Sang Yup Lim

GFR and Cardiovascular Outcomes After Acute Myocardial Infarction: Results From the Korea Acute Myocardial Infarction Registry

BACKGROUNDnDespite strong evidence linking decreased glomerular filtration rate (GFR) to worse outcomes, the impact of GFR on mortality and morbidity in patients with acute myocardial infarction (AMI) is not well defined.nnnSTUDY DESIGNnRetrospective cohort study.nnnSETTING & PARTICIPANTSn12,636 patients with AMI in the Korea AMI Registry database from November 2005 to July 2008. 93% of patients in this registry had coronary angiography, and 91% of patients with coronary angiography had percutaneous coronary intervention (PCI).nnnPREDICTORnGFR was estimated (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and patients were grouped into 5 eGFR categories: >90, 60-89, 30-59, 15-29, and <15 mL/min/1.73 m(2).nnnOUTCOMESnPrimary end points were death and in-hospital complications. Secondary end points were major adverse cardiac events (MACEs) during a 1-month (short-term) and 1-year (long-term) follow-up after AMI.nnnRESULTSnMean eGFR was 72.8 ± 24.6 mL/min/1.73 m(2), mean age was 64 ± 13 years, and 70.4% were men. A graded association was observed between eGFR and clinical outcomes. In adjusted analyses, compared with eGFR >90 mL/min/1.73 m(2), patients with eGFR of 30-59, 15-29, and <15 mL/min/1.73 m(2) experienced increased risks of short- (respective HRs of 2.30 [95% CI, 1.70-3.11], 3.10 [95% CI, 2.14-4.14], and 3.64 [95% CI, 2.44-5.43]; P < 0.001) and long-term MACEs (HRs of 1.58 [95% CI, 1.32-1.90], 2.12 [95% CI, 1.63-2.75], and 2.50 [95% CI, 1.89-3.29]; P < 0.001). Older age, Killip class higher than I, PCI, and high-sensitivity C-reactive protein level also were associated with higher short- and long-term MACEs. Use of β-blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and statins was associated with decreased risk of MACEs.nnnLIMITATIONSnSingle assessment of serum creatinine.nnnCONCLUSIONneGFR was associated independently with mortality and complications after AMI. PCI, β-blocker, ACE inhibitor or ARB, and statin use were associated with decreased risks of short- and long-term MACEs.

The effect of alpha lipoic acid in a porcine in-stent restenosis model

BACKGROUNDnThe aim of this study was to investigate the effect of alpha lipoic acid (α-LA) on a porcine in-stent restenosis (ISR) model.nnnMETHODSnIn protocol 1, porcine vascular smooth muscle cells (PVSMC) were stimulated by granulocyte-colony stimulating factor (G-CSF) in the presence or absence of α-LA. MTT (3-[4,5-dimethylthiazole-2-yl] 2,5-diphenyl tetrazolium bromide) assay and western blotting were used to determine the cell growth inhibitory rate and anti-inflammatory effect associated with nuclear factor-κb (NF-κb) and extracellular signal-regulated kinase (ERK). In protocol 2, 28 days after balloon overdilation injuries, 24 bare metal stents were placed in coronary artery of 12 pigs. The pigs were randomly divided to receive control diet with or without α-LA (100 mg/kg). In protocol 3, 8 control stents and 8 α-LA coated stents were randomly implanted in 2 coronary arteries of 8 pigs and follow-up coronary angiogram and histopathologic assessment were performed 4 weeks after stenting.nnnRESULTSnProtocol 1. The proliferation of PVSMC was inhibited and protein expression of NF-κb and ERK were attenuated by α-LA pretreatment. Protocol 2. On histopathologic analysis, the neointimal area (4.0+/-1.0 mm(2) vs. 1.5+/-0.7 mm(2), p<0.001) and histopathologic area of stenosis (66.7+/-10.7% vs. 24.2+/-9.7%, p<0.001) were reduced in the α-LA feeding group compared to controls. Protocol 3. On histopathologic analysis, the neointimal area (3.9+/-0.8 mm(2) vs. 1.0+/-0.4 mm(2), p<0.001), and the histopathologic area of stenosis (67.1+/-8.8% vs. 17.4+/-10.0%, p<0.001) were reduced in the α-LA coated stent group compared to the control stent group.nnnCONCLUSIONSnα-LA feeding and α-LA coated stents inhibit neointimal hyperplasia in porcine ISR, possibly through inhibiting the activation of NF-κb pathway and proliferation of PVSMC.

Effect on Short- and Long-Term Major Adverse Cardiac Events of Statin Treatment in Patients With Acute Myocardial Infarction and Renal Dysfunction

The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) reduce major adverse cardiac events (MACE) and mortality in patients with acute coronary syndrome. We investigated the effectiveness of statin therapy in reducing MACE in patients with acute myocardial infarction (AMI) and renal dysfunction (RD). In the present retrospective study of 12,853 patients with AMI, the patients were categorized into 4 groups: group I, statin therapy and no RD (estimated glomerular filtration rate ≥60 ml/min/1.73 m(2)); group II, neither statin therapy nor RD; group III, statin therapy and RD; group IV, no statin therapy but RD. The primary end points were death and complications during the hospital course. The secondary end points were MACE during 1 year of follow-up after AMI. Significant differences in the composite MACE during 12 months of follow-up were observed among the 4 groups (group I, 11.7%; group II, 19.0%; group III, 26.7%; and group IV, 45.5%; p <0.001). In a Cox proportional hazards model, mortality at 12 months increased stepwise from group II to IV compared to group I. Moreover, MACE-free survival in the severe RD group (estimated glomerular filtration rate <30 mL/min/1.73 m(2)) was also greater in the statin-treated group. In conclusion, statin therapy reduced MACE at 1 year of follow-up in patients with AMI regardless of RD.

Relationship between Strain Rate Imaging and Coronary Flow Reserve in Assessing Myocardial Viability after Acute Myocardial Infarction

Objectives: To evaluate the relationship between strain rate (SR) imaging and coronary flow reserve (CFR) in assessing viability of akinetic myocardium after acute myocardial infarction (MI). Methods: Forty patients with acute first ST‐elevation MI were analyzed. SR imaging and CFR by intracoronary flow measurement were obtained on the same day, 3∼5 days after primary percutaneous coronary intervention. Viability of the akinetic myocardium was determined on 6‐week echocardiography. Results: Systolic SR (SRs, −0.42 ± 0.10 vs. −0.35 ± 0.11 per second, P = 0.03), early diastolic SR (SRe, 0.68 ± 0.31 vs. 0.41 ± 0.22 per second, P = 0.003), and systolic strain (Ss, −5.9 ± 3.4 vs. −2.5 ± 4.0%, P = 0.04) were greater in akinetic, but viable myocardium of 21 patients than in akinetic and nonviable myocardium of 19 patients. CFR was also higher in patients with akinetic, but viable myocardium (2.0 ± 0.5 vs. 1.5 ± 0.5, P < 0.001). SRs, SRe, and Ss were significantly related to CFR (r =−0.50, r = 0.58, r =−0.56, respectively, all P ≤ 0.001) and SRe was most related to CFR (P < 0.001). The sensitivity and specificity to predict myocardial viability were 85.7% and 68.4% for CFR (cutoff = 1.75), and 90.5% and 57.9% for SRe (cutoff = 0.37 per second), respectively. Conclusions: The degree of myocardial deformation determined by SR imaging was related to the degree of microvascular integrity determined by CFR, and can be used as a noninvasive method to predict myocardial viability after acute MI. (Echocardiography 2010;27:977‐984)

A Case of Stent Thrombosis Occurred at 5 Years after Sirolimus-Eluting Stent Implantation

Drug-eluting stents (DES) have reduced the rate of repeated revascularization of target lesions. For this reason, DES are considered to be superior to bare-metal stents in reducing the restenosis rate. However, some problems have been reported after implantation of DES. One of them, stent thrombosis, has arisen as a fatal complication. Dual antiplatelet therapy is recommended for at least 12 months after implantation of DES to prevent stent thrombosis. Here, we report a case of very late stent thrombosis that occurred 1 week after discontinuation of clopidogrel at 5 years (1832 days) after implantation of a sirolimus-eluting stent.

Very late stent thrombosis after drug-eluting stent implantation in a patient without aspirin and clopidogrel resistance.

Very late stent thrombosis (VLST) after implantation of drug-eluting stent is rare, but very fatal complication after percutaneous coronary intervention. We report a case of VLST of a sirolimus-eluting Cypher™ stent (Cordis, Johnson and Johnson) presenting as acute ST elevation myocardial infarction at 26 months after deployment with continued combined dual antiplatelet medication of aspirin and clopidogrel. The patient did not show anti-platelet resistance.

Angiographic and clinical comparison of novel Orsiro Hybrid sirolimus-eluting stents and Resolute Integrity zotarolimus-eluting stents in all-comers with coronary artery disease (ORIENT trial): study protocol for a randomized controlled trial

BackgroundThe Orsiro Hybrid sirolimus-eluting stent is a newly developed third-generation drug-eluting stent, featuring a unique dual-polymer mix. An active bioabsorbable polymer delivers the anti-proliferative drug, sirolimus, via controlled release, while a passive biocompatible polymeric coating shields the metallic strut from surrounding tissue, preventing interaction. To date, the Orsiro Hybrid sirolimus-eluting stent has excelled in terms of late lumen loss at 9 months in a first-in-man single-arm trial. However, the efficacy and safety data for Orsiro Hybrid sirolimus-eluting stents in a broader population of all-comers are limited. The present study offers an angiographic and clinical comparison of the Orsiro Hybrid sirolimus-eluting stent and the Resolute Integrity zotarolimus-eluting stent in the treatment of patients with coronary artery disease.Methods/designThe ORIENT trial is a multicenter, randomized, open-label, parallel-arm study designed to demonstrate the non-inferiority of the Orsiro Hybrid sirolimus-eluting stent relative to the Resolute Integrity zotarolimus-eluting stent. A total of 375 patients with a spectrum of coronary artery disease will undergo prospective, random assignment to a Orsiro Hybrid sirolimus-eluting stent or Resolute Integrity zotarolimus-eluting stent (2:1 ratio), for a primary endpoint of in-stent late lumen loss at 9 months by quantitative coronary angiography. Secondary 12-month clinical endpoints are death, target lesion revascularization, target vessel revascularization, myocardial infarction, stent thrombosis and target lesion failure (a composite of cardiac death, target lesion revascularization and target vessel-related myocardial infarction).DiscussionThe ORIENT trial is the first study to date comparing the Orsiro Hybrid sirolimus-eluting stent with the Resolute Integrity zotarolimus-eluting stent for efficacy and safety in a population of all-comers with coronary artery disease.Trial registrationClinicaltrials.gov NCT01826552

A Case Report of Primary Pericardial Malignant Mesothelioma Treated with Pemetrexed and Cisplatin

Primary pericardial malignant mesothelioma (PPM) is a very rare malignancy, with an incidence of less than 0.002% and represents less than 5% of all mesotheliomas. The cause of pericardial mesothelioma is uncertain that differ from pleural mesothelioma which is associated with asbestos exposure. This malignancy is terribly aggressive and has very poor prognosis with less than six months of overall survival. We present a case of a 71-year-old woman who was diagnosed with cardiac tamponade caused by PPM and received chemotherapy with pemetrexed and cisplatin for six months. During two years she was alive without disease progression. To better understand the clinical, pathologic features and treatment outcome of this entity, we reviewed 23 cases described in the English literature from 2009, together with our case, provided a total of 24 cases. Based on this review, we suggest that PPM must be considered in patients who have unexplained massive pericardial effusion and recommend chemotherapy with pemetrexed and cisplatin for the better outcome of PPM.

Effect of volume of percutaneous coronary intervention on clinical outcomes in patients with acute myocardial infarctions in hospitals with and without onsite cardiac surgery backup.

creatinine in Japan. Am J Kidney Dis 2009;53:982–92. [6] Niwa T, Ise M. Indoxyl sulfate, a circulating uremic toxin, stimulates the progression of glomerular sclerosis. J Lab Clin Med 1994;124:96–104. [7] Kitagawa K, Hougaku H, Yamagami H, et al. Carotid intima-media thickness and risk of cardiovascular events in high-risk patients. Results of the Osaka FollowUp Study for Carotid Atherosclerosis 2 (OSACA2 Study). Cerebrovasc Dis 2007;24:35–42. [8] Henry RM, Kostense PJ, Bos G, et al. Mild renal insufficiency is associated with increased cardiovascular mortality: the Hoorn Study. Kidney Int 2002;62:1402–7.