Echo conference R4 우종신 R4 우종신

Case 1 김 O 석 ( ) The GH/IGF axis and the cardiovascular system : clinical implications Clin Endocrinol 2008 May 6.

Growth hormone regulation of somatic growth, including cardiac development and function regulation of somatic growth, including cardiac development and function by stimulating the production of IGF-I, that mediates GH action on peripheral tissues by stimulating the production of IGF-I, that mediates GH action on peripheral tissues GH and IGF-I receptors are expressed in cardiac myocytes GH and IGF-I receptors are expressed in cardiac myocytes hypertrophy of cultured rat cardiomyocytes and delays cardiomyocyte apoptosis hypertrophy of cultured rat cardiomyocytes and delays cardiomyocyte apoptosis direct effects on myocardial contractility, by increasing the intracellular calcium content and enhances the calcium sensitivity of myofilaments direct effects on myocardial contractility, by increasing the intracellular calcium content and enhances the calcium sensitivity of myofilaments endothelial cells have high-affinity binding sites for IGF-I and IGF-I stimulates nitric oxide (NO) production endothelial cells have high-affinity binding sites for IGF-I and IGF-I stimulates nitric oxide (NO) production inflammation-linked angiogenesis and repair processes following ischemic events inflammation-linked angiogenesis and repair processes following ischemic events

Cardiovascular and metabolic correlates of increased IGF-I in the general population

Effect of GH deficiency on atherosclerosis

GH excess (acromegaly) Concentric biventricular hypertrophy : most common feature Concentric biventricular hypertrophy : most common feature –Thickened cardiac walls –Cardiac chambers are rarely enlarged –left ventricular mass index significantly increased from young ( 60 yrs) patients Arterial hypertension Arterial hypertension Rhythm disturbances, such as ectopic beats, paroxysmal atrial fibrillation, paroxysmal supraventricular tachycardia, sick sinus syndrome, ventricular tachycardia and bundle branch blocks Rhythm disturbances, such as ectopic beats, paroxysmal atrial fibrillation, paroxysmal supraventricular tachycardia, sick sinus syndrome, ventricular tachycardia and bundle branch blocks

Control of GH and IGF-I excess s.c. octreotide, lanreotide and octreotide-LAR s.c. octreotide, lanreotide and octreotide-LAR can arrest the progression of cardiac disorders can arrest the progression of cardiac disorders recovery from cardiac hypertrophy recovery from cardiac hypertrophy improves diastolic dysfunction and systolic dysfunction at peak exercise, mostly in young patients who had had a presumably short exposure to GH and IGF-I excess improves diastolic dysfunction and systolic dysfunction at peak exercise, mostly in young patients who had had a presumably short exposure to GH and IGF-I excess cardiac valve disease : no change cardiac valve disease : no change

Case 2 고 O 남 ( ) New diagnostic strategies for pulmonary embolism Lancet 2008 Vol

Pulmonary embolism common, sometimes fatal, complication of deep-vein thrombosis common, sometimes fatal, complication of deep-vein thrombosis 1 million cases of venous thromboembolism every year in six European countries 1 million cases of venous thromboembolism every year in six European countries about patients had symptomatic pulmonary embolism about patients had symptomatic pulmonary embolism about died from complications related to venous thromboembolism about died from complications related to venous thromboembolism patients had sudden fatal pulmonary embolism or died from undiagnosed pulmonary embolism patients had sudden fatal pulmonary embolism or died from undiagnosed pulmonary embolism

recurrence rate of about 30% after 8 years

Only a quarter of patients with suspected pulmonary embolism actually has the disease Only a quarter of patients with suspected pulmonary embolism actually has the disease The Revised Geneva Score Clinical assessment D-dimer multislice CT 12

Thrombolytics, embolectomy massive pulmonary embolism and cardiogenic shock streptokinase, urokinase, recombinant tPA Anticoagulants unfractionated heparin low molecular weight heparin oral anticoaculat IVC filter contraindications to anticoagulants severe bleeding during anticoagulant use recurrent pulmonary embolism while on adequate treatment Treatment of venous thromboembolism

Anticoagulant Fixed-dose, weight-adjusted, subcutaneous LMWH is as effective and safe as intravenous unfractionated heparin Fixed-dose, weight-adjusted, subcutaneous LMWH is as effective and safe as intravenous unfractionated heparin –recommended by the American College of Chest Physicians –fondaparinux, an indirect factor Xa inhibitor –Idraparinux, a long-acting indirect factor Xa inhibitor incidence of recurrence after 3 months in the idraparinux group was twice as high as that in patients receiving standard therapy incidence of recurrence after 3 months in the idraparinux group was twice as high as that in patients receiving standard therapy –rivaroxaban, an oral direct factor Xa inhibitor –dabigatran, an oral direct thrombin inhibitor phase III trials phase III trials can be continued for secondary thromboprophylaxis after the initial treatment can be continued for secondary thromboprophylaxis after the initial treatment

Contraindications to Anticoagulant Therapy Braunwald’s Heart Disease. 2nd ed. Philadelphia: W.B. Saunders, 2002:97-153

Inferior vena cava filter

Use of inferior vena cava filters

Compilation of inferior vena cava (IVC) filter data Blood. 2000;95:3669 –3677

NEJM 2004:351:268-77