High dose immune globulin therapy ameliorates peripartum cardiomyopathy with elevated serum antibody titer to influenza virus: case report of two patients.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a rare complication characterized by heart failure that arises between the last month of pregnancy and the first 5 months after delivery. The etiology of this disorder has not been clarified due to its low incidence. We describe two patients with PPCM and elevated antibody titers to influenza virus in paired sera that were recovered by high doses of intravenous immune globulin. CASE REPORT: Case 1. One day before delivery by cesarean section, a 32-year-old woman developed PPCM that was immediately improved after the administration of a total cumulative dose of 1.7 g/kg immunoglobulin together with intra-aortic balloon pumping and percutaneous cardiopulmonary support. Antibody titers to influenza virus subtypes A and B were elevated in paired sera from this patient. Case 2. Four days postpartum, a 29-year-old woman developed PPCM and a total of 2.0 g/kg immunoglobulin recovered her cardiac function. The antibody titer to influenza virus subtype B was elevated in paired sera from this patient. Evidence of myocarditis was absent in endomyocardial specimens from both patients. CONCLUSIONS: These cases suggest that viral infection including influenza contributes to PPCM and that high doses of immunoglobulin constitute an effective treatment for this disorder.

[Evaluation of metabolic syndrome in elderly age patients of coronary heart disease].

BACKGROUND: Recently, metabolic syndrome is increasing in Japan and it is thought to be the cause of coronary heart disease. In this study, we evaluated the metabolic syndrome and insulin resistance that is thought to be located in the upstream of metabolic syndrome in high age patients of coronary heart disease. PATIENTS AND METHODS: Coronary risk factors were examined and OGTT with measurement of plasma glucose and serum insulin was done to evaluate metabolic syndrome and insulin resistance in 214 patients who underwent coronary angiography; 102 patients were over 65 years old (high age group) and another 112 were young age group. We compared the two groups. RESULTS: The rate of hypertension was significantly high and that of obesity, LDL-cholesterol level and triglyceride level were significantly low in high age group compared with the young age group. There was no difference in the ratio of metabolic syndrome between the two groups. The frequency of insulin resistance confirmed by HOMA-R was significantly high in the young age group, however there was no difference confirmed by 2 hour serum insulin level after OGTT. CONCLUSION: The influence of glucose metabolism and insulin resistance was equal between the two groups. The frequency of metabolic syndrome was the same, but the coronary risk factors were different between the two groups. Abnormal glucose metabolism and insulin resistance were common to both groups. To diagnose insulin resistance, 2 hour serum insulin level was more effective than HOMA-R.

Comparison of the Brachial-ankle Pulse Wave Velocity between Patients with Acute Coronary Syndrome and Effort Angina Pectoris.

Objective Coronary artery disease (CAD) is one of the clinical categories of atherosclerotic diseases. There have been reports indicating that the pathological findings of coronary artery plaque differ between acute coronary syndrome (ACS) and effort angina pectoris (EAP). The brachial-ankle pulse wave velocity (baPWV) has been reported to be a good indicator of atherosclerotic disease. However, the baPWV may not be equally effective for evaluating ACS and EAP. In this study, we compared the baPWV in patients with ACS and those with EAP. Methods Two hundred and seventy patients were enrolled in this study. All patients underwent coronary angiography, and were separated into normal (CONT), ACS and EAP groups according to the clinical and coronary angiographic findings. The baPWV was evaluated and the results were compared among the groups. Results The baPWV was significantly higher in the EAP group than in the other groups. The baPWV in the ACS group was almost the same as that of the CONT group and was significantly higher in the EAP group than in the ACS group across almost all age groups. Conclusion The present study showed that the baPWV is high in patients with EAP. In contrast, the baPWV in the ACS group was almost normal and was similar to that of the CONT group. ACS occurs due to plaque rupture induced by atherosis, which may occur independent of sclerosis in the coronary artery. EAP may occur in proportion to systemic arterial sclerosis. The baPWV is suitable for screening for EAP, but not for ACS.

Calcification around the Struts of a Sirolimus-eluting Stent Approximately 16 Months after Implantation in an Autopsy Case.

Drug-eluting stents (DES) are widely used for the treatment of coronary artery disease, and a sirolimus-eluting stent (SES; Cypher) was the first DES introduced into clinical practice. Although pathological reactions of coronary arteries to SES have been described in autopsy cases, there are few reports regarding calcification of the coronary arteries after SES implantation. The present report describes the findings of an autopsy conducted 16 months after SES implantation that showed remarkable persistent calcification. In addition, previously reported pertinent pathological findings are also described.

Characteristic clinical findings of reversible left ventricular dysfunction.

OBJECTIVE: In this study, clinical findings were evaluated in 16 patients with reversible left ventricular dysfunction (RLVD) who showed a clinical picture similar to that of acute myocardial infarction, in addition to akinesis or dyskinesis of the left ventricular apex without showing any abnormalities in the coronary artery. RESULTS: The frequency of RLVD was markedly higher in women than in men in these 16 patients (men:women = 1:7). In addition, these patients showed ECG changes similar to those observed in ischemic heart diseases, such as ST elevation or depression, negative T waves and QT prolongation. However, the serum cardiac markers were only slightly increased, and no specific changes were detected by histological examinations of the heart muscle. CONCLUSION: These patients also showed a clinical picture similar to the stunned myocardium caused by myocardial ischemia. However, the frequency of RLVD was higher in women than in men compared to the frequency of other coronary artery diseases, and there was no severe stenosis in the coronary artery. Moreover, most of these patients showed negative results for the coronary spasm provocation test. Therefore, RLVD may be an atypical ischemic heart disease if it is caused by coronary arteriosclerosis. Since RLVD developed during the course of other diseases or under severe mental stress, autonomic nerves may be involved in the etiology of RLVD. Furthermore, 2 patients who received the coronary spasm provocation test during the acute phase showed positive results. Therefore, other factors that transiently increase the sensitivity of the coronary artery may also be involved in the etiology of RLVD.

Effect of pimobendan in addition to standard therapy for heart failure on prevention of readmission in elderly patients with severe chronic heart failure.

AIM: We evaluated the effect of pimobendan, a positive inotropic agent, in elderly patients with frequent readmission as a result of heart failure despite conventional therapy. METHODS: Pimobendan was given to five male patients with severe chronic heart failure (New York Heart Association class III-IV) (age range 69-89 years; mean 78 ± 8 years; ischemic cardiomyopathy in three cases, dilated cardiomyopathy in two cases) who required repeated admission for heart failure despite conventional therapy with angiotensin inhibitors, beta-blockers, diuretics and anti-arrhythmic agents. After the addition of pimobendan at a dose of 1.25-3.75 mg/day, we evaluated serum levels of brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF), septal e' and left ventricular end-diastolic diameter (LVDD) by echocardiography, as well as readmission rates for more than 2 years. RESULTS: The serum level of BNP significantly decreased after treatment with pimobendan, although its level returned to pretreatment levels after 2 years. LVEF significantly improved after the treatment, with the improvement continuing beyond the 2 years, although LVDD did not change after treatment. Septal e' significantly improved after the treatment, although its level returned to pretreatment levels at 2 years after the treatment. Readmission rates significantly decreased for 2 years after the treatment, although one patient required cardiac resynchronization therapy for severe heart failure, and another patient required cardiac pacemaker implantation for sick sinus syndrome 2 years after adding pimobendan. CONCLUSIONS: Pimobendan in conjunction with conventional therapy for heart failure decreases the readmission rate in elderly patients with severe heart failure for at least 2 years.

Evaluation of glucose tolerance, post-prandial hyperglycemia and hyperinsulinemia influencing the incidence of coronary heart disease.

BACKGROUND: Recently, the frequency of patients who have glucose intolerance has been increasing in Japan. Glucose intolerance and insulin resistance/hyperinsulinemia are thought to influence the progression of atherosclerosis. The present study examined glucose tolerance, insulin resistance, post-prandial hyperglycemia/hyperinsulinemia and coronary risk factors by using 75 g oral glucose tolerance test (OGTT). PATIENTS AND METHODS: Coronary risk factors were examined and OGTT with measurement of plasma glucose and serum insulin was done to evaluate the glucose metabolism and insulin resistance in 263 patients who underwent coronary angiography; 202 subjects were diagnosed as having coronary heart disease (CHD) and 61 subjects were normal. We compared the two groups. RESULTS: The rate of having diabetes was significantly high in the CHD group. From the result of OGTT, 22.3% of CHD patients had diabetes mellitus and 36.6% had impaired glucose tolerance, thus the total glucose intolerance rate was 57.7% in the CHD group. No significant difference was noted in the homeostatic model assessment-R (HOMA-R), but glucose and insulin at 2 hours after OGTT were all significantly high in the CHD group. CONCLUSION: The rate of glucose intolerance and the levels of post-prandial glucose and insulin were high in the CHD group. We concluded that the post-prandial hyperglycemia and hyperinsulinemia influenced the incidence of CHD.