Jin-Jin Kim

Impact of diabetes duration on the extent and severity of coronary atheroma burden and long-term clinical outcome in asymptomatic type 2 diabetic patients: evaluation by Coronary CT angiography

AIMS We investigated the association between diabetes duration and the extent and severity of coronary artery disease (CAD) as well as long-term clinical outcomes using coronary computed tomography angiography (CCTA) in asymptomatic type 2 diabetic patients. METHODS AND RESULTS We analysed 933 asymptomatic type 2 diabetic patients without known CAD who underwent CCTA. Patients were divided into three groups according to the duration of diabetes: <5 years, 5-10 years, and ≥10 years. Stenosis by CCTA was scored as none (0%), non-obstructive (1-49%), or obstructive (≥50%) for each coronary artery segment. For these patients, we compared the prevalence, extent, and severity of CAD, including coronary artery calcium score (CACS), atheroma burden obstructive score (ABOS), segment involvement score (SIS), and segment stenosis score (SSS). Major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, non-fatal myocardial infarction, and stroke, within a follow-up period were also compared.Patients with longer duration of diabetes possessed higher rates of obstructive CAD (P < 0.001). Patients with longer duration of diabetes also manifested greater degree of CACS, ABOS, SIS, and SSS (P < 0.001 for all) with associated higher rate of MACCE (P = 0.025). Presence of obstructive CAD as assessed by CCTA was an independent predictor of MACCE after adjusting for confounding risk factors (hazard ratio: 1.979, confidence interval: 1.178-3.327, P = 0.010). CONCLUSION In asymptomatic diabetic patients, longer diabetes duration is associated with a higher prevalence, extent, and severity of CAD as well as risk of MACCE. Moreover, greater CAD burden increases the risk of MACCE independent of co-existing CAD risk factors.

Status of hypertension and coronary stenosis in asymptomatic type 2 diabetic patients: Analysis from Coronary Computed Tomographic Angiography Registry

BACKGROUND Limited data exist regarding the prevalence of coronary artery disease (CAD) as well as clinical outcomes in asymptomatic diabetic patients with normotension, controlled hypertension, and uncontrolled hypertension. METHODS We enrolled 935 consecutive asymptomatic type 2 diabetic patients without known CAD. Coronary computed tomography angiography was used to evaluate the prevalence and severity of CAD. Blood pressure was measured at baseline. Patients were assigned to one of the three groups: normotension (n=314), controlled hypertension (systolic blood pressure (SBP)< 140 mm Hg with treatment, n=458), or uncontrolled hypertension (SBP ≥ 140 mm Hg with or without treatment, n=163). RESULTS Obstructive CAD (≥ 50% stenosis) increased from the prevalence in normotensive patients (33%) to that in patients with controlled (40%) or uncontrolled hypertension (52%) (p=0.003). The incidence of obstructive CAD in multivessel or left main CAD also increased across the three groups (13%, 21%, 32%, respectively, p<0.001). A multivariate logistic regression analysis showed that uncontrolled hypertension was an independent predictor of obstructive CAD (adjusted odds ratio, 2.13; 95% confidence interval (CI), 1.42 to 3.21, p<0.001). During a median follow-up of 3.1 years, uncontrolled hypertension was associated with increased risk of cardiac death or myocardial infarction compared to the risk in normotensive patients (hazard ratio, 6.11; 95% CI, 1.65 to 22.6, p=0.007). CONCLUSION In asymptomatic type 2 diabetic patients, uncontrolled hypertension was associated with increased risk of CAD and poor clinical outcomes.

Computed Tomography Angiography Images of Coronary Artery Stenosis Provide a Better Prediction of Risk Than Traditional Risk Factors in Asymptomatic Individuals With Type 2 Diabetes: A Long-term Study of Clinical Outcomes

OBJECTIVE We investigated the efficacy of coronary computed tomography angiography (CCTA) in predicting the long-term risks in asymptomatic patients with type 2 diabetes and compared it with traditional risk factors. RESEARCH DESIGN AND METHODS We analyzed 933 patients with asymptomatic type 2 diabetes who underwent CCTA. Stenosis was considered obstructive (≥50%) in each coronary artery segment using CCTA. The extent and severity scores for coronary artery disease (CAD) were evaluated. The primary end point was major adverse cardiovascular events (MACE), including all-cause mortality, nonfatal myocardial infarction, and late coronary revascularization during a mean follow-up period of 5.5 ± 2.1 years. RESULTS Ninety-four patients with MACE exhibited obstructive CAD with a greater extent and higher severity scores (P < 0.001 for all). After adjusting for confounding risk factors, obstructive CAD remained an independent predictor of MACE (hazard ratio 3.11 [95% CI 2.00–4.86]; P < 0.001]). The performance of a risk prediction model based on C-statistics was significantly improved (C-index 0.788 [95% CI 0.747–0.829]; P = 0.0349) upon the addition of a finding of obstructive CAD using CCTA to traditional risk factors, including age, male, hypertension, hyperlipidemia, smoking, estimated glomerular filtration rate, and HbA1c. Both integrated discrimination improvement (IDI) and net reclassification improvement (NRI) analyses further supported this finding (IDI 0.046 [95% CI 0.020–0.072], P < 0.001, and NRI 0.55 [95% CI 0.343–0.757], P < 0.001). In contrast, the risk prediction power of the coronary artery calcium score remained unimproved (C-index 0.740, P = 0.547). CONCLUSIONS Based on our data, the addition of CCTA-detected obstructive CAD to models that include traditional risk factors improves the predictions of MACE in asymptomatic patients with type 2 diabetes.

Relationship between airflow obstruction and coronary atherosclerosis in asymptomatic individuals: evaluation by coronary CT angiography

Airflow obstruction is associated with increased cardiovascular morbidity and mortality. However, the causal mechanisms linking airflow obstruction with higher incidence of cardiovascular events remain elusive. We evaluated the relationship between airflow obstruction, a key feature of chronic obstructive pulmonary disease (COPD), and prevalence, extent, and severity of coronary atherosclerosis in a large cohort of asymptomatic subjects. Participants were recruited from those undergoing spirometry and coronary computed tomography angiography (CCTA) as part of a general health evaluation from March 2009 to February 2011. Subjects were required to be over 40 years of age with no known CAD. Airflow obstruction was defined as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) < 70%. Obstructive CAD, as measured by CCTA, was defined as maximum intra-luminal stenosis ≥ 50%. Participants with airflow obstruction or normal lung function were compared in terms of obstructive CAD prevalence, the extent and severity of coronary atherosclerosis; including coronary artery calcium score (CACS), atheroma burden score (ABS), atheroma burden obstructive score (ABOS), segment involvement score (SIS), and segment stenosis score (SSS). A total of 1888 subjects were eligible for study inclusion. Compared with participants with normal lung function, those exhibiting airflow obstruction were more likely to have obstructive CAD (p = 0.002). Airflow obstruction was associated with higher CACS (p = 0.043), ABS (p = 0.002), ABOS (p = 0.017), SIS (p = 0.003), and SSS (p = 0.002). Multivariable analyses adjusted for conventional cardiovascular risk factors revealed that airflow obstruction was independently associated with presence of CAD (odds ratio 1.673, confidence intervals [CI] 1.002–2.789, p = 0.048). In this asymptomatic population, the presence of airflow obstruction was associated with a greater prevalence, extent, and severity of coronary atherosclerosis and was seen to be an independent predictor of the presence of CAD.

PS 02-10 Relationship of brachial-ankle pulse wave velocity and coronary atherosclerosis in asymptomatics: Evaluation by coronary CT angiography

Objective: We investigated the association of arterial stiffness, assessed by pulse wave velocity (PWV) with the prevalence, extent, and severity of coronary atheroma burden using coronary computed tomography angiography (CCTA) in community-dwelling Korean adults without chest pain. Design and Method: We analyzed 749 individuals without known or suspected coronary artery disease (CAD) undergoing CCTA. Participants were divided into two groups according to the mean value of PWV: 1455 cm/sec. Obstructive CAD, as measured by CCTA, was defined as maximum intra-luminal stenosis ≥ 50%. We compared the prevalence, extent, and severity of coronary atheroma burden, including coronary artery calcium score (CACS), atheroma burden obstructive score (ABOS), segment involvement score (SIS), and segment stenosis score (SSS) between groups. Multivariable logistic regression analysis was also performed to identify independent predictors of CAD. Results: Individuals with higher PWV possessed higher obstructive CAD (p < 0.001). Higher PWV was associated with greater degrees of CACS, ABOS, SIS, and SSS on CT scans (p < 0.001 for all). Multivariable analyses adjusted for conventional cardiovascular risk factors, including age, sex, and diabetes mellitus revealed that higher PWV was an independent predictor of obstructive CAD (odds ratio 2.694, confidence intervals 1.382–5.252, p = 0.004). Conclusions: Arterial stiffness assessed by PWV was associated with higher prevalence, extent, and severity of coronary atherosclerosis as well as increased risk of obstructive CAD in asymptomatics. Figure. No caption available.

MPS 05-02 PULSE PRESSURE AND CORONARY STENOSIS IN CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY IN ASYMPTOMATIC TYPE 2 DIABETIC PATIENTS

Objective: Limited data exist regarding the prevalence, extent and severity of coronary artery disease (CAD) as well as clinical outcomes in asymptomatic diabetic patients according to pulse pressure. Design and Method: We enrolled 935 consecutive asymptomatic type 2 diabetic patients without known CAD. Coronary computed tomography angiography was used to evaluate the prevalence and severity of CAD. Brachial blood pressure was measured at baseline. Patients were assigned to quartile of pulse pressure (<40, 40–49, 50–59, and >=60 mmHg). Results: The prevalence of obstructive CAD (≥50% stenosis) was increased from the lowest quartile of patients (26.5%) to the highest quartile of patients (54.5%) (p = <0.001). The incidence of obstructive CAD in multivessel or left main CAD also increased across the quartiles (11.7% to 32.0%, p < 0.001). Increase of pulse pressure by 10 mmHg was an independent predictor of obstructive CAD after adjusting for risk factors including systolic blood pressure (adjusted odds ratio, 1.293; 95% confidence interval (CI), 1.07–1.57, p = 0.008). During a median follow-up of 3.1 years, the highest quartile of pulse pressure was associated with increased risk of cardiac death or myocardial infarction compared to the risk in the lowest quartile (0% vs. 5.2%, log rank p = 0.019). Conclusions: In asymptomatic type 2 diabetic patients, increased pulse pressure was associated with increased risk of CAD and poor clinical outcomes.

Robot-Assisted Laparoscopic Myomectomy, an Alternative to Laparotomy for Numerous Myomas (Over 10)

Study Objective: To evaluate the feasibility of robot-assisted laparoscopic myomectomy in multiple myomas over 10 in number Design: A retrospective chart review. Setting: An academic medical center. Patients:Womenwho underwent removal of 10 ormore uterinemyomas by robotics. Intervention: This study is a retrospective chart review of 216 patients who underwent robot-assisted laparoscopic myomectomy by a single operator at St. Mary’s Fibroid Center in Seoul between October 1, 2010 and January 31, 2014; in the selected patients, 10 or more uterine myomas were removed. We reported the characteristics of the removed myomas including the with maximum diameter of the myomas, the sum of the diameter of each myoma, and the types of the combined surgeries with robot-assisted laparoscopic myomectomy that were used on 10 or more myomas; we the organized surgical outcomes that were measured including the operative time, length of hospital stay, and perioperative complications. Measurements and Main Results: A total of 14 women underwent the removal of 10 or more uterine myomas by robotics. The patient age was 38.0 3.8 years and all of the patients were nulliparous. The operation time was 434.1 100.6 min. The number of removed myomas for each case was 13.3 3.6. The myoma with the maximum diameter was 6.6 0.8 centimeters. The sum of the diameters was 34.8 9.6 centimeters (range 20.0-54.5 centimeters). No case was converted into conventional laparoscopy or laparotomy. The postoperative hospital stay was 2.6 0.6 days. One patient had post-operative neck pain, which regressed spontaneously. Conclusion: This report is the first to describe the feasibility of robotassisted laparoscopic myomectomy in multiple myomas over 10 in number. In robot-assisted laparoscopic myomectomies, supplementary techniques including preoperative MRI assessment, intraoperative sonographic navigation, and palpation by an assistant to localize the myomas are helpful in overcoming the absence of haptic perception. This technique is considered to be an alternative to laparotomy for more than 10 myomas.

Vaginal Cuff Closure With Unidirectional Barbed Suture During Total Laparoscopic Hysterectomy is a Safe and Feasible Procedure.

Different intravenous iron preparations are available and have been successfully utilized in the preoperative management in these cases, but older high molecular weight dextran-based products were cumbersome to use and posed significant risk of anaphylaxis. Newer molecules are currently available and can safely deliver high doses of iron in short periods of time with rapid improvements in hemoglobin levels, thus allowing for more prompt interventions and avoiding or minimizing transfusions of blood products. Intravenous iron replacement in these cases resulted in significant improvements in hemoglobin levels and replenishing of the body iron stores, which allowed to operate under better conditions improving patient’s safety and well-being. The administration of intravenous ferric carboxymaltose represents a valid alternative to current treatment modalities in the perioperative management of moderate to severe iron deficiency anemia.