender interaction for the association between SHS exposure and MetS (P for interaction=0.010). In the multivariate regression analyses, SHS exposure was associated with increased MetS odds only in females (odds ratio [95% confidence interval], 1.02 [0.94 to 1.11] in male vs. 1.17 [1.06 to 1.29] in female). In particular, females with SHS exposure of ≥1 hour/day and ≥3 times showed increased odds of MetS compared with those without SHS exposure (1.22 [1.02 to 1.45], 1.30 [1.14 to 1.49]). @*Conclusion@#This cross-sectional study showed that SHS exposure was significantly associated with prevalence of MetS in self-reported and cotinine-verified female never smokers.

Association of Self-Reported and Cotinine-Verified Smoking Status with Atrial Arrhythmia

Background@#The relationship between self-reported and urinary cotinine-verified smoking status and atrial arrhythmia (AA) is unclear. The aim of this study was to evaluate the association of self-reported and urine cotinine-verified smoking status with AA.Method: A total of 201,788 participants (106,375 men, mean age 37 years) who had both a urinary cotinine measurement and electrocardiogram were included. Cotinine-verified current smoking was defined as a urinary cotinine level above 50 ng/mL. Individuals were divided into three groups based on self-reported smoking and two groups based on cotinineverified smoking status. @*Results@#Among overall subjects, 505 had documented AA (0.3%) and 135 had atrial fibrillation (AF) (0.1%). Self-reported current smoking was associated with an increased risk of AA (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.06–1.91; p = 0.019) and AF (OR, 2.20; 95% CI, 1.24–3.90; p = 0.007), whereas self-reported former smoking had no significant association with AA (OR, 1.30; 95% CI, 0.97–1.73; p = 0.078) and AF (OR, 1.74; 95% CI, 1.00–3.04; p = 0.051). Cotinine-verified current smoking showed no significant association with AA (OR, 1.24; 95% CI, 0.98–1.58; p = 0.080) and AF (OR, 1.20; 95% CI, 0.79–1.83; p = 0.391). @*Conclusion@#Self-reported current smoking was associated with AA and AF, while selfreported former smoking and cotinine-verified current smoking showed no significant association with AA and AF.

Association between Cigarette Smoking and New-Onset Diabetes Mellitus in 78,212 Koreans Using Self-Reported Questionnaire and Urine Cotinine

BackgroundNo study has assessed association between cigarette smoking and new-onset diabetes mellitus (NODM) incidence using two different smoking classification systems: self-reported questionnaire and urine cotinine. The objective of this longitudinal study was to evaluate NODM risk using the above two systems in Korean adults.MethodsAmong individuals enrolled in Kangbuk Samsung Health Study and Cohort Study who visited between 2011 and 2012 at baseline and 2014 at follow-up, 78,212 participants without baseline diabetes mellitus were followed up for a median of 27 months. Assessment of NODM incidence was made at the end of follow-up period. Cotinine-verified current smoking was having urinary cotinine ≥50 ng/mL.ResultsPercentages of self-reported and cotinine-verified current smokers were 25.9% and 23.5%, respectively. Overall incidence of NODM was 1.5%. According to multivariate regression analyses, baseline self-reported current smoking (relative risk [RR], 1.33; 95% confidence interval [CI], 1.07 to 1.65) and cotinine-verified current smoking (RR, 1.27; 95% CI, 1.08 to 1.49) increased NODM risk compared to baseline self-reported never smoking and cotinine-verified current non-smoking. Higher daily amount and longer duration of smoking were also associated with increased NODM risk (P for trends <0.05). In particular, self-reported current smokers who smoked ≥20 cigarettes/day (RR, 1.62; 95% CI, 1.25 to 2.15) and ≥10 years (RR, 1.34; 95% CI, 1.08 to 1.67) had the highest RRs for NODM. These results remained significant in males, although there was no gender interaction.ConclusionThis longitudinal study showed that baseline self-reported and cotinine-verified current smoking were associated with increased risks of NODM, especially in males.

Association between Secondhand Smoke Exposure and Metabolic Syndrome in 118,609 Korean Never Smokers Verified by Self-Reported Questionnaire and Urine Cotinine

Background@#No study has reported the association between secondhand smoke (SHS) exposure and metabolic syndrome (MetS) in self-reported never smokers verified by both self-reported questionnaire and urine cotinine. @*Methods@#A total of 118,609 self-reported and cotinine-verified never smokers (38,385 male; age 34.8±7.1 years) who participated in the Kangbuk Samsung Health Study between 2011 and 2016 were included. Cotinine-verified never smokers were defined as individuals with urinary cotinine <50 ng/mL. SHS exposure was defined as current exposure to passive smoking indoors at home or workplace. @*Results@#Prevalence of SHS exposure in the overall population was 22.6% (27.4% for males and 20.3% for females (P<0.001). The overall prevalence of MetS was 6.8% and was higher in males than in females (10.7% vs. 4.9%, P<0.001). In both genders, MetS prevalence was higher in the SHS exposure group than the non-SHS exposure group (11.3% vs. 10.4%, P=0.010 for males; 5.8% vs. 4.6%, P<0.001 for females). However, there was significant gender interaction for the association between SHS exposure and MetS (P for interaction=0.010). In the multivariate regression analyses, SHS exposure was associated with increased MetS odds only in females (odds ratio [95% confidence interval], 1.02 [0.94 to 1.11] in male vs. 1.17 [1.06 to 1.29] in female). In particular, females with SHS exposure of ≥1 hour/day and ≥3 times showed increased odds of MetS compared with those without SHS exposure (1.22 [1.02 to 1.45], 1.30 [1.14 to 1.49]). @*Conclusion@#This cross-sectional study showed that SHS exposure was significantly associated with prevalence of MetS in self-reported and cotinine-verified female never smokers.

2018 Guidelines for the Management of Dyslipidemia in Korea

No abstract available.

Erratum: 2018 Guidelines for the management of dyslipidemia in Korea

The title and author names are incorrect.

What Do We Get from Recent Statin and CETP Inhibitors Trials?

Recent clinical trials and meta-analyses have indicated that high-intensive statin treatment lowers low-density lipoprotein cholesterol (LDL-C) levels and reduces the risk of nonfatal cardiovascular (CV) events compared with moderate-intensity statin treatment. However, there are residual risks of CV events and safety concerns associated with high-intensity statin treatment. The Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) study showed that ezetimibe plus moderate-intensity statin therapy after acute coronary syndromes incrementally lowers LDL-C levels and improved CV outcomes compared with moderate-intensity statin therapy. However, despite the LDL-C-lowering effects, a substantial residual CV risk still remains, which includes other lipid abnormalities such as low high-density lipoprotein cholesterol (HDL-C). The most representative agents that primarily increase HDL-C are cholesteryl ester transfer protein (CETP) inhibitors. Until now, 4 CETP inhibitors, including torcetrapib, dalcetrapib, evacetrapib, and anacetrapib, have been introduced and all have significantly raised the HDL-C from 30% to 133%. However, the results for CV outcomes in clinical trials differed, based on the 4 agents. Torcetrapib increased the risk of CV events and total mortality in patients at high CV risk (ILLUMINATE trial). Dalcetrapib and evacetrapib did not result in lower rate of CV events in patients with recent acute coronary syndrome and high risk vascular disease, respectively (dal-OUTCOMES and ACCELERATE trials). However, anacetrapib significantly decreased the incidence of major coronary events in patients with atherosclerotic vascular disease (REVEAL trial). This topic summarizes the major results of recent statin and CETP inhibitor trials and provides framework to interpret and implement the trial results in real clinical practice.

Valsartan 160 mg/Amlodipine 5 mg Combination Therapy versus Amlodipine 10 mg in Hypertensive Patients with Inadequate Response to Amlodipine 5 mg Monotherapy

BACKGROUND AND OBJECTIVES: When monotherapy is inadequate for blood pressure control, the next step is either to continue monotherapy in increased doses or to add another antihypertensive agent. However, direct comparison of double-dose monotherapy versus combination therapy has rarely been done. The objective of this study is to compare 10 mg of amlodipine with an amlodipine/valsartan 5/160 mg combination in patients whose blood pressure control is inadequate with amlodipine 5 mg. SUBJECTS AND METHODS: This study was conducted as a multicenter, open-label, randomized controlled trial. Men and women aged 20-80 who were diagnosed as having hypertension, who had been on amlodipine 5 mg monotherapy for at least 4 weeks, and whose daytime mean systolic blood pressure (SBP) ≥135 mmHg or diastolic blood pressure (DBP) ≥85 mmHg on 24-hour ambulatory blood pressure monitoring (ABPM) were randomized to amlodipine (A) 10 mg or amlodipine/valsartan (AV) 5/160 mg group. Follow-up 24-hour ABPM was done at 8 weeks after randomization. RESULTS: Baseline clinical characteristics did not differ between the 2 groups. Ambulatory blood pressure reduction was significantly greater in the AV group compared with the A group (daytime mean SBP change: -14±11 vs. -9±9 mmHg, p<0.001, 24-hour mean SBP change: -13±10 vs. -8±8 mmHg, p<0.0001). Drug-related adverse events also did not differ significantly (A:AV, 6.5 vs. 4.5%, p=0.56). CONCLUSION: Amlodipine/valsartan 5/160 mg combination was more efficacious than amlodipine 10 mg in hypertensive patients in whom monotherapy of amlodipine 5 mg had failed.

Saccular Coronary Artery Aneurysm and Fistula with Organized Thrombi

Saccular coronary artery aneurysm, associated with coronary artery fistula, is a very rare condition. A 48-year-old woman was referred to our hospital for the evaluation of an abnormal shadow on the left cardiac border from a chest X-ray film during regular medical health examination. A huge saccular aneurysm with organized thrombi in the proximal left anterior descending artery (LAD) and coronary artery fistulae from LAD and conus branch of the right coronary artery to pulmonary artery was diagnosed by transthoracic echocardiography, multi-detector computer tomography (MDCT), and coronary angiography. The patient received surgical treatment, including thrombectomy of aneurysm, ligation of the inlet and outlet of aneurysmal sac, coronary artery bypass graft (left internal mammary artery-to-distal LAD), and ligation of fistulae. The postoperative course was uneventful, and postoperative echocardiography and MDCT revealed patent bypass graft; however, a small fistula from proximal LAD across aneurysmal sac to pulmonary artery was observed.

Saccular Coronary Artery Aneurysm and Fistula with Organized Thrombi

Saccular coronary artery aneurysm, associated with coronary artery fistula, is a very rare condition. A 48-year-old woman was referred to our hospital for the evaluation of an abnormal shadow on the left cardiac border from a chest X-ray film during regular medical health examination. A huge saccular aneurysm with organized thrombi in the proximal left anterior descending artery (LAD) and coronary artery fistulae from LAD and conus branch of the right coronary artery to pulmonary artery was diagnosed by transthoracic echocardiography, multi-detector computer tomography (MDCT), and coronary angiography. The patient received surgical treatment, including thrombectomy of aneurysm, ligation of the inlet and outlet of aneurysmal sac, coronary artery bypass graft (left internal mammary artery-to-distal LAD), and ligation of fistulae. The postoperative course was uneventful, and postoperative echocardiography and MDCT revealed patent bypass graft; however, a small fistula from proximal LAD across aneurysmal sac to pulmonary artery was observed.

Diabetes Mellitus and Coronary Angiography / 임상당뇨병

Diabetes mellitus is one of the major causes of cardiovascular morbidity and mortality, and its prevalence is increasing. Although there have been great efforts regarding the early diagnosis and treatment of coronary artery disease in diabetic patients with the development of non-invasive imaging modalities, many diabetic patients are still managed with invasive coronary therapies such as percutaneous coronary intervention or coronary artery bypass graft in clinical practice. Coronary angiography is a gold standard method for detecting and treating coronary artery disease; however, this method is invasive and thus can elicit a relatively higher prevalence of procedure-related complications than non-invasive diagnostic methods. Accordingly, the appropriate use of coronary angiography could play an important role in the reduction of unnecessary complications as well as physician decision making. Recently, appropriate use criteria for coronary angiography in many types of patients with suspected or known coronary artery disease have been documented. This article demonstrates several aspects to be considered when performing coronary angiography and the appropriate use criteria of coronary angiography in diabetic patients.

Spontaneous Complete Occlusion of Middle Cerebral Artery Aneurysm: Case Report

There are few observation papers regarding the natural history of an aneurysm. We report on a case of a completely occluded middle cerebral artery (MCA) aneurysm. A 47-year-old female patient presented with a headache and was diagnosed with rupture of a right MCA aneurysm. Due to a high risk of direct neck clipping, she received conservative treatment after craniotomy and wrapping of her aneurysm. The patient's condition showed improvement, with complete occlusion of the aneurysm and considerable reduction of the aneurysm in size after approximately three years. This is a rare case of an aneurysm of MCA that showed spontaneous resolution. Finally, on the angiogram, characteristics of an aneurysm to occlude spontaneously will be presumed based on literature reviews.

Recurrent Mesalazine-Induced Myopericarditis in a Patient with Ulcerative Colitis

Inflammatory bowel disease (IBD) is considered as a dysregulated immune mediated disease. Pericarditis in IBD is a very rare disease both as an extra-intestinal manifestation of IBD and an adverse reaction of therapeutic drug for IBD such as mesalazine or sulfasalazine. A 26-year-old IBD male patient who had been taking mesalazine regularly for about 1 month was referred to our hospital because of fever, chest discomfort, and abnormal electrocardiographic findings. The patients was diagnosed as acute myopericarditis, and recovered after cessation of mesalazine using steroid and aspirin. When mesalazine was re-medicated some days after discharge, he suffered from myopericarditis again. Subsequently, myopericarditis was resolved just after cessation of mesalazine again. These findings suggest that the development of myopericarditis is caused by mesalazine.

The Relationship Between Heart Rate Recovery and Brain Natruretic Peptide in Patients With Chest Discomfort

BACKGROUND AND OBJECTIVES: The correlation between brain natruretic peptide (BNP) level and cardiac autonomic function has been studied in type 2 diabetic patients. However, there is limited data from patients with normal systolic function. We evaluated the association between heart rate recovery (HRR) representing autonomic dysfunction and three plasma BNP levels: pre-exercise, post-exercise, and change during exercise in patients with normal systolic function. SUBJECTS AND METHODS: Subjects included 105 patients with chest pain and normal systolic function. HRR was defined as the difference between the peak heart rate and the rate measured two minutes after completion of a treadmill exercise test. We measured plasma BNP levels before exercise, 5 minutes after completion of exercise, and during exercise (absolute value of difference between pre- and post-exercise BNP levels). RESULTS: Patients with abnormal HRR values (< or =24 beats for the first 2 minutes of HRR) had lower high-density lipoprotein, lower peak heart rates, and higher pre- and post-exercise BNP levels than patients with normal HRR values. The patients with coronary artery disease (CAD) had abnormal HRR. However, no significant differences were found between the two groups in terms of history of hypertension (HTN), diabetes, and peak systolic blood pressure (SBP) and diastolic blood pressure (DBP). HRR was significantly associated with pre-exercise BNP (r=-0.36, p=0.004) and post-exercise BNP (r=-0.27, p=0.006), but not BNP changes. Further, pre-exercise BNP levels showed a greater association with HRR than post-exercise BNP levels. CONCLUSION: HRR is independently associated with pre-exercise and post-exercise BNP levels, even in patients with normal systolic function.