Joo Hee Zo

Additive beneficial effects of valsartan combined with rosuvastatin in the treatment of hypercholesterolemic hypertensive patients.

Background and Objectives We compared the efficacy and safety of valsartan and rosuvastatin combination therapy with each treatment alone in hypercholesterolemic hypertensive patients. Subjects and Methods Patients who met inclusion criteria were randomized to receive 1 of the following 2-month drug regimens: valsartan 160 mg plus rosuvastatin 20 mg, valsartan 160 mg plus placebo, or rosuvastatin 20 mg plus placebo. The primary efficacy variables were change in sitting diastolic blood pressure (sitDBP) and sitting systolic blood pressure (sitSBP), and percentage change in low-density lipoprotein-cholesterol (LDL-C) in the combination, valsartan, and rosuvastatin groups. Adverse events (AEs) during the study were analyzed. Results A total of 354 patients were screened and 123 of them were finally randomized. Changes of sitDBP by least squares mean (LSM) were -11.1, -7.2, and -3.6 mm Hg, respectively, and was greater in the combination, as compared to both valsartan (p=0.02) and rosuvastatin (p<0.001). Changes of sitSBP by LSM were -13.2, -10.8, and -4.9 mm Hg, and was greater in the combination, as compared to rosuvastatin (p=0.006) and not valsartan (p=0.42). Percentage changes of LDL-C by LSM were -52, -4, and -47% in each group, and was greater in the combination, as compared to valsartan (p<0.001), similar to rosuvastatin (p=0.16). Most AEs were mild and resolved by the end of the study. Conclusion Combination treatment with valsartan and rosuvastatin exhibited an additive blood pressure-lowering effect with acceptable tolerability, as compared to valsartan monotherapy. Its lipid lowering effect was similar to rosuvatatin monotherapy.

B-Type Natriuretic Peptide in Isolated Severe Tricuspid Regurgitation: Determinants and Impact on Outcome

Background The plasma B-type natriuretic peptide (BNP) level is a useful prognostic marker in heart failure and valvular heart disease. In patients with isolated severe tricuspid regurgitation (TR), little is known about the determinants of plasma BNP levels and the correlation with future outcome. The purpose of this study was to identify the determinants of plasma BNP levels in patients with isolated severe TR and the value of the BNP level in predicting postoperative outcomes after corrective surgery. Methods We prospectively enrolled 39 patients with isolated, severe TR undergoing corrective surgery. A plasma BNP assay and cardiac magnetic resonance (CMR) imaging were performed before surgery. The combined end-point was the occurrence of cardiac death or readmission due to heart failure. Results Linear regression analysis showed that the left ventricular ejection fraction and right ventricular end systolic volume were the most important determinants of the BNP levels (p = 0.002, R2 = 0.315). Based on the receiver operating characteristics (ROC) curve, we were able to derive an optimal cutoff value (200 pg/mL) to predict postoperative cardiac death with a sensitivity of 80% and a specificity of 85%. The one-year survival rate was 96% in patients with a BNP < 200 pg/mL and 53% in patients with a BNP ≥ 200 pg/dL (p = 0.001). Conclusion An elevation in the BNP level is determined by the functional status of the right and left ventricles in patients with isolated, severe TR. An elevated BNP predicts adverse events after corrective surgery. Therefore, the BNP level should be included in the clinical evaluation and risk stratification of patients with isolated TR.

Hepatopulmonary Syndrome in Poorly Compensated Postnecrotic Liver Cirrhosis by Hepatitis B Virus in Korea

Background Hepatopulmonary syndrome (HPS) refers to the association of hypoxemia, intrapulmonary shunting and chronic liver disease. But there is no clear data about the prevalence of HPS in postnecrotic liver cirrhosis by hepatitis B virus (HBV), the most common cause of liver disease in Korea. The aim of this study was to investigate the prevalence of HPS in poorly compensated postnecrotic liver cirrhosis by HBV, and the correlation of the hepatopulmonary syndrome with clinical aspects of postnecrotic liver cirrhosis by HBV. Methods: Thirty-five patients underwent pulmonary function test, arterial blood gas analysis and contrast-enhanced echocardiography. All patients were diagnosed as HBV-induced Child class C liver cirrhosis and had no evidence of intrinsic cardiopulmonary disease. Results: Intrapulmonary shunt was detected in 6/35 (17.1%) by contrast-enhanced echocardiography. Two of six patients with intrahepatic shunts had significant hypoxemia (PaO2 < 70 mmHg) and four showed increased alveolar-arterial oxygen gradient over 20 mmHg. Only cyanosis could reliably distinguish between shunt positive and negative patients. Conclusions: The prevalence of intrapulmonary shunt in poorly compensated postnecrotic liver cirrhosis by HBV was 17.1% and the frequency of hepatopulmonary syndrome was relatively low (5.7%). ‘Subclinical’ hepatopulmonary syndrome (echocardiographically positive intrapulmonary shunt but without profound hypoxemia) exists in 11.4% of cases with poorly compensated postnecrotic liver cirrhosis by HBV. Cyanosis is the only reliable clinical indicator of HPS of HBV-induced poorly compensated liver cirrhosis. Further studies are required to determine if the prevalence and clinical manifestations of HPS varies with etiology or with geographical and racial differences.

Adult Sail Sign: Radiographic and Computed Tomographic Features

Background: The sail sign is a well-known radiographic feature of the pediatric chest. This sign can be observed in an adult population as well, but for a different reason. Purpose: To investigate the sail sign appearing in adult chest radiography. Material and Methods: Based on two anecdotal adult cases in which frontal chest radiographs showed the sail sign, we prospectively screened radiographs of 10,238 patients to determine the incidence of the sail sign found in adults in their 40s or older. The cause of the sail sign was assessed using computed tomography (CT). Results: The sail sign was revealed in 10 (seven males, three females; median age 60.6 years) of 10,238 patients. Of these 10 patients with a sail sign on frontal radiographs, eight underwent CT. The frontal radiographs of these 10 patients showed a concave superior margin toward the lung in nine patients, a concave inferior margin in five, and a double-lined inferior margin in three. Lateral radiographs disclosed a focal opacity over the minor fissure in five of six patients, which was either fuzzy (n = 4) or sharp (n = 1) in its upper margin, and was sometimes double lined in the inferior margin (n = 3). CT revealed the anterior mediastinal fat to be the cause of the radiographic sail sign, which stretched laterally from the mediastinum to insinuate into the minor fissure. Conclusion: The incidence of sail sign on adult chest radiographs is about 0.1%. The sign is specific enough to eliminate the need for more sophisticated imaging.

Prognostic Value of Renal Function for Cardiac Events in Patients Without Significant Stenosis on Coronary Computed Tomography Angiography

This study was conducted to determine clinical parameters predicting future major adverse cardiovascular events (MACEs) in patients without significant stenosis on coronary computed tomographic angiography (CCTA). A total of 625 patients with suspected coronary artery disease (CAD) who underwent CCTA that revealed insignificant (< 50%) CAD was reviewed in three cardiac centers. The MACEs including cardiac death, non-fatal myocardial infarction (MI), unstable angina and late (> 90 days after CCTA) revascularization were assessed. During the mean follow-up period of 819 ± 529 days (median 837 days), there were 28 cases of MACEs (4.5%). In multivariable Cox regression analysis, independent predictors for MACEs were male sex (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.01-5.69; P = 0.046) and low estimated creatinine clearance (eCCr) (< 60 mL/min/1.73 m2) (HR, 3.07; 95% CI, 1.22-7.74; P = 0.017). Low eCCr was the only independent predictor for hard events including cardiac death and MI (HR, 17.6, 95% CI, 1.44-215.7; P = 0.025). In conclusion, renal function is an independent predictor for cardiovascular events among patients without significant CAD by CCTA. Careful monitoring and preventive strategy are warranted in patients with impaired renal function even without significant CAD. Graphical Abstract

Nonbacterial Thrombotic Endocarditis in a Patient with Bowel Infarction due to Mesenteric Vein Thrombosis

Ante mortem cases of venous thrombosis in patients with nonbacterial thrombotic endocarditis (NBTE) have not yet been reported. We describe a rare case of NBTE in a patient with mesenteric vein thrombosis. A healthy 37-year-old man with abdominal pain and fever underwent emergency small bowel resection due to bowel ischemia resulting from mesenteric vein thrombosis. Transthoracic echocardiography revealed multiple mobile masses attached to the anterior leaflet of the mitral valves and their chordae tendineae. On suspicion of infective endocarditis, the cardiac masses were excised through open-heart surgery. However, pathologic reviews were compatible with NBTE. The patient was stable after the cardiac surgery and was treated with warfarin. Laboratory and imaging findings regarding his hypercoagulable condition were all negative.

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.