Apparent treatment-resistant hypertension among ambulatory hypertensive patients: a cross-sectional study from 13 general hospitals.

BACKGROUND/AIMS: To examine the prevalence and clinical characteristics of apparent treatment-resistant hypertension among ambulatory hypertensive patients. METHODS: We enrolled adult ambulatory hypertensive patients at 13 well-qualified general hospitals in Korea from January to June 2012. Apparent resistant hypertension was defined as an elevated blood pressure > 140/90 mmHg with the use of three antihypertensive agents, including diuretics, or ≥ 4 antihypertensives, regardless of the blood pressure. Controlled hypertension was defined as a blood pressure within the target using three antihypertensives, including diuretics. RESULTS: Among 16,915 hypertensive patients, 1,172 (6.9%) had controlled hypertension, and 1,514 (8.9%) had apparent treatment-resistant hypertension. Patients with apparent treatment-resistant hypertension had an earlier onset of hypertension (56.8 years vs. 58.8 years, p = 0.007) and higher body mass index (26.3 kg/m2 vs. 24.9 kg/m2, p < 0.001) than those with controlled hypertension. Drug compliance did not differ between groups. In the multivariable analysis, earlier onset of hypertension (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99; p < 0.001) and the presence of comorbidities (OR, 2.06; 95% CI, 1.27 to 3.35; p < 0.001), such as diabetes mellitus, ischemic heart disease, heart failure, and chronic kidney disease, were independent predictors. Among the patients with apparent treatment-resistant hypertension, only 5.2% were receiving ≥ 2 antihypertensives at maximally tolerated doses. CONCLUSION: Apparent treatment-resistant hypertension prevalence is 8.9% among ambulatory hypertensive patients in Korea. An earlier onset of hypertension and the presence of comorbidities are independent predictors. Optimization of medical treatment may reduce the rate of apparent treatment-resistant hypertension.

Clinical Impact of Lesion Complexity on 2-Year Outcomes After Zotarolimus-Eluting Stents Implantation.

Background: The clinical efficacy and safety of second-generation drug-eluting stents in complex percutaneous coronary interventions (PCIs) are not well established. Objectives: The clinical influence of the lesion complexity after PCI with zotarolimus-eluting stents (ZES) was evaluated. Methods: From a prospective multicenter observational study, a total of 926 patients that underwent successful PCIs with ZES were included. Complex PCIs were defined as patients with ≥3 lesions treated, 3 vessels treated, severe calcified lesions, bifurcated lesions with 2 stents implanted, left main disease, chronic total occlusion lesions, and/or diffuse long (total stent length ≥60 mm) lesions and were compared to the noncomplex group. The primary outcome was incidence of target lesion failures at 2 years, defined as a composite of cardiac death, target lesion-myocardial infarctions, and target lesion revascularization. Results: The patients were divided into complex PCI (n = 249) and noncomplex (n = 677) groups. In the complex PCI group, the 2-year risk of a target lesion failure was not significantly higher than in the noncomplex PCI group (4.8% vs 3.7%; adjusted hazard ratio: 1.373; 95% confidence interval: 0.689-2.738; P = 0.367). The same trend was observed for all composites of the clinical outcomes. Older age and advanced chronic kidney disease were independent predictors for the primary outcome. Conclusions: Up to 2 years after a ZES implantation, the clinical outcomes did not differ according to lesion complexity.

Relationship between health-related quality of life and blood pressure control in patients with uncontrolled hypertension.

We sought to investigate the psychosocial characteristics of patients with uncontrolled hypertension and examine factors that influence blood pressure (BP) control. A total of 1011 patients with uncontrolled hypertension were enrolled in 13 tertiary hospitals. Uncontrolled hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg despite on antihypertensive therapy. Socio-demographics, anthropometrics, behavioral risk factors, medication pattern, adherence, and measures of health-related quality of life (HRQoL; EuroQol 5D visual analog scale [EQ-5D VAS]) were assessed at baseline and during follow-up visits (3 and 6 months). Patients were divided into 2 groups based on BP control status at 6 months (controlled group [n = 532] vs uncontrolled group [n = 367]). There were no differences in clinical characteristics except the proportion of smokers and baseline BP between patients with controlled BP and uncontrolled BP. At 6 months, the adherence of antihypertensive medication did not differ between the groups but the proportion of combination therapy with ≥3 antihypertensives was significantly higher in patients with uncontrolled BP. EQ-5D VAS at follow-up was significantly lower in patients with uncontrolled BP despite similar baseline values. Multivariate logistic regression analysis revealed that EQ-5D VAS at follow-up significantly correlated with BP control. Patients with worse HRQoL had higher Charlson Comorbidity Index and higher proportion of taking ≥3 antihypertensives, but medication adherence was similar to those with better HRQoL. These findings suggest that along with pharmacologic intervention of hypertension, management of comorbid conditions or psychological support might be helpful for optimizing BP control in patients with uncontrolled hypertension.

Effectiveness and Safety of Zotarolimus-Eluting Stent (Resolute™ Integrity) in Patients with Diffuse Long Coronary Artery Disease.

BACKGROUND AND OBJECTIVES: Diffuse long coronary artery disease (DLCAD) still has unfavorable clinical outcomes after successful percutaneous coronary intervention (PCI). Therefore, we aimed to evaluate the effectiveness and safety of Resolute™ zotarolimus-eluting stent (R-ZES; Resolute™ Integrity) for patients with DLCAD. METHODS: From December 2011 to December 2014, 1,011 patients who underwent PCI using R-ZES for CAD with longer than 25 mm lesion were prospectively enrolled from 21 hospitals in Korea. We assessed the clinical outcome of major adverse cardiac events (MACE) defined as the composite of cardiac death, non-fatal myocardial infarction (MI), and clinically-driven target vessel revascularization at 12 months. RESULTS: Mean age was 63.8±10.8 years, 701 (69.3%) patients were male, 572 (87.0%) patients had hypertension, 339 (33.8%) patients had diabetes, 549 (54.3%) patients diagnosed with acute MI and 545 (53.9%) patients had multi-vessel disease (MVD). A total of 1,697 stents were implanted into a total of 1,472 lesions. The mean diameter was 3.07±0.38 mm and the length was 28.27±6.97 mm. Multiple overlapping stents were performed in 205 (13.8%) lesions. A 12-month clinical follow-up was available in 1,004 patients (99.3%). The incidences of MACE and definite stent thrombosis at 12-month were 3.0% and 0.3% respectively. On multivariate Cox-regression analysis, multiple overlapping stents implantation, previous congestive heart failure, MVD, and age ≥75 years were independent predictors of one-year MACE. CONCLUSIONS: Our study shows that R-ZES has an excellent 1-year clinical outcome in Korean patients with DLCAD.

A comparison of echocardiographic variables of right ventricular function with exercise capacity after bosentan treatment in patients with pulmonary arterial hypertension: Results from a multicenter, prospective, cohort study.

PURPOSE: Bosentan reduces pulmonary arterial pressure and improves exercise capacity in patients with pulmonary arterial hypertension (PAH). However, there are limited data regarding the extent to which the changes in echocardiographic variables reflect improvements in exercise capacity. We aimed to assess the improvement of echocardiographic variables and exercise capacity after 6 months of bosentan treatment for PAH. METHODS: We performed a prospective study from June 2012 to June 2015 in seven participating medical centers. Echocardiography, including tissue Doppler imaging (TDI) and the 6-minute walk test distance (6MWD), was performed at baseline and after 6 months of bosentan treatment. RESULTS: We analyzed 19 patients with PAH: seven with congenital shunt, six with collagen vascular disease, and six with idiopathic PAH. After bosentan treatment, mean 6MWD increased by 50 meters. Right ventricle (RV) systolic pressure, tricuspid annular plane systolic excursion, myocardial performance index (MPI) derived from TDI (MPI-TDI) of RV and left ventricle (LV), RV fractional area change, and RV ejection fraction were significantly improved. In particular, the magnitude of RV and LV MPI-TDI showed good correlation with changes in the 6MWD. CONCLUSIONS: The magnitude of RV and LV MPI-TDI was strongly associated with improvements in exercise capacity. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:28-34, 2017.

Late-acquired incomplete stent apposition after everolimus-eluting stent versus sirolimus-eluting stent implantation in patients with non-ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction.

AIMS: Our aim was to evaluate the incidence and clinical outcomes of late-acquired incomplete stent apposition (LAISA) after implantation of first- and second-generation drug-eluting stents in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: Late-Acquired incomplete stent aPPOsition after everolimus-eluting stent versus sirolimus-eluting Stent ImplanTatION in pAtients with non ST-segment elevation Myocardial Infarction and ST-segment elevation myocardial infarction (APPOSITION-AMI) was a prospective, randomised study comparing LAISA after everolimus-eluting stent (EES) and sirolimus-eluting stent (SES) implantation in AMI patients. Intravascular ultrasound examination was serially performed post-procedurally and at eight-month follow-up in 195 AMI patients (205 native coronary lesions: 100 EES; 105 SES). LAISA was observed in 6.0% and 16.2% of EES- vs. SES-treated lesions (p=0.021), respectively. In 64.7% of SES-treated lesions, LAISA was caused by positive remodelling, whereas thrombus dissolution or plaque reduction was observed in 66.7% of EES-treated lesions. Among patients with LAISA, MACE developed in one (4.5%) in the SES group with no ST in either group up to one year. CONCLUSIONS: The incidence of LAISA was lower in AMI patients treated with EES as compared to SES, mainly secondary to positive remodelling in SES- but not EES-treated lesions. Patients with LAISA in both groups showed a very low MACE incidence at one-year follow-up.

Efficacy and safety of antiplatelet-combination therapy after drug-eluting stent implantation.

BACKGROUND/AIMS: Combination single-pill therapy can improve cost-effectiveness in a typical medical therapy. However, there is a little evidence about the efficacy and tolerability of combination single-pill antiplatelet therapy after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS: From June to November 2012, in total, 142 patients who met the following criteria were enrolled: at least 18 years old; successful PCI with DES at least 3 months earlier; and regular medication of aspirin and clopidogrel with no side effects. After VerifyNow P2Y12 and aspirin assays, the combination single pill of aspirin and clopidogrel was given and laboratory tests were repeated 6 weeks later. RESULTS: At baseline, the incidence of aspirin resistance, defined as aspirin reaction unit (ARU) ≥ 550, was 9.2%, that of clopidogrel resistance, defined as P2Y12 reaction unit (PRU) ≥ 230, was 46.5%, and that of percent inhibition of PRU < 20% was 32.4%. At follow-up, the incidence of resistance by ARU value was 7.0%, 50.0% by PRU value, and 35.9% by percentage inhibition of PRU, respectively. The mean values of ARU (431.5 ± 63.6 vs. 439.8 ± 55.2; p = 0.216) and PRU (227.5 ± 71.4 vs. 223.3 ± 76.0; p = 0.350) were not significantly different before versus after antiplatelet-combination single-pill therapy. Five adverse events (3.5%) were observed during the study period. CONCLUSIONS: Combination single-pill antiplatelet therapy, which may reduce daily pill burden for patients after PCI with DES, demonstrated similar efficacy to separate dual-pill antiplatelet therapy.

Isolated double-chambered right ventricle in a young adult.

Double-chambered right ventricle (DCRV) is a rare congenital heart disorder in which the right ventricle is divided by an anomalous muscle bundle into a high pressure inlet portion and a low pressure outlet portion. We report a case of isolated DCRV without symptoms in adulthood, diagnosed through echocardiography, cardiac catheterization and cardiac magnetic resonance imaging.

Improvement in left ventricular systolic dyssynchrony in hypertensive patients after treatment of hypertension.

BACKGROUND AND OBJECTIVES: Left ventricular (LV) dyssynchrony has been commonly detected among hypertensive patients with normal LV systolic function and no evidence of congestive heart failure. The purpose of our study was to assess the changes in LV systolic dyssynchrony (SDS(LV)) among hypertensive patients after antihypertensive treatment, and to determine the relationship between SDS(LV) and other conventional echocardiographic parameters. SUBJECTS AND METHODS: Forty one hypertensive patients with normal LV ejection fraction were enrolled. By performing a conventional echocardiographic study, the SDS(LV) was measured as the time difference between the shortest and longest time of the peak myocardial systolic velocities among 12 segments of the basal and mid-levels of the 3 apical views, and radial dyssynchrony of the basal (RDS(base)) and mid-levels (RDS(mid)) measured as the time difference between the earliest and latest peak values on the radial strain curves of each level of the parasternal short-axis views. RESULTS: Compared to baseline after six months of antihypertensive treatment, the SDS(LV) improved significantly (48.7±37.9 ms vs. 29.5±34.1 ms, p=0.020). Also the RDS(base) and RDS(mid) improved significantly in respect to the baseline values (129.9±136.3 ms vs. 38.8±45.4 ms, p=0.002 and 75.2±63.8 ms vs. 28.2±37.7 ms, respectively, p<0.001). CONCLUSION: The severity of SDS(LV) improved with antihypertensive treatment, and was associated with the regression of LV mass. Furthermore, it might precede improvement in the mitral inflow pattern, as assessed by conventional echocardiography, so that early detection of the benefit of antihypertensive treatment may be possible.

Effect of valsartan on N-terminal pro-brain natriuretic Peptide in patient with stable chronic heart failure: comparison with enalapril.

BACKGROUND AND OBJECTIVES: The plasma concentration of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a st-rong prognostic indicator for patients with heart failure (HF) across all stages of the condition. Several clinical trials have de-monstrated convincingly that neurohormonal modulation on the renin angiotensin system (RAS) decreases plasma NT-pro-BNP level and results in favorable outcomes. But there are still limited comparative data on the neuro-hormonal modulatory effects of two RAS inhibitors: angiotensin converting enzyme inhibitor and angiotensin receptor blocker. SUBJECTS AND METHODS: This study was a prospective, multi-center, randomized, open-label, controlled, and non-inferiority study involving 445 patients with left ventricular ejection fraction (LVEF) less than 45%. Patients were assigned to receive either valsartan (target dose of 160 mg bid) or enalapril (target dose of 10 mg bid) for 12 months. We compared plasma NT-pro-BNP, high sensitive C-reactive protein (hs-CRP) level and echocardiographic parameters before and after treatment with valsartan or enalapril. RESULTS: The NT-pro-BNP and hs-CRP levels were significantly decreased after 12 months of treatment with valsartan and enalapril. The percentage change was similar between both groups. LVEF improved and left ventricular internal dimensions were decreased in both groups, and there were no significant differences between two groups. CONCLUSION: Valsartan is as effective on improving plasma NT-pro-BNP level as enalapril in patients with stable chronic HF.

Left ventricular dyssynchrony in patients showing diastolic dysfunction without overt symptoms of heart failure.

BACKGROUND/AIMS: Few studies have assessed left ventricular (LV) dyssynchrony in cases of diastolic dysfunction that do not include overt symptoms of heart failure. We hypothesized that systolic or diastolic dyssynchrony involves unique features with respect to the degree of diastolic impairment in isolated diastolic dysfunction. METHODS: We examined 105 subjects with no history of overt symptoms of heart failure and a left ventricular ejection fraction > 50% for mechanical dyssynchrony using tissue Doppler imaging. RESULTS: In terms of longitudinal dyssynchrony, four cases showed (6.3%) LV intraventricular systolic dyssynchrony (SDS(LV)), whereas none had LV intraventricular diastolic dyssynchrony (DDS(LV)) or co-existing systolic dyssynchrony. Radial dyssynchrony (RD) was found in six cases (9.4%). After adjusting for age, SDS(LV) and DDS(LV) were found to be significantly related to increases in the E/E' ratio (r = 0.405 and p < 0.001 vs. r = 0.216 and p = 0.045, respectively). RD at the base and apex was also significantly related to increases in E/E' (r = 0.298 and p = 0.002 vs. r = 0.196 and p = 0.045, respectively). CONCLUSIONS: Systolic and diastolic dyssynchrony in subjects with isolated diastolic dysfunction but without overt symptoms of heart failure was not as common as in patients with diastolic heart failure; however, the systolic and diastolic intraventricular time delay increased with increases in the E/E' ratio, an indicator of diastolic dysfunction.

The relationship between chronic atrial fibrillation and reduced pulmonary function in cases of preserved left ventricular systolic function.

BACKGROUND AND OBJECTIVES: The purpose of this study was to investigate the relationship between chronic atrial fibrillation (AF) and reduced pulmonary function. SUBJECTS AND METHODS: Eighty-six chronic AF patients who were enrolled from annual health examination programs were studied using echocardiography and pulmonary function tests (PFT). Echocardiography and PFT matched for age, gender, and year performed were selected by the control group who had normal sinus rhythms. Patients with ejection fractions <50%, valvular heart disease, or ischemic heart disease were excluded. RESULTS: In the chronic AF patients, the forced expiratory volume at one second (FEV(1)), FEV1%, and FEV(1)/forced vital capacity (FVC) were significantly reduced, and the right ventricular systolic pressure was significantly increased. Episodes of heart failure were more frequently associated with the chronic AF patients than the controls. In particular, the FEV1% had the most meaningful relationship to chronic AF after an adjustment for cardiovascular risk factors {p=0.003, Exp (B)=0.978, 95% confidence interval (CI):0.963-0.993}. CONCLUSION: Reduced FEV1%, which represents the severity of airway obstruction, was associated with chronic AF, and the greater the pulmonary function impairment, the greater the co-existence with AF and congestive heart failure in those with preserved left ventricular systolic function.

Relationship between left atrial size and stroke in patients with sinus rhythm and preserved systolic function.

BACKGROUND/AIMS: Increased left atrial (LA) size has been proposed as a predictor of poor cardiovascular outcome in the elderly. In the present study, we evaluated the relationship between LA size and stroke in subjects of all ages who presented with preserved left ventricular systolic function (LVSF) and sinus rhythm (SR), and investigated the relationships between LA size and other echocardiographic parameters of diastolic function. METHODS: A total of 472 subjects were enrolled in the study (161 men, 311 women) and divided into the stroke group (n=75) and control group (n=397). A conventional echocardiographic study was then performed. Subjects with valvular heart disease, atrial fibrillation, or coronary heart disease were excluded. RESULTS: The mean subject age was 65.2+/-5.1 years in the stroke group and 65.6+/-5.9 years in the control group. Mitral inflow pattern and E & A velocity showed no significant relationship with stroke (p=NS, p=NS, respectively). Left ventricular mass index and LA dimension were significantly related to stroke (p=0.003, p=0.023, respectively), and hypertension showed a marginal relationship with stroke (p=0.050). Age was not related to stroke in the present study (p=NS). CONCLUSIONS: The LA dimension is significantly related to the incidence of stroke. Therefore, strategies for prevention of stroke in patients with preserved LVSF and SR should be considered in cases of LA enlargement.

Characteristics of myocardial deformation and rotation in subjects with diastolic dysfunction without diastolic heart failure.

BACKGROUND AND OBJECTIVES: There have been very few pathophysiologic studies on isolated diastolic dysfunction. We hypothesized that the characteristics of isolated diastolic dysfunction would be located, on the clinical continuum, between those of a normal heart and diastolic heart failure. SUBJECTS AND METHODS: We enrolled 102 subjects who had no history of overt symptoms of heart failure and who had a left ventricular ejection fraction of more than 50%. They were examined for myocardial deformation and rotation using the two-dimensional speckle tracking image (2D-STI) technique. RESULTS: The circumferential strains and radial strain at the apical level (RS(apex)) were related to the ratio of the transmitral early peak velocity over the early diastolic mitral annulus velocity (E/E'). After adjustment for age, the RS(apex) showed a positive relationship with the E/E' ratio; whereas, the circumferential strains did not. Instead, the circumferential strains demonstrated a significant correlation with age. Basal rotation and left ventricular (LV) torsion were also related to age, but had no relationship with the E/E' ratio. However, as the E/E' ratio value increased, systolic mitral annular velocity decreased. CONCLUSION: Except for the RS(apex), LV myocardial deformation and rotation did not vary with the degree of E/E' ratio elevation when there was no associated diastolic heart failure. Additionally, in clinical situations such as isolated diastolic dysfunction, the advancement of age has a relatively greater influence on characteristics of LV myocardial deformation and rotation rather than on the E/E' ratio.