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Purpose The goal of this study was to review recent clinical studies of azilsartan medoxomil (AZL-M) and chlorthalidone (CLD), a combined angiotensin receptor blocker and thiazide-like diuretic, and its role in recently published guidelines. This review explores the role of AZL-M/CLD in treating patients with hypertension. Methods A systematic review of literature published from 1990 to 2018 was performed by using the following key words: Edarbyclor, azilsartan, chlorthalidone, pharmacokinetic, and hypertension. Available English-language data from reviews, abstracts, presentations, and clinical trials regarding the use of AZL-M/CLD therapy specifically detailing effects of lowering blood pressure (BP) and outcomes on cardiovascular disease in humans and rats were reviewed. Findings One study compared a single–pill combination of AZL-M/CLD with co-administration of AZL-M and hydrochlorothiazide and found a greater reduction in clinic systolic BP with AZL-M/CLD (−35.1 mm Hg vs −29.5 mm Hg) than for AZL-M and hydrochlorothiazide. Another study of 153 patients with chronic kidney disease who received AZL-M/CLD or other single–pill combination agents found that AZL-M/CLD was more effective in lowering BP, achieving superior adherence. According to new guidelines, an increase in the prevalence of resistant hypertension can occur as a result of trying to lower target BP. Implications A powerful and effective medication that can increase patient compliance is essential to reduce the incidence of resistant hypertension. AZL-M/CLD is a powerful and safe antihypertensive medication that has been thoroughly studied in patients with hypertension.

Background Pericardial effusion is a common feature of end-stage liver disease. In this case report we describe the intraoperative management of recurrent pericardial effusion, without re-pericardiocentesis, to prevent circulatory collapse during a critical surgical time-point; that is, during manipulation of the major vessels and graft reperfusion. Methods A 47-year-old woman with hepatitis B was scheduled to undergo deceased donor liver transplantation (LT). A large pericardial effusion was preoperatively identified using transthoracic echocardiography (TTE). The patient also had paroxysmal atrial fibrillation. Two days before surgery, preemptive pericardiocentesis was performed and the 1150-mL effusion was drained. Intraoperatively, recurrence of the large pericardial effusion was identified using transesophageal echocardiography (TEE). During inferior vena cava manipulation, the surgeon consulted the anesthesiologist to evaluate the hemodynamic changes in the patient. After 3 attempts, the transplant team was able to determine the most appropriate anastomosis site, defined as that with the least impact on cardiac function. To prevent the development of severe postreperfusion syndrome, 10% MgSO4 (2 g) was gradually infused 20 minutes before portal vein declamping, and immediately before graft reperfusion a 100-μg bolus of epinephrine was administered. Results During graft reperfusion, there was no evidence of heart chamber collapse or flow disturbance, as seen on the TEE findings. Postoperatively, the patient recovered completely and was discharged from the hospital. Six months after surgery, there was no sign of pericardial effusion on follow-up TTE. Conclusion Our intraoperative strategy may prevent cardiac collapse in patients with pericardial effusion detected during LT. Intraoperative TEE plays an important role in guiding hemodynamic management.

BackgroundThe aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT).Patients and methodsA total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency.ResultsThe study population was largely male (68.3%), and the median age was 54 (49-59) years. The median model for end-stage liver disease score was 12 (6-22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations.ConclusionsThe 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group.

BACKGROUND The importance of the right ventricle (RV) has been increasingly recognized, and accurate RV measurement has become necessary. However, assessment of the RV with two-dimensional (2D) echocardiography has several limitations. As the development of novel methods for RV measurement continues, we can expect more accordant values related to RV geometry. METHODS Fifty-eight subjects who were examined by transthoracic echocardiography (TTE) immediately before and after hemodialysis (HD) were enrolled. Real-time, full-volume, three-dimensional (3D) echocardiographic images were acquired and analyzed using dedicated software. Conventional RV parameters for RV size and function were measured for comparison with pre-HD and post-HD values by both 2D-TTE and 3D-TTE. RESULTS 3D RV volumes and ejection fractions were significantly decreased after HD. The values of the 3D image-derived RV dimensions, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and longitudinal strain were also affected by acute preload changes (TAPSE pre-HD: 22.4 ± 4.0 mm, post-HD: 19.0 ± 4.2 mm, p < 0.001; FAC pre-HD: 49.6% ± 5.9%, post-HD: 46.4% ± 5.5%, p < 0.001; septal longitudinal strain pre-HD: -20.1% ± 3.7%, post-HD: -16.8% ± 3.8%, p < 0.001). With the exception of FAC, most 2D RV parameters were well correlated with the 3D values. CONCLUSIONS Various parameters representing RV anatomy and function were acquired easily and more accurately from 3D echocardiographic images than from 2D images but were affected by acute preload changes. 3D TTE could be a new modality for assessing RV function and size, but each value from 3D TTE should be interpreted with caution while considering the loading condition of the patients.

Background Whether patients with acute heart failure syndrome (AHFS) need to reach the target dose of renin-angiotensin-system (RAS) blocker and beta-blocker to obtain a benefit in terms of clinical outcome remain uncertain. We aimed to evaluate the dose response relationship of RAS blocker and beta-blocker using the Korean Acute Heart Failure (KorAHF) registry. Methods The KorAHF registry is a prospective observational multicenter cohort study of AHFS in Korea. We investigated the relationship between usage and doses of RAS blocker and beta-blocker with 180 days overall survival outcome in these patients. Results Among 2,829 patients who discharged alive with reduced ejection fraction (≤ 40%), RAS blocker was prescribed in 2,197 patients (77.7%) and beta-blocker 1,623 patients (57.4%). 180 day all-cause mortality was 13.2% (N=374). Usage of both RAS blocker (p Conclusion While usage of RAS blocker or beta-blocker showed clear benefit in terms of clinical outcome, dose response relationship was evident only in RAS blockers but not in beta-blockers. Further research is needed to understand the dose response relationship of these medications and potential application of individualized dose-titration regimen.

Jae-Beom Lee,1 Yun-Seok Choi,2 Woo-Baek Chung,2 Ami Kwon,2 Chul-Soo Park,2 Man-Young Lee2 1Anyang Sam Hospital, 2Division of Cardiology, Department of Internal Medicine, Youido St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Purpose: High coronary calcium score (CCS) and post-procedural cardiac enzyme may be related with poor outcomes in patients with coronary stent implantation. Methods: A total of 1,072 patients (63.2% male, mean age: 61.7±10.3 years) who underwent coronary multi-detect computed tomography at index procedure and follow-up coronary angiography (CAG) after drug-eluting stent (DES) were divided into two groups: those with and without target lesion revascularization (TLR; >50% reduction in luminal stent diameter or angina symptoms on follow-up CAG). The CCSs for predicting stent revascularization were elucidated. Results: There were no significant differences between the two groups with regard to risk factors. The initial CCS was significantly higher in the TLR group (1,102.4±743.7 vs 345.8±51.05, P=0.04). After adjustment of significant factors for TLR, only CCS and post-procedural creatine kinase MB form (CK-MB) elevation were significant predictors of coronary artery TLR. Receiver operation curve revealed that >800 in CCS had 69% in sensitivity and 88% in specificity about predicting the TLR. Conclusion: High CCS with post-procedural CK-MB might be the useful predictors for TLR after DES implantation. Keywords: coronary restenosis, drug-eluting stents, calcium, creatine kinase

It has been shown that triple antiplatelet therapy with cilostazol results in better clinical outcomes than dual therapy in patients treated with a first-generation drug-eluting stent (DES); however, it is unclear whether triple antiplatelet therapy has a similar efficacy after the implantation of second-generation DES. In the COACT (Cath Olic medical center percutAneous Coronary in Tervention) registry, 1248 study subjects who underwent percutaneous coronary intervention with an everolimus- or zotarolimus-eluting stent (Endeavor, Xience V, or Promus) were analyzed. The patients were divided into 2 groups after propensity score matching (n = 724; M = 422 [58.3%]; mean age = 66.1 ± 11.0 years): Group 1: patients treated with dual antiplatelet drugs (aspirin and clopidogrel; n = 362; M = 213 [58.8%]; mean age = 65.6 ± 11.7 years); Group 2: patients treated with triple antiplatelet drugs (aspirin, clopidogrel, and cilostazol; n = 362; M = 209 [57.7%]; mean age = 65.6 ± 11.7 years). The mean follow-up duration was 13 ± 10 months, and the cumulative incidence of major cardiovascular events (MACE) was 6.3% in Group 1 and 7.7% in Group 2. There were no significant differences in MACE (death, nonfatal myocardial infarction, and stroke) between the 2 groups (OR, 1.210; 95% CI: 0.772–1.898; P = 0.406). Kaplan–Meier curves for MACE did not show any survival benefit for triple antiplatelet therapy, even in patients with acute coronary syndrome. In patients treated with a second-generation DES implantation, there is no added clinical benefit to using triple rather than dual antiplatelet therapy.

The differential diagnosis of hypercalcaemia in patients with end-stage renal disease undergoing dialysis should be considered for causes related or unrelated to renal failure itself or therapies for renal failure. In particular, peritoneal dialysis may hinder awareness of a clinical problem due to its own peculiarities and effects on homeostasis of the body, thus creating misconceptions in interpreting laboratory data and diagnosing a disease. We describe here a case of systemic sarcoidosis which was delayed due to failure to recognise underestimated hypercalcaemia in a patient undergoing peritoneal dialysis. Clinicians need to remain aware of the change of minerals that may arise from peritoneal dialysis and should perform an extensive investigation for the cause of hypercalcaemia.

Objective:There are many reports about white coat hypertension (WCH), still the clinical significance and pathophysiology of WCH is ambiguous. The aim of this study was to find out the difference of RAAS activity in WCH compared with the essential hypertension (EH) group, which could suggest the rol

Osteoprotegerin (OPG) is a kind of tumor necrosis factor, which is related to bone metabolism and vascular calcification. The increase of Osteoprotegerin concentration in serum is related to cardiovascular diseases in humans. The purpose of this study was to figure out the relevance between osteoprotegerin in serum and carotid calcification. Serum OPG concentrations were compared in 145 patients who underwent carotid sonography (average age: 68 ± 9 years old, male: female = 81:64). A calcified plaque (CP) (37 people [27%]), a noncalcified plaque (NCP) (54 people [37%]), and a nonplaque (NP) (54 people [37%]) were classified for this study. No significant differences among 3 groups were demonstrated in the distribution of age, diabetes, high blood pressure, and hyperlipidemia. Serum osteoprotegerin concentrations were significantly increased in CP group rather than NCP group or NP group; (median [interquartile range], 4016 [1410] vs 3210 [1802] pg/mL, P

Colonoscopy is a widely used diagnostic and therapeutic intervention with an excellent safety profile. Although an intraperitoneal hemorrhage is a rare complication after colonoscopy, and usually associated with splenic injury or solid organ pathology, it is potentially serious and can be life-threatening. We report a rare case of spontaneous intraperitoneal hemorrhage after diagnostic colonoscopy without splenic injury or intra-abdominal abnormality, known as idiopathic spontaneous intraperitoneal hemorrhage. This case emphasizes that physicians should be aware of the emergence of acute abdomen after colonoscopy. (Korean J Med 2013;85:178-182)

Chylothorax is the accumulation of chyle-containing lymphatic fluid within the pleural space. It is mainly caused by injury or obstruction of the thoracic duct due to neoplasm or trauma. There have been several reports of chylothorax associated with chromosomal anomaly such as Down syndrome. Most cases are congenital, and development of chylothorax in an adult with Down syndrome is rare. Here, we report a case of chylothorax in an adult with Down syndrome who had been treated with mechanical ventilation. A 31-year-old woman with Down syndrome was admitted with urosepsis. She was treated with mechanical ventilation due to severe respiratory acidosis. Four days after mechanical ventilation, she developed unilateral pleural effusion, and analysis indicated chylothorax. After conservative treatment, including fasting and total parenteral nutritional support, the chylous formation completely disappeared. (Korean J Med 2013;84:279-283)

Phytobezoars are the most common bezoars composed of non-digestible food materials, such as fiber, seeds, skin of fruits. The predisposing factors of bezoars are altered gastrointestinal motility and anatomy. It is uncommon for bezoars occurring in patient with normal gastric anatomy to cause impaction on the duodenal bulb. We experienced a phytobezoar at the duodenal bulb causing gastric outlet obstruction in a patient who had no predisposing factors. The patient was treated by endoscopic removal. (Korean J Helicobacter Up Gastrointest Res 2011;11:201-204)