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￭ Sun-137 ￭
ST segment elevation myocardial infarction by coronary embolism in prosthetic valve thrombosis
경상대학교병원
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유수지, 강민규
Introduction: Coronary embolism can lead to fatal acute myocardial infarction, requiring emergent medical intervention. The incidence of systemic embo- lization in patients with prosthetic valves who are on anticoagulants is 1% per patient year and few cases of coronary embolism with prosthetic valve thrombosis are reported. Case Report: A 75-year-old male patient with a history of rheumatic heart disease and mitral and aortic valve replacement 20 years earlier was referred. The patient was complaining of chest pain and the electrocardiogram showed atrial fibrillation with ST segment elevation in leads aVR and V2 to V4. The patient was immediately referred for primary percutaneous coronary intervention. Coronary angiography revealed that the left circumflex artery was totally occluded and the other epicardial coronary arteries had little atherosclerotic stenosis (Figure 1-A). Intracoronary glyco- protein IIb/IIIa was administered and aspiration thrombectomy removed large amount of thrombus. After aspiration thrombectomy without stenting, the pa- tient achieved relief from chest pain, complete resolution of ST segment elevation, and recovery of coronary flow. Transthoracic echocardiography revealed limited motion of the prosthetic mitral valve with increased pressure gradient (mean 8 mmHg, peak velocity 2.5 cm per second). Transesophageal echo- cardiography showed a small echodense mass suggesting prosthetic mitral valve thrombosis (Figure 1-B). After 3 months with maintaining of intensive an- ti-thrombotic therapy including aspirin, clopidogrel, and warfarin, a follow-up coronary angiography showed normal coronary flow and a redo of mitral and aortic valve replacement was performed without cardiovascular adverse events. Discussion:In this case, restoration of coronary flow was achieved through aspiration thrombectomy with intensive anti-thrombotic treatment. The etiology was determined as prosthetic mitral valve thrombosis in atrial fibrillation.
Physicians should watch for risk of coronary embolism and preventive anticoagulation theray with optimal therapeutic window is required in high risk pa- tients of systemic embolization.
￭ Sun-138 ￭
Homeostatic model assessment insulin resistance: a predictor of CAD in asymptomatic DM patients
가톨릭의대 서울성모병원
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승재호
Background/Aims: Insulin resistance (IR) is an important risk factor for cardiovascular disease. Using coronary CT angiography (CCTA), we evaluated the association between coronary artery disease (CAD) and homeostatic model assessment insulin resistance (HOMA-IR) in asymptomatic diabetic patients. Methods: We analyzed 372 asymptomatic type 2 diabetic patients without known coronary artery disease who underwent 64-channel dual-source CCTA and laboratory measurement. Any presence of maximal intra-luminal stenosis ≥50% in major epicardial coronary artery was defined as obstructive CAD. For the prediction of obstructive CAD, the optimal cut-off value of HOMA-IR was derived from ROC curve analysis. Results: Obstructive CAD was observed in 146 patients (39.2%) and the mean HOMA-IR was 5.44±4.86. The value of HOMA-IR ≥9.0 showed 24.0% of sensitivity and 88.9% of specificity in predicting the presence of obstructive CAD. After adjusting age, sex, hypertension and metabolic syndrome, multivariate logistic regression analysis showed that HOMA-IR≥9.0 was an independent risk factor for obstructive CAD (odds ratio2.85, 95% confidence interval 1.56-5.18, p=0.001) in asymptomatic diabetic patients. In addition, HOMA-IR ≥9.0 was associated with an increased risk of all-cause death, myocardial infarction and stroke after adjusting for conventional cardiovascular risk factors (hazard ratio 2.159, 95% confidence interval 1.130-4.127, p=0.020). Conclusions: Increased insulin resistance successfully identified high-risk individuals with obstructive CAD on CCTA and this may be a useful screening index in asymptomatic diabetic patients.
