Jang Hoon Lee

Incidence of Hypertension in Korea: 5-Year Follow-up Study

Limited data are available about the incidence of hypertension over the 5-yr in non-hypertensive subjects. The study subjects were 1,806 subjects enrolled in a rural area of Daegu, Korea for a cohort study from August to November 2003. Of them, 1,287 (71.3%) individuals had another examination 5 yr later. To estimate the incidence of hypertension, 730 non-hypertensive individuals (265 males; mean age = 56.6 ± 11.1 yr-old) at baseline examination were analyzed in this study. Hypertension was defined as either a new diagnosis of hypertension or self-reports of newly initiated antihypertensive treatment; prehypertension was if the systolic blood pressure was 120-139 mmHg and/or diastolic blood pressure was 80-89 mmHg. During the 5-yr follow-up, 195 (26.7%) non-hypertensive individuals developed incident hypertension. The age-adjusted 5-yr incidence rates of hypertension were 22.9% (95% confidence interval [CI] = 19.9-29.0) in overall subjects, 22.2% (95% CI = 17.2-27.2) in men, and 24.3% (95% CI = 20.4-28.2) in women. The incidence rates of hypertension significantly increased with age. In the multivariate analysis, prehypertension (Odds ratio [OR] 2.25; P < 0.001) and older age (OR 2.26; P = 0.010) were independent predictors for incident hypertension. In this rapidly aging society, population-based preventive approach to decrease blood pressure, particularly in subjects with prehypertension, is needed to reduce hypertension.

Incremental Predictive Value of Red Cell Distribution Width for 12-Month Clinical Outcome After Acute Myocardial Infarction

The incremental predictive value of red cell distribution width (RDW) for major adverse cardiac events (MACEs) has not been fully investigated in patients with acute myocardial infarction (AMI).

White Blood Cell, Hemoglobin and Platelet Distribution Width as Short-Term Prognostic Markers in Patients with Acute Myocardial Infarction

The aim of this study was to assess the prognostic value of combined use of white blood cell (WBC), hemoglobin (Hb), and platelet distribution width (PDW) in patients with acute myocardial infarction (AMI). This study included 1,332 consecutive patients with AMI. Patients were categorized into complete blood cell (CBC) group 0 (n=346, 26.0%), 1 (n=622, 46.7%), 2 (n=324, 24.3%), and 3 (n=40, 3.0%) according to the sum of the value defined by the cut-off levels of WBC (1, ≥14.5×103/µL; 0, <14.5×103/µL), Hb (1, <12.7 g/dL; 0, ≥12.7 g/dL), and PDW (1, ≥51.2%; 0: <51.2%). In-hospital death occurred in 59 (4.4%) patients. Patients who died during index hospitalization had higher WBC and PDW and lower Hb. The patients could be stratified for in-hospital mortality according to CBC group; 1.2%, 2.7%, 9.0%, and 22.5% in CBC groups 0, 1, 2, and 3 (P<0.001), respectively. In multivariate logistic regression analysis, CBC group≥2 (odds ratio, 3.604; 95% confidence interval, 1.040-14.484, P=0.043) was an independent predictor for in-hospital death. The prognostic impact of the combined use of CBC markers remained significant over 12 months. In conclusions, combination of WBC, Hb, and PDW, a cheap and simple hematologic marker, is useful in early risk stratification of patients with AMI.

Impact of Multivessel Coronary Disease With Chronic Total Occlusion on One-Year Mortality in Patients With Acute Myocardial Infarction

Background and Objectives The impact of multivessel coronary disease (MVD) with chronic total occlusion (CTO) on one-year mortality in patients with acute myocardial infarction (AMI) is not clearly known. We investigated the impact of MVD with concurrent CTO lesion on one-year mortality in patients with AMI. Subjects and Methods We studied 1008 consecutive patients who underwent coronary angiography between November 2005 and December 2008 with a diagnosis of AMI. Results Among 1008 patients, 432 patients (43%) had MVD, and 88 patients (8.7%) had CTO lesion. The one-year overall mortality was higher in patients with MVD than in patients with single vessel disease (SVD) (10.2% vs. 5.9%, p=0.012). However, the one-year overall mortality was not significantly higher in patients with CTO lesion than in patients without that lesion (12.5% vs. 7.3%, p=0.080). In multivariate analysis, independent predictors of one-year overall mortality were age older than 65 years {hazard ratio (HR) 2.41, 95% confidence interval (CI): 1.43 to 4.08}, Killip class ≥III (HR 3.59, 95% CI: 2.24 to 5.77), ST-elevation myocardial infarction (HR 2.45, 95% CI: 1.49 to 4.05) and MVD (HR 1.76, 95% CI: 1.07 to 2.89). Conclusion Patients with MVD showed higher one-year mortality than patients with SVD. However, the presence of CTO was not an independent predictor of one-year mortality in this study that included patients with successfully revascularized CTO lesion.

Catecholaminergic Polymorphic Ventricular Tachycardia in a Patient With Recurrent Exertional Syncope

A 16-year-old male with a prior history of recurrent syncope was referred to our hospital after being resuscitated from cardiac arrest developed while playing volleyball. His electrocardiogram (ECG) demonstrated ventricular fibrillation at a local emergency department. After referral, an ECG showed bidirectional ventricular tachycardia (VT) and nonsustained Torsade de Pointes. Two days later, his heart rate became regular, and no additional episodes of VT were observed. His ECG showed sinus rhythm with a corrected QT interval of 423 msec, and two-dimensional echocardiography was unremarkable. We made the diagnosis of a catecholaminergic polymorphic VT. However, only premature ventricular complex bigeminy was induced on exercise ECG and epinephrine infusion tests, and the patient showed no episodes of syncope. His father and mother had different missense mutations in the cardiac ryanodine receptor on genetic testing. The proband had both mutations in different alleles and was symptomatic. It was recommended that the patient avoid competitive physical activities, and a β-blocker was prescribed.

Threshold Level of Low‐Density Lipoprotein Cholesterol for the Short‐Term Benefit of Statin Therapy in the Acute Phase of Myocardial Infarction

Little is known about the threshold level of low‐density lipoprotein cholesterol (LDL‐C) for statin therapy in acute myocardial infarction (AMI).

Angiotensin II type 1 receptor blockers as a first choice in patients with acute myocardial infarction

Background/Aims: Angiotensin II type 1 receptor blockers (ARBs) have not been adequately evaluated in patients without left ventricular (LV) dysfunction or heart failure after acute myocardial infarction (AMI). Methods: Between November 2005 and January 2008, 6,781 patients who were not receiving angiotensin-converting enzyme inhibitors (ACEIs) or ARBs were selected from the Korean AMI Registry. The primary endpoints were 12-month major adverse cardiac events (MACEs) including death and recurrent AMI. Results: Seventy percent of the patients were Killip class 1 and had a LV ejection fraction ≥ 40%. The prescription rate of ARBs was 12.2%. For each patient, a propensity score, indicating the likelihood of using ARBs during hospitalization or at discharge, was calculated using a non-parsimonious multivariable logistic regression model, and was used to match the patients 1:4, yielding 715 ARB users versus 2,860 ACEI users. The effect of ARBs on in-hospital mortality and 12-month MACE occurrence was assessed using matched logistic and Cox regression models. Compared with ACEIs, ARBs significantly reduced in-hospital mortality(1.3% vs. 3.3%; hazard ratio [HR], 0.379; 95% confidence interval [CI], 0.190 to0.756; p = 0.006) and 12-month MACE occurrence (4.6% vs. 6.9%; HR, 0.661; 95% CI, 0.457 to 0.956; p = 0.028). However, the benefit of ARBs on 12-month mortality compared with ACEIs was marginal (4.3% vs. 6.2%; HR, 0.684; 95% CI, 0.467 to 1.002; p = 0.051). Conclusions: Our results suggest that ARBs are not inferior to, and may actually be better than ACEIs in Korean patients with AMI.

A Randomized, Double-blind, Candesartan-controlled, Parallel Group Comparison Clinical Trial to Evaluate the Antihypertensive Efficacy and Safety of Fimasartan in Patients with Mild to Moderate Essential Hypertension

PURPOSEnA new antihypertensive drug that selectively blocks angiotensin II receptor type 1, fimasartan, has a potent and rapidly acting antihypertensive effect. We investigated the antihypertensive effects of fimasartan 60 and 120 mg and its safety in comparison to 8 mg of candesartan.nnnMETHODSnThis clinical trial is a multicenter, randomized, double-blind, active comparator, and parallel group study. Three hundred sixty-two individuals were screened, and 290 patients aged 19 to 75 years with mild to moderate hypertension (diastolic blood pressure [DBP], 90-110 mm Hg) were randomly assigned to 60 to 120 mg/d of fimasartan or 8 mg/d of candesartan after a 2-week placebo run-in period. Treatments were administered for 12 weeks without dosage adjustment. The primary end point was the differences in DBP changes at week 12.nnnFINDINGSnAfter 12 weeks of treatment, DBP and systolic blood pressure (SBP) decreased significantly in all 3 groups. The decrease in DBP at week 12 was larger but not statistically significant in the fimasartan 60 mg compared with the candesartan 8 mg group with a mean (SD) difference of 1.72 (8.32) mm Hg (95% CI, -0.71 to 4.15 mm Hg; P = 0.17). The lower margin of the CI (-0.71 mm Hg) exceeded the noninferiority margin (-3.5 mm Hg). The DBP-lowering effect of fimasartan 120 mg was also nonsignificantly larger than candesartan 8 mg (difference, 1.58 [8.27] mm Hg; P = 0.20). The decrease in SBP was also nonsignificantly larger in the fimasartan 60 mg group compared with the candesartan 8 mg group (difference, 3.50 [12.63] mm Hg; P = .06). The SBP-lowering effect of fimasartan 120 mg was statistically larger than candesartan 8 mg (difference, 4.98 [13.99] mm Hg; P = .02). Response rate (DBP <90 mm Hg or DBP lowering >10 mm Hg at week 12) was also nonsignificantly greater in both fimasartan groups (Fimasartan 60 mg, 81%; fimasartan 120 mg, 72%; candesartan 8 mg, 71%). The safety profile of the fimasartan 60 mg and 120 mg was similar to candesartan 8 mg, with a slightly higher, but statistically not significant, incidence of hepatic enzyme elevation in fimasartan 120 mg.nnnIMPLICATIONSnThe antihypertensive effect of fimasartan, a newly available angiotensin II receptor type 1 blocker, is comparable, although not superior, to candesartan with a good safety profile. ClinicalTrials.gov identifier: NCT01135212.

Prediction of improvement in cardiac function by high dose dobutamine stress echocardiography in patients with recent onset idiopathic dilated cardiomyopathy

The prognosis of patients with recent onset idiopathic dilated cardiomyopathy (DCM) is grave and highly variable [1]. Dobutamine stress echocardiography (DSE) has been used to assess contractile reserve in patients with ischemic and idiopathic DCM. Several studies have suggested that contractile reserve assessed by DSE can be of prognostic value inpatientswith idiopathic DCM [2–5]. In this study,we investigated whether contractile reserve on DSE could predict late improvement of cardiac function and had incremental prognostic value for future cardiac events in recent onset idiopathic DCM. Between December 2004 and May 2011, forty-one patients were enrolled in this study. The study population consisted of patients with idiopathic DCMwho had symptom durations of less than 6 months. All study subjects underwent coronary angiography to exclude ischemic heart disease, and endomyocardial biopsies were performed in 35 patients (85%) to exclude reversible causes, such as myocarditis. Patients with chronic kidney disease (estimated glomerular filtration rate b60 ml/min/1.73 m) were also excluded. All patients had a complete echocardiographic study and follow-up echocardiogram was performed after 6 month and 12 month, then when any clinical events occurred. The interval between the time of DSE and last follow-up echocardiogramwas 16±15 months. Dobutamine was infused in 5-min dose increments, starting from 5 μg/kg/min and increasing to 10, 20, 30, and finally, to the maximal dose of 40 μg/kg/min. The infusion was discontinued before the maximal dose was reached if 85% of the maximal predicted heart rate for the age group was achieved, or if symptomatic complex ventricular arrhythmias, defined as the presence of multiform or repetitive ventricular extrasystoles, were observed. Beta-blockers were stopped 48 h before dobutamine testing in all patients taking these agents. The institutional committee of Kyungpook National University Hospital approved the study protocol. Informed consent was obtained in all patients. Cardiac death and hospitalization were combined end-point. The mean age of the patients was 50±14.8 years, and 24 patients (59%)weremale. During themean follow-up period of 30±24 months, 14 patients (34%) experienced cardiac events, and 5 (12%) of them died. Three (7%) of themwere sudden cardiac death, and two (4%) were low cardiac output death. Of the remaining patients, 9 (21%) were rehospitalized due to aggravation of heart failure. During dobutamine infusion, no significant complications occurred. Tenpatientsdidnot reachapeakdoseof dobutamine. Sixpatients reached maximal heart rates before thepeakdose of dobutamine, and in 4patients the test was stopped before the peak dose due to frequent premature complex. The mean value of the maximal dobutamine dose given was 35.6±8.7 μg/kg/min. We investigated the correlation between follow-up LVEFand clinical and echocardiographic parameters (Table 1). The followup LVEF correlated with baseline LVEDV (r=−0.519, p=0.001), LVESV (r=−0.499, p=0.001), LVEDV at peak dose (r=−0.509, p=0.001), LVEFat peakdose (r=0.692, pb0.001), and the changeof LVEF (r=0.515, p=0.001) from baseline to peak dose of dobutamine. Among them, LVEF at the peak dose of dobutamine was the most significant predictor of follow-up LVEF. Follow-up LVEFwas predicted by LVEF at the peak dose of DSE (y=1.033×−0.979, r=0.465, p=0.001). Receiver-operating characteristic analysis was used to determine the optimal cutoff value for predicting cardiac events with respect to the change of LVEF. The optimal change in LVEFwas 9.8%, The Kaplan–Meier survival estimates were stratified according to the results of baseline to peak LVEF variation during dobutamine administration (Fig. 1). The presence of inotropic response after dobutamine infusion, identified in this study as a change of LVEF≥9.8%, showed a significantly better outcome than little inotropic response (pb0.001). In the Cox-proportional hazard model, the change of LVEF from peak to baseline (hazard ratio [HR] 0.834, 95% confidence interval [CI] 0.713–0.976, p=0.024), in addition to age (HR 0.921, 95% CI 0.863– 0.984, p=0.015), log NT-ProBNP (HR 0.261, 95% CI 0.091–0.749, p=0.013), deceleration time (HR 0.964, 95% CI 0.932–0.998, p=0.039) and E/E′ ratio (HR 1.177, 95% CI 1.046–1.325, p=0.007) was also a significant independent predictor of cardiac event (Table 2). Moreover, the LVEF change in DSE had incremental prognostic value to

Serum Levels of PCSK9 Are Associated with Coronary Angiographic Severity in Patients with Acute Coronary Syndrome

Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a circulating protein that promotes degradation of the low density lipoprotein receptor. PCSK9 has emerged as a target for lipid-lowering therapy, but the predictive value of the serum level of PCSK9 for the severity of coronary disease is largely unknown. Methods From December 2009 to July 2012, 121 individuals who underwent coronary angiography (CAG) because of clinically suspected acute coronary syndrome were enrolled in this study. Serum levels of PCSK9 and metabolic parameters were measured. SYNTAX (SYNergy between percutaneous coronary intervention with [paclitaxel-eluting] TAXUS stent and cardiac surgery) and GRACE (Global Registry of Acute Coronary Events) scores were calculated. Results Individuals with CAG lesions (n=100) had significantly higher levels of PCSK9 than those without lesions (n=21). The study population was stratified into three groups according to serum levels of PCSK9. The odds radio for occurrence of one or more CAG lesions was significantly higher in the group with the highest level of PCSK9 (odds ratio, 7.468; P=0.011) than in the group with the lowest level of PCSK9. Serum PCSK9 was positively associated with the number of involved coronary arteries. Multivariable linear regression indicated that levels of PCSK9 were positively correlated with GRACE risk scores and SYNTAX scores. Conclusion Serum PCSK9 concentrations are higher in patients with coronary artery lesions, and are associated with SYNTAX and GRACE scores, suggesting that PCSK9 is a potential biomarker of the severity of coronary artery disease.