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.

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.

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.

The predictive value of computed tomography calcium scores: a comparison with quantitative volumetric intravascular ultrasound.

OBJECTIVE: To evaluate the relationship between coronary artery calcium scoring (CACS) and intravascular ultrasound (IVUS) calcification and disease severity. METHODS: Forty-five angina patients who underwent CACS 18+/-23 days before IVUS were studied. The CACS was recorded for each lesion matched to a specific IVUS lesion. Cross-sectional area measurements of the external elastic membrane, lumen area, plaque and media, and plaque burden were performed. The arc and length of calcification were measured. RESULTS: There were 106 calcified lesions detected by IVUS. Eighty-five of those lesions (80%) were detected by CACS, but 21 calcified lesions (20%) were missed. Fourteen (50%) out of 28 of the lesions with an IVUS-calcium arc below the 25th percentile (51.4 degrees ) were detected by CACS vs. 91% of lesions with an IVUS-calcium arc >51.4 degrees (P<.05). Similarly, 21 (58%) of 36 lesions 3 mm (P<.05). We divided IVUS-calcified lesions into CACS 10. Mean plaque burden, calcified length, and arc of calcium increased significantly, while minimum lumen area decreased with increasing CACS. There was the same tendency in culprit and nonculprit calcified lesions, respectively. Multivariate analysis showed a calcified length (regression coefficient=8.718, 95% CI 4.668-12.77, P<.001) and an arc of calcium (regression coefficient=2.789, 95% CI 1.419-4.119, P<.001) were significant predictors for CACS. CONCLUSIONS: This study suggests that a CACS could evaluate coronary calcium burden noninvasively through the accurate estimation of calcium-arc and length.

Five-year outcomes of moderate or ambiguous left main coronary artery disease and the intravascular ultrasound predictors of events.

The long-term outcome of a moderately diseased left main coronary artery (LMCA) remains unknown. One hundred and fourteen patients who underwent angiographic and intravascular ultrasound (IVUS) evaluation for moderate LMCA disease (< 50% diameter stenosis) without intervention were followed for 5 years. There were 11 patients who underwent coronary artery bypass graft surgery (CABG) within 30 days of IVUS analysis based on IVUS findings and 3 patients who died of noncardiac diseases during the follow-up period. These 14 patients were excluded from the cohort, and 100 patients comprised the study group. Six patients (6%) died (1 of cardiac causes and 5 of unknown causes) at a follow up of 31.5 +/- 17.0 months post-IVUS assessment. Two patients (2%) underwent CABG at a follow up of 19.0 +/- 7.1 months. There were no percutaneous LMCA interventions and no myocardial infarctions. Univariate predictors for events were age, mean plaque and media (P&M) area and plaque burden over the entire length of the LMCA lesion, and minimum luminal area (MLA), P&M area, plaque burden, and arc of calcium > 90 degrees at the MLA site. By multiple logistic regression analysis, plaque burden at the MLA (odds ratio = 1.34, 95% confidence interval 1.04-1.73; p = 0.025) was the only independent predictor of events. In conclusion, moderately diseased LMCAs had a 5- year event rate of 8%. The occurrence of future events in moderate diseased LMCAs is dependent on the amount of disease at the MLA site.

Comparison of intravascular ultrasound to contrast-enhanced 64-slice computed tomography to assess the significance of angiographically ambiguous coronary narrowings.

The efficacy of contrast-enhanced multislice computed tomography (MSCT) for assessment of ambiguous lesions is unknown. We compared both quantitative coronary angiography (QCA) and MSCT to the gold standard for a significant stenosis-minimum luminal area (MLA) by intravascular ultrasound (IVUS)-in 51 patients (64 +/- 10 years old, 19 men) with 69 angiographically ambiguous, nonleft main lesions. The MSCT was performed 17 +/- 18 days before IVUS analysis. Overall diameter stenosis by QCAwas 51.0 +/- 9.8%; 39 of 51 patients (76%) eventually underwent revascularization (38 by percutaneous coronary intervention and 1 by coronary artery bypass graft). By univariate analysis, minimum luminal diameter, MLA, lumen visibility by MSCT, and minimum luminal diameter by QCA were significant predictors of MLA by IVUS