Kun Joo Rhee

Non-invasively measured aortic wave reflection and pulse pressure amplification are related to the severity of coronary artery disease

BACKGROUND Augmentation index (AIx) and pulse pressure amplification (PPA, here the aortic/brachial pulse pressure ratio) are an age-related emerging risk factor for cardiovascular disease. However, it has not been clearly shown that AIx and PPA predict a high risk of coronary artery disease (CAD). OBJECTIVES The aim of the study was to investigate the association between non-invasively measured aortic wave reflection (AWR) and PPA and CAD. METHODS The study group consisted of 80 patients who were admitted to our institute for elective coronary angiography. We non-invasively measured augmentation pressure (AP), AIx, and PPA using radial applanation tonometry. RESULTS When the extent of CAD was divided by no or minimal CAD, 1- or 2- and 3-vessel disease (VD), there was a significant association between the extent of CAD and AIx and PPA in patients aged <65 years, but not in patients aged ≥ 65 years. In multivariate regression analysis after controlling the traditional risk factors, the odds ratio of having 3VD was significant in patients aged <65 years: 2.15 (1.04-4.44; p=0.039) per 5% increase of AIx and 2.02 (1.15-3.55; p=0.015) per 0.05 increase of PPA, but not in patients aged ≥ 65 years. The severity of CAD expressed as a Gensini score showed a significant correlation with AP, AIx, and PPA in patients aged <65 years, but not in patients aged ≥ 65 years. CONCLUSION Increasing of non-invasively measured AWR and PPA is related to the severity of CAD, particularly in younger patients up to 65 years of age.

Regular exercise training reduces coronary restenosis after percutaneous coronary intervention in patients with acute myocardial infarction.

BACKGROUND It is well known that cardiac rehabilitation (CR) including regular exercise training (ET) is cardioprotective with respect to clinical events in patients with acute myocardial infarction (AMI). However, it is not known whether the regular ET may affect coronary restenosis after percutaneous coronary intervention (PCI) with stenting in AMI. The aim of this study was to evaluate the effect of regular ET on a stented coronary segment and its association with inflammatory markers in AMI. METHODS Consecutively 74 AMI patients who underwent PCI with implantation of a drug-eluting stent and 9 month follow-up angiography were included. Thirty seven patients who received CR with ET were assigned to the ET group. Another 37 patients who did not participate in ET, of similar age to those of participants, were assigned to the control group. At 9 months, angiographic restenosis measured as in-segment late luminal loss of the stented coronary artery was analyzed via quantitative coronary angiography using CAAS 5.9. RESULTS There were no significant differences in baseline characteristics including age, sex, body mass index, smoking, DM, hypertension, lipid profile, use of statin, and complete blood cell between two groups. On 9 month follow-up angiography, late luminal loss per stent was significantly smaller in the ET group compared to the control group (0.14 ± 0.57 vs. 0.54 ± 0.88 mm, p=0.02). Maximal oxygen consumption (VO2max) significantly improved in the ET group after 9months (27.9 ± 6.4 vs. 30.8 ± 5.2 mL/kg/min, p<0.001). Increment in high density lipoprotein-cholesterol (HDL-C) was significantly larger in the ET group at 9 months (0.15 ± 0.12 vs. 0.04 ± 0.24 mg/dL, p=0.03). CONCLUSION Regular ET contributes to a significant reduction in late luminal loss in the stented coronary segment in AMI patients. This effect was associated with increased exercise capacity and increased HDL-C.

Primary Cardiac Lymphoma Presenting With Atrioventricular Block

Primary cardiac lymphomas (PCL) are extremely rare. Clinical manifestations may be variable and are attributed to location. Here, we report on a case of PCL presenting with atrioventricular (AV) block. A 55 year-old male had experienced chest discomfort with unexplained dyspnea and night sweating. His initial electrocardiogram (ECG) revealed a first degree AV block. Along with worsening chest discomfort and dyspnea, his ECG changed to show second degree AV block (Mobitz type I). Computed tomography (CT) scan showed a cardiac mass (about 7 cm) and biopsy was performed. Pathologic finding confirmed diffuse large B-cell lymphoma. The patient was treated with multi-drug combination chemotherapy (R-CHOP: Rituximab, cyclophoshamide, anthracycline, vincristine, and prednisone). After treatment, ECG changed to show normal sinus rhythm with complete remission on follow-up CT scan.

Prediction of Coronary Artery Disease in Patients With Lower Extremity Peripheral Artery Disease

Coronary artery disease (CAD) is a major determinant of long-term prognosis in patients with peripheral artery disease (PAD). We investigated the predictors of CAD in patients with lower extremity PAD.A total of 107 patients with PAD who underwent peripheral and simultaneous coronary angiography were reviewed. PAD was defined as (≥ 50%) stenosis associated with claudication or critical limb ischemia. PAD was divided into proximal and distal lesions. CAD was defined as angiographically significant (≥ 50%) stenosis of coronary arteries.The prevalence of CAD in patients with PAD was 62% (67/107), and of this 62%, only 13% (9/67) had angina and 72% (48/67) had multi-vessel disease. Diabetes significantly increased the risk of CAD in patients with PAD and the odds ratio of having multi-vessel CAD was 2.5 (1.1-5.9, P = 0.037) in multivariate regression analysis. The patients with multi-vessel CAD had more cardiovascular risk factors than those with normal, minimal and single CAD (P = 0.032). Interestingly, the prevalence of proximal PAD was higher in the normal or single CAD group than the multi-vessel CAD group, whereas both proximal and distal involvement of PAD was higher in the multi-vessel CAD group.Diabetes, multi-cardiovascular risk factors, and involvement of both proximal and distal lesions significantly increased the risk of multi-vessel CAD. Therefore, simultaneous CAD evaluation should be considered in patients with lower extremity PAD having diabetes, multi-cardiovascular risk factors, or multi-level disease.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count.

Background and Objectives Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. Subjects and Methods Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (<5,300/mm3, 5,300-7,600/mm3, and >7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. Results There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. Conclusion A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

A Case of Primary Cardiac Lymphoma Mimicking Acute Coronary and Aortic Syndrome

Primary cardiac lymphoma (PCL) is a rare disorder, but the incidence is increasing and its clinical manifestations are various. We report a case of PCL, which mimics an acute coronary and aortic syndrome. A 51 year-old female was presented with chest pain radiating to the back. Her initial electrocardiogram revealed T wave inversion in the leads of V 5-6, II, III and aVF. Additionally, cardiac troponin-T was slightly elevated. Chest radiography showed marked mediastinal widening. Computed tomography scan showed a huge pericardial mass. The histopathologic findings of the mass were compatible with diffuse large B cell lymphoma. She died of refractory ventricular tachycardia, probably, due to an extensive infiltration of PCL to the myocardium.

The relation of non-invasively and invasively assessed aortic pulsatile indices to the presence and severity of coronary artery disease

Abstract Objectives. The aim of the study was to assess the relationship between non-invasively (NIA) and invasively assessed (IA) aortic pulsatile indices and the presence and severity of coronary artery disease (CAD). Subjects and Methods. The study group consisted of 58 patients who were admitted to our institute for elective coronary angiography (CAG). We measured the aortic systolic, diastolic and mean blood pressure (BP) using non-invasive and invasive techniques. We assessed the pulsatile indices of the aortic pressure waveform (APW) including pulse pressure (PP), fractional PP (FPP, the ratio of PP to mean BP) and pulsatility index (PI, the ratio of PP to diastolic BP). The severity of CAD was assessed by Gensini score. Results. IA aortic PP, FPP and PI were significantly higher in patients with CAD than without CAD, but NIA indices did not show significant differences between two groups. After multivariate stepwise adjustment, the odds ratio (OR) and confidence interval (CI) of having significant CAD was: PP per 10 mmHg, OR = 2.51 (95% CI 1.12–5.63); FPP per 0.1, OR = 3.30 (95% CI 1.25–8.72); and PI per 0.1, OR = 1.88 (95% CI 1.09–3.23). In linear regression analysis, IA aortic systolic BP (SBP), PP, FPP and PI were significantly correlated with Gensini score, but NIA indices were not correlated. The NIA aortic PP was lower than IA aortic PP (mean difference: 6.1 ± 15.8 mmHg). Conclusion. IA aortic PP, FPP and PI were related to the presence and severity of CAD, but NIA assessed indices of APW were not related. NIA aortic PP underestimated IA aortic PP.

Primary Cardiac Angiosarcoma Presenting With Cardiac Tamponade

Primary cardiac angiosarcoma is a very rare disease with a poor prognosis. We report a case of a patient with a primary cardiac angiosarcoma who presented with cardiac tamponade; the angiosarcoma was successfully resected surgically.

Reduced systemic vascular resistance is the underlying hemodynamic mechanism in nitrate-stimulated vasovagal syncope during head-up tilt-table test.

Nitroglycerin (NTG) challenge during head‐up tilt‐table testing (HUTT) is often utilized to determine the etiology of unexplained vascular syncope. However, conflicting results concerning nitrate‐induced hemodynamic changes during HUTT have been reported. The purpose of this study was to assess the determinants of presyncopal symptoms during NTG‐stimulated HUTT.

Hemorheological and Glycemic Parameters and HDL Cholesterol for the Prediction of Cardiovascular Events

Background Hemorheological and glycemic parameters and high density lipoprotein (HDL) cholesterol are used as biomarkers of atherosclerosis and thrombosis. Objective To investigate the association and clinical relevance of erythrocyte sedimentation rate (ESR), fibrinogen, fasting glucose, glycated hemoglobin (HbA1c), and HDL cholesterol in the prediction of major adverse cardiovascular events (MACE) and coronary heart disease (CHD) in an outpatient population. Methods 708 stable patients who visited the outpatient department were enrolled and followed for a mean period of 28.5 months. Patients were divided into two groups, patients without MACE and patients with MACE, which included cardiac death, acute myocardial infarction, newly diagnosed CHD, and cerebral vascular accident. We compared hemorheological and glycemic parameters and lipid profiles between the groups. Results Patients with MACE had significantly higher ESR, fibrinogen, fasting glucose, and HbA1c, while lower HDL cholesterol compared with patients without MACE. High ESR and fibrinogen and low HDL cholesterol significantly increased the risk of MACE in multivariate regression analysis. In patients with MACE, high fibrinogen and HbA1c levels increased the risk of multivessel CHD. Furthermore, ESR and fibrinogen were significantly positively correlated with HbA1c and negatively correlated with HDL cholesterol, however not correlated with fasting glucose. Conclusion Hemorheological abnormalities, poor glycemic control, and low HDL cholesterol are correlated with each other and could serve as simple and useful surrogate markers and predictors for MACE and CHD in outpatients.