Evaluation of episodes of sleep apnea in patients with liver cirrhosis.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) has been reported to be a new complication of liver cirrhosis with ascites. This fact prompted a study of episodes of sleep apnea as a function of the severity of cirrhosis. METHODS: Forty eight patients with type C liver cirrhosis were divided according to the Child-Pugh score into 3 groups: Group A (16 patients with grade A cirrhosis), Group B (16 patients with grade B cirrhosis), and Group C (16 patients with grade C cirrhosis). Portable sleep polygraphs (Fuji RC, Inc. Tokyo, Japan) were attached to the subjects, and oronasal respiration, tracheal sounds, respiratory movements of the chest, and percutaneous arterial oxygen saturation continuously were recorded. A decrease in the mean airflow to 50% or less was defined as hypopnea, and the number per hour of episodes of apnea and hypopnea per hour lasting 10 seconds or longer (AHI) was counted. A Holter ECG was also recorded, and spectral heart rate variability during sleep was analyzed by measuring low frequency power (0.04-0.15 Hz, LF power), high frequency power (0.15-0.40 Hz, HF power), the ratio of LF power to HF power (LF/HF ratio), and very low frequency power (0.008-0.04 Hz, VLF power). The difference in QT interval between the lead CM5 and the lead CM1 (QTc dispersion) was also examined. RESULTS: AHI was significantly higher in Group C than in Groups A and B (p<0.05). In Group C, 6 patients with 20 times or more AHI per hour, obstructive sleep apnea, in which respiratory chest movements occur but oronasal respiration decreases or disappears, was observed. Spectral analyses of heart rate variability showed a decrease in HF power without sleep apnea, but increases in HF power and VLF power were observed during sleep apnea. The QTc dispersion increased during episodes of sleep apnea. CONCLUSIONS: As the stage of liver cirrhosis advanced, sleep apnea appeared, and changes in autonomic nervous activities were observed. Furthermore, QTc dispersion was increased during episodes of sleep apnea, presumably increasing the risk of ventricular arrhythmia.

Effects of thrombus suction therapy on myocardial blood flow disorders in males with acute inferior myocardial infarction.

Several studies have reported that the use of a distal protection device decreases the incidence of slow-flow and/or no-reflow in patients with myocardial infarctions. In the present study, we investigated the influence of a RESCUE/Thrombuster system and a PercuSurge GuardWire catheter on coronary microcirculation disorders in patients with acute myocardial infarction using the natriuretic polypeptide (ANP), the brain natriuretic peptide (BNP), and (99m)Tc-tetrofosmin myocardial scintigraphy (TF). The group consisted of a 77 patients with initial inferior myocardial infarction who had undergone emergency coronary angioplasty. The patients were randomly divided into: Group D (n=28), in which a direct stent alone was inserted, Group R/T (n=25), in which a stent was inserted after RESCUE system or a Thrombuster system was performed, and Group P (n=24), in which a stent was inserted after thrombus suction using a PercuSurge GuardWire catheter. Patients with coronary slow-flow/no-reflow were 3, 2 and 0 cases in Group D, Group R / T and Group P, respectively. In the present study, patients with good-reflow were enrolled in order to investigate the coronary microcirculation disorder in patients with visually similar coronary blood flow obtained in coronary angiography after percutaneous coronary reperfusion therapy. TF myocardial scintigraphy was performed 10+/-3 days after admission. Bull's eye images were divided into 8 sections, and each section was evaluated in 4 grades. The grade of each segment was regarded as the defect score. The results were compared with the database prepared based on bull's eye maps from 50 healthy adults in our hospital, and count areas of -2 x SD (standard deviation) or less were calculated as the extent score (%), reflecting the area in which myocardial blood flow was decreased. The extent and severity scores in Groups P and R/T were significantly lower than those in Group D. Coronary angiography at the chronic stage (6 months after surgery) showed the patency of the responsible vascular lesion in all patients. However, the ANP, BNP, cardiac index, and pulmonary capillary wedge pressure (PCWP) were significantly improved in Groups R/T and P, compared to Group D (p<0.01). These results suggest that the use of a RESCUE/Thrombuster system and a PercuSurge GuardWire catheter system in patients with acute inferior wall infarction improves coronary microcirculation disorders and acute- to chronic-phase cardiac function.

The effects of atorvastatin on coronary endothelial function in patients with recent myocardial infarction.

BACKGROUND: Endothelial dysfunction is a key early event in atherosclerosis that occurs in acute coronary syndrome. It was reported that atorvastatin improves the endothelial function of skeletal muscle vessels, but the effect on the coronary artery is unknown. HYPOTHESIS: The purpose of this study is to determine the effects of atorvastatin on coronary endothelial function in humans. METHODS: Non-infarct-related coronary arteries of 48 patients with acute myocardial infarction who had undergone successful percutaneous transluminal coronary angioplasty were examined. Three groups were studied: hyperlipidemia with use of atorvastatin (Group 1, n=17), hyperlipidemia without statin use (Group 2, n=18), and normal cholesterol level controls (Group 3, n=13). Statin treatment was started at discharge. Acetylcholine (Ach) was infused into the coronary artery and the diameter was assessed by quantitative angiography at baseline and after 6 months. RESULTS: Acetylcholine given in doses of 1, 3, 10, and 30 mg/min increased the coronary artery diameter change in a dose-dependent manner. In the initial study, patients in the three groups had similar responses to Ach. The mean diameter change after 6 months was significantly improved in Group 1 compared with Groups 2 and 3 (-11 +/- 3% vs. -20 +/- 7% and -21 +/- 6%, respectively; p < 0.01 in each case). Multivariate regression analysis showed that atorvastatin (p < 0.01) was the significant determinant for improvement of endothelial function. CONCLUSIONS: These findings suggest that atorvastatin improves endothelial function of the coronary artery in patients with myocardial infarction.

Efficacy of stenting after rotational atherectomy for ostial LAD and ostial LCX stenosis in patients with diabetes.

OBJECTIVE: The goal of this study was to investigate the efficacy of stenting after rotational atherectomy (rotastent) for ostial LAD and ostial LCX stenosis in patients with diabetes. BACKGROUND: Previous studies have demonstrated that rotastent for non-aorto ostial stenoses can be performed safely with high clinical success rate. However, in diabetic patients, long-term results of rotastent for ostial stenoses are still unknown. METHODS: A series of 70 patients with de novo non-aorto ostial stenosis who underwent successful elective stenting after rotational atherectomy were the subject of this study. Clinical, angiographic, and procedural characteristics, as well as acute and chronic results were obtained for all patients. RESULTS: There were no significant differences between diabetic versus non-diabetic patients in terms of baseline clinical characteristics, lesion characteristics, and procedural factors. The restenosis rate of diabetic patients was significantly higher than that of non-diabetic patients as assessed by the follow-up angiogram (53% versus 28%, respectively; p < 0.05). The rate of lesion progression which meant the development of new left main or non-treated artery-ostial narrowing was significantly higher in diabetic patients at follow-up angiography (23% versus 5%; p < 0.05 compared to non-diabetic patients). By use of multiple regression analysis, diabetes mellitus was identified as an independent predictor of restenosis and lesion progression. CONCLUSIONS: These results suggest that diabetic patients are more likely to have not only higher rates of restenosis but also development of new left main narrowing or non-treated artery ostial narrowing compared to non-diabetic patients.

Usefulness of coronary flow reserve immediately after primary coronary stenting in predicting wall motion recovery in patients with anterior wall acute myocardial infarction.

This study examined whether coronary flow reserve (CFR) measured immediately after primary coronary stenting could predict wall motion recovery in patients who have acute myocardial infarction. CFR significantly correlated with the change of wall motion score (r = 0.68, p <0.0001), and the optimal cut-off value of CFR for predicting wall motion recovery was 1.4 (sensitivity 85%, specificity 94%).

Influence of diabetes mellitus on outcome in the era of primary stenting for acute myocardial infarction.

The purpose of the present study was to examine the influence of diabetes mellitus (DM) on the clinical and angiographic outcomes in 62 diabetic and 152 nondiabetic patients with acute myocardial infarction (AMI) treated with primary coronary stenting within 12 h of the onset of symptoms. The diabetic patients had a greater incidence of hyperlipidemia, prior myocardial infarction (MI) and multivessel disease. There were no statistically significant differences in other variables. Procedural success was similar in the 2 groups. At a mean follow-up of 2.1 +/- 0.6 years, 13% of diabetic and 11% of nondiabetic patients had died (p = 0.70). The percentage of target vessel revascularization (TVR) was 37% of diabetic and 20% of nondiabetic patients (p = 0.003). Rates of major adverse cardiac events (MACE: death, non-fatal MI, TVR) were 50% of diabetic and 32% of nondiabetic patients (p = 0.007). On multivariate analysis, DM was not a predictor of death. Independent predictors of death were age, multivessel disease, TIMI < or = 2 and cardiogenic shock. However, DM and age were independent predictors of MACE. In conclusion, DM is not an independent predictor of death in patients with AMI after stenting, but diabetic patients had a higher incidence of TVR, making DM an independent predictor of MACE.

Specific findings of the standard 12-lead ECG in patients with 'Takotsubo' cardiomyopathy: comparison with the findings of acute anterior myocardial infarction.

The clinical course of 'Takotsubo' cardiomyopathy closely resembles that of acute myocardial infarction (AMI) and coronary angiography (CAG) is usually performed to distinguish the 2 conditions during the acute phase. The present study was designed to determine whether the standard 12-lead electrocardiogram (ECG) findings could help to distinguish 'Takotsubo' cardiomyopathy from anterior AMI. The study group comprised 13 patients with 'Takotsubo' cardiomyopathy and 13 consecutive patients with anterior AMI. Patients with 'Takotsubo' cardiomyopathy had abnormal Q waves less frequently than patients with anterior AMI (15% vs 69%, p=0.008). No reciprocal changes were seen in the inferior leads in patients with 'Takotsubo' cardiomyopathy (p=0.0003). The ratio of ST-segment elevation in leads V(4-6) to V(1-3) (SigmaSTeV(4-6)/V(1-3)) was significantly higher in patients with 'Takotsubo' cardiomyopathy (1.55+/-0.53 vs 0.57+/-0.58, p=0.0004). The QTc interval was significantly longer in patients with 'Takotsubo' cardiomyopathy. The absence of reciprocal changes, absence of abnormal Q waves, and a SigmaSTeV(4-6)/V(1-3) >/=1 all showed a high sensitivity and specificity for diagnosing 'Takotsubo' cardiomyopathy. Furthermore, the combination of the absence of reciprocal changes and a SigmaSTeV(4-6)/V (1-3) >/=1 had a greater specificity (100%) and overall accuracy (91%) than either criteria. Therefore, the standard 12-lead ECG on admission can help to distinguish 'Takotsubo' cardiomyopathy from anterior AMI.