Sex Differences in Coronary Artery Disease: Insights From the KoRean wOmen’S chest pain rEgistry (KoROSE)

Interest in sex differences in coronary artery disease (CAD) has been steadily increasing.Concurrently, most of the data on these differences have primarily been Western-oriented.The KoRean wOmen’S chest pain rEgistry (KoROSE), started in 2011, has since published numerous research findings. This review aims to summarize the reported differences between men and women in CAD, integrating data from KoROSE. Cardiovascular risk in postmenopausal women escalates dramatically due to the decrease in estrogen levels, which normally offer cardiovascular protective effects. Lower estrogen levels can lead to abdominal obesity, insulin resistance, increased blood pressure, and endothelial dysfunction in older women. Upon analyzing patients with CAD, women are typically older and exhibit more cardiovascular risk factors than men. Diagnosing CAD in women tends to be delayed due to their symptoms being more atypical than men’s. While in-hospital outcome was similar between sexes, bleeding complications after percutaneous coronary intervention occur more frequently in women. The differences in long-term prognosis for CAD patients between men and women are still a subject of ongoing debate. Pregnancy and reproductive factors also play a significant role as risk factors for cardiovascular disease in women. A notable sex disparity exists, with women found to use fewer cardiovascular protective drugs and undergo fewer interventional or surgical procedures than men. Additionally, women participate less frequently than men in clinical research. Through concerted efforts to increase awareness of sex differences and mitigate sex disparity, personalized treatment can be provided. This approach can ultimately improve patient prognosis.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women’s Chest Pain Registry

Background/Aims@#Chest pain in patients with obstructive coronary artery disease (OCAD) is affected by several social factors. The gender-based differences in chest pain among Koreans have yet to be investigated. @*Methods@#The study consecutively enrolled 1,549 patients (male/female, 514/1,035; 61 ± 11 years old) with suspected angina. The predictive factors for OCAD based on gender were evaluated. @*Results@#Men experienced more squeezing type pain on the left side of chest, while women demonstrated more dull quality pain in the retrosternal and epigastric area. After adjustment for risk factors, pain in the retrosternal area (odds ratio [OR], 1.491; 95% confidence interval [CI], 1.178 to 1.887) and aggravation by exercise (OR, 2.235; 95% CI, 1.745 to 2.861) were positively associated with OCAD. In men, shorter duration (OR, 1.581; 95% CI, 1.086 to 2.303) and dyspnea (OR, 1.610; 95% CI, 1.040 to 2.490) increased the probability for OCAD, while left-sided chest pain suggested a low probability for OCAD (OR, 0.590; 95% CI, 0.388 to 0.897). In women, aggravation by emotional stress (OR, 0.348; 95% CI, 0.162 to 0.746) and dizziness (OR, 0.457; 95% CI, 0.246 to 0.849) decreased the probability for OCAD. @*Conclusions@#This is the first study to focus on gender differences in chest pain among Koreans with angina. Symptoms with high probability for OCAD were different between sexes. Our findings suggest that patient’s medical history in pretest assessment for OCAD should be individualized considering gender.

Gender difference in the association between brachial-ankle pulse wave velocity and cardiovascular risk scores

BACKGROUND/AIMS@#Although brachial-ankle pulse wave velocity (baPWV) has been validated as a novel method to predict the cardiovascular risk in general population, the relevance of baPWV to the traditional risk scores has not been clearly revealed. This study investigated the relationship between baPWV and four different cardiovascular risk-predicting scores in men and women.@*METHODS@#A total of 539 subjects (58.1 ± 12.2 years, 50.1% men) without cardiovascular disease (CVD) who underwent health examinations including baPWV measurement were retrospectively analyzed. Four cardiovascular risk scores (Framingham risk score [FRS; 1998], Adult Treatment Panel [ATP] III revised FRS [2002], generalized FRS [2008], and American College of Cardiology/American Heart Association [ACC/AHA] CVD risk [2013]) were calculated in each subject.@*RESULTS@#In a total population, baPWV was moderately correlated with four cardiovascular risk scores (r = 0.577 for FRS; r = 0.594 for ATP III revised FRS; r = 0.589 for generalized FRS; r = 0.571 for ACC/AHA CVD risk; p < 0.001 for each). These correlations were stronger in women than in men (r = 0.649 vs. 0.451 for FRS; r = 0.719 vs. 0.411 for ATP III revised FRS; r = 0.735 vs. 0.540 for generalized FRS; r = 0.699 vs. 0.552 for ACC/AHA CVD risk; p for gender difference ≤ 0.005 for each).@*CONCLUSIONS@#In middle-aged and elderly Koreans without CVD, baPWV was identified as having a moderately positive correlation with four different risk scores. The correlation was stronger in women than in men, implying the better performance of baPWV in women for predicting cardiovascular risk of healthy population.

Effect of Hyperglycemia on Myocardial Perfusion in Diabetic Porcine Models and Humans

BACKGROUND: Diabetes mellitus (DM) causes macro- and microvasculopathy, but data on cardiac microvascular changes in large animals are scarce. We sought to determine the effect of DM on macro- and microvascular changes in diabetic pigs and humans. METHODS: Eight domestic pigs (4 with type I diabetes and 4 controls) underwent coronary angiography with optical coherence tomography (OCT; at baseline and 1 and 2 months), coronary computed tomography angiography, cardiac magnet resonance (CMR) imaging, and histologic examination. RESULTS: The diabetic pigs had more irregular capillaries with acellular capillaries and a smaller capillary diameter (11.7 ± 0.33 μm vs. 13.5 ± 0.53 μm; P < 0.001) than those of the control pigs. The OCT showed no significant epicardial stenosis in either group; however diabetic pigs had a greater intima-media thickness. CMR results showed that diabetic pigs had a lower relative upslope at rest (31.3 ± 5.9 vs. 37.9 ± 8.1; P = 0.011) and during stress (18.0 ± 3.0 vs. 21.6 ± 2.8; P = 0.007) than the control pigs, implying decreased myocardial perfusion. Among the 79 patients with ST elevation myocardial infarction, 25 had diabetes and they had lower myocardial perfusion on CMR as well. CONCLUSION: DM causes microvascular remodeling and a decrease in myocardial perfusion in large animals at a very early stage of the disease course. Early and effective interventions are necessary to interrupt the progression of vascular complications in diabetic patients.

Clinical Factors Associated with Obstructive Coronary Artery Disease in Patients with Out-of-Hospital Cardiac Arrest: Data from the Korean Cardiac Arrest Research Consortium (KoCARC) Registry

BACKGROUND: Although coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA), there has been no convinced data on the necessity of routine invasive coronary angiography (ICA) in OHCA. We investigated clinical factors associated with obstructive CAD in OHCA. METHODS: Data from 516 OHCA patients (mean age 58 years, 83% men) who underwent ICA after resuscitation was obtained from a nation-wide OHCA registry. Obstructive CAD was defined as the lesions with diameter stenosis ≥ 50% on ICA. Independent clinical predictors for obstructive CAD were evaluated using multiple logistic regression analysis, and their prediction performance was compared using area under the receiver operating characteristic curve with 10,000 repeated random permutations. RESULTS: Among study patients, 254 (49%) had obstructive CAD. Those with obstructive CAD were older (61 vs. 55 years, P < 0.001) and had higher prevalence of hypertension (54% vs. 36%, P < 0.001), diabetes mellitus (29% vs. 21%, P = 0.032), positive cardiac enzyme (84% vs. 74%, P = 0.010) and initial shockable rhythm (70% vs. 61%, P = 0.033). In multiple logistic regression analysis, old age (≥ 60 years) (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.36–3.00; P = 0.001), hypertension (OR, 1.74; 95% CI, 1.18–2.57; P = 0.005), positive cardiac enzyme (OR, 1.72; 95% CI, 1.09–2.70; P = 0.019), and initial shockable rhythm (OR, 1.71; 95% CI, 1.16–2.54; P = 0.007) were associated with obstructive CAD. Prediction ability for obstructive CAD increased proportionally when these 4 factors were sequentially combined (P < 0.001). CONCLUSION: In patients with OHCA, those with old age, hypertension, positive cardiac enzyme and initial shockable rhythm were associated with obstructive CAD. Early ICA should be considered in these patients.

Findings of Single-Photon Emission Computed Tomography and Its Relation with Quantitative Coronary Angiography in Patients with Significant Stenosis of the Left Main Coronary Artery

OBJECTIVE: Unrecognized left main coronary artery disease (LMCD) is often fatal; however, accuracy of non-invasive tests for diagnosing LMCD is still unsatisfactory. This study was performed to elucidate single-photon emission computed tomography (SPECT) detection of LMCD using quantitative coronary angiography (QCA) data. MATERIALS AND METHODS: Fifty-five patients (39 men; mean age, 68.1 ± 10.9 years) diagnosed with significant left main (LM) stenosis (≥ 50%) by invasive coronary angiography (ICA) were retrospectively reviewed. All study patients underwent SPECT with pharmacologic stress within 30 days of ICA. All coronary lesions were quantified via QCA, and SPECT findings were compared with QCA results. RESULTS: Only four patients (7.3%) had isolated LMCD; all others had combined significant stenosis (≥ 70%) of one or more other epicardial coronary arteries. Patients with more severe coronary artery disease tended to have higher values for summed difference scores in a greater number of regions, but the specific pattern was not clearly defined. Summed stress score of SPECT did not differ according to LM stenosis severity. Only three patients (5.4%) had a typical LM pattern of reversible perfusion defect on SPECT. A significant negative linear correlation between stenosis severity and stress perfusion percent was found in the left anterior descending artery region (r = −0.455, p < 0.001) but not in the left circumflex artery. CONCLUSION: Single-photon emission computed tomography findings were heterogeneous, not specific and poorly correlated to QCA data in patients with significant LMCD. This may be due to highly prevalent significant stenosis of other epicardial coronary arteries.

Double Right Coronary Arteries Originated from Separate Ostia with Total Occlusive Lesion in One of the Two Right Coronary Arteries

Double right coronary arteries (RCA) are very rare congenital anomalies of coronary artery. We report a case of double RCA with total occlusion, incidentally found by collateral flows. A 71-year-old patient underwent percutaneous coronary intervention of left coronary arteries for angina, and the presence of double RCA was missed at initial coronary angiography (CAG). About 20 months later, second CAG was performed due to recurrent angina, and the CAG showed newly developed collateral flow suggesting the presence of the other missed RCA. There was a total occlusion at missed RCA and the lesion was successfully revascularized with drug eluting stent. If there was no collateral flow, the other RCA could not be found and its critical lesion could not be managed properly. Our case suggests that collateral flow can be a useful clue in detecting coronary anomaly. Besides, it is important to fully understand coronary anatomy, not to miss uncommon coronary lesion.

Re-mobilization of Lost Coronary Stent From the Axillary Artery to the Femoral Artery

Stent migration and loss are rare but can be devastating complications during percutaneous coronary intervention (PCI) for coronary artery disease. We report a unique case of wandering stent from the right coronary artery to the femoral artery via the axillary artery. Initially, the stent was stripped from the delivery catheter and embolized to axillary artery during emergent PCI. An intra-aortic balloon pump might have forced retrograde movement of the stent to axillary artery which have subsequently remobilized to the femoral artery. After stabilization, the stent was successfully removed by a percutaneous approach using a snare. Immediate retrieval of wandering stent is recommended for the prevention of secondary embolization.

Head to Head Comparison of Stress Echocardiography with Exercise Electrocardiography for the Detection of Coronary Artery Stenosis in Women

BACKGROUND: Exercise-stress electrocardiography (ECG) is initially recommended for the diagnosis of coronary artery disease. But its value has been questioned in women because of suboptimal diagnostic accuracy. Stress echocardiography had been reported to have comparable test accuracy in women. But the data comparing the diagnostic accuracy of exercise-stress ECG and stress echocardiography directly are few. The aim of the study was to compare the diagnostic accuracy of exercise-stress ECG and dobutamine stress echocardiography (DSE) in Korean women. METHODS: 202 consecutive female patients who presented with chest pain in outpatient clinic, and who underwent treadmill exercise test (TET), DSE and coronary angiography were included for the study. The diagnostic accuracy TET and DSE were calculated by the definition of > 50% or > 75% coronary artery stenosis (CAS). RESULTS: The sensitivity and specificity were higher with DSE (70.4, 94.6%) than TET (53.7, 73.6%) for detection of > 50% CAS. The higher accuracy of DSE was maintained after exclusion of the patients who could not achieve over 85% age predicted heart rate before ischemia induction. DSE also showed greater diagnostic accuracy than TET by > 75% CAS criteria, and in subsets of patient with intermediate pretest probability. CONCLUSION: In the diagnosis of CAS, DSE showed higher accuracy than TET in female patients who presented with chest pain. As well as the test accuracy, adequate stress was more feasible with DSE than TET. These finding suggests DSE may be used as the first-line diagnostic tool in the detection of CAS in women with chest pain.

Recurrent Acute Decompensated Heart Failure Owing to Severe Iron Deficiency Anemia Caused by Inappropriate Habitual Bloodletting

A 68-year-old woman visited the emergency department twice with symptoms of acute heart failure including shortness of breath, general weakness, and abdominal distension. Laboratory findings showed extremely low level of serum hemoglobin at 1.4 g/dL. Echocardiographic examination demonstrated dilated left ventricular cavity with systolic dysfunction and moderate amount of pericardial effusion. In this patient, acute heart failure due to severe iron deficiency anemia was caused by inappropriate habitual bloodletting.

Acute Stent Thrombosis after Coronary Stenting in Patients with Acute Coronary Syndrome

Acute stent thrombosis after percutaneous coronary intervention (PCI) is still problematic because of the subsequent development of myocardial infarction and poor prognosis. The incidence of acute stent thrombosis, occurring within 0-24hours after PCI, is relatively low, but underlying causes and treatment strategy are not well defined. Multi-vessel disease, ST-elevated myocardial infarction (STEMI), and large thrombotic burden are known risk factors of acute stent thrombosis. Thrombus aspiration, balloon angioplasty and glycoprotein IIb/IIIa receptor blocker could be therapeutic options. Recently we experienced two cases of acute stent thrombosis which developed during PCI with the aggravation of chest pain, and acute stent thrombosis were diagnosed immediately and successfully treated. Here we report two cases of acute stent thrombosis during PCI for one patient with STEMI and the other with acute coronary syndrome, which were successfully treated with thrombus aspiration and intravenous infusion of glycoprotein IIb/IIIa receptor blocker.

Prevalence and Gender-Related Characteristics of Metabolic Syndrome in Korean Community

OBJECTIVE: There are still a limited number of studies assessing the prevalence of metabolic syndrome in the community. The aim of this study is to investigate the prevalence and gender-related characteristics of metabolic syndrome in Korean community. METHODS: A total of 417 community subjects (mean age was 60.7+/-13.6 years, 35.3% were men) who attended the routine check-up were analyzed. National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP) III clinical guideline was used to define metabolic syndrome. RESULTS: Metabolic syndrome was diagnosed in 38.1% of study subjects. The prevalence of metabolic syndrome was not different between men and women (men 39.0% vs. women 37.5%, p=0.766). The positive association between age and the prevalence of metabolic syndrome was more pronounced in women (chi2=17.52, p for trend or =50 years). The most prevalent factor of metabolic syndrome was hypertriglyceridemia (49.9%) and hypertension (47.6%) in both genders. Among metabolic syndrome components, central obesity (40.5% vs. 25.2%, p=0.002) and hypertriglyceridemia (54.5% vs. 41.8%, p=0.015) were more prevalent in women than in men, and the prevalence of other components were similar between genders. CONCLUSIONS: In the community, metabolic syndrome was highly prevalent in middle-aged and elderly Korean adult. Age related change in the prevalence of metabolic syndrome was gender specific. Age and gender effects should be considered for the effective control of metabolic syndrome in the community.

The incidence and predictors of overall adverse effects caused by low dose amiodarone in real-world clinical practice

BACKGROUND/AIMS: Most current knowledge regarding amiodarone toxicity derives from clinical trials. This study was performed to investigate the incidence and risk factors of overall adverse effects of amiodarone in real-world practice using a large sample size. METHODS: Between January 1, 2000 and March 10, 2012, a total of 930 consecutive patients who had been treated with amiodarone for arrhythmia were reviewed retrospectively. An amiodarone-associated adverse event was considered in cases of discontinuation or drug dose reduction due to an unexpected clinical response. RESULTS: The mean daily dose of amiodarone was 227 +/- 126 mg, and the mean duration was 490 +/- 812 days. During the mean follow-up duration of 982 +/- 1,137 days, a total of 154 patients (16.6%) experienced adverse effects related to amiodarone, the most common being bradycardia or conduction disturbance (9.5%). Major organ toxicities in the thyroid (2.5%), liver (2.2%), eyes (0.6%), and lungs (0.3%) were rare. All patients recovered fully without complications after amiodarone discontinuation or dose reduction. The only independent predictor of adverse effects was the duration of amiodarone treatment (odds ratio, 1.21; 95% confidence interval, 1.03 to 1.41; p = 0.016, per year). CONCLUSIONS: Low-dose amiodarone is well tolerated in a real-world clinical population. Further studies with a prospective design are needed to confirm this finding.

Acute Pulmonary Embolism due to Thrombus-in-Transit in the Right Atrium During Bipolar Endoprosthesis of the Hip / 대한내과학회지

Venous thromboembolism is a relatively common condition in inhospital patients, but it may also manifest as a lethal disease. However, the diagnosis is not suspected clinically in the vast majority of cases. Most hospitalized patients are at risk of venous thromboembolism, but the risk can be reduced significantly by appropriate prophylaxis. We herein report a case of a huge right atrial thrombus that presented as sudden cardiogenic shock during bipolar endoprosthesis of the hip due to a femoral neck fracture. Although the patient was elderly and immobile for 3 days before hip surgery, she did not receive prophylaxis for venous thromboembolism. More attention should be paid to venous thromboembolism prophylaxis in high-risk patients.

Triglyceride and Cardiovascular Disease

Hypercholesterolemia is a well-known risk factor for cardiovascular disease. However, cardiovascular risk still remains even after achieving target goals for total and low density lipoprotein (LDL) cholesterol. There is a controversy whether triglyceride (TG) is directly related with atherosclerosis and/or cardiovascular disease. Some studies demonstrate that hypertriglyceridemia is associated with cardiovascular disease, especially in patients with insulin resistance or metabolic syndrome. Triglyceride level below 100 mg/dL is considered as metabolically healthy state. Nonfasting TG level can be used to detect incident cardiovascular disease. Fasting lipid panel should be checked if nonfasting TG level is equal or greater than 200 mg/dL. Target goals of TG are <200 mg/dL in nonfasting state, and <150 mg/dL (normal) or <100 mg/dL (optimal) in fasting state. Overall treatment of hypertriglyceridemia is intensive life style modification including reducing body weight, decreasing carbohydrate intake, increasing n-3 fatty acid intake, reducing alcohol intake, and increasing aerobic exercise. Pharmacological therapy focuses on reducing LDL-cholesterol with statin. Drug therapy for reducing TG seems to have less evidence of reducing cardiovascular events. If TG level is equal or higher than 500 mg/dL, TG lowering therapy is recommended in addition to life style modification to prevent pancreatitis.

Simultaneously Presented Acute Ischemic Stroke and Non-ST Elevation Myocardial Infarction in a Patient with Paroxysmal Atrial Fibrillation

Although atrial fibrillation is the most frequent cause of embolic stroke, coronary embolism from atrial fibrillation is a very rare cause of acute myocardial infarction. Therefore, simultaneously presented acute ischemic stroke and acute myocardial infarction due to atrial fibrillation in the same patient has not been documented. The present report describes the case of a 58-year-old man with paroxysmal atrial fibrillation who initially presented with a large cerebral infarction due to embolic occlusion of the left middle cerebral artery. Four hours after the diagnosis of cerebral embolism, he was subsequently diagnosed with acute myocardial infarction due to concurrent coronary embolism. He underwent successful coronary revascularization with a drug-eluting stent. The possibility of combined coronary embolism as a rare etiology should be kept in mind when a patient with acute embolic stroke presents, especially when there is evidence of acute myocardial infarction.

Simultaneously Presented Acute Ischemic Stroke and Non-ST Elevation Myocardial Infarction in a Patient with Paroxysmal Atrial Fibrillation

Although atrial fibrillation is the most frequent cause of embolic stroke, coronary embolism from atrial fibrillation is a very rare cause of acute myocardial infarction. Therefore, simultaneously presented acute ischemic stroke and acute myocardial infarction due to atrial fibrillation in the same patient has not been documented. The present report describes the case of a 58-year-old man with paroxysmal atrial fibrillation who initially presented with a large cerebral infarction due to embolic occlusion of the left middle cerebral artery. Four hours after the diagnosis of cerebral embolism, he was subsequently diagnosed with acute myocardial infarction due to concurrent coronary embolism. He underwent successful coronary revascularization with a drug-eluting stent. The possibility of combined coronary embolism as a rare etiology should be kept in mind when a patient with acute embolic stroke presents, especially when there is evidence of acute myocardial infarction.

A randomized, prospective, two-center comparison of sirolimus-eluting stent and zotarolimus-eluting stent in acute ST-elevation myocardial infarction: the SEZE trial / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The zotarolimus-eluting stent has shown larger in-stent late lumen loss compared to sirolimus-eluting stents in previous studies. However, this has not been thoroughly evaluated in ST elevation myocardial infarction.</p><p><b>METHODS</b>This was a prospective, randomized, controlled trial evaluating angiographic outcomes in patients presenting with ST elevation myocardial infarction, treated with zotarolimus-eluting stents or sirolimus-eluting stents. From March 2007 to February 2009, 122 patients were randomized to zotarolimus-eluting stents or sirolimus-eluting stents in a 1:1 fashion. The primary endpoint was 9-month in-stent late lumen loss confirmed by coronary angiography, and secondary endpoints were percent diameter stenosis, binary restenosis rate, major adverse cardiac events (a composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization), and late-acquired incomplete stent apposition.</p><p><b>RESULTS</b>Angiographic in-stent late lumen loss was significantly higher in the zotarolimus-eluting stent group compared to the sirolimus-eluting stent group ((0.49 ± 0.65) mm vs. (0.10 ± 0.46) mm, P = 0.001). Percent diameter stenosis at 9-month follow-up was also larger in the zotarolimus-eluting stent group ((30.0 ± 17.9)% vs. (17.6 ± 14.0)%, P < 0.001). In-segment analysis showed similar findings. There were no significant differences in binary restenosis rate, major adverse cardiac events, and late-acquired incomplete stent apposition.</p><p><b>CONCLUSIONS</b>Compared to sirolimus-eluting stents, the zotarolimus-eluting stent is associated with significantly higher in-stent late lumen loss at 9-month angiographic follow-up in the treatment of ST elevation myocardial infarction. Although there was no significant difference in 1-year clinical outcomes, the clinical implication of increased late lumen loss should be further studied.</p>

Radial Arteriovenous Fistula Developed Late after Coronary Angiography: A Case Report

Transradial access is a widely accepted method for percutaneous coronary diagnostic and interventional procedures, and it has dramatically reduced access site vascular complications compared to transfemoral access. Arteriovenous fistula formation at the access site is an especially rare complication in transradial access. We report an extremely rare case of delayed radial arteriovenous fistula that developed one year after transradial coronary angiography, which was successfully treated by surgical repair.

A Remnant Mitral Subvalvular Apparatus Mimicking Aortic Valve Vegetation after Mitral Valve Replacement

Preservation of the subvalvular apparatus has the merits of postoperative outcomes during mitral valve replacement for mitral regurgitation. We performed mitral valve replacement with anterior and posterior leaflet chordal preservation in a 65-year-old woman. On the 2nd postoperative day, routine postoperative trans-thoracic echocardiography showed an unknown aortic subvalvular mobile mass. We report a case of a remnant mitral subvalvular apparatus detected by echocardiography after chordal preserving mitral valve replacement which was confused with postoperative aortic valve vegetation.