Cardiovascular disease (CVD) is becoming more prevalent worldwide and is one of the leading causes of death [1]. To lower CVD mortality, aggressive and comprehensive management of its risk factors, including dyslipidemia, hypertension, diabetes mellitus, and smoking, are crucial [2]. The incidence of coronary artery disease (CAD) is rising in South Korea and although cerebral hemorrhage has declined since 2002, cerebral infarction is on the rise [3]. This is speculated to be due to the elevated prevalence of dyslipidemia and diabetes mellitus with the growing obesity population, while hypertension is well-managed and smoking rate has reached a plateau [4]. Thus, aggressive diagnosis and treatment of dyslipidemia, the most important risk factor for atherosclerosis, are critical for lowering the incidence and mortality of CAD and cerebral infarction.

To promote appropriate treatment of dyslipidemia, the Korean Society of Lipid and Atherosclerosis (KSo-LA) published the first guidelines for the management of hyperlipidemia in 1996, the second guideline in 2003, the second revision in 2009, and the third guidelines for treatment of dyslipidemia with added contents in 2015, in collaboration with 18 other relevant academic societies and organizations [5]. However, new guidelines were published in Europe in 2016 and in the United States in 2017 based on new study findings, and new drugs, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been launched [6-8]. Therefore, the KSoLA Treatment Guideline Committee developed the fourth guidelines for treatment and management of dyslipidemia specific to Koreans based on evidence and expert opinions on the dynamically changing treatment modalities for dyslipidemia.

The fourth guideline consists of information about the epidemiology of dyslipidemia, diagnosis and treatment criteria, lifestyle interventions, drug therapy, and dyslipidemia in specific patient groups. Finally, we present currently available data and the need to develop and validate scales to assess the risk of CVD specific to Koreans and CVD biomarkers appropriate for the Korean population. The level of evidence and strength of recommendations used in the fourth guideline are shown in Table 1. The fourth guideline is available in full text and an abstract form including tables and figures in Korean. This paper is an English summary of the full text. We hope the fourth guidelines for the treatment of dyslipidemia will be useful for health professionals treating dyslipidemia.

Table 1.

Levels of evidence: classes of recommendation

/pdf/2018-guidelines-for-the-management-of-dyslipidemia-49qcw69lov.pdf

2018 Guidelines for the management of dyslipidemia

/pdf/2018-guidelines-for-the-management-of-dyslipidemia-in-korea-216hb81quh.pdf

2018 Guidelines for the Management of Dyslipidemia in Korea

OBJECTIVES
This study assessed the clinical utility of mitral annulus velocity in the evaluation of left ventricular diastolic function.


BACKGROUND
Mitral inflow velocity recorded by Doppler echocardiography has been widely used to evaluate left ventricular diastolic function but is affected by other factors. The mitral annulus velocity profile during diastole may provide additional information about left ventricular diastolic function.


METHODS
Mitral annulus velocity during diastole was measured by Doppler tissue imaging (DTI) 1) in 59 normal volunteers (group 1); 2) in 20 patients with a relaxation abnormality as assessed by Doppler mitral inflow variables (group 2) at baseline and after saline loading; 3) in 11 patients (group 3) with normal diastolic function before and after intravenous nitroglycerin infusion; and 4) in 38 consecutive patients (group 4) undergoing cardiac catheterization in whom mitral inflow velocity and tau as well as mitral annulus velocity were measured simultaneously.


RESULTS
In group 1, mean +/- SD peak early and late diastolic mitral annulus velocity was 10.0 +/- 1.3 and 9.5 +/- 1.5 cm/s, respectively. In group 2, mitral inflow velocity profile changed toward the pseudonormalization pattern with saline loading (deceleration time 311 +/- 84 ms before to 216 +/- 40 ms after intervention, p < 0.001), whereas peak early diastolic mitral annulus velocity did not change significantly (5.3 +/- 1.2 cm/s to 5.7 +/- 1.4 cm/s, p = NS). In group 3, despite a significant change in mitral inflow velocity profile after nitroglycerin, peak early diastolic mitral annulus velocity did not change significantly (9.5 +/- 2.2 cm/s to 9.2 +/- 1.7 cm/s, p = NS). In group 4, peak early diastolic mitral annulus velocity (r = -0.56, p < 0.01) and the early/late ratio (r = -0.46, p < 0.01) correlated with tau. When the combination of normal mitral inflow variables with prolonged tau (> or = 50 ms) was classified as pseudonormalization, peak early diastolic mitral annulus velocity < 8.5 cm/s and the early/late ratio < 1 could identify the pseudonormalization with a sensitivity of 88% and specificity of 67%.


CONCLUSIONS
Mitral annulus velocity determined by DTI is a relatively preload-independent variable in evaluating diastolic function.

Assessment of Mitral Annulus Velocity by Doppler Tissue lmaging in the Evaluation of Left Ventricular Diastolic Function

The role of glutathione S- transferase M1 and T1 gene polymorphisms and oxidative stress-related parameters in Egyptian patients with essential hypertension.

To clarify the role of glutathione S-transferases (GSTs; GSTM1 and GSTT1) status in susceptibility to coronary heart disease (CHD), a meta-analysis of published studies was performed. A total of 19 studies including 8020 cases and 11 501 controls were included in this meta-analysis. In a combined analysis, the relative risks for CHD of the GSTM1 null and GSTT1 null polymorphisms were 1.47 [95% confidence interval (CI): 1.08-2.01] and 1.26 (95% CI: 0.90-1.75), respectively. Three potential sources of heterogeneity including ethnicity, source of control and sample size of study were also assessed. However, no significant association was found in stratified analyses. By pooling data from eight studies (2909 cases and 3745 controls) that considered combinations of GSTT1 and GSTM1 genotypes, a statistically significant increased risk for CHD [odds ratio (OR = 2.38, 95% CI: 1.03-5.48)] was detected for individuals with combined deletion mutations in both genes compared with positive genotypes. Results from the meta-analysis of five studies on GSTs stratified according to smoking status showed an increased risk for individuals with null genotype (OR = 2.21, 95% CI: 1.24-3.92 for GSTM1 and OR = 3.29, 95% CI: 1.49-7.26 for GSTT1) versus non-null genotypes. This meta-analysis suggests that the GSTM1 null genotype may slightly increase the risk of CHD and that interaction between unfavourable GSTs genotypes may exist.

Genetic polymorphisms of glutathione S-transferase genes GSTM1, GSTT1 and risk of coronary heart disease

Glutathione S-transferase (GST) plays a key role in the detoxification of xenobiotic atherogen generated by smoking. To analyze the effect of GSTM1/T1 gene polymorphisms on the development of smoking-related coronary artery disease (CAD), 775 Korean patients who underwent coronary angiography were enrolled. The subjects were classified by luminal diameter stenosis into group A (>50%), B (20-50%), or C (<20%). GSTM1 and GSTT1 gene polymorphisms were analyzed using multiplex polymerase chain reaction (PCR) for GSTM1/T1 genes and CYP1A1 gene for internal control. Of 775 subjects, 403 patients belonged to group A. They had higher risk factors for CAD than group B (N=260) and group C (N=112). The genotype frequencies of null GSTM1 and GSTT1 showed no significant differences among 3 groups. Considering the effect of GSTM1 gene polymorphisms on the smoking-related CAD, smokers with GSTM1 null genotype had more increased risk for CAD than non-smoker with GSTM1 positive genotype (odds ratios [OR], 2.07, confidence interval [CI], 1.06-4.07). Also the effect of GSTT1 gene polymorphism on smoking-related CAD showed the same tendency as GSTM1 gene (OR, 2.00, CI, 1.05-3.84). This effect of GSTM1/T1 null genotype on smoking-related CAD was augmented when both gene polymorphisms were considered simultaneously (OR, 2.76, CI, 1.17-6.52). We concluded that GSTM1/T1 null genotype contributed to the pathogenesis of smoking-related CAD to some degree.

/pdf/impact-of-glutathione-s-transferase-m1-and-t1-gene-3xhc0wv1ne.pdf

Impact of Glutathione S-Transferase M1 and T1 Gene Polymorphisms on the Smoking-Related Coronary Artery Disease

Background and Objectives：A new Doppler time index of myocardial performance (the Tei index) has been studied as a useful predictor of global cardiac function. It is defined as (a-b)/b, where a is the interval between the end and onset of the mitral inflow, and b is the ejection time of the left ventricular outflow. However, the Doppler time intervals are not measured on the same cardiac cycle. Subjects and Methods：We compared the tissue Doppler imaging (TDI)-derived Tei index, which can be measured on the same cardiac cycle, with the conventional Tei index as measured by pulsed wave Doppler method, in healthy persons (n=44), in patients having diastolic dysfunction with an E/E’ ratio >10 (DD, n=56), and in patients having systolic dysfunction with an ejection fraction <50% (SD, n=10). At the septal and lateral mitral annulus from the apical 4-chamber view, the time interval between the end and onset of the mitral annular velocities during diastole (a’) minus the duration of the systolic wave (b’) divided by b’, which is (a’-b’)/b’, is defined as the TDI-tei index. Results： The TDI-Tei index and the conventional Tei index were significantly higher in the SD group than in the DD group, and they were also higher in the DD group than in the healthy controls. The TDI-Tei index at the septal and lateral annulus correlated well with the Tei index (r=0.71, r=0.65, respectively, p<0.001) and this showed a good correlation with other echocardiographic parameters of diastolic function. Conclusion：We demonstrated that the TDI-Tei index correlates well with the conventional Tei index along with having the advantage of simultaneous recording of the systolic and diastolic velocities in adults. (Korean Circulation J 2005;35:315-321)

Tissue Doppler Image-Derived Myocardial Performance(Tei Index) as a Simple Assessment of Global Cardiac Function in Adults

Background and Objectives:A non-dipping pattern in hypertensive patients has been shown to be associated with a greater left ventricular (LV) hypertrophy, LV diastolic impairments and prolonged ventricular repolarization. The dynamic parameters of the QT dispersion (QTd) have been highlighted as markers of ventricular repolarization heterogeneity. The aim of this study was to demonstrate if the extent of nocturnal blood pressure (BP) fall was related to the LV mass, LV diastolic function and dynamic parameters of the QTd. Subjects and Methods:122 subjects, receiving electrocardiography, 24-hour ambulatory BP monitoring, 12 lead-24hr Holter monitoring and 2-dimensional Doppler echocardiography examinations, were enrolled. The subjects were classified as normotensive, dipper and non-dipper. The LV mass (LVM) and LV diastolic indices were measured. Using the QT Guard software, with 12 lead-24hr Holter monitoring, the QTd, mean QTd, QTd variation (the difference between the maximum minus the minimum QTd value observed over the recording time), QTd maximum (the maximum difference of QTd between consecutive beats) and QTd variability (QTd standard deviation) were analyzed. Results:Of the 122 patients, 39 and 40 were placed in the dipper and non-dipper groups, respectively. The non-dipper group had a greater LVM index (LVMI) than the dipper group (p<0.01). The nondipper group had greater increases in their A velocity (p<0.01), and more prolonged deceleration (p<0.01) and isovolumic relaxation (p<0.01) times than the dipper group. There were no significant differences in the QT and QTc interval between the 3 groups, but the QTd was much more increased in the non-dipper than the dipper and normotensive groups (p<0.01). For the dynamic parameters of the QTd, the QTd variation, QTd maximum and QTd variability were significantly increased in the non-dipper compared to the dipper and normotensive groups (p<0.05). Comparing the dipper and normotensive groups, there were no significant differences in the LVMI, LV diastolic indices, QTd and dynamic parameters of the QTd. Conclusion:The nondipper group of hypertensive patients had a greater LVMI, more impaired LV diastolic function and greater increases in their QTd and dynamic parameters of the QTd compared to the dipper and normotensive groups, suggesting the possibility of a much greater chance of cardiovascular events, and their complications, in the nondipper compared to the dipper group. (Korean Circulation J 2005;35:382-388)

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The Relation of Circadian Blood Pressure Variation to Left Ventricular Mass, Diastolic Function, and Dynamic QT Dispersion

Relationship of Ambulatory Blood Pressure Monitoring Data to Echocardiographic Findings in Hemodialysis Patients

Background:The electrocardiogram may provide valuable information regarding the identity of the culprit coronary artery and the location of obstructing lesion within the artery, which may be of guidance in selecting the therapeutic modality Previous studies have concluded that changes in lateral leads (I, aVL, V5, V6) are predictive of left circumflex coronary artery obstruction in inferior wall acute myocardial infarction Electrocardiographic criteria for determining the location of the obstructing lesion, however, have not been well established The purpose of this study is to investigate the patterns of ST segment depression in lateral leads in inferior wall acute myocardial infarction and the obstruction site of culprit artery according to ST segment depression in lateral leads Methods:We examined 78 patients with inferior wall acute myocardial infarction analizing their electrocardiogram and coronary angiography which performed during acute hospitalization Results:Of the fifty-five patients in which the culprit artery could be determined , 1) in 41 the culprit artery was the right coronary artery (19 proximal to the right ventricular branch and 22 distal), and in 14 the left circumflex coronary artery (7 proximal to the first obtuse marginal branch or involving a high first obtuse marginal branch, and 7 with distal obstruction) 2) Significant ST depression (ST≤1 mm) in leads I and aVL was more common in right coronary artery obstruction (p<005 and p<001 respectively) than left circumflex artery 3) It was difficult to define the location of obstruction with ST segment change of lateral precordial leads (V5, V6) Conclusions:In acute inferior wall myocardial infarction, ST segment depression in lateral limb leads (I, aVL) can be indicative of the right coronary artery obstruction and the ST segment depression pattern in lateral precordial leads was not indicative of the site of obstruction (Korean Circulation J 1998;28(11):1836-1840)

/pdf/st-segment-depression-in-lateral-leads-in-inferior-wall-3cv3l29y05.pdf

Jung Sang Song

Papers

Impact of Glutathione S-Transferase M1 and T1 Gene Polymorphisms on the Smoking-Related Coronary Artery Disease

Tissue Doppler Image-Derived Myocardial Performance(Tei Index) as a Simple Assessment of Global Cardiac Function in Adults

The Relation of Circadian Blood Pressure Variation to Left Ventricular Mass, Diastolic Function, and Dynamic QT Dispersion

Relationship of Ambulatory Blood Pressure Monitoring Data to Echocardiographic Findings in Hemodialysis Patients

ST Segment Depression in Lateral Leads in Inferior Wall Acute Myocardial Infarction