Kwen-Chul Shin

Significant differential effects of omega-3 fatty acids and fenofibrate in patients with hypertriglyceridemia

BACKGROUND Omega-3 fatty acids and fenofibrate are both used to treat patients with hypertriglyceridemia. However, a head-to-head comparison of the lipoprotein and metabolic effects of these two medicines has not been published. METHODS This was a randomized, single-blind, placebo-controlled, parallel study. Age, sex, and body mass index were matched among groups. All patients were recommended to maintain a low fat diet. Fifty patients in each group were given placebo, omega-3 fatty acids 2 g (most commonly used dosage in Korean patients), or fenofibrate 160 mg, respectively daily for 2 months. RESULTS Omega-3 fatty acids therapy decreased triglycerides by 21% and triglycerides/HDL cholesterol and improved flow-mediated dilation (P<0.01), however, did not significantly change insulin, plasma adiponectin levels, and insulin sensitivity (determined by QUICKI) relative to baseline measurements. Fenofibrate therapy decreased total cholesterol, triglycerides by 29%, and triglycerides/HDL-cholesterol (all P<0.01) and improved flow-mediated dilation when compared with baseline. When compared with placebo and omega-3 fatty acids, fenofibrate therapy decreased non-HDL cholesterol (P<0.001) and triglycerides/HDL cholesterol (P=0.016) while increasing HDL cholesterol (P<0.001) and apolipoprotein AI (P=0.001). Of note, when compared with omega-3 fatty acids, fenofibrate therapy decreased fasting insulin (P=0.023) and increased plasma adiponectin (P=0.002) and insulin sensitivity (P=0.015). CONCLUSIONS Omega-3 fatty acids and fenofibrate therapy promoted similar changes in triglycerides and endothelium-dependent dilation. However, fenofibrate therapy had substantially better effects on lipoprotein and metabolic profiles in patients with hypertriglyceridemia.

Diffuse multi-vessel coronary artery spasm: Incidence and clinical prognosis

BACKGROUND The incidence and clinical prognosis of diffuse and multivessel coronary spasm has not been reported. METHODS Patients with suspected vasospastic angina were prospectively enrolled. Left and right coronary angiogram was performed simultaneously after intravenous ergonovine injection. Spasm (>70% luminal narrowing) was sub-classified as diffuse (more than 20mm length), multivessel (more than 2 epicardial arteries). Clinical characteristics and prognosis were analyzed. RESULTS Patients (96 consecutive patients, 56 males, mean age 48 years) were divided into 3 groups: diffuse-multivessel spasm (group I, n=16, 16.7%), other types of spasm (group II, n=12, 12.5%) and control group (group III, n=68, 70.8%). The rates of males, alcohol drinkers and the mean triglyceride were higher, and high density lipoprotein was lower in group I compared to group III (all p<0.05), but similar to group II (all p=NS). Hard cardiovascular event rates did not differ among groups (one cardiac arrest but successful resuscitation in group I, one non-fatal myocardial infarction in group III) during follow up periods (mean, 41.2 ± 13.7 months). Chest pain free survivals during 1 year were lower in group I (66.7%) compared to group III (90%), but similar to group II (58.3%) (group I vs III, p<0.05 and group I vs II, p=NS). CONCLUSIONS Diffuse-multivessel spasm was not rare in patients with vasospastic angina and its prognosis is pretty good similar to patients with previously known variant angina with recommended medical treatment.

Repeated sudden cardiac death in coronary spasm: Is IVUS helpful to decide treatment strategy?

Coronary spasm is thought to be the main pathogenic mechanism of variant angina. Despite medical treatment, ischemic events are continued in some patients, often associated with serious complications [1,2]. Ventricular arrhythmias and sudden cardiac death have been predominantly reported in cases of multivessel coronary artery spasm [3]. In medically intractable coronary spasm, coronary stent or Implantable cardioverter defibrillators (ICD) have suggested as a treatment strategy, but optimal therapy is still unknown. We report a young patient of medically intractable vasospastic angina who experienced sudden cardiac death twice and successfully treated with stent after intravascular ultrasound study. A 27-year-old male patient came to emergency room because of sudden cardiovascular collapse during sleeping. He was a non smoker and other cardiovascular risk factors were absent. Initial electrocardiogram (ECG) showed ventricular fibrillation. Basic life support including defibrillation (biphasic 200 J) successfully restored sinus rhythm without neurologic sequel. Follow up ECG showed markedly elevated ST segments at all leads (Fig. 1A) and cardiac enzymes were elevated. Emergency coronary angiography, however, showed no significant coronary artery stenosis (Fig. 1B and C). He was started on intravenous administration of nitrates, and calcium antagonist under suspicion of coronary spasm. Echocardiography ruled out myocarditis or pericarditis. Duringhospital stay, no signs of rhythmdisturbances or

Pachydermoperiostosis accompanied by heart failure.

Pachydermoperiostosis or primary hypertrophic osteoarthropathy is an uncommon disease of acromegaloid facial feature, but characterized by unique phenotype (digital clubbing and pachydermia) and distinctive radiographic appearances like periostosis. We experienced a case with complete form of pachydermoperiostosis accompanied by heart failure. He presented with typical features consisting of clubbing with enlargement of the hand, thickening of facial skin and periosteal new bone formation involving lower leg. Echocardiography revealed severely decreased left ventricular systolic function. Treatment with medications resulted in an improvement of cardiac function and symptom. There is no previous report documenting pachydermoperiostosis accompanied by heart failure. We report that case for the first time.

A Comparison of Two Brands of Clopidogrel in Patients With Drug-Eluting Stent Implantation

Background and Objectives Although generic clopidogrel is widely used, clinical efficacy and safety between generic and original clopidogrel had not been well evaluated. The aim of this study was to evaluate the clinical outcomes of 2 oral formulations of clopidogrel 75 mg tablets in patients with coronary artery disease (CAD) undergoing drug-eluting stent (DES) implantation. Subjects and Methods Between July 2006 and February 2009, 428 patients that underwent implantation with DES for CAD and completed >1 year of clinical follow-up were enrolled in this study. Patients were divided into the following 2 groups based on treatment formulation, Platless® (test formulation, n=211) or Plavix® (reference formulation, n=217). The incidence of 1-year major adverse cardiovascular and cerebrovascular event (MACCE) and stent thrombosis (ST) were retrospectively reviewed. Results The baseline demographic and procedural characteristics were not significantly different between two treatment groups. The incidence of 1-year MACCEs was 8.5% {19/211, 2 deaths, 4 myocardial infarctions (MIs), 2 strokes, and 11 target vessel revascularizations (TVRs)} in Platless® group vs. 7.4% (16/217, 4 deaths, 1 MI, 2 strokes, and 9 TVRs) in Plavix® group (p=0.66). The incidence of 1-year ST was 0.5% (1 definite and subacute ST) in Platless® group vs. 0% in Plavix® group (p=0.49). Conclusion In this study, the 2 tablet preparations of clopidogrel showed similar rates of MACCEs, but additional prospective randomized studies with pharmacodynamics and platelet reactivity are needed to conclude whether generic clopidgrel may replace original clopidogrel.

Single right coronary artery giving off anomalous origin of left anterior descending artery with diffuse myocardial bridge: the role of computed tomography scan.

A 58-year-old woman who presented with resting chest pain underwent coronary angiography and multidetector computed tomography (MDCT), with detection of a single right coronary artery giving off an anomalous origin of the left anterior descending artery, subpulmonic type with diffuse myocardial bridge. The myocardial bridge was detected by MDCT, not by coronary angiography. Our findings suggest that MDCT has an important role in the more precise evaluation of clinical and anatomical information in patients with a single coronary artery.

COMPARISON OF INFLAMMATORY MARKERS FOR PREDICTION OF NEOINTIMAL HYPERPLASIA PROLIFERATION AFTER DRUG-ELUTING STENT IMPLANTATION

Methods: We performed PCI with a single DES in 42 consecutive stable angina patients (26 men; 59.7±10.1 years of age). The plasma hs-CRP, IL-6 and MMP-9 values were serially measured before the PCI and at 24, 72 hours after the PCI. The difference (Δ) of each inflammatory markers between baseline and each stages after intervention was calculated. Patients were grouped into quartiles according to inflammatory marker and Δ inflammatory marker values at each stage. An angiography and IVUS study were performed at pre and post PCI and 9 months after the PCI in all patients.

Predictors of edge stenosis after paclitaxel-eluting stent implantation.

BackgroundAlthough edge stenosis (ES) is a main limitation of drug-eluting stents, the predictors for ES are not well known. We evaluated the predictors for ES after paclitaxel-eluting stent implantation. MethodsOne hundred and eleven angina patients (64 men; 62.2±8.4 years of age) were divided into ES (n=9) and non-ES groups (n=102). The clinical findings, procedural factors, and intravascular ultrasound (IVUS) parameters were analyzed. ResultsAlthough clinical characteristics were not different between groups, diabetes mellitus (DM) was more common in the ES group (P=0.002). The vessel, plaque, and lumen areas of the lesions were not different between groups; however, the vessel area of the proximal and distal reference artery was smaller in the ES group. Lesions with positive remodeling were more common in the ES group (P=0.015). On the basis of univariate analysis, predictors of ES included DM, lesions with positive remodeling, IVUS parameters, and procedural factors. After adjusting for clinical findings, angiographic factors, and IVUS parameters, the presence of DM [odds ratio (OR): 9.20; 95% confidence interval (CI): 1.40–60.62, P=0.021] and lesions with positive remodeling (OR: 5.93; 95% CI: 1.13–31.02, P=0.035) were independent predictors of ES. The lumen area in the distal 1 mm reference segment was a protective factor for ES (OR: 0.05; 95% CI: 0.00–0.74, P=0.029). ConclusionThe risk of ES after paclitaxel-eluting stent implantation was higher in patients who had DM and lesions with positive remodeling. Of the IVUS parameters, the lumen area in the distal 1 mm reference segment was a protective factor against ES.