Efficacy and safety of cilostazol-based triple antiplatelet therapy compared with clopidogrel-based dual antiplatelet therapy in patients with acute ST-elevation myocardial infarction undergoing percutaneous coronary intervention: A multicenter, randomized, open-label, phase 4 trial.

BACKGROUND: Previous studies reported that compared to conventional dual antiplatelet therapy (DAT; aspirin + clopidogrel), triple antiplatelet therapy (TAT), involving the addition of cilostazol to DAT, had better clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). However, the optimal duration of TAT is yet to be determined. METHODS: In total, 985 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) were prospectively enrolled in 15 PCI centers in South Korea and China. We randomly assigned patients into 3 groups: DAT (aspirin and clopidogrel for 12 months), TAT 1M (aspirin, clopidogrel, and cilostazol for 1 month), and TAT 6M (aspirin, clopidogrel, and cilostazol for 6 months). The primary endpoint was 1-year major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, recurrent myocardial infarction, stroke, or repeat revascularization. RESULTS: The primary endpoint did not differ among the 3 groups (8.8% in DAT, 11.0% in TAT 1M, and 11.6% in TAT 6M; hazard ratio for TAT 1M vs DAT, 1.302; 95% confidence interval [CI], 0.792-2.141; P = .297; hazard ratio for TAT 6M vs DAT, 1.358; 95% CI, 0.829-2.225; P = .225). With respect to in-hospital outcomes, more bleeding events occurred in the TAT group than in the DAT group (1.3% vs 4.7% vs 2.6%, P = .029), with no significant differences in major bleeding events. Additionally, the TAT group had a higher incidence of headaches (0% vs 1.6% vs 2.6%, P = .020). CONCLUSIONS: The addition of cilostazol to DAT did not reduce the incidence of 1-year MACEs compared with DAT alone. Instead, it may be associated with an increased risk of drug intolerance and side effects, including in-hospital bleeding and headaches.

A case of successful reperfusion through a combination of intracoronary thrombolysis and aspiration thrombectomy in ST-segment elevation myocardial infarction associated with an ectatic coronary artery.

BACKGROUND: Large thrombus burdens in ectatic coronary arteries that remain after aspiration thrombectomy can negatively impact outcomes following percutaneous coronary interventions in patients with acute myocardial infarction. CASE PRESENTATION: A 53-year-old man presented with ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed an ectatic right coronary artery (RCA) that was completely occluded in the mid portion by a large amount of thrombus. Catheter-directed intracoronary thrombolysis with alteplase led to recovery of coronary blood flow, which multiple attempts of aspiration thrombectomy had failed to achieve. Coronary angiography 9 days later showed good blood flow and insignificant stenosis remaining in the RCA; this had completely resolved in 6 months' follow-up coronary angiography. CONCLUSION: Catheter-directed intracoronary thrombolysis can be performed effectively and safely when repeat aspiration thrombectomy fails to produce satisfactory coronary reperfusion in STEMI patients with large thrombus burdens in ectatic coronary arteries.

A case of microscopic polyangiitis associated with aortic valve insufficiency.

Microscopic polyangiitis (MPA) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis characterized by inflammation of small-sized vessels. Although there have been some reports of ANCA-associated vasculitis presenting as aortitis syndrome, MPA rarely involves large-sized vessels such as the aorta. We report an unusual case of MPA combined with severe acute aortic valve insufficiency in a 56-year-old man. He initially presented with prolonged fever, skin rash, and rapidly progressive glomerulonephritis. P-ANCA and anti-myeloperoxidase (MPO) antibodies were positive, but the c-ANCA and anti-proteinase-3 antibodies were negative. Skin biopsy of the lower leg showed necrotizing arteritis. Kidney biopsy was also performed, which revealed diffuse necrotizing and crescentic glomerulonephritis (GN) consistent with pauci-immune ANCA-associated GN. Serial echocardiographic evaluations revealed aortic valve changes and worsening acute aortic valve insufficiency over a two-month period. Despite intensive treatment, our patient developed sudden cardiac arrest and died. Our patient demonstrated typical clinical features and histopathologic findings for systemic vasculitis and had a positive anti-MPO antibody, all of which were consistent with the diagnosis of MPA. Thus, MPA may have been the cause of acute aortic valve insufficiency in this case.

A reverse dipping pattern predicts cardiovascular mortality in a clinical cohort.

An abnormal dipping pattern in ambulatory blood pressure monitoring (ABPM) is a cardiovascular (CV) risk factor. However, its impact on CV mortality has not been investigated sufficiently in clinical practice to be considered a standard parameter. We assessed the association between abnormal dipping patterns and increased CV mortality in a tertiary hospital in Korea. Our retrospective cohort study included 401 patients who underwent ABPM between 1994 and 1996 in Hanyang University Hospital, Seoul, Korea. The patients were classified as risers (<0% drop in systolic BP; n=107), and others included dippers and non-dippers (≥0% drop, n=294). The follow-up period was 120 months. The frequency of CV mortality was 14.0% in risers and 5.8% in others. A Cox regression analysis found a significant association between dipping pattern and CV mortality, after adjusting for age, gender, body mass index, hypertension, diabetes mellitus, smoking and hypercholesterolemia. Risers were at greater risk of CV death than others (RR, 3.02, P=0.022), but there was no difference in event rates between dippers and non-dippers. The reverse dipping pattern may be more frequent in clinical settings than in the population at large, and it is strongly associated with increased risk of CV mortality in Korea.

Revised definition of predicted left ventricular mass using ambulatory blood pressure in healthy Korean adults.

BACKGROUND: Left ventricular hypertrophy is influenced by both hemodynamic and non-hemodynamic factors. Ambulatory blood pressure is correlated with left ventricular hypertrophy. We established the influences of hemodynamic and non-hemodynamic factors, including ambulatory blood pressure, on variation in left ventricular mass in healthy Korean adults. METHOD: We included 172 subjects (male = 71, female = 101), with normal body mass index and blood pressure, in an analysis of data from the Yangpyung and Yeoju cohort studies and a tertiary cardiovascular center. Left ventricular mass was calculated using the equation: [1.04 × (IVSd + LVDd + PWTd) 3-(LDVs3)] × 0.8 + 0.6. Stroke volume was calculated (mL/beat) using Teichholz's formula. Stroke work (SW in gram-meters/beat [g-m/beat]) was computed as ambulatory systolic BP × stroke volume × 0.0144. RESULTS: Stroke work was the most important determinant associated with left ventricular mass (adjusted R2 = 0.442, p < 0.001), independent of height2.7 and sex. In a regression model including stroke work, height,2.7 and sex, the left ventricular mass was predicted by the equation: 43.11 + 0.61 × SW (g-m/beat) + 9.21 × height2.7-13.99 × sex (male = 1, female = 2) (constant = 43.11 ± 25.88, adjusted R2 = 0.532, p < 0.001). CONCLUSION: We examined ambulatory blood pressure, as in previous studies, and identified stroke work, height2.7, and sex as important determinants of left ventricular mass in Korean adults of normal weight and normal blood pressure. Ambulatory blood pressure is superior to clinical blood pressure for determining stroke work and predicted left ventricular mass.

Relationship between nocturnal blood pressure and 24-h urinary sodium excretion in a rural population in Korea.

BACKGROUND: The relationship between sodium intake and blood pressure (BP) is affected by many factors such as absolute level of sodium intake, salt sensitivity, and the accuracy or the timing of the BP measurement. There is no epidemiologic study using both ambulatory BP monitoring (ABPM) and 24-h urine sample in a middle-aged general population. METHODS: In the rural area, Yeojoo County, Gyunggi Province in South Korea, 218 subjects with age between 30 and 59 years old were measured with ABPM and 24-h urine sample. ABPM device was TM2430, and the 24-h urine sample was collected using the aliquot cup. Metabolic syndrome (MetS) score was calculated by the sum of the number of abnormal criteria other than BP. RESULTS: For both ABPM and 24-h urine sample, 148 subject data was acceptable for the analysis by the creatinine equation and/or the completeness of collection. Age was 47.4 ± 8.3 years (range 30 to 59 years), and female was 85 (57.4%). In multiple linear regression analysis, sodium intake was not an independent factor for casual BPs and daytime BPs whereas sodium intake was an independent factor for nighttime systolic BP (ß = 1.625, p = 0.0026) and nighttime diastolic BP (ß = 1.066, p = 0.0017). When compared to the lowest quartiles of sodium intake, daytime diastolic BP and nighttime BPs were in the higher three quartile groups. CONCLUSIONS: Sodium intake was associated not with casual BPs and daytime BPs but with increased nighttime BPs in the middle-aged general population in Korea.

The relationship between adiponectin and left ventricular mass index varies with the risk of left ventricular hypertrophy.

BACKGROUND: Adiponectin directly protects against cardiac remodeling. Despite this beneficial effect, most epidemiological studies have reported a negative relationship between adiponectin level and left ventricular mass index (LVMI). However, a positive relationship has also been reported in subjects at high risk of left ventricular hypertrophy (LVH). Based on these conflicting results, we hypothesized that the relationship between serum adiponectin level and LVMI varies with the risk of LVH. METHODS: A community-based, cross-sectional study was performed on 1414 subjects. LVMI was measured by echocardiography. Log-transformed adiponectin levels (Log-ADPN) were used for the analysis. RESULTS: Serum adiponectin level had a biphasic distribution (an increase after a decrease) with increasing LVMI. Although Log-ADPN did not correlate with LVMI, Log-ADPN was modestly associated with LVMI in the multivariate analysis (ß = 0.079, p = 0.001). The relationship between adiponectin level and LVMI was bidirectional according to the risk of LVH. In normotensive subjects younger than 50 years, Log-ADPN negatively correlated with LVMI (r = -0.204, p = 0.005); however, Log-ADPN positively correlated with LVMI in ≥50-year-old obese subjects with high arterial stiffness (r = 0.189, p = 0.030). The correlation coefficient between Log-ADPN and LVMI gradually changed from negative to positive with increasing risk factors for LVH. The risk of LVH significantly interacted with the relationship between Log-ADPN and LVMI. In the multivariate analysis, Log-ADPN was associated with LVMI in the subjects at risk of LVH; however, Log-ADPN was either not associated or negatively associated with LVMI in subjects at low risk of LVH. CONCLUSION: Adiponectin level and LVMI are negatively associated in subjects at low risk of LVH and are positively associated in subjects at high risk of LVH. Therefore, the relationship between adiponectin and LVMI varies with the risk of LVH.

Correlation between Proximal Abdominal Aortic Stiffness Measured by Ultrasound and Brachial-Ankle Pulse Wave Velocity.

BACKGROUND AND OBJECTIVES: The proximal portion of the abdominal aorta (AA) is characterized by minimal arteriosclerosis compared with other aortic segments. To assess the clinical usefulness of this characteristic, the correlation between ultrasonographically measured proximal AA stiffness and brachial-ankle pulse wave velocity (baPWV) was examined. SUBJECTS AND METHODS: 285 subjects were analyzed, half with hypertension and half with normal blood pressure. Proximal AA was examined using ultrasonography; strain, distensibility, elastic modulus, and the stiffness index were determined. After adjustment for age, gender, body mass index (BMI), systolic blood pressure (SBP), and heart rate, the relationships between baPWV and all these parameters were tested. RESULTS: The mean age of the study subjects was 58.1±12.8 years and the mean BMI was 24.3±3.8 kg/cm(2). 58.9% of the subjects were female. 42.8% were hypertensive subjects. Among the hypertensive subjects, 56.0% were taking antihypertensive medication. Adjusted partial correlation coefficients for the relationship between baPWV with strain, distensibility, elastic modulus, and the stiffness index of the proximal AA were -0.203 (p=0.01), -0.121 (p=0.129), 0.304 (p=0.0001), and 0.299 (p=0.0001), respectively, in normotensive subjects. In the multivariate analyses, such correlations were observed mainly in the normotensive group, whereas there was no association among hypertensive subjects regardless of antihypertensive medication status. CONCLUSION: baPWV is moderately correlated with the stiffness parameters for the proximal AA, mainly in normotensive subjects.

A case of deep vein thrombosis after coronary angiography in a patient using antidepressants and anxiolytics.

Deep vein thrombosis (DVT) is a rare but potentially serious complication of coronary angiography (CAG) affecting just under 5 in 10000 patients. Most of the cases regarding DVT after CAG reported in the literature were associated with procedure-related vascular complications or with risk factors for venous thromboembolism (VTE). Here, we describe the case of a 50-year-old woman during treatment for anxiety disorder, who developed significant DVT after CAG without a history of VTE and with no significant risk factors for VTE, which was treated with an anticoagulant. This case reminds us that clinicians should consider the possible occurrence of VTE after diagnostic CAG even in patients without significant risk factors.

Relationship between sodium intake and blood pressure according to metabolic syndrome status in the Korean National Health and Nutrition Examination Survey.

OBJECTIVES: The relationship between sodium intake and blood pressure (BP) in population studies varies depending on the dietary habit and the characteristics of the population studied. Asian dietary patterns and salt sensitivity have been suggested to explain this association. Aging and metabolic syndrome (MS) are the most common reasons for salt sensitivity in populations. PARTICIPANTS AND METHODS: We therefore examined the dietary patterns in the Korean National Health and Nutrition Examination Survey. RESULTS: In a multiple regression model for 3757 patients, age, antihypertensive medication, BMI, family history of hypertension, and MS were positively associated with systolic BP, whereas female sex, income, educational status, and fruit intake were negatively associated with systolic BP. Fruit intake was the only dietary factor that was negatively associated with systolic BP (P=0.017). In MS (n=712), sodium and fruit intake was independently positively and negatively associated with systolic BP, respectively, discounting age and medication. In contrast, in normal individuals (n=3045), diet was not related to systolic BP. The relationship between diet and systolic BP is more clear-cut in MS. CONCLUSION: Dietary pattern and salt sensitivity at the population level could be a cause of the relationship between sodium intake and BP.

The relationship between coronary artery calcification and bone mineral density in patients according to their metabolic syndrome status.

BACKGROUND AND OBJECTIVES: The extent of coronary artery calcification (CAC) is closely related to total atherosclerotic plaque burden. However, the pathogenesis of CAC is still unclear. Conditions such as diabetes mellitus, renal failure, smoking, and chronic inflammation have been suggested to link vascular calcification and bone loss. In the present study, we hypothesized that bone loss can contribute to the pathogenesis of CAC in patients with the chronic inflammatory condition that accompanies metabolic syndrome (MetS). The objective of this study was to investigate the relationship between CAC and bone mineral density (BMD) in patients with MetS and in patients without MetS, by using coronary multidetector-row computed tomography (MDCT). SUBJECTS AND METHODS: Data from 395 consecutive patients was analyzed retrospectively. From the MDCT database, only those patients who underwent both coronary MDCT and dual-energy X-ray absorptiometry within an interval of one month, were selected. The presence of MetS was determined by the updated criteria as defined by the Third Adult Treatment Panel Report of the National Cholesterol Education Program. RESULTS: In patients with MetS, a significant correlation was found between CAC and age {odds ratio (OR)=1.139, 95% confidence interval (CI) 1.080 to 1.201, p<0.001}, CAC and male sex (OR=3.762, 95% CI 1.339 to 10.569, p=0.012), and CAC and T-score of L-spine (OR=0.740, 95% CI 0.550 to 0.996, p=0.047) using a forward multiple logistic regression analysis model including clinical variables of gender, age, lipid profile, body mass index, diabetes mellitus, hypertension, smoking, and BMD. But in patients without MetS, BMD by itself was not found to contribute to CAC. CONCLUSION: BMD was inversely correlated with CAC only in patients with MetS. This finding suggests that low BMD accompanied by MetS, may have significant clinical implications.

[Esophageal sinus formation due to cyanoacrylate injection for esophageal variceal ligation-induced ulcer bleeding in a cirrhotic patient].

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.

Non-Dipper Pattern is a Determinant of the Inappropriateness of Left Ventricular Mass in Essential Hypertensive Patients.

BACKGROUND AND OBJECTIVES: Inappropriately high left ventricular mass (iLVM) is known to be related to cardiovascular prognosis. A non-dipper pattern has a greater mean left ventricular (LV) mass than the dipper pattern in hypertensive patients. However, the appropriateness of LV mass in dipper or non-dipper patterns has not been adequately investigated. The aim of this study was to define the relationship between nocturnal dipping and the appropriateness of LV mass. SUBJECTS AND METHODS: Using the ambulatory blood pressure monitoring (ABPM) database, the data of 361 patients who underwent ABPM and echocardiography was analyzed retrospectively. Appropriateness of LV mass was calculated as observed/predicted ratio of LV mass (OPR) using a Korean-specified equation. Nocturnal dipping was expressed as percent fall in systolic blood pressure (BP) during the night compared to the day. RESULTS: Daytime, nighttime and 24 hours BP in hypertensive patients was 140.4±14.8 mmHg, 143.7±15.2 mmHg and 129.4±20.0 mmHg, respectively. OPR was 106.3±19.9% and nocturnal dipping was 10.2±10.9 mmHg. In a multiple linear regression model, 24 hours systolic BP (ß=0.097, p=0.043) and nocturnal dipping (ß=-0.098, p=0.046) were independent determinants of OPR as well as age (ß=0.130, p=0.025) and body mass index (BMI) (ß=0.363, p<0.001). Odds ratio of the non-dipper pattern was 2.134 for iLVM (p=0.021) and 3.694 for obesity (p<0.001; BMI >25 kg/m(2)). CONCLUSION: The non-dipper pattern is independently associated with iLVM in hypertensive patients as well as obesity.

The relationship between ambulatory arterial stiffness index and blood pressure variability in hypertensive patients.

BACKGROUND AND OBJECTIVES: Ambulatory arterial stiffness index (AASI) is well known as a predictor of cardiovascular mortality in hypertensive patients. Mathematically, AASI reflect the standard deviation (SD) of blood pressure (BP) variation. AASI is measured higher levels in non-dipper than dipper. Thus, AASI has a possibility of not only reflecting arterial stiffness but also BP variability and/or autonomic nervous dysfunction. SUBJECTS AND METHODS: Consecutive data from 418 untreated hypertensive patients were analyzed retrospectively. We examined the association between the 24-hour ambulatory BP monitoring (ABPM) parameters and AASI. RESULTS: AASI had a simple correlation with age (R=0.189, p<0.001), relative wall thickness (RWT) (R=0.115, p=0.019), left ventricular mass index (LVMI) (R=0.192, p<0.001), average systolic BP (SBP) (R=0.232, p<0.001), average pulse pressure (PP) (R=0.363, p<0.001), SD of diastolic BP (DBP) (R=-0.352, p<0.001), SD of PP (R=0.330, p<0.001), SD of heart rate (HR) (R=-0.268, p<0.001), and nocturnal dipping (R=-0.137, p=0.005). In multiple linear regression analysis model including clinical parameters and 24 hour-ABPM parameters, independent predictors of AASI were SD of PP (ß=1.246, p<0.001), SD of DBP (ß=-1.067, p<0.001), SD of SBP (ß=-0.197, p<0.001), and non-dipper (ß=0.054, p=0.033). CONCLUSION: AASI is closely correlated with BP variability. The result of this study shows that AASI is not only a parameter for arterial stiffness, but also a parameter for BP variability.