Impact of hyperuricemia on coronary blood flow and in-hospital mortality in patients with acute myocardial infarction undergoing percutaneous coronary intervention.

BACKGROUND: Although serum uric acid (UA) is considered as a risk factor for cardiovascular disease, few data exist regarding the relationship between hyperuricemia, coronary blood flow, and subsequent outcome in patients with acute myocardial infarction (AMI). The purpose of our study is to assess whether hyperuricemia is associated with suboptimal coronary flow and increased risk of mortality in patients with AMI after percutaneous coronary intervention (PCI). METHODS: Using the Rural AMI registry data, 989 consecutive patients with AMI who underwent emergent PCI and had UA measurement at admission were analyzed. We defined hyperuricemia as serum UA ≥7.0 mg/dL in men and ≥ 6.0 mg/dL in women. The primary endpoint was suboptimal coronary flow, defined as post PCI Thrombosis In Myocardial Infarction flow grade ≤ 2. The secondary outcome was in-hospital mortality. RESULTS: Hyperuricemia was found in 249 (25.2%) patients. Patients with hyperuricemia were more often complicated with cardiogenic shock compared with those without (16.9% vs. 7.4%, p < 0.001). In addition, the median high-sensitivity C-reactive protein was significantly higher in patients with hyperuricemia (0.18 mg/dL; IQR, 0.09-0.71 mg/dL) than in those without (0.14 mg/dL; IQR, 0.07-0.41 mg/dL, p < 0.05). Under these conditions, the prevalence of suboptimal coronary flow after PCI (17.3% vs. 10.1%, p < 0.05) and in-hospital mortality (10.8% vs. 3.6%, p < 0.001) were significantly higher in patients with hyperuricemia compared with those without. Multivariable logistic regression analysis revealed that hyperuricemia was significantly associated with suboptimal coronary flow [odds ratio (OR), 1.60; 95% confidence interval (CI), 1.02-2.49; p < 0.05] and in-hospital mortality (OR, 2.08; 95% CI, 1.05-4.12; p < 0.05). CONCLUSIONS: Assessment of serum UA upon admission provides useful information for predicting suboptimal coronary flow and in-hospital mortality in patients with AMI undergoing PCI.

Comparison of Door-to-Balloon Time and 30-Day Mortality According to Symptom Presentation in Patients With Acute Myocardial Infarction.

Background: We hypothesized that symptom presentation in patients with acute myocardial infarction (AMI) may affect their management and subsequent outcome. Methods and Results: Using Rural AMI Registry data, 1,337 consecutive patients with AMI who underwent percutaneous coronary intervention were analyzed. Typical symptoms were defined as any symptoms of chest pain or pressure due to myocardial ischemia. We considered the specific symptoms of dyspnea, nausea, or vomiting as atypical symptoms. The primary outcome was 30-day mortality. There were 150 (11.2%) and 1,187 (88.8%) patients who presented with atypical and typical symptoms, respectively. Those who presented with atypical symptoms were significantly older (mean [±SD] age 74±12 vs. 68±13 years; P<0.001) and had a higher Killip class (46.7% vs. 21.8%; P<0.001) than patients presenting with typical symptoms. The prevalence of door-to-balloon time of ≤90 min was significantly lower in patients with atypical than typical symptoms (40.0% vs. 66.3%; P<0.001). At 30 days, there were 55 incidents of all-cause death. Multivariate Cox proportional hazards regression analysis revealed that symptom presentation was associated with 30-day mortality (hazard ratio 2.33; 95% confidence interval 1.20-4.38; P<0.05). Conclusions: Atypical symptoms in patients with AMI are less likely to lead to timely reperfusion and are associated with increased risk of 30-day mortality.

Myocardial Native T1 Predicts Load-Independent Left Ventricular Chamber Stiffness In Patients With HFpEF.

OBJECTIVES: This study sought to evaluate the potential of cardiac magnetic resonance T1 mapping to detect load-independent left ventricular (LV) chamber stiffness by histological confirmation. BACKGROUND: Accurate noninvasive diagnosis of LV diastolic dysfunction in heart failure with preserved ejection fraction (HFpEF) remains challenging. METHODS: Nineteen HFpEF patients (14 female, 65 ± 16 years of age) without primary cardiomyopathy were prospectively enrolled. Cine, late gadolinium enhancement cardiac magnetic resonance, and triple-slice T1 mapping using a modified Look-Locker inversion recovery sequence were performed at 3-T. Extracellular volume (ECV) was quantified from pre- and post-contrast T1 values of the blood and myocardium with hematocrit correction. LV stiffness constant (beta) was assessed by calculating the slope of the end-diastolic pressure-volume relationship curve during vena cava occlusion. Biopsy samples were used for quantification of collagen volume fraction (CVF) and myocardial cell size. RESULTS: Six patients showed focal scar on late gadolinium enhancement. There was no significant difference in histological CVF between patients with and without focal myocardial scarring (p = 0.2). Septal ECV rather than native T1 was a better surrogate marker for detecting histological CVF (r = 0.54; p = 0.02, and r = 0.44; p = 0.06, respectively). Global native T1 and ECV, but not native T1 and ECV in the septal myocardium, correlated well with the beta of passive LV stiffness, and had similar ability for predicting LV stiffness to histological CVF (r = 0.54, 0.50, 0.53, all p < 0.05, respectively). When the beta ≥0.054 was considered as moderately increased LV stiffness, global native T1 ≥1,362 ms provided 88% sensitivity and 64% specificity with the C-statistic of 0.81 (95% confidence interval: 0.56 to 0.95). CONCLUSIONS: Myocardial native T1 provides comparable ability in predicting LV stiffness to ECV and histological CVF and may be useful for monitoring patients with HFpEF who have renal dysfunction, allergy to gadolinium, or wheezing that can simulate asthma. Our feasibility study shows the potential of native T1 to allow for insight of heterogeneous pathophysiology and better risk stratification of HFpEF.

Effects of sitagliptin on exercise capacity and hemodynamics in patients with type 2 diabetes mellitus and coronary artery disease.

Sitagliptin attenuates left ventricular (LV) dysfunction and may improve oxygen uptake in animals. The effects of sitagliptin on oxygen uptake (VO2) and exercise hemodynamics have been unclear in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD). Thirty patients with T2DM and CAD were randomized into a sitagliptin (50 mg/day) or voglibose (0.6 mg/day) group. Patients underwent maximal cardiopulmonary exercise testing. VO2 and hemodynamics were evaluated at rest, anaerobic threshold and peak exercise. Resting LV diastolic function (E', peak early diastolic mitral annular velocity) and geometry were evaluated by echocardiography, and endothelial function by reactive hyperemia peripheral arterial tonometry. A total of 24 patients (69 ± 9 years) completed 6 months of intervention. Peak VO2 in the sitagliptin and voglibose groups (25.3 ± 7.3 vs. 24.0 ± 7.4, 22.7 ± 4.8 vs. 22.1 ± 5.2 ml/kg/min) was slightly decreased after 6 months (time effect p = 0.051; group × time effect p = 0.49). No effects were observed on LV ejection fraction, E', or reactive hyperemia index in either group. Heart rate during exercise was unaffected in both groups. Systolic blood pressure was unchanged by sitagliptin at rest and during exercise, but slightly lowered by voglibose at anaerobic threshold and peak exercise. In patients with T2DM and CAD, sitagliptin had little effect on resting LV and arterial function, exercise capacity, or exercise hemodynamics. Further studies need to be conducted with more patients as the number of the patients in this study was limited.

Successful Peritoneal Dialysis for the Treatment of Inotrope-Dependent End-Stage Heart Failure.

Extra- and/or intracorporeal renal replacement therapy can improve the cardiorenal hemodynamics in patients with advanced heart failure (HF) refractory to medical therapy and renal failure. Here, we report the case of a 51-year-old woman with inotrope-dependent end-stage HF and chronic renal failure due to anthracycline-induced cardiomyopathy, in whom the induction of hemodiafiltration and subsequent chronic peritoneal dialysis (PD) provided a dramatic improvement of her cardiac hemodynamics from restrictive to almost normal physiology assessed by echocardiography and cardiac catheterization. The patient returned to office work with New York Heart Association functional class I-II symptoms for at least 3 years with continuous ambulatory PD after hospital discharge.

Predictors of confirmatory test results for the diagnosis of primary hyperaldosteronism in hypertensive patients with an aldosterone-to-renin ratio greater than 20. The SHRIMP study.

It remains unknown which surrogate markers can predict diagnostic test results for primary hyperaldosteronism (PA). The Secondary Hypertension Registry Investigation in Mie Prefecture (SHRIMP) study has sequentially and prospectively recruited 128 patients with hypertension with an aldosterone-to-renin ratio (ARR) greater than 20, evaluated the differences among essential hypertension (EHT), idiopathic hyperaldosteronism (IHA), and aldosterone-producing adenoma (APA), and analyzed the predictors for the confirmatory tests. The patients underwent saline-loading, captopril-challenge, and upright furosemide-loading tests. Carotid, renovascular, and cardiac echography, brachial ankle pulse wave velocity (baPWV), endothelial function, nocturnal blood pressure decline, and the apnea hypopnea index were evaluated. Multivariate regression analyses showed that the plasma aldosterone concentration (PAC) at screening was a strong predictor of the saline and captopril test results. The plasma renin activity (PRA) at screening, urine ß2-microglobulin, and left ventricular mass index (LVMI) were independent predictors for the captopril test. The estimated saline PAC and captopril 60 and 90 min ARRs predicted by the equations were highly correlated with the real values. The ROC curve analysis showed PAC at screening among each of predictors for the diagnostic tests and PAC after the saline-loading test had the highest diagnostic abilities of APA. Patients with IHA were older and had glucose intolerance and increased U-Alb/gCre and resistive indices. In patients with APA, the levels of U-Alb/gCre and urine ß2-microglobulin were increased, and levels of insulin and the HOMA-IR were decreased. In conclusion, our proposed equations may be useful for estimating saline PAC and captopril ARR. Diagnostic predictors may differ for each confirmatory test.

Multicenter, Prospective Study on Respiratory Stability During Recovery From Deterioration of Chronic Heart Failure.

BACKGROUND: The respiratory instability frequently observed in advanced heart failure (HF) is likely to mirror the clinical status of worsening HF. The present multicenter study was conducted to examine whether the noble respiratory stability index (RSI), a quantitative measure of respiratory instability, reflects the recovery process from HF decompensation. Methods and Results: Thirty-six of 44 patients hospitalized for worsening HF completed all-night measurements of RSI both at deterioration and recovery phases. Based on the signs, symptoms, and laboratory data during hospitalization, the Central Adjudication Committee identified 22 convalescent patients and 14 patients with less extent of recovery in a blinded manner without any information on RSI or other respiratory variables. The all-night RSI in the convalescent patients was increased from 27.8±18.4 to 34.6±15.8 (P<0.05). There was no significant improvement of RSI, however, in the remaining patients with little clinical improvement. Of the clinical and laboratory variables, on stepwise linear regression modeling, body weight, peripheral edema, and lung congestion were closely related to the RSI of recovered patients and accounted for 56% of the changes in RSI (coefficient of determination, R2=0.56). CONCLUSIONS: All-night RSI, a quantitative measure of respiratory instability, could faithfully reflect congestive signs and clinical status of HF during the recovery process from acute decompensation.

Effect of Sitagliptin on Coronary Flow Reserve Assessed by Magnetic Resonance Imaging in Type 2 Diabetic Patients With Coronary Artery Disease.

BACKGROUND: The present study was conducted to assess the cardiovascular effects of dipeptidyl peptidase-4 inhibitors (DPP4i) on coronary flow reserve (CFR), left ventricular (LV) function and endothelial function of the peripheral artery by comparison with those of α-glucosidase inhibitors (αGI) in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD).Methods and Results:We randomly assigned 30 patients with T2DM and CAD to receive either sitagliptin or voglibose, and 28 patients (age 69±9 years, 75% male, hemoglobin A1c [HbA1c] 6.62±0.48%) completed the study (14 in each group). CFR and LV function, assessed by cardiac magnetic resonance imaging, and endothelial function, assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT), were measured at baseline and 24 weeks after treatment. Clinical and laboratory parameters, including HbA1c level, plasma active glucagon-like peptide-1 concentrations, and biomarkers of inflammation, were unchanged in both groups after 24 weeks of treatment. CFR were unchanged in both the αGI group (3.01±0.98 at baseline and 3.06±0.8 after treatment, P=NS) and the DPP4i group (4.29±2.04 at baseline and 3.63±1.31 after treatment, P=NS), with no interaction effect. LV functional parameters and the reactive hyperemia index also remained unchanged after the 24-week treatment. CONCLUSIONS: DPP4i did not improve CFR, LV function or endothelial function of the peripheral artery in patients with relatively well-controlled T2DM and CAD.

Rural-Urban Disparity in Emergency Care for Acute Myocardial Infarction in Japan.

BACKGROUND: There are few reports examining regional differences between rural prefectures and metropolitan areas in the management of acute myocardial infarction (AMI) in Japan.Methods and Results:In the Rural AMI registry, a prospective, multi-prefectural registry of AMI in 4 rural prefectures (Ishikawa, Aomori, Ehime and Mie), a total of 1,695 consecutive AMI patients were registered in 2013. Among them, 1,313 patients who underwent primary percutaneous coronary intervention (PPCI) within 24 h of onset were enrolled in this study (Rural group), and compared with the cohort data from the Tokyo CCU Network registry for AMI in the same period (Metropolitan group, 2,075 patients). The prevalence of direct ambulance transport to PCI-capable facilities in the Rural group was significantly lower than that in the Metropolitan group (43.8% vs. 60.3%, P<0.01), which resulted in a longer onset-to-balloon time (OTB: 225 vs. 210 min, P=0.02) and lower prevalence of PPCI in a timely fashion (OTB ≤2 h: 11.5% vs. 20.7%, P<0.01) in the Rural group. Multivariate analysis revealed that direct ambulance transport was the strongest predictor for PPCI in a timely fashion (odds ratio=4.13, P<0.001). CONCLUSIONS: AMI patients in rural areas were less likely to be transported directly to PCI-capable facilities, resulting in time delay to PPCI compared with those in metropolitan areas.

A novel method for the quantitative evaluation of diurnal respiratory instability in patients with heart failure: A pilot study.

BACKGROUND: There is no established method to quantitatively measure the presence and the severity of respiratory instability (RI). The purpose of this pilot study was to propose a novel index of diurnal RI as a surrogate measure of clinical severity of heart failure (HF). METHODS AND RESULTS: We prospectively enrolled 60 patients with symptomatic HF [70±14 years, 75% male, and New York Heart Association (NYHA) functional classes II-IV] who underwent right heart catheterization (RHC), and recorded diurnal respiration using a nasal pressure sensor during bed rest while awake within 2 days before or after RHC. Non-uniformity of the breath-by-breath respiratory slopes during 15min calculated as the ratio of peak expiratory amplitude to corresponding peak-to-peak interval was assessed by histogram-based frequency distribution measurement, and was defined as the "RI-index". The RI-index was significantly different among NYHA functional classes and was highest in NYHA class IV. The presence of atrial fibrillation (ß coefficient: 0.300, p=0.01) and stroke volume index (ß coefficient: -0.462, p<0.01) were independently associated with RI index among hemodynamic parameters. Furthermore, the high RI index above the median value was the independent predictor of the composite outcome of death from any cause, a life-threatening arrhythmia, and an unplanned hospitalization for worsening HF. CONCLUSIONS: The RI index stratified functional severity of HF well, and was a significant independent predictor of poor outcomes.

Postdischarge Light-Intensity Physical Activity Predicts Rehospitalization of Older Japanese Patients With Heart Failure.

PURPOSE: Regular physical activity (PA) is recommended for patients with heart failure (HF). However, the clinical and social characteristics of older HF patients with low-level PA and the impact of light-intensity PA on 6-mo postdischarge adverse cardiovascular events are still unclear. METHODS: Forty-one older patients who had been admitted because of decompensated HF (American College of Cardiology [ACC]/American Heart Association [AHA] HF classification stage C/D: 76 ± 5 y) were prospectively enrolled. Light-intensity (1.5-2.9 metabolic equivalents [METs]) and moderate-intensity (≥3 METs) PAs were determined by triaxial accelerometry for at least 7 d postdischarge. Six-min walk distance and 36-item Short Form questionnaire (SF-36) score were evaluated at discharge. HF patients were stratified into either the HFPA-high or HFPA-low group according to median daily PA. Twenty-nine older ACC/AHA stage A/B outpatients (HF-risk), who were at risk for HF but no symptoms of HF had developed, also completed these assessments. Clinical predictors for 6-mo postdischarge HF rehospitalization were assessed. RESULTS: HF patients were anemic and less active. HFPA-low patients were less likely to engage in household work, took fewer steps, and had less light and moderate-intensity PA than HFPA-high patients. There were no differences in 6-min walk distance, SF-36 score, or left ventricular ejection fraction between HFPA-low and HFPA-high patients. Postdischarge PA, especially light-intensity PA, was independently associated with HF rehospitalization. CONCLUSION: Low volume of PA postdischarge, especially at 1.5 to 2.9 METs, predicts 6-mo postdischarge HF rehospitalization in older HF patients.

Native T1 Mapping and Extracellular Volume Mapping for the Assessment of Diffuse Myocardial Fibrosis in Dilated Cardiomyopathy.

OBJECTIVES: The purpose of this study was to examine the histological correlation of native myocardial T1 and extracellular volume fraction (ECV) measurement at 3-T for the assessment of diffuse pathological changes in the myocardial tissue, including myocardial fibrosis and extracellular space in dilated cardiomyopathy (DCM). BACKGROUND: Cardiac magnetic resonance T1 techniques allow the quantification of diffuse myocardial fibrosis. However, there are no definitive head-to-head studies of native T1 versus ECV for the detection, quantification, and characterization of pathological changes in the myocardial tissue in DCM by using histological samples for confirmation. METHODS: A total of 36 subjects with DCM (31 men, mean age 56 ± 16 years) underwent pre- and post-contrast T1 mapping as well as late gadolinium enhancement (LGE) cardiac magnetic resonance at 3-T. Biopsy samples were used for the quantification of collagen volume fraction using picrosirius red staining and an extracellular space component from hematoxylin and eosin-stained myocardium. RESULTS: Nonischemic LGE was observed in 14 of 36 patients. Although patients with LGE had significantly greater biopsy-proven collagen volume fraction than those without LGE (21 ± 12% vs. 11 ± 8%; p < 0.01), there was substantial overlap of collagen volume fraction values between patients with and without LGE. Both native T1 value and ECV were similarly and significantly associated with biopsy-proven collagen volume fraction (r = 0.77 and r = 0.66, respectively; p < 0.05). Furthermore, ECV had a strong correlation with the biopsy-proven extracellular space component (r = 0.86), whereas native T1 had only a moderate correlation (r = 0.55). Interobserver and intraobserver reproducibility for native T1 and ECV were 0.89, 0.95, 0.96, and 0.98, respectively. CONCLUSIONS: Native T1 exhibited comparable ability as ECV measurement in the detection and quantification of histological collagen volume fraction, with high reproducibility, and therefore diffuse myocardial fibrosis in DCM may be reliably assessed by native T1 mapping without the administration of gadolinium contrast agent. In addition, cardiac magnetic resonance-derived ECV showed excellent agreement with histological extracellular space.

Effect of Anemia on Cardiovascular Hemodynamics, Therapeutic Strategy and Clinical Outcomes in Patients With Heart Failure and Hemodynamic Congestion.

BACKGROUND: We investigated the effect of anemia on cardiovascular hemodynamics, therapeutic strategies and clinical outcomes in heart failure (HF) patients.Methods and Results:We divided 198 consecutive HF patients who underwent right heart catheterization before in-hospital HF treatment into 2 groups according to the presence or absence of hemodynamic congestion (HC: mean pulmonary capillary wedge pressure ≥15 mmHg and/or mean right atrial pressure ≥10 mmHg). The hemoglobin level correlated with the cardiac index (CI) and systemic vascular resistance index (SVRI) (r=-0.34 and 0.42, P<0.05, respectively), and was the strongest contributor of SVRI only in the HC group. Anemic patients more frequently required intravenous inotropic support despite having higher CI and lower SVRI than non-anemic patients in the HC group. The novel hemodynamic subsets based on mean right atrial pressure and estimated left ventricular stroke work index but not Forrester subsets appropriately predicted the need for intravenous inotropic support. The probability of hospitalization for worsening HF during 2-year follow-up period was significantly higher in anemic patients than in non-anemic patients in the HC group. CONCLUSIONS: Anemia had a direct effect on cardiovascular hemodynamics and thus can confound therapeutic planning in HF patients with HC. The novel hemodynamic subsets can be applied in daily clinical practice regardless of the presence or absence of anemia.

Combination of Urinary Sodium/Creatinine Ratio and Plasma Brain Natriuretic Peptide Level Predicts Successful Tolvaptan Therapy in Patients With Heart Failure and Volume Overload.

To evaluate the short-term clinical and hemodynamic effects of tolvaptan therapy and to identify predictors of the therapeutic outcomes, we retrospectively recruited 60 consecutive hospitalized heart failure (HF) patients (70 ± 11 years) with volume overload. The subjects were divided into two groups on the basis of the changes in HF symptom scores and hemodynamic status assessed by right heart catheterization after tolvaptan therapy (median: 7 days). The majority of patients were successfully treated (group 1). However, 22% of patients (group 2) were unsuccessfully treated, in whom 1) the HF symptom score worsened or 2) there was a stationary HF symptom score ≥ 6 points, and mean PCWP > 18 mmHg and mean RAP > 10 mmHg, after tolvaptan therapy. HF symptom scores, hemodynamic parameters, and plasma brain natriuretic peptide (BNP) level improved in group 1, but all of these parameters remained unchanged in group 2. Lower urine sodium/creatinine ratio (UNa/UCr) and higher BNP level at baseline were independently associated with unsuccessful tolvaptan therapy, and UNa/UCr best predicts unsuccessful tolvaptan therapy with a cut-off value of 46.5 mEq/g·Cr (AUC 0.847, 95% CI: 0.718-0.976, sensitivity 77%, specificity 81%, P < 0.01). Double-positive results of UNa/UCr < 46.5 mEq/g·Cr and plasma BNP level > 778 pg/mL predicted unsuccessful tolvaptan therapy with high diagnostic accuracy (sensitivity 54%, specificity 100%, positive predictive value 100%, negative predictive value 89%, and accuracy 90%). In summary, short-term tolvaptan therapy ameliorated HF symptoms and provided hemodynamic improvement in the majority of patients, and UNa/UCr and BNP level strongly predicted the therapeutic outcomes.

Renal resistive index as an indicator of the presence and severity of anemia and its future development in patients with hypertension.

BACKGROUND: We examined whether renal resistive index (RI), a simple index of renal vascular resistance, is associated with the presence and severity of anemia, and can predict the future development of anemia in patients with hypertension. METHODS: We retrospectively examined 175 patients with hypertension (mean age 67 ± 11 years, 32-85 years, 134 males) who underwent renal ultrasonography. Anemia was defined as a reduction in the concentration of hemoglobin <13.0 g/dL for men and <12.0 g/dL for women. Renal RI was measured in the interlobar arteries. RESULTS: Anemia was present in 37% of men and 34% of women. The mean estimated glomerular filtration rate (eGFR) was 58 ± 23 ml/min/1.73 m(2) (median: 56 ml/min/1.73 m(2), range: 16-168 ml/min/1.73 m(2)) and the mean renal RI was 0.70 ± 0.09 (median: 0.70, range: 0.45-0.92). Proteinuria was present in 29% of patients. Both eGFR and renal RI correlated significantly with hemoglobin levels. In the stepwise multivariate linear regression analysis, renal RI was associated with hemoglobin levels independently of potential confounders including eGFR. During the follow-up period (median: 959 days, range: 7-3595 days), Kaplan-Meier curves demonstrated that patients with renal RI above the median value had a higher incidence of the future development of anemia than other patients. Cox regression analysis showed that renal RI (hazard ratio 1.18, 95% CI 1.02-1.37 per 0.05 rises in renal RI, p =0.03) and the presence of proteinuria were (hazard ratio 1.80, 95% CI 1.08-3.01, p =0.03) were independently associated with the future development of anemia after correcting for confounding factors. CONCLUSIONS: Measurement of renal RI can be useful for elucidating the pathogenesis of anemia and for inferring its potential risk in patients with hypertension.

Vacuum Rabi spectra of a single quantum emitter.

We report the observation of the vacuum Rabi splitting of a single quantum emitter by measuring its direct spontaneous emission into free space. We use a semiconductor quantum dot inside a photonic crystal nanocavity, in conjunction with an appropriate cavity design and filtering with a polarizer and an aperture, enabling the extraction of the inherently weak emitter's signal. The emitter's vacuum Rabi spectra exhibit clear differences from those measured by detecting the cavity photon leakage. Moreover, we observe an asymmetric vacuum Rabi spectrum induced by interference between the emitter and cavity detection channels. Our observations lay the groundwork for accessing various cavity quantum electrodynamics phenomena that manifest themselves only in the emitter's direct spontaneous emission.

Haemodynamic collapse in a patient with acute inferior myocardial infarction and concomitant traumatic acute spinal cord injury.

A 71-year-old man suddenly collapsed and went into cardiopulmonary arrest. The cardiopulmonary resuscitation attempt succeeded in restoration of spontaneous circulation. The initial 12-lead electrocardiogram showed inferior acute myocardial infarction (AMI). The patient was initially diagnosed as having cardiogenic shock associated with inferior AMI. In spite of early coronary revascularisation, bradycardia and hypotension were sustained. After termination of sedation and extubation, he was found to have a quadriplegia and diagnosed with a cervical spinal cord injury (SCI). Therefore, the patient was finally diagnosed with neurogenic shock caused by acute cervical SCI due to the traumatic injury preceded by loss of consciousness complicating inferior AMI. We should recognise that SCI has unique haemodynamic features that mimic those associated with inferior AMI, but requires very different treatment.