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Background: Limited evidence exists regarding the incidence of recurrent venous thromboembolism (VTE) in patients diagnosed with isolated distal deep vein thrombosis (DVT) who are at risk of thrombosis extension whether they receive anticoagulation therapy or not. Objectives: The study aimed to investigate the incidence of recurrent VTE and the impact of rivaroxaban in this patient population. Methods: This open-label, exploratory, and randomized controlled trial was conducted at 7 centers in Japan between April 2019 and April 2022. Adult patients with isolated distal DVT at risk of thrombosis extension received either rivaroxaban combined with physical therapy or physical therapy alone for 90 days. Whole-leg ultrasound was performed at 14 and 90 days. We assessed a composite outcome of symptomatic or asymptomatic proximal DVT or symptomatic pulmonary embolism as the primary outcome until the end of the treatment period using an intention-to-treat analysis. Major bleeding was evaluated as a key secondary outcome. Results: Out of 90 enrolled patients, 3 were excluded due to withdrawal of consent; therefore, we analyzed 87 participants. The rivaroxaban group (n = 42) reported no primary outcomes (0%; 95% CI, 0.0%-8.4%), whereas the physical therapy group (n = 45) had 2 cases of symptomatic proximal DVT (4.4%; 95% CI, 0.5%-15.1%). Major bleeding events occurred in 4 patients in the rivaroxaban group (9.5%; 95% CI, 2.7%-22.6%), whereas no events occurred in the physical therapy group (0%; 95% CI, 0%-7.9%). Conclusion: Preliminary data suggest that rivaroxaban may reduce the risk of VTE recurrence among this patient subset, albeit with an increased incidence of bleeding events.
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An 89-year-old man with an intermittent 2:1 second-degree atrioventricular block received a permanent pacemaker (Medtronic Azure XT DR; Medtronic Inc., Minneapolis, MN, USA). Reactive antitachycardia pacing (ATP) was engaged in all transmissions 3â¯weeks later. Intracardiac recordings revealed a far-field R wave (FFRW) oversensing, occurring between atrial waves and premature atrial contractions. This event triggered the delivery of reactive ATP, which induced atrial fibrillation. A 79-year-old man underwent permanent pacemaker implantation for an intermittent complete atrioventricular block. One month after implantation, reactive ATP was initiated. The atrial electrogram of intracardiac recordings revealed one being a spontaneous P wave and the other an oversensed R wave. The criterion for an atrial tachycardia was fulfilled, and the device initiated reactive ATP. As a result, atrial fibrillation was induced by inappropriate reactive ATP. It was difficult to completely avoid inappropriate reactive ATP. Finally, we discontinued reactive ATP. The two cases presented in this study demonstrate the possibility of inappropriate reactive ATP due to FFRW oversensing, with the inappropriate reactive ATP inducing atrial fibrillation. All patients treated with reactive ATP should be carefully assessed for the presence of FFRW oversensing during pacemaker implantation and during the follow-up period. Learning objective: We present two cases of inappropriate reactive ATP caused by far-field R-wave oversensing. Inappropriate reactive ATP has not been previously reported. Therefore, we suggest that all patients provided with a DDD pacemaker should be carefully assessed for the presence of FFRW oversensing during pacemaker implantation and during the follow-up period. Remote monitoring enables very early detection of inappropriate reactive ATP delivery for rapid implementation of preventive measures.
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BACKGROUND: The simple risk index recorded in the emergency room (ER-SRI), which is calculated using the formula (heart rate × [age / 10]2) / systolic blood pressure, was shown to be able to stratify the prognosis in ST-elevation myocardial infarction (STEMI) patients. However, the prognostic impact of the prehospital simple risk index (Pre-SRI) remains unknown.MethodsâandâResults: This study enrolled 2,047 STEMI patients from the Mie Acute Coronary Syndrome (ACS) registry. Pre-SRI was calculated using prehospital data and ER-SRI was calculated using emergency room data. The primary endpoint was 30-day all-cause mortality. The cut-off values of Pre-SRI and ER-SRI for predicting 30-day mortality were 34.8 and 34.1, with accuracies of 0.816 and 0.826 based on receiver operating characteristic analyses (P<0.001 for both). There was no difference in the accuracy of the 2 indices. Multivariate Cox regression analysis demonstrated that a High Pre-SRI (≥34) was a significant independent predictor of 30-day mortality. With combined Pre-SRI and ER-SRI assessment, patients with High Pre-SRI/High ER-SRI showed significantly higher mortality than those with High Pre-SRI/Low ER-SRI, Low Pre-SRI/High ER-SRI, and Low Pre-SRI/Low ER-SRI (P<0.001). The addition of High Pre-SRI to High ER-SRI showed incremental prognostic value of the Pre-SRI. CONCLUSIONS: Pre-SRI can identify high-risk STEMI patients at an early stage and combined assessment with Pre-SRI and ER-SRI could be of incremental prognostic value for risk stratification in STEMI patients.
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Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Niño , Pronóstico , Riesgo , Síndrome Coronario Agudo/diagnóstico , Servicio de Urgencia en Hospital , Medición de RiesgoRESUMEN
BACKGROUND: Aortic valve stenosis (AS) leads to increased cardiovascular mortality and morbidity, and recent studies reported that even mild-to-moderate AS was associated with poor prognosis in the general population. This study investigated the prognostic impact of mild or moderate AS, defined as 2.0 m/s ≤ peak aortic jet velocity (Vmax) ≤3.9 m/s using echocardiography in acute myocardial infarction (AMI) patients.MethodsâandâResults: This study enrolled 3,049 AMI patients using data from the Mie ACS registry. Patients were divided into 2 groups according to Vmax: Group 1: Vmax <2.0 m/s and/or visually intact aortic valve in which all 3 leaflets are fully and evenly open; Group 2: 2.0 m/s ≤ Vmax ≤ 3.9 m/s. There were 2,976 patients in Group 1and 73 patients in Group 2. The Group 2 patients were older, had a higher percentage of males and had lower body mass index and Killip ≥2 than the Group 1 patients. Angiographic data, door-to-balloon time, and mechanical support were not different between the 2 groups. The Group 2 patients demonstrated a significantly higher all-cause mortality rate (P<0.01) and composite of cardiovascular death and heart failure hospitalization (P<0.01), and Kaplan-Meier analysis showed the same tendency in propensity score-matched patients. CONCLUSIONS: The present study revealed that mild or moderate AS based on Vmax is associated with poor prognosis following AMI.
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Estenosis de la Válvula Aórtica , Infarto del Miocardio , Humanos , Masculino , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico por imagen , Pronóstico , Índice de Severidad de la Enfermedad , Volumen SistólicoRESUMEN
Ebstein's anomaly is an uncommon congenital disorder affecting the tricuspid valve. We herein report a 38-year-old woman who experienced consciousness and sensory disturbance during treatment for heart failure caused by Ebstein's anomaly. Urgent magnetic resonance imaging and cerebral angiography demonstrated acute cerebral infarction and internal carotid artery obstruction with the development of collateral arteries. We diagnosed her with multiple cerebral infarctions due to moyamoya disease. Ebstein's anomaly concomitant with moyamoya disease is extremely rare. However, we should consider the possibility of this rare but important concurrence when treating patients with heart failure due to Ebstein's anomaly to avoid excessive diuresis and vasodilation and irreversible brain injury.
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Anomalía de Ebstein , Insuficiencia Cardíaca , Enfermedad de Moyamoya , Femenino , Humanos , Adulto , Anomalía de Ebstein/complicaciones , Anomalía de Ebstein/diagnóstico por imagen , Enfermedad de Moyamoya/complicaciones , Enfermedad de Moyamoya/diagnóstico por imagen , Válvula Tricúspide , Insuficiencia Cardíaca/complicacionesRESUMEN
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 ≥7.0â¯mg/dL in men andâ¯≥â¯6.0â¯mg/dL in women. The primary endpoint was suboptimal coronary flow, defined as post PCI Thrombosis In Myocardial Infarction flow gradeâ¯≤â¯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%, pâ¯<â¯0.001). In addition, the median high-sensitivity C-reactive protein was significantly higher in patients with hyperuricemia (0.18â¯mg/dL; IQR, 0.09-0.71â¯mg/dL) than in those without (0.14â¯mg/dL; IQR, 0.07-0.41â¯mg/dL, pâ¯<â¯0.05). Under these conditions, the prevalence of suboptimal coronary flow after PCI (17.3% vs. 10.1%, pâ¯<â¯0.05) and in-hospital mortality (10.8% vs. 3.6%, pâ¯<â¯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; pâ¯<â¯0.05] and in-hospital mortality (OR, 2.08; 95% CI, 1.05-4.12; pâ¯<â¯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.
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Hiperuricemia , Infarto del Miocardio , Intervención Coronaria Percutánea , Femenino , Mortalidad Hospitalaria , Humanos , Hiperuricemia/complicaciones , Masculino , Intervención Coronaria Percutánea/efectos adversos , Factores de Riesgo , Resultado del Tratamiento , Ácido ÚricoRESUMEN
Purpose: To investigate the impact of the size and location of waterclefts (WC), which are one of several cataract subtypes, on visual function by optical simulation analysis. Methods: An optical simulation software (CODE V) was used to develop a schematic eye model and several sizes of WC central and peripheral types that were located below the anterior and posterior subcapsules of the crystalline lens, and analyses of refraction, higher-order aberrations (HOA), and the modulation transfer function (MTF) were performed. Results: An increase in the WC size increased the refraction and HOA and decreased the MTF. The impact of the WC below the posterior subcapsule on the visual function was more enhanced than that below the anterior subcapsule. Large WC demonstrated a remarkable hyperopic shift in refractive power as well as an increase in HOA. The MTF decreased slightly with increasing WC size at a spatial frequency of 20 cycles/mm, and it decreased remarkably at 60 cycles/mm. Conclusions: The impact on the visual function increased with increasing WC size. It was revealed that eyes with WC below the posterior subcapsule are more hyperopic than those with WC below the anterior subcapsule, and the former have a higher HOA and lower MTF than the latter.
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Catarata/fisiopatología , Simulación por Computador , Errores de Refracción/fisiopatología , Agudeza Visual/fisiología , Anciano , Catarata/diagnóstico por imagen , Aberración de Frente de Onda Corneal/fisiopatología , Femenino , Humanos , Persona de Mediana Edad , Refracción Ocular/fisiologíaRESUMEN
Background: We hypothesized that symptom presentation in patients with acute myocardial infarction (AMI) may affect their management and subsequent outcome. MethodsâandâResults: 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.
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BACKGROUND: Chronic total occlusion (CTO) in a non-infarct-related artery (IRA) in patients with acute coronary syndrome (ACS) is associated with a poor prognosis. However, whether the prognostic impact of non-IRA CTO differs according to left ventricular ejection fraction (LVEF) is unclear. METHODS AND RESULTS: A total of 2060 consecutive acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) were classified into 2 groups according to their LVEF (reduced EF: LVEF < 50%, preserved EF: LVEF ≥ 50%) and further subdivided according to the presence of concomitant non-IRA CTO. In the reduced EF group, patients with CTO had a higher 1-year all-cause death rate (20.3% vs. 34.3%, P = 0.001) and major adverse cardiac event rate (MACE: 19.6% vs. 39.6%, P < 0.001) compared to those without CTO, but they were similar between patients with and without CTO in the preserved EF group. Non-IRA CTO was an independent predictor of all-cause death (HR 1.58, 95% CI 1.06-2.33, P = 0.02) and MACE (HR 1.67, 95% CI 1.14-2.46, P = 0.009) only in the reduced EF group. In addition, the outcomes of successful CTO-PCI seemed to be similar to those without CTO in the reduced EF group. CONCLUSIONS: CTO in a non-IRA may contribute to a poor prognosis only in AMI patients with reduced LVEF.
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BACKGROUND: Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by elevated low-density lipoprotein cholesterol concentration and premature acute coronary syndrome (ACS). However, hereditary diseases may have regional characteristics, and few data are available regarding the prevalence of FH throughout particular regions in Japan. This study investigated the prevalence and prognosis of FH in patients with ACS in Mie Prefecture, Japan.MethodsâandâResults:This study investigated 738 ACS patients from the Mie ACS Registry in Mie Prefecture, and 706 (95.7%) with sufficient data to diagnose FH were enrolled for analysis. Eighteen patients (2.5%) were diagnosed with FH, which was similar to findings of another multidistrict registry conducted in Japan. Patients with FH were significantly younger and had a higher prevalence of premature onset of ACS than patients with non-FH (P<0.01). Incidence of major adverse cardiac and cerebrovascular events (MACCE) was not statistically different between patients with FH and non-FH in this study population, even in the propensity score-matched analysis. CONCLUSIONS: Prevalence of FH in ACS patients from the Mie Prefecture was similar to that found in another Japanese multidistrict registry. Among ACS patients, short-term incidence of MACCE was not statistically different between patients with FH and non-FH in this study population.
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Síndrome Coronario Agudo , Hiperlipoproteinemia Tipo II , Síndrome Coronario Agudo/epidemiología , Síndrome Coronario Agudo/etiología , Humanos , Hiperlipoproteinemia Tipo II/epidemiología , Japón/epidemiología , Prevalencia , Pronóstico , Sistema de Registros , Factores de RiesgoRESUMEN
BACKGROUND: Fractional flow reserve (FFR) is useful for assessing the functional significance of coronary artery stenosis, even in lesions with prior myocardial infarction (pMI). Instantaneous wave-free ratio (iFR) is a vasodilator-free alternative for the physiological assessment of coronary artery stenosis. In addition, iFR shows good diagnostic agreement with FFR and an iFR-guided revascularization strategy was non-inferior to an FFR-guided revascularization strategy. However, the clinical usefulness of iFR for the evaluation of a coronary artery lesions with pMI has not been evaluated. METHODS AND RESULTS: A total of 200 lesions from 200 patients (44 pMI territories lesions and 156 non-pMI coronary artery lesions) were analyzed retrospectively. Major adverse cardiac events (MACE) were defined as cardiovascular death, non-fatal MI, unstable angina pectoris, fatal arrhythmia and heart failure during 12â¯months follow-up after the physiological assessment of coronary artery stenosis. iFR was closely correlated with FFR in pMI and non-pMI lesions (râ¯=â¯0.81 and 0.72; Pâ¯<â¯0.001, respectively). In pMI lesions, an iFR cut-off of 0.89 was optimal against a clinical FFR cut-off of 0.80 according to receiver operating characteristics (ROC) curve analysis, whereas in non-pMI lesions, the iFR cut-off value was 0.92 without statistical significance. In addition, the event rate of MACE was similar between pMI and non-pMI patients during follow-up even in the presence or absence of an PCI procedure. CONCLUSIONS: iFR may be a useful alternative method compared with FFR for clinical decision-making even in pMI patients.
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AIM: Although high on-treatment platelet reactivity (HTPR) with dual antiplatelet therapy (DAPT) correlates with long-term adverse outcomes in patients undergoing percutaneous coronary intervention, the correlation in Japanese patients remains unclear. Therefore, we examined the relationship between platelet reactivity during DAPT with aspirin and clopidogrel and 1-year clinical outcomes following successful coronary stent implantation. METHODS: A prospective, multicenter registry study (j-CHIPS) was conducted in patients undergoing coronary stenting and receiving aspirin and clopidogrel at 16 hospitals in Japan. A VerifyNow point-of-care assay was used to assess platelet reactivity, and a cutoff value to define HTPR was established. RESULTS: Between February 2011 and May 2013, 1047 patients were prospectively enrolled, of which 854 patients with platelet function evaluation at 12-24 h after PCI were included in the final analysis. After 1 year of follow-up, the incidence of the primary endpoint (a composite of all-cause mortality, myocardial infarction, stent thrombosis, and ischemic stroke) was significantly higher in patients with HTPR than in those without (5.9% vs. 1.5%, p=0.008), and HTPR showed a modest ability to discriminate between patients who did and did not experience major adverse cardiac and cerebrovascular events (area under the curve, 0.60; 95% confidence interval, 0.511-0.688, p=0.039). HTPR status did not identify patients at risk for major or minor bleeding events. CONCLUSION: HTPR was significantly associated with adverse ischemic outcomes at 1 year after PCI in Japanese patients receiving maintenance DAPT, indicating its potential as a prognostic indicator of clinical outcomes in this high-risk patient population.
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Aspirina/administración & dosificación , Clopidogrel/administración & dosificación , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Stents/efectos adversos , Anciano , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Infarto del Miocardio , Pruebas de Función Plaquetaria , Accidente CerebrovascularRESUMEN
BACKGROUND: Obesity is associated with increased morbidity and mortality. However, obesity paradox has been discussed in some patients with cardiovascular disease. OBJECTIVES: We investigated the mechanisms of the obesity paradox in acute myocardial infarction (AMI) patients. METHODS: We evaluated 1634 AMI patients with primary percutaneous coronary intervention (PCI). Patients were divided into 6 subgroups according to baseline body mass index (BMI) (low BMI: <20â¯kg/m2, normal BMI: 20-24.9â¯kg/m2, high BMI: ≥25â¯kg/m2) and age (the younger and elderly groups consisting of patients <70 and ≥70â¯years old). The primary outcome was defined as all-cause mortality. RESULTS: During the follow-up periods (median, 620â¯days; range, 344 to 730â¯days), 8.7% of patients experienced all-cause death. According to the Kaplan-Meier survival analysis, the patients in the younger age group with high BMI demonstrated significantly higher all-cause mortality compared to the other patients in the same age group (Pâ¯=â¯0.012). In contrast, patients in the elderly age group with low BMI demonstrated significantly higher all-cause mortality compared to the others in the same age group (Pâ¯<â¯0.001). Multivariate cox regression analyses showed that low BMI in the elderly age group (HR 1.69, 95% CI 1.12 to 2.55, Pâ¯=â¯0.012) and high BMI in the younger age group (HR 2.77, 95% CI 1.19 to 6.45, Pâ¯=â¯0.018) were independent predictors of all-cause mortality. CONCLUSIONS: The obesity paradox was recognized only in patients in the elderly age group and not in the younger age group. The prognostic impact of BMI may differ by age in AMI patients.
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Índice de Masa Corporal , Infarto del Miocardio/epidemiología , Obesidad/epidemiología , Intervención Coronaria Percutánea , Sistema de Registros , Medición de Riesgo/métodos , Distribución por Edad , Factores de Edad , Anciano , Causas de Muerte/tendencias , Angiografía Coronaria , Femenino , Estudios de Seguimiento , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/etiología , Obesidad/complicaciones , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
This study aimed to clarify the difference between the durations of first and second periods of depression-induced sick leave and to identify predictors of a prolonged second period of depression-induced sick leave. Among Japanese employees who were registered in the Japan sickness absence and return to work (J-SAR) study, the subjects were those employees who returned to work after an initial period of depression-induced sick leave (F3; ICD-10, based on a psychiatrist's certificate), and returned to work after a second period of depression-induced sick leave. The subjects' second periods of sick leave (mean: 156.9 d) were longer than their first periods of sick leave (107.3 d) (Wilcoxon test, p=0.007). In the logistic regression analysis (Table 2), "longer duration of the first period of sick leave" (Odds ratio: 3.258, 95%CI: 1.780-5.963, p<0.001) was identified as a significant predictor of a longer recurrent period of sick leave. Individuals who experience a long initial period of depression-induced sick leave should be supported carefully by occupational health professionals after they RTW.
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Depresión/epidemiología , Reinserción al Trabajo/estadística & datos numéricos , Ausencia por Enfermedad/estadística & datos numéricos , Adulto , Femenino , Humanos , Japón/epidemiología , Masculino , Salud Laboral/estadística & datos numéricos , Factores de TiempoRESUMEN
A 67-year-old woman presented with exertional dyspnea. An electrocardiogram showed complete left bundle branch block. Cardiac magnetic resonance imaging revealed left ventricular (LV) dilatation with reduced ejection fraction, no evidence of myocardial ischemia and late gadolinium enhancement (LGE) in the inferior LV wall. She was diagnosed with decompensated heart failure (HF) secondary to non-ischemic dilated cardiomyopathy. Narrowing of the QRS complex, disappearance of LGE, and remarkable LV reverse remodeling along with improvement in HF symptoms were achieved by combination therapy with angiotensin II receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist. This case highlights the role of triple-blockade therapy in the treatment of HF.
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Cardiac pacemakers using rate response technologies represent the effectiveness of increasing the heart rate and cardiac output during exercise. Minute ventilation (MV) sensors are popular and estimate rates using transthoracic impedance by emitting very low amperage short electrical current pulses between the pacemaker lead tip and pulse generator. We present a case of an incomplete pacemaker lead fracture developing inappropriate pacing inhibition due to oversensing caused by the electrical current emitted by the MV sensor. A permanent pacemaker replacement was performed, resulting in no further abnormal findings such as inappropriate pacing inhibition.
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BACKGROUND: There are few reports examining regional differences between rural prefectures and metropolitan areas in the management of acute myocardial infarction (AMI) in Japan.MethodsâandâResults: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.
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Servicios Médicos de Urgencia/normas , Infarto del Miocardio/terapia , Tiempo de Tratamiento/normas , Anciano , Ambulancias , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea , Sistema de Registros , Servicios de Salud Rural/normas , Servicios Urbanos de Salud/normasRESUMEN
BACKGROUND: Recent studies using stress-rest perfusion cardiovascular magnetic resonance (CMR) demonstrated a close correlation between myocardial ischemia and reduced fractional flow reserve (FFR). However, its diagnostic concordance may be reduced in patients with multivessel disease. We sought to evaluate the concordance of adenosine stress-rest perfusion CMR for predicting reduced FFR, and to determine the additive value of measuring global coronary flow reserve (CFR) in the coronary sinus in multivessel disease. METHODS AND RESULTS: Ninety-six patients with angiographic luminal narrowing >50% underwent comprehensive CMR study and FFR measurements in 139 coronary vessels. FFR <0.80 was considered hemodynamically significant. Global CFR was quantified as the ratio of stress-rest coronary sinus flow measured by phase-contrast cine CMR. In 25 patients with single-vessel disease, visual assessment of perfusion CMR yielded high diagnostic concordance for predicting flow-limiting stenosis, with the area under receiver operating characteristic curve of 0.93 on a per-patient basis. However, in 71 patients with multivessel disease, perfusion CMR underestimated flow-limiting stenosis, resulting in the reduced area under receiver operating characteristic curve of 0.74. When CFR of <2.0 measured in the coronary sinus was considered as global myocardial ischemia, combined assessment provided correct reclassifications in 7 patients with false-negative myocardial ischemia, and improved the diagnostic concordance to 92% sensitivity and 73% specificity with the area under receiver operating characteristic curve of 0.88 (95% confidence interval, 0.80%-0.97%, P=0.002). CONCLUSIONS: Visual analysis of stress-rest perfusion CMR has limited concordance with FFR in patients with multivessel disease. Multiparametric CMR integrating stress-rest perfusion CMR and flow measurement in the coronary sinus is useful for detecting reduced FFR in multivessel disease.
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Adenosina/administración & dosificación , Cateterismo Cardíaco , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Seno Coronario/diagnóstico por imagen , Estenosis Coronaria/diagnóstico por imagen , Reserva del Flujo Fraccional Miocárdico , Imagen por Resonancia Cinemagnética , Imagen de Perfusión Miocárdica/métodos , Vasodilatadores/administración & dosificación , Anciano , Velocidad del Flujo Sanguíneo , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/fisiopatología , Seno Coronario/fisiopatología , Estenosis Coronaria/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
Aims: Unrecognized myocardial scar by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) is strongly associated with cardiac event in patients with stable coronary artery disease. The purpose of this study was to evaluate the prognostic impact of unrecognized non-infarct-related LGE (non-IR-LGE) in patients with acute myocardial infarction (AMI). Methods and results: We studied 269 patients with a first clinical episode of AMI underwent cardiac MRI within 6 weeks after onset (209 men; age, 66 ± 12 years). LGE, cine MRI and T2-weighted imaging were obtained to evaluate the presence and extent of LGE and to evaluate cardiac function. Major adverse cardiac events (MACE) were defined as cardiovascular death, non-fatal AMI, unstable angina requiring revascularization, fatal arrhythmia, and heart failure. Unrecognized non-IR LGE was observed in 13.0% of patients. During follow-up periods (median, 22 months; range, 3-95 months), 8.9% of patients experienced MACE in this study. In addition, 22.9% of patients with unrecognized non-IR LGE and 6.8% of patients without unrecognized non-IR-LGE experienced MACE (P < 0.01). The presence of unrecognized non-IR LGE predicted MACE with a hazard ratio of 3.45 (95% confidential interval, 1.03-11.47; P < 0.01). In addition, unrecognized non-IR LGE was the strongest independent predictors of MACE with a hazard ratio of 3.30 by the Cox proportional hazards model (P < 0.01). In contrast, angiography-proven multi-vessel disease and transmural extent of infarct-related LGE were not independently associated with MACE. Conclusion: Among patients with a first clinical episode of AMI, unrecognized non-IR myocardial scar provides incremental prognostic value for predicting MACE beyond that of common clinical, angiographic and functional variables.