STATT: a titrate-to-goal study of simvastatin in Asian patients with coronary heart disease. Simvastatin Treats Asians to Target.

BACKGROUND: Most published studies on the use of lipid-lowering agents to treat hypercholesterolemia have focused on Western populations, with few data on Asian populations. OBJECTIVE: The Simvastatin Treats Asians to Target (STATT) study used a titrate-to-goal protocol to evaluate the efficacy and tolerability of simvastatin 20 to 80 mg/d in the treatment of Asian patients with coronary heart disease. METHODS: This was a multicenter, open-label, uncontrolled, 14-week study in patients with coronary heart disease and serum low-density lipoprotein cholesterol (LDL-C) levels of 115-180 mg/dL and triglyceride levels of < or = 400 mg/dL. The dose of simvastatin was titrated from 20 to 80 mg/d to achieve the National Cholesterol Education Program (NCEP) LDL-C target of < or = 100 mg/dL. The primary efficacy measure was the percentage of patients achieving the NCEP target. Among secondary measures were the percentage of patients achieving European Society of Cardiology/European Atherosclerosis Society/European Society of Hypertension target LDL-C levels of < or = 115 mg/dL and the percentage change from baseline in lipid parameters. Tolerability was assessed in terms of the overall incidence of adverse experiences and the incidences of the most commonly reported adverse experiences. RESULTS: The intent-to-treat analysis included 133 Asian patients (93 men, 40 women; mean age, 59.5 years), of whom 125 completed 14 weeks of therapy. Their mean blood pressure was 130.2/79.4 mm Hg. Overall, 104 (78.2%) patients treated with simvastatin achieved LDL-C levels < or = 100 mg/dL at week 14, and 125 (94.0%) achieved this target at some point during the study. Similarly, 122 (91.7%) patients achieved an LDL-C level < or = 115 mg/dL at week 14, and 130 (97.7%) achieved this target at some point during the study. Treatment with simvastatin had favorable effects on the lipid profile, producing significant percentage changes from baseline in all parameters (P < 0.001). Simvastatin was well tolerated across the dose range. Overall, 40 patients (30.1%) had > or = 1 clinical adverse experience. Only 14 (10.5%) had adverse experiences that were possibly, probably, or definitely related to study drug; none of these experiences were considered serious. The most common adverse experiences (> or = 3% incidence) were abdominal pain (6%); chest pain (5%); dizziness (4%); and asthenia/fatigue, fibromyalgia, headache, insomnia, and upper respiratory tract infection (3% each). No new or unexpected adverse experiences were seen at the higher doses. CONCLUSIONS: Simvastatin was effective and well tolerated at doses of 20, 40, and 80 mg/d in Asian patients with coronary heart disease. Titration enabled the majority to achieve target LDL-C levels of < or = 100 mg/dL.

Acute and follow-up results of laser angioplasty: single center experience.

Excimer laser angioplasty was used to treat total occluded coronary arteries and instent restenosis lesions with high success rate. To assess immediate and long-term results of patients treated with excimer laser, we analyzed demographic information and the immediate results of 44 patients who underwent ELCA. The patients were followed up and assessed for clinical restenosis. The initial success rate of ELCA was 86.4 per cent which is comparable to plain balloon angioplasty performed during the same period. Clinical restenosis was 29 per cent. In conclusion, ELCA for patients with coronary artery disease can be performed with initial high success rate and reasonable long-term restenosis.

Perforation of interventricular septum in acute myocardial infarction.

Eight cases of ruptured interventricular septum associated with myocardial infarction were diagnosed at Siriraj Hospital between 1985-1995. Clinical congestive heart failure and holosystolic murmur were found in all. Diagnosis was confirmed by echocardiogram and right heart catheterization in all patients. Two patients died from congestive heart failure preoperatively and the third case died from organ failure and sepsis postoperatively. Another five cases underwent successful ventricular septal defect closure and coronary artery bypass with good results.

Experience of the first 60 cases of intracoronary stent placement.

In conclusion, elective stent placement, compared to angioplasty, has a higher clinical success rate. However, in our early experience major complications did occur.

Immediate angioplasty results of total coronary artery occlusion in Thai population.

Attempted angioplasty of totally occluded vessels may be done. However, a lower success rate is expected compared to those with subtotal occlusion. The complication rate is comparable to that of partial occlusion in experienced hands.

Congenital coronary artery fistula: a report of 24 patients.

Clinical, hemodynamic and angiographic findings of 24 adolescent or adult patients with coronary artery fistula were retrospectively analyzed. There were 7 males and 17 females with the average age of 41.4 years. Nineteen of 24 patients (79.2%) were symptomatic and 18 were older than 20 years of age. Continuous murmur was present in 17 patients, "to and fro' murmur was audible in 2, apical systolic murmur was audible in 1. The remaining 4 patients had no audible murmur. Location of murmur in all patients was unusual for patent ductus arteriosus. Cardiomegaly on chest X-ray was found in 17 patients (70.8%) in whom 8 had prominent pulmonary artery. Electrocardiographic abnormalities were detected in 10 of 24 patients (41.6%) i.e. left ventricular hypertrophy (4 patients) biventricular hypertrophy (2 patients), incomplete right bundle branch block (2 patients), and ischemic changes (2 patients). The intracardiac pressures were slightly elevated and the mean Qp/Qs ratio was only 1.4 +/- 1.2. Angiographically, 28 fistulas were demonstrated in 24 patients. The origins of fistula were from right coronary artery in 12 patients (50%), left coronary artery in 8 patients (33.3%) and both coronary arteries in 4 patients (16.7%). Fistulas drained into the right atrium in 5 patients (20.8%), into coronary sinus in 2 patients (8.3%), into right ventricle in 4 patients (16.7%), into pulmonary arteries in 10 patients (41.7%) and into left ventricle in 3 patients (12.5%).

Non-invasive diagnostic approaches of the dissection of the aorta: transesophageal echocardiography vs computed tomography.

The accuracy of non-invasive diagnosis of aortic dissection between transesophageal echocardiography (TEE) and computed tomography (CT) was studied in 21 patients. All patients had both diagnostic procedures. With TEE examination, De Bakey's type I was found in 9 patients, type II in 1 and type III in 10 while CT imaging revealed aortic dissection in 19 out of 21 patients. If the dissection found by both diagnostic procedures was considered definitive then both examinations were similarly sensitive. TEE is a preferred choice of non invasive work up for aortic dissection. Medical and surgical therapy in appropriate cases evaluated by TEE give rise to good results in the majority of patients.

Relationship between exercise capacity and left ventricular function in aortic and mitral regurgitation.

The exercise capacity as assessed by treadmill exercise or functional class from clinical history cannot predict standard echocardiographic findings in patients with AR/MR, in terms of EF, LVDs, ESVI. Therefore, exercise capacity cannot be used to predict the timing for surgery in those patients. However, symptomatic patients with dilated LV usually have low LVEF such as in our group.

High pressure stent-assisted balloon coronary angioplasty: a case report.

We reported the first high pressure stent assisted balloon angioplasty successfully implanted in this country. The use of intracoronary stent and its future direction were also reviewed. Regimen for post stent can be adjusted for each individual patient.

Prevalence of myocarditis in idiopathic dysrhythmias: role of endomyocardial biopsy and efficacy of steroid therapy.

In order to study the prevalence of myocarditis, EMB was carried out prospectively in 53 consecutive patients with various idiopathic dysrhythmias and efficacy of steroid therapy was evaluated. The patients consisted of 24 males and 29 females with ages ranging between 12 to 80 yrs. Histologic studies revealed myocarditis in 36 per cent. Steroid therapy resulted in good response in 14 of 18 patients (77.8%) with biopsy-proven myocarditis and in 5 of 17 patients (29.4%) with biopsy-negative but with clinically suspected myocarditis. The remaining patients did not have good response to steroid and there was 1 sudden death in each group.

Endomyocardial biopsy: its diagnostic usefulness.

In order to assess the diagnostic usefulness of EMB in patients with clinically suspected myocardial diseases, with and without heart failure or dysrhythmias, a prospective study was carried out in 84 consecutive patients. With EMB, the histological diagnosis was considered specific in 33 patients (39.3%), confirmative in 12 patients (14.3%) and negative in 39 patients (46.4%). It was found particularly useful in patients with unexplained heart failure and idiopathic dysrhythmias and in the differentiation between restrictive cardiomyopathy and constrictive pericarditis. The procedure can be safely performed with minimal morbidity and there was no mortality in the present study.

Transthoracic and transesophageal echocardiographic diagnosis of cor triatriatum: operation without catheterization in an adult patient.

Cor triatriatum presenting in adulthood is extremely rare. An 18-year-old female patient presented with a clinical picture masquerading mitral valvular heart disease. Both transthoracic and transesophageal echocardiography demonstrated a membrane in the left atrium with no other cardiac anomaly. The patient was successfully operated on without the need for catheterization.

Echocardiographic diagnosis of a ruptured aneurysm of the sinus of Valsalva: operation without catheterisation in seven patients.

A ruptured aneurysm of the sinus of Valsalva was diagnosed by Doppler, colour, and cross sectional echocardiography in a consecutive series of seven patients. The diagnoses were confirmed at operation without cardiac catheterisation. Examination by pulsed and continuous Doppler echocardiography showed continuous turbulence in six patients with aneurysms rupturing into the right ventricular outflow tract and in the patient with rupture of an aneurysm of the non-coronary sinus into the right atrium. Colour Doppler echocardiography showed turbulent flow across the defects in all seven patients. A ventricular septal defect with aortic regurgitation was detected in one patient and an associated ventricular septal defect in another. Doppler, colour, and cross sectional echocardiography were useful non-invasive techniques for diagnosing a ruptured aneurysm of the sinus of Valsalva without the need for cardiac catheterisation.

Multivariate analysis in the prediction of death in hospital after acute myocardial infarction.

Prognostic factors in patients with acute myocardial infarction based on clinical and investigative data on admission were evaluated prospectively in 111 consecutive patients. Seventeen patients (15.3%) died during hospital stay. Age, a previous infarct, high Killip class, cardiomegaly, high serum concentrations of cardiac enzymes, a low ejection fraction, and a high wall motion score index correlated significantly with in-hospital mortality; whereas sex, risk factors, and pericardial effusion did not. Multivariate analysis showed that age and the wall motion score index were the best predictors of death in hospital. Wall motion detected by cross sectional echocardiography may reflect the extent of myocardial involvement. Age and wall motion score index predicted in-hospital mortality with a sensitivity of 76.5%, a specificity of 91.5%, and a predictive accuracy of 89.2%. Age and the wall motion score index can be determined on admission and are useful for identifying patients at high risk of cardiac death who might benefit from early intervention.

Accuracy of two-dimensional echocardiography in diagnosis of aortic dissection.

The usefulness of transthoracic and transabdominal two-dimensional echocardiography (2-D echo) in patients who presented with dilated aorta with or without acute chest pain and/or abdominal pain was assessed for diagnosis of aortic dissection (AD) both acute and chronic forms. The criterion for diagnosis of AD was the constant appearance of undulating motion of abnormal linear echo in the aortic lumen in more than one scan plane. During a 4-year period (1984-1988), a prospective analysis of 16 patients was carried out and the result disclosed that 11 had AD (6 in acute AD, 5 in chronic AD) while the other 5 did not have AD. 2-D echo findings were diagnostic of De Bakey Type I in 7 patients, Type II in one, Type III in two, false negative Type I in one, and true negative in the remaining five. Therefore, the sensitivity was 91 per cent and the positive predictive value was 100 per cent. Thus, our data indicates that 2-D echo is a reliable non-invasive method for diagnosis of AD in either the acute or chronic form and proximal or distal AD.

Short and long term mortality after acute myocardial infarction as predicted by two-dimensional echocardiography.

We have non-invasively determined the extent of the acute myocardial insult shortly after admission in a large group of patients with acute myocardial infarction. There appeared a fairly sharp distinction between patients with low and high likelihood of in-hospital death and one year mortality on the basis of echocardiographic findings. The use of wall motion score index and ejection fraction in the prediction of short term mortality (in-hospital death) is good, but the prediction of long term mortality is not that good, since several patients survived up to one year even with high wall motion score index (greater than 2.2) or low ejection fraction (less than or equal to 35%) on admission. One-year survival is high up to 90 per cent in patients with low wall motion score index or high ejection fraction on admission.

Two-dimensional echocardiographic detection of in-hospital complications in acute myocardial infarction.

The two-dimensional echocardiogram is an ideal noninvasive method for evaluation of the global and regional wall function of left ventricle particularly the apical part in the early phase of acute myocardial infarction. Apical dysfunction, right ventricular infarction, left ventricular thrombi can be detected by 2D-Echo. It is especially useful in the identification of a high risk group of patients with acute myocardial infarction, as a guideline for attempting different therapeutic modalities in these patients.