Direct oral anticoagulants in atrial fibrillation following cardiac surgery: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Direct oral anticoagulants (DOACs) have been increasingly used as anticoagulation therapy in the postoperative period. However, their effectiveness in post-cardiac surgical atrial fibrillation is yet to be determined.

METHODS

We conducted a meta-analysis, searching three international databases from 1 January 2003 to 26 January 2022 for studies reporting on DOACs in at least 10 adult patients (>18 yr of age) with post-cardiac surgical atrial fibrillation. The primary outcomes were major neurological events (MNEs) and bleeding; secondary outcomes were mortality, hospital and ICU length of stay, cost, and other complications from therapy. We included studies of any design, including RCTs, cohort studies with and without propensity score matching methods, and single-armed case series.

RESULTS

Twelve studies (8587 DOACs; 8315 warfarin) were included in this meta-analysis. The incidences of postoperative bleeding and MNEs with DOACs were 7.3% (95% confidence interval [CI]: 3.4-14.7%) and 2.2% (95% CI: 0.9-4.9%), respectively. The incidence of MNEs was lower in high-risk patients, including those with hypertension and higher CHA₂DS₂-VASc score, whereas patients with prior transient ischaemic attack or stroke had higher incidence of bleeding. Trial sequential analysis revealed that the cumulative Z-curve crossed the conventional boundary of benefit. Compared with warfarin, DOACs reduced the risk of bleeding (relative risk [RR] 0.74; 95% CI: 0.62-0.89; P=0.0011) and MNEs (RR 0.63; 95% CI: 0.48-0.83; P=0.0012) but not mortality (RR 1.02; 95% CI: 0.77-1.35; P=0.090).

CONCLUSIONS

DOACs reduced bleeding and MNEs in patients with post-cardiac surgical atrial fibrillation, appearing safer than warfarin in this context. However, which DOAC provides the most effective anticoagulation in this patient population needs further investigation.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42021282777.

Age estimation from structural changes of teeth and buccal alveolar bone level

Forensic odontology plays a vital role in the identification and age estimation of unknown deceased individuals. The purpose of this study is to estimate the chronological age from Cone-Beam Computed Tomography (CBCT) images by measuring the buccal alveolar bone level (ABL) to the cemento-enamel junction and to investigate the possibility of employing the age-related structural changes of teeth as studied by Gustafson. In addition, this study will determine the forensic reliability of employing CBCT images as a technique for dental age estimation. A total of 284 CBCT images of Malays and Chinese patients (150 females and 134 males), aged from 20 years and above were selected, measured and stages of age-related changes were recorded using the i-CAT Vision software. Lower first premolars of both left and right side of the jaw were chosen and the characteristics described by Gustafson, namely attrition, secondary dentine formation and periodontal recession were evaluated. Linear regression analysis was performed for the buccal bone level and the R values obtained were 0.85 and 0.82 for left and right side respectively. Gustafson's characteristics were analysed using multiple regression analysis with chronological age as the dependent variable. The results of the analysis showed R values ranged from 0.44 to 0.62. Therefore it can be safely concluded that the buccal bone level highly correlated with the chronological age and is consequently the most suitable age-related characteristic for forensic age estimation.

Non-motor manifestations in essential tremor: use of a validated instrument to evaluate a wide spectrum of symptoms

INTRODUCTION

Recent studies suggest an association between non-motor symptoms and essential tremor (ET). Few studies have assessed psychological symptoms in ET. These studies were limited to western white populations and utilized scales that were specific to only one or two psychiatric domains. By contrast, the Symptom Checklist-90R (SCL-90R) is a validated clinical scale to screen for symptoms related to a spectrum of nine different psychological domains.

OBJECTIVE

To determine whether a wide spectrum of non-motor manifestations is associated with ET in patients in an Asian cohort.

METHODS

Consecutive ET patients and a group of control subjects were evaluated using the SCL-90R, which is comprised of items in nine major symptom dimensions and three global indices, including the positive symptom distress index.

RESULTS

ET patients (N = 84) and controls (N = 78) were similar in age (50.0+/-18.0 vs 46.0+/-14.4 years), gender and other demographic variables. ET patients had higher scores in three of nine major symptom dimensions: anxiety, phobic anxiety (p < 0.0005) and psychoticism (p = 0.005). In multivariate analysis, the anxiety (p < 0.0005) and the positive symptom distress index scores (p < 0.0005) were greater in ET patients compared to controls after adjusting for sex, age, marital status and educational level. The severity, but not duration of ET was correlated with the severity of anxiety symptoms.

CONCLUSIONS

Utilizing the SCL-90R, we highlighted that ET patients reported more non-motor symptoms than healthy controls. The more frequent occurrence of anxiety symptoms in our Asian cohort extends the observation that such non-motor manifestations should be considered in the clinical management of ET.

Restless hand symptoms in carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a nerve entrapment disorder, involving the median nerve when it passes the carpal tunnel at the wrist. Using a case-control methodology, 312 electrophysiologically confirmed CTS patients with mean age of 51.3+/-9.4 (27-74) years (81.7% women) and 100 controls with mean age of 50.4+/-9.2 (21-88) years (75% women) were examined utilising a questionnaire similar to the clinical diagnostic criteria of restless legs syndrome (RLS). Forty-four (14.1%) of the CTS patients have symptoms compatible with restless hand syndrome compared with none (0%) in the control group (p < 0.0001). The severity of CTS was not significantly associated with the motor restlessness. Our observations suggest that entrapment syndromes such as CTS can be associated with a form of restlessness in the hands, analogous to RLS.

Effect of hormone replacement therapy on nitric oxide bioactivity and monocyte chemoattractant protein-1 levels

BACKGROUND

Vascular inflammation plays an important role in the pathogenesis of atherosclerosis. We investigated the effect of hormone replacement therapy (HRT) on vasomotor function and monocyte chemoattractant protein (MCP)-1 levels, an important serological marker of inflammation.

METHODS

We administered micronized progesterone (MP) 200 mg for 10 days with conjugated equine estrogen (CEE) 0.625 mg for 25 days and remaining 5 days off cyclically during 2 months to 20 healthy postmenopausal women (PMW). We measured NO bioactivity and plasma levels of MCP-1 before and after HRT in 20 PMW. And we measured plasma levels of MCP-1 in each 20 subjects of premenopausal women, men <50, and men >50 years, respectively.

RESULTS

MP combined with CEE significantly improved the percent flow-mediated dilator response to hyperemia relative to baseline measurements (P<0.001). PMW receiving HRT had lower levels of MCP-1 than those not receiving HRT (121+/-38 versus 146+/-44 pg/ml, P<0.001). In all comparisons, subjects with high estrogen status had significantly lower MCP-1 levels than subjects with low estrogen status (P<0.001 by ANOVA). Premenopausal women had lower levels of MCP-1 than men of a similar age (106+/-14 versus 164+/-40 pg/ml, P<0.001). PMW not receiving HRT had similar levels of MCP-1 compared with men of a similar age (146+/-44 versus 143+/-29 pg/ml, P=0.816). Premenopausal women had markedly lower levels of MCP-1 than PMW not receiving HRT (106+/-14 versus 146+/-44 pg/ml, P=0.001). PMW receiving HRT had similar levels of MCP-1 compared with premenopausal women (121+/-38 versus 106+/-14 pg/ml, P=0.323).

CONCLUSION

These findings might provide at least a partial explanation for the protection against cardiovascular disease experienced by premenopausal women, and the loss of that protection following menopause.

Vascular effects of estrogen in type II diabetic postmenopausal women

OBJECTIVES

We assessed the effects of estrogen on vascular dilatory and other homeostatic functions potentially affected by nitric oxide (NO)-potentiating properties in type II diabetic postmenopausal women.

BACKGROUND

There is a higher cardiovascular risk in diabetic women than in nondiabetic women. This would suggest that women with diabetes do not have the cardioprotection associated with estrogen.

METHODS

We administered placebo or conjugated equine estrogen, 0.625 mg/day for 8 weeks, to 20 type II diabetic postmenopausal women in a randomized, double-blinded, placebo-controlled, cross-over design.

RESULTS

Compared with placebo, estrogen tended to lower low-density lipoprotein (LDL) cholesterol levels by 15 +/- 23% (p = 0.007) and increase high-density lipoprotein (HDL) cholesterol levels by 8 +/- 16% (p = 0.034). Thus, the ratio of LDL to HDL cholesterol levels significantly decreased with estrogen, by 20 +/- 24%, as compared with placebo (p = 0.001). Compared with placebo, estrogen tended to increase triglyceride levels by 16 +/- 48% and lower glycosylated hemoglobin levels by 3 +/- 13% (p = 0.295 and p = 0.199, respectively). However, estrogen did not significantly improve the percent flow-mediated dilatory response to hyperemia (17 +/- 75% vs. placebo; p = 0.501). The statistical power to accept our observation was 81.5%. Compared with placebo, estrogen did not significantly change E-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, monocyte chemoattractant protein-1 or matrix metalloproteinase-9 levels. Compared with placebo, estrogen tended to decrease tissue factor antigen and increase tissue factor activity levels by 7 +/- 46% and 5 +/- 34%, respectively (p = 0.321 and p = 0.117, respectively) and lower plasminogen activator inhibitor-1 levels by 16 +/- 31% (p = 0.043).

CONCLUSIONS

The effects of estrogen on endothelial, vascular dilatory and other homeostatic functions were less apparent in type II diabetic postmenopausal women, despite the beneficial effects of estrogen on lipoprotein levels.

Role of angiotensin II type 1 receptor in the regulation of cellular adhesion molecules in atherosclerosis

BACKGROUND

Inflammation is a central feature of coronary artery disease (CAD) that is characterized by increased expression of cellular adhesion molecules with the exception of L-selectin. L-selectin is a leukocyte adhesion molecule that is rapidly shed after leukocyte activation so that it appears to be decreased in CAD. The renin-angiotensin system (RAS) is implicated in atherogenesis and up-regulates these molecules.

OBJECTIVES

The aim of this study was to investigate the effect of angiotensin type 1 (AT1) receptor antagonism on serum and leukocyte adhesion molecule expression in patients with CAD. Blood samples were collected from 31 patients before and after 8 weeks of treatment with losartan (44 +/- 2 mg/d, mean +/- SE), an AT1 receptor antagonist. We measured serum intercellular adhesion molecule-1, vascular cell adhesion molecule-1, endothelial-leukocyte adhesion molecule, and C-reactive protein (CRP). By flow cytometry, we also measured the expression of leukocyte CD11a, CD11b, CD11c, CD18, CD31, CD49d, and CD62L (L-selectin) in 13 patients.

RESULTS

Treatment with losartan decreased systolic blood pressure (141 +/- 3 vs 135 +/- 4 mm Hg, P =.04) and increased plasma renin activity (1.2 +/- 0.4 vs 2.7 +/- 0.5 ng/mL/h, P =.001). There was a significant increase in L-selectin expression on monocytes (86 +/- 6 vs 118 +/- 10 MESF units, P =.007), lymphocytes (52 +/- 10 vs 79 +/- 8, P =.01), and granulocytes (124 +/- 7 vs 156 +/- 18, P =.056). However, there were no changes in the other leukocyte and serum adhesion molecules or CRP.

CONCLUSIONS

These findings suggest that AT1 receptor antagonism selectively modulates L-selectin expression on leukocytes and that endogenous stimulation of AT1 receptors by the RAS contributes to the activation of leukocytes and decreased expression of L-selectin in CAD.

Non-lipid effects of statin on hypercholesterolemic patients established to have coronary artery disease who remained hypercholesterolemic while eating a step-II diet

BACKGROUND

Results of clinical trials of statin therapy demonstrate that an improvement in incidence of cardiovascular end points and coronary stenosis can be achieved. The beneficial effects of statins on clinical events may involve nonlipid mechanisms that affect endothelial function, such as inflammatory responses, formation of thrombi, and stabilization of plaque.

OBJECTIVE

To investigate levels of serologic markers, which may be useful surrogates for activity of vascular disease after administration of statin.

METHODS

We administered 20-40 mg simvastatin daily for 14 weeks to 13 patients established to have coronary artery disease who remained hypercholesterolemic during step-II diet therapy.

RESULTS

Administration of simvastatin significantly lowered lipoprotein levels and the low: high-density lipoprotein cholesterol level ratio and apolipoprotein B:A-I level ratio compared with pretreatment values (P < 0.01). Administration of simvastatin significantly lowered plasma levels of matrix metalloproteinase-9 (MMP-9) and monocyte chemoattractant protein-I [33+/-46 and 13+/-19%, respectively (P = 0.027 and 0.020, respectively)]. Furthermore, administration of simvastatin tended to lower plasma levels of plasminogen activator inhibitor type-1 and tumor necrosis factor-alpha [by 20+/-44 and 13+/-29%, respectively (P= 0.066 and 0.110, respectively)]. There were significant inverse correlations between pretreatment levels of MMP-9 and the degree of change in those levels after administration of simvastatin (r = -0.714, P= 0.005). However, there was no significant correlation between levels of lipoprotein and levels of MMP-9, monocyte chemoattractant protein-I, and plasminogen activator inhibitor type-1 during administration of simvastatin.

CONCLUSIONS

Our current data support the hypothesis that nonlipid mechanisms elicited by administration of simvastatin contribute to the decrease in incidence of cardiovascular events and explain the early clinical benefit observed in clinical trials, independent of changes in levels of lipoprotein.

STATT: a titrate-to-goal study of simvastatin in Asian patients with coronary heart disease. Simvastatin Treats Asians to Target

BACKGROUND

Most published studies on the use of lipid-lowering agents to treat hypercholesterolemia have focused on Western populations, with few data on Asian populations.

OBJECTIVE

The Simvastatin Treats Asians to Target (STATT) study used a titrate-to-goal protocol to evaluate the efficacy and tolerability of simvastatin 20 to 80 mg/d in the treatment of Asian patients with coronary heart disease.

METHODS

This was a multicenter, open-label, uncontrolled, 14-week study in patients with coronary heart disease and serum low-density lipoprotein cholesterol (LDL-C) levels of 115-180 mg/dL and triglyceride levels of < or = 400 mg/dL. The dose of simvastatin was titrated from 20 to 80 mg/d to achieve the National Cholesterol Education Program (NCEP) LDL-C target of < or = 100 mg/dL. The primary efficacy measure was the percentage of patients achieving the NCEP target. Among secondary measures were the percentage of patients achieving European Society of Cardiology/European Atherosclerosis Society/European Society of Hypertension target LDL-C levels of < or = 115 mg/dL and the percentage change from baseline in lipid parameters. Tolerability was assessed in terms of the overall incidence of adverse experiences and the incidences of the most commonly reported adverse experiences.

RESULTS

The intent-to-treat analysis included 133 Asian patients (93 men, 40 women; mean age, 59.5 years), of whom 125 completed 14 weeks of therapy. Their mean blood pressure was 130.2/79.4 mm Hg. Overall, 104 (78.2%) patients treated with simvastatin achieved LDL-C levels < or = 100 mg/dL at week 14, and 125 (94.0%) achieved this target at some point during the study. Similarly, 122 (91.7%) patients achieved an LDL-C level < or = 115 mg/dL at week 14, and 130 (97.7%) achieved this target at some point during the study. Treatment with simvastatin had favorable effects on the lipid profile, producing significant percentage changes from baseline in all parameters (P < 0.001). Simvastatin was well tolerated across the dose range. Overall, 40 patients (30.1%) had > or = 1 clinical adverse experience. Only 14 (10.5%) had adverse experiences that were possibly, probably, or definitely related to study drug; none of these experiences were considered serious. The most common adverse experiences (> or = 3% incidence) were abdominal pain (6%); chest pain (5%); dizziness (4%); and asthenia/fatigue, fibromyalgia, headache, insomnia, and upper respiratory tract infection (3% each). No new or unexpected adverse experiences were seen at the higher doses.

CONCLUSIONS

Simvastatin was effective and well tolerated at doses of 20, 40, and 80 mg/d in Asian patients with coronary heart disease. Titration enabled the majority to achieve target LDL-C levels of < or = 100 mg/dL.

Restless legs syndrome in an Asian population: A study in Singapore

In face-to-face interviews, we examined 157 consecutive individuals aged 55 years and older, selected from the general population in Singapore, and 1,000 consecutive individuals aged 21 years and older, from a primary healthcare center. Based on the IRLSSG criteria, the prevalence of restless leg syndrome (RLS) was 0.6% and 0.1%, respectively.

Vascular effects of synthetic or natural progestagen combined with conjugated equine estrogen in healthy postmenopausal women

BACKGROUND

Synthetic, not natural, progestagen may negate the favorable effects of estrogen. Nonetheless, observational studies report no differences in risk for clinical cardiovascular events between users of unopposed estrogen and users of estrogen combined with synthetic progestin.

METHODS AND RESULTS

In a double-blind study, we randomly assigned 20 healthy postmenopausal women to micronized progesterone (MP) 200 mg or medroxyprogesterone acetate (MPA) 10 mg for 10 days with conjugated equine estrogen (CEE) 0.625 mg for 25 days and the remaining 5 days off cyclically during 2 months, followed by crossover to the alternate therapy. CEE+MP and CEE+MPA significantly improved the percent flow-mediated dilator response to hyperemia relative to baseline measurements (P=0.004 by ANOVA) by a similar degree (P=0.863). Both therapies significantly decreased E-selectin, intercellular adhesion molecule (ICAM)-1, and vascular cell adhesion molecule (VCAM)-1 levels from baseline values (P<0.001, P=0.048, and P=0.016 by ANOVA, respectively) by a similar degree (P=0.977 for ICAM-1 and P=0.541 for VCAM-1, respectively). CEE+MPA decreased E-selectin levels more than CEE+MP did (P=0.040). Both therapies significantly decreased monocyte chemoattractant protein-1 levels from baseline values (P<0.005 by ANOVA) by a similar degree (P=0.194). Both therapies significantly decreased tissue factor antigen and increased tissue factor activity levels from baseline values (P=0.003 and P<0.001 by ANOVA, respectively) by a similar degree (P=0.652 for antigen and P=0.173 for activity). Both therapies significantly lowered plasma plasminogen activator inhibitor-1 levels from baseline values (P<0.001 by ANOVA) by a similar degree (P=0.533).

CONCLUSIONS

CEE+MP and CEE+MPA provide similar improvement in endothelium-dependent vasodilator responsiveness and effects on markers of inflammation, hemostasis, and fibrinolysis inhibition in healthy postmenopausal women.

Efficacy of heparin-coated stent in early setting of acute myocardial infarction

Primary stenting has been reported to be superior to balloon percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI) for recurrent ischemia, target lesion revascularization, and restenosis. However, concerns about early reocclusion or thrombosis after stenting in the very thrombotic environment of acute myocardial infarction still remain. Therefore, postprocedural short-term heparin or GpII(b)/III(a) receptor blockades has been used. The aim of our study was to evaluate the safety, feasibility, and long-term efficacy of heparin-coated stent in the early setting of AMI without postprocedural heparin or GpII(b)/III(a) receptor blockade infusion. We studied 102 consecutive patients presenting to cardiac catheterization laboratory < or = 6 hr from the onset of chest pain. No patients who were implanted with heparin-coated stents received heparin or GpII(b)/III(a) receptor blockade infusion after the procedures, not even patients who showed an angiographically large thrombus burden before stenting. Patients were evaluated for clinical endpoints at 30 days and 6 months. Coronary angiography was required for all patients at 2 weeks and 6 months after the procedure. Angiographic and procedural successes were 100% and 98%, respectively. Two patients (2%) died of heart failure without evidence of reocclusion of stented vessel during the hospitalization and 4 (4%) additional patients died of refractory heart failure within the first 6 months. Major bleeding complication occurred in one patient (1%). Recurrent myocardial infarction developed in one patient at 4 months. Early angiographic follow up at 2 weeks was performed in 88% of all patients, none of whom showed thrombotic stent occlusion. Six-month angiographic follow-up was completed in 71%(64/91) of eligible patients and binary restenosis was present in 17.2% of stented vessels. Eight(8%) patients underwent repeat PTCA. Cardiac event-free survival rate at 6 months was 86.3%. This study demonstrates that heparin-coated stents are safe in the early setting of acute myocardial infarction and no additional heparin infusion after stenting is necessary, which may reduce bleeding complications. Angiographic restenosis rate compares favorably to the binary restenosis rate from other studies with uncoated stents.

Variant angina with a strong spasmodic trait

A 55-year-old man came to the hospital because of chest pain, mostly occurring in the early morning at rest. He had to get isosorbide dinitrate intravenously with continuous infusion. Following ergonovine provocation test, total occlusion of mid-left anterior descending artery was identified with marked elevation of ST segment as exercise test showed despite isosorbide dinitrate.

Effects of HMG-CoA reductase inhibitor on hemostasis

Clinical trials of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) therapy have demonstrated improvement in coronary atherosclerosis progression and reduction in risk of cardiovascular events. However, improvement in cardiovascular end-points is incompletely explained by the baseline or treated LDL cholesterol level. The beneficial effects of statins on clinical events may involve nonlipid mechanisms that modify hemostasis. Local activation of platelets and thrombus formation adjacent to atheromatous plaques, especially where ruptured or eroded, are now recognized to be of pathophysiological importance in the acute and chronic clinical expression of coronary heart disease. Thus, favorable effects of statins on hemostasis may be relevant to decreasing or delaying the progression and clinical manifestations of atherosclerosis.

Effects of statins on vascular wall: vasomotor function, inflammation, and plaque stability

Clinical trials of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors or statin therapy demonstrate an improvement in cardiovascular end points and coronary stenosis. However, an improvement in cardiovascular end points and coronary stenosis is incompletely explained by the baseline or treated LDL cholesterol level. The beneficial effects of statins on clinical events may involve nonlipid mechanisms that modify endothelial function, smooth muscle cells, and monocyte-macrophage: vasomotor function, inflammatory responses, and plaque stability. Augmented bioactivity of NO by statin therapy either indirectly by its effect on lipoprotein levels and protection of LDL from oxidation, or directly by effects on NO synthesis and release, might account for enhancement of endothelium-dependent vasodilation. Recent experimental and animal studies have demonstrated that statins dose-dependently decrease smooth muscle cells migration and proliferation, independently of their ability to reduce plasma cholesterol. Moreover, statins are able to reduce the in vitro cholesterol accumulation in macrophages and expression of matrix metalloproteinase, resulting in plaque stability. These effects of statins were completely prevented by the addition of mevalonate and partially by all-trans farnesol and all-trans geranylgeraniol, confirming the specific role of isoprenoid metabolites, probably through prenylated proteins, in regulating these cellular events. Statins have been shown to prevent the activation of monocytes into macrophages, inhibit the production of pro-inflammatory cytokines, C-reactive protein, and cellular adhesion molecules. Statins decrease the adhesion of monocyte to endothelial cells. Accordingly, statins exert their cardiovascular benefits through a direct antiatherogenic properties in the arterial wall, beyond their effects on plasma lipids.

Vascular effects of estrogen and vitamin E therapies in postmenopausal women

BACKGROUND

Estrogen and vitamin E therapies have been suggested to reduce cardiovascular risk, but comparison of the vascular effects of these therapies to determine mechanisms of potential benefit has not been performed in postmenopausal women.

METHODS AND RESULTS

In a double-blind, 3-period crossover study, we randomly assigned 28 healthy postmenopausal women to conjugated equine estrogens (CE) 0. 625 mg/d, vitamin E 800 IU/d, and their combination, with measurements made before and after each 6-week treatment period. The ratio of LDL to HDL cholesterol and lipoprotein(a) decreased on therapies including CE but increased on vitamin E alone (P<0.001 and P=0.002, respectively, by ANOVA). Brachial artery flow-mediated dilation improved on all therapies (all P<0.001 versus pretreatment values) and to a similar degree (P=0.267 by ANOVA). No therapy improved the dilator response to nitroglycerin. CE lowered serum levels of cell adhesion molecules E-selectin, ICAM-1, and VCAM-1 (all P<0.05 versus pretreatment values). Vitamin E had no significant effect on levels of these markers of inflammation (P<0. 001 by ANOVA for E-selectin). CE alone or combined with vitamin E but not vitamin E alone lowered or showed a trend for lowering plasma levels of plasminogen activator inhibitor type-1 (P=0.069 by ANOVA).

CONCLUSIONS

Estrogen and vitamin E therapies similarly improved arterial endothelium-dependent vasodilator responsiveness consistent with increased nitric oxide in healthy postmenopausal women, despite divergent effects on atherogenic lipoproteins. However, only estrogen reduced markers of vascular disease.

Primary and elective stenting of unprotected isolated left main coronary ostial stenosis in acute coronary syndrome

Direct surgical angioplasty or coronary artery bypass graft has been done in patients who have left main coronary ostial stenosis. Recent reports have demonstrated that stenting of unprotected left main coronary artery stenosis has been attempted as an alternative to bypass surgery in selected patients with normal LV function. We report two patients with isolated left main coronary ostial stenosis who are undergoing primary and elective stenting, respectively. Major cardiac events did not occur during a 3-month follow-up. This study suggests that stenting of isolated left main coronary ostial stenosis in acute coronary syndrome is feasible and results in excellent outcomes.

Implications for atypical antioxidative properties of manganese in iron-induced brain lipid peroxidation and copper-dependent low density lipoprotein conjugation

Our group recently observed that manganese prevents oxidative brain injury in the iron-induced parkinsonian animal model. It has also been suggested that manganese retards while copper promotes the development of atherosclerosis. In this report, we provide further evidence to support a controversial notion that manganese is an atypical antioxidant. Among transition metals, Cu2+ and Fe2+ (0.1 to 125 microM), but not Mn2+, converted hydrogen peroxide to reactive hydroxyl radicals via the Fenton reaction at pH 7.4. Iron's pro-oxidative rate is relatively slow, but it is accelerated further by ascorbate (50 microM) in 37 degrees C Dulbecco's phosphate buffered saline. Moreover, Mn2+ (0-80 microM) concentration dependently retarded diene conjugation of human low density lipoproteins stimulated by 5 microM Cu2+. This new result is consistent with our recent finding that Mn2+ (0 to 20 microM) does not initiate brain lipid peroxidation while it inhibits iron-induced peroxidation of polyunsaturated fatty acids. These unexpected manganese results are somewhat at odds with a prominent theory that manganese is a prooxidative transition metal. Furthermore, iron and copper induced free radical generation and lipid peroxidation are suppressed by lowering the incubation temperature; this suggests that hypothermia may decrease the oxidative stress and damage in vivo. In conclusion, normal dietary intake of manganese may protect cells and neurons from oxidant stress through the inhibition of propagation of lipid peroxidation caused by hydroxyl radicals generated by pro-oxidative transition metals such as iron and copper. Potential therapeutical uses of manganese, manganese SOD mimetics and hypothermia for protecting brain neurons and vascular endothelial cells against oxidative stress and damage have been successfully demonstrated in both animal models and clinical trials.

Relation of fibrinolytic potentiation by estrogen to coagulation pathway activation in postmenopausal women

To determine whether enhanced fibrinolysis is a primary effect of estrogen or is secondary to activation of coagulation, we measured hemostatic factors before and after conjugated equine estrogen 0.625 mg/day for 1 month in 9 postmenopausal women. We found that potentiation of fibrinolysis is a primary effect of conjugated equine estrogens at this commonly used dosage in healthy postmenopausal women.

Mechanism by which quinapril improves vascular function in coronary artery disease

Angiotensin-converting enzyme (ACE) inhibition has been shown to improve endothelium-dependent vasodilator responsiveness, but the contribution and mechanism of enhanced nitric oxide (NO) bioactivity to this effect in patients with coronary artery disease are unknown. We investigated the effect of ACE inhibition on brachial artery dilator responsiveness to increased shear stress after forearm ischemia by ultrasonography as a bioassay for endothelial NO available to vascular smooth muscle in 9 men with coronary artery disease. Serum nitrogen oxides were measured after 3 days of nitrate-restricted diet as an index of endothelial NO release. Patients received quinapril 20 to 40 mg/day for 8 weeks. Relative to pretreatment measurements, quinapril increased flow-mediated dilation (from 2.4+/-0.4 to 10.8+/-2.2, p <0.001), with significant improvement persisting 1 week after discontinuation of therapy (6.7+/-2.5%, p <0.01). However, quinapril decreased serum nitrogen oxide levels by 19+/-17% compared with pretreatment values (from 58.2+/-19.0 to 46.0+/-13.3 micromol/L, p <0.01). Thus, ACE inhibitor therapy with quinapril selectively improves endothelium-dependent vasodilator responsiveness by increased NO bioactivity in relation to vascular smooth muscle in patients with coronary artery disease, an effect achieved at a lower rate of NO release from the endothelium. These findings suggest that ACE inhibitors may reduce angiotensin II-induced oxidant stress within the vessel wall and protect NO from oxidative inactivation. This effect may reduce endothelial NO synthesis required for vasomotor regulation.

Vascular effects of estrogen and cholesterol-lowering therapies in hypercholesterolemic postmenopausal women

BACKGROUND

Lipoproteins affect endothelium-dependent vasomotor responsiveness. Because lipoprotein effects of estrogen and cholesterol-lowering therapies differ, we studied the vascular responses to these therapies in hypercholesterolemic postmenopausal women.

METHODS AND RESULTS

We randomly assigned 28 women to conjugated equine estrogen (CE) 0.625 mg, simvastatin 10 mg, and their combination daily for 6 weeks. Compared with respective baseline values, simvastatin alone and combined with CE reduced LDL cholesterol to a greater extent than CE alone (both P<0.05). CE alone and combined with simvastatin raised HDL cholesterol and lowered lipoprotein(a) to a greater extent than simvastatin alone (all P<0.05). Flow-mediated dilation of the brachial artery (by ultrasonography) improved (all P<0.001 versus baseline values) on CE (4.0+/-2.6% to 10.2+/-3.9%), simvastatin (4.3+/-2.4% to 10.0+/-3.9%), and CE combined with simvastatin (4.6+/-2.0% to 9.8+/-2.6%), but similarly among therapies (P=0.507 by ANOVA). None of the therapies improved the dilator response to nitroglycerin (all P>/=0.184). Only therapies including CE lowered levels of plasminogen activator inhibitor type 1 and the cell adhesion molecule E-selectin (all P<0. 05 versus simvastatin).

CONCLUSIONS

Although estrogen and statin therapies have differing effects on lipoprotein levels, specific improvement in endothelium-dependent vasodilator responsiveness is similar. However, only therapies including estrogen improved markers of fibrinolysis and vascular inflammation. Thus, estrogen therapy appears to have unique properties that may benefit the vasculature of hypercholesterolemic postmenopausal women, even if they are already on cholesterol-lowering therapy.

Recurrent restenosis following stent and rotational atherectomy of coronary artery stenosis in Takayasu's arteritis

We report a patient with Takayasu's arteritis who had recurrent restenosis following intracoronary bifurcation stenting of proximal left anterior descending and first diagonal arteries, and rotational atherectomy for in-stent restenosis. After all, the patient underwent coronary artery bypass grafts (CABG) and has remained asymptomatic during 3 months without damaging myocardium. We suggest that endoluminal stenting or rotational atherectomy may be an alternative treatment for the patients with coronary artery stenosis due to active Takayasu's arteritis as a therapy to postpone CABG.

Effects of hormone therapy on inflammatory cell adhesion molecules in postmenopausal healthy women

To investigate the effect of estrogen with antioxidant potential on soluble markers of chronic vascular inflammation, we administered either transdermal 17beta-estradiol 0.1 mg/day (9 women) or 17beta-estradiol 0.1 mg and medroxyprogesterone acetate 2.5 mg/day (11 women) for 1-month treatment in a randomized design, with measurement of cell adhesion molecules. Hormone therapy significantly lowered intercellular adhesion molecules-1 levels by 8% (p = 0.009) and tended to lower E-selectin levels (by 6%, p = 0.096), and VCAM-1 levels (by 4%, p = 0.084).

New scoring system using tumor markers in diagnosing patients with moderate pericardial effusions

We performed diagnostic and therapeutic pericardiostomy with drainage and biopsy in 51 patients with moderate to large pericardial effusions of different etiologies from August 1991 to July 1995. Patients were divided into 4 groups (group 1, tuberculous pericarditis; group 2, suspected tuberculous pericarditis; group 3, acute pericarditis; group 4, malignancy). The pericardial fluid adenosine deaminase level in tuberculosis (87 +/- 10 U/l) was significantly higher than that in malignancy or acute pericarditis (21 +/- 4 U/l, 23 +/- 7 U/l, respectively) (P = 0.0001). The mean pericardial fluid carcinoembryonic antigen level (1.8 +/- 0.3 ng/ml) in benign disease was significantly lower than that (170.7 +/- 46.4 ng/ml) in malignant disease (P = 0.0001). Follow-up study has been done. With a new scoring system (each score 1 for adenosine deaminase > or = 40 U/l, or carcinoembryonic antigen < or = 5 ng/ml) in 25 patients since November 1993, we could diagnose 5 among 7 patients (71%) with tuberculosis, 11 among 13 patients (85%) with malignancy (adenosine deaminase < or = 40 U/l, or carcinoembryonic antigen > or = 5 ng/ml) and 5 among 5 patients (100%) with acute pericarditis (adenosine deaminase < or = 40 U/l, or carcinoembryonic antigen < or = 5 ng/ml), respectively. Our long-term follow-up study suggests that with the new scoring system we can decrease complications or avoid unnecessary procedures or treatments of patients.

Effects of hormone-replacement therapy on fibrinolysis in postmenopausal women

BACKGROUND

Plasma levels of plasminogen-activator inhibitor type 1 (PAI-1), an essential inhibitor of fibrinolysis in humans, increase in women after menopause, and this may contribute to the risk of cardiovascular disease. We studied the effects of hormone-replacement therapy on PAI-1 levels.

METHODS

In a randomized, crossover study, we investigated the effects of oral conjugated estrogen (0.625 mg per day) in 30 postmenopausal women and transdermal estradiol (0.1 mg per day) in 20 postmenopausal women, either alone or in combination with medroxyprogesterone acetate (2.5 mg daily) for one month, on plasma PAI-1 antigen levels. Degradation products of cross-linked fibrin (D-dimer) were measured in serum as an index of fibrinolysis.

RESULTS

PAI-1 levels were inversely associated with D-dimer levels at base line (r= -0.540, P=0.002). Conjugated estrogen, both alone and in combination with medroxyprogesterone acetate, reduced mean (+/-SD) plasma levels of PAI-1 from 32+/-34 ng per milliliter to 14+/-10 ng per milliliter (P<0.001) and from 31+/-29 ng per milliliter to 15+/-11 ng per milliliter (P=0.003), respectively; there was a significant inverse correlation between pretreatment PAI-1 levels and the degree of reduction in these levels during therapy (r= -0.631, P<0.001 for conjugated estrogen; r = -0.507, P=0.004 for combined therapy). The degree of reduction in PAI-1 levels was associated with increases in D-dimer levels both when conjugated estrogen was given alone (r= -0.572, P=0.001) and when combined hormone therapy was given (r= -0.541, P=0.002). Transdermal estradiol caused no significant changes in PAI-1 levels from base-line values.

CONCLUSIONS

Conjugated estrogen, alone or combined with progestin therapy, reduced PAI-1 levels by approximately 50 percent in postmenopausal women and was associated with enhanced systemic fibrinolysis. These findings may partly explain the protective effect of hormone-replacement therapy with respect to coronary artery disease.

Comparison of clinical and laboratory findings between patients with diffuse three-vessel coronary artery spasm and other types of coronary artery spasm

Our purpose was to compare patients with diffuse three-vessel coronary artery spasm and other types of coronary artery spasm without significant organic stenosis, and to elucidate clinical characteristics and risk factors. Patients were divided into two groups: group I consisted of 26 patients showing other types of coronary artery spasm; group II consisted of 5 patients with diffuse three-vessel coronary artery spasm. The mean age of patients in groups I and II was 52 and 50 years, respectively. The incidence of variant angina was higher in men than in women. The incidence of smoking was high in each group, but not significantly different. Exercise tests showed no significant differences between groups. All mean values of laboratory data, including lipoprotein (a) and low-density lipoprotein cholesterol in the two groups, were within normal ranges. There was no significant difference between groups. The incidence of spontaneous spam was much higher in patients with diffuse three-vessel coronary artery spasm (P < 0.01). Electrocardiographic (ECG) findings before the spasm were almost normal. All 5 patients with diffuse three-vessel coronary artery spasm demonstrated no important ST segment changes with episodes of angina during a coronary angiography on 12-lead ECG, compared to patients with other types of coronary artery spasm (P < 0.01). First, we conclude, diffuse three-vessel coronary artery spasm mostly occurs spontaneously. Second, we emphasize that diffuse three-vessel coronary artery spasm must be considered when 12-lead ECG shows no important ST segment changes with episodes of angina. Third, it is not easy to distinguish diffuse three-vessel coronary artery spasm from other types of coronary artery spasm on the basis of history, laboratory data, or electrocardiographic findings, including exercise tests.

Comparative study of efficacy and safety of low-dose diltiazem or betaxolol in combination with digoxin to control ventricular rate in chronic atrial fibrillation: randomized crossover study

BACKGROUND

The combination therapy of low-dose diltiazem or bexatolol with digoxin can be a useful adjunct for achieving heart rate control with minimal side effects. But there has not been a study including patients with impaired left ventricular function and evaluating whether the beneficial effects of medication will be maintained during a follow-up period.

OBJECTIVES

The purpose of this study was three-fold: (1) to compare the efficacy of digoxin with low-dose diltiazem and digoxin with low-dose betaxolol on randomized crossover study; (2) to evaluate whether the beneficial effects of medication will be maintained after 7 months; (3) to evaluate the safety of the combination therapy in patients with impaired left ventricular function.

METHODS

We did a prospective randomized crossover study in 35 patients with chronic atrial fibrillation (AF) including 15 patients with left ventricular dysfunction. After enrollment, each patient was evaluated for heart rate, blood pressure, rate-pressure products, maximal exercise tolerance at rest and during symptom-limited treadmill test before medication, at 4 weeks after medication of digoxin (0.125-0.5 mg daily) with diltiazem (90 mg twice daily), and at 4 weeks after digoxin with betaxolol (20 mg once daily). We performed 24-h ambulatory electrocardiogram (ECG) in 15 patients at the end of each phase of treatment. We repeated symptom-limited treadmill test like above method in 15 patients at 7 months of medication.

RESULTS

(1) Ventricular rates were significantly reduced in digoxin with low-dose betaxolol therapy at rest and during exercise (67 +/- 3, 135 +/- 5 (mean +/- S.E.M.) beats/min, respectively) in comparison to digoxin with low-dose diltiazem therapy (80 +/- 7, 154 +/- 5) (P < 0.05). (2) Rate-pressure products were significantly less in digoxin with low-dose betaxolol at rest and during exercise (85 +/- 4, 213 +/- 12 x 10(2) mmHg/min) than in digoxin with low-dose diltiazem therapy (105 +/- 6, 269 +/- 12) (P < 0.05). (3) Exercise capacity was significantly improved in digoxin with low-dose betaxolol (9.3 +/- 0.5 METS) or digoxin with low-dose diltiazem (9.7 +/- 0.5) in comparison to control state (8.3 +/- 0.5) (P < 0.05). (4) At 7 months evaluation, there was no significant difference between at 4 weeks and at 7 months. (5) Results on 24-h ambulatory ECG showed the same findings as on treadmill test. (6) Although side effects occurred more frequently in digoxin with low-dose betaxolol therapy, they were minimal and no patient had to withdraw medication. Worsening of left ventricular dysfunction was not observed.

CONCLUSION

Our study suggested that (1) combination therapy of low-dose betaxolol with digoxin was more superior to low-dose diltiazem with digoxin in controlling ventricular rate and reducing rate-pressure products; (2) the effects controlling ventricular rate, reducing rate-pressure products and improving exercise capacity have been well maintained even after 7 months of medication with each combination therapy.

Interaction of intravenous heparin and organic nitrates in acute ischemic syndromes

We evaluated whether a drug interaction between intravenous nitroglycerin or isosorbide dinitrate and heparin exists. Ninety-six patients with a diagnosis of acute myocardial infarction, unstable angina, or other thromboembolic disorders were divided into 3 groups: group I (control group, n = 35) received intravenous heparin alone; group II (n = 31) received combined intravenous nitroglycerin and heparin; and group III (n = 30) received combined intravenous isosorbide dinitrate and heparin. We determined the mean of 2 separate measurements of heparin dosage requirement, antithrombin III activity, and the dose of intravenous nitroglycerin or isosorbide dinitrate at the time that the ratio of activated partial thromboplastin time (aPTT) to baseline aPTT was 1.5 to 2.0. The mean therapeutic heparin dose standardized to total body weight of each group was 13.8, 15.4, and 15.5 U/kg/hour, respectively. At that time, patients were receiving intravenous nitroglycerin at doses of 58.8 +/- 38.6 micrograms/min or intravenous isosorbide dinitrate at doses of 3.7 +/- 2.0 mg/hour. The mean antithrombin III activity of each group was 22.2, 22.8, and 21.3 mg/dl, respectively. The overall results for groups I, II, and III, and results for the subgroup of patients with acute ischemic syndromes in those groups, did not differ significantly. The heparin dose did not show a significant correlation to the dose of intravenous nitroglycerin (r = -0.26, p > 0.05) nor to that of isosorbide dinitrate (r = 0.30, p > 0.05).

Does prevalence of migraine and Raynaud's phenomenon also increase in Korean patients with proven variant angina?

BACKGROUND

The incidence of coronary artery spasm in oriental patients is higher than that in western patients. Oriental patients with variant angina (VA) frequently show normal or insignificant coronary artery stenosis by angiogram, compared with western patients. The prevalence of migraine and Raynaud's phenomenon in oriental patients with VA has not yet reported.

OBJECTIVE

We did a prospective study on the prevalence of migraine and Raynaud's phenomenon in patients with proven VA compared with those in two control groups using a radioisotope technique following ice water exposure. Simultaneously, we studied lipid profiles of each group.

METHODS AND RESULTS

migraine was diagnosed if the score in part A totalled 7 or more of 26, and Raynaud's phenomenon was diagnosed if the score in part B totalled 4 or more of 11 by Miller et al. Technetium-99m-labeled red blood cells (99mTc-RBC) radionuclide angiography was performed in all patients. Patients were included in a prospective protocol. Patients were grouped as follows: Group I: 20 patients with proven VA; Group II: 30 patients with coronary artery disease; Group III: 31 patients without heart disease. Age and sex of patients were not statistically different among the three groups. Migraine was diagnosed in 8 patients (40.0%) of group I and in 6 patients (20.0%) of group II and in 12 patients (38.7%) of group III. Raynaud's phenomenon was reported in 2 (10.0%) of the patients in group I and in 5 (16.1%) of the patients of group III. The mean index ratio of the digital blood flow of right over left hand on static image was 0.85 +/- 0.07 (mean +/- S.E.M.) of the patients of group I, 0.73 +/- 0.03 of the patients of group II and 0.74 +/- 0.04 of the patients of group III. The mean flow index ratio of right over left hand of the digital blood flow on dynamic study was 0.51 of the patients of group I, 0.43 of the patients of group II and 0.43 of the patients of group III. The score of migraine did not differ significantly among the three groups. The score of Raynaud's phenomenon of patients with variant angina did not differ significantly from that of patients in the non-coronary control group, although it differed significantly from that of patients in the coronary control group. But, the prevalence of migraine and Raynaud's phenomenon (questionnaire and radionuclide angiography) in patients of group I did not differ significantly from that in groups II and III. In the end, more patients with variant angina than coronary or non-coronary control group did not reach the predetermined point level for the diagnosis of migraine and Raynaud's phenomenon. Lipid profiles were not significantly different among three groups.

CONCLUSIONS

This result suggests that variant angina may not be a manifestation of a generalized vasospastic disorder in Korean patients.

Association of lipoprotein levels with atherosclerotic changes in patients with coronary artery spasm and insignificant coronary artery stenosis

BACKGROUND

Coronary artery spasm readily occurs at sites of atheromatous plaque. Some lipid profiles are related to the genesis of coronary artery spasm. In Korean patients, it is frequently observed in grossly normal coronary arteries, in contrast to the situation in western patients, who frequently have coronary artery spasm superimposed on significant coronary artery stenosis. Intravascular ultrasound examination has shown that mild or diffuse atherosclerotic changes in patients with focal vasospasm, even in the absence of angiographic coronary disease.

OBJECTIVES

We studied prospectively 104 patients in order to find out which lipid profiles were associated with atherosclerotic changes in patients with coronary artery spasm.

METHODS

Patients were grouped as follows: group I, control, 50 patients (34 men, 16 women); group II, 35 patients (26 men, 9 women) with significant coronary artery disease; group III, 19 patients (13 men, six women) with significant coronary artery spasm and either no coronary artery stenosis or insignificant stenosis. There was no significant difference in age (group I 55 +/- 1 years, group II 56 +/- 2 years, group III 54 +/- 2 years) or sex among the groups. The following parameters were evaluated: hypertension, cigarette smoking, diabetes mellitus, and lipid profile.

RESULTS

The incidence of hypertension in group II patients was higher than in group I or III (P < 0.05). No significant difference was found in the percentage of cigarette smokers and patients with diabetes mellitus among three groups. The lipid profiles of each group were analysed. Group II patients had higher lipoprotein (a) levels (39 +/- 6 mg/dl) than those in group I (21 +/- 3 mg/dl) or group III (13 +/- 3 mg/dl) (P < 0.05). Other lipid profiles were not significantly different among the groups.

CONCLUSION

Our results indicate that the atherosclerotic changes in the coronary arteries of group III patients were not associated with lipid profiles, including lipoprotein (a).

Ruptured aneurysm of the sinus of Valsalva in a patient with Behçet's disease

The vast majority of sinus of Valsalva aneurysm originated from a localized congenital defect of the aortic media and less frequently from infections or degenerative processes affecting the aortic wall. But aneurysm of sinus of Valsalva has not been reported up to the present in a patient with Behçet's disease. We report a 39-year-old woman presenting ruptured aneurysm of the sinus of Valsalva and Behçet's disease.

Torsade de pointes induced by terfenadine in a patient with long QT syndrome

Torsade de pointes is a form of polymorphic ventricular tachycardia that is associated with prolongation of the QT interval. Although torsade de pointes is found in many clinical settings, it is mostly drug induced. Similar problems have been described with nonsedating H1-receptor antagonists, such as astemizole and terfenadine. Terfenadine is a widely used antihistamine. The authors report a case of torsade de pointes in a patient with a possible congenital sporadic form of QT interval prolongation who was receiving a therapeutic dose of terfenadine.

Pulmonary artery aneurysm associated with hereditary hemorrhagic telangiectasia

A patient with typical features of hereditary hemorrhagic telangiectasia was found to have massive dilatation and tortuosity of the main, right and left pulmonary artery with pulmonary hypertension. Pulmonary artery aneurysm with pulmonary hypertension has not been previously noted in patients with hereditary hemorrhagic telangiectasia. We report a 64-year-old woman showing this feature.

Adenosine deaminase and carcinoembryonic antigen in pericardial effusion diagnosis, especially in suspected tuberculous pericarditis

BACKGROUND

Adenosine deaminase (ADA) and carcinoembryonic antigen (CEA) have been measured in pleural fluid to help distinguish malignant from benign effusions, especially in tuberculous pleurisy. We investigated ADA and CEA levels in patients with moderate to large pericardial effusions of different etiologies.

METHODS AND RESULTS

We performed diagnostic and therapeutic pericardiostomy with drainage and biopsy. We measured ADA and CEA levels in the pericardial fluid in 26 patients with moderate to large pericardial effusion and 19 control patients. Patients were included in a prospective protocol from August 1991 to August 1993. Patients were grouped as follows: group 1, 9 patients with tuberculous pericarditis (TP) confirmed by bacteriologic culture or histology of pericardial biopsy; group 2, 5 patients with clinically strongly suspected TP; group 3, 12 patients with malignancy (8) and acute pericarditis (4); group 4, 19 control patients without pericardial disease. We treated patients with TP with isoniazid, rifampin, and either streptomycin or ethambutol for 12 months and pyrazinamide for 2 months. We observed for symptoms and signs of recurrent pericarditis or constrictive pericarditis on follow-up. In group 1 the ADA activity was significantly higher (101 +/- 14 U/L) than that in group 3 (22 +/- 5 U/L) or that in group 4 (17 +/- 2 U/L) (P < .05). There was no significant difference between ADA activity in group 1 (101 +/- 14 U/L) and that in group 2 (100 +/- 26 U/L). With a cutoff value for ADA activity of 40 U/L, sensitivity was 93% and specificity 97% in the diagnosis of TP. In benign diseases, the CEA level was significantly lower (1.0 +/- 0.3 ng/mL) than that in malignant diseases (135.1 +/- 79.7 ng/mL) (P < .05). With a cutoff value for CEA level of 5 ng/mL, sensitivity was 75% and specificity 100% in the diagnosis of malignant pericarditis. Follow-up study (mean, 12.9, 19.8, and 11.8 months in groups 1, 2, and 3, respectively, showed no symptoms or signs of constrictive pericarditis, except for 1 patient.

CONCLUSIONS

Pericardial fluid ADA and CEA are useful for the differential diagnosis of pericardial effusion of various causes. They also have great value in early diagnosis of TP, particularly when the results of other clinical and laboratory tests are negative.

Variant angina complicating ergot therapy of migraine

A 55-year-old man demonstrated typical reflux esophagitis, not esophageal spasm, by esophageal manometry, although he demonstrated classic migraine, positive Raynaud's scan, and proven coronary artery spasm. He suffered from severe chest pain by medication of ergotamine tartrate. Ergot alkaloids should be avoided in patients with symptomatic coronary artery spasm.

Isolated left main coronary ostial stenosis: intraoperative transesophageal echocardiography during surgical angioplasty

OBJECTIVE

We hypothesized that transesophageal echocardiography could be used to image the repair of a left ostium or main coronary artery following surgical angioplasty.

METHODS AND RESULTS

Six patients, all women, were found to have isolated left main coronary ostial stenosis. We performed preoperative transesophageal echocardiography (TEE) in three and intraoperative TEE in four of six patients. Their mean age was 48 years. They presented with severe angina (Class III or IV) with a short duration (6.8 +/- 7.8 months). They had a low incidence of risk factors while histopathologic examinations showed typical atherosclerosis in all four patients. Preoperative two-dimensional echocardiography demonstrated left main coronary ostial stenosis in three patients. We clearly observed the patency of the pericardial or saphenous venous patch with basal short-axis scan on two-dimensional and color Doppler echocardiography in all four patients after weaning them from cardiopulmonary bypass and finished operation without complications.

CONCLUSIONS

Our study shows that TEE can be used to image the repair of a left ostium or main coronary artery following surgical angioplasty and provide the surgeon with the required information about the adequacy of the repair.

Left and right coronary artery to left ventricular fistula: demonstration of myocardial ischemia by treadmill test and Holter monitoring--a case report

Fistulous communication from the coronary artery to the left ventricle is extremely rare. The authors report such a case in a sixty-year-old woman with chest pain. They demonstrated myocardial ischemia on treadmill test and Holter monitoring in this patient.

Coronary vasospasm, multiple coronary thrombosis, unstable angina and essential thrombocytosis

Rarely, essential thrombocythemia has led to coronary artery occlusion. Only one patient has been described, in whom coronary angiography demonstrated multiple coronary thrombosis. We report a case of coronary vasospasm, multiple coronary thrombosis involving right and left coronary artery and possibly leading to myocardial infarction and unstable angina pectoris in a woman with migraine, Raynaud's phenomenon, and essential thrombocytosis.

Isolated left main coronary ostial stenosis in Oriental people: operative, histopathologic and clinical findings in six patients

OBJECTIVES

This study was performed to determine whether there are differences in the operative, histopathologic, angiographic and clinical findings of isolated ostial stenosis between Oriental and western patients.

BACKGROUND

Angiographic, clinical and histologic findings in isolated ostial stenosis have been reported in western but not in Oriental patients.

METHODS

Six patients, all women (0.88% of a total of 684 patients who underwent coronary angiography between March 1989 and July 1991), were found to have isolated left main coronary ostial stenosis. We performed surgical ostial angioplasty with the autologous pericardial or saphenous venous patch and biopsy at the aortic arteriotomy site in four of the six patients.

RESULTS

All six patients presented with severe angina (angina class III or IV) of short duration (mean +/- SD 6.2 +/- 6.2 months) and had a very low incidence of risk factors, although histopathologic examination showed typical atherosclerosis in four of the six patients. They were young to middle-aged women (mean 45 +/- 3 years) except for Patient 6 (62 years). Exercise duration was short and ST segment depression, accompanied by typical angina, was observed in many leads in the warm-up period or stage I. Despite the crucial location of the lesion, most patients had well preserved left ventricular function and normal wall motion. There was no angiographically definable collateral circulation from either ipsilateral or contralateral vessels except for grade I collateral circulation in Patient 5. Operative findings demonstrated mostly yellow atheroma in the aortic wall and left coronary ostium. Coronary angiography showed only ostial stenosis of the left coronary artery in all six patients, but operative findings documented atheromatous change in the left main coronary artery in two of the six.

CONCLUSIONS

The clinical, angiographic, histopathologic and operative findings of Oriental patients were similar to those reported in western patients, but the incidence of isolated left main coronary ostial stenosis was higher in the Oriental group. Angiographically definable isolated coronary ostial stenosis may often not be true isolated ostial stenosis.

Various 12-lead electrocardiographic findings of diffuse three-vessel coronary artery spasm

Electrocardiographic signs of diffuse three-vessel coronary artery spasm may show various findings including no ST segment changes, according to whether or not a difference of an electrical gradient develops between the anterior and inferior regions because of global ischemia. This study suggests that diffuse three-vessel coronary artery spasm must be considered when the 12-lead electrocardiogram (ECG) shows no important ST segment changes with episodes of angina and diffuse coronary artery spasm during an ergonovine provocation test in patients with strongly suspected variant angina.

Infective endocarditis in a patient with Williams' syndrome--case report

An 18-year-old male was admitted to Seoul National University Hospital for the evaluation of fever and chill on February 3, 1988.

On physical examination, his face showed a characteristic “elfin” facial appearance. His face was characterized by abnormalities of dental development, a broad overhanging upper lip, high arched palate and gum hypertrophy. He also showed mental retardation.

Cardiac catheterization with selective cineangiocardiography demonstrated a supravalvular aortic narrowing, grade 2 aortic insufficiency, and moderately dilated proximal coronary arteries with normal distribution without an intraluminal narrowing. There was a systolic pressure gradient (55mmHg) between the aortic root and ascending aorta distal to a stenotic segment.

MRI showed a supravalvular aortic stenosis.

Vegetation was not found on echocardiograpghy. Unidentified G(−) rods were isolated in 3 out of 9 bottles in blood culture test.

He was treated with Na-penicillin and gentamicin for 28 days.