Absent fourth heart sound as a marker of adverse events in hypertrophic cardiomyopathy with sinus rhythm.

BACKGROUND: Patients with hypertrophic cardiomyopathy (HCM) in sinus rhythm commonly show the fourth heart sound (S4). The lack of S4 may be a marker of impaired atrial function in HCM patients with sinus rhythm. METHODS AND RESULTS: This retrospective study consisted of 47 patients with HCM who had undergone phonocardiography and a cardiopulmonary exercise test. The primary outcome was a composite of cardiac death, stroke, hospitalization for worsening heart failure, and newly developed atrial fibrillation (AF). S4 was detected in 38 of 43 patients with sinus rhythm (88%). Peak oxygen consumption was the highest in 38 sinus rhythm patients with S4 (23.6 ± 5.6 mL/kg/min), middle in five sinus rhythm patients without S4 (19.3 ± 6.7 mL/kg/min), and lowest in four patients with AF (15.7 ± 3.3 mL/kg/min, p = 0.01). After a median of 40.5 months, the incidence of the primary outcome was higher in patients without S4 than in those with S4 (33% vs. 8%; hazard ratio, 6.17; 95% confidence interval, 1.02 - 37.4; p = .04) and higher in sinus rhythm patients without S4 than in those with S4 (60% vs. 8%; hazard ratio, 12.05; 95% confidence interval, 2.31 - 71.41; p = .007). CONCLUSIONS: The absence of S4 on phonocardiography was associated with impaired exercise tolerance and adverse cardiac events in HCM patients with sinus rhythm.

Simple Phonocardiography with the Ankle-Brachial Index Measurement System as a Tool for Detecting Fourth Heart Sounds of Hypertrophic Cardiomyopathy.

Conventional phonocardiography is useful for objective assessment of cardiac auscultation, but its availability is limited. More recently, an ankle-brachial index (ABI) measurement system equipped with simple phonocardiography has become widely used for diagnosing peripheral artery disease, however, whether this simple phonocardiography can be an alternative to conventional phonocardiography remains unclear.This retrospective study consisted of 48 patients with hypertrophic cardiomyopathy (HCM) and 107 controls. The presence of the fourth sound (S4) was assessed by conventional phonocardiography, in addition to apexcardiography and auscultation, in all patients with HCM. S4 was also estimated by the ABI measurement system with the phonocardiographic microphone on the sternum (the standard method) or at the apex (the apex method) in HCM patients and controls.S4 on conventional phonocardiography was detected in 42 of 48 patients (88%) with HCM. Auscultation for the detection of S4 had a sensitivity of 0.78, specificity of 0.57, and accuracy of 0.75. These diagnostic values were generally superior to those of the standard method using the ABI measurement system, whereas the apex method using the ABI measurement system had better diagnostic values, with an excellent specificity of 1.0, sensitivity of 0.77, and accuracy of 0.80. No significant differences were observed in low ABI defined as < 0.9.Simple phonocardiography equipped with the ABI measurement system may be an alternative to conventional phonocardiography for the detection of S4 in patients with HCM when the phonocardiographic microphone is moved from the sternum to the apex.

The Bezold-Jarisch reflex in a patient with coronary spastic angina.

Acute inferior myocardial damage can induce transient bradycardia and hypotension-the Bezold-Jarisch reflex, which is explained by the preferential distribution of vagal nerves in the inferior wall of the left ventricle. We report a 76-year-old man who showed a perfusion defect in the inferior wall with redistribution on exercise scintigraphy with thallium-201. Of note, during exercise at an intensity of 100 watts, the patient's heart rate transiently decreased from 122 to 95 bpm in sinus rhythm, accompanied by ST-segment depression. A diagnosis of coronary spastic angina was made since no stenotic lesions were observed on conventional coronary angiography.

Ventricular late potentials and myocardial fibrosis in hypertrophic cardiomyopathy.

AIMS: Ventricular late potentials (VLPs) represent delayed conduction due in part to myocardial fibrosis. We sought to examine the relationship of signal-averaged electrocardiography findings with myocardial fibrosis as assessed by cardiac magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM). METHODS: This study consisted of 41 HCM patients with sinus rhythm who had undergone risk assessment including CMR and signal-averaged electrocardiography such as VLPs, filtered QRS duration, low amplitude signal duration of the terminal filtered QRS below 40 µV (LAS), and root mean square voltage of the late 40 ms of the filtered QRS (RMS). The concordance rate between VLPs and myocardial fibrosis as assessed by CMR was examined. RESULTS: Late gadolinium enhancement (LGE) on CMR was detected in 13 patients, and VLPs were detected in 14. Filtered QRS duration, LAS, RMS, and VLPs were not associated with LGE. The results of LGE and VLPs were concordant in 26 patients, whereas 15 exhibited discordance. Patients with discordance had a higher maximum wall thickness (24.1 ±â€¯4.0 mm versus 21.0 ±â€¯5.9 mm, p < 0.05), higher LGE volume (2.3 ±â€¯1.2 g/cm versus 0.0 ±â€¯0.8 g/cm, p < 0.01), lower LGE volume/the total number of sites with LGE (1.5 ±â€¯0.7 versus 3.1 ±â€¯2.8, p < 0.01), and predominant LGE location of the interventricular septum and anterior wall (60% versus 8%, p < 0.01) than patients with concordance. CONCLUSION: VLPs were not a reliable marker for the detection of myocardial fibrosis as assessed by LGE on CMR in our cohort of patients with HCM. CONDENSED ABSTRACT: Ventricular late potentials on signal-averaged electrocardiography represent delayed conduction due in part to myocardial fibrosis but were not an alternative to cardiac magnetic resonance for detecting myocardial fibrosis in patients with hypertrophic cardiomyopathy.

Insight into the Time Course of Type III Kounis Syndrome: A Case Report.

BACKGROUND: Kounis syndrome is a rare condition that is characterized by the coexistence of acute coronary syndrome and allergic reactions; however, its time course remains unclear. We report a case of anaphylactic shock with subsequent development of ST-segment elevation myocardial infarction. CASE REPORT: A 47-year-old man with food allergies presented to the emergency department of our hospital with breathing difficulties after eating bread. He had a history of angina and underwent stent implantation 3 years earlier. On examination, he was lethargic, disoriented, and in shock. He had a rash on his face and anterior chest wall, as well as severe itching and sweating. Anaphylaxis was diagnosed and, 3 min after presentation, 0.5 mg epinephrine was injected intramuscularly into the right thigh. Electrocardiography, which was recorded 2 min after the administration of epinephrine, was normal; however, chest pain developed suddenly 18 min later. Repeat electrocardiography showed ST-segment elevations, and emergency coronary angiography revealed total occlusion of the left anterior descending coronary artery (i.e., the previous stenting site). Recanalization of the left anterior descending coronary artery was achieved after repeated thrombus aspiration with difficulty, followed by stent implantation inside of the stent under the support of intra-aortic balloon pumping. The clinical course was uneventful. He was discharged and advised to avoid eating wheat and carry an epinephrine self-injection kit for anaphylaxis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The present case highlights the importance of recognizing Kounis syndrome in the management of anaphylactic shock because treatment may be difficult, particularly in patients with type III Kounis syndrome.

Childhood dietary intake: Comparison between anorexia nervosa and healthy leanness.

BACKGROUND: The number of adolescent patients with anorexia nervosa is increasing. In addition, an increase in pre-adolescent patients with premenarchal onset has also been recognized. Detection of the disease in childhood and adolescence, however, is not always easy because the symptoms are not characteristic during this period. This study was performed to investigate detection of anorexia nervosa in children/adolescents by comparing energy and nutrient intake between patients with anorexia nervosa and healthy thin persons. METHODS: The subjects consisted of 13 girls aged 14.4 ± 3.5 years with anorexia nervosa and 320 healthy girls aged 12.4 ± 1.3 years. Dietary intake was evaluated using a validated diet history questionnaire designed for children/adolescents. Daily energy and nutrient intake were expressed as a percentage of the age- and sex-matched reference amount. RESULTS: Healthy lean (body mass index [BMI], <50th percentile) girls with an above-average score for desiring thinness had higher fat and lower cereal intake, and a trend of lower carbohydrate intake. In contrast, patients with anorexia nervosa, compared with thin (BMI <5th percentile) girls, characteristically had significantly lower energy, fat, zinc, vitamin C, and confectionery intake. CONCLUSIONS: Lean girls with an above-average desire for thinness appear to restrict their energy intake by reducing their intake of carbohydrates such as cereals while maintaining a relatively high fat intake. In contrast, girls with anorexia nervosa avoided fat and had a preference for vegetables. This characteristic eating pattern could be a useful clue for detection of anorexia nervosa in thin children and adolescents.

Imaging of Right-to-Left Shunt in an Adult Patient with Unroofed Coronary Sinus with Persistent Left Superior Vena Cava.

A 54-year-old woman with a history of multiple cardiac surgeries suffered from hypoxemia caused by a right-to-left intra-cardiac shunt due to coronary sinus (CS) anomaly with persistent left superior vena cava (PLSVC). Both the contrast echocardiography and enhanced computed tomography (CT) provided conclusive diagnosis of this rare congenital anomaly, which was overlooked for a long time. However, an important diagnostic clue was left-arm injection of the contrast media. In the present case, previously performed enhanced CT with its routine manner, i.e., contrast through the right arm, missed this anomaly. It is crucial to note that the unusual type of unroofed CS with PLSVC, presenting with an entirely right-to-left intra-cardiac shunt, cannot be delineated on an enhanced routine chest CT if the contrast media is injected through the right arm.

Association between serum soluble low-density lipoprotein receptor levels and metabolic factors in healthy Japanese individuals.

BACKGROUND: Soluble low-density lipoprotein receptor (sLDL-R) is formed by cleavage of the extracellular domain of low-density lipoprotein receptor (LDL-R). It is unclear whether serum sLDL-R is a marker of diseases associated with triglyceride (TG) metabolism. We investigated the association between serum sLDL-R concentrations and other biochemical parameters in healthy Japanese individuals. METHODS: Study subjects consisted of 102 healthy adult Japanese volunteers (42 men, 60 women) with body mass index (BMI) < 30 kg/m(2) and serum TGs, LDL cholesterol (LDL-C), aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase, and glucose concentrations within normal ranges. Serum sLDL-R concentrations were determined by enzyme-linked immunosorbent assay and their correlations with biochemical parameters were analyzed. RESULTS: Mean serum sLDL-R concentration was 120.9 ± 39.9 ng/ml. Serum sLDL-R levels were significantly and positively correlated with BMI (rs = 0.252) and TG (rs = 0.408) and LDL-C (rs = 0.325) concentrations. Multiple regression analysis adjusted for age, gender, and smoking showed that BMI (ß = 0.274), TG (ß = 0.328), and LDL-C (ß = 0.224) were factors independently correlated with sLDL-R levels. CONCLUSION: Serum sLDL-R concentration may be a marker of diseases associated with TG metabolism. This is the first report to date describing the clinical relevance of sLDL-R.

Jugular Venous Response for Risk Stratification in Heart Failure.

BACKGROUND:  The response of jugular venous pressure (JVP) to increased preload with inspiration has been recognized as a method of stratifying risk in the management of heart failure (HF). Whether the JVP response to inspiration may be more effective than other simple approaches in this setting remains unclear. METHODS:  This study enrolled 79 patients with stable HF. JVP was assessed from the right internal jugular vein in the sitting position and was considered high if visible above the right clavicle at rest. JVP responses to inspiration, the five-repetition sit-to-stand test (5-STS), and squatting were also evaluated. The primary outcome was a composite of all-cause death and hospitalization for worsening HF. RESULTS:  JVP assessment after 5-STS and during squatting was not conducted in two and 14 HF patients, respectively, due to physical limitations. During a mean follow-up of 837 days, the primary outcome was associated with a high JVP at rest (hazard ratio, 2.47; 95% confidence interval [CI], 1.09 to 5.60; P <0.05), with inspiration (hazard ratio, 2.53; 95% CI, 1.17 to 5.46; P <0.05), after 5-STS (hazard ratio, 2.61; 95% CI, 1.23 to 5.97; P <0.05), and during squatting (hazard ratio, 2.40; 95% CI, 1.03 to 6.06; P <0.05). Among patients without a high JVP at rest, the specificity of the primary outcome at one year was greater for the JVP response to inspiration (89%) and squatting (92%) than for the response to 5-STS (80%). CONCLUSIONS:  JVP response to increased preload with inspiration may be a simple and practical method for risk assessment in patients with stable HF.

Takotsubo cardiomyopathy induced by acute coronary syndrome: A case report.

Takotsubo cardiomyopathy (TC) can be provoked by various triggers. It should be differentiated from acute coronary syndrome (ACS). Herein, we report a case of TC triggered by ACS. An 80-year-old woman was referred to the emergency room because of prolonged chest pain and ST-segment elevations. Echocardiography demonstrated left ventricular apical ballooning, findings suggestive of TC rather than ACS. Emergency coronary angiography revealed severe stenosis of the first diagonal branch of the left anterior descending coronary artery with distal flow delay. Recanalization of the diagonal branch was achieved by stent implantation and her chest pain was resolved. Cardiac magnetic resonance imaging showed increased signal intensities in the apex and the inner layer of the anterior wall on fat-suppressed, T2-weighted imaging. The present case highlights the importance of recognizing TC in relation to ACS not only as a differential diagnosis but also as a possibly concomitant condition unless clinical features fit one diagnosis. Learning objective: Takotsubo cardiomyopathy can be provoked by various conditions and differentiated from acute coronary syndrome based on the presence or absence of coronary artery stenosis. Our case highlights the importance of acknowledging that takotsubo cardiomyopathy may be induced by acute coronary syndrome.

High Glucose-stimulated aPKC Activation Promotes Pancreatic Cancer Cell Progression Through YAP Signaling.

BACKGROUND/AIM: Persistent hyperglycemia caused by diabetes mellitus is a risk factor for pancreatic cancer (PC). We have previously reported that aberrant activation of atypical protein kinase C (aPKC) enhances PC cell progression. However, no reports have elucidated whether hyperglycemia promotes PC cell progression and whether aPKC activation is related to PC cell progression mechanisms. MATERIALS AND METHODS: We examined whether high-glucose stimulation accelerates PC cell proliferation, migration, and invasion. Furthermore, to determine whether PC cells activate aPKC upon high-glucose stimulation, we measured the phosphorylation of aPKC at T560 in PC cells. RESULTS: High-glucose stimulation accelerated PC cell proliferation, migration, and invasion. High-glucose treatment increased aPKC's activated form, with T560 phosphorylation, in PC cells. However, aPKC knockdown attenuated these effects. aPKC reportedly induces cell transformation through Yes-associated protein (YAP) activation. YAP expression was increased in high glucose-treated PC cells but not in aPKC-knockdown cells. aPKC interacts with partitioning defective 3 (Par-3), which aids in establishing cell polarity and inhibits aPKC by binding as a substrate. In Par-3-knockdown PC cells, YAP expression increased independently of high-glucose treatment. Over-expression of Par-3 and aPKC-dominant negative mutants prevented the high glucose-stimulated nuclear localization of YAP. YAP forms a complex with the zinc finger E-box binding homeobox 1 protein (ZEB1), an activator of epithelial-mesenchymal transition. ZEB1 expression was increased by high glucose treatment or Par-3 knockdown, but aPKC knockdown suppressed this increase. CONCLUSION: High glucose-induced aPKC activation promotes PC progression by enhancing the YAP signaling pathway.

Holter monitoring and long-term prognosis in hypertrophic cardiomyopathy.

OBJECTIVES: Limited data are available regarding Holter monitoring for cardiovascular events except for ventricular tachycardia as a risk marker for sudden death in hypertrophic cardiomyopathy (HCM). We aimed to examine Holter findings in relation to the long-term prognosis in patients with HCM. METHODS: Ambulatory Holter monitoring was performed in 106 HCM patients with sinus rhythm. All were prospectively followed for the composite endpoint of sudden death, cardiovascular death, and hospitalization for heart failure or stroke associated with atrial fibrillation. RESULTS: Cardiovascular events occurred in 19 patients during a mean follow-up of 10.1 years. Neither arrhythmia information nor autonomic information as assessed by heart rate variability and turbulence significantly differed between HCM patients with and without cardiovascular events. Average heart rates were lower in HCM patients with cardiovascular events (64.7 ± 11.2 beats/min) than in those without (73.7 ± 10.2 beats/min, p = 0.001). Multivariate Cox proportional hazards regression analysis after adjustment for baseline characteristics showed that lower average heart rate remained an independent predictor of cardiovascular events (HR: 0.47 per 10 increase; 95% CI: 0.25-0.87; p = 0.016). CONCLUSION: Average heart rate on Holter monitoring predicted long-term prognosis in our cohort. Further multicenter studies are needed to confirm our results.

Impaired Left Ventricular Contractile Reserve in Patients With Hypertrophic Cardiomyopathy and Abnormal Blood Pressure Response: A Stress Echocardiographic Study.

BACKGROUND: Abnormal blood pressure response (ABPR) has been reported to be a risk factor for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). We aimed to elucidate the relationship between ABPR during exercise stress echocardiography (ESE) and impaired left ventricular (LV) contractile reserve based on two-dimensional strain in patients with HCM. METHODS: Patients with HCM underwent ESE with treadmill exercise. Patients whose blood pressure elevation at maximum workload was lower than 20 mmHg from baseline were classified as having ABPR. Echocardiographic parameters were compared between patients with and without ABPR.  Results: Of 26 patients with HCM, nine patients were diagnosed with ABPR. Significant LV outflow tract obstruction (>50 mmHg) was provoked only in one patient with ABPR (baseline to the conclusion of the exercise, 15.2 mmHg to 63.0 mmHg). Change in cardiac output (CO) and the ratio of early diastolic velocity to early annular velocity (E/e') from baseline to just after the conclusion of exercise did not differ between patients with and without ABPR (CO, 102±40% vs. 122±45%, P = 0.19; E/e', 4±22% vs. 2±20%, P = 0.86). Change in systemic vascular resistance change was not significant (patients with vs. without ABPR, -52±10% vs. -46±13%, P = 0.24). Percent change in LV global longitudinal strain was lower in patients with ABPR than patients without ABPR (12±17% vs. 27±15%, P = 0.02). CONCLUSION: In conclusion, impaired LV contractile reserve during exercise might contribute to ABPR in patients with HCM.

Jugular Venous Pressure Response to Inspiration for Risk Assessment of Heart Failure.

Simplifying jugular venous pressure (JVP), visibility of the right internal jugular vein above the right clavicle in the sitting position, has been proposed in the management of heart failure (HF) because of its convenience. However, this method may be undervalued for the detection of mildly to moderately increased JVP. Increased JVP on inspiration, known as Kussmaul sign, may be a useful physical finding in this condition. This study consisted of 138 patients who were admitted for the management of HF. Using this simple method, JVP was assessed at rest in the sitting position before discharge; its response to inspiration was also examined if no high JVP was noted at rest. The primary outcome was a composite of cardiac death and hospitalization for worsening HF. Among all the patients, 16 patients (12%) had high JVP at rest and another 16 patients (12%) had high JVP not at rest but on inspiration. During a follow-up period of 249 ± 182 days, a primary outcome event occurred in 63 patients (46%). The incidence of adverse cardiac events was higher in patients with a high JVP at rest (69%; hazard ratio 3.31, 95% confidence interval 1.64 to 6.67, p = 0.0009) and in patients with a high JVP on inspiration (56%; hazard ratio 2.18, 95% confidence interval 1.02 to 4.63, p = 0.043) than in patients without a high JVP in both conditions (41%). In conclusion, a high JVP not only at rest but also on inspiration was associated with a poor prognosis. The response of JVP to inspiration using this simple technique of physical examination may be a new approach in the management of HF.

Effects of a Self-efficacy Theory-Based Training Program for Peers of Patients with Type 2 Diabetes.

BACKGROUND: Training peer leaders to deliver patient education is expected to be a low-cost approach to providing healthcare in urban-poor areas affected by a shortage of healthcare professionals. The purpose of this study was to examine the effects of a training program on the self-efficacy and knowledge of peer leaders with type 2 diabetes. METHODS: A single-group longitudinal survey with baseline, intervention, and follow-up periods was conducted at a diabetes clinic in a small municipality in Metro Manila, Philippines. The intervention, a self-efficacy theory-based training program for peer-leaders of diabetic patients conducted in August 2017, comprised hands-on learning, demonstrations, quizzes, role-playing, group sharing, physical exercise, and a buffet lunch. The primary outcome was participants' self-efficacy for management of their diabetes. Secondary outcomes were participants' knowledge of diabetes and levels of emotional distress, motivation, and confidence for guiding their peers, satisfaction with the training program, hemoglobin A1c, and quality of life. RESULTS: At 12 and 18 months after the intervention, participants' knowledge of diabetes was significantly increased compared with baseline (both P < 0.05). At earlier time points, an increasing, but not significant, trend was observed. The change in knowledge of diabetes from baseline to 18 months after intervention tended to be positively correlated with the change in self-efficacy (r = 0.594, P = 0.054). No significant differences were observed for any of the other outcomes, although the descriptive statistics showed an increasing trend for all of the outcomes except motivation. CONCLUSION: The training program significantly improved participants' knowledge of diabetes at 12 and 18 months after the training programs compared with baseline. A positive correlation between the changes in the levels of knowledge and self-efficacy suggested that the observed improvement of self-efficacy was facilitated by the improvement of knowledge of diabetes.

A Randomized Placebo-controlled Trial of an Oral Preparation of High Molecular Weight Fucoidan in Patients with Type 2 Diabetes with Evaluation of Taste Sensitivity.

BACKGROUND: Fucoidan is derived from seaweed widely used in Japanese cuisine, but little is known about its influence on glucose metabolism. To obtain information about the physiological effects of fucoidan on glucose metabolism, the digestive system, and the gustatory system controlling taste sensation in patients with type 2 diabetes, we conducted a randomized, double-blind, placebo-controlled study. METHODS: Thirty patients with type 2 diabetes on diet therapy were recruited from an outpatient clinic (22 men and 8 women aged 59.10 ± 13.24 years, body mass index: 25.18 ± 3.88, hemoglobin A1c: 7.04 ± 1.24%). They were divided into 2 groups and underwent 2 interventions with a 4-week interval. One group received fucoidan for 12 weeks (a daily 60 mL test beverage containing 1,620 mg of fucoidan) and then placebo (60 mL) for the subsequent 12-week period, while the order was reversed in the other group. Evaluation was performed just before and after each intervention. Taste sensitivity was measured for 5 basic tastes by the filter paper disk method and food intake was evaluated with a validated diet questionnaire. RESULTS: No adverse events occurred during the study period. Despite no change of the diet, stool frequency increased during fucoidan intake (from 7.78 ± 4.64/week in Week 1 to 9.15 ± 5.03/week in Week 5, P < 0.001), and it increased more in lean subjects. In 11 subjects whose stool frequency exceeded the mean value, the thresholds for sweet, salty, bitter and umami tastes were significantly reduced (enhancement of sensitivity) after fucoidan intake. In 14 subjects with normal HOMA-IR (homeostatic model assessment of insulin resistance, < 2.5), hemoglobin A1c decreased after fucoidan intake (from 6.73 ± 1.00 to 6.59 ± 1.00%, P < 0.05), as did the fasting plasma level of GLP-1 (glucagon-like peptide-1, from 6.42 ± 3.52 to 4.93 ± 1.88 pmol/L, P < 0.05). CONCLUSION: Sustained fucoidan intake led to alterations of gastrointestinal function, including increased stool frequency and enhanced taste sensitivity, which could contribute to better control of diabetes.

Intraoral application of hyperdry amniotic membrane to surgically exposed bone surface.

Hyperdry amniotic membrane, a novel preservable material derived from the human amnion, has been introduced clinically in ophthalmology and other fields. This membrane is available as a wound dressing material for surgical wounds of the tongue and buccal mucosa but has not been used on wounds of the alveolar mucosa. This paper reports 2 cases in which intraoral alveolar wounds with bone exposure were successfully treated with the use of hyperdry amniotic membrane: a 74-year-old woman with gingival leukoplakia of the edentulous mandible, and a 43-year-old man who underwent vestibuloplasty of the reconstructed mandible. The results indicate that the hyperdry amniotic membrane is a useful dressing material, not only for soft tissue wounds, but also for exposed bone in the oral cavity.

Diagnostic performance of ultrasonic tissue characterization for subendocardial ischaemia in patients with hypertrophic cardiomyopathy.

AIMS: Hypertrophic cardiomyopathy (HCM) patients often develop left--ventricular subendocardial ischaemia, a cause of chest symptoms, despite normal epicardial coronary arteries. The aim of this study was to examine whether ultrasonic tissue characterization or late gadolinium enhancement on cardiac magnetic resonance imaging can detect subendocardial ischaemia in patients with HCM. METHODS AND RESULTS: Subendocardial ischaemia was quantified on exercise Tc-99m tetrofosmin myocardial scintigraphy in 29 non-obstructive HCM patients with asymmetric septal hypertrophy. Ultrasonic tissue characterization using cyclic variation of integrated backscatter (CV-IB) and late gadolinium enhancement on cardiac magnetic resonance imaging were analysed separately in the right halves and the left halves of the ventricular septum in relation to subendocardial ischaemia. Subendocardial ischaemia was identified in 17 (59%) patients. The ratio of CV-IB in the right-to-left halves of the ventricular septum was significantly higher in patients with subendocardial ischaemia (1.19 ± 0.10) than those without (0.84 ± 0.10, P = 0.04). The optimal cutoff for the detection of subendocardial ischaemia was the ratio of CV-IB >1.0, with a sensitivity of 80%, specificity of 71%, and accuracy of 76%. On the other hand, late gadolinium enhancement was not associated with subendocardial ischaemia in our cohort. CONCLUSION: Ultrasonic tissue characterization using CV-IB separately in the right and left halves of the ventricular septum, but not late gadolinium enhancement on magnetic resonance imaging, provided useful information in detecting subendocardial ischaemia in patients with HCM. Ultrasonic tissue characterization may be useful in selecting patients who will benefit from medications to relieve chest symptoms.